AN OUNCE OF PREVENTION: A MODEL

FOR WORKING WITH COUPLES AT-RISK

FOR BATTERING
Philip J. Perez
Kip Rasmussen
ABSTRACT: Literature on preventing spousal battering before it
starts is virtually non-existent. This article describes a prevention of
abuse program that targets couples at-risk for battering. At-risk cou-
ples and the process of engaging them in couples counseling are de-
scribed. The prevention model is based on a Bowenian approach that
focuses on partner differentiation and reducing emotionality and pro-
moting rational thinking. It is assumed that increasing differentia-
tion decreases the risk of spousal battering. The various techniques
used to facilitate differentiation are presented as well as a case exam-
ple illustrating a successful prevention of abuse experience.
KEY WORDS: domestic violence; violence prevention; couples therapy.
A story has it that a highway bridge spanning a gorge washed
away in a terrible storm. Before the bridge could be rebuilt, many
unsuspecting motorists plunged to ruin at the bottom. This alarmed
local townspeople so they stationed an ambulance at the bottom of the
gorge to provide more effective service for those who drove over the
edge. The townspeople soon realized that a warning barrier, blocking
the road to the washed out bridge, was a prudent investment of com-
munity resources.
Philip Perez, PhD, a marriage and family therapist residing at 17200 NW 64th
Avenue, Apt. 210, Hialeah, PL 33015, formerly was a resident at the Marriage and
Family Counseling Service in Rock Island, Illinois. Kip Rasmussen, PhD, is a therapist
at Whipple Heights in Rochester, Minnesota. Please address reprint requests to Dr.
Perez.
Contemporary Family Therapy, 19(2), June 1997
C 1997 Human Sciences Press, Inc. 229
CONTEMPORARY FAMILY THERAPY
Despite the improbability of this story, it illustrates the message
that prevention efforts can decrease pain and suffering by helping
people at-risk for injury. This kind of wisdom has not taken hold in
the current health care system's approach to spousal battering. It is,
however, an idea whose time has come.
Fifteen percent of married couples experienced at least one epi-
sode of physical aggression in the year preceding a 1975 National
Violence Survey (Straus, Gelles, & Steinmetz, 1980). The lifetime
prevalence rate of marital aggression was 30%. The findings of more
recent studies support these percentages (Straus & Gelles, 1986).
While research, professional literature, and intervention pro-
grams have historically focused on conceptualizing and/or treating
the batterers and their victims (Pagelow, 1984), published descrip-
tions of spousal battering prevention programs are almost non-exis-
tent. Spousal battering prevention has long been ignored by the
marriage and family therapy field. Large gaps exist in the conceptual-
ization, assessment, and treatment of these kinds of couples. This ar-
ticle attempts to fill these gaps and inspire researchers, administra-
tors, and clinicians to redirect their resources toward prevention.
Since 1992 Rock Island Marriage and Family Counseling Service
program has provided an experimental Prevention of Abuse Service
to the Illinois and Iowa Quad Cities community. The aim is to engage
at-risk individuals/couples demonstrating early signs of potential
abuse and provide education and counseling to prevent possible fu-
ture abuse. This article is a report of the these initial years of the
program and its conceptualization of at-risk couples, treatment goals,
therapeutic process, and techniques. A case example is offered to il-
lustrate a prevention success.
DEFINING THE AT-RISK COUPLE
Despite vast media attention and the growing number of studies
examining spousal battering, there are major conceptual gaps. O'Leary
(1993) suggests there are two forms of domestic violence: (1) mild/
moderate (e.g., restraining, grabbing, and pushing) and (2) severe
(e.g., choking, beating, and using weapons). Conditions and processes
by which batterers move between pre-abuse, mild, and severe forms
of violence remains unclear. The lack of longitudinal and process ori-
ented research has left preventionists groping in the dark.
Research has failed to examine the temporal relationships be-
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PHILIP J. PEREZ AND KIP RASMUSSEN
tween spouse battering and characteristics correlated with it; thus, it
cannot be established whether correlates are risk factors or merely
consequences of abuse (Sedlak, 1988). Until there is more empirical
evidence and clearer conceptual frameworks, we must assume that
spouses who move from psychological and interpersonal aggression
(e.g., intimidation, humiliation, and threats of violence) to mild physi-
cal violence are at-risk for inflicting more severe acts.
Spousal relationships refers to any couple, self-identified as such,
who are married, cohabiting, and/or recently separated. A couple is
diagnosed "at-risk" when at least one of two criteria are met: (1) a
pattern of aggressive arguments, coercion and conflict characterized
by humiliating, intimidating, and/or physically threatening state-
ments or behavior, and (2) a pattern of using "mild" forms of violence
characterized by throwing objects, pushing, and physical restraining.
ASSOCIATED FACTORS
Empirical research, delineating the correlates of spousal batter-
ing, is inconclusive and offers limited guidance for clinicians working
with at-risk couples. Predictive models for at-risk men and couples do
not exist in the therapy literature. Clinical observations and research
suggests, however, that battering couples often experience one or
more associated factors. These associated factors are: alcohol/drug
abuse (Miller, Downs, & Condole, 1989: Kantor & Straus, 1987; Neff,
Holamon, & Schluter, 1995; Gelles, 1993), financial stress (Pagan,
Barnett, & Patton, 1983; Gelles & Straus, 1988), marital stress
(Gelles, 1974: Rounsaville, 1978, Steinmetz, 1978; Leonard & Blane,
1992), low sex-role egalitarianism (Yllo, 1993; Grossman, Stith, &
Bender, 1990), beliefs that violence in relationships are acceptable
(Crossman, Stith, & Bender, 1990; Stith, 1990), and observed domes-
tic violence as a child/adolescent (Arias, 1984; Rosenbaum & O'Leary,
1981; Rouse, 1984; Telch & Lindquist, 1984). At-risk couples often
present with one or more of these associated factors.
IDENTIFYING AT-RISK COUPLES
Currently a majority of the couples participating in the program
are heterosexual, white, middle-class or working class, with one or
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CONTEMPORARY FAMILY THERAPY
more episodes of the man using highly coercive behavior or "mild"
violence to control the woman and/or the mutual use of coercive behav-
ior or "mild" violence. Rarely have participants in the program been
involved in violent criminal behavior outside the couple relationship.
Participants are either referred to the program by other health
care providers or targeted for prevention after clinical assessment
and evaluation at our counseling center. Participants seldom refer
themselves to the agency self-identified as at-risk for spousal batter-
ing. However, widespread media coverage of partner violence has
helped some couples recognize warning signs and seek help for other,
seemingly less stigmatized reasons,.
An assessment is conducted to determine the level of risk. Cou-
ples targeted for prevention services are not subjected to a formal
admission process. No special fees are applied other than the agency's
sliding fee scale.
ENGAGING AT-RISK COUPLES: MEDIA OUTREACH
The program utilizes media outreach to inform local communities
and health care agencies about the warning signs of abuse and the
Prevention of Abuse Program. Prevention services are offered by a
non-profit, United Way sponsored agency operating in the community
for over 25 years with access to several newspapers and television
news programs. Each year, the prevention program director makes
contact with columnists and news program directors regarding the
program, its goals, methods and techniques, as well as who will be
staffing the position.
Media reports include, among other things, statistics derived
from nationally representative samples, such as the fact that 11-12%
of women experienced some form of physical aggression from their
partner within the previous year and that 50-60% of women seeking
marital therapy report some degree of violence in their relationship
(O'Leary, 1993). The spokesperson clarifies the prevention role of the
program by differentiating it from local domestic violence services
that focus on stopping moderate and severe violence. The aim is to
complement and not overlap existing local domestic violence services.
The program is staffed each year by a doctoral student with at
least three years of previous therapy experience. This resident is des-
ignated as the prevention of abuse specialist who is given all abuse
prevention cases as they are referred, self-referred, or discovered dur-
ing assessment at the center.
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PHILIP J. PEREZ AND KIP RASMUSSEN
FAMILY SYSTEMS THINKING AND
POTENTIAL BATTERING
Research and clinical observation suggest that manifestations of
gender inequality trap women in abusive relationships and support
male battering (e.g., Stith & Farley, 1993). Traditionally, family ther-
apy has ignored gender inequity contributing to power imbalances
(Avis, 1992; Bograd, 1992). Pure family systems thinking suggests cli-
nicians "see past the symptoms to the underlying emotional process"
(Kerr & Bowen, 1988, p. 151). The recursive nature of interactions
and their "underlying emotional processes" are emphasized; cause
and effect (i.e., fist hitting face) and personal responsibility are de-
emphasized and/or minimized.
Our program addresses the issues of power/gender inequality by
integrating systems and cause and effect perspectives. They coexist
pragmatically as a both/and relationship. This means cause and effect
realities, such as the potential for physical harm, frame the systemic
nature of couple relationships. Once safety, and the personal respon-
sibility necessary to ensure it are established, clinicians can then pro-
ceed to "see past the symptoms." This blending of systems and cause
and effect perspectives filters into our interpretation of differentia-
tion. Highly differentiated partners possess an emotionally neutral
sense of personal responsibility. For example, unhooking oneself emo-
tionally from a partner's aggressive behavior does not mean one is
condoning the behavior. In fact, it frees the potentially battered part-
ner to rationally explore options to maintain physical safety and non-
violence in relation to an abusive partner.
CORRECTING POWER IMBALANCES
At-risk couples with power imbalances often resist changing rela-
tionship patterns to correct them. Male partners fear the loss of
power, control, and role certainty. Female partners either minimize
their partner's emotional abusiveness, experience fear of physical ret-
ribution and/or other barriers to leaving the relationship (e.g., mini-
mal financial resources, limited social support network, child care
responsibilities, social stigma associated with battering, and/or psy-
chological dependency).
When correcting power imbalances, clinicians balance a respect
for the couple's cultural values and autonomy to make their own deci-
sions with a responsibility for providing safe, effective treatment. To
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CONTEMPORARY FAMILY THERAPY
achieve this, a "holding environment" is established to help couples
experiment with new ways of thinking, feeling, and behaving. The
therapeutic context is firm, safe, and sensitive.
A value free therapeutic stance is not possible or desirable for
prevention work. The battering literature suggests that a shift in
values is necessary for perpetrators and victims of violence (Claes,
Connolly, Daniel, & Engel, 1992). For example, perpetrators need to
move from entitlement to mutuality, from holding one's spouse/part-
ner responsible for their acts/words to taking responsibility for one's
own words and actions, from denying one's own regret and grief to
owning feelings related to abuse. Similar value shifts are encouraged
when working with at-risk couples to begin shifting power imbalances
and attaining lower levels of aggression.
Because moderate/severe violence has not occurred, at-risk part-
ners sometimes deny the risks associated with their relationship ag-
gression. In those cases, it is important to raise awareness and create
some leverage to motivate partners toward change. This often can be
found in family values, egalitarian religious/spiritual beliefs, concern
for their children, or concern for other people they hold in high regard.
Resistance is managed by exploring the couple's anxieties, fears,
and anger about changing roles and values. Partners are encouraged
to acknowledge and own emotions, which can be intense at times.
Each partner's unique experience of change is affirmed. As power im-
balances are corrected, a grieving process often occurs. Letting go of
old relationship patterns often leaves partners feeling "out of sorts" or
"sad."
Because of the nature of at-risk couples, recommendations to end
relationships are rarely necessary to correct power imbalances and
ensure safety. If prevention efforts do not reduce aggression,, or vio-
lence occurs, a referral to domestic violence services is made. Couples
therapy is stopped but work is continued with individual partners to
help them transition into their perpetrators and "victims" groups. We
have found that prevention work makes both partners more likely to
use domestic violence services by laying the conceptual groundwork
and demystifying and destigmatizing the programs.
PREVENTION TREATMENT PROCESS
Couples typically participate in weekly, one hour-and-fifteen-
minute sessions. The number of sessions can range from one to as
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PHILIP J. PEREZ AND KIP RASMUSSEN
high as 50 but the average is eight to 10. A successful prevention
experience consists of three phases: (1) assessment and diagnosis, (2)
linking prevention efforts to presenting problems, and (3) treatment
through facilitating differentiation.
Assessment and Diagnosis
Individual interviews. The first step in prevention is accurate as-
sessment and diagnosis. Couples not specifically referred to the pre-
vention of abuse program must be screened for abuse potential. We
instruct couples that on average a two-to-three session assessment
phase is necessary after which a treatment contract (usually verbal)
is negotiated. Assessment begins with explaining the therapeutic
boundaries. Couples are verbally instructed and given a written
handout explicating confidentiality, duty to warn, mandated report-
ing of child abuse/neglect, informed consent, and emergency services.
Clients are instructed that violence against a partner is an assault
which initiates a referral to domestic violence treatment.
Clinicians employed in the program are systems oriented and
typically work with partners in the same room. However, during the
assessment phase, partners are interviewed separately for the pur-
pose of eliciting their level of emotional and physical safety. Individ-
ual time is necessary because of the limitations of assessing violent
behaviors and/or coercive couple dynamics in the presence of an in-
timidating, physically threatening partner (Saraenow, 1995). Inter-
viewing partners in the presence of their offender can be like Red
Cross workers interviewing prisoners of war in the presence of their
captors (Kaufman, 1992). Questions are asked such as: "Have any of
your arguments deteriorated to the point of pushing, hitting, holding
down, restraining, or preventing someone from leaving the situation?
Think about the worst argument you had with your partner, how did
it start? Then what happened?"
As in cases of sexual abuse, if therapists do not ask, clients will
generally not mention it on their own (Kaufman, 1995; O'Leary,
1993). Individual interviews are a critical component in understand-
ing the level of coercive behavior, and the risk of escalation of symp-
toms. Clients are instructed that periodic individual interviews may
be used to assess treatment progress.
Evaluating the cycle of tension. One diagnostic indicator is the
presence of a "cycle of violence" process (Walker, 1983). We assume
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CONTEMPORARY FAMILY THERAPY
that at-risk couples do not have defined "cycles of violence," however,
aggressive arguments follow similar patterns of those identified in
violent couples. With at-risk couples, we call this the "cycle of ten-
sion." This cycle is diagrammed below:
Tension > Coercion/Blowup - Contrition/Honeymoon
In exploring this cycle, the focus is understanding the couples'
unique expression of it and how it has become entrenched in their
relationship (Pagelow, 1984). Typically, the cycle is reinforcing be-
cause of the associated release of tension and seductive contrition/
honeymoon phase. External stressors, conflict avoidance, and/or poor
conflict resolution also serves to fuel the cycle. In this way, heated
arguments become mechanisms for tension reduction and intimacy
modulation, rather than a more differentiated, less emotionally reac-
tive problem resolution and negotiation process.
Warning signs of abusive control. Another diagnostic task is eval-
uating the level of control, usually of the male partner over the fe-
male partner. Samenow (1995) suggests abusive men experience a
need to control some aspect of their lives and this need is often fueled
by an extreme emotional dependency on the female partner. To cover
their dependency or seek to keep the dependency operative, they in-
timidate or dominate the person they ostensibly love and/or depend
on the most. This pattern also often exists in at-risk couples.
Abusive control includes behaviors such as a demanding or coerc-
ing interpersonal involvement and/or sex, extreme jealousy, and pre-
occupation with unfaithfulness, interrogating, checking or stalking
the partner, restricting contact with others, and dictating dress or
personal preferences. Coercive ultimatums such as "If you do or don't
do , then I'll " Threats of violence toward inanimate objects
or animals are also signs of abusive control. These behaviors are po-
tential precursors of spousal battering.
LINKING PREVENTION EFFORTS WITH
PRESENTING PROBLEMS
At-risk couples who enter therapy but are not self-identified as
at-risk and/or have problems they feel take priority over at-risk is-
sues have certain expectations about therapy. For such couples, clini-
cians must understand each partner's expectations, conceptually inte-
grate prevention efforts, and negotiate a treatment plan.
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PHILIP J. PEREZ AND KIP RASMUSSEN
One or both partners may not be customers for prevention work.
Minimizing and rationalizing the impact of aggression and abusive
control indicates a failure to take responsibility for ones actions and
an ambivalence toward stopping the behaviors. Ambivalence is con-
fronted by clarifying expectations for therapy, finding unique motiva-
tions for change, and negotiating a treatment contract that includes
an integration of presenting problems and abuse prevention.
Each partner may have unique interpersonal and intrapersonal
links to aggression. It is assumed, because of the interdependent na-
ture of individual, couple, and family functioning, that aggression can
be linked to most presenting problems on one systems level or an-
other. Negotiation of a treatment plan requires the therapist to illus-
trate the relationship between the presenting problem and prevention
efforts.
THE PREVENTION APPROACH:
FACILITATING DIFFERENTIATION
Treatment Goals
The prevention model is based on a technically eclectic Bowenian
(Kerr & Bowen, 1988) approach which assumes that increased differ-
entiation reduces the risk of battering. At-risk couples are encouraged
to "differentiate" (Kerr & Bowen, 1988) to inoculate themselves
against coercive interactional patterns and physical aggression. Pre-
vention objectives emphasize: (1) increasing differentiation which in-
cludes: reducing emotionality, increasing rational reasoning and per-
sonal responsibility; (2) increasing the perception of choices; and (3)
helping partners integrate the value that physical aggression within
families is unacceptable (Hansen & Goldenberg, 1993).
Differentiation is defined as a process of partially freeing oneself
from the emotional chaos of one's family and family of origin (Guerin,
Fay, Burden, & Kautto, 1987), thus reducing emotionality and reac-
tivity and increasing rational thinking. Becoming differentiated re-
quires analyzing one's own role as an active participant in relation-
ship systems, instead of blaming problems on everyone but one's self.
A partner's "adaptive level of functioning" is the ability to continue
rational functioning in the face of stress. It is the capacity to make a
conscious effort to be objective and behave rationally in the face of
pressures of emotionality (Nichols & Schwartz, 1991). At-risk couples
have a diminished capacity to balance their thinking and feeling (in-
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CONTEMPORARY FAMILY THERAPY
trapersonally and inter-personally) when experiencing intense differ-
ences or "hot topics." The degree to which partners can maintain this
balance determines their level of differentiation.
Facilitating differentiation starts with the development of a geno-
gram which includes: (1) placing associated factors and aggression in
the context of the couple and multigenerational system, (2) identify-
ing central symptomatic relationship triangles, and (3) helping part-
ners detriangulate to reduce intrapersonal emotional arousal and in-
terpersonal reactivity.
Relationship triangles are found when a two-person relationship
seeks to resolve its tension by attaching to someone who is emo-
tionally detached. Once the other is triangulated the twosome bring
their relationship back into equilibrium but the third person is at-risk
to develop an uncomfortable outsider position. She or he then may
become symptomatic in order to maintain triangulation.
"Detriangling is probably the most important technique in family
systems therapy" (Kerr & Bowen, 1988 p. 150). It starts when part-
ners recognize relationship triangles. This requires adopting a sys-
tems perspective that fosters a more emotionally neutral position,
which frees up psychic energy for rational thinking which in turn pro-
motes less reactive, emotionally charged behavior. It does not mean
partners are being wishy-washy about boundaries around violence
(Kerr & Bowen, 1988).
TECHNIQUES
The art of this program lies in the therapist's ability to know
which approach best facilitates a couple's journey toward increased
differentiation. A directive approach educates, suggests, challenges,
confronts, and explains. A nondirective approach utilizes active lis-
tening, affirming strengths, and circular and solution-focused ques-
tioning. Differentiating simply as a technique offers little chance that
a therapeutic maneuver will accomplish its intent (Kerr & Bowen,
1988). All techniques are embedded in a larger Bowenian framework
that focuses on helping partners balance emotionality and rationality
in their significant relationship triangles. However, techniques are
sometimes used strategically. For example, behavioral contracts and
unpacking arguments are developed to lower anxiety and, thus, cre-
ate a less reactive relationship atmosphere that is more conducive for
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PHILIP J. PEREZ AND KIP RASMUSSEN
detriangling work. How techniques are used reflects the both/and re-
lationship between systems and cause and effect perspectives.
Genograms
Genograms, family diagrams that record and codify information
about family members and their relationships over at least three gen-
erations (McGoldrick & Gerson, 1985), are used in our program to
organize family data so partners can begin to understand their poten-
tial for abuse and create a systemic perspective which helps to track
family issues through space and time. Genograms help couples see
the larger picture, both currently and historically. Information about
structure and function can be viewed both horizontally across the cou-
ple and vertically through the generations. (McGoldrick & Gerson,
1985).
We regularly use genograms to chart intergenerational structure
and illuminate how parents, grandparents, and proximal relatives
dealt with emotions such as anxiety, affection, and anger/rage. Cou-
ples are encouraged to compare their handling of emotions to that of
their family of origin and extended family. Associated factors such as
sex roles, observation and approval of family violence, alcohol abuse,
and marital and financial distress are identified and explored in
terms their associated myths, rules, and beliefs. Genograms external-
ize emotionally charged family processes, reduce anxiety, lessen emo-
tional arousal, and foster rational observation.
Using Analogy
We have found analogies to be a powerful tool in helping couples
understand and confront shameful, embarrassing, and anxiety pro-
ducing relationship dynamics. Emotionally, it helps people connect
with their disowned feelings and processes and provides a scene or
story which couples can use as an emotionally "safer" way to ratio-
nally discuss explosive interpersonal dilemmas. It is also used to re-
frame feelings, interactions, events, and so on.
For example, the popular film The Wizard of Oz has been used to
illustrate how vulnerability and insecurity are often hidden behind
displays of aggression. We invited a couple to consider one particular
scene in the movie where Dorothy and her entourage confront the
"almighty Wizard of Oz" and discover a fearful individual who is des-
perately trying to manipulate others to preserve his fragile sense of
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CONTEMPORARY FAMILY THERAPY
efficacy. Partners' intimidation, threats, and aggression are subtly
framed as evidence of weakness and cowardice. The male partner was
encouraged to describe what is threatening about the female part-
ner's position and visa versa.
Male aggression toward women is often used to define masculin-
ity and maintain control. This analogy helps reframe masculinity and
challenge underlying attitudes, beliefs, and attributions associated
with low sex-role egalitarianism.
Analogies can reflect past, current, or future ways of relating.
They can be elicited from couples, co-constructed, or presented in a
psychoeducational manner. Analogy should resonate with partners in
ways that clarify, simplify, and connect individual and relationship
dynamics.
Unpacking an Argument
Aggressive arguments are "unpacked" to emphasize their recur-
sive nature and clarify and critique the unworkable premises about
gender and power that underlie dangerous relationships. (Goldner,
Penn, Sheinberg, & Walker, 1990). It is assumed that "abusive rela-
tionships exemplify, in extremis, the stereotypical gender arrange-
ments that structure intimacy between men and women generally"
(Goldner, Penn, Sheinberg & Walker, 1990, p. 343). A couple's aggres-
sive escalation and cycle of tension contain many highly condensed
triggers rooted in contradictory family of origin/parental loyalties re-
lated to gender.
For men, we look for oscillations between "feminized" devotion
and "macho" domination which characterizes the stance of abusive
men. We assume that women form a sense of self, self-worth, and a
feminine identity through their ability to build and maintain relation-
ships with other. Independent aspirations and attempts to differenti-
ate and separate are often labeled as destructive or crazy. For women,
we attempt to co-construct an explanation for their getting "caught"
in an aggressive relationship.
The contrition and redemptive phase of a couple's cycle of tension
is quite powerful. Goldner and colleagues (1990) assert that for abu-
sive relationships, the redemptive moment in a couple's cycle is as
complexly structured as the violent tide that produced it. Both parts
of this cycle must be deconstructed, their elements unpacked, and cri-
tiqued. It is assumed that a very similar process is necessary for at-
risk couples.
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PHILIP J. PEREZ AND KIP RASMUSSEN
The therapist deconstructs both phases of the couple's cycle. Spe-
cifically, we listen for unworkable gender premises and paradoxes as
well as memories of past and present relationships leading up to the
coercion/blowup phase. Questions are asked, often using client termi-
nology, to elicit meanings and ideas that had been disconnected from
one another and from the overwhelming affects that overtake part-
ners in the heat of their arguments. The family genogram is used to
explore the relational politics and how each partner constructed his
or her gender identity. This helps partners begin to understand the
messages they received about masculinity and femininity. In addition,
we ask partners to deconstruct the progression through anger. Ques-
tions are asked like, "Where in your body do you first feel the tension?
Do you think your partner knows about this tension?" An immediate
goal is to slow down and clarify the anger-building process fueled by
the improbable gender premises and gender paradoxes. The intent is
to increase intrapersonal and interpersonal awareness and develop
options that help to directly master their emotionality.
This technique helps partners calmly step back and look at the
process of their arguments so they begin to understand themselves
and each other and recognize intrapersonal and interpersonal di-
lemmas that fuel emotional escalation. This is often the groundwork
for stopping provocative actions and increasing self-control and per-
sonal responsibility.
Time-Out
Time-out techniques imply that during escalating arguments
partners have the right to stop action to cool emotions and stop ag-
gressive communication. If necessary, it permits partners to physi-
cally exit the interaction after calling time-out. Either partner has
the right to exit the interaction if: (I) they feel themselves losing emo-
tional control and rationality and/or (2) their partner is losing emo-
tional control and rationality. If a partner calls time out, he or she is
responsible for setting a time to initiate a resumption of the discus-
sion when emotionality is decreased. Physically restraining partners
calling time outs is forbidden. Couples are instructed about the mis-
use of time outs such as failing to initiate a resumption of discussion
or abandoning the other partner.
The success of this technique often depends on the couple's ability
to self-monitor their arguments and catch themselves early in the es-
calation. This typically requires in-session practice such as role-play-
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CONTEMPORARY FAMILY THERAPY
ing. Partners learn an interpersonal option that facilitates personal
responsibility and control over anger and communication.
Solution-Oriented Techniques
Solution-oriented questioning focuses on intrapersonal and inter-
personal strengths and successes. To set goals and envision the fu-
ture, we ask: "If you get your relationship on track, so that it is work-
ing well for the both of you, what will you notice is different?" (Claes,
Connolly, Daniel, & Engel, 1992). Scaling questions (e.g., "How angry
did you feel on a scale of one to 10?") are used to identify incremental
changes in ability to communicate, levels of emotionality, and feelings
of safety (O'Hanlon & Weiner-Davis, 1988).
Couples are asked to notice exceptions, the times when they man-
age to argue nonaggressively. We ask questions such as, "What hap-
pened that day? Where were you? What was different, what was simi-
lar to previous arguments? What does it say about your relationship,
that he can tell you about this and you can listen? What was the
difference that made a difference? Did your children notice that you
two are doing things differently? What might they notice?"
We also use Claes and associates' (1992) solution-oriented ques-
tions for assessing alcohol and other associated factor's roles within
the couple relationship. For example: "How does alcohol relate to your
giving away control of your anger? When you change your drinking
pattern, how will your life be different? If I run into you a year from
now, and your marriage is less aggressive, happy and feeling support-
ive for both of you, what will your beliefs about physical aggression
be? How will they have changed?"
Solution-oriented questions are used to build personal respon-
sibility. For example: "It sounds as if she is pushing your buttons.
How do you give her control over your buttons? Are there times when
you keep control over your own buttons? How do you do it? Where did
you get the courage to admit that the violence was your own doing
and not someone else's fault?"
Behavioral Contracting
The three most common contracts created for at-risk couples are
"no-harm," "in-house," and "out-of-home" therapeutic separation. All
are used to structurally facilitate differentiation by creating and clari-
fying mutually agreed upon interpersonal boundaries. It is assumed
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PHILIP J. PEREZ AND KIP RASMUSSEN
structural changes decrease emotionality by creating space and time
for partners to reflect on their process.
No-harm contracting spells out mutually agreed upon verbal,
non-verbal and behavioral aggression triggers for both partners and
how to respond to them. Using previous work with individual inter-
views, genograms, and mapped arguments, partners negotiate with
the clinician the terms of the contract. Verbal and behavioral aggres-
sion is operationally defined and a "safety plan" developed. The
"safety plan" delineates community, family, and legal resources in the
event of violence.
In-home and out-of-home therapeutic separation contracts spec-
ify duration and locations of separation, frequency of conjoint and/or
individual therapy sessions, frequency and nature of contact with
partner, boundaries around sexual contact with partner or others,
contact with children, financial arrangements, commitment to com-
pleting homework assignments, and the contract duration. Terms are
mutually agreed upon, put in writing, and signed by both partners
and the therapist. Couples are instructed that fine tuning the con-
tract is often necessary during the first week or two.
We have found these separation contracts to be powerful inter-
ventions when couples can tolerate the anxiety associated with in-
creased personal responsibility and autonomy. It is assumed that
partners press or cross the boundaries of the contract to "medicate"
the emotional intensity of increased differentiation. Clinicians pro-
cess these contract violations and contract adherence with the couple
in a way that illustrates healthy and unhealthy relationship interde-
pendencies. For example, we ask circular and solution-oriented ques-
tions such as: "Of the both of you, who will be most likely to initiate a
pressing of the contract boundaries next time? Why do you think your
partner 'takes the bait' and follows your lead in the pressing of
boundaries? How did you manage to not call your partner more than
twice this week? What was different this week that helped you to
stick to the contract? How do you know when violations of the con-
tract are unavoidable or regression back to 'old behaviors'?''
TREATMENT EVALUATION
Successful prevention occurs when prevention treatment goals
are met sufficiently. One important marker of progress is a couple's
ability to consistently handle their differences (e.g., gender, family of
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CONTEMPORARY FAMILY THERAPY
origin, personality) and stressors (e.g., financial and career) in a non-
aggressive manner. Partners demonstrate greater ability in avoiding
reactivity and maintaining rationality during the other partner's
emotionality.
Therapist observation and client self-report are used to assess
progress. An important marker of successful treatment is elimination
of verbal and behavioral aggression. There is less reactivity and more
physical and emotional safety when the partners are engaging in
open conflict or asserting needs. There is new confidence in communi-
cating, problem solving, tolerating differences, and overall marital
satisfaction.
Couples appear less tense, more relaxed and open. Complaining
is reduced, and sessions tend to become less intense or even some-
what awkward. If other individual or relationship problems continue
to exist or emerge in therapy, goals are renegotiated or couples are
referred to the appropriate professional.
CASE EXAMPLE: CINDY AND KENT
Cindy, 24-years-old, and her husband Kent, 25-years-old, re-
ferred themselves for marriage counseling. They had dated for one
year, been married for three, and had two children Michael, three-
years-old and Marc, ten-months-old. Both spouses are white, fourth
generation Americans from European descent. Cindy is a clinical sec-
retary for a psychiatric unit at a regional hospital and Kent works for
a construction firm as a semi-skilled laborer.
Cindy arranged for a marriage counseling session several days
after she and Kent had an explosive argument about family finances.
Since the argument, Kent had been staying with his brother and sis-
ter-in-law. Both Kent and Cindy had abused alcohol and experi-
mented with drugs as teenagers but denied any problems with alcohol
currently. Kent had three beers the night of the argument.
As the argument escalated Kent felt the need to leave the house
and started for the door. Cindy, familiar with Kent's tendency to
abandon her in the middle of arguments, attempted to block his exit.
Kent grabbed Cindy's arm and pulled her away from the door slam-
ming her against the refrigerator. Kent took off to a local bar in a
rage while Cindy remained in the house trying to calm their ten-
month-old child who had been disturbed by the incident.
244
PHILIP J. PEREZ AND KIP RASMUSSEN
Assessment and Diagnosis
During the initial session, the therapist asked about the events
that caused them to seek therapy. Cindy responded by describing the
above incident. Kent confirmed her interpretation and added that he
did not want to return home until there were improvements in the
relationship. Cindy wanted him home and feared losing him to an-
other woman. Both expected therapy to help them come to an agree-
ment about parenting, sex/affection, and finances that would then re-
duce incidents similar to the one experienced the previous week.
Each partner was seen for approximately 15 minutes individu-
ally. The goal was to collect more detailed information about each
partner's experiences within the marriage. This included understand-
ing the frequency, intensity, and interactional aspects of their argu-
ment, current risk of physical aggression and appropriateness for cou-
ples therapy.
During her individual time Cindy reported that the last argu-
ment was the most physically aggressive of their relationship. She
reported one other mutually aggressive incident when they were dat-
ing and at a party. Cindy has a substance abusing sister and an ac-
tively alcoholic mother whom she witnessed being physically abused
by previous spouses. Her mother was currently living with her fifth
husband.
Cindy was fearful of Kent's anger, and physical intimidation
when he was standing up, raising his voice, and pointing his finger in
her face. However, she asserted, "I'm not a battered wife or anything
and I will not back down when he gets that way." The latest incident
did scare her and was interpreted as an indication that the relation-
ship was deteriorating. Reportedly, Kent was "good with the kids"
and reported three episodes where Kent slapped the children on their
buttocks.
During his individual session Kent admitted that pushing Cindy
was wrong. He refused to return home until the risk of arguments
deteriorating to that level was eliminated. His father abused alcohol
and was described as "bossy," "hard to get along with," and "domi-
neering." His mother was described as "saintly," "quiet," and "giving."
He reported being physically disciplined by his father but denied wit-
nessing his father being physically abusive with his mother.
During their individual sessions both Cindy and Kent reported
the risk of physical aggression was minimal at that time. Neverthe-
less, the presence of several associated factors and patterned use of
245
CONTEMPORARY FAMILY THERAPY
verbal and physical aggression supported an. at-risk diagnosis. The
couple was brought together to wrap up the initial session. Three con-
tracts for alcohol use, out-of-home separation, and physical aggres-
sion were presented. The contracts were described as necessary rules
or boundaries for the couple to be permitted to be involved in conjoint
counseling.
Cindy became tearful about the out-of-home separation contract
and Kent not returning home that evening. Kent protested mildly
about the restrictions on drinking but agreed to commit to the con-
tract. Both partners were in agreement about the no-harm, physical
aggression contract. In fact, they thought that would be the easiest to
maintain. The therapist asked the couple to take home the generic
separation contracts and "really consider whether they wanted to
commit to couples counseling."
Linking Aggression to Presenting Problems
The second interview debriefed the couple about their concerns
and questions with the contracts. As with many couples, they were
curious about the therapist's rationale for the contracts and its rele-
vance to presenting problems. The therapist illustrated on a wall
board how some relationships have emotional thresholds similar to
boiling points. To address their distressing communication, financial,
and partner differences, they needed to first turn down the thermo-
stat of the relationship. Finding the right temperature, not too hot
(e.g., past the emotional threshold, aggression) or not too cold (e.g.,
partners drift apart, no passion) was the first step. Both partners
agreed wholeheartedly.
The contracts were described as training wheels, transitional
tools to move partners to more advanced tasks such as learning new
ways to communicate and handle differences. Partners were encour-
aged to find a healthy and safe "temperature" in their "house'Yre-
lationship before moving on to more advanced "renovations'/skills
building. The couple committed to the contracts and eight weekly cou-
ple counseling sessions with periodic individual sessions to evaluate
treatment progress.
Treatment Approach: Facilitating Differentiation
For three sessions the couple maintained the behavioral con-
tracts sufficiently while working on developing their genograms. Ge-
246
PHILIP J. PEREZ AND KIP RASMUSSEN
nograms revealed multigenerationai, symptomatic triangulation for
both partners. There was strong evidence both "acted out" (e.g. alco-
hol/drug abuse, promiscuous sex, decreased school performance) as
teenagers as part of parental triangling to cope with anxieties over
distressed marriages. Genogram work and its systemic emphasis
helped the couple examine their behavior with a more emotionally
neutral attitude. This was the beginning of their detriangulation pro-
cess.
Initially, Kent interpreted genogram work as a blame game and
being disloyal to family members. While exploring these interpreta-
tions, feelings of embarrassment and shame about the depth and
breadth of conflict in their families was uncovered. The couple were
reassured that these feelings were "normal" and praised for their
ability to recognize them. Their poorly differentiated relationship
with their family of origin was slowly being challenged. The de-
triangulation process was beginning.
Kerr and Bowen (1988) suggest that "effective detriangling is
contingent not only on achieving a way of thinking or attitude of emo-
tional neutrality, but also on the ability to communicate that attitude
effectively" (p. 151). However, communicating a differentiated posi-
tion can be difficult if not impossible for families experiencing high
anxiety (Kerr & Bowen, 1988). This was the case for Kent and Cindy
for several sessions.
Anxiety levels were still high despite the separation contract and
genogram work. They escalated quickly over seemingly insignificant
issues, the couple being unable to control the intensity of their argu-
ments. Arguments were feared and avoided which led to a "walking
on eggshells" atmosphere. The couple were encouraged to map an ar-
gument in session to continue turning down the relationship "heat."
The session ended with the therapist instructing the couple to
notice, during the next week, those times when they are able to con-
trol the escalation of an argument. A handout was distributed to each
partner to help them collect "facts" about the controlled argument.
The handout contained questions and phrases such as, "Topic of argu-
ment. Place of argument. Who was around? What happened that day?
How did you feel when it started? What helped prevent an escala-
tion?"
Several sessions focused on the process of their "good" argu-
ments. Arguments were scaled from one to 10, one being the least
intense, 10 being the most intense. Communication skills were devel-
oped and fine-tuned. For example, the couple developed code phrases
247
CONTEMPORARY FAMILY THERAPY
to orient themselves during conflict. Cindy communicated to Kent
that his raised voice was reaching threatening levels by saying "I
have to go to the Chiro." Kent let Cindy know he needed space and
time to cool down by saying "I'm going to call Denny."
Emotional intensity began to gradually decrease during conflicts.
Partners became increasingly aware of their role in avoiding emo-
tional escalation. They experienced confidence in their ability to con-
trol emotionality and reduced their anxiety to levels conducive for de-
triangling efforts. To initiate this process, the therapist refocused the
couple back to genogram work.
Effective and efficient detriangling is facilitated through eliciting
experience and encouraging self-discovery. It requires the therapist to
avoid instructing/enlightening partners about what she or he thinks
they are doing (Kerr & Bowen, 1988). Therefore, the therapeutic
approach became less directive in order to accommodate the de-
triangling process. As the couple's ability to think systematically in-
creased, treatment moved toward discovering ways (verbally and non-
verbally) for detriangling their significant relationships.
An argument was unpacked to initiate the detriangling process.
The exercise revealed that during their most recent violent episode
Kent raised his voice in response to a perception that Cindy was un-
willing to give him space. He felt as if he were being treated like a son
rather than a husband. He backed Cindy off with aggression to seem-
ingly to avoid the threat of losing his sense of being masculine. Cindy
frightened and threatened by Kent's raised voice, believed that "stand-
ing up to him" was the only way to remain safe. Mutual defensiveness
caused an escalation that ended in Kent yelling the loudest, pushing
Cindy, and leaving the home.
A "run in" Kent had with his father helped highlight the gender
premises and gender paradoxes under which he was operating. He
revealed a conflicted relationship with his father and fused relation-
ship with his mother. As far back as he could remember, his parents
had maintained an emotionally distant marital relationship during
which he became mother's confidant and protector and his father's
sparring partner. His relationship with his mother was a covert coali-
tion of sorts. Being too close with her exposed him to the risk of being
labeled a "moma's boy," but he had to protect "mom" and be her "little
man."
To further enhance the detriangulation process several sessions
focused on helping Kent clarify the gender premises and paradoxes
and move toward a less conflicted relationship with his father and
248
PHILIP J. PEREZ AND KIP RASMUSSEN
stronger boundaries with his mother. His ability to resist the pres-
sures to triangulate with his parents helped Kent to be more of a self
(balancing emotionality and rationality) in his relationship with
Cindy and the children. Detriangling efforts continued to focus on
several other significant relationships. The most salient were family
of origin and the couples' relationship with their children.
Healthier personal boundaries were slowly emerging. After
approximately 10 weeks Kent returned home. By the end of their
treatment (six months and 18 sessions in total), Kent and Cindy dem-
onstrated a significant increase in their ability to balance their emo-
tionality and rationality. During their individual termination ses-
sions, both reported increased marital satisfaction and ability to
handle differences. In-session interactions suggested an increase in
personal responsibility and decreased reactivity.
CONCLUSION
Intuitively, helping couples alter dangerous individual and rela-
tionship patterns before they develop into more severe abuse is a wise
use of our health care dollars. The Prevention of Abuse Program uses
a technically eclectic approach to facilitate the differentiation process
of at-risk partners to reduce the likelihood of physical violence in the
relationship.
Survey research, determining clients' level of satisfaction with
treatment, has proved disappointing. For the four years, the response
rate averaged at 10 percent. Many surveys were returned unan-
swered because participants had moved without a forwarding ad-
dress. Prevention therapist status reports have proved to be more in-
formative. Out of the 118 couples that participated in the program
between September 1, 1992 to July 31, 1995, 62% were improving or
improved, 27% had little improvement or no improvement, and the
remaining 11% were in crisis or referred.
More extensive methods of evaluating outcome, such as periodic
follow-up sessions and evaluating community rates of domestic vio-
lence, are necessary. As it stands, this program may be too small to
produce a significant reduction in violent episodes within a commu-
nity of 350,000. Until stronger evaluation methods are used, we are
left to use clinical judgment on a case-by-case basis. More extensive
empirical research verifying its effectiveness is needed before larger
investments are made in developing comprehensive programs.
249
CONTEMPORARY FAMILY THERAPY
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