What works in batterer intervention programs

UNIVERSITY OF JYVÄSKYLÄ What works in batterer intervention programs? Juha Holma Psychologist, psychotherapist, PhD University of Jyväskylä, Finland Psychotherapy Training and Research Centre juha.holma@psyka.jyu.fi https://www.jyu.fi/ytk/laitokset/psykologia/en/research/psychotherapy_ /research_mens_groups UNIVERSITY OF JYVÄSKYLÄ Jyväskylä model for preventing and treating domestic violence g In Jyväskylä a multi-professional cooperation in preventing and treating domestic violence started in 1995 – Social and welfare agencies – Police g A programme for men was created in the crisis centre “Mobile” in collaboration with the Psychotherapy Training and Research Centre of the University of Jyväskylä – Own programme to victims and eye-witnesses but closely connected and monitored to men’s programmes UNIVERSITY OF JYVÄSKYLÄ Multiprofessional networking UNIVERSITY OF JYVÄSKYLÄ The individual treatment phase for men g Immediate intervention – “Voluntary” attendance – Active intervention g g Lasts from one to six months Aimed at: – – – – concretising violent acts finding ways to avoid abusive behaviour taking responsibility of these situations motivate men to group g Group treatment only after the individual sessions UNIVERSITY OF JYVÄSKYLÄ Men’s programme UNIVERSITY OF JYVÄSKYLÄ g During the years 2001-2008 – 373 men contacted Mobile crises center because of their violence against their partner • 58 % were referred by social and welfare agencies and police. 26 % contacted themselves and in 16% the partner was active – 138 (37%) ended up their treatment before their 5th individual meeting • Most of them (66%) ended up their treatment by their own – 156 (42%) had 5-8 meetings – 44 (11%) of them had over 8 meetings – Only 52 (14%) started the group meetings • Half of them reported lack of motivation • no difference who referred or did he contacted by himself UNIVERSITY OF JYVÄSKYLÄ Group treatment g g Earlier phase: – Closed group: 15 sessions. New phase: – Open-ended group from autumn 2001. Refilled regularly. – Once a week 1.5 hour’s session. – Max. 7 participants. – Conducted by two therapists (also male and female). – Men commit for at least 15 sessions. – No explicit schedule, structure. – No psychodrama, homework, lectures. Only discussions focussing on violence and it’s context. UNIVERSITY OF JYVÄSKYLÄ g Feedback system – Women partners are met in the beginning and in the end of the group by the therapy clinic worker. • They are interviewed about the violence they have met. They get information about the services for them and about the programme for men. ACBI • In the end of the group they are asked feedback and about the violence during the group – Two years follow-up interviews for both the men and the women UNIVERSITY OF JYVÄSKYLÄ g Men’s interviews before entering the group (124 men, 1996-2008) – Divorced 18%, lives separate 3%, married 50%, cohabiting 25%. In most of the cases relationship continues. – 64% had over 5 years relationship to current partner – Current relationship had lasted over 10 years 30% – 20% had been violent less than one year; 39% over 3 years – When current partnership has lasted over 10 years in 88% violence had lasted over 3 years – Only 3% mentioned psychological/emotional violence – 47% of the victims had needed medical services for their injuries • Most common injuries were bruises and bleeding • In 50% of these cases had lead to criminal procedure – 41% of the victims had left their home for the violence – Police was involved in 63% of the cases – 40% any kind of criminal procedure UNIVERSITY OF JYVÄSKYLÄ – – – – – – – – – – 73% said their children had seen their violence 47% had been physically violent against their children 25% child protection services were involved 33% reported that either of the parents had alcohol problem 56% had been nearly always drunk during the violent act (21% had been in an abuse treatment) 16% had been always sober during the violent act • The group that abused only when drunk managed better to avoid violence during the group 56% had seen their own father been violent against their mother 57% had been object of the violence of their parent 67% had suicidal thought ever 52% had been in mental health treatment • 21% depression, 6% exhaustion, no information 74% UNIVERSITY OF JYVÄSKYLÄ Violence against the children g g g g 51 men: 40 of them had children and answered properly 132 children lived in these families 80% of men reported that their children had witnessed their violent acts 16 (40%) had punished their children physically – shaked by the hair (10) – whipped (2) – hit by strap or belt (2) g 3 fathers who said they have not punished their children reported their had shaked by the hair, hit by strap or other ways punished physically UNIVERSITY OF JYVÄSKYLÄ g Statistics of women whose partner attended the group during 2001-2006 – Total number: 36 – Interview in the beginning and in the end of the group and relationship continues: 15 – Has violence ended? • 14: Yes – Has abuse and control changed or got new modes? • decreased: 4 • new modes, same or increased: 11 UNIVERSITY OF JYVÄSKYLÄ – ACBI: • 14 woman: physical violence decreased – no violence: 5 – emotional and sexual violence decreased: 8 – physical violence decreased but emotional violence increased: 4. In 3 cases also sexual violence increased. • One case where there was much violence in the the beginning and it continued or even increased during the group (drop-out). UNIVERSITY OF JYVÄSKYLÄ Relations between the Intergenerational Transmission of Violence, alcohol usage and outcome effectiveness. (Ensomaa, 2009) g g g g The sample consisted of 39 men, who had taken part in intake interview and whose spouses had filled an inquiry form about domestic violence in the beginning and at the end of the treatment group. Method: t-test, variance analysis 64 % of men reported that they had seen intimate partner violence in their childhood. NO relation to the amount of their own violence in intimate relationship before the group. 56 % of them reported that had been physically abused in their childhood by either of the parents. NO relation to the amount of their own violence in intimate relationship before the group. UNIVERSITY OF JYVÄSKYLÄ g There was no correlation between alcohol usage and any forms of intimate violence. • Minor consumption= 1-3 doses/week • Average consumption= 4-12 doses/week • Heavy usage= 13 or more doses/week No use n = 10 ka sd Minor consuption Average consumption Heavy usage n=7 ka sd .55 .55 .75 n = 12 ka 1.59 .56 .79 sd 1.13 .68 .59 N = 10 ka 1.08 .55 .65 sd .79 .57 .38 F df1 df2 p 35 .53 35 .94 35 .80 psychological 1.56 .73 1.46 sexual physical .68 .53 .95 .90 .53 .77 .74 3 .12 3 .32 3 UNIVERSITY OF JYVÄSKYLÄ g Violence victimization in childhood and alcohol usage had an interaction with sexual domestic violence. – Statistically significant differences showed up between those who did not use alcohol and those who used it a lot. UNIVERSITY OF JYVÄSKYLÄ g g Physical and sexual violence decreased statistically significantly during the programme. Psychological violence decreased nearly significantly. Eta square and Cohen D: – Cohen (1988) effect size: small (0.2), average (0.5) and big (0.8). 2 d .24 .45 .89 Psychological violence Sexual violence Physical violence .13 .22 .48 UNIVERSITY OF JYVÄSKYLÄ g g g The duration of the treatment (more than 15 session vs. less than 15 sessions) did not have an effect on the outcome. (Less than 15 sessions is actually a drop-out). The higher the amount of domestic violence in the beginning of the treatment program, the more it decreased. The changes in emotional and sexual domestic violence correlated strongly with each other (r = .71, p < .01) , but the changes occurred in physical violence was not related to the other two forms of domestic violence. UNIVERSITY OF JYVÄSKYLÄ Sexual violence g g 33 women partner interviews (ACBI) during years 2001-2007 12 months before the group – in only one case there was not sexual violence – most common modes: • Withheld affection from you (70%) • Been insensitive to your needs and desires (64%) • Withheld sex from you (46%) • Threatened to have an affair (42%) – Other modes: • Pressured you for sex (21%) • Hurt you sexually (12%) • Physically forced you to sex (12%) • Pressured you to perform any sex act which you were unhappy about (15%) UNIVERSITY OF JYVÄSKYLÄ g Frequency: – 41% sexual violence occurred once or twice in last 12 months – 16% at least once a month but less than once a week – 9% (n = 3) at least once a week g During the group: – in 21 cases of 27 sexual violence had decreased – in 5 cases increased and on same level in one case – Only in one case: Hurt you sexually, physically forced you to sex, pressured you to perform any sex act which you were unhappy about UNIVERSITY OF JYVÄSKYLÄ Case studies of the changes during the batterer’s group treatment g g g No randomization into different treatment groups or comparison between drop-outs vs. completed (quasitrial). Comparison is done between those who carry on behaving violently (physical, sexual or emotional violence) and those who succeed in behaving nonviolently (as reported by (ex)partners). The research shows what changes take place during the treatment, how these changes are connected to desirable changes in behaviour and what interventions facilitate changes during the treatment. UNIVERSITY OF JYVÄSKYLÄ Individual changes in discursive practices of batterers during group treatment: - different theorethical approaches Identified by qualitative analysis methods from recordings of therapy meetings Individual changes in violent behavior reported by women (ex)partner: - In-depth interviews - Abusive and Controlling Behaviour Inventory (ACBI) Change between before and after the treatment, and two years after completing the treatment. UNIVERSITY OF JYVÄSKYLÄ The attachment style talk of martially violent men (Lohman & Kuznetsov, 2007) g g Research has consistently supported the thesis that attachment style is associated to behavior in conflict situations in relationships as well as to domestic violence. Four-category model of adult attachment, in which attachment styles are related to different kinds of experiences in intimate relationships, is used. UNIVERSITY OF JYVÄSKYLÄ g g Material: – discussions of five men in fourteen videotaped therapy sessions and one follow-up session – Self-report questionnaires completed by the participants’ partners, in which the respondents report the amount of experienced abuse in their relationships. The questionnaires were conducted in the beginning, ending and 2 years after the therapy process. The data of group treatment sessions was analyzed by using the method of content-analysis, by categorizing men’s discussions about their partners and relationship with her according to the four-category attachment model. UNIVERSITY OF JYVÄSKYLÄ g Results: – All the participants’ accounts fall mainly into the insecure attachment categories in the beginning – Attachment style talk changed towards the secure attachment style during the program – This change was associated to the change in violent behavior in close relationship: • Two men changed they way of talking to more secure attachment style talk by noticing and getting aware on their own dependency and insecurity in relationship to their partner. • One man started to integrate also negative aspects in his image of the partner. • In these three cases all modes of violence decreased. • In two cases security was gained by outer reasons (marriage) and the psychological violence continued. UNIVERSITY OF JYVÄSKYLÄ The Process of Therapeutic Change in Batterers’ Treatment: A CognitiveConstructivist Approach (Keltanen & Räsänen, 2007) g g g According the cognitive-constructivist therapy psychotherapeutic change means construction of new kind of reflexive processes. By reflexivity we refer to the level and quality of an individual’s self-awareness: the way the ongoing psychological processes and the emotional experience are perceived and interpreted. The opposing ends of dimensions have been identified as the reactive and reflexive positions. Therapeutic process has been divided into qualitative and process categories and subcategories. UNIVERSITY OF JYVÄSKYLÄ g g The development of the men’s reflexive capacities was studied by making a step-by-step microanalysis based on the process model of reflexivity development introduced by Toskala and Hartikainen (2005) The model consists following phases (Toskala & Hartikainen (2005): – 1) recognizing the problematic experience as an inner process, originating in the self. – 2) the client conceptualize and reformulate his problematic experience in order to reach essential core and give it a new, more descriptive name. – 3) the client is creating an alternative relationship with this experience. The client is able to step of and place himself beside the experience and explore it more openly. – 4) The problematic experience is integrated and accepted to his selfhood and he has created new agency to the problematic experience. Reflexive position. UNIVERSITY OF JYVÄSKYLÄ g g With all the therapy clients the development of reflexivity set forward. Reactive position was described as – Lack of means to handle the situation – Unable to control own reactions – blaming alcohol, spouse etc. g When recognizing the problematic experience as an inner process they started to described – Emotions related to problematic situation, physical experiences and reactions. – Some preliminary insight on spouses experience. – Outer means of controlling behaviour (time-out). – Preliminary but weak sense of control. UNIVERSITY OF JYVÄSKYLÄ g The turning point in the therapeutic process was the reformulation of the problematic experience. Men described – Helplessness, powerlessness during quarrel, argumentation. – Feelings of being subjucated, humiliated, rejected and unfairly treated by their spouses. – Experiences of shame, guilt and psychological loneliness. – Also jealousy, sexual unconfidence and lack of trust to the spouse was articulated. g The men understood how problematic experience was constituted. – They started to describe longer processes prior to the problematic experiences, emotions. – Some of them starter to relate their violent acts to their way to stem problematic experiences and feelings inside themselves. They started to express these feeling when they appeared in everyday living. – Some started to focus more on they psychological wellbeing. Lowered the stress at work etc. UNIVERSITY OF JYVÄSKYLÄ – The better the men understood that the problem arises from within themselves, the better they were able to regulate their emotional reactions and behavioral responses. A new kind of attitude appeared in regard to accepting responsibility, and towards motivation to change. – Men started to gain insight what were their own emotions, experiences and what feelings and experiences were their spouses. – Men also started to understand spouses reactions, for example fear. UNIVERSITY OF JYVÄSKYLÄ g The problematic experience is integrated and accepted to his selfhood and he has created new agency to the problematic experience. Reflexive position. – Not coded. – Experiences of helplessness, powerlessness etc. would not be so threatening anymore causing defensive or self-protective reactions. – Increased sense of agency to own experiences thus sense of control to own behavior. g No partner interviews. UNIVERSITY OF JYVÄSKYLÄ Domestic violence from the viewpoint of mentalization (Kuurtokoski, 2009) g g Mentalization can be defined as an ability to perceive own mind separate from the other’s mind, to perceive physical behaviour as a continuum of emotions and needs and to make flexible interpretations of minds based on physical behaviour (Fonagy) Mentalization has implications for attachment-theory as well as self-development. According to Fonagy, individuals without proper attachment (e.g. due to physical, psychologial or sexual abuse), can have greater difficulties in the development of mentalization-abilities. UNIVERSITY OF JYVÄSKYLÄ g g g The aim of this research is to evaluate the quality of mentalizing speech of male batterers when starting therapeutic group treatment. The aim is also to identify and describe the process of mentalizing speech development during the treatment and to compare the development profile with the change in the violent behaviour. The material consists of the speech of two men participating the group treatment. UNIVERSITY OF JYVÄSKYLÄ g The results of the study show that both men had severe and wide deficits in their mentalizing speech when entering the treatment program. It appeared as: – Denial to verbalize inner states or experiences: • ”I do not know”, • ”I can not describe”, • ”I have not thought about it”. – Neglecting the questions concerning inner states or experiences. – Lack of describing emotions or motivations. Discussions concerned typically concrete events, doings and sayings. – Causes for actions were described as ”physical states”: • ”I lost my nerves”, • ”Something clicked in my head”, • ”Everything went black”. – No attempt to understand, mentalize, spouses mind. Or total security of spouses inner states (usually same as man’s own. • ”We both did not want do that” UNIVERSITY OF JYVÄSKYLÄ g The development of mentalizing speech started for both men during the treatment. First preliminary mentalizing speech appeared: – Mentalization started with concrete thoughts used in describing behavior or people. – Preliminary mentalization on the other’s mind. • T: ”How do you know that your wife is stressed?” • M: ”She snaps at home” g Later also good mentalization speech was identified: – Preliminary recognition and naming of abstract ideas and emotions. – initial understanding of behavior as a continuum of emotions was developed • T: ”Does it matter what the others think of you if you back off from threatening situation?” • M: ”Before I had to act as a tough guy and never back off. I had to reserve my prestige, not to loose my face. Probably it was need for acceptance." UNIVERSITY OF JYVÄSKYLÄ g g The quality of mentalizing speech varied according to themes of speech; discussing conflicts with the spouse appeared to be most challenging. Later there appeared more mentalization on the other’s mind, both emotions and motives. • [Discussion on spouse’s reaction to men’s acts.] • M: "It was a revenge, when she announced suddenly that she is going out. It was obvious that she got angry, but did not say a word." g There is also some understanding that you can not be sure what the other thinks or feels. UNIVERSITY OF JYVÄSKYLÄ g g Partner interviews show decrease in violent behavior for both men during the treatment. The other one continued however psychological violence. – He had during the treatment deficits in metalizing others mind. He spoke about his spouse as provocative, threatening and defending person. – This refers to Fonagy’s ideas that traumatic attachment is activated in intimate relationship and a spouse is seen as childhood object representation. UNIVERSITY OF JYVÄSKYLÄ What works in batterer intervention programmes g Focus on violence – Also psychological and sexual violence – Violence against children – Do not forget what is happening now. Violence may continue. g Focus on insecure experiences in relationship to the partner. – Insecure relationship can be changed by noticing and getting aware on man’s own dependency and insecurity in relationship to their partner. UNIVERSITY OF JYVÄSKYLÄ g Focus on emotions related to problematic situation, physical experiences and reactions. Experiences as – Helplessness, powerlessness during quarrel, argumentation. – Feelings of being subjucated, humiliated, rejected and unfairly treated by their spouses. – Experiences of shame, guilt and psychological loneliness. g Focus on longer processes prior to the problematic experiences, emotions. – what were their own emotions, experiences and what feelings and experiences were their spouses. – Try to find connections of past events, often traumatic events in childhood, with present experiences. It helps men to accept and own these painful experiences, emotions as a part of oneself. g Focus on mental states of his own as well as the partners