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In their 2019 meta-analysis on psychological abuse and mental health (published in Systematic Reviews), Sarah Dokkedahl and colleagues found that psychological violence is estimated to be the most prevalent form of intimate partner violence, yet there is very little research on the individual impact of psychological abuse on mental health.

Historically, psychological abuse has been widely overlooked, despite the staggering statistics. In the National Intimate Partner and Sexual Violence Survey: 2010 Summary Report, Michele Black and colleagues reported that approximately half of Americans had experienced emotional abuse by a partner in their lifetime. In addition, they found that psychological abuse causes long-term damage to a victim’s mental health and that subtle psychological abuse is more harmful than overt psychological abuse or direct aggression. These findings indicate the urgency to educate clinicians on how to accurately identify psychological abuse and power imbalances in a relationship, particularly when the more overt forms of abuse are not present.

Furthermore, victims of psychological abuse often do not know that they are experiencing abuse, even though research has repeatedly shown that there is a strong link between psychological abuse alone and a range of mental health disorders and physical conditions such as posttraumatic stress disorder, anxiety, depression, suicidal thoughts, irritable bowel syndrome, gynecological problems, chronic pain, substance use, physical injury and sleep disturbances. In fact, Mary Ann Dutton and colleagues’ article published in the Journal of Interpersonal Violence in 2006 and Mindy Mechanic and colleagues’ article published in Violence Against Women in 2008 both found that psychological abuse is a stronger predictor of posttraumatic stress disorder than physical abuse among women. If clinicians are not sufficiently trained in psychological abuse, then this population will lack adequate support, or even worse, abuse victims may be further victimized by the untrained therapist, particularly in couples therapy.

Misconceptions about abuse

Many misconceptions about abuse have created certain social stigmas and prevent those experiencing abuse from accurately identifying what is occurring in their relationship and seeking help. Some of the most common misconceptions include that abuse only occurs among poor individuals and minorities, that abuse is only physical or sexual, that abuse is the fault of both parties, and that victims of abuse have grown up in abusive homes and are just returning to something familiar (which does happen but is also frequently not the case).

A prevalent misconception involves incorrectly profiling victims of abuse. Many have a preconceived notion that victims of abuse present as meek or timid and are therefore easy to identify. But this is not true at all. In fact, many victims of abuse are strong, well-educated, financially successful and independent. Many are top employees or leaders in their field. The outside world would never guess that behind closed doors, the person is being criticized unrelentingly, monitored by their partner, threatened if they try to leave and guilted for having other support systems. Counselors must be aware of their own beliefs around abuse so as not to overlook what may be occurring for their clients.

A common example of this is the tendency to overlook men as victims of psychological abuse when the reality is that nearly half of women and men in the United States have experienced psychological aggression by an intimate partner. This results in many men not recognizing that they are being abused, so a large percentage of this population doesn’t seek help because they feel confused, ashamed or embarrassed or they believe that it is their fault. In addition, there is a cultural expectation that men are supposed to be “strong” and assertive and know how to stand up for themselves. Compounding the issue, boys and men who have been raised to be respectful of women may take this to mean that they shouldn’t set boundaries even if they are being mistreated by their partner. And traits such as being highly empathetic, emotionally sensitive, overly responsible and conscientious may not only put men at greater risk for being mistreated by their partner but also increase the likelihood that they will stay in an unhealthy dynamic.

For victims of psychological abuse, the term “abuse” may be hard to accept if physical violence is not occurring. Once counselors identify that physiological abuse is occurring, they can begin to support their clients to accept this reality. If the client is not ready to accept or use the term abuse, counselors can explain the dynamic using the concept of bullying in their relationship. This can help victims of abuse digest the information until they are ready to fully accept what is happening to them. Victims of abuse often carry a substantial amount of shame around not seeing or ignoring early warning signs, not leaving sooner, or falsely believing that they have done something to cause the abuse to occur. Most victims of abuse have engaged in ways that they would not have otherwise behaved if they had not been coerced, forced or scared. Supporting these clients through abuse education and trauma recovery, helping them develop other support systems and fostering their sense of worth and self-esteem are all vital to intervention.

Signs of psychological abuse

Psychological abuse is insidious, and often there are no overt signs of violence. It is imperative, therefore, that counselors know warning signs that indicate abuse is occurring. Here are some important factors to look for when working with clients who may be in an abusive relationship:

• A person who seems insincere or overly friendly
• A person who exhibits grandiose displays of attention during the courting phase of the relationship
• A person who withholds affection, attention, love, sex, money or children
• A person who speaks disrespectfully about their partner, to their partner or in front of others
• A person who puts their partner down through humor or is overly critical
• A person who isolates their partner by sabotaging their support systems
• A person who speaks disrespectfully about their former partners
• A person who has a history of not cooperating with others professionally or personally
• A person who has more power in the relationship
• A person who has a pattern of possessive, controlling or jealous behavior
• A person who has a pattern of not taking responsibility, dishonesty or infidelity
• A person who intimidates their partner when they’re angry
• A person who has negative views toward women or double standards
• A person who consistently takes the opposing stance from their partner
• A person who lacks empathy for their partner

Keep in mind that it is unlikely that all of these patterns will occur within the relationship. A combination of symptoms is typically present, and inquiring about the couple’s history and the beginning of the relationship can provide valuable insight for clinicians. For example, frequent calling or texting with seemingly “loving” messages may actually be an attempt to keep tabs on a partner. The partner may not make this connection but might report feeling anxious without knowing why. A client may also report engaging in excessive exercise, and with further inquiry, the clinician may learn that the client’s partner is critical of her family and friends and claims that they are not good influences, which causes the partner to worry about her mental health. Thus, the client becomes isolated from their support system and instead turns to excessive exercise as a coping mechanism. On the surface, these criticisms may seem to come from a place of love or concern, but they could be signs of an unhealthy dynamic at play.

Assessing for psychological abuse

In my clinical practice, I have observed some patterns that appear to be prevalent in abusive relationships. Clinicians need to be aware that these patterns exist in both physically abusive relationships and partnerships with psychological abuse alone. At the heart of an abusive relationship lies the abuser’s core desire for power and control. Abusers’ styles may vary somewhat, but the underlying mechanisms they often use to gain power and control include the following.

Lack of empathy. Empathy and conscience are directly correlated. The higher one’s level of empathy, the greater likelihood their conscience can clearly differentiate between right and wrong. An abusive person has diminished empathy for others and a reduced capacity for distinguishing between right and wrong. This directly affects the abuser’s value system, making the abuser less responsive to the needs of their partner and/or children.

Sense of entitlement. Abusers have a high need for control. One presentation of this can be seen in an abuser’s sense of entitlement or belief that they know best and/or that their partner owes them. At the core, an abuser is insecure and compensates for this insecurity by undermining their partner. An abuser sees their partner’s autonomy as a threat. In an effort to reduce this threat, an abuser will try to diminish their partner’s character, accomplishments and other relationships. The presentation of this pattern is often more covert and can even play into an abuser’s charm. The abuser, for example, may use humor to put their partner down, have double standards or play devil’s advocate, all of which enhance the power differentiation.

Defensiveness and manipulation. Clinicians may have a difficult time recognizing an abuser’s manipulative tactics. Abusers often present themselves with charisma. They may impress clinicians with their “psychological awareness.” In couples therapy, they may seem like the “good” one, while their partner seems to be more emotionally reactive, hysterical, or physically or mentally unwell. Counselors are often unaware of abusive relationship patterns and will unconsciously support the seemingly balanced and logical abuser, which gives the abuser more leverage against their partner and furthers the abuse. Clinicians must pay attention to each person’s account of behavior at home and keep the possibility of a power differentiation in mind. Furthermore, counselors should pay attention to their own feelings in response to each client. Often a clinician may feel uneasy or intimidated by a client, but they may not be able to identify why. Examples of this include a client who is overly flattering to the therapist or a client who causes the therapist to question themselves. It may be hard for the clinician to pinpoint what is occurring, which is a telltale indication of a good manipulator.

Lack of responsibility. Abusers typically do not take responsibility for their behaviors or actions. This can be seen in interactions with their partner and often in their professional interactions. They often blame others or external events for their actions, rather than holding themselves personally accountable. This frequently presents as being a victim, so clinicians must pay careful attention to the person’s overall pattern of limited accountability. Typically, an abusive client will quit therapy once they realize that they are unable to manipulate the therapist. When this occurs, therapists must realize that this is not a failure on their part, but rather an indication that the abuser does not want to take responsibility for or change their hurtful behavior. When this happens, therapists can focus their work on supporting the abused partner.

Playing the victim. Playing the role of the victim is likely the abuser’s most powerful manipulation. They can cleverly disguise their aggressive behavior by appearing to be the injured party; for example, the abuser may blame their partner for the exact hurtful behaviors that they are actually doing. The partner then blames themselves and believes the abuser’s story of victimhood. An abuser is highly skilled at making others, including their partner, feel sorry for them; they know exactly which buttons to push to evoke sympathy. This makes the partner blame themselves and often prevents them from identifying the bigger issue because they take more than their fair share of the blame and responsibility. Clinicians can often be led astray and fall for the abuser’s manipulation.

The push/pull pattern. An abuser is not mean and cruel all of the time. If they were, then their partner would be more likely to leave the relationship. An abuser pushes boundaries, escalating mistreatment. And when the abuser gets away with the abuse, the severity of the abuse escalates. This represents a win for an abuser because they gain more power in the relationship and their partner is increasingly rendered powerless, which in turn makes them easier to control. The abuser then displays “loving” gestures to keep their partner off balance and questioning themselves. This is often seen in the “honeymoon phase” of the abuse cycle when the abuser is attempting to atone for misconduct. The abuser might do something for their partner that they know their partner has always wanted. This demonstration fills the partner with positive feelings for the abuser and with the hopeful, but false, belief that the relationship can be the way that it was in the beginning.

Abuse is gradual and cyclical. Abuse is not obvious at first, but it escalates over time. The more committed the relationship becomes, the more the abuser escalates the abuse because they know that their partner is less likely to leave if there is a strong commitment (e.g., shared finances, children). The severity of abuse increases as the victim tolerates the mistreatment and does not leave the relationship. More overtly abusive episodes are followed by a honeymoon phase, where the abuser may act remorseful and appears to have changed. This leads into the buildup phase where an abuser’s partner begins to feel tension and anticipates the next overtly abusive episode. During this phase, the abuser’s partner is likely to either tread lightly to avoid conflict or initiate conflict in hope that the abusive episode will not be as severe if the buildup phase has not lasted as long. Both behaviors are an effort to manage the abuser’s reaction and an attempt to give the victim some sense of control over the severity of the abuse.

If a counselor suspects psychologically abusive behaviors in the relationship after identifying the presence of some of these patterns, it is important to address it. Clinicians need to ascertain the level of the abuse and whether any physical or sexual abuse has ever occurred. It can be quite helpful to work with both parties individually in addition to couples therapy. Working individually with the victim can allow a safe environment for full disclosure, and counselors can support the client through abuse education and help them to recover their confidence and self-esteem. Best practices include trauma work and building on the client’s strengths and available resources. Working individually with the perpetrator allows the clinician to explore past trauma, their need to control and anger management.

It is important to note that there is a spectrum of abuse, ranging from being overly critical and controlling to pointing a gun or battery. Individuals who fall on the lower end of the spectrum are a lot more likely to respond positively to interventions versus those who display more aggressive signs of violence. There is also a correlation between the perpetrator’s level of accountability and empathy for others and the likelihood that therapy will be successful. As previously mentioned, most perpetrators of abuse (both overt and covert) are unwilling to take responsibility for their behavior, meaning that once confronted by the counselor, they typically quit coming to therapy. There is very little that counselors can do to avoid the discontinuation of treatment if the perpetrator of abuse does not want to participate in therapy.

For therapy to be effective, counselors must address the abusive behavior. If the individual is unwilling to confront their behavior, counselors must not take this as a failure on their part but understand that it is a symptom of the abuser’s personality structure. Clinicians must continually evaluate the level of risk to their clients and to themselves when working with individuals who abuse and refer to available resources when necessary. If there are concerns about the physical safety of the victim or the counselor, appropriate steps must be taken to ensure everyone’s safety.

Conclusions and recommendations

My primary recommendation to the counseling field is a call for more research in the area of psychological abuse. Despite the prevalence of psychological abuse worldwide, numerous studies confirm that it still remains a severely neglected area of study. Because research drives clinical practice recommendations, it is imperative that we start here. Psychological abuse is a complex issue, and identification and intervention are difficult at best. Because covert forms of psychological abuse may be harder to identify, clinicians need to pay particular attention to how both people feel in their relationship. When counselors are aware of the characteristics and patterns of an abusive relationship, they can use intervention strategies to adequately support their clients in clinical practice.

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Read more in Avery Neal's online exclusive "Does your personality make you more vulnerable to abuse?"

Avery Neal holds a doctorate in psychology and is a licensed professional counselor, a practicing psychotherapist, and an international author and speaker. In 2012, she opened the Women’s Therapy Clinic, which offers psychiatric and counseling support to women. She is also the author of If He’s So Great, Why Do I Feel So Bad?: Recognizing and Overcoming Subtle Abuse, which has been translated and published in 12 languages. Contact her through her website at averyneal.com.

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