Your book is called ‘Trapped in a Violent Relationship’. What does that trap actually look like from the inside?

It looks like this: you and everyone around you know that you’re in a dysfunctional and harmful relationship. But although you know, you don’t know how to get out. And most of the time you judge yourself harshly; you think you’re irrational or stupid. Yet as soon as you start describing what actually happens in your mind, you discover a great deal about yourself.

The majority of victims of violence feel profound shame. They often ask themselves: ‘Why didn’t I leave sooner? Why didn’t I protect my children?’ They come to me filled with guilt. That guilt says nothing about their character, but about how psychologically complex this situation truly is.

There are also people who don’t recognise their situation as problematic at all. That is precisely the hardest case for the therapist; the therapist too finds herself in a kind of internal conflict: ‘Should I intervene? Or does she have the right to make her own choices?’ The same ambivalence the client experiences plays out for the professional as well.

You make an important distinction between healthy affective dependence and Pathological Affective Dependence (PAD). Where exactly does the line lie, and why does that distinction matter clinically?

Affective dependence is, in itself, normal. We all depend on the people who matter to us. It becomes pathological when that dependence is unregulated and abuse is present, and yet the dependence on the abuser persists. Take a six-year-old child who is sexually abused at home but has nowhere else to go. That child develops the idea that the abuser is simultaneously the person on whom its survival depends. Such a pattern leaves deep traces. Of course this is an extreme illustration, and relationships with children and partners are not interchangeable, but PAD often starts early in life.

People with PAD do not simply stumble upon the wrong person. They unconsciously seek someone who resembles the person who hurt them in the past, in an attempt to finally resolve that old trauma. Someone who genuinely loves and cares for them feels ‘boring.’ That distinction, seeking confirmation versus seeking repetition, is clinically essential.

Your cognitive model describes three types of internal conflict: absent, alternate, and akrasic. What does a psychologist actually see in the consulting room at each stage?

In the absent conflict, the client is unaware of the dysfunctional nature of the relationship, while everyone around her can already see the red flags. She describes the relationship as the best she has ever had, while you as a therapist are thinking: ‘This doesn’t add up. He controls who she sees, he checks her phone.’ But to her, that is love.

In the alternate conflict, two opposing mental states alternate without integration. One week the client absolutely wants to separate. The following week she stops taking contraception because they have decided to have children together. It is as though you are dealing with two different people. She does not recognise the alternation herself.

The akrasic conflict is the most workable starting point for the therapist. The client says: ‘I know I have to leave. I have tried several times. But I keep coming back. I feel glued to him.’ The two mental states are now integrated and she sees the problem, but she does not know how to get out. This is where the real therapeutic work begins. Akrasia does not mean the door is blocked. I am speaking about situations where the door is open, family is waiting with open arms, and yet the person stays. That is PAD.

PAD clients often come to therapy for something else entirely, burnout, insomnia, panic attacks, without recognising the relationship as the problem. What should alert a psychologist?

First of all, there is a validated measurement tool: the Pathological Affective Dependence Scale (PADS), now also available in Dutch. The scale is included in the book and will be made freely available in open access.

But the most important step is simpler: ask about the quality of the relationship. As soon as you hear red flags, controlling behaviour, isolation from friends, systematic humiliation, test specifically for PAD. Do not wait for the client to make the connection herself. She may be in the absent conflict stage and genuinely experience the relationship as wonderful. There is also an interesting profile worth noting: people with PAD are often high achievers. Because they have no limits with respect to themselves, they tend to be workaholics and highly productive. Someone who is a company director, has all the financial means to leave, and yet stays: that is PAD. Not a lack of resources, but a psychological blockade.

Your model describes four prototypical PAD profiles: the Saver, the Unworthy, the Traumatic, and the Mixed. Does each profile require a different therapeutic approach?

The core treatment is the same across profiles: you always work on the three frustrated basic needs, love, dignity, and safety. But if a client has specific deep trauma around safety, you go deeper into that part of the work.

What surprised me: I initially thought the Traumatic profile would be the most difficult to treat. In practice, the Saver profile turns out to be the most resistant. The Traumatic client fundamentally does not want to be mistreated. The Saver, however, genuinely believes that helping others is a virtue, that placing herself second is normal and good. This is egosyntonic: she does not experience it as a problem, but as a quality. ‘I am a good person because I take care of others.’ Shifting that belief takes a great deal of time.

You argue that PAD is both a trait and a state condition, meaning it can be activated by a dysfunctional environment and may largely resolve when someone leaves it. How does this change assessment and treatment?

I always use the example of rheumatoid arthritis. Someone with rheumatism carries the underlying predisposition, that is the trait. But it only flares when the environment is damp. Sleep in a dry, healthy environment and you feel almost no pain. PAD works the same way: the vulnerability is latently present but only activates within an abusive relationship.

I arrived at this insight through my own clinical practice. I administered personality questionnaires to clients and saw profiles resembling borderline personality disorder at intake. After treatment, once they were outside the toxic relationship, those same traits had largely disappeared. They were not borderline; they were responding to a sick system.

Treating PTSD after someone has left the relationship is necessary but not sufficient. If you do not address the underlying PAD vulnerability, the client will return. And that return is precisely the most dangerous moment: the risk of escalating violence is highest in the first eighteen months after separation.

In forensic psychology, we often encounter both victims and perpetrators of IPV. What does your model tell us about the perpetrator?

The origin of PAD is the same for both victims and perpetrators: a chronic frustration of the basic relational needs for love, dignity, and safety. The difference lies in the coping strategy. Victims respond with self-sacrifice and submission. Perpetrators respond with control, violence, and acting out.

My hypothesis is that if we also treat the PAD of the perpetrator, we work on both sides of the problem. Incarceration alone is not enough. If someone leaves prison carrying the same underlying trauma and the same coping strategies, the pattern will repeat.

Victims and perpetrators do not find each other by accident. They recognise something familiar in one another, complementary needs. A fragile person is drawn to a dominant one. Both are repeating the dynamic they learned in childhood. I sometimes ask clients to bring me photographs of their parents and of the perpetrator. You can see physical overlaps, a smile, a way of looking. They are searching for the familiar, even when that familiar thing once caused them pain.

PAD is a latent condition that can be triggered by an abusive environment. What does that mean for prevention?

Yes. Those who have experienced a chronic frustration of basic relational needs in their past are more vulnerable to violent relationships. You are not simply unlucky in your choice of partner; you are unconsciously seeking someone who resembles the person who hurt you before, hoping to finally resolve that trauma. Within an IPV context, that is a path that never ends well. If I had all the resources in the world, I would invest them in supporting healthy family relationships. The roots lie in the family. By the time you are treating a victim, it has already happened.

Prevention begins with children, with families, with schools. We assume that people intuitively know how to have healthy relationships. But they often don’t. We learn from our parents, who learned from theirs, with all the intergenerational trauma that entails. It is also striking that the figures in the Netherlands and Italy are nearly identical, despite the cultural differences. That speaks to how universal this phenomenon is. Culture plays a role, but PAD transcends cultural boundaries.

Your clinical work grew partly out of your self-help group Millemé. How has listening to survivors shaped your theoretical model?

Millemé has existed for nearly nine years now. The name means ‘a thousand times me’, a double meaning: ‘I am not alone, and there are thousands of people living the exact same story, with different voices but the same scrip’t. What the group does that individual therapy finds harder to achieve: it breaks the conviction that your suffering is unique. Almost every client thinks: ‘You don’t understand. My situation is different. He really will come back for me.’ But in the group, they hear others speaking the exact same words. That has a sobering effect, and a healing one. ‘My situation is not special?’ That realisation can accelerate the movement from the alternate to the akrasic conflict, after which the trauma work can truly begin.

What is the one thing you wish every psychologist knew about PAD before walking into a session with a client who might be experiencing it?

That knowing alone is not enough. Not for the client, and not for ourselves as therapists either. Psychoeducation about violence cycles and PAD profiles increases understanding, but it does not unlock the emotional blockade. A client can understand everything intellectually and still return, because the trauma lies deeper than rationality can reach.

Treat the PAD itself, not only the presenting complaint, not only the PTSD after the fact. And stay alert: the most dangerous moments are not when someone is still in the relationship, but just after leaving. When a client says ‘I left him,’ that is the moment to be most vigilant, not to lean back in relief.

Tekst: Thirsa van Til