Interventions for Perpetrators of Intimate Partner Violence

SPECIAL REPORT

Intimate partner violence (IPV) occurs at an alarmingly high rate. According to the most recent survey of US adults, almost 7 million women and 5.5 million men experience physical violence, stalking, or rape by an intimate partner each year.¹ Psychological/emotional abuse, including threats of violence and a wide range of intimidating, denigrating, humiliating, and controlling behaviors, is also highly prevalent. Common physical health sequelae from IPV include contusions, soft tissue injuries, sprains, strains, fractures, maxillofacial injuries, and traumatic brain injuries.² In addition, the prevalence of PTSD; depression; and anxiety, mood, and substance use disorders is elevated in victims of IPV.^3,4

Table 1 provides a summary of salient points regarding IPV. Although the rates of physical IPV are roughly similar for men and women, the rates of physical injury and death are higher for women, and men are most frequently referred for treatment as perpetrators of IPV.^5,6 “Common couple violence,” which is typically bidirectional, non-injurious, and an outgrowth of poor conflict resolution, is distinguished from “intimate terrorism,” which is often unilateral, injurious, intensely controlling, and more gender-based in nature.⁷ Nevertheless, the findings on gender similarity and mutuality of violence challenge the common assumption that IPV is solely a male-to-female problem.^8,9

Table 1: Intimate partner violence (IPV): important points

Table 2: Treatment approaches for perpetrators of intimate partner violence (IPV)

Risk factors

Although there is no singular profile of the IPV perpetrator, there are several well-documented risk factors and correlates. A high percentage of court-referred IPV perpetrators have been physically abused and/or witnessed inter-adult abuse in childhood.^10,11 A history of conduct disorder in adolescence and antisocial personality traits or disorder have been found to confer risk for IPV, and adolescent and young adult couples with a history of IPV are characterized by a tendency of both partners to possess similar antisocial traits (ie, assortative partnering).¹²

PTSD is a substantial risk factor for IPV in veteran populations.¹³ A number of psychiatric disorders have been associated with men committing IPV, including depression, dysthymia, generalized anxiety, alcohol dependence, adult antisocial behavior, and nonaffective psychosis.¹⁴ A variety of indicators of negative emotion dysregulation are also associated with IPV, including borderline personality features, disorganized and insecure patterns of attachment, and anger problems.^15,16 The incidence of IPV is typically greater than 50% among both men and women who seek treatment for substance use disorders as well as for couples in marriage therapy.^17-21 The incidence of head injuries among IPV perpetrators is very high, as is that of subtle neurocognitive impairments that involve impulsivity, poor response inhibition, and deficits in executive functions.²²

Assessment

IPV is not commonly reported as a presenting concern, but it is readily detected through a brief structured interview or questionnaire. In addition to more extensive self-report measures, such as the Revised Conflict Tactics Scale, a number of brief IPV screening instruments have been developed and validated.^23,24 Several appear to have good sensitivity for detecting IPV, including the Partner Violence Screen, the Woman Abuse Screening Tool, and the Abuse Assessment Screen.^25-27 Although it is important to note that research on medical screening of IPV focuses almost exclusively on victims, clinical experience suggests that individuals seeking treatment for other problems, such as substance abuse, are often quite forthcoming about being abusive.

Intervention strategies

Psychosocial counseling for IPV perpetrators is widely available, with well over 1000 programs in the US. Most of these programs predominantly serve court-mandated populations and are focused on men who have assaulted women. Although a range of program philosophies and practices exist (Table 2), programs for perpetrators of IPV, often labeled batterer intervention programs (BIPs), tend to advocate an open admissions group modality and can last from 8 to 52 weeks.

There are 2 common types of BIPs. The first assumes a gender-themed root cause of IPV, such that the patriarchal nature of societal and institutional structures reward male domination and justify any means (including physical aggression) that reinforce male power, control, and privilege.²⁸ For example, the widely adopted Duluth Abuse Intervention Project model aims to prevent IPV via largely didactic psychoeducational reprogramming of (male) offenders. This model focuses on exposing patriarchal/misogynistic attitudes, encourages accountability and personal responsibility, and promotes gender-egalitarian behaviors. Although this approach has been criticized because of theoretical inconsistencies and lack of empirical support, most existing intervention programs use some variation of this model.^8,29-31

A second BIP model uses cognitive-behavioral therapy (CBT).^32,33 This model aims to change behavior through a collaborative therapeutic relationship, exposure and disputation of distorted cognitions, and various problem-solving and mood-regulating techniques.^34-38 Couples-based CBT that focuses on enhancing communication and problem-solving skills between partners remains controversial because of concerns about a heightened risk of injury to partners who remain with an abusive individual while simultaneously receiving treatment for potentially volatile relationship conflicts.

Despite the widespread adoption of BIPs, evidence for their effectiveness is limited and inconclusive. Most studies of BIP effectiveness have substantial methodological limitations, including very high rates of sample attrition, inadequate treatment standardization, little or no documentation of treatment fidelity, and systematic biases in random assignment.^37,39 For men assigned to BIPs, average violence recidivism rates are about 5% lower than those for men assigned to control conditions (eg, probation monitoring), with no differences in effectiveness between the Duluth model and therapeutic CBT programs.³⁸ Couples-based approaches have not been found to be more effective, or more dangerous, than gender-specific IPV treatments.⁴⁰ Thus, the empirical status of BIPs is decidedly uncertain, despite the enormous public health and safety concerns about IPV and the promise that such interventions have in rehabilitating offenders.

Alternative strategies

Interventions designed to enhance motivation and readiness to change have added value, beyond traditional BIP services.³⁹ In recent years, the focus has been on developing and evaluating alternative interventions, including medication therapy, comprehensive mental health case management, integrated treatment for substance use problems and IPV, culturally specific interventions, trauma-informed therapies, and interventions targeting motivation to change. Whereas all of these approaches can be well justified conceptually, empirical support remains limited.

An integrated CBT program for substance use problems and IPV produced significant short-term benefits in violence reduction during treatment; however, these differences were not maintained at a 6-month follow-up.⁴¹ Kraanen and colleagues¹⁸ evaluated the effectiveness of a CBT program that primarily targeted substance use disorders with a single session dedicated to IPV. At the 8-week follow-up, significant reductions in IPV and substance abuse were seen. The researchers concluded that a CBT program that targets substance abuse with some content regarding IPV may be a more economical solution in terms of financial and labor costs.

One study of a culturally focused program compared a group of African American men with mixed-race and same-race groups receiving a conventional BIP program. The results did not support same-race or culturally specific programs-the re-arrest rate for participants in the same-race groups was higher than for men in the conventional mixed-race groups.⁴²

A trauma-informed treatment for veterans who have perpetrated IPV was recently developed.⁴³ The treatment was designed to help veterans understand the effect of military and combat experiences on intimate relationships while emphasizing strength and coping resources and the development of new relationship skills. Initial pilot findings suggest that this approach was favorably received by veterans; however, no controlled trial data have been presented.

The focus of several interventions is on motivation and readiness to change, areas of considerable challenge in working with IPV perpetrators (who are often forced by courts or partners to seek treatment). Brief motivational interviewing-a supportive and highly empathic counseling style designed to resolve ambivalence about change-has been shown to enhance positive treat-ment engagement and compliance with behavior change recommendations.^44,45 Group approaches designed to help clients move through the stages of intentional behavior change have increased treatment adherence for highly resistant IPV offenders in one study and produced lower posttreatment violence relative to standard BIP services in another.^46,47

Research on medication therapies for IPV perpetrators is woefully limited. One randomized placebo-controlled trial examined flu-oxetine in combination with alcohol treatment and CBT for alcohol-dependent men who were perpetrators of IPV.⁴⁸ Medication produced significant reductions relative to placebo on measures of irritability and partner-reported IPV during this 12-week trial.

Practice recommendations supported by studies

Structured screening for IPV in mental health practice may be warranted for all cases but is particularly indicated for individuals with substance use problems, antisocial behavior, anger problems, a history of head injury, notable impulsivity, or emotion dysregulation.^12,15 When possible, including a confidential interview with the relationship partner can improve screening outcomes. Screening for IPV victimization in general medical settings remains a controversial topic, in part because a large multisite study found no significant benefits regarding morbidity or mortality.⁴⁹ Findings indicate that in more than half of the patients who screened positive for IPV, doctors never discussed the issue with them. Clearly, screening alone is not a magic bullet without subsequent intervention.

Strategies that focus on motivation and readiness to change appear to have added value in engaging IPV perpetrators into treatment and enhancing participation in behavior change interventions. Motivational interviewing uses a high level of empathic reflection and gentle guidance to evoke individuals’ articulation of motivation and commitment to change.⁵⁰

Effective treatment for substance use problems can have a substantial benefit in reducing IPV. Integrated approaches that teach relationship skills or involve partners in dyadic relationship enhancement may have added benefit for substance-abusing populations.⁵¹

Conclusion

Substantial progress has been made in the development of etiologic models of IPV and interventions for individuals who assault their intimate partners. Although clinical approaches based on long-standing models of IPV intervention have modest efficacy, there is a solid conceptual rationale for several alternative strategies for IPV perpetrators. Careful screening for IPV in mental health practice; supportive strategies to motivate behavior change; and integrated services that address IPV in the context of treatment for substance abuse, traumatic stress, neurocognitive conditions, and emotion dysregulation are amenable to integration into regular clinical practice and may have effects that match or exceed standard group interventions that take a one-size-fits-all approach to the treatment of IPV.

Disclosures:

Dr Eckhardt is Associate Professor and Director of the Purdue Institute for Relationship Research and Mr Sprunger is an advocate doctoral student in clinical psychology in the department of psychological sciences at Purdue University in West Lafayette, Ind. Dr Murphy is Professor and Chair in the department of psychology at the University of Maryland, Baltimore County. They report no conflicts of interest concerning the subject matter of this article.

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