Addressing Domestic Violence and Mental Illness in Couples Counseling

Couples counseling is rewarding work – but it also brings counselors face to face with some of the most complex and high-stakes situations in clinical practice. Two of the most challenging are domestic violence and mental illness. Both can be present in a relationship at the same time, both demand specialized knowledge, and both require the counselor to think well beyond the standard relational framework. Understanding how to navigate these issues – safely, ethically, and effectively – is essential for any counselor working with couples.

Domestic violence in couples counseling: understanding the landscape 🔗

Intimate partner violence (IPV) is far more common in clinical settings than many expect. Research shows that as many as 70% of couples seeking couples and family therapy in generalist settings have experienced physical aggression and relational violence. This means that a counselor seeing couples will almost certainly encounter IPV – whether or not it is the presenting issue.

IPV can involve physical, sexual, and emotional abuse, as well as controlling behaviors by an intimate partner. It occurs across all settings and among all socioeconomic, cultural, and religious groups. Its effects are not limited to physical injury; domestic violence causes long-lasting emotional and physical health problems , with mental health consequences that can persist long after the violence has stopped.

Two distinct types of violence 🔗

Not all relationship violence is the same, and accurately identifying the type of violence is one of the counselor’s first and most important tasks. According to the American Counseling Association, two primary forms are recognized in clinical practice:

Situational couple violence describes relationship violence that occurs exclusively in the context of conflict situations and does not reflect underlying patterns of power and control dynamics. This type is more reactive – both partners may engage in it, and it is not rooted in a systematic effort by one partner to dominate the other.

Battering (intimate terrorism) is significantly more serious. Battering involves a patterned and repeated use of coercive controlling behavior to limit, direct, and shape a partner’s thoughts, feelings, and actions. It is typically more severe and more likely to result in negative consequences, and it carries a greater safety risk due to the power and control tactics that serve as its basis.

Counselors must be knowledgeable about the differences between situational IPV and power and control-related IPV in order to appropriately assess and treat the situation. The type of violence determines the treatment pathway – and getting this wrong can have serious consequences.

Safety first: the non-negotiable priority 🔗

Before any therapeutic work begins, safety must be established – not assumed. Safety must be the primary consideration, and safety risks associated with any counseling interventions must be considered and carefully monitored. This includes both the immediate session environment and what happens between sessions.

Couples seeking conjoint treatment should be assessed separately, not in the presence of the partner. Conducting assessments together creates conditions where the victim may minimize or conceal the abuse. Out of fear of further abuse, the victim may not be honest about the abuse or other issues in the couples session, giving a false impression to both the therapist and their partner that things are much better than they are.

It is equally important that counselors do not pressure clients toward any particular course of action. It is not the job of the counselor to decide whether the client should leave the abusive partner. Furthermore, in many cases, leaving increases the client’s immediate safety risks when involved in an IPV situation. Counselors should listen carefully, validate clients’ decisions, and work within the reality of their circumstances rather than imposing an outside judgment about what they “should” do.

When conjoint couples counseling is and isn’t appropriate 🔗

This is one of the most debated questions in the field. Couples therapy is not recommended when couples are experiencing intimate terrorism – a form of IPV characterized by one partner using violence against the other as a means to intimidate, control, and gain power over their partner. In these cases, conjoint sessions can increase danger by giving the abusive partner more information, more opportunity to retaliate, and a platform to manipulate both the process and the victim.

However, conjoint therapy is not off the table for all IPV situations. Research demonstrates a moderate effect of couple therapy in reducing male-perpetrated situational relationship violence against females , particularly when both parties have been carefully screened. Couple therapy can be appropriate and as effective as other interventions when both the violence and the couples are carefully screened and appropriately assessed for conjoint therapy.

Safety planning as an ongoing process 🔗

Safety planning is not a one-time checklist – it is a continuous process that evolves with the client’s situation. Safety planning is a broad term referring to strategies that increase women’s safety by increasing situational awareness of IPV-related risks and empowering women with necessary skills to enhance safety. Practical elements of a safety plan can include identifying safe locations to go, memorizing key phone numbers, and having important documents accessible in an emergency.

Counselors should also coordinate with other services. Counselors should coordinate their services with other involved agencies and resources from which the client is also seeking help, including victim advocates, law enforcement, and Child Protective Services. No counselor should work in isolation when IPV is present.

Trauma and mental health in IPV survivors 🔗

Domestic violence and mental health do not exist in separate silos – they are deeply intertwined. PTSD is one of the most prevalent mental disorders found in women in abusive relationships, and counselors should provide evidence-based treatments to address PTSD-related symptoms. Especially when left unaddressed, PTSD is related to a risk of future revictimization, making resolution of trauma an important treatment goal.

Using a trauma-informed approach is essential. Trauma-informed principles include acknowledgement, safety, trust, choice and control, compassion, collaboration, and a strengths-based focus. Labeling survivors with psychiatric conditions without understanding the context of their abuse can lead to mistrust and disengagement from care.

Among the evidence-based therapeutic options for IPV survivors, cognitive behavioral therapy (CBT) has strong support. Dialectical Behavior Therapy (DBT) has also been adapted specifically for IPV victims, and the HOPE program (Helping to Overcome PTSD through Empowerment) was developed for battered women with PTSD, focusing on stabilization, safety, and empowerment – without pressuring women into leaving the abusive relationship.

Mental illness in the couple relationship 🔗

When one or both partners are living with a mental illness, the relational dynamic shifts in ways that require specific clinical attention. Mental illness brings about disintegration in the relationship because the partner without mental illness takes on more responsibilities than before. This can subject them to multiple risks, including stress and burden of care. Meanwhile, the partner with the diagnosis may feel diminished or ashamed at needing ongoing support.

According to the National Alliance on Mental Illness, nearly 1 in 5 adults in the U.S. experiences mental illness each year. When one or both partners struggle with mental health issues, it can create misunderstandings, communication breakdowns, and emotional distance. These challenges, left unaddressed, can erode even strong relationships over time.

How mental illness affects relationship functioning 🔗

The effects of mental illness on a relationship are wide-ranging. People struggling with mental health issues may struggle to articulate themselves or communicate their feelings, making conversation difficult and causing the relationship to flounder. Depression can cause apathy toward communicating, and anxiety can cause unfounded mistrust between a couple.

Role disruption is another significant consequence. Couples adapt when one partner is experiencing increased psychiatric symptoms by taking over the partner’s daily tasks such as cooking or grocery shopping or altering the couple’s overall roles or routine. While this can be a healthy form of mutual support in the short term, it can generate resentment and imbalance over time if not actively managed.

When both partners have mental health diagnoses, the complexity increases further. Partners with the same psychiatric diagnosis often manifest their symptoms in different ways , meaning shared experience does not automatically translate into shared understanding.

The role of couples counseling when mental illness is present 🔗

There is evidence supporting couple-based interventions for depression, anxiety, posttraumatic stress, and alcohol problems in an adult partner. Typical components of couple-based interventions emphasize partner support, improved communication, and increased attention to the disorder’s adverse impact on the couple relationship.

Psychoeducation is one of the most valuable tools in this context. Psychoeducation and problem-solving skills can help couples deal with changes brought on by mental illness, as well as support a division of labor within the household. The partner without the mental illness should receive emotional and social support, as it restores a state of homeostasis in the relationship.

Therapists coach couples in communication skills, which include active listening and the use of non-blaming language when expressing needs and preferences. Partners are helped to use these skills to express their needs and emotions without risk of triggering negative reactions from the other partner. “I” statements – focusing on one’s own feelings rather than accusations – are a practical tool that counselors can introduce early and revisit throughout the therapeutic process.

Ensuring access to medical care 🔗

Couples counseling in the context of mental illness does not replace psychiatric or medical care – it complements it. When a partner has a diagnosable condition such as bipolar disorder, schizophrenia, or major depression, medication management and psychiatric support may be essential for stabilizing symptoms enough to make relational work possible. Couple-based interventions for physical health problems comprise an expanding application, with evidence beginning to emerge supporting the benefits of couple therapy across a broad spectrum of conditions.

Counselors should actively support clients in accessing and staying consistent with medical treatment, and where appropriate, coordinate directly with prescribing psychiatrists or treating physicians. Systemic interventions are as effective as evidence-based individual psychotherapeutic interventions for a range of problems, and more effective than individual therapy for some, including relationship distress and delaying relapse in schizophrenia.

When both issues co-occur 🔗

Domestic violence and mental illness frequently overlap. A survivor of IPV may present with depression, anxiety, or PTSD that is directly caused or worsened by the abuse. At the same time, a partner with untreated mental illness may exhibit behaviors that escalate conflict or create unsafe relationship dynamics. Counselors must be careful not to conflate the two – mental illness does not cause domestic violence, and abusive behavior is never explained away by a diagnosis.

IPV intersects with many other challenges, including financial trouble, parenting issues, housing disruption, and myriad mental health issues that commonly bring clients to counseling. This means assessment needs to be holistic, and treatment planning must account for the full picture of a client’s life – not just the presenting concern.

Counselors play a key role in addressing IPV by providing a safe space for victims to express feelings, identify abusive patterns, and understand that the abuse is not their fault. They offer resources and support, including safety planning and mental health services, and listen for signs of controlling behaviors and tactics used by abusers to minimize or blame their behavior.

What do you think? When a couple presents for counseling and one partner discloses violence during a separate intake session, how should a counselor navigate the decision to continue or terminate conjoint sessions – and who should that decision ultimately center? And when mental illness is present in a relationship, at what point does the caregiving dynamic between partners shift from healthy mutual support to a pattern that may itself need therapeutic attention?

References

1. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html
2. https://manifold.counseling.org/read/intimate-partner-violence-treating-victims/section/59c335fa-4263-48d6-8dfa-ef213dd7b904
3. https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-Competency/IPV-Guide/APA-Guide-to-IPV-Among-Women.pdf
4. https://wbma.cc/psychiatry-for-relationship-problems/