Violence between partners seeking therapy is estimated to be between 20% to 58% and while couple therapy is entirely inappropriate where there is a climate of fear and abuse, decision making becomes murky when violence is perpetrated by both parties and neither indicate terror or coercion by the other. Couples who engage in reciprocal violence often do not identify it as a major concern and when denied couples therapy will seek it elsewhere. Practitioners may choose to sidestep the issue for fear of being seen as unethical or adopt a blanket policy of refusing services to any couple who have physically hurt each other. Clearly there is a significant gap between clients’ requests for couples therapy and practitioners’ willingness and confidence to offer it.
When to Exclude and When to Accept?
While earlier clinical research excluded couples who reported physical aggression , ‘more recent outcome studies of couples with mutual physical Intimate Partner Violence (IPV) have since shown that conjoint treatment can be delivered safely in select situations with some clinical benefits on relationship satisfaction and IPV perpetration.’
Authors Sullivan et al (2025) acknowledged the challenge they faced as experienced researchers and therapists and undertook to ‘explore practices and perspectives of clinicians and scientists involved in IPV research on whether and how to treat couples with mutual physical IPV.’ They recruited 12 expert clinician researchers who they interviewed to better understand treatment exclusion decisions.
What Were They Told?
No participant excluded the possibility of couple therapy while stressing the importance of clinical judgement premised on comprehensive assessment and training. They noted the ethical dilemma of balancing the need to minimize potential harm that may come from couples therapy with the justice of providing evidence-based care to reduce mutual violence. However, participants differed in the weight given to mental health and substance misuse, with some clear that this was a ‘no go’ while others seeing it more as a ‘red flag.’
Intervention strategies to address mutual physical IPV were drawn from existing couples therapy approaches including maintaining safety, skills development, teaching conflict management and de-escalation and increasing relationship satisfaction. Mapping the pattern of interaction around conflict was identified as important. Emotional regulation and anger management, strategies from individual approaches were also incorporated into joint work.
Barriers to working with these couples included a lack of support outside the therapy session, training, and a paucity of research to guide safe and effective practice.
Implications for Clinical Practice
To make the decision to offer or withhold conjoint therapy, the authors stressed the need for clinicians to remain abreast of guidelines derived from research to support assessment and safe decision making. A second suggestion is to ‘conduct flexible, ongoing IPV assessment that considers important contextual factors’ and to integrate safety planning as an ongoing aspect of care. The final proposal is that clinicians should be aware of alternate supports for couples when it is decided that conjoint therapy is not appropriate. More generally there is a requirement to expand training in assessment to assist clinicians in making the difficult decision to offer or refuse therapy.
In Conclusion
The decision to offer couples therapy when IPV is present will remain ethically and practically challenging. However, failing to address it will undermine development of safer and more effective assessment and intervention tools and leave both practitioners and their clients unsupported.
Sullivan, T. Daniel O’Leary, K., Sarah M. Bannon, S. A Qualitative Study of Couple Therapy Exclusion Practices Related to Mutual Physical Intimate Partner Violence Journal of Marital and Family Therapy, 2026; 52:e70108 https://doi.org/10.1111/jmft.70108
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