Using the Stages of Change to Counsel Victims of Intimate Partner Violence

The CDC has identified intimate partner violence (IPV) as an important public health problem with significant physical and mental health implications, with approximately 37% of women nationwide experiencing IPV during their lifetime (Smith et al., 2017). IPV has been characterized by various typologies (e.g., Johnson, 1995). IPV typologies provide context for the nature of violence occurring within couples. Due to overlap among some IPV typology characterizations, Carlson and Jones (2010) developed the Continuum of Conflict and Control to help conceptualize factors such as severity and frequency of the violence, psychopathology of the abuser, context of the violence, and the consequences that follow the violence.

The Continuum of Conflict and Control has important implications for treatment plans when IPV is a concern (Carlson & Jones, 2010) because it helps counselors determine when it is safe to work with couples, or when a referral may be more appropriate. Couple's counseling may be an appropriate intervention for couples with lower levels of IPV. However, couple's counseling is not appropriate when one partner has engaged in tactics to establish power and control over the other, as danger to the victim may be increased (Bograd & Mederos, 1999). The issue of working with couples experiencing IPV, and screening and assessing for IPV in general, is very complex and not intended as the primary focus of this paper. Readers are encouraged to consult established works on this topic (see Whiting et al., 2009). Instead, we focus this paper on working with victims who have suffered and survived relationships where their partner has systemically engaged in tactics to establish and maintain power and control over them. Throughout this paper, we use the term victim to refer to women experiencing power and control related IPV perpetrated by men. This is not meant to ignore or deny IPV experienced by males or those in same-sex relationships (see Jacobson et al., 2015) but is intended to reflect our focus on a model for power and control related IPV which has primarily been documented in heterosexual couples.

Golding (1999) found that the prevalence for mental health problems such as depression, suicidality, posttraumatic stress disorder, and substance abuse is higher for IPV victims than among the general population. IPV victims’ worsening mental health symptoms, including anxiety, depression, and suicidal ideation, may lead them to seek individual counseling (Nichols et al., 2018). These studies highlight the need for counselors to accurately identify and respond to IPV. However, counselors regularly do not assess for and respond to IPV appropriately (Daire et al., 2014). In a nationwide sample of 620 marriage and family therapists, only half of the sample reported routinely screening couples for IPV and only 4% reported adequately implementing the screening guidelines recommended by IPV experts (Schacht et al., 2009). Further, Bozorg-Omid (2006) found that only 50% of counselors had received graduate training regarding IPV and 78% of those reported that the training they had received was inadequate. Although these studies occurred several years ago, we found no published studies updating this data, and have no other reason to suspect this identified trend has changed. Lack of counselor preparation leads to poor assessment and response when clients have experienced IPV, which may place victims in greater danger and discourage further engagement in counseling (Daire et al., 2014). Schacht et al. (2009) reported that clinicians who had received some level of IPV training were more likely to universally screen for IPV, abuse, and other types of trauma; help clients develop safety plans; document abuse appropriately; and provide clients with IPV resources.

Over the past 20 years, researchers have sought to delineate specific guidelines for counseling IPV victims (Brown, 1997; Cluss et al., 2006). This growing body of research indicates that IPV victims’ attempts to improve their safety is a multi-step and multi-strategy process which aligns with the transtheoretical model (Brown, 1997; Burke et al., 2004; Chang et al., 2006; Edwards et al., 2012). The transtheoretical model explains the safety-seeking processes of IPV victims and guides practitioners’ interventions for IPV victims (Cluss et al., 2006; Reisenhofer & Taft, 2013). The transtheoretical model was developed to describe how people create intentional changes in their lives, both with and without counseling interventions (Prochaska et al., 1992).

Closely related to the transtheoretical model is motivational interviewing, a counseling style which requires the counselor to use empathic listening and collaborative therapy techniques to explore clients’ values and goals to increase their motivation to change (Rollnick & Miller, 1995). Like the transtheoretical model, motivational interviewing acknowledges that clients enter counseling at different levels of readiness to change (Miller & Rollnick, 2002). Therefore, the therapist does not directly confront clients’ resistance or ambivalence about change, but instead engages clients in therapeutic conversations that help increase intrinsic motivation to create change in their own lives (Hughes & Rasmussen, 2010). Motivational interviewing is cost-effective, time-sensitive, evidence-based, and culturally sensitive making it a desirable approach for counseling in IPV shelters, where brief interventions are necessary (Rasmussen et al., 2008). Further, motivational interviewing uses reflective listening skills to help clients identify realistic individualized goals and small steps which builds self-efficacy, making it a logical fit for IPV victims who face many barriers to taking action which could improve their safety and well-being (Saftlas et al., 2014).

As shown in Figure 1, both the transtheoretical model and motivational interviewing can be applied to the stages IPV victims experience when attempting to enhance their safety. Implementing a stage-based approach enables the counselor to understand the impacts of internal and external forces that IPV victims face in abusive relationships (Brown, 1997). While the problem behavior lies with the abusive partner, not the victim, stage of change informed models capture the fact that victims are faced with important choices and changes that impact themselves and the entire family when attempting to reduce exposure to violence and ensure safety (Frasier et al., 2000; Reisenhofer & Taft, 2013).

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Figure 1.

Stage of change movement for IPV victims with the transtheoretical model & motivational interviewing. Note. This figure shows how counselors can use both the transtheoretical model and motivational interviewing to support victims of IPV. The transtheoretical model provides interventions counselors can use to promote movement between specific stages while motivational interviewing outlines specific skills counselors can use to support movement between the specific stages.

Victims who seek counseling may be assessing how they wish to proceed in their relationship. The counselor's role must be to empower victims to make their own decisions, not to encourage them to leave their relationships (Kress et al., 2008; Reisenhofer & Taft, 2013). The goal is to end the violence and distress that victims experience, and leaving the relationship is not a guaranteed way to achieve this goal (Walker, 1994). Both the transtheoretical model and motivational interviewing provide guidelines and strategies which help the clinician focus on each victim's individual goals while acknowledging their unique needs and circumstances.

Some IPV agencies have naturally developed their programs in ways that honor the stages of change that victims traverse when making changes to increase their safety (Brown, 1997), but there is minimal empirical guidance on this topic in the counseling literature. Despite the prevalence of the transtheoretical model in counseling, research on its use with IPV victims is primarily located in medical and family health journals. Similarly, motivational interviewing is an approach with a counseling basis that has been used with abusers, but only a handful of studies to date have explored its utility with IPV victims and these studies were not published in counseling journals. Overall, there has been minimal focus on the stages of change for IPV victims in counseling literature.

Both the transtheoretical model and motivational interviewing can ensure that counselors meet IPV victims’ needs and empower them to make choices that will improve their safety. The way that victims describe surviving abuse and making choices to improve their safety aligns with the stages of change (Brown, 1997; Burke et al., 2004: Frasier et al., 2000; Reisenhofer & Taft, 2013). Therefore, the transtheoretical model may be helpful to counselors in conceptualizing IPV victims’ counseling needs, while motivational interviewing outlines specific counseling skills that improve counselors’ ability to engage victims in services appropriately (Miller & Rollnick, 2002, 2013).

Given the potential utility of the transtheoretical model and motivation interviewing for counseling IPV victims, the purpose of this paper is to explore how both models have been applied to IPV interventions and how they can inform counselors’ work with IPV victims. First, we summarize both the transtheoretical model and motivational interviewing and how they can be applied with IPV victims. We then review the current research that is available in other fields utilizing both models with IPV victims. Finally, we discuss the implications for the counseling profession.

IPV Victims & The Transtheoretical Model

The transtheoretical model is a comprehensive explanation of how people create change in their lives that can help IPV victims more accurately understand the abuse they are experiencing and process the potential future outcomes for themselves and their family members (Frasier et al., 2000). Further, the transtheoretical model can improve services for IPV victims by helping counselors conceptualize the steps and changes that IPV victims must make when trying to manage or escape violence (Chang et al., 2006). The transtheoretical model consists of stages and processes of change as well as mediating factors that impact change.

Understanding the stages and processes that support change at each stage can help providers identify the most effective interventions for their clients (Brown, 1997; Prochaska et al., 1992). The stages represent a series of phases people pass through when attempting to make changes, moving from thinking about making changes to choosing to change behaviors to maintaining new habits. Prochaska et al. (1992) defined the processes of change as activities that individuals use to modify problem behaviors. Counselors must use their knowledge of the clients’ stage of change and processes of change to determine the most effective interventions for each client. Counselors must match their interventions and suggestions to victims’ level of readiness in order “to be helpful and sometimes even to be heard” (Brown, 1997, p. 15). Women in Chang et al.'s (2006) study often returned to earlier stages after receiving negative responses to their change efforts. In each stage, victims should receive information and resources that will prepare them to move to the next stage when they are ready.

IPV victims in precontemplation may present as being in denial of the abuse, as minimizing the abuse, or as feeling hopeless about the abuse (Frasier et al., 2000). When minimizing the abuse, they may acknowledge that it occurs but attempt to rationalize the partner's behavior. Victims who feel hopeless may also acknowledge the abuse but indicate that nothing can change the situation. Victims in this stage may be resistant discussions of the abuse (Frasier et al., 2000). As they move into contemplation, victims become more aware of the abuse. They may actively consider actions that could improve their safety but do not have any definite plans to act within the next six months (Frasier et al., 2000). This stage may be quite lengthy, but victims are beginning to consider a future without abuse.

In precontemplation and contemplation, victims would benefit from consciousness raising (Brown, 1997; Burke et al., 2004). Consciousness raising involves increasing victim's information about themselves and IPV (McGirr & Sullivan, 2016) which helps victims identify their experiences as abuse, understand that it is wrong, and know that it is not their fault. Further, consciousness raising can help victims recognize their own abilities and ways they can exert control in their relationship (McGirr & Sullivan, 2016). Finally, consciousness raising can assist clients in recognizing systemic factors, such as cultural beliefs or poverty, that impact IPV and may have impacted their own experiences of abuse.

In contemplation, dramatic relief, self-reevaluation, and environmental-reevaluation may be most effective for victims (Brown, 1997; Burke et al., 2004). Dramatic relief allows victims to experience and share grief over letting go of the idealized relationship with the abusive partner as well as other potential losses, such as losing relationships with their partner's family members (Haggerty & Goodman, 2003). It is important that the counselor allows space for dramatic relief while avoiding making negative remarks about the abusive partner which may cause victims to feel defensive (Haggerty & Goodman, 2003). In self-reevaluation, the counselor uses validation and compassionate support to help victims assess and alter their emotional and cognitive values related to the abuse (Burke et al., 2004) and change any negative self-attributions they may have from the abusive relationship (Haggerty & Goodman, 2003). The counselor uses active listening skills to communicate to victims that they are important and worthy and consistently places blame for the abuse with the abuser. Lastly, environmental-reevaluation helps victims understand how the abuse has impacted their environment and others in it (Rosen, 2000). Victims in Burke et al.'s (2004) study identified environmental-reevaluation as an important motivating factor as they realized how the abuse impacted their children.

IPV victims in preparation are actively planning to take action to improve their safety within the next month, such as seeking employment (Frasier et al., 2000). Victims also may already be making small changes at this stage, such as seeking legal assistance. Frasier et al. (2000) emphasized the importance of a plan at this stage which can support victims and help prevent regression to previous stages. Victims in the action stage are implementing the changes which they have been contemplating and preparing for in the previous stages. This may look like attending counseling, joining a local support group, leaving the abusive relationship, or becoming employed, among other possibilities (Frasier et al., 2000).

In preparation and action, victims would benefit from counterconditioning, helping relationships, social liberation and contingency management (Brown, 1997; Burke et al., 2004). Counterconditioning may help victims identify patterns of behavior in the relationship that put them at risk and plan to avoid those patterns. Keeping a diary of abusive experiences as reminders, talking about their experiences in a support group, and reviewing positive changes that come from safety-seeking behaviors can help clients identify patterns of behavior, triggers for those behavior, and plan for ways to avoid those behaviors when they are able (Haggerty & Goodman, 2003). Helping relationships allow victims to develop supportive connections with understanding individuals which reduces isolation (Haggerty & Goodman, 2003). Victims can develop helping relationships in social support groups or in supportive community groups such as a church. The counselor can also provide a helping relationship by communicating care, concern, and empathy for the victim and by validating their thoughts, feelings, and experiences (Haggerty & Goodman, 2003). In social liberation, the counselor helps victims increase awareness of societal values that contrast or condemn abuse and community efforts that support IPV victims (Rosen, 2000). Through contingency management, the counselor communicates to victims that their actions are courageous and appropriate as they begin to make changes.

In maintenance, the person strives to continue the gains made during action and prevent relapse to previous behaviors (Prochaska et al., 1992). Maintenance lasts at least six months but the time frame for the end of the maintenance stage varies depending on the problem. IPV victims in this stage strive to continue with choices they made in the action stage, such as remaining employed, continuing counseling or fighting the urge to return to the abusive relationship if they had left (Frasier et al., 2000).

During the maintenance stage, victims need continued support and would benefit from contingency management and stimulus control to help them avoid regression in the changes they have made (Brown, 1997; Burke et al., 2004). The counselor would continue to communicate acceptance and validate any choices victims have made to create change. In stimulus control, victims must avoid temptation to return to previous patterns that may have increased their danger in the relationship. Avoiding social settings that involve people connected to the abuser and building new relationships can help victims maintain progress (Haggerty & Goodman, 2003).

Progress through the stages is not linear and returning to previous stages can be expected (Brown, 1997; Prochaska et al., 1992). Prochaska et al. (1992) stated “relapse is the rule rather than the exception” (p. 1105). Most people who relapse do not return to precontemplation but instead may return to contemplation or preparation before beginning to move forward again, creating a spiral pattern of change. In this way, maintenance becomes more achievable as people learn from their mistakes (Prochaska et al., 1992). Returning to a previous stage can be positive as it allows for additional opportunities to learn how to change (Frasier et al., 2000). Change is difficult and relapse is common even in areas over of individual control, such as weight loss or smoking. With IPV, change is made even more difficult by threat of harm, limitations on social and financial resources, and the involvement of children (Brown, 1997). Therefore, the spiral pattern of change is considered normal, particularly for IPV victims.

When counselors tailor their interventions to clients’ current stage of change, they support change in a developmentally appropriate way. Using the transtheoretical model to conceptualize and respond to IPV victims’ concerns helps the counselor provide appropriate support (Brown, 1997; Burke et al., 2004; Edwards et al., 2012). Further, the transtheoretical model normalizes IPV victims’ reluctance to label their experiences as abuse and returning to the abuser after attempting to leave. Normalizing these common occurrences provides optimism for the counselor and potentially victims, as it explains that change is nonlinear and that normalizes common responses victims have in IPV relationships (Brown, 1997).

IPV Victims & Motivational Interviewing

Motivational interviewing is a directive, client-centered approach that elicits change by helping clients work through ambivalence (Miller & Rollnick, 2002, 2013; Rollnick & Miller, 1995). The counselor uses empathic listening skills to come alongside clients in session and avoids imposing ideas about desired change on clients. Motivational interviewing allows clients to maintain their dignity and self-respect while feeling heard and acknowledged (Miller & Rollnick, 2002, 2013; Rollnick & Miller, 1995).

Three primary concepts of motivational interviewing are readiness, ambivalence, and resistance. Readiness to change is a state that varies over time and is impacted by others (Miller & Rollnick, 2002). Readiness can be conceptualized as a continuum or through the stages of change. While it is not necessary to identify specific stages of change for motivational interviewing, it is important to maintain congruence with the client's readiness to change and the stages of change indicate clients’ readiness (Miller & Rollnick, 2002; Rollnick & Allison, 2004). Like in the transtheoretical model, ambivalence is considered normal. Ambivalence in motivational interviewing means that clients experience multiple emotions about their situations and choices they must make (Hughes & Rasmussen, 2010). Ambivalence may prevent clients from stopping unwanted behaviors and keep them in undesirable situations, such as abusive relationships. Many factors, such as isolation, financial dependence, and love for their partner contribute to IPV victims’ ambivalence about engaging in change behaviors related to their abusive relationships (Rollnick & Miller, 1995). Lastly, resistance in motivational interviewing is understood as a disconnect between the clients’ readiness to change and the interventions the counselor implements (Miller & Rollnick, 2002). For IPV victims, resistance may arise if they are encouraged to take steps for which they are not ready or when they feel that the counselor is disparaging their partner.

In motivational interviewing, the counselor helps clients identify differences between their goals and current choices, increase their self-efficacy, and make necessary choices to create and maintain desired behavioral changes (Miller & Rollnick, 2002). To achieve these goals, the counselor must engage clients in counseling, focus the sessions and client's interests, evoke change talk from the client, and support the client's self-efficacy (Miller & Rollnick, 2013). Whereas the transtheoretical model specifies unique counselor interventions which promote client movement within each stage, the motivational interviewing processes must build on each stage. This means that counselors continue to use previous processes while adding new ones as clients’ readiness to change increases (Miller & Rollnick, 2002, 2013).

To engage victims in counseling, the counselor expresses empathy and acceptance by asking open questions, affirming the client, summarizing what the client has said, and using reflective listening skills (Miller & Rollnick, 2013; Rollnick & Allison, 2004). Due to the abusive relationship and the advice giving of well-meaning friends and family, many IPV victims have not been able to explore their own thoughts and feelings related to their relationship. Through empathy and active listening, the counselor provides a safe, non-judgmental space for victims to process their internal reactions and desires.

The counselor then continues to use active listening to help clients develop discrepancies, which helps them focus on desired change. The counselor does not seek to cause discomfort or point out discrepancies to victims but instead reflects back their desired goals and current problem areas. As the counselor reflects victims’ goals and problem areas, victims are able to explore discrepancies between their stated goals and the problems within their relationship (Rollnick & Allison, 2004). In this way, motivation to create change is elicited from within victims, rather than being imposed by the counselor. As mentioned earlier, with IPV the problem behavior lies with the abuser, so the counselor must take care not to imply that victims can control the abuse. However, the counselor can help victims reflect on their desires for love and safety and choices that will help them achieve those desires, whether in their current relationship or not.

As discrepancies are developed, victims begin to engage in change talk which the counselor affirms. Change talk occurs when the client acknowledges disadvantages of their situation and advantages of change and expresses optimism about change or intention to change (Miller & Rollnick, 2002). When evoking change talk, the counselor must roll with resistance. In motivational interviewing, resistance is understood as an observable behavior which develops when the counselor is not in congruence with the victims’ readiness to change (Miller & Rollnick, 2002). When IPV victims exhibit resistance in counseling, the counselor has moved beyond the victims’ readiness level and returns to reflective listening to ensure that they feel heard (Rollnick & Allison, 2004). In this way, ineffectual therapy in which the counselor imposes goals and change on victims is avoided.

Finally, the counselor supports victims’ self-efficacy by eliciting self-motivating statements that highlight their ability to respond to manipulation and abuse in their relationship, as well as their ability to seek necessary help and resources that can increase safety (Miller & Rollnick, 2013). Because of the abuse they have experienced, many IPV victims have been isolated from their loved ones and present with low autonomy and self-efficacy (Rollnick & Miller, 1995). The counselor elicits self-motivating statements such as “I can cope in this situation’ and “I will do this in that difficult situation” to highlight victims capability (Rollnick & Allison, 2004, p. 110). The counselor uses empathic listening skills to help victims identify their own self-motivating statements without making suggestions or applying their own desired statements.

Preliminary studies of motivational interviewing with IPV victims have yielded promising results. Saftlas et al.'s (2014) study suggested that motivational interviewing positively impacted victims’ depressive symptoms, self-efficacy, and stage of change at greater levels than the control group. Rasmussen et al. (2008) found that motivational interviewing contributed to progress in readiness to change as measured by the stages of change. Control group participants tended to exhibit regression in readiness to change whereas the experimental group either maintained their stage of change or progressed into higher stages of change. Hughes and Rasmussen (2010) found that motivational interviewing increased victims’ commitment to making safety improving choices despite fear of their abuser and helped victims understand characteristics that increased their vulnerability to entering abusive relationships.

Limitations of Using the Transtheoretical Model & Motivational Interviewing with IPV

As mentioned previously, guidance for counselors to implement both the transtheoretical model and motivational interviewing with IPV victims is lacking. Counselors would need to access research from other fields. Unfortunately, some of the available research misconstrues aspects of the stages of change for IPV victims. For example, one article labeled safety seeking behavior such as calling the police when the abuser was physically violent as action (Chang et al., 2006). Calling the police in a crisis does not indicate that the person is in the action stage, as action requires planning and commitment. Another article focused on victims leaving the relationship as the primary way to increase safety in the action stage (Cluss et al., 2006). As previously stated, victims should leave a relationship on their own time and may not need to leave to increase their safety. Further research is needed to assess the effectiveness of both models for IPV and to ensure that counselors have adequate guidance on using them with victims in order to provide ethical and effective services.

Ethical Considerations

Counselors who work with IPV victims are faced with a major ethical question—“How do I respect client autonomy and do no harm, while also facilitating client safety and welfare?” (Kress et al., 2008, p. 205). As discussed earlier, ending an abusive relationship is not a guaranteed way to increase safety and danger may in fact increase. Therefore, clients may be safer remaining in the abusive relationship unless they are fully prepared to leave and have a thoughtful plan for their next steps (Walker, 1994). Regardless of the victims’ readiness to change there are several components that should be present in all aspects of IPV counseling: 1) emphasize that IPV is wrong and that no one deserves abuse; 2) provide information about IPV, community resources and services, and options for responding to IPV; 3) ask victims what help they need or want and communicate support; and 4) collaborate on a safety plan (Chang et al., 2006). Because of their developmental nature and focus on empowerment, both the transtheoretical model and motivational interviewing support the ethical mandate to facilitate client safety and welfare while respecting autonomy and doing no harm.

Conclusion

Both the transtheoretical model and motivational interviewing have been investigated as potential treatment models for IPV in medical, family health, and trauma journals but have received minimal attention in counseling journals. By providing a way to conceptualize IPV victims’ processes of increasing safety, the transtheoretical model can help counselors identify victims’ readiness to make change and appropriate interventions to use. Motivational interviewing can help counselors use appropriate skills for victims’ readiness change rather than imposing change ideas on the victim. Meeting victims’ needs based on their readiness to change can improve treatment effectiveness and encourage victims to continue services because they feel supported. Further research is needed on using the transtheoretical model and motivational interviewing with IPV victims, but they remain promising models to explain how victims seek safety in abusive relationships and guide how counselors work with IPV victims.