Wednesday, July 2, 2014

Mental Health Treatment for Domestic Violence; Medicalization of Criminal Behavior

Mental Health Counseling or Treatment is not an appropriate strategy to address abusive behavior; especially domestic violence. A Certified Batterers Intervention Program (BIP) is the appropriate intervention.
Anger management providers are usually licensed clinicians. They will often diagnose, or label, abusive behavior as a “medical condition” or “mental health problem”. They will assign a DSM label such as “Impulse Control Disorder” and will then draft an individualized treatment plan to treat the disorder. This labeling serves to provide abusers with more justifications and excuses for their behavior such as, “I couldn’t help it; I have a problem. I am sick.”

The two most common diagnoses used with abusive men are Intermittent Explosive Disorder and Impulse Control Disorder Not Otherwise Specified. These disorders frame the client as a victim of neurological misfiring, and assert that the client, who is now a victim, has no control over their behavior.

If abusiveness were the result of individual pathology, it would make sense to provide mental health treatment as a response to it. Framing abuse as pathology in need of treatment goes something like this:

  1. He must be sick to act that way. That is, he wouldn’t be abusive if he didn’t have an underlying psychological problem (Intermittent Explosive Disorder, Antisocial Personality Disorder, substance abuse, insecurity, anger, trauma, etc.).
  2. If I treat his underlying disorder, he will quit being abusive.

This way of understanding abuse hands the abusive person an excuse for their behavior. The likely result is that they will begin to say, “It’s not my fault; my (fill in the blank mental health disorder) made me do it.” They beg or pressure their partner to hang in there with them while they work on their problem, and promise that things will get better. Because that’s what their victim wants, they may agree to stay in the relationship, deferring their own need for safety and freedom. The therapist has unintentionally become the abuser’s ally in continuing to control their partner.

To avoid feeling guilty and accepting personal responsibility for their behavior, abusers will (consciously or subconsciously) blame anyone or anything they can. In addition to blaming the victim for provoking them, they will blame alcohol, drugs, stress, etc. Regardless of whether these factors contribute to abuse, abusers need to accept full responsibility for their behavior in order to begin the process of personal change. Mislabeling abusive behavior as a medical condition or mental health problem exacerbates the real problem of the abusive person accepting personal responsibility to end their self-delusional beliefs that excuse, justify, minimize, and enable their abuse.

Therapy should not be the standard response to abusers generally, because those attitudes that lead to domestic violence are often not specifically addressed in treatment, including:

  1. Entitlement attitudes. Most abusers believe that there is something that entitles them to control their partners. In the case of men’s abuse of women, that something is often a belief in male dominance. Some abusers choose to examine and change these attitudes during therapy, but treatment cannot be reliably used to change attitudes – especially ones that operate to the abusive person’s benefit.
  2. Cultural and social support for entitlement attitudes. Social support is a powerful reinforcement that keeps abusive behavior going, and clinicians cannot stop abusers from receiving it.
  3. Tactics of control. Abusive behavior is not random. It often boils down to carefully chosen tactics, which are used intentionally to achieve the abusive person’s goal of control. Co-occurring mental health or substance abuse problems do not make tactics into a sickness that can be cured.
As I previously stated, probably the most common diagnoses used with abusive men are Intermittent Explosive Disorder and Impulse Control Disorder Not Otherwise Specified. These disorders frame the client as a victim of neurological misfiring, and assert that the client, who is now a victim, has no control over their behavior. Yet abusers often perpetuate abuse in a premeditated systematic manner using tactics of power and control. Abusers themselves will often claim to be “triggered” to become abusive.

Thus neither of these diagnoses applies, and to use them in order to seek third party reimbursement is at minimum unethical and more likely illegal. The client is then left with an inaccurate diagnosis as part of their medical record, which may be problematic for the client in the future. This also could be harmful for the reputation of the clinician.

Let’s say for a moment, upon the recommendation of their physician, a person wants to quit smoking to avoid a potential medical problem. They enroll in a class to learn techniques to successfully change their behavior and quit smoking. If the facilitator of the class is a Licensed Mental Health Counselor (LMHC) is it ethical and appropriate for them to diagnose the client with an anxiety disorder in order to get health insurance to pay for cost of providing the class? Suppose the client revealed to the counselor that they’ve been smoking for a real long time and they feel a little anxious about “giving it up?” Is it appropriate now for the counselor to diagnose the client to seek reimbursement to fund the class?

An ICADV-Certified Batter Intervention Program (BIP) does not call what it does “treatment.” Treatment is a term for service provided to address a “medical condition” or “mental health” problem. BIPs advocate against viewing abuse as anything other than immoral, inappropriate (often criminal) behavior. Labeling abuse as a “medical condition” or “mental health problem” provides an excuse, “I couldn’t help it, I have a problem.” Thus abusers avoid accepting personal responsibility for their behavior.

Mental health-related problems such as anxiety, depression, anger, substance abuse, personality disorders, intermittent explosive disorder, and childhood trauma are not the cause of abusive behavior toward a partner and/or children. These problems are often correlated with domestic abuse and may influence the shape it takes in a particular case, but wanting to quit drinking or feel better emotionally is not the same thing as wanting to treat one’s partner or children better. Abusive behavior pays off for the abusive person, regardless of its cost to his partner and children, and treatment is unlikely to get him to stop it for their benefit.

If an abusive person is found to have concurrent mental health disorders along with their violent or abusive behavior, they should be referred for appropriate treatment to address those concerns prerequisite to attending a certified BIP. However, the mental health treatment should never be allowed to substitute for attending a certified batterer intervention program.

Terry A. Moore, LCAC
ICADV Certified Senior BIP Facilitator 

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