Practical Psychotherapy

Conjoint Couple Therapy with a Woman

Survivor of Intimate Partner Violence:
Strengths and Challenges
Roniyamol Roy1 , Mysore Narasimha Vranda1 , Aarti Jagannathan1 ,
Vasanthra Radhakrishnan Cicil1 and James Ranjith Prabhu1

ABSTRACT or unmarried partners or directed to- IPV.8,9 Meta-analysis by Karakurt et al.10

Intimate Partner Violence (IPV) or
Domestic Violence (DV) affects the
mental health of women. Systemic
family therapy has been found to help
bring change in a couple's relationship
and the cessation of violence in the
relationship, provided both couples are
motivated by the therapy to preserve
the marital relationship. This article
presents a case of offering brief tailor-
made individual intervention as well
as couple therapy for a woman with
depression experiencing violence.
Keywords: Couple therapy, depression,
intimate partner violence, practical
psychotherapy
wards children.2 According to the recent
report by the National Family Health Sur-
vey 2021,3 the number of married women
aged 18–49 to ever experience spousal
violence has sharply increased, doubling
from 20.6% in 2014–2015 to 44.5% in
2019–2021. Sexual violence among young
women aged 18–29 has risen from 10.3%
in 2014–2015 to 11% in 2019–2021. IPV
is frequently connected to health issues
ranging from small injuries to serious
health repercussions and even death.4
The survivors experience significant anx-
iety, depression, post-traumatic stress
disorders, suicidality, and substance
abuse.5,6 Survivors of IPV/DV frequently
suggests that couple therapy helps violent
couples improve communication difficul-
ties,11 issues in conflict management,12
and relationship difficulties.13 This report
illustrates the process of offering a brief
tailor-made individual intervention as
well as couple therapy for a woman with
depression undergoing IPV, in the clinical
setting. A written informed consent was
taken from the patient for the purpose of
publication.
Case Scenario
A 28-year-old married woman, home-
maker, with primary education, from
rural lower socioeconomic background

I
ntimate Partner Violence (IPV) or
Domestic Violence (DV) is globally a
public health problem. IPV/DV can be
defined as any “violent, abusive, or threat-
ening behavior among adults who are
relatives or partners/ex-partners.”1 IPV/
DV can be physical, sexual, or emotional
violence among intimate partners, such
as same- or other-sex partners or married
visit health facilities with IPV-related
health issues but rarely disclose their
IPV experiences to clinicians, due to
lack of privacy; fear of threat, violence,
and re-traumatization; shame, and
guilt.7 Often, clinicians fail to iden-
tify IPV due to the time constraint,
fear of offending women, and lack
of training and skills in identifying
and having two children, presented with
complaints of low mood, reduced interest
in activities, reduced energy, decreased
sleep and appetite, and a history of multi-
ple suicidal attempts in the last one year,
with worsening of symptoms and active
suicidal ideation for the past six months
following separation from her husband
and children. The onset of the symptoms

National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India.
1

HOW TO CITE THIS ARTICLE: Roy R, Vranda MN, Jagannathan A,Cicil VR and Prabhu JR. Conjoint Couple Therapy with a Woman
Survivor of Intimate Partner Violence: Strengths and Challenges. Indian J Psychol Med. 2023;XX:1–5.

Address for correspondence: Dr. Mysore Narasimha Vranda, National Institute of

Mental Health and Neuro Sciences (NIMHANS), Institute of National Importance, Submitted: 26 Jul. 2022
Bengaluru 560029, Karnataka, India. Accepted: 12 Jan. 2023
E-mails: vrindamn@gmail.com; vrandamn@nimhans.ac.in Published Online: XXXX

Copyright © The Author(s) 2023

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative
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which permits non-Commercial use, reproduction and distribution of the work without further permission ACCESS THIS ARTICLE ONLINE
provided the original work is attributed as specified on the SAGE and Open Access pages (https:// Website: journals.sagepub.com/home/szj
us.sagepub.com/en-us/nam/open-access-at-sage). DOI: 10.1177/02537176231154820

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2023 1

Roy et al.
was gradual, and the course, continuous.
She was diagnosed with severe depression
without psychotic symptoms. She was
treated with Electroconvulsive Therapy
(ECT), and medications were initiated.
She gradually improved with treatment
and, upon consent, was referred to AWAKE
a special clinic for women experiencing
IPV, where she was offered individual
therapy and couple therapy to address
marital violence.
Psychosocial Assessment
The patient had a non-consanguineous
arranged marriage with mutual consent
when she was 18. She lived in a nuclear
family with her husband and two chil-
dren. She reported that the early years
of the marriage was alright. Gradually,
she started noticing the controlling and
dominating behavior of the husband,
who would verbally abuse her for minor
issues. Five years into the marriage, he
started consuming alcohol and there
was increased verbal and physical abuse
whenever he was intoxicated. About a
year ago, his niece joined their family after
her husband’s demise. Since then, the vio-
lence towards the patient had aggravated
drastically. Eventually, it was understood
that the husband’s family wanted him to
divorce the patient and marry the niece.
According to the patient, the couple’s
interpersonal issues intensified when the
husband started avoiding her but contin-
ued to abuse her physically. He would tell
her to leave, so that he can marry the niece.
The patient made multiple deliberate
self-harm (DSH) attempts, and parallelly,
the violence from the partner continued.
During one such episode, around six
months ago, she was sent to her parents’
house, without her children. She wasn’t
allowed back into her family of procre-
ation, nor was she allowed to meet her
children. She had filed a complaint at the
local police station against the husband
and the in-laws for DV and for prohib-
iting her from meeting the children.
According to the patient, the police had
advised the husband and in-laws to allow
the patient to meet the children, but they
did not oblige. Furthermore, the husband
kept forcing her to go for a divorce, and
the abuse continued over the phone.
The patient reported that she could not
deal with the mental trauma and pres-
sure from the husband, which resulted
in an emotional breakdown, ultimately
2 Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2023
resulting in worsening of depression and
multiple serious DSH attempts.
Interventions
Therapy Goals
The short-term objective of individual
sessions was to evaluate the patient’s
current requirements and concerns as
well as to enhance social support and
safety through risk assessment and
safety planning. The long-term objective
was to teach coping and problem-solving
skills, conjoint couple therapy sessions
to address ongoing relationship issues,
and to educate regarding legal options
available to preclude further IPV and
also have the custody of the children.
Individual Sessions
The initial stage of sessions focused on
building rapport with the patient, vali-
dating her emotional experiences, and
offering supportive therapy to acknowl-
edge her psychological distress. The
mother, who was the primary caregiver,
was educated about the suicide risk pre-
vention strategies, and we ensured close
monitoring of the patient in the ward.
The therapist offered a safe space for the
patient to express her feelings and con-
cerns. The therapist empathized with
her feelings and emotions by providing
supportive statements. As she started
feeling better clinically, further sessions
focused on resolving the ongoing marital
problems. Using a problem-solving
approach,14 she made an elaborate list of
her problems, chose a few concerns that
bothered her the most, and tried to list
out their possible solutions. She wanted
to continue the marital relationship
and also get her husband treated for his
drinking problem. She was referred to
the free legal aid clinic, where she was
made aware of the legal means of having
the custodial rights of the children.
The transtheoretical model of behavior
change15 was applied to understand that
the patient was in the contemplation
stage of behavior change, unsure about
seeking assistance and keeping in mind
family and societal pressure. She was
also worried about raising the children
without a father and how the society
might treat the children and herself. She
wanted to exercise legal action as a last
option and resolve the marital issues with
the formal network of family members.
The therapist observed that the patient
minimized the abuse by blaming herself.
Her self-esteem was low, as she constantly
spoke in a degrading manner about her
values and self-worth. In order to inter-
rupt the cycle of violence and gain control
of her position, the therapist assisted her
in becoming aware of the dynamics and
power control that existed within the
marital relationship. She was educated
on her legal choices and rights. In further
sessions, the patient’s decision-making and
problem-solving abilities were strength-
ened, which improved her self-efficacy
to handle the situations. Safety skills
were taught to safeguard herself and
her children, in view of the ongoing IPV.
Information about the local women’s
helpline was provided to call for help in
a crisis.
Couple Therapy
The traditional approach to the treat-
ment of couples experiencing IPV is
to have separate sessions with each of
them. Couple therapy may be helpful for
couples who have experienced mild to
moderate psychological and/or physical
abuse, though separation of the abusive
partner and the survivor may be required
to maintain safety in cases of extreme
physical abuse. Conjoint treatment,
when deemed safe, helps intervene in
couple interactions contributing to the
abusive cycle and yields the optimal
outcome.16 Couple treatment for IPV is
also indicated when the violence is recip-
rocal, its intensity is mild to moderate,
and both partners voluntarily agree to
the therapy to end the violence and wish
to remain together.17
Since the patient wished to continue
the marital relationship and have couple
therapy, the therapist contacted the
husband to visit the patient in the hospital.
The husband was initially reluctant to visit
her but later agreed to undergo marital
or couple therapy. He had entered the
contemplation stage regarding drinking
of the transtheoretical model of behav-
ior change.15 In the beginning, he tried to
justify the violence, blaming alcohol for
his abusive behavior. He also justified that
when things get out of control, his family
suggested going for divorce and marrying
his widowed niece. In the initial psycho-
education sessions, emotional regulation
 Practical Psychotherapy
TABLE 1.

Details of the Sessions and Techniques.

Session Phases
Initial phase (Sessions 1–4)
Duration: 30–45 min
Intermediate phase (Sessions 5–11)
Duration: 45 min to 1 h
Termination phase
(Sessions 12–16)
Duration approximately 20 min
Objectives
· Address the suicidal risk of the patient
·  Establish rapport
·  Psychoeducation of mother
·  Assess the immediate needs of the client and
offer support
· Conduct risk assessment and safety planning
·  Reduce passive and active violence in the home
environment. Increase positive coping and healthy
communication in the couple’s relationship
·  Motivational interviewing with husband to
address drinking behavior
·  Impart positive parenting skills and directions
for legal proceedings to the patient
·  Explore social support and make an appropriate
referral based on the needs of the patient
·  Discuss safety and assertiveness skills with
the patient
·  Follow up on family functioning, treatment
compliance, and economic self-sufficiency
of the patient
· Enhance the self-confidence and self-esteem
of the patient
Techniques Used
·  Psychoeducation of mother on managing the
suicidal risk of the patient
·  Psychological first aid to handle the crisis
·  Reassurance and ventilation
·  Education about identifying the signs of abuse and
awareness of the dynamics of a violent relationship
·  Problem-solving approach
·  Supportive techniques
·  Conflict resolution skills - Positive coping strategy
to deal with trigger situations
·  Couple communication skills
·  Behavioral and cognitive tasks
·  Emotional regulation skills and stress management
·  Discussion on parenting strategies
·  Guided discussion
·  Referral
·  Discussion on approaching legal and societal
options for ensuring safety. Education on the
healthy expression of emotions and utilization of
the support system
·  Ensuing treatment adherence using
psychoeducation
·  Acknowledging the client’s strength

was taught to the couple through anger
management and stress reduction tech-
niques. The training in communication
and conflict resolution targeted construc-
tive conflict management by the couple.
The sessions focused on reducing the risk
of aggression and, parallelly, revoking the
relationship lost due to IPV (Table 1). Verbal
descriptions were given of constructive
and destructive communication. Effective
expression of feelings and listening skills
were explained, along with corrective feed-
back. The cultural influences, including
the in-laws’ involvement in the relation-
ship and gender roles in the relationship,
were explored, because those were the
presenting concerns of the couple. Mutu-
ally acceptable ways to improve the
quality of the marital relationship were
discussed. The couple was also explained
deescalation skills, including about being
empathetic and non-judgmental and
respecting each other’s personal space and
boundaries. The patient was also allowed
to describe the marital difficulties. Both
appeared to have dysfunctional communi-
cation and relationship patterns and poor
conflict resolution skills.
The husband’s patterns of minimiza-
tion and blaming the patient for violence
were confronted and he was made to
own his behavior. Treatment goals with
the husband included psychoeducation
Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2023
about the forms of violence in intimate
relationships and options with which IPV
can be substituted, improving individual
accountability for the use of violence, reduc-
ing and finally eliminating IPV through
anger management and conflict resolution
techniques, and improving communication
and problem-solving abilities to enhance
relationship satisfaction and constructive
couple interactions. The sessions focused on
teaching the healthy ways of having recipro-
cal communication with the patient without
indulging in violence/abuse. The couple
was taught about open communications
and sharing of household and child-
rearing responsibilities. Victim blaming was
addressed with an emphasis on changing the
attributional style and owning responsi-
bility for the abuse. Separate sessions were
also held with the husband to address the
drinking behaviors and to teach healthy
coping and problem-solving skills. The
legal consequences of a second marriage
and persistent DV were also explained to
him in the individual sessions.
The patient was discharged with
consent for a tele-follow-up with the
therapist.
Follow-up Sessions
The follow-up tele-sessions were held by
phone, separately with the client and the
couple. During the sessions, the thera-
pist ensured utmost safety of the client.
Before the session, she was instructed
that if the husband suddenly entered the
home while the session is in progress, she
should convey the matter to the therapist
using code words. She was also instructed
to respond only with “yes” or “no”, use
code words, or switch to a neutral topic
if he was around while she is disclosing a
recent episode of violence. Currently the
patient report that the violence from the
husband has stopped and that his drink-
ing is occasional only. Her self-esteem and
depressive cognitions have improved sig-
nificantly. The follow-up sessions guided
the couple to prevent tendencies for relapse
and to engage in mutually pleasurable
positive behaviors.
Strength and Challenges in
Couple Therapy
Offering couple therapy had specific chal-
lenges in the current case scenario. The
strength was that the therapist relied on
the family system theory, which acted as
a secure base for the therapist to go back
to when overwhelmed by the complexity
of the clinical work before her. Treatment
of couples with IPV necessitate under-
standing the dynamics present in the
system that created the partner violence.
In this case, the therapist could identify
3
Roy et al.
the base of triggering factors for the cycle
of violence and cease it, as both had poor
conflict resolution skills. The therapist
could identify the cycle of violence and
how it is maintained, and giving feed-
back was helpful in the therapy. Cycle
work refers to identifying the defeating
pattern of interaction within a couple
that is repetitive and negatively rein-
forcing. Based on systemic patterns, the
therapist could identify triggers, primary
and secondary emotions, and inter- and
intra-personal elements at play in the
context of cycle work. The structured,
supervised sessions helped reduce
anxiety and increased the therapist’s
confidence in carrying out the sessions.
Having been already trained in struc-
tural and systemic family therapy in the
institute was helpful for the therapist.
The challenge in using couple therapy
was the uncertainty about using sys-
temic foundations and maintaining
safety of the couple at the same.
At times, the fear of compromising
client safety overwhelmed the therapist.
The therapist had to manage her own
anxiety in the session, anticipating vio-
lence at the home despite assessment and
planning for safety overwhelmed and bur-
dened the therapist. There were feelings
of great worry about applying systemic
work with the couple to bring change in
the relationship and uncertainty about
sustaining the change in behavior pat-
terns in complete cessation of violence.
Discussion
This article focused on the process of con-
joint couple therapy for IPV using family
system theory,18 with special attention
to the issues of accountability, healthy
communication, and conflict resolution
strategies. Using these techniques, mean-
ingful results were obtained in the form
of cessation of violence and enhancement
of healthy communication patterns in
the husband. Family systemic approach
helps the couple recognize the inequal-
ities in power between the partners and
helps develop a more equitable model of
interaction. It also helps both partners
to understand their present behaviors in
light of the attitudes, expectations, and
gender role stereotypes they acquired in
their families of origin. Rather than jus-
tifying the perpetrator’s actions, systemic
approach can be employed to encourage
the man to accept full responsibility for
4 Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2023
his behavior and empower the woman
to take control over her safety and emo-
tional well-being.19,20
According to Sprenkle et al.,21 in couple
therapy, the clients commonly attempt
to justify their behavior by blaming the
partner. With regard to the problematic
attributional style, avoiding the blame
game resulted in taking accountabil-
ity and owning responsibility for the
violent behaviors. Conjoint treatment
encourages the offender to commit to
change and assume responsibility for
his behavior.22 Treatment can be tailored
for each couple based on meticulous
screening and the application of safety
precautions. In the present case, the
husband was taught de-escalation skills,
resulting in non-abusive behaviors with
the patient. Though they are currently in
the action phase of the transtheoretical
model of behavior change,15 there may
be relapses as it happens in some cases.
Hence it is crucial to continue to follow
up with such couples.
Conclusion
Even though couple therapy is not
encouraged, conjoint couple therapy
is an appropriate intervention for IPV
if certain conditions are present as
determined by the clinician.23 Couple
therapists should undergo structured
training in systemic therapy and have
practice skills and cultural competency
while dealing with cases of IPV. Conjoint
couple therapy should be taken into
consideration only after careful assess-
ment of the appropriateness of couple
therapy for that particular couple and
after taking necessary precautions to
ensure the safety of both partners.10
Declaration of Conflicting Interests
The authors declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
Funding
The authors received no financial support for the
research, authorship, and/or publication of this
article.
ORCID iDs
Roniyamol Roy https://orcid.org/0000-
0002-9843-5445
Mysore Narasimha Vranda https://orcid.
org/0000-0002-8456-5468
Aarti Jagannathan https://orcid.org/0000-
0002-2792-1075
Vasanthra Radhakrishnan Cicil https://orcid.
org/0000-0003-2202-3791
James Ranjith Prabhu https://orcid.org/0000-
0002-8584-5664
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