How to write treatment plans for survivors of domestic violence

It's essential to note that the clinical approach to supporting survivors is dependent on their current safety status. Treatment will look fundamentally different for an individual in an active domestic violence scenario (where the focus must remain on safety planning and risk assessment as the first priority) versus someone who is experiencing distress or PTSD in the aftermath of domestic violence (where trauma processing and other therapeutic approaches become the primary focus). With that in mind, safety and risk assessment are always paramount before beginning more in-depth work.

Let’s take a look at what treatment interventions may be useful when working with survivors of domestic violence. Knowing the effective routes you can take with a client can inform your planning and treatment implementation.

Safety planning and risk assessment 

Risk assessment involves first evaluating imminent safety concern or level of risk. If active risk is identified, steps must be taken to protect the patient. If imminent risk is ruled out, risk assessment refers to evaluating the lethality and likelihood of further harm, violence, homicide, or suicide. Client reports are factored in giving weight to the survivor's subjective perception of risk. Building trust is essential to creating space where the patient can respond honestly. Empirical risk factors should be assessed, such as past violence/lethality history, violence and suicide history, current threats, escalation, hopelessness, access to weapons, and recent or pending separation status of the relationship. Assessments such as the Danger Assessment have been validated and can provide useful information, though providers should seek proper training before enacting these types of assessments.

Safety planning follows risk assessment and is a dynamic, collaborative, and personalized strategy intended to increase safety for clients and prepare them for potential crisis situations. Working out a unique plan with a client might include identifying warning signs that a crisis may be occurring, distress tolerance and emotional regulation skills (coping skills), crisis resources to contact, having a packed bag, pre-identified safe routes/locations, having safe people to call with code words, securing important belongings in advance, having a plan for children and pet care, and having a safe place to go. The Domestic Violence Crisis Center website has a helpful guide to safety planning.

Trauma-informed talk therapy 

Trauma-informed therapy should be infused in any care provided to survivors of domestic violence. This therapy approach is continually mindful of the significant impact of the trauma that domestic violence can cause for survivors. Therapists should emphasize safety, empowerment, collaboration, and avoiding re-traumatizing the client throughout treatment. Coping skills and resilience are often focuses of the therapy. Research has shown trauma-focused cognitive behavioral therapy (TF-CBT) and narrative exposure therapy as two talk-based therapies that have results on the mental health impacts of domestic violence.

Crisis intervention resources 

Part of a good safety plan must include crisis resources. You can supply these for clients who are not already aware of them. These are services that can provide immediate support, shelter, safety, and counsel in emergency situations. Some good places to start include:

• National Domestic Violence Hotline (1-800-799-SAFE): Provides free and confidential crisis intervention, support, education, and referrals to local services
• Sexual Assault Hotline (1-800-656-HOPE): Offers support and resources to survivors of sexual assault including crisis counseling, and referrals
• Domesticshelters.org: A website to find local DV shelters, programs, hotlines, and education on how to escape and find recovery
• Advocacy services that can be found by contacting hotlines, state or county services, or local community organizations

Support groups for survivors 

Group interventions for domestic violence survivors have been proven through research to have a strong impact on symptom reduction and reduced isolation. Particularly CBT group-based interventions have proven to be as effective as individual therapy. It is important to note that psychological interventions for domestic violence survivors, both individual and group, have proven to improve mental health symptoms but do not necessarily reduce the client’s participation in relationships containing domestic violence. 

Psychoeducation on abuse and trauma cycles

Normalizing the effects of trauma for clients and educating them on the patterns of abuse can be helpful once safety is established. The cycle of abuse is an educational tool promoted by domestic violence educators and support providers. Use clinical judgment to determine when a client is ready to receive psychoeducation based on their ability to tolerate distress, receive new information, and exhibit cognitive flexibility. 

Addressing PTSD, anxiety, and depression

For insurance purposes, there are T-codes that capture domestic violence. But these codes should almost always be used in acute-care settings, not by outpatient providers. 

Often, it may be favorable for outpatient providers to bill for the mental health challenges related to domestic violence, such as PTSD, anxiety, or depression.

When these mental health symptoms are present and related to domestic violence, they should be addressed in the treatment plan. Research has proven that multiple interventions, including EMDR and CBT, are effective in reducing symptoms for survivors of domestic violence. In addition to these, the American Psychiatric Association (APA) recommends skills training in affect and interpersonal regulation (STAIR), interpersonal therapy (IPT), and cognitive processing therapy (CPT). 

Empowerment and self-esteem building 

Survivors of domestic violence often are stripped of choice and control, which can erode self-esteem over time. Empowerment and self-esteem oriented therapy focuses on giving control and choice back to survivors through every aspect of treatment. Support in decision making — as well as skill building in communication, boundary-setting, and emotional regulation — can also be part of empowerment and self-esteem building. It’s important to address conversation around leaving a partner sensitively. When approaching the topic of separation, clinicians must prioritize client autonomy and safety. Pushing or suggesting that a client leave an abusive partner is clinically inappropriate, as it risks shattering the therapeutic alliance and causing them to shut down. Crucially, the period surrounding separation is statistically the highest-risk time for violence, including lethality, meaning any discussion must be immediately framed around enhanced, client-driven safety planning. This runs the risk of breaking trust with the client or causing them to shut you out. Focusing on motivational interviewing and building resources can further empower survivors.

Individual or group CBT, acceptance and commitment therapy, support groups, and schema therapy are interventions that are proven to boost self-esteem and resourcefulness. The APA recommends HOPE (helping to overcome PTSD through empowerment) and RPRS (relapse prevention and relationship safety) as some interventions focused on safety and empowerment. 

Legal advocacy and case coordination

In navigating the complexities of domestic violence, other supports are often involved beyond just therapy. This might include legal advocacy. Referrals can be made when survivors need help to navigate protective orders, custody hearings, or divorce proceedings. Therapists can only share as much with a legal advocate as the client wants them to share. Other care might be offered through case managers, doctors, or shelter staff, for example. It should be determined with the client and other support team members what makes sense for the cadence and depth of coordination. Appropriate coordination of holistic care through a multidisciplinary team improves outcomes for DV survivors.  

Note on legal and ethical duties: Providers should document any safety concerns discussed with a patient, particularly when domestic violence is mentioned or when the patient remains in contact with the perpetrator. Careful documentation supports continuity of care, facilitates appropriate follow-up, and ensures compliance with reporting obligations.

Involving trusted support systems 

Defining who a survivor can trust as part of their social support team is an effective intervention. Family members, close friends, neighbors, faith leaders, or professionals are all possibilities to fill the role of support team. Directing the client towards this support team can enhance emotional safety, physical safety, support for practical needs, and empowerment. Where appropriate, signed consent can be obtained from the client to give permission for these support people to join certain sessions of therapy or safety planning. If collaborating with these support people, it is critical to determine their role and purpose as part of treatment. Boundaries, consent, and confidentiality should be discussed with the client about anyone involved in this way.