Ethical, Professional and Methodological Concerns about the Handling of COVID-19

What follows is not exhaustive but is a professional, critical examination of the current COVID-19 crisis in the United States.  It is known and noted by the author that there are numerous professional opinions outside of what is written here, and there are many more considerations beyond what can be written here.  This article is simply a critical examination of the current narrative in the United States through the lens of professional training and practice in the mental health field from a Licensed Professional Counselor with a Master's degree in Counseling Psychology with a very heavy emphasis on research methodology, epistemology, data interpretation, study formulation and treatment planning.  It is not intended to supplant or undermine public policy or directives, but simply to stimulate thought to the public from a professional perspective in addition to the ones in the media.

Introduction

As a mental health professional, a counselor, it is alarming to see how the COVID-19 pandemic is being presented in the American media and by medical professionals to the American public.  In the healthcare professions, methodology, ethics, consideration of impact, and a well-informed process are central to the practices in addition to the outcomes achieved.  As a citizen being affected alongside every other American regarding the COVID-19 virus, I am seeing many failures and lapses across the board in how this crisis is being addressed both by the media and politicians, but mostly with the healthcare professionals who are  the voice behind the decisions and directives that are affecting us all.  

It appears we are facing a near-total systems-failure in terms of the areas mentioned, that has caused harm to millions of Americans and will result even more significantly if this continues, far beyond what the virus can do.

What follows are some professional considerations as a mental healthcare professional of the issue as it is being presented to the public.

Primary Concern

For as contagious and deadly as this is being presented as being, and for as long as it appears the virus as been in the United States, the hospitals should already be full of the dead and dying.  The numbers, however, indicate that this has a survival rate of more than 97%, especially when factoring in that many who have it will be asymptomatic.  The numbers do not add up to indicate this is the crisis being presented.  However, this piece will be focused on methodology, ethics, presentation of data, and treatment planning.  Numbers will change, but when methodology and ethics are sound and consistent, the overall picture will be far more informative than numbers.

Language and Presentation

The use of vague language to inform the public regarding COVID-19 is especially disruptive.  There are repeated references to "cases" of COVID-19, not death rates or casualty rates, just "cases".   Cases and deaths are two different things.  Most people recover from COVID-19.  If they didn't, there would be far more deaths than there have been.

Maps presented on state and national websites combine data from different variables into one variable, the most recent being "cases and deaths" by county for the state of Idaho.  

Presenting this as a "case and death" is very inaccurate to say the least.  To present an issue in this fashion to a mental-health client, depending on their mental faculties and impressions of the world, this would constitute abuse because it is implying that simply having a condition will result in death.  And yet, this is what is being presented to the entire country and this is how data is being presented by agencies responsible for public health, by medical professionals who are educated to know better, and is being repeated by the media. 

Additionally, there is the concern that "cases" are being presented that anyone and everyone regardless of age or condition are equally susceptible to this virus.  There is definitely data indicating that the most susceptible are the elderly and those with pre-existing conditions. Some stay-at-home orders note that some people are more vulnerable than others including the elderly and those with pre-existing conditions - a tacit acknowledgement that not all are at the same risk, and therefore do not all require the same protections or to take the same actions to protect ourselves.

The word "pandemic" is applicable because this is, by definition, a pandemic - spread across continents and is infectious.  However, the word is being used in a way that sounds terrifying, yet it does not necessarily mean the virus is more lethal - just that it has spread further and infected more people.  So "pandemic" is accurate but not precise, and can be said the way it is being used and presented is not correct. 

It is a fine differentiation, but it is one that has a significant impact on all involved in terms of responses to it.

  

Data Measurement

The measurement and descriptions of variables is a central skill to mental health.  Both qualitative (descriptive - e.g. good, healthy, stressed) measurements, as well as quantitative (numerical - e.g. percent, total numbers, Likert scales etc.) are used in mental health.  But going back up to the language and presentation, the data being presented or the impression being communicated with the presentation is very misleading.  

The virus is being presented as "highly contagious" and yet, what does that mean?  What percent probability does any given individual have of dying or experiencing lifelong complications if they do contract it?   This is not being presented or talked about by the public. 

Now, many are saying "we don't know" a lot about this virus.  In order to make an informed assessment or plan treatment, professionals have to go off what is known, and  have to be accountable for how they came to know it, and be able to demonstrate that they did so.

It appears this virus has been in the United States well before January, 2020.  For as contagious as it is being said to be, and efforts to quarantine were not taken until March, 2020, and for all of the traffic and sociality in the United States we have, unless this is a virus that doesn't actually kill people for at least three months after contracting it, there should be a very high number of deaths at this point are not being seen.

Additionally, there is the need for context.  Death happens every day.  Death is a part of life.  Whether of COVID-19, a car accident, or other causes.  The numbers being presented on COVID-19 deaths that have happened, when put in context to all other causes of death are far less alarming.  For example, heart disease in the United States claims well over 600,000 deaths annually, and there are nearly 3,000,000 deaths annually in the United States.  A report on the radio yesterday (4/6/2020) stated there are over 300,000 "cases" of COVID-19 in the United States -  it would have to hit at least a 15% fatality rate or approximately 1:8 death rate to enter onto the top ten list of leading causes of death in the United States.  Given that it is said most of those who have it will not show symptoms, by the numbers, the death rate would have to be even higher, and current trends do not indicate this is going to happen or become the trend in the United States. 

Treatment Planning

Treatment plans are to be "evidence based" and should be as non-invasive and as least-disruptive as possible in order to achieve the greatest result.  The impact on all parties involved in any treatment plan is always to be considered, with an appropriate "cost/benefit" analysis as well as well as even an appropriate assessment of risk.  Treatment plans should encourage and foster as much autonomy as possible, respecting a client's unique circumstances, and ultimately need to be patient-centered - meaning, centered around their needs, well-being, safety and that of the community's and all others' involved.  

This being said, some treatment plans will be quite simple and of brief duration, and may only require a limited set of planned sessions for treatment with a specific outcome measure relatively easily accomplished for some people - such as an examination of beliefs surrounding a relationship that may be contradicted by the evidence.

Other treatment plans may be far more comprehensive in scope, require an interdisciplinary treatment team of multiple health professionals across a spectrum of services within an inpatient facility requiring a large number of support staff of an indefinite duration, with continuing evaluations of risk, wellness, and effectiveness being conducted in order to keep the individual and others' safe from harm.

But regardless of complexity, in no treatment plan are we to ever take the mentality that "the ends justify the means".  The process itself is as important - if not more - than the outcome.  Processes poorly done can render the outcome irrelevant if it causes more problems than it solves.  Being aware of the impacts of the processes are the responsibility and obligation of the clinical practitioner and the healthcare professional - it's what we're paid for, in short. When we fail to do this, we are no longer acting as a professional.

There is a lot of evidence as well as acknowledgement that the most vulnerable to COVID-19 are the sick and elderly.  This being said, in a treatment plan, the most ethical as well as effective thing to do is to tailor your treatment plan to target the vulnerable, put plans in place to help them stay safe, and let others retain as much autonomy as possible.

When the treatment plan impacts people who are not as vulnerable, in this case those who are young and healthy, but instead it cost them jobs, educations, increases stress, decreases productivity, threatens legal action, harms economic stability in the name of safety, it has not only undermined the very people supposedly being protected by cutting their support systems out from under them, but is doing far more significant collateral damage.

Perspective

In treatment planning and assessments there is a need to compare apples to apples - even if they are different types of apples, otherwise assessments or treatment planning will not be very effective. 

People frequently reference the number of deaths in Italy from COVID-19 as the basis of their fear in the United States.  Comparing Italy to the United States is useful ONLY IF acknowledging the differences between them.  Given that the United States is vast with entirely different customs, social histories, transportation systems, sanitation systems, climates, housing arrangements, medical systems and social services infrastructure, demographics, health histories, and much much more, using Italy as a predictor of outcomes within the United States would be a fallacy at the very least (unless you account for differences).  Every competent medical professional and healthcare professional knows to do this and why it is important, but it is not being done in the media.

Going back up to treatment planning, all healthcare professionals have an ethical obligation to protect their patients using the best information possible and to disclose that information so that patients can make informed decisions, except in cases where doing so would result in harm according to the best professional judgement of the practitioner.  In terms of treatment planning and the resulting fear and economic harm that has resulted in the United States, there are plenty of reason that these differences should be being discussed.

COVID-19 has been compared to the Spanish Influenza pandemic in which an estimated fifty million died with an estimated five-hundred million exposed (an estimated 10% fatality rate with other health complications to many others).  But what are the similarities to the Spanish Influenza, AND what are the differences?  What is different in the world between 2020 and when the Spanish Influenza occurred over a century ago?  Healthcare and sanitation have improved drastically in the United States, to say the least. In terms of informing the public, this is very relevant but is being left out.

In any treatment planning it is essential to collaborate and make sure all points of view are examined.  When the view is unanimous and no alternative considerations are presented or acknowledged between professionals, the saying "when everyone is thinking the same thing, someone isn't thinking" becomes relevant.  Recently a media outlet accused President Trump of not listening to medical experts on COVID-19, but there was not any acknowledgement that not all "medical experts" agree with each other on this.  It is presented as if there is one single solution, there is no collateral information outside the current narrative, the president is ignoring it and we are all going to recklessly die.  This is where it begins to look like this is not a medical issue so much as a political or media issue, which is touched on more a little later in the piece. 

Impact 

"Social Distancing" is its own stressor.  Creating lines at the store, marks all over the floors showing how far to stand from each other, having senior citizens shop at a very early hour can be extremely difficult in that those who are medically fragile may require more sleep, more rest and instead have to exert even more energy to go out earlier, paying attention to how close you are to others at all times to an abnormal degree for weeks on end, all increase stress which impacts ability to resist diseases.  Lines at the store, reports of police being called for people being too close or arrests for "assault by coughing" with the accompanying fear seem to make the actual virus a distant secondary danger.  While social distancing may leave people feeling less crowded in the checkout line, many are more stressed about being in public; the negative effects of social distancing are going to be felt long after this ends and some people will still be afraid to get close together long after this is over. 

Additionally, going out to the store or leaving the house is necessary to reduce stress, buying toys with children, grabbing a fun snack, going to work gives our minds a rest, shift our focuses to enable us to feel better and even make ourselves healthier.  

Locking people up at home while their jobs are lost, stressing about money, fearing being arrested or being ordered back to their homes for a curfew, and signs and interventions everywhere for a virus that is now seen to have a very high survival rate is not healthy on an individual or a national scale.  

The suggestions that people wear masks to the store or while out for a walk: is this an informed, evidence-based directive, or is this being overly cautious and in consequence doing more harm than good by causing more stress and fear? 

For those who are mandated to treatment for violent crimes, being isolated with their families at homes by stay-at-home orders, losing their jobs, being unable to schedule doctors appointments for several weeks while hospitals lay otherwise empty waiting for an influx of the sick that has not come, and stopping therapy in person as many clinics have done, increases risk of harm to others as well as the risk of relapse and other complications to them, and further stokes fear.  

Law enforcement releasing those who are violent from jails and prison and ceasing making arrests on the fears of a virus that has not been demonstrated to be as deadly as it is portrayed increases further risk to both past victims and future victims.  There are far more domestic violence victims than there are COVID-19 deaths, and government orders in this case are increasing the danger to the public rather than decreasing it.  

Further, some presentations by educators to school-children are also unethical and unnecessarily cause fear and distress by their explanations of government officials' decisions to shut schools down.   Going back to the fact that they are our future generations, in terms of education it has to be asked: what are they being taught when this is the response?  They certainly aren't learning best-possible-practice, but more the-ends-justifies-the-means-regardless-of-cost, as well as their formal educations are being impacted.  Families may be growing closer together where parents suddenly find themselves home-schooling their children, on the other hand, but this is one of the very few positives I have seen from the current handling of this issue.  

Scope of Practice

Elected officials are just that: elected officials.  They are not doctors or psychiatrists or surgeons in most cases.  Elected officials have a few jobs, among which are to keep the public safe, as well as get re-elected or run for election so they can keep the public safe.  When healthcare takes on a political tone or has democratic motives, especially with an uninformed media that is not familiar with the nuances of healthcare, the best practices of healthcare stop being done.  Doing too much can be even more dangerous than not enough.  

It has been said that we will not know if we did too much, but we will know if we did too little.  

This is a fallacy. 

The fallout from doing too much can and will most certainly be seen.  There is not only current data, but there will be more data, that when ethically collected and interpreted accounting for and acknowledging limitations, will allow it to be seen in hindsight whether the response was too much or too little. 

Further there is the fallacy that the only choices are to do either too much or not enough.   The question is, how much is too much, and what is prudent as well as effective?  Doing too much in the name of caution is not the same as being prudent and effective, and when it comes to healthcare, does more harm.  

Conclusion

While I am not a virologist or an immunologist or even a biologist, my profession requires me to work with interdisciplinary treatment teams and to not just look at the numbers, but look at how we are thinking and approaching an issue, look at numbers and graphs and be able to derive probabilities in multiple ways as well as be able to identify weaknesses within studies and data.  The current COVID-19 scare appears to be causing more harm than it is preventing.  It is costing people emotionally, mentally, socially, physically, spiritually, professionally, intergenerationally, medically - far more than any deaths.

While this entry is not exhaustive in scope, and it is not being suggested that COVID-19 requires no intervention at all or that it is not harmful, there remain a great many more questions to be asked and perspectives to be examined.  We need to be making informed decisions.  

In the end, when healthcare ethics and evidence-based practice are followed, issues will be identified far more quickly and effectively, with far lower numbers of those harmed and those impacted by unintentional collateral damage, and overall wellness will increase. 

What Causes Domestic Violence

A brief overview of how domestic violence is a choice that abusers make.

Domestic Violence: Blaming the Victim

This is a brief clip on some of the key focuses of domestic violence treatment - recognizing the role played in abuse by focusing on the language used to describe it, which shapes how we think about it.

Questions and Flaws with Red-Flag Laws

(The following piece is written about the considerations and realities of the "gun violence debate" from the perspective of a mental health practitioner specializing in forensics, evaluations, criminal behaviors and abuse - what follows is not meant to be nor can it be considered comprehensive or exhaustive in scope, but is meant to simply illustrate some of the considerations that go into forensic evaluations, highlight that more questions need to be asked on addressing the issues of mental health, violence with guns, abuse in general, evaluations, legal processes, and how they affect all concerned)

There are a lot of very concerning flaws with the so-called "red-flag laws" beginning with the the unanswered question as to whether this is a legal issue or a mental health/behavioral health issue.

We need to beware of following in the footsteps of the witch-trial era where accusations are made, fear is the motivator, ignorance is the tool, and society pays the price on a number of fronts with due process and scientific processes / knowledge being ignored, while ignoring the core issues and creating others.  

A doctor, a lawyer, a judge, an attorney, a police officer, a detective, are not specifically trained and certified in clinically or forensically evaluating risk of violence as a part of their job description - they may be mandatory reporters or charged with addressing violence, but that is far different than evaluating and assessing risk of future violent behaviors.  Even being a clinician - psychologist, psychiatrist, counselor, social worker - does not automatically grant an acumen in dealing with criminal behaviors - which is it's own specialty.

We absolutely can handle this as a legal issue, a mental health/behavioral health issue, or a combination of both.  But if we were to consider this from a mental health / behavioral health issue:

For domestic violence there are tools/instruments such as the Ontario Domestic Assault Risk Assessment and the Spousal Abuse Risk Assessment which can include, but are not restricted to violence and abuse with guns.

What assessment tool would they propose we use to predict risk of violence with guns?  Is it valid, reliable - will it actually predict what we think it is going to predict, and is it broadly applicable to both males and females of all intelligence and cultures?  Or just use the existing tools with a focus on violence with guns?

What if we address one area of concern and ignore others?  For example, someone is reported that they are at risk of committing suicide with a gun - in which case we would be assessing for suicide risk rather than violence with a gun against others. In response, let's say their guns are taken.  Who is to say they will not be afraid of losing their freedom and decide to end their life with an overdose instead?  Or let's say the individual has been reported for being at risk for violent behavior, and they decide to retaliate and find a way to carry out a crime against the reporter / intended victim regardless before they can be stopped, using another method?

What steps will we take to address these hypothetical but very real scenarios or ones like them?

What process will there be for those reported?  Will they be allowed recourse? 

And what records would we obtain for the evaluation of risk?  

If they have no criminal record, what records would we want to use? 

Would we use juvenile records?  

Traffic records?  

Gun purchase records?  

Mental health records?  

Medical records?  

Employment records?  

Who decides what's relevant to ask and what is not? 

Would the evaluators have power to request and obtain those records?  

Or would they be required to be included and simply submitted upon the order for an evaluation?  

Would we require no records and use  interviews with no collateral evidence?  

What training would evaluators have in the overview of the records used?

Would we mandate that others participate as witnesses in the evaluation and they have to be interviewed as well?  

Do we interview children?  

Coworkers?  

Family?  

What risks does this pose for the one being evaluated?  

How about for the witnesses?  

Can they opt out?  

If they decline are they now a "co conspirator" with the "accused"?  

Would there be a "cross examination" of witnesses?

For many of the red-flag laws, someone is making a report to the authorities already - do they get to be interviewed?  

Do they have to be?  

Do they do so anonymously?  

Is everyone anonymous, or do the "witnesses" have rights to be anonymous, or do they count as "accusers" in a court of law, where what they say is now public record and testimony with the reported person having the right to confront them  - thereby putting some people at risk of retaliation, and in other instances due to external pressure refusing to participate accurately, thereby skewing the record?

Is the record private? 

Public?  

Who can access it?  

Is it sealed after it's used to determine risk?

How long is it considered valid for?  

Can those evaluated as being a high risk get a second evaluation?  

Who pays for it?  

Who does the evaluator work for?  

Are they like a public defender, or an independent contractor?

Do you get a "public defender" type evaluator if you can't afford a private evaluator?  

And in which case does the quality of your evaluation - the validity and reliability - go up or go down or is it guaranteed to stay the same?  What has to go into the report?  

Are we looking at sexual abuse history?

Substance use history?  

What happens if they don't wish to participate?

Is the fact that someone accused them or reported them an instant grounds for mandatory participation in an evaluation, and like a DUI if they refuse to participate, they are cited as being "guilty" and lose their rights?

What credentials and training do the evaluators have to have, or should they have?  

What degrees?  

Who determines the standards for evaluators?

Would it be on a state-by-state basis or a national standard?  

Would the credentials fall under an organization such as the American Counseling Association, American Psychological Association or other association?  

Who would determine whether or not the standards are in need of change if they are not working? 

What consequences exist for those who report someone but do so wrongfully?  

Are they considered to have made a good-faith report?  

Or are there criminal and civil liabilities if they are found to be not-at-risk?

What constitutes a valid threshold for making a report against someone?  

Is fear alone a justifiable basis?  

Do we have to quantify fear with a numerical or a descriptive basis?  

Does there have to be evidence, or just the belief that they are dangerous?  

How would we verify the claims?  

It would be easy to deny, and then would we turn to collateral information from other reports as mentioned above? 

Would there be a "no-risk" category?  

Or would there be a "low risk" category at the minimum?  

Does evaluating someone as "low risk" mean that there IS risk, and they receive the label simply because someone accused/reported them, and they can never receive a "no risk" label/assessment?

Will the government avoid a "no risk" category because of it's own liability if the assessment turns out wrong?  

What immunity / protections does the evaluator have?

Does the evaluator make recommendations for actions to be taken?  

Who makes the final decision about what response is to be taken and how are they supposed to use the evaluation?  

Who carries out the recommendations?  

Can the recommendations be completely disregarded?  

Would the recommendations be negotiable in  a court of law?

Who is ultimately responsible if the evaluation turns out to be faulty?  

Will the fact that someone received an evaluation / was reported ever be used in the future for other assessments should a crime occur?

If I actually believed that it was as simple as it is being presented in the media - see something, say something, the government does something, and we save something - I would be all in favor of it.

But, one of the mandates of the counseling profession is to "do no harm" and that includes to those being evaluated for risk, making sure evaluations are valid, reliable, protect their rights as well as everyone else related to the evaluations.

I'm not in favor of "doing nothing" nor am I in favor of "doing anything because we can't do nothing" - I prefer whatever is decided be done right, whatever it is. I think it needs to be handled the best way that's going to provide the least disruption that provides the most safety and privacy.   But I don't think we have figured out what that is yet.

Evaluations and government processes can be abused at the expense of the individual private citizen and we want to be aware and honest about this possibility with anything we do.  Mental and behavioral health evaluations have been rampantly abused in totalitarian states, and as mental health professionals, we have a responsibility to speak up about the processes being used and how we see them impacting the public as well as how well they do / don't protect the public.

This being said, I think the government and the public has a lot more homework to do on this subject before anything they produce is going to be able to be considered effective.  I think there are a lot more questions that need to be considered, asked and answered.

If there is anything I am in favor of it is beginning to inform the public about some of the realities we deal with in behavioral / mental health; so they can consider some of the points above as a matter of public policy, or be able to form additional relevant questions.

I also think we are ignoring the fact that in a volatile situation even if the guns are taken, that does not automatically remove the desire / ability to harm - in prison even a ball point pen is not allowed because it can be used as a lethal weapon...or anywhere else someone wants to use it as such.  Most abusers don't even need that. 

 This brings to light the issue of magazine restrictions, and firearms restrictions - banning certain capacity magazines and types of firearms.  Its worth pointing out wars were being fought and murders carried out with hundreds of millions killed over millennia without guns.  The firearms or their capacity aren't the issue - if they were, the most heavily armed country in the world would have been eliminated long before now for the massive amount of firearms in our country.  Remove a few major cities where the "gun violence" is heaviest and the firearms restrictions are also the heaviest in the country - and it becomes obvious the issue isn't the guns but a matter of local policy and conditions - most of which are claimed by their supporters to "solve" "gun violence."  And even then, again, prisons are some of the most controlled environments in the world, yet among the most dangerous because of the motives of those incarecerated there - with everyday objects being used as lethal weapons. But on the outside, we don't live in prisons, not should we make everyday life like a prison under the guise and false promise of "safety."

How we think about the problem is just as much an issue as the problem itself.  But we also need to look down the road to make sure our solutions to the problem aren't causing more problems, as well as making sure the solutions are going to do what we want them to do.  All of this requires us to be very honest with ourselves, look at the results, have more background information on the subject matter, and ask more questions.

 

Why Domestic Violence Offenders Should Not Be Allowed to Participate in Domestic Battery Treatment Prior to Sentencing

One of the things domestic violence treatment providers need to screen for is people who have been charged but not yet sentenced for domestic violence. 

Abusers often have a history of manipulating others, both inter-personally as well as using systems such as employment, mediation services, courts, religious organizations or legal systems to do so.

When people are arrested for domestic violence, their defense attorney will often suggest they enroll in a domestic violence treatment class to make themselves look good before the judge and to show sincerity and earnestness in getting help for their problems as a means to have their sentence reduced.

If they do enroll in treatment at this point in order to manipulate the system they are actually not being treated - the therapist is tacitly endorsing the manipulation, taking money for it as well as sending messages to the victim that the abuser is once-again getting away with manipulating others - all sorts of ethical issues here on the parts of therapists and treatment providers.

The problem with power and control issues/abusive behaviors is that these are a part of a larger pattern and are ingrained behaviors.  There is a significant difference between developing accountability, insight, empathy and understanding of one's issues, and simply admitting them.

Admitting an offender "has a problem" may happen in the courtroom, or upon being confronted with evidence that they had committed a crime/were abusive or even upon being arrested.  Admittance however does not instantly give anyone the insight, skills or tools necessary to navigate life's difficulties or pursue healthy parenting or relationships. Admittance is unfortunately simply a step in the cycle of violence and abuse and often does not have a lasting impact. Abusers will say "I'm sorry" and "I messed up" and buy themselves time from the victim until they resume their abusive behaviors and the victim is hurt all over again. 

Conversely interpersonal skills, Insight and accountability, however are gained over a period of months and years, depending on the individual and the effectiveness of the treatment.

While awaiting sentencing, offenders will attend their treatment with the mentality that they only have to go through the motions for a short time to escape their consequences, so the commitment to change, developing insight and lasting behavior simply is not going to be present.  Often the judge may then assess the abuser as truly penitent, leave them to attend their treatment on their own, give them a reduced sentence and once again the abuser manages to con a system without being forced to make any lasting changes.  If the judge does require them to attend treatment, they may allow the treatment that was participated in (with a manipulative mentality) for the previous several-months/weeks to count as a part of their sentence.  At this point the treatment has lost a lot of it's edge and the therapist has lost credibility and effectiveness to help the offender make lasting changes and ultimately help protect victims.  The abuser returns eventually to their relationship or starts a new one without having made meaningful changes, and as we know the cycle of violence escalates over time, and the risk to the victim has increased. 

Admitting offenders into treatment in this manner is going to have a negative impact on the other members of the group as well.  They are now attending treatment that is supposedly about taking responsibility, gaining accountability and making personal change through insights gained; yet the therapist is taking money from people who they are now helping to escape consequences and to con the legal system, completely undermining the lessons of "treatment."

Under the current rules (as of the writing of this article) of the Idaho Council on Domestic Violence and Victim Assistance, once sentenced to treatment, abusers are not allowed to attend couples/conjoint counseling as a part of their treatment - it increases the risk to the victim because the victim will be sharing personal things that will be exploited by the abuser later, the therapist is seldom specifically trained in the treatment of power and control relationships and will often miss power and control tactics being used right in the middle of session and unwittingly endorse abusive behavior against the victim, and abusive behavior is not a shared problem as it is solely the responsibility of the abuser.

It is my opinion, that once charged with domestic violence or any abusive crime, treatment providers should not provide mandated-type treatment for that abusive behavior until after their sentence is given; or at the least, judges and juries should be prohibited from taking into consideration whether the abuser entered treatment before the sentencing in the formulation of the sentence, and any treatment received at that point should not count towards fulfilling their sentencing requirements.

Using Timelines and Police Reports to Develop Accountability in Domestic Abusers

While the Idaho Council on Domestic Violence and Victim Assistance (ICDVVA) has certain language regarding "intervention" and "treatment" for the purpose of this article, the word "treatment" will be used simply to describe the court-mandated interactions in the clinical setting for domestic abusers. All treatment and therapy needs to be client-centered, and the clinician needs to use their individual skills and assessments to determine how to be most effective with clients.  What follows is simply one tool / method I've found to help me as a clinician fulfill the mandates of accountability and to sort through the often non-linear, error-laden thinking of clients surrounding their criminal offenses and abusive behaviors within the particular program I work with. 

As of the writing of this article, the ICDVVA guidelines on Domestic Batterer Treatment state that treatment, or intervention, courses are to consist of a minimum of 52 ninety-minute sessions.  Generally this takes place over 52 weeks with the expectation that these will be completed within 15 months of sentencing.  Abusers typically have some deeply ingrained thinking errors and negative-core beliefs about themselves, responsibility for behaviors, relationships and others, that it easily takes three to six months just to begin to see some acceptance of beliefs other than their own or insight into their own thought processes.

Group therapy is recognized as one of the most effective modes of treatment for criminal behavior as it allows offenders who have progressed farther in treatment to model healthy behavior for newer members, as well as providing additional insight, experience and accountability factors with the combined group experience that simply can't be provided in an individual setting regardless of the therapist's credentials and experience.  Additionally, many offenders would prefer individual therapy so as to avoid having to feel exposed to others, believing that their offenses were unique and therefore require special treatment - all in an effort to continue to escape responsibility for their actions and in an attempt to avoid seeing themselves "like other criminals" and be confronted with the reality of their offenses - common to narcissist thinking and traits.

As part of the intake procedures for treatment it is strongly recommended that the therapist obtain a copy of the police incident report for the instant offense, and a domestic batterers evaluation where possible.

In my training and experience I've found that the police reports are an indispensible part of treatment and my professional reccomendation is that treatment providers do not allow individuals to start treatment without receiving all that are available for their violent offenses.  The reasons for this are several fold.

First, central features of abusive behavior are dishonesty, denial, minimization, rationalization and blame.  With a police report, a therapist can actually confront an abuser on the actual offense rather than relying on the abuser's account, and the desire to avoid accountability for their behaviors, and thereby confront thinking errors and a host of other criminogenic thinking - all a part of developing accountability.

But a central part of the treatment that I've learned to use is the "processing" (cognitively) of the abuser's police incident reports.

With a 52 session sentence, the processing is typically done about the halfway point when possible, about 26 weeks, but typically not before.

Up until that time, they will have seen other's process their police reports, have had significant time to participate and learn the different types of abuse and thinking errors associated with their abuse.  The actual processing consists of a time when the therapist reads the relevant parts of their police report and the victim's statements and the investigation out loud in the group.  The therapist will ask them to elaborate on their thinking at the time, how it impacted their victim, controlling behaviors through the report.

This is important for several reasons - one of the main being that this is often the first time in their lives where they haven't gotten to control what others hear about the offense and abusive behavior or how it's presented in its entirety - for those who have power and control issues and narcissistic tendencies and traits, this can be very critical to their growth and development.

But in addition to having it presented, it gives them a chance to demonstrate what they've learned in treatment about abusive behaviors, the impact on victims, and victim thinking, and apply it specifically to their own case and all aspects relevant to the expected outcomes of treatment.  It gives them a chance to be accountable, as well as for others who may be thinking that they are "different" to see the common patterns of abuse in a real-life setting beyond simply having material from a textbook or homework presented.  This experience is where senior-group members being accountable is an excellent modeling tool for those newer to treatment.

Additionally, as abusers often have a tendency to discredit others' views because they "aren't correct" or exactly the way they remember it they are therefore invalid and once again the abuser becomes the "victim" (another symptom of power and control issues).  Having the police reports with the different interpretations gives the abusers a chance to experience having to sit through listening to someone else's views and experiences without being able to change and control the narrative - as well as demonstrate accountability or even experience remorse as they will often add and share details that aren't in the reports.

Unfortunately, there are times when individuals may go to process their police report and may still be engaging in thinking errors and impression management.  Often with heavy and chronic substance use and abuse issues, or even simply lower functioning individuals, non-linear thinking or even attempts to avoid accountability with irrelevant details in an attempt to confuse others so as to avoid dealing with their behaviors is a common issue.

At this point I've found an invaluable tool in the clinic is a large (as large as I could find) white-board with dry erase markers (as many colors as I can find).  When I begin to hear signs and symptoms of unaccountability or attempts to avoid responsibility or even difficulties following linear thinking, I've found it helpful to begin writing their statements on the board for everyone to see (and even use different colors for different aspects/thoughts/issues).  This allows them the opportunity to see what they are saying and focus on accountable use of language, severely cuts down on the ability to deny or blame (or other thinking errors), but also have the relevant lessons applied to their thinking, or any contradictions spelled out right in front of them as well as for the rest of the group. 

But in addition to this, I've found that making a time-line of their accounts allows me to further pin down any inconsistencies or attempts to dissemble in group as well as get a better idea of where they are cognitively - and compare the timeline to the police incident reports - and it gives them a visual so that they can understand what they may need to focus on in order to make treatment successful for them.  Or, it can provide the therapist a visual as to why this particular treatment may not be effective for them (especially if they are still blaming the victim or resistant to treatment still) and they may need to be referred out try another approach (e.g. Moral Recognition Therapy) or why it may be recommended that their treatment be extended so they can learn the required principles from treatment to successfully graduate.

The processing of the police report can take multiple 90-minute sessions depending on what else needs to be addressed in the session or depending on the needs of the group. 

After the processing of the police report, a review of their self-reported abusive behaviors on the RAVEN/Violence and Abuse Inventory in their intake packet is performed with the group being asked to be able to identify how each of the acknowledged behaviors is a form of abuse and what type of abuse it is (i.e. emotional, blocking, physical, threats, intimidation, economic etc.).

As always, there is no silver bullet to develop accountability or even stop abuse.  However, most clients I have seen, who have reported feeling that their time in treatment is a success, state that the processing of their police reports, as well as the time to focus on them individually within the group and focus on their specific case and history were invaluable to them.  While the processing of the police report is a required part of treatment in the program I work in, the use of the white-board may be done on an as-needed basis, with the additional bonus that I can use what's on the board for my progress reports.

In the end, there are often sensitive parts in the police report that are not appropriate to share in group or may be irrelevant to their abusive behaviors (e.g. gender identity issues).  The processing of police incident reports, like most other practices in therapy, is something that's best learned from someone who has experience in making it a successful part of the treatment process and I wouldn't recommend it be done without it.  However, when it comes to client-based therapy and identifying issues central to their thinking and history, as well as identifying whether or not treatment is working or cutting through the issues for more resistant or difficult clients, the processing of the police incident reports combined with the use of the visual of the white board can be one of the more effective tools in developing accountability in treatment for domestic violence.

Why Domestic Violence Can't Be / Shouldn't Be Treated by Couples Counseling

(It is noted that there are female abusers, and I facilitate groups that are devoted solely to treating them, but for this entry the abusers are referred to as male and the victims as female).

In domestic violence relationships, the thinking often is that if they can work on something together as a couple, they can heal the marriage and relationship.  As a result, well-wishing friends and family, clergy, or even other mental health professionals who don't work with domestic violence may recommend marriage / couples' counseling.  Community groups may even facilitate couples education classes inviting disaffected couples in the hopes that they will be able to mend their relationships.  But few are actually skilled at handling abuse specifically and the knowledge that follows isn't generally known by the well-intentioned public. 

Unfortunately, couples counseling tends to have the opposite effect when domestic violence is involved, and actually has been recognized to put the victim at increased risk of harm, death and even divorce - divorce might not seem like a bad thing, except that victims are often financially dependent on their abusers, have limited support systems, and may not have the emotional ability or strength to simply transition out of an abusive relationship to providing for themselves and their children independently.  Additionally, separation or divorce can put her at risk of stalking, or even child abduction from the former partner or retaliation against others who help her.  When a victim leaves their abuser, their risk for harm and even death increases dramatically in retaliation.

The reality is that abusive behavior is the choice, actions and responsibility of the batterer.  Typically the thinking of the predominant aggressor in treatment is that they were responding to the abusive dysfunctionalities of their partner - i.e. they needed to engage in abuse to control her, her abuse was just as bad, they were both abusive so it's okay, they were out of control and therefore not responsible for their behavior, the alcohol or drugs made them do what they did, what they are doing isn't as bad as what their parents did and therefore what they are doing is okay, "this is just how the world operates" - any number of thinking errors that absolve the abuser from the fact that he made a choice to abuse. They are usually successful at convincing others around them that these are the case as well to build a coalition against the victim to sanction and justify the abuse.

Unfortunately, by the time domestic battery has taken place in the relationship, the abuser has spent a lot of time working to convince the victim that she is to blame for her abuser's behavior, and that she is partly responsible for being abused as well - and under the stress of the relationship, and as a victim in an attempt to feel some semblance of control in her life, and with high levels of codependent need to protect her abuser - the victim will begin to believe it also and lose a sense of her own reality and protections and fail to see the full scope of the danger she is in and what is happening to her.  The abuse becomes normal, and seemingly-less-severe abuse gets minimized against the backdrop of other more severe abuse, and then becomes tolerated, accepted and even expected.  Sometimes the victim will finally "snap" and retaliate against their abuser or try to provoke what she know is coming to have some sense of control and predictability in her world, or even try to defend themselves and then find themselves being arrested for battery.  This will be used to show that "she's crazy" and the abuser will then justify that he needed to protect himself from her and further destroy her psychologically for what's essentially an expected and unsurprising response on her part.

Combine this together in a counseling setting where a non-domestic-violence-therapist is going to be receiving input from the couple on what the issue is - the therapist isn't going to get a straight picture of what is happening in the relationship.  (More on this in a moment).

Additionally, the most common and yet devastating abuse a victim will endure is mental and emotional abuse and the actual physical component is the smallest part of the abuse cycle - less than 1% of the entire time she is being abused.  The physical violence tends to be the crowning event of abuse, and the rest of the time with various tactics being used to remind her of what could happen to her if she doesn't comply with his wishes (threats and intimidation). 

This being said, much abuse is actually invisible to the public or to friends and family - and it's designed to be.  Many abusers report "testing the waters" to find out how much they can get away with, and getting their abuse to have the maximum effect on their victims with minimum effort and they don't want to get caught and go to jail - so they become experts at hiding it or getting others to sanction it.  Many abusers have reported even being able to condition their victim so that he can shift in his chair in a certain way right in the middle of a crowded party such that he can send a message to her of "you know what's coming".  He can send a lot of his non-verbal clues when he's becoming angry that preceded her being harmed - i.e. breathing changes, playing with his ring, a certain look, cracking his knuckles....any number of things that as a victim (who is traumatized) has learned to recognize precede the abuse, and are going to have a devastating effect on her psychologically and even physically...and he gets away with it right in public - which achieves the psychological damage of isolating her right in front of friends and family where she can't even ask for help.  She would be labeled as "crazy" for identifying what he was doing, and him shifting in his chair isn't admissible evidence in court regardless that it's being used to send a message to threaten and intimidate, and is easily denied by the abuser - further devastating her that she's experiencing a nightmare and isn't believed.  Further the abuser will often cite that "it only happened one time" (you only have to experience trauma one time to develop PTSD) to further deny and minimize the impact of his behavior on her.

Which leads us back to the therapists couch and office as a couple.

Unfortunately, for the victim, sharing vulnerable thoughts and feelings usually put her at risk for all types of exploitation and abuse.  Many abusers will make a mental list of vulnerable feelings and issues so that he can harm her with them or embarrass her later - often in front of friends and family or children in an attempt to cut her off from social support or esteem, making it more impossible for her to ask for help.  This combines to actually make the therapist's office a very unsafe place for the victim - literally a physically and emotionally dangerous place for the victim.  Not just because she can be sharing emotionally vulnerable feelings, but if she expresses something the abuser doesn't like in the office about him or their relationship or her perceptions about the issues, he will often "make her pay" for it after the session, physically, sexually, or emotionally.   Even more, going back up to most abuse can be done in public and among friends and family, changing postures, a look, a glance, shifting in his seat and so on, can all be done surreptitiously right in front of the therapist and further abuse her without it even being caught further contributing to the experience of isolation and helplessness. Or if through the process of discussing her feelings, she begins to actually become agitated and share pent-up feelings in the session, the abuser will often make her pay the penalty afterwards for embarrassing him or "telling lies" in the session (or however he chooses to spin it).  Also remember, there are often children, pets and other family members involved in these scenarios who can also be at risk for various types of retaliation.

Abusers rarely admit the full scope of their abuse, and certainly aren't to be expected to fully disclose their abuse to a therapist, even if they are mandated to treatment and have been sentenced.  "Regular" clients rarely fully disclose their issues to a therapist, so it would be entirely unreasonable and unrealistic to expect someone with criminogenic thinking who is hiding their abuse to be transparent in an attempt to resolve an issue. This is one reason when treating clients, a copy of the police incident report for the instant offense is required so that the therapist can get something other than the abuser's minimized and uninsightful account of the events to work with.  It isn't going to be safe for victims to disclose issues either, and their perceptions are going to be distorted as a result of the abuse - so forming a regular "treatment plan" is likely to be inaccurate, harmful, and even be exploited by the abuser in terms of things she has to work on to please him and contribute to a relationship he's actively destroying.

When we're dealing with the high probability of even sexual abuse in domestic violence (accepted to be around 60%) - and the scope and spectrum of sexual abuse goes far beyond rape - even some couples' therapies that are aimed at intimacy / sex will further victimize the victim.  Sex is often used to cover up or make up for abuse, it may itsself be abusive, or may precede abuse.  Essentially, couples treatment is unsafe for the victim and becomes yet another place where the victim is further abused but now with the unwitting sanction of the mental health community who is "supposed to" be able to recognize and help these things.  

So what to do as a therapist when you discover or suspect domestic abuse in the relationship?

There are a few realizations that need to take place at this juncture.

First, this is where the therapist actually needs to be careful.   Going back to the fact that therapy is actually a dangerous setting for a domestic abuse victim - it's going to be important to avoid sanctioning the abuse by minimizing it, or, putting the victim at risk by setting up a conflict that can result in her being harmed or exploited after the session.  It is also important to realize you aren't going to be getting the full picture from the clients, and this issue is going to go much farther and deeper than the clients may admit or even realize for the reasons listed above.

Second, is realizing that this is not going to be solved as a couple.  The victim is not to blame for her abuse. She does not share responsibility for being abused, and she is not responsible for his behaviors.  She does not need to fix herself in order for him to stop abusing her - it's not her fault.  Most often, as abusers become accountable for their own actions, identify their own thinking errors, and behavior patters, become accountable to their partners and learn healthy communication patterns, and engage in the required mental health care, couples counseling is unnecessary.  Also, this is going to take years to straighten out the damage, mistrust and trauma.  My experience is that it can take 3-6 months for an abuser to begin to recognize / be accountable for the fact that he is actually abusing someone else, and another 3-6 months after that for him to begin to be able to articulate and recognize the abuse he has used in the past and that have become a part of his personality up to this point and its impact on his victims.  Even after that point victims may have a decade-plus or even a lifetime of healing to take place for them. 

The third is to recognize that forensics and dealing with criminal behavior is it's own specialty that requires years of training, exposure and experience for the clinician to begin to recognize the reality of what they are dealing with - just like any other specialty in mental health.  The clinician is going to be played by the abuser.  Many have told me of the delight they took in getting the clinician to side with them against their victim right in the therapist's office before they ever were held accountable by domestic batterer intervention.  Criminal thinking and manipulation is not one we are generally adept at identifying in our world to the nuance and degree which it is practiced by the abuser.  Recognizing not only that the therapy setting is dangerous for the victim, but that having a second or even third set of experienced and practiced eyes to help keep your clients safe is key and it might be necessary to terminate treatment, make another recommendation for treatment, or involve other agencies.  Remember also that the family is likely to have a distorted perception of what's taken place as well as a result of a number of reinforcing factors not the least of which is the spin that the abuser himself will put on the situation.  Even family members may have a vested interest in denying the abuse for a number of reasons (children may feel as though they are betraying the abuser and are especially vulnerable to retaliation).  When you come upon domestic violence, or suspect it is going on, as they teach us in school: Consult! Consult! Consult!  An experienced and skilled domestic battery counselor will not only be able to give a deeper perspective on how to evaluate the full scope of the issues and make recommendations on how to proceed with the clients as a therapist, but will also be familiar with community resources specifically devoted to the needs of the family / couple.

In the end, what I've described above is pretty depressing and may seem extreme and out of the ordinary, but unfortunately by the time offenders are sentenced to treatment, these histories and behaviors are more the rule than the exception and we don't want them to progress any farther.   We have to remember that "harm is harm" and "abuse is abuse" - there isn't really a hierarchical categorization of "good harm" or "bad harm", or "good charges and bad charges".   We need to be diligent, sensitive, thoughtful and have the client's best interests in mind as well as their and everyone else's safety.  At the first sign of abuse, we need to be taking the appropriate steps to protect our clients and gather information so we can respond as will be most beneficial to protect those who can't protect themselves.

But the bottom line is that domestic violence is not a couples' problem or marriage issue.  It should be consulted on, and if possible evaluated by a clinician specifically trained, experienced and skilled at handling and recognizing the dynamics of domestic violence and family abuse.

There's unfortunately no silver-bullet for stopping domestic violence, and despite our best efforts, we know much abuse is going to continue on behind the scenes and outside of our awareness.  But at the very minimum we need to do our best to make sure our own therapy isn't putting clients at risk, and make sure we are consulting, being informed and engaging in best-practice to help those we serve.