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Couples Treatment for Interpersonal Violence: A Review of Outcome Research Literature and Current Clinical Practices

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Abstract

Conjoint couples treatment for interpersonal partner violence (IPV) remains controversial despite a growing body of research and practice experience indicating that it can be effective and safe. In addition, developing typologies of couples who are violent suggest that a "one-size-fits-all" treatment approach to IPV is not appropriate and conjoint treatment may have a place in the treatment of at least some couples. In this article, we review the experimental studies and clinical practices of conjoint treatment. Based on this review, we suggest current best practices for this approach to treatment. Best practices include couples treatment as part of a larger community response to IPV, careful screening of couples for inclusion in couples treatment, modification of typical conjoint approaches to promote safety and ongoing assessment of safety with contingency plans for increased risk.
Couples Treatment of IPV 1
Couples Treatment for IPV:
A Review of Outcome Research Literature and Current Clinical Practices
McCollum, E.E., & Stith, S.M. (2008). Couples treatment for interpersonal
violence: A review of outcome research literature and current clinical practices. Violence
and Victims, 23, 2, 187-201.
Eric E. McCollum, Ph.D.
ericmccollum@vt.edu
Marriage and Family Therapy Program
Virginia Tech – Northern Virginia Center
Falls Church, VA
Sandra M. Stith, Ph.D
sstith@ksu.edu
Marriage and Family Therapy Program
Kansas State University
Manhattan, KS
Couples Treatment of IPV 2
Abstract
Conjoint couple treatment for Interpersonal Partner Violence (IPV) remains controversial
despite a growing body of research and practice experience indicating that it can be
effective and safe. In addition, developing typologies of couples who are violent suggest
that a “one size fits all” treatment approach to IPV is not appropriate and conjoint
treatment may have a place in the treatment of at least some couples. In this paper, we
review the experimental studies and clinical practices of conjoint treatment. Based on
this review, we suggest current best practices for this approach to treatment. Best
practices include couples treatment as part of a larger community response to IPV,
careful screening of couples for inclusion in couples treatment, modification of typical
conjoint approaches to promote safety and on-going assessment of safety with
contingency plans for increased risk.
Couples Treatment of IPV 3
Couples treatment when there has been intimate partner violence (IPV) remains
controversial and objections to it have generally taken two forms – one pragmatic and
one philosophical. On the pragmatic side, the assumption has been widely made that
conjoint treatment sessions increase the likelihood of violence. Adams (1988) states
plainly, “Many battered women report that past family therapy sessions were followed by
violent episodes” (p. 187). The mechanism proposed is that women are asked to be open
and honest about their complaints and grievances in a conjoint session – sometimes with
a false sense of security arising from the fact that the man has agreed to treatment – only
to face retaliatory violence after the session for embarrassing or challenging him.
The philosophical objection to conjoint treatment is based on a critique of the
systemic paradigm that underlies most relationship therapy. Critics propose that, as
Bograd (1992) puts it, “Systems formulations still either implicate the battered woman or
diffuse responsibility for male violence” (p. 246). By looking at violence in an
interactional context, critics fear that women will be put in the position of having to help
control their partner’s violent behavior of which they are a victim. In addition, instead of
the man being held squarely responsible for his actions, his responsibility may evaporate
in discussions of couple interaction patterns, conflict resolution skills, family of origin
issues, and the myriad other things that comprise couples therapy.
The critique of couples treatment has been influential with clinicians, state
certification bodies, and other policy makers who have often opted for the presumably
safer standard treatment of gender-specific groups for male batterers and female victims.
Currently, 44 states have promulgated standards for batterer intervention. In a 2005
analysis of these standards, Maiuro and Eberle (in press) report that 68% of states with
Couples Treatment of IPV 4
standards expressly prohibit couples treatment during the time that primary domestic
violence intervention is on-going in favor of gender-specific treatment. This actually
represents an increase in the percentage of states prohibiting couples treatment since
Maiuro and colleagues’ 2001 survey of state standards (Maiuro et al., 2001). However,
as Saunders (in press) points out, there is not yet sufficient evidence for the efficacy of
male-only batterer intervention programs. Thus, other promising treatments like conjoint
couples treatment are being foreclosed in favor of traditional but not necessarily effective
approaches.
The Case for Couples Treatment
We take the safety – both physical and psychological – and the empowerment of
our clients to be fundamental in all the clinical work that we do. At the same time, we
have been involved in developing and studying couples treatment for domestic violence
for a number of years. How do we justify our commitment to couples treatment in light
of the many objections to it? We have a number of reasons for this stance.
In our view, the primary philosophical objection to couples treatment – that a
systemic approach blames the victim and relieves the perpetrator of responsibility for his
acts – is based on a simplistic and out-dated understanding of systems models. Simplistic
circular causality models of interaction have given way to more complex and layered
models – models that include the individual and the social context along with the
interactions between partners. Sprenkle (1994) contends that few, if any, systemic family
therapists would consider a woman’s actions the cause for her partner’s violence against
her, nor would they eschew taking a firm stand against violence in favor of “systemic
neutrality.” The models of couples treatment for IPV described in this paper have begun
Couples Treatment of IPV 5
to operationalize this theoretical position and provide ways to both hold violent partners
accountable and examine couple interaction.
A second aspect of our consideration for the use of couples therapy is the growing
realization that not all violence in intimate relationships is the same. In the 1980’s and
early ‘90s, a number of typologies of male batterers emerged driven by data from
national random surveys and by the widening societal definition of violence that has
brought a much broader spectrum of violent acts to the attention of the courts and
treatment providers. Holtzworth-Munroe and Stuart (1994) aggregated these typologies
to propose 3 profiles of male batterers based on the severity and frequency of the
violence within the relationship, whether the man is only violent in intimate relationships
or also outside the relationship, and whether or not psychopathology is present.
Johnson (1995) proposed a simpler model, delineating two types of violence in
intimate relationships – “patriarchal terrorism” (now called intimate terrorism) and
common couple violence” (now called situational violence)
1
. Intimate terrorism is a
pervasive attempt to dominate one’s partner and generally exert control over the
relationship with violence being the foundational, but not sole, tactic of the abuser.
Johnson and Leone (2005) suggest that Pence and Paymar’s (1993) Power and Control
Wheel is the most succinct description of the actions of an intimate terrorist. Fear on the
part of the victim and pervasive control by the abuser are the two distinguishing
characteristics of intimate terrorism. In contrast, situational violence is defined as
violence in intimate relationships that is not embedded in a pervasive pattern of control
and domination. Situational violence occurs as a result of an escalating conflict that gets
out of hand resulting in one or both partners using physical aggression. While either type
Couples Treatment of IPV 6
of violence can result in lethal or gravely injurious acts, Johnson and Leone report that
situational violence (compared to intimate terrorism) has a lower frequency of occurrence
per couple, is not as likely to escalate over time, is not as likely to involve severe
violence, and is not as likely to involve unilateral male-to-female assault.
What do typologies tell us about the use of couples treatment? The fact that
batterers and couples in which violence occur are heterogeneous groups suggests that the
strategy of prescribing the same intervention for all cases of IPV (male-only, pro-feminist
psychoeducation) may not be sound. Johnson’s work, in particular, suggests that a
significant portion of IPV springs from relationship conflict, leading us to conclude that
efforts to change relationship dynamics may be the most appropriate treatment for a
carefully selected subset of couples in which there has been violence.
We see three dangers when partners in relationships in which situational violence
occur are treated separately. First, the role of the woman’s aggression may be ignored or
downplayed. In intimate terrorism situations, women are less likely to assault their
partners. When they do use aggression, they typically do so in self-defense, and tend to
stop when their own violence makes their partner’s violence worse. In contrast, women
and men in relationships in which situational violence occurs tend to assault each other
with nearly the same frequency and assaults often arise from conflict and efforts to exert
control over a specific situation and not as part of a pervasive pattern of domination
(Johnson, 1995). Not attending to women’s aggression in this latter situation leaves out
a major piece of the interactional puzzle since cessation of violence by one partner is
highly dependent on cessation of violence by the other partner (Feld & Straus, 1989;
Gelles & Straus, 1988). An equally important finding is that when women assault their
Couples Treatment of IPV 7
partners, they increase their risk of injury by their partners significantly (Feld & Straus,
1989; Gondolf, 1998).
A second reason to consider the use of couples treatment is the role that marital
discord plays in IPV. Marital discord itself is a strong predictor of IPV. Pan, Neidig and
O’Leary (1994) found that for every 20% increase in marital discord, the odds of mild
partner assault rise 102%, and the odds of severe assault rise 183%. Treating the couple
separately, without attention to their relational patterns, may not adequately address the
marital discord that is adding to the potential for on-going violence.
The final reason to consider conjoint couples therapy in the wake of IPV, springs
from the real world experience of professionals who work daily with men and women
who assault one another and/or are the victims of partner assaults. Rather than the first
act of violence being a signal to end a distressed relationship or leave a domineering
oppressor, violent couples tend to stay together. Feazelle, Mayers and Deschner (1984)
report that from 50% to 70% of assaulted women stay with their abusive partners or
return to them after separating. Thus, in addition to managing violence, these couples
continue to face the day-to-day stresses of parenting, running a household, and
maintaining jobs and income – all sources of marital conflict. Conjoint therapy holds the
potential to help mitigate such stresses, and it is often requested couples who want to rid
themselves of the violence in their relationship but not of the relationship itself. Treating
the man in isolation leaves the couple on their own to do this difficult work.
In the rest of this paper, we examine both the outcome literature and current
clinical practices to suggest best practices when couples treatment is used with IPV.
Experimental Studies Evaluating the Effectiveness of Conjoint Treatment for IPV
Couples Treatment of IPV 8
Four groups of studies have used experimental designs (i.e., couples are randomly
assigned to two or more treatment conditions) in examining the effectiveness of conjoint
treatment for IPV. In each of the published studies the couples treatment condition was at
least as effective in ending violence as the comparison approach. In this section of the
paper we examine: (1) the research conducted at the Families and Addiction Program,
Harvard Medical School and the Research Institute on Addictions, University at Buffalo,
SUNY, by Timothy O’Farrell and William Fals-Stewart; (2) studies examining a version
of Peter Neidig’s Domestic Conflict Containment Program (DCCP) or the revised
Physical Aggression Couples Treatment (PACT) conducted at the State University of
New York: Stony Brook by Daniel O’Leary, Peter Neidig, Richard Heyman and Steven
Brannen; (3) studies examining the Domestic Violence Focused Couples Treatment
program conducted at Virginia Tech, Falls Church, by Sandra Stith, Eric McCollum and
Karen Rosen; and (4) the only study which included a “no treatment control group”
conducted through the Navy by Frank Dunford.
Intervening to End IPV through Substance Abuse Treatment
A strong relationship has been found between IPV and substance abuse. Across
male substance abusing inpatient samples, the prevalence of IPV in the year prior to
assessment ranged from 58% to 84% (Bennett et al., 1994; T. G. Brown et al., 1998;
Gondolf & Foster, 1991). In outpatient samples of male alcoholics, the prevalence of
male-to-female violence in the year before treatment ranged from 54% to 66% (Murphy
& O'Farrell, 1994; Murphy et al., 2001; Stuart et al., 2003). Furthermore, research
indicates that on those days an abuser drinks, he is more likely to be abusive. One study
Couples Treatment of IPV 9
indicates that among men entering treatment for IPV or for substance abuse, IPV was 5 to
10 more likely on drinking days than on non-drinking days (Fals-Stewart, 2003).
During the past 10 years, a variety of studies documenting the effectiveness of
Behavioral Couples Therapy (BCT) for substance abuse on reducing IPV have been
undertaken at the Families and Addiction Program, Harvard Medical School and the
Research Institute on Addictions, University at Buffalo, SUNY (Fals-Stewart et al., 1996;
Fals-Stewart et al., 2002; O'Farrell et al., 2004; O'Farrell & Murphy, 1995). BCT has
been delivered in a variety of forms in the course of this research. It is primarily a
behavioral program of couples treatment aimed at providing couples with skills and
changing dysfunctional interaction patterns in order to provide a family environment that
will support long-term alcohol and drug abstinence. BCT is typically delivered in 15-20
outpatient conjoint couple sessions over 5 to 6 months but may also be delivered in an
outpatient multi-couple group format (Fals-Stewart et al., 2004). Inclusion criteria for
BCT varied according to the study undertaken, but generally included: the couple had to
be in a stable relationship with each other for at least one year; the male partner had to
meet abuse or dependence criteria for at least one substance and agree to refrain from
using psychoactive substances during treatment and also refrain from seeking additional
substance abuse treatment during the treatment period except self-help meetings.
Couples were excluded if the female partner also met the criteria for a substance abuse
disorder within the past 6 months; either partner had a psychotic disorder or evidence of
organic impairment sufficient to impair project participation; or either partner was
participating in a methadone maintenance program. Since the original work, the Harvard
and Rochester groups have also chosen to exclude couples in instances where the
Couples Treatment of IPV 10
reported violence is significant enough to result in serious injury or intimidation, or when
participants do not agree to refrain from engaging in partner violence during treatment.
The findings from this body of research concerning IPV are consistent and telling.
Each of the studies that examined the effect of BCT on IPV has supported the efficacy of
BCT in reducing IPV for substance abusing couples. For example, in a study of the
natural history of domestic violence before and after alcoholism treatment, O’Farrell,
Van Hutton, and Murphy (1999) followed couples receiving an early version of BCT for
two years. Comparison rates of domestic violence for a matched nonalcoholic sample
were derived from a nationally representative survey of violence in American families
(Straus & Gelles, 1990). In the year before BCT, the alcoholic group had a significantly
higher prevalence of violence than did the nonalcoholic comparison group. In the treated
group, however, the percentage of couples experiencing any violent act decreased from
61.3% in the year before BCT to 22.7% in the first year after BCT and 18.7% in the
second year after BCT. Additionally, the prevalence and frequency of violence by
alcoholics were no longer significantly higher than among their counterparts in the
nonalcoholic comparison group. In another study, Fals-Stewart and colleagues (2002)
randomly assigned 80 married or cohabiting drug-abusing couples to either individual
treatment or BCT. While violence was reduced in both treatment conditions, couples
attending BCT were significantly less likely to be violent in the year after treatment than
couples in which only the male substance-abusing partner attended treatment.
How can we explain the fact that an intervention that does not directly focus on
IPV achieves such significant reductions in it? Fals-Stewart and Kennedy (2005) suggest
that one reason conjoint treatment is more effective than individual treatment in reducing
Couples Treatment of IPV 11
IPV is that when only the identified patient is in treatment, the reduction in violence is a
result of only the substance abuser remaining abstinent. However, when both partners are
in treatment, the partner learns coping skills and measures to increase safety when faced
with a situation where the likelihood of violence increases. “In particular, emphasis is
placed on using behaviors that reduce the likelihood of aggression when a partner is
intoxicated (e.g., leaving the situation, avoiding conflictual and emotionally-laden
discussion topics when a partner is intoxicated)” (p. 11). Fals-Stewart and Kennedy go on
to assert that conjoint therapy for partner-violent couples with concurrent substance abuse
problems can be a significant improvement over traditional treatment approaches. They
describe five exclusion criteria for substance-abusing clients who have engaged in
intimate partner violence: one or both partners report fear of injury, death, or significant
physical reprisal from their significant other; severe violence (defined as resulting in
injury and/or hospitalization) has occurred within the past 2 years; one or both partners
have been threatened and/or harmed by their significant other using a knife, gun, or other
weapons; one or both partners are fearful of participating in couples treatment; and one or
both partners want to leave the relationship due, in whole or in part, to the degree and
severity of partner aggression. Interestingly, while they agree with most intimate partner
researchers that conjoint therapies are contraindicated for certain couples, they report that
they have rarely had to exclude couples on these grounds (Fals-Stewart & Kennedy,
2005) .
Neidig, O’Leary, Heyman Models
A series of studies have examined the effectiveness of Peter Neidig’s Domestic
Conflict Containment Program (DCCP) and various revisions of it (Brannen & Rubin,
Couples Treatment of IPV 12
1996; P. D. Brown et al., 1997; Heyman et al., 1999; Heyman & Neidig, 1997; Neidig,
1985; O'Leary et al., 1999; Schlee et al., 1998). Neidig (1985) developed the initial
program in response to a request from the U.S. Marine Corps. The DCCP is a highly
structured skill building program for couples experiencing IPV. Much of the program is
devoted to teaching participants skills to contain conflict since Neidig believed that most
violence occurs during conflict escalation. Participants are taught to identify cues which
signal that violence is likely, and they rehearse alternative responses to various steps in
their violence sequence.
The DCCP multi-couple group consists of 6 to 8 couples and meets weekly for
two hours for 10 weeks (Neidig, 1985). The core curriculum is designed to help
participants: “accept personal responsibility for violent behavior; contract for a
commitment to change; develop and utilize time-out and other security mechanisms;
understand the unique factors involved in the violence sequence; master anger-control
skills; and develop the ability to contain interpersonal conflict” (p. 199-200). The training
approach includes three basic components, instruction, rehearsal, and feedback from the
facilitator. Outcome studies indicated that 8 out of 10 participants remain violence-free
at four month follow-up. However, since Neidig’s work took place in the military where
a great deal of monitoring occurred and the consequences of missing sessions or repeat
violence may have been more powerful than in the civilian community, it was not clear
how well this program would translate to the civilian community.
Brannen and Rubin (1996) were the first to systematically test Neidig’s DCCP
treatment model and to compare it with a gender-specific treatment program in the
civilian community. They randomly assigned 49 court ordered civilian men and their
Couples Treatment of IPV 13
partners who wanted to stay in the relationship to either a multi-couple group based on
Neidig’s treatment model or a gender-specific group based on a model developed at the
Domestic Abuse Project (DAP) (Rusinoff, 1990). In the DAP condition, the female
partners participated in a group designed to increase empowerment and enhance safety.
Both gender-specific and multi-couple groups met weekly for 90 minutes for 12 weeks.
The most important change Brannen and Rubin (1996) made to Neidig’s (1985)
model was adding treatment components designed to enhance the safety of female
victims. A separate orientation was held for victims. During this time victims were
given information about shelters and were given phone numbers of the local law
enforcement agencies. Each week both partners completed separate questionnaires
concerning continued physical and psychological abuse, and were asked whether any
issues raised during treatment led to physically or psychologically abusive arguments. If
any woman appeared to be in danger, a follow-up phone call was made and she was
encouraged to make use of resources discussed in the orientation session.
The next group of researchers to study a modification of Neidig’s (1985) model
was a team from the University of New York, Stony Brook (P. D. Brown et al., 1997;
Heyman et al., 1999; Heyman & Neidig, 1997; O'Leary et al., 1999; Schlee et al., 1998).
They called their modification of Neidig’s model Physical Aggression Couples Treatment
(PACT) (Heyman & Neidig, 1997). In their description of the program, they argue that
therapeutic efforts to reduce anger and to increase competence in relationship skills will
reduce the risk for physical violence.
To qualify for the treatment program a wife must, in a separate interview, indicate
that she is comfortable with conjoint treatment, not fearful of speaking in front of her
Couples Treatment of IPV 14
husband, and has not needed to seek medical attention for injuries from IPV. Couples are
also screened out if the husband meets the criteria for alcohol abuse or dependence, if the
wife reports that the husband has a drinking problem, if the couple is not married or is
separated, if either partner has an untreated serious mental illness or violent criminal past,
or if the screening clinician judges that the wife will not be safe. Despite these stringent
criteria, only five couples were excluded (O'Leary et al., 1999).
PACT is delivered by a male-female professional co-therapy team. The first half
of PACT is focused on anger management skills. The last seven sessions focus on
couples’ issues such communication, fair fighting, gender differences, sex and jealousy.
The purpose of the second half is to decrease conflicts and increase alternatives that may
reduce the likelihood of violence (Heyman & Neidig, 1997).
A number of studies have tested the efficacy of DCCP or PACT using a sample of
military personnel (Neidig, 1985), court-ordered civilians (Brannen & Rubin, 1996), and
couples seeking help voluntarily (O'Leary et al., 1999). Each of these studies reported
the treatment program was effective in helping men reduce their level of violence. In
addition, the series of studies that compared DCCP or PACT with a gender specific
treatment, with the exception of a finding by Brannen and Rubin, reported no significant
differences between gender specific or conjoint groups in dropout or violent recidivism
rates. Brannen and Rubin found that for court-ordered participants with a history of
alcohol abuse, the multi-couple intervention was more effective than the gender-specific
intervention in reducing the levels of violence within the marital relationship.
Domestic Violence Focused Couples Treatment
Couples Treatment of IPV 15
Sandra Stith, Eric McCollum, and Karen Rosen at Virginia Tech, Falls Church,
developed and tested a couples treatment program for IPV, Domestic Violence Focused
Couples Treatment (DVFCT) which is based on a solution-focused treatment approach
(Rosen et al., 2003; Stith et al., 2002; Stith et al., in press; Stith et al., 2004; Tucker et
al., 2000). The program is designed for couples in ongoing relationships where mild-to-
moderate violence has occurred and both partners want to remain together and end the
violence in their relationship. The primary goal of the program, like most other
programs described here, is to end violence of all kinds. A secondary goal is to help
couples improve the quality of their relationship whether they stay together or separate
Couples are excluded if either partner has used severe violence that resulted in a
need for medical care, if they are unwilling to remove handguns from their immediate
access, if they have problems understanding English, or if they have severe untreated
psychopathology that prevents them from being able to participate in a group treatment
program. In addition, each partner participates in gender-specific treatment most of the
time during the first six weeks of the program. Ongoing screening occurs during these
six weeks to ensure that the couple is appropriate for conjoint treatment.
Topics for the first six weeks include developing a vision of a healthy relationship
or their “miracle”, safety plans, types of abuse, escalation signals, dealing with anger,
mindfulness meditation, motivational interviewing around substance abuse (if
appropriate), and developing a negotiated time-out plan (Rosen et al., 2003). After the
six mostly separate sessions, the couple works together either in a multi-couple group or
as an individual couple with two co-therapists. To enhance safety, each session begins
and ends with a gender-specific meeting. If the couple is receiving individual couple
Couples Treatment of IPV 16
treatment, the male client meets with one therapist and the female client meets with the
other therapist. If they are a part of a multi-couple group, the men meet together with one
therapist while the women are meeting with the other therapist. The purpose of the pre-
session meeting is to find out if there has been any violence, if there are major issues that
need to be discussed in the conjoint session, or if any couple should not participate in the
conjoint session that day for safety reasons. After the pre-group meeting, the therapists
meet and finalize the plan for the conjoint session. At the end of the conjoint session,
separate meetings are held to make sure everyone feels safe and calm. If either partner is
distressed, he or she is encouraged to use the previously developed safety plan or to use
meditation which is a part of the beginning of every session, and each partner has an
opportunity to discuss distressing feelings before leaving.
To test the effectiveness of DVFCT, Stith, et al. (2004) randomly assigned 42
couples to individual couple treatment (n=20) or to multi-couple group (n=22). Nine
couples who completed pre-tests and follow-up tests but did not begin treatment served
as a no-treatment comparison group. Drop out rate did not differ between treatment
groups (30% for individual couple; 27% for multi-couple group). At pre-test scores of
the couples in the different conditions did not differ on any of the dependent measures
(i.e., marital aggression (psychological, minor physical or severe physical), marital
satisfaction, attitudes about wife beating). Results of the study indicated that participants
in the multi-couple group showed positive changes across all three dependent measures.
Neither individual couple treatment nor the untreated comparison group reported any
significant changes in these variables. Stith et al also found that, according to female
partner reports, men who participated in either of the two couples treatment programs
Couples Treatment of IPV 17
were less like to recidivate than men in the comparison group at both the 6-month and 2-
year follow-up. In fact, only one of the 19 women contacted (5.4%) who had participated
in either couple treatment program reported that her partner had been violent since the 6-
month follow-up.
The Navy Study
Frank Dunford (2000) has conducted the only experimental study to date that
included a conjoint treatment condition and a “no treatment” control group. He randomly
assigned 861 Navy couples to one of four interventions: a 26-week cognitive behavioral
therapy (CBT) men’s group followed by six monthly sessions, a 26-week CBT multi-
couple group followed by six monthly sessions, a “rigorously monitored” group, and a
control group. The control group did not receive any formal intervention. Victimized
wives in the control group were contacted by the military agency responsible for
preventing and responding to domestic violence in the Navy—the Family Advocacy
Center (FAC)—as soon as possible after the event occurred to ensure that the women
were not in immediate danger. FAC provided the women with safety planning
information. No other formal intervention was offered.
In the rigorously monitored group, a social worker at FAC saw perpetrators
monthly for 12 months and provided individual counseling. Every 6 weeks a record
search was completed to determine if a re-arrest had occurred. Wives were called
monthly and asked about repeat abuse. At the end of each treatment session, social
workers sent progress reports to perpetrators and their commanding officers, specifying
the presence or absence of instances of abuse.
Couples Treatment of IPV 18
Treatment in the men’s groups was based on curriculum developed by Saunders
(1996) and Wexler (1999). Each session had a series of tasks that the group leader was
expected to complete including both didactic and process activities. The multi-couple
group curriculum was also based on the cognitive behavioral model and was developed
by Geffner and Mantooth (2000). The interventions were similar to those used in the
men’s group, with the expectation that the presence of wives would alter the dynamics of
the conjoint group interventions. It was expected that with wives present there would be
less “women bashing” and that empathy would be enhanced. “In addition, the ability of
wives to witness authority figures confronting the offensive and oppressive nature of
spouse abuse, as well as address constructive ways to deal with conflict, were proposed
as sources of empowerment and confidence not available to women whose husbands
were assigned to the other interventions” (Dunford, 2000, p.469).
FAC records indicated that 71% of the cases were judged as having successfully
completed treatment. Fifteen percent of the men were discharged from the Navy and did
not complete treatment. Thus, 14% were considered as not having completed treatment.
No significant differences were found in victim reports of having been injured, hit or
pushed, or having felt endangered between participants in any of the four experimental
conditions (i.e., men’s group, multi-couple group, rigorous monitoring, and “no-treatment
control group”) at either the 6-month or one year follow-up period.
Two issues limit the usefulness of this study for understanding the effectiveness
of conjoint treatment in the general population. First, this study was conducted with
active duty military members. When repeat violence occurs, commanders are notified
and recidivism can affect the offender’s career. Thus, it is not clear that a “no treatment”
Couples Treatment of IPV 19
condition really exists when the offender is identified and his violence is a part of his
military health record. Also, a major problem with this study’s assessment of the
conjoint intervention is that the number of wives actually attending the treatment was
relatively low. The ratio of women to men was 2 women for every 5 men. Thus, in
actuality, few couples actually participated in the conjoint treatment condition. The active
duty husbands were mandated to treatment but the wives, mostly civilian, were not
mandated and may not have volunteered to participate. Rather than being a systemic
intervention focused on addressing couples issues, the treatment seemed to involve
treating men with wives as observers. However, the study did provide some suggestion
that conjoint treatment was as effective as any other type of treatment.
Clinical Approaches to Couples Treatment of IPV
Much of the clinical work currently being done in the area of couples treatment
for IPV has developed not on the basis of a research program but from clinical practice
and the application of both feminist and systemic theoretical models to this difficult issue.
In this section we review two such approaches that have been used widely enough that
they can help suggest best practices.
The Ackerman Institute Model
Virginia Goldner and her colleagues at the Ackerman Institute (Goldner, 1998;
Goldner et al., 1990) represent one effort to integrate feminist and systemic thinking in
the couples treatment of domestic violence. From the feminist perspective, the Ackerman
group makes clear that they see male violence toward women as the central problem to
address in therapy. They invoke an ethical framework in their work – holding men
responsible for their use of violence and intimidation, and women responsible for their
Couples Treatment of IPV 20
own safety. They are clear, however, that a sociopolitical stance alone does not fully
explain the complexities of violence in intimate relationships and add psychological and
systemic approaches in a therapy that may move from “a feminist narrative highlighting
issues of power and control, and then reconfigure into another gestalt that brings forth the
issues of vulnerability and despair” (Goldner, 1998). Thus, this model sidesteps the
typology issue by seeing all male violence as both an attempt at power and control and an
expression of escalation within the dyad. Given this understanding, social control, re-
socializing men to egalitarian views, and psychological and systemic understandings all
have a place in treatment.
Greenspun (2000) provides the most systematic description of the Ackerman
model. Therapy is provided in an outpatient setting with one or two therapists actually
working with the couple face-to-face while a consultant or consulting team observes.
Therapy begins with a three-session evaluation during which a determination is made
concerning whether or not couples therapy should be attempted. Couples are excluded
from treatment for the following reasons: severe substance abuse by either partner, man’s
history of head injury or other neurobiological condition necessitating treatment, man’s
history of sociopathy, woman’s severe eating disorder or PTSD secondary to childhood
trauma, the woman being coerced into treatment or not feeling safe in treatment, or the
man’s unwillingness to take responsibility for his violence. The assessment occurs in
both conjoint and individual interviews with individual interviews occurring first and
being used to explore the extent of the violence and the exclusion criteria.
If the therapists judge that proceeding with conjoint sessions is justified, couple
sessions are used to explore relational patterns and to begin the process of the man
Couples Treatment of IPV 21
acknowledging to his partner his responsibility for his violence. Of particular importance
is assessing the strength of the romantic bond between the partners. If an emotional bond
no longer holds the couples together (and they remain for financial or parenting reasons
alone), they are unlikely to have the motivation to continue with the difficult work of
couples therapy.
The Cultural Context Model
Almeida and Durkin (1999) report on an approach to couples treatment that relies
on a multi-layered cultural analysis to understand the genesis of male violence against
women. This model is based on Almeida’s cultural context model (Almeida et al.,
1998)– a framework that takes as its goal not just intervening with batterers, couples, or
families, but “fostering the development of safe, respectful, nurturing, and empowering
relationships for all participants in community and family life” (Almeida & Dolan-Del
Vecchio, 1999). We include this model as an approach to couples treatment of IPV
because the cultural context model grew from work in treating IPV and couples treatment
plays a prominent role in it.
The specific couples treatment model for IPV originally described by Almeida
and Durkin (1999) sees the termination of abusive or coercive acts of all kinds as the
ideal outcome of treatment. Thus, accountability is an overarching theme for the work
with male perpetrators. During the initial phase of treatment, an assessment of couple
functioning is conducted. Since many couples come to treatment without presenting
violence as a concern, the first step is to assess for it. Using both conjoint and individual
interviews with the partners, the extent of violence is ascertained as well as the potential
for immediate danger to the woman. Safety planning (including the man leaving the
Couples Treatment of IPV 22
home and the use of restraining orders if necessary) is accomplished and the stage is set
for the couple’s entry into the separate men’s and women’s group phase of the program.
Men’s groups begin with psychoeducation about the role of violence and other
forms of control and include a process of “sponsorship.” Men who have successfully
completed treatment, as well as non-abusive men from the community are recruited to
participate along with current clients. Sponsors both represent the clients’ own cultures
and the beliefs and traditions coming from them as well as help hold clients accountable
for their abusive actions and attitudes. Women’s groups also include psychoeducation
but the focus is on empowering women and encouraging them to become less responsible
for the overall well-being of their families. Anger, not guilt, is proposed as the
appropriate response to violence and oppression (Almeida & Durkin, 1999).
The final phase of treatment begins when men demonstrate appropriate changes in
their attitudes and behavior – moving to a non-violent, non-coercive stance – and their
female partners corroborate those changes in the women’s group. The program sets a
minimum of 36 weeks of gender-specific treatment for men who are mandated to
treatment by the judicial system. Couple or family sessions may begin during the later
stages of the 36 weeks if the therapists feel the men are accepting responsibility both for
their violence and for their use of non-violent control tactics. Regardless of when
conjoint therapy starts, both partners remain involved in their gender-specific groups
during the course of couples work.
Almeida and Durkin (1999) report that in the 15 years of its operation, at the time
of their 1999 article, “no woman participating in our program has ever been physically
hurt” (p. 321). They offer no information on how this finding was arrived at (e.g.
Couples Treatment of IPV 23
whether systematically measured or informally assessed) nor on any other aspect of
treatment outcome such as completion rates or changes in marital satisfaction, etc.)
Best Practices
Coordinated community response
None of the treatment programs described in this manuscript is meant to be used
in isolation. Best practices for treatment of IPV include collaborating with local
domestic violence programs and would involve a full-range of options. For some
offenders, legal sanctions are most appropriate options and for some victims restraining
orders and shelters are most appropriate. The coordinated community response also
includes victim advocates, prevention programs, support groups, batterer intervention
programs, programs for child witnesses and other programs tailored to the needs of each
individual in the community. No single program or type of program can work in
isolation and, as Vetere and Cooper’s (2001) work in the U. K. illustrates, community
agencies can be effectively included in couples treatment as a resource to both clients and
therapists.
Careful Screening of Clients for Conjoint Treatment
One of the most consistent findings which emerged from our review of both empirical
and clinical papers regarding conjoint treatment of IPV is the importance of careful
assessment and screening for the appropriateness of this treatment modality. Although
most programs serving voluntary clients found that they only had to exclude a small
number of clients, all programs emphasized the importance of screening. Best practices
would include individual assessments of male and female clients and the use of screening
tools that allow participants to report thoroughly on the violence they have experienced
Couples Treatment of IPV 24
or used. In addition, when either partner is afraid of the other, or concerned that they may
not be able to express themselves freely in front of the partner; individual treatment
should precede, or replace, conjoint treatment. No clients should ever feel coerced into
participating in conjoint treatment. Throughout this manuscript exclusion criteria used by
each program have been reported. Common exclusion criteria include a history of severe
violence, weapon use in previous violent incidents, and sociopathy or untreated serious
mental illness of the offender. None of the programs reviewed here advocate for
conjoint treatment as the only treatment offered for IPV. All recommend that this
approach is most appropriate for a specific group of couples who have been carefully
screened to meet clearly developed criteria.
Modification of Typical Conjoint Practice to Support Safety
Best practices for the use of conjoint treatment of IPV include modifications of
typical conjoint treatment to support safety. In addition to careful screening and
selection, most of the programs reviewed here teach specific violence reduction strategies
such as time-out and safety planning. Clinicians doing conjoint treatment of IPV need to
be well-versed in both systemic treatment and also in IPV. They also need to be aware
of risk factors for escalating violence and to be sensitive to the real danger that can occur
from allowing angry confrontations to proceed in the conjoint session. All of the
treatment discussed here is delivered by experienced couples therapists with knowledge
of IPV and is not traditional marriage counseling or couples therapy. Rather, it is
specifically focused on eliminating violence in relationships and modified to safely
achieve that goal.
On-going assessment of safety with contingency plans for increased risk or recurrence
Couples Treatment of IPV 25
Best practices for providing conjoint treatment for IPV also include a process of
ongoing assessment of safety with contingency plans for increased risk or recurrence.
Many of the programs discussed here include regular check-ins (either in writing or in
person) to insure that neither violence, nor risk of violence, is escalating. Programs
offering conjoint treatment need to include an ongoing discussion among providers
regarding these issues and a protocol for addressing increased risk and/or recurrence of
violence. Data may emerge during the course of treatment that leads therapists to
temporarily suspend, or completely discontinue, couples work. For instance, the
therapists may discover that substance abuse is more severe than was originally reported,
or another assault may occur. In these cases, re-evaluation of conjoint work is needed.
Summary
In reviewing the literature on conjoint treatment of IPV, it is clear that couples
treatment can be used safely to end IPV. In this review, we have provided both an
overview of clinical experience and outcome research that supports the use of conjoint
treatment in certain conditions. In fact, in all of the empirical studies, conjoint treatment
proved to be at least as effective as traditional men’s treatment programs. The research
conducted in the field of substance abuse provides a particularly compelling case that
conjoint treatment may be the treatment of choice for many violent couples.
Furthermore, withholding conjoint treatment as an option for some couples may not serve
them well if we believe in the evidence produced by a variety of typology studies
including Michael Johnson’s work which separates intimate terrorism from situational
couple violence.
Couples Treatment of IPV 26
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Footnotes
1. Johnson (2005) later expanded his typology to include “violent resistance” in
which victims of intimate terrorists strike back at their abusers. These acts remain
embedded in the context of pervasive control that characterizes intimate terrorism,
however, and thus are different than the bi-directional assaults that occur in situational
violence.
... As a result of these concerns, most states prohibit the use of conjoint approaches to DV interventions 19,20 . It is noteworthy that many studies now challenge the assumption that conjoint treatment is never advised for DV, particularly when it is provided under certain controlled conditions [21][22][23] . ...
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A structured, skill-building treatment approach aims at eliminating violent behavior between abusive couples. Principles, components, and screening and evaluation procedures of the program are described. The program, developed for military families, could be adapted for civilian use.
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There is relatively little research describing the victims of court-ordered batterers, compared to the extensive descriptions of the batterers themselves. The partners of men ordered to batterer programs in four cities were interviewed about their backgrounds, victimization, helpseeking, and perceptions of the batterers (N = 482). These battered women tend to be from lower economic status and educational levels. A substantial portion have also suffered severe assaults and injury. More than half of these women have previously contacted the criminal justice system in response to abuse, but only about a quarter have received any counseling for domestic violence, and less than 10% have previously visited a battered women's shelter. The women's perceptions of their batterers are overly optimistic, despite the severe abuse and information from batterer programs. The victims of court-ordered batterers appear to be different at least in terms of their helpseeking than battered women in shelters and may therefore warrant special program and research attention.
Article
The likelihood of partner physical aggression on days of male partners' alcohol consumption, during a 15-month period, was examined for men entering a domestic violence treatment program ( n =137) and domestically violent men entering an alcoholism treatment program ( n =135). For men entering the domestic violence treatment program (alcoholism treatment program odds in parentheses), the odds of any male-to-female physical aggression were more than 8 times (11 times) higher on days when men drank than on days of no alcohol consumption. The odds of severe male-to-female physical aggression were more than 11 times (11 times) higher on days of men's drinking than on days of no drinking. These findings support the proximal effect model of alcohol use and partner violence. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
This article argues that there are two distinct forms of couple violence taking place within families in the United States and other Western countries. A review of evidence from large-sample survey research and from qualitative and quantitative data gathered from women's shelters suggests that some families suffer from occasional outbursts of violence from either husbands or wives (common couple violence), while other families are terrorized by systematic male violence (patriarchal terrorism). It is argued that the distinction between common couple violence and patriarchal terrorism is important because it has implications for the implementation of public policy, the development of educational programs and intervention strategies, and the development of theories of interpersonal violence.
Article
An empirical review and critique of existing state standards for batterer programs in the domestic violence field appeared timely, given the current debate about their status and utility. Although there has been a considerable amount of polemic discussion of the topic, relatively limited data have been reported. The present article surveyed the content of standards developed in 30 states within the United States. Five categories of interest were examined including: (1) the minimum length of treatment specified; (2) specification of treatment orientation, methods, and content; (3) preferred or allowable modalities of treatment; (4) whether research findings were mentioned or endorsed as a basis for development of treatment standards; and (5) methods for developing and revising standards. A related area, the minimum education required for providers, was also included as an area of interest to further describe the current pool of practitioners targeted for regulation. An analysis of the content of these standards was then performed with regard to existing peer-reviewed research in the field. The results are discussed in terms of the strengths and weaknesses of current standards, the areas in which further research is needed, and specific recommendations regarding steps that might be taken to improve existing efforts.
Article
In this article we describe a project which aims to ensure prevention and continued protection from violence for family members. We outline our theoretical approach to assessment and working with violence in family relationships and the associated ethical problems. We identify three recurrent themes: risk, collaboration, and responsibility. We focus on our work with couples, where the man is violent towards the woman. Within this discussion we identify other important clinical issues.