Pro Bono Psychotherapy With Survivors of Intimate Partner Violence

Abstract

This article describes a program called “Connect and Change” in which psychotherapists in private practice offer long-term psychotherapy to women who have experienced intimate partner violence. The program is for women who cannot pay for therapy on their own.

The widespread prevalence of intimate partner violence in our society has devastating effects on women and children. The statistics are staggering. According to a 2011 report, the lifetime prevalence of violence by an intimate partner was an estimated 31.1% of women among whom 71.1% experienced the violence before they were 25 (Breiding, 2014). Some women are killed. Others need medical attention for bruises, broken bones, and knife wounds. Women experience traumatic brain injuries, back or pelvic pain, headaches, cardiovascular, gastrointestinal, endocrine conditions, gynecological disorders, sexual dysfunction, preterm delivery, and unwanted pregnancies. The psychological consequences include anxiety, depression, post-traumatic stress disorder (PTSD), flashbacks, sleep disturbances, and suicidal thoughts (Centers for Disease Control and Prevention, 2015).

Children who witness abuse are at greater risk of being abused. Young children experience “excessive irritability, sleeping problems, emotional distress, fear of being alone, immature behavior, and problems with toilet training and language development.” Older children have trouble in school and difficulty concentrating, psychosomatic illnesses, depression, and suicidal tendencies. Later in life, these children are at greater risk for substance abuse and juvenile pregnancy (UNICEF, 2006, p. 4). Despite the fact that intimate partner violence is so widespread, it is often difficult for clients or clinicians to locate appropriate and ongoing treatment.

Background and History

In 2004, I was one of a small group of psychotherapists from the Women’s Therapy Centre Institute in New York City (NYC) who set out to help address this shortage of services. We began a project called Connect and Change to provide pro bono psychotherapy in our private offices to women who had experienced intimate partner violence. The Women’s Therapy Centre Institute grew out of the Women’s Movement and was established in 1981 for the purpose of bringing a feminist perspective to the work of psychoanalysis and psychotherapy. Today, the Institute offers a training program for therapists as well as programs for practitioners and the general public focused on topics relevant to understanding the way culture impacts the development of personality.

We had learned of a group of psychotherapists in Philadelphia who were offering pro bono psychotherapy to formerly homeless women as part of Project Home (housing opportunities, medical, and employment). At the same time, we learned that in NYC, there is a serious need for ongoing psychotherapy for intimate partner violence survivors. While many women receive social services when they are in crisis, once they leave a shelter or end their involvement with social service agencies they are without therapy they can afford. Inspired by the therapists from Project Home, we founded Connect and Change. Our clients who are of all races and socioeconomic backgrounds are in financial need when they come to us.

The Model

Organizational Structure

We began Connect and Change with great enthusiasm, considerable experience, some trepidation, and an awareness of our own naïveté in working with this particular group of women. We met monthly and began by educating ourselves about intimate partner violence. We met with psychiatrists, lawyers, and experts versed in the emotional, cultural, financial, and political constellation of intimate partner violence. We made alliances with social service agencies that served this population—Sanctuary for Families, Safe Haven, the Gay and Lesbian Anti-Violence Project, the John Jay College counseling department and the Crime Victims Treatment Center—and arranged for them to refer clients to us. The member of our group most experienced with intimate partner violence took on the role of director and with it the task of screening potential therapists and clients. Another member became codirector and took on the administrative work. The criterion for clients are that they not be living with their abuser, be unable to afford therapy on their own, and have demonstrated to the referring person an ability and willingness to follow through on scheduled appointments and do the work of therapy.

Our monthly meetings are generally divided into two parts—discussion of reading or a meeting with an outside speaker followed by peer supervision. As in any supervision group, members benefit from the insights and support of others not directly involved in the case. We often come to feel what our clients feel—overwhelmed, helpless, angry, and even despairing. When we become discouraged about the pace of change, group members reinforce the value for clients of our dependability, nonjudgmental attitude, and openness to hearing about all of their feelings. Because dissociation is a major defense for our clients, an attempt to protect themselves from overwhelming feelings, we as therapists help each other avoid joining with the dissociation in order to stay focused on the issue of abuse.

Theoretical Framework

We work with our clients to uncover self-defeating patterns of behavior that are a reflection of or an attempt to deal with problematic past relationships that have been internalized. We are all therapists trained to work psychoanalytically and are versed in contemporary relational and object relations approaches, particularly the work of D. W. Winnicott. His concept of the “holding environment” has been particularly helpful. According to Winnicott (1965), the therapist’s holding of the patient “takes the form of conveying in words at the appropriate moment something that shows that the analyst knows and understands the deepest anxiety that is being experienced” (p. 240). We see our work as trying to understand and bear the pain of these women who have been physically and psychologically abused.

We have come to realize that although our work with these clients is primarily psychodynamic, at times we may need to intervene in additional ways. We begin therapy by discussing safety, assessing with the client her living situation, and making sure she has a plan if she feels in danger. We connect our clients with agencies or professionals who can help them with medical, housing, legal, or financial needs. We educate our clients about the nature and characteristics of intimate partner violence and the larger social context within which it occurs.

As the result of our reading of the literature on intimate partner violence, we have come to see that intimate partner violence must be understood in a larger context. Judith Herman’s work (1992) provided us with a thorough and deeply insightful exploration of the historical and cultural context in which violence occurs. She considers a broad range of traumatic experiences, including intimate partner violence, to tease out what is common among these experiences in terms of the psychological consequences and the process of recovery. Our clients find it helpful to learn that their symptoms are common for those who have experienced trauma. We believe that understanding the cultural context of intimate partner violence helps our clients feel less alone and allows them to mobilize their resources.

The work of Abby Stein (2014) has also been extremely helpful. Stein’s work helped us formulate what we as a group were sensing—that in our work with these women we needed something in addition to a psychodynamic approach. Stein argues that the therapy must include “psychoeducational work to help the client recognize the inequality and abusiveness in gendered relations … ” (p. 48). She states that “all partner abuse should be understood not only in terms of the interpersonal dynamics but in the context of the institutionalized norms that promote and maintain gender inequality” (p. 21). When appropriate, we talk with our clients about the way power dynamics play out in relationships. We take seriously Stein’s notion that primary in the work is helping “clients recognize and express negative affects” (p. 48). As we have seen, it is not unusual for our clients to downplay the seriousness of the abuse, to excuse the abuser, or to blame themselves. We work to help them face what has happened to them and to express their anger without being overwhelmed.

Case Example

To illustrate this model, I will discuss my work with Lara, a woman in her 40s who was physically and psychologically abused by her mother and then brutally abused by her husband for over a decade. She was finally able to leave her husband and take her three children to a shelter. There she received an array of services and was referred to Connect and Change for psychotherapy. When she first came to see me, she was severely depressed and without a job. Today she lives as a single mother, supports her family with the income from her job working for the city, and is involved in a nonabusive relationship.

Lara was the first client referred to Connect and Change and I have seen her once a week for 10 years. She is representative of many of the women seen through this and other intimate partner violence programs. She began therapy feeling hopeless and depressed. Having never had much experience talking about her problems, she was fearful and had great difficulty discussing the abuse. A few things became clear. Lara was clearly overwhelmed by the concrete problems of her life. Like many women who leave abusive partners, she lacked external support as she tried to provide for her children independently. She was enrolled in a training program to become an electrician, a challenging but much welcomed opportunity. She struggled to arrange child care, deal with the housing, make sure her health care was in order, and attend her children’s school events. During her apprenticeship, the program was discontinued. She finally found a secure job with the city but one that required she work night shifts. As a result, she had to leave the children in the care of the oldest sibling.

Lara told me her life story but with very little affect. When she was a child, her mother would chain her and her siblings to the radiator, while she went to work. Lara laughingly related that when the mother left them alone, they would “playfully” dangle each other out of the window of their apartment building. She viewed these experiences as childish pranks rather than signs of neglect. In much the way Stein describes, she seriously understated her abuse.

She was somewhat more in tune with the pain of the abuse she suffered later. When she was a teenager, her pastor advised her to marry the man who had raped her and also told her that divorce was forbidden. Her husband continued to beat her viciously throughout their marriage, even kicking her in the stomach when she was pregnant. She described a birthday celebration at which he beat her in front of her family and neither her father nor her brothers intervened to protect her. While she did find enough anger in herself to eventually leave her husband, she continues to keep a distance from her anger. Any discussion of her abuse threatens her sense of stability, so we proceed carefully.

Early on in the treatment, Lara would often miss sessions, generally to deal with the immediate, real demands of life. I spoke about this in our supervision group, and it became clear that I was overidentified with Lara’s sense of being overwhelmed, and I was undervaluing the importance of therapy for Lara. The members urged me to speak with Lara about the importance of her making time for her sessions and using the therapeutic space to focus on herself and her feelings. Lara managed to become more organized in her life to make her sessions and the regular therapeutic support allowed the work to deepen.

A turning point in the therapy came a few years into the treatment when Lara visited her mother and brothers in Tennessee. Although we had spent considerable time discussing her mother’s physical and psychological abuse of her, Lara continued to expect a loving family experience. During that visit to her family, Lara was in a restaurant with her mother who became so verbally abusive that Lara fled the restaurant in a rage, went out to the car, and called me on the phone. This was the first time she had ever allowed herself to call me outside of a session. She described what had happened, how hurt, and enraged she was. After we talked, she found the courage to tell her mother she would not accept her abuse, and when things did not improve she cut the trip short. Not only was she able to stand up to her mother, but she was also able to depend on me. Since then, she approaches family events with greater caution and always with the option to leave.

Lara would take things we discussed in session and make immediate use of them—some basic understanding about relationships and some parenting ideas. For example, Lara was very focused on getting her children to do chores immediately after school. She was following the example of her own mother whose insistence on chores was actually pathological and brutal. With time Lara began to be in touch with her pain at the memory of working herself to the bone and having no chance to be a child. She came to see that her children needed to be greeted with a warm hug and asked about their day. She then went further and decided to make sure she had time alone with each child to talk with them about their feelings.

Lara’s increasing knowledge about intimate partner violence has been important in her treatment. From her reading and our sessions, she came to understand the characteristics of an abuser. When she first began therapy, she had described her then boyfriend, the father of her fourth child, as so much better than her abusive ex-husband. Yet, as time went on, she began to see the ways he tried to control her. He objected to her going to work, fearing her contact with other men and her independence. She began to express her anger at being controlled and to see that his gifts to her were a way to placate her. She also saw that he treated the children in equally controlling ways. Eventually, she ended that relationship, stating very clearly to me that she could no longer allow abusive people in her life.

To my surprise, Lara worked to preserve the relationship between her three oldest children and their father, her ex-husband, the abuser who lived in Florida. Lara went to great lengths to arrange for the children to visit him despite the fact that they would return visibly upset over his harsh and psychologically abusive treatment of them. It would take weeks for the children to recover from visits. They would be equally disturbed after phone conversations with him. Nonetheless, Lara went out of her way to make possible a continued relationship between the children and their father.

I wondered how Lara could send the children to someone who had so viciously abused her. I learned that Lara’s mother had prevented Lara from having a relationship with her own father. So profound was this loss that she did everything she could to preserve her children’s relationship with their father even though he had abused her. Over time, she came to see that her children’s father, unlike her own father with whom she developed a more positive relationship as an adult, was a destructive person in her children’s life. Rather than insist that the children never say anything negative about their father, she began to listen to their feelings of anger, disappointment, and fear and to accept their refusal to visit him.

As Lara came to understand more about the nature of abuse, she determined not to allow people who abused her into her life. This included family members who took advantage of her generosity. Yet in her present healthier relationship, it took time and work for her to be able to speak up about things that angered her. Initially, her boyfriend was generous to her and the children, bringing them groceries, taking them out as a family, but over time he became less available, not spending time with Lara despite promises to do so. Lara became extremely depressed, withdrawn, and immobilized. We came to understand that she did not believe she had a right to her anger, given that he had been so good to her. And she feared that expressing her anger might mean losing him. Eventually she was able to express her feelings of hurt and anger, and he became more responsive and dependable. She recently told me that she felt more afraid of being someone who did not speak up than she was of losing him.

Lara and I continue to work together. In many ways, her life continues to be chaotic, something our supervision group has helped me tolerate, recognizing that I can only do so much to help change her situation. Lara and I spend less time in sessions on problem solving and more on the emotional issues and conflicts that upset her. She now comes to sessions with particular issues in mind, able to pinpoint where she is having difficulty and then to explore it. Overall, she feels more empowered and makes better choices about the people in her life.

Discussion

Initially, in my work with Lara, because of her multiple concrete needs, I undervalued the role of therapy in her life. Lara was dealing with so many issues related to her abuse, financial insecurity, and single parenting that there seemed little room for her to reflect and integrate the insights of therapy into her life. Lara proved me wrong. She was hungry to understand and intent on making changes in her life. I came to see that therapy for her was by no means a luxury but was critically important in her taking control of her life.

The question I faced as her therapist was one I shared with the other therapists doing this work. Is it possible for these women to benefit from psychotherapy, given the overwhelming stresses in their lives? Our clients, and therefore we, repeatedly felt the frustration of dealing with overstressed social service agencies. This was not news to our clients. They knew the drill—standing in line for hours, filling out forms, and being referred to the next agency. And, in fact, many were quite savvy about how to handle the many bureaucracies in their lives. We came to see that we had to feel our way—helping out wherever we could with concrete services, doing the work of therapy as much as possible. We also came to appreciate the fact that the consistency of the therapeutic relationship and the focus on the client’s feelings and needs send a message to the client that she is valuable. For women who have been belittled and devalued in abusive relationships, this message is critical.

In looking back over the work of Connect and Change these last 10 years, there is much that we are proud of. To our knowledge, none of our clients have returned to an abusive situation. Very few of our clients have terminated prematurely, a fact that speaks to the importance of therapy to them. On average, our clients have worked with a therapist for 3–4years. As therapists, we have come to admire our clients’ ability, perseverance, and strength. Time and again, they would find ways to manage in situations that seemed unmanageable.

We continue to evaluate and fine-tune the program. In our first few years, a number of therapists did excellent work with their clients but chose not to take on a second client. In retrospect, it is clear that their clients were in particularly challenging situations that required a great deal of work with the courts and outside agencies and which raised particularly difficult countertransference issues. Since then, we have been careful to select clients whose needs fall more within the parameters of what we can offer. There has been little turnover among the therapists since then.

Still, we continue to struggle with the question of how best to serve our clients’ needs for social services. As individual therapists we have done our best to find help when needed and as a group we have tried to partner with agencies and professionals who could serve our clients. We wonder if perhaps it would make more sense for us as a group to work as adjuncts to some kind of social service agency. Project Home, for example, offers an array of concrete services to their clients leaving the psychotherapists to focus on the psychotherapeutic treatment itself.

Our monthly supervision has been critical. We have kept the group small with no more than 10 members at a time because we believe it is necessary for us as therapists to get to know and trust one another. The countertransference issues that come up in the group can be difficult. As Abby Stein points out, these include “vicarious traumatization, complicity in suppressing clients’ detailed memories of violent incidents, over identification with the client’s powerlessness” (2014, p. 95). One therapist whose client was demeaning and critical of her was able to help her client because of the support the group offered and the insights she gained discussing her countertransference reactions. I have been able to continue my work with Lara and bear her pain and stress because of the support of the group.

When we began our program, our intention was to work with our clients for “as long as it takes.” My work with Lara has certainly been long term and will continue. We have realized, however, that with some clients a shorter treatment makes sense. At a certain point, some clients seem ready to move on; others have found jobs with health insurance that allows them to pay, and it seems to be a positive step for them to move on from Connect and Change; some clients move away. Perhaps “as long as it takes” can be defined as as long as it takes for our clients to be free of abusive relationships and to be safely on their feet. We try to assess what makes sense for each of our clients while keeping in mind that we would like to be available to take on new clients.

Our work has sometimes involved seeing the children of our clients in session or, more likely, referring them out for therapy. Sometimes our clients cannot afford transportation to sessions and we have been able to help with funding. Early on, we received funding from the Far Fund, the Viola Bernard fund, and EILEEN FISHER which we used for administration, education, supervision, and funding for some client needs. While we were immensely grateful for the funding and appreciated that funders wanted to see the program grow, we decided to keep the program small in order to concentrate on our work with clients.

Conclusion

Over the years, many of our clients have made significant changes in their lives. One woman whose abuse extended from childhood through several relationships and two marriages reported that she sought out men who were “rough and tough.” She is now dating with greater discretion and looking forward to a future with a loving and caring partner. Another woman’s history of abuse caused her to have great difficulty parenting her rebellious teenage daughter who reminded her of her abuser. Against great odds, she was ultimately able to help her daughter complete high school. My patient, Lara, continues to provide her children with both financial and emotional support and is careful to avoid abusive situations in her life.

Overall, the experience of both therapists and clients in this program has been very positive. As therapists, we feel privileged to work with such intelligent and resilient clients eager to use the insights of therapy to make changes in their lives. Our clients have expressed their gratitude for the opportunity to understand what left them open to and kept them in abusive situations. As one client puts it, “therapy has helped me understand that the abuse left me with scars. The scars may never go away, but I’m learning to live with them and move on.”