U.S. Air National Guard photo by Airman 1st Class Jeremiah Johnson

Olivia Bentley, Ph.D., LPCC-S, Felisha Garcia, Psy.D., and Lt. Cmdr. Dierdra Oretade-Branch, DSW, LCSW, BCD, U.S. Public Health Service
June 4, 2024

When a patient discloses that they are experiencing abuse at the hands of their romantic partner, how do you proceed therapeutically?

Intimate partner violence is a type of trauma that is of major concern in civilian, military, and veteran populations,^1,2 and is identified as a threat to mission readiness.³ Stressors, such as frequent transitions or deployments, may put military relationships at a higher risk for IPV.³

Adjustments in your existing therapeutic approach can create a safe and supportive environment. This blog will provide an overview of an evidenced-based, trauma-informed approach, as well as some simple strategies to incorporate into therapy with patients who experience IPV.

Overview of Trauma-Informed Approach

Trauma-informed care acknowledges how trauma contributes to patients’ presenting symptoms and identifies individual and institutional practices that should change to avoid retraumatizing patients.^4,5 A trauma-informed approach is guided by six principles⁵

• Safety
• Trustworthiness and transparency
• Peer support
• Collaboration and mutuality
• Empowerment, voice, and choice
• Cultural, historical, and gender issues

Being trauma-informed requires health care providers to recognize the prevalence and impact of trauma, build on strengths and resilience, and create safety that is necessary for healing to occur.⁵

Therapists should be trauma-informed in all aspects of treatment, beginning with a comprehensive intake assessment.⁶ Trauma exposure can factor into co-occurring diagnoses and provide important context to explain patient behaviors.⁶ Trauma-informed care is more effective than usual care at reducing psychological issues such as posttraumatic stress disorder, depression and anxiety in women experiencing IPV.⁷ Viewing the patient through a trauma-informed lens can lead to a better understanding of how their trauma impacts their behaviors. For example, some patients may have adapted their behavior for self-preservation in their abusive relationships. These behaviors can spill into the therapy room and present as avoidance, confrontation, or resistance to vulnerability.⁶

All behavioral health providers should apply a trauma-informed approach.⁶ It is not limited to providers who are trained to deliver trauma-focused therapies and it can be applied with all patients, regardless of whether they have a diagnosis of PTSD.

All behavioral health providers play a role in creating a safe, therapeutic space for all patients.

How to Apply a Trauma-Informed Approach

Here are some suggestions for applying trauma-informed principles in your therapeutic approach with patients with IPV:

• Acknowledge and validate the impact of trauma and IPV in the lives of patients, regardless of gender.⁵
• Use strengths-based language that reflects the resilience of those who have survived IPV.⁶
• Display cultural competence and cultural humility as part of creating safety and trust in the clinical environment.⁵
• Make your physical office or clinic spaces welcoming, comfortable, and calming.^5,6
• Empower patient choice in all interpersonal interactions to restore control that may have been taken from them because of IPV.⁵
• Collaborate with patients, their trusted family and friends, colleagues, and other providers as appropriate.⁵
• Demonstrate trustworthiness to patients by displaying empathy and active listening.
• They may be initially distrustful because of past traumatic experiences.⁶
• Clearly communicate expectations for therapy, roles and responsibilities of patient and therapist, and limits to confidentiality to minimize ruptures in therapeutic rapport. ⁵
• Avoid being confrontational because it can reactivate trauma response. ⁶
• Maintain boundaries but be flexible when enforcing rules when therapeutically appropriate. ^5,6
• Encourage peer support by suggesting patients talk to a trusted friend or contact Military OneSource for peer-to-peer counseling 24/7. ⁵

Summary and Takeaways

Trauma-informed care involves a shift in your entire approach to patient care. Consider how you can incorporate these guiding principles of trauma-informed care into your own practice. The identified strategies are helpful in creating a therapeutic environment that is conducive to growth for those who experience IPV, but it is not an exhaustive list. For more about trauma-informed care, see the resources and references below.

Relevant Policies

DHA-AI 6490.01 Behavioral Health System of Care (Feb. 22, 2023)

DODI 6400.01 Family Advocacy Program (FAP) (May 1, 2019)

DHA-PI 6310.01 Healthcare Management of Patients with Interpersonal Violence and the Department of Defense Forensic Healthcare Program (August 10, 2023)

Resources

Sexual Assault Prevention and Response Office

Family Advocacy Program

Mental Health Stigma Reduction Toolkit

References:

1. Cowlishaw, S., Freijah, I., Kartal, D., Sbisa, A., Mulligan, A., Notarianni, M., Couineau, A. L., Forbes, D., O'Donnell, M., Phelps, A., Iverson, K. M., Heber, A., O'Dwyer, C., Smith, P., & Hosseiny, F. (2022). Intimate partner violence (IPV) in military and veteran populations: A systematic review of population-based surveys and population screening studies. International journal of environmental research and public health, 19(14), 8853. https://doi.org/10.3390/ijerph19148853
2. Kwan, J., Sparrow, K., Facer-Irwin, E., Thandi, G., Fear, N. T., & MacManus, D. (2020). Prevalence of intimate partner violence perpetration among military populations: A systematic review and meta-analysis. Aggression and violent behavior, 53, 101419. https://doi.org/10.1016/j.avb.2020.101419
3. Miller, L. L., Khodyakov, D., Hero, J. O., Wagner, L., Farris, C., Feistel, K., Dao, E., Rollison, J., Li, R., Ryan, J., Holliday, S. B., Martin, L. T., & Shearer, A. L. (2023). Domestic abuse in the armed forces: Improving prevention and outreach. RAND Corporation. https://www.rand.org/pubs/research_reports/RRA1550-1.html
4. Department of Defense. (2023, August 10). Healthcare management of patients associated with interpersonal violence and the department of defense forensic healthcare program (DHA Procedural Instruction 6310.01). Defense Health Agency, U.S. Department of Defense. https://health.mil/Reference-Center/DHA-Publications/2023/08/10/DHA-PI-6310-01
5. National Mental Health and Substance Use Policy Laboratory. (2023). Practical guide for implementing a trauma-informed approach (SAMHSA Publication No PEP23-06-05-005). U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. https://store.samhsa.gov/sites/default/files/pep23-06-05-005.pdf
6. Levenson, J. (2020). Translating trauma-informed principles into social work practice. Social Work, 65(3), 288-298. https://doi.org/10.1093/sw/swaa020
7. Chu, Y., Wang, H., Chou, F., & Hsu, Y. (2023). Outcomes of trauma-informed care on the psychological health of women experiencing intimate partner violence: A systematic review and meta-analysis. Journal of Psychiatric Mental Health Nursing, 00, 1-12. https://doi.org/10.1111/jpm.12976

Dr. Bentley is a licensed professional clinical counselor and contracted subject matter expert at the Psychological Health Center of Excellence who specializes in trauma-informed care. 

Dr.Garcia is a licensed clinical psychologist and contracted subject matter expert for the Defense Health Agency, PHCoE. She specializes in forensic psychology with extensive experience in the treatment of trauma.

Dr. Dierdra Oretade-Branch is a board certified clinical social worker and Lieutenant Commander in the Commissioned Corps of the United States Public Health Service. She is a subject matter expert at PHCoE and specializes in military and forensic social work within the civilian, veteran, and active duty service member populations.