Treatment Goals, Methods and Evaluation

The Domestic Violence Court-Mandated Perpetrator Treatment Program was developed to help clients stop physical, sexual and psychological violence and to assist them in developing more adaptive ways of solving conflict and managing emotional stress in interpersonal relationships. It is critical that the client understands and agrees with the program goals in order to benefit from the treatment process. Because the court mandated client has strong incentive to agree with these goals (since resistance to treatment may have dire consequences) it is important for the clinicians to continually assess for denial, minimization and other defensive coping mechanisms throughout the treatment process. From the initial interview, the group leaders are firm in their belief that there is no justification for using physical, sexual or psychological violence except for legal self-defense. Even then, it takes considerably less force to get away from someone than to engage in a fight or retaliation. In cases where violence could be used in self-defense, the client is encouraged to leave such a dangerous environment until such time as the threat is reduced.

Treatment Goals

There are three primary treatment goals, which are attended to each and every group meeting:

Goal 1. Emotional regulation

Clients learn how to 1) identify emotions; 2) control escalation of dysphoric moods; and 3) communicate all emotions in positive and adaptive ways.

Methods

1. Learn to identify emotions

Emotions are identified through the use of emotional sensitization exercises. Clients are taught that emotions may be experienced viscerally (in the body) and observed behaviorally before the person becomes cognitively aware. Clients are taught to pay attention to their physical/bodily experiences as well as behavioral indicators of emotions. This information is frequently discussed in the group in a didactic manner, but more importantly, clinicians are to reinforce this learning by drawing the clients’ attention to these phenomena in the group while they discuss situations inside or outside of the treatment setting.

Use of the anger journal is another mechanism for learning how to identify physical and behavioral cues to anger. These skills will generalize to other emotional states as well. However, because many men can more easily identify their anger, the focus is on this emotion at the beginning of treatment.

2. Learn to control escalation of dysphoric moods

Clients are taught the relationship between cognition (thinking) and emotions and how dysfunctional thinking can escalate dysphoric (difficult) affect. Clinicians are to teach cognitive restructuring techniques to help clients learn to self-soothe. In it’s most simplistic form, cognitive restructuring can be divided into positive and negative self-talk. Negative self-talk is any cognitive attribution that ultimately leads to escalation of dysphoric affect, whereas positive self-talk is any cognitive attribution that results in a calming effect. Clinicians may teach the full range of dysfunctional thinking outlined in cognitive therapy texts, but at the least must make the differentiation between cognition (thoughts) that escalate and cognition that soothe.

The Time-Out is another important technique the clients should learn to use to better manage their emotions and prevent future violence. Consistent use of Time-Outs is one of the most important skills necessary for successful attainment of this goal. Using “Practice Time-Outs” is a very important component of successful treatment. The practice and use of Time-Outs is a necessary component of successful completion of this program.

The anger journal is another mechanism for learning how to manage dysphoric affect through the use of cognitive restructuring and removing oneself from the negative stimulus. Again, focus is on anger because of its relationship to violence and the relative ease in talking about this emotion.

3. Learn to communicate other feelings in adaptive ways

Clients are taught how to communicate their feelings using the “I feel ____” model. They are taught the difference between expression of thoughts or judgments and the appropriate expression of emotion. In addition to the positive modeling by fellow group members, clients are given enactments in the group as a mechanism for practicing expression of emotions. For many clients, confrontation or directive behavioral techniques will be useful in helping to express emotions, whereas a significant percentage of the clients will have extreme difficulty expressing vulnerable emotions and will resort to common defenses such as splitting, projecting, etc. In these cases, the clinician is presented with the task of interpreting the behavior so that the client is able to connect his/her acting out with the dysphoric affect.

Evaluation

All of these skills are evaluated through a number of means:

1. Self report,
2. Observation by the clinician, (client interaction with clinician and peers)
3. Reviewing anger journals (and other homework) on a regular basis, and
4. Partner reports.

Goal 2. Education on the dynamics of domestic violence with emphasis on each client better understanding their own causes of violence

Clients learn about the impact of alcohol and drugs on violence, explore belief/assumptions regarding gender differences, explore power and control issues in intimate relationships, learn about the effects of violence on children, and come to understand how violence was used in the family of origin and later reinforced by society in general. In order to successfully complete the program, each client must develop insight into their violence, how it developed, how it is reinforced or continues, what affect it has had on family and friends, and how to identify volatile situations.

Methods

1. Didactic lecture
2. Video presentation
3. Reading
4. Homework

Evaluation

All of these skills are evaluated through a number of means:

1. Self report
2. Observation by the clinician (client presenting information in group)
3. Reviewing power/control and anger journals (and other homework) on a regular basis, and
4. Partner reports.

Goal 3. Social problem solving skills that promote family safety

The program is designed to teach and demonstrate effective problem solving techniques with the primary goal being family safety. Effective social problem solving skills include such behaviors as constructive expression of feelings, reflective listening/empathy and negotiation. These skills are taught, modeled and reviewed throughout the program. Stress management skills and developing realistic expectations of self and others contribute to increased effective problem solving. Additionally, because of the high overlap between domestic violence and child abuse, considerable time is spent helping clients develop more effective methods of handling problems related to parenting (such as co-parenting conflicts, discipline, etc.).

Methods

1. Didactic presentation (developing social problem skills)
2. Therapeutic enactments (group members can learn and practice constructive social problem solving skills within the context of material they bring to the group)
3. Group member interactions (clinicians can utilize material that occurs between group members in session)
4. Stress management skills

Evaluation

All of these skills are evaluated through a number of means:

1. Self report,
2. Observation by the therapist (client presenting information in group),
3. Reviewing anger journals (and other homework) on a regular basis, and
4. Partner reports.

Secondary Goals

There are numerous other secondary goals in domestic violence treatment (e.g., decreasing social isolation, developing parenting skills, processing grief related to loss of relationship, etc.), in addition to the client’s individual needs, however, the above goals must be the first priority for the attention of the group leaders.

Running the Group

The Check-In

Each group begins with a check-in process. The purpose of this is to alert the leader(s) to crisis issues and track each member’s progress with the primary program goals. This process also allows for structuring the group: prioritizing who needs to work first. Below are the questions each group member is to answer during this process. Questions are usually put on the board so that each member can report on the specific information. This process should not take more than 15-20 minutes (with eight to ten group participants). The group leader(s) need to make sure that individuals do not use the check-in to work on their individual issues. It is important that group leaders follow this process exactly as it is described so that clients can prepare each week for the check-in and so consistency in treatment is maintained.

Check-In Questions

1. Did you perpetrate any physical, sexual or psychological violence since the last group session? If so, which types?
2. Did you take any real time-outs since the last group sessions? Did you write about them in your anger journal?
3. Were there any situations in the last week, where you might have taken a time-out but didn’t?
4. Did you take any practice time outs?
5. Are you in a volatile or stressful situation (including, witnessing of violence, being victimized or being involved in violence in any way)?
6. Is there anything specific you would like to work on in group today (success, failures or needing help with an issue)? If so, give the headlines.

Prioritizing Client Work: Processing Acts of Violence

After the group check-in, the clients who perpetrated violence need to discuss their situation first. In doing so they should try to address the following questions:

1. What violence did you perpetrate? What specifically did you do?
2. When did you notice you were becoming angry? How did you know you were angry? Discuss the escalation process and the choices you made along the way.
3. When could you have chosen to act in another way? What might have been another way of dealing with the situation?
4. What is your plan of action for the next week? What can you do to lessen the chance of another incidence of violence?
5. Have you contacted your probation officer? If no, when do you plan to do so?

Each client must develop a plan of action to avoid another incident. This plan may include finding an individual counselor, attending AA or another chemical abuse program, separating, taking a practice time-out every day, and/or reading and completing the exercises in a particular chapter in “Learning to Live Without Violence.” Whatever the plan, it should involve specific, observable behaviors. Vague or general statements such as, “I’ll try harder,” or “I’ll never do it again,” or “I’ll just stop it,” do not set up adequate markers for measuring improvement. Interventions, as a rule, should be behavioral in nature so as to best measure their effectiveness.

Prioritizing Client Work: Reporting Acts of Violence

All acts of physical and sexual violence (and some forms of psychological violence) must be reported to probation within twenty-four hours. Psychological violence consisting of illegal acts (e.g., threats to kill, threats of violence, attempts at violence (assaults), stalking, as well as acts resulting in serious psychological harm, are required to be reported to probation. The counselor should recommend that the client call probation him/herself, but the group counselor must report the incident as well.

If the counselor hears of the re-offense before the group session, from the victim directly, the victim should be encouraged to immediately call probation. The counselor must evaluate his/her safety needs and make appropriate referrals and recommendations.

For all acts of violence (reportable) a Critical Incident Report (see Forms) must be completed and placed in the client’s chart. Additionally, all reported incidents of violence must be included in the client chart, including a description of the violence, treatment plan changes, all collateral contacts (victim, probation, supervision/consultation, collaboration with mental health providers, etc.).

Prioritizing Client Work: Volatile Situations

If no clients have been physically, sexually or psychologically violent in the past week, attention should turn to those in crisis or in highly volatile situations. Additionally, clients who have been using power and control tactics in their relationships should also be addressed. When discussing this material, the focus should be primarily on developing: emotional self-regulation, anger management skills, communication and social problem solving skills. Group leaders are encouraged to use role plays, enactments, etc. to help the client increase his/her awareness of feelings and develop the necessary skills to avoiding additional acts of violence.

Prioritizing Client Work: Reporting of Violence Perpetrated Towards The Client

Acts of physical and sexual violence, and some forms of psychological violence perpetrated towards the client, may be reported to probation (e.g., threats to kill, threats of violence, attempts at violence (assaults, stalking). The counselor should recommend that the client call probation him/herself. The purpose of this reporting requirement is to convey to the client the seriousness of the violence in their lives and the inevitable volatility of such situations.

For these acts of violence, a Critical Incident Report (see Forms) must be completed and placed in the client’s chart. Additionally, all reported incidents of violence must be included in the client chart, including a description of the violence, treatment plan changes, all collateral contacts (victim, probation, supervision/consultation, collaboration with mental health providers, etc.).

Prioritizing Client Work: Non-use of Anger Management Skills

If no group members meet the above criteria, attention should focus on those who have not been utilizing the anger-management material (taking time-outs, taking practice time outs, writing in anger journal). The assumption of the program is that only through weekly rehearsals or practice will clients be able to easily utilize the anger-management material when it is truly needed — during a conflict with their partner.

Therapists must explore the reasons for the lack of use of prescribed therapeutic interventions. Resistance to utilizing the anger-management material may be an indicator of lack of motivation or inappropriateness for treatment and may be grounds for termination or a referral to alternative treatment interventions.

If none of the clients meet the above criteria, then group may focus on specific client issues and/or educational material. Of course, educational material may be interspersed throughout any of the above issues with the goal being to increase the client’s awareness of feelings and options for dealing with stressful situations.

Prioritizing Client Work: Summary

The following is the order of priorities group leaders should utilize when determining which clients will work in any specific group:

1. Clients who have been physically, sexually psychologically violent in past week;
2. Clients who are in crisis or living in a stressful situation;
3. Clients not utilizing the anger management material (taking time-outs, taking practice time outs, writing in anger journal, etc.);
4. Clients needing help with specific situations/problems;
5. Group leader facilitated discussion.

Introducing New Members into the Group

When new members enter a group, they are asked to introduce themselves before the check-in process by answering the following questions:

1. What was the situation that brought you to this group? Describe how you were physically, sexually, or psychologically violent.
2. How has your violence affected your partner? Your children?
3. What are you looking to receive from this group?
4. How will you know you achieved your goals?

After the new member introduces him/herself, the rest of the group may want to also answer several of the same questions. After this process, new members are likely to feel somewhat more comfortable in this new and unusual setting. Another way to help clients become oriented to the group process is by assigning new members with a buddy, similar to an AA sponsor, who will be available between sessions in case of an emergency and who will help familiarize him to the experience of being in a batterers group. When new members start the group, this is an opportunity for older members to explain the material. The group leader is to ask members to explain the various issues, time-outs, anger journals, etc. Even though this was already discussed with the client during the assessment phase, continual reiteration of this crucial material is necessary for it to be successfully integrated and routinely utilized by the client. In observing their explanation of the concepts, the group leader(s) are also able to evaluate the “older” participants’ progress towards treatment goals.

Homework for Group Members

Regular homework serves several functions. First, clients are encouraged to think about the material learned in-group during the intervening days. Homework serves this function by requiring the client to take some time outside of the group to think about their situation and how to increase their knowledge base and change their behavior. Second, depending on the homework (educational versus behavioral), the client may exercise the new skills learned in the group on a regular, basis, so that he/she will be less likely resort to old behaviors when confronted with a conflict or otherwise stressful situation. Lastly, homework is a measure of a client’s motivation and progress in treatment.

However, therapists are not encouraged to utilize homework in a rote manner.  Not all clients need to be completing the same assignments each week. In spite of what I discussed in the prior paragraph, there is no evidence that frequent homework assignments are effective, therefore clinicians should use homework specifically tailored to the client’s needs judiciously. I have found that the work in the group can be more influential in changing behavior than paperwork at home.

Non-completion of homework, specifically Time-Outs and the anger journal, is a complicated issues. For some clients, this is clear indication of lack of motivation for change and therefore may need to be addressed administratively via probation. For some clients, incomplete or non-cooperation with homework assignments may be more related to other clinical issues such as acting out, avoidance as a means to protect oneself from feelings of vulnerability. For other clients, the lack of completion of homework may also be a function of an already chaotic life that leaves little time for self-care. Additionally, there is some evidence that violent individuals, even those with average or above average intelligence, may not perform commensurate to their potential due to functional frontal lobe deficits affecting impulsivity, inhibition and perseveration. Furthermore, long-term substance abuse problems can also negatively affect cognition. Therefore, clinicians need to carefully explore the specific reasons a particular client does not complete his/her homework or utilize the clinician interventions. The challenge lies with the clinician to formulate more effective methods of engage in the change process and developing interventions that work for each particular client within the context of his/her unique situation.

These thoughts aside, this program has three primary homework exercises that clients are required to complete on a regular basis throughout the treatment process. The first and most important exercise is the Time-Out.

The Basic Homework Assignments

The Time-Out: A Definition

Introducing clients to the time-out technique is critical in the early stages of treatment. Clients may be given a handout describing the technique. The time-out procedure should be explained to clients at the first assessment appointment. They are instructed to immediately take “practice time-outs” on a weekly basis so as to get used to walking away from a conflict situation.

The Time-Out is one method for stopping the violence. The client is encouraged to make a conscientious effort to do this exercise faithfully.

Time-Out: Whenever the client feels anger rising, their body getting tense like it is going to explode, or they begin to feel frustrated or out of control, say out loud to themselves and their partner:

"I'm beginning to feel angry and I need to take a Time-Out."

The client is to leave his/her home for one hour (no longer and no shorter), during which he/she cannot drink and should not drive (unless it is absolutely necessary). It is most preferable for the client to go for a walk or run, to do something physical. If they begin to think about the situation that made them angry, they are encouraged to just say to themselves: "I'm beginning to feel angry and I need to take a Time-Out." In this way the client will be taking a mental Time-Out as well as a physical Time-Out.

When he/she returns in one hour, they should check in and tell their partner that they have come back from their Time-Out and ask if their partner would like to talk. If they both want to discuss the situation, then they should tell their partner what it was that made them feel angry. They may also want to talk about what it was like to take a Time-Out. If one of the partners doesn't want to talk about the situation, then they should not discuss the situation. In either case, if either partner finds himself or herself feeling angry again, the client should take another Time-Out (even if it's the partner that's getting angry).

Some topics of conversation may be too charged to talk about. If this is true in the client’s situation, the client needs to learn to put that issue on the shelf for a while, acknowledging that it is too difficult for the two of them to discuss alone. Clients need to understand that even if it's an important issue that is making them angry, they need to think of their priorities. Nothing can be more important than stopping the violence!

How Time-Outs Work

The Time-Out is an effective method (albeit not the only one) to reduce dysphoric reactions to relationship conflict and stress. By making an "I-statement” the client begins by talking about him or herself, as opposed to externalizing by focusing on their partner. Another important aspect of the time out is that they are talking about their feelings rather than acting them out. Expressing these feelings may contribute to a reduction of their intensity. The client is also stating to his/her partner that they are not going to hit; instead, they are going to do something else, take a Time-Out. Taking a Time-Out helps build up trust with their partner. By staying away for the full hour, the client is allowing sufficient time to reduce the intensity of their feelings. During their Time-Out, clients are encouraged to find more adaptive methods of coping with uncomfortable feelings. They are encouraged to not drive or use mind-altering chemicals for obvious reasons. Aside from these outlets, clients are encouraged to find alternative ways to deal with their feelings. Exercise, creative endeavors, talking are just a few of the ways the clients can work out their feelings so, when they do return, they are more calm and able to talk about the situation or conflict. It is important to remind the client and his/her partner that if they do no more than check in after their Time-Out, the exercise was successfully completed. If the client goes on to talk about his/her feelings in a constructive manner, they receive valuable experience and practice in communicating and discussing emotional issues

The client needs to understand that when there has been violence in a relationship, their partner loses trust in their safety. This Time-Out exercise not only helps to stop the violence, but also helps to rebuild trust. However, trust takes some time to rebuild. Just because the client may take one or two Time-Outs, it doesn't mean that their partner will automatically trust them. Therefore patience is necessary.

Difficulties in taking Time-Outs

Although time-outs are easy in theory, they can be quite difficult for many men to practice.

Time-outs are hard to do because many people believe that walking away from a fight is a sign of cowardice or a concession of defeat. Also, it may be very important for some individuals to resolve the issue at hand. Group leaders should explain that unresolved issues are common and normal in relationships. It is better that an issue remain unresolved than that it escalate into violence. Once tempers flare, conflicts are rarely resolved until both parties have had the opportunity to calm down, think of constructive ways to solve the conflict, and be open to listening to the other person. It is important to remind clients that their first goal is to stop violence and rebuild trust. Solving the original conflict may have to wait until these initial goals have been met.

Many male clients have expressed the fear that their partners will be gone when they return. Similarly, women victims have feared that their partner will not return after his time-out. If the woman does not feel safe, she may be gone when he returns, but if he has taken a time-out, at least there will not have been any violence, which is the priority of the counseling program. It is strongly recommended that clients return at the promised time so that trust may begin to be reestablished in the relationship.

Another frequent problem some clients have with time-outs is staying away from alcohol and other drugs. It is important for counselors to emphasize that the time-out is a chance to calm down and think clearly in order to best solve the problem. Alcohol and other drugs obviously impede this process.

The time-out procedure was originally conceived as a time for the client to be alone and not get support from others. The idea was that people not talk with friends who might ultimately take sides and support defensiveness and blaming of the partner. However, clients may be encouraged to call fellow group members, who are more likely to see the value of supporting a calming down process and not reacting defensively towards the partner.

If group members have friends outside of the program who support personal growth and the counseling program goals, there is no reason why they shouldn’t call those friends in times of crisis or during time-outs. It is important that clients understand that time-outs are not social time, but time to learn new ways of coping with anger and conflict in interpersonal relationships. Ultimately, clients need to be encouraged to use the time-outs even if they feel they no longer have a problem with violence or they believe they are in control of their anger. It can be explained to the client that if one doesn’t or can’t take a time-out when he doesn’t need one (feeling low-level anger), he’s not likely to take one when he does need one (experiencing extreme anger)!

Occasionally, some clients will refuse to take time-outs as the group leaders prescribe them. This situation needs to be quickly addressed, because clients who refuse to take time-outs are at high risk for future violence. It is important to explore this problem directly with the client. Occasionally, partners may resist the time-outs and therefore may be overtly or covertly pressuring them to not use the technique. If this is the case, group leaders may want to meet with the couple, discuss their concerns, and explore solutions. Another reason that clients may refuse to take time-outs is because they either don’t believe they are at risk for future violence or may be in denial altogether as to the seriousness of their problem. There is some evidence that long-term drug or alcohol use can impair cognitive functioning. Therefore, some clients may not think about taking Time-Outs when the situation arises. For these individuals, therapists may utilize the group dynamics to help the client develop a stronger observing self. For example, a situation may arise in the group that may trigger feelings within the clients. The clinician could utilize these moments to help certain clients to thing about what feelings they are having and begin to process of exploring alternative reactions, such as taking a Time-Out. Obviously, some clients who refuse to take time-outs are simply being noncompliant with the treatment, are devaluing the therapist and the other group members, and stating indirectly their opposition to being in treatment. In these cases, clinicians need to evaluate whether the client is suitable for the treatment program. In the long run, it is important that clients develop constructive alternatives to violence, whether it’s taking a Time-Out, utilizing cognitive restructuring techniques (positive self-talk, self soothing statements, etc.) or meditation. Like the suicidal client who refuses medication or voluntary hospitalization, the batterer who refuses to utilize behavioral techniques geared to prevent violence is at great risk for harming others — which in turn increases professional liability for the treating therapist.

Practice Time-Outs

Practice Time-Outs help clients to take real Time-Outs. A Practice Time-Out is the same as a real Time-Out except for two things: First, in a practice Time-Out the client is not feeling angry. Second, the practice Time-Out is only half an hour. Practice time-outs are just practice at saying the words and walking away. Clients are required to take practice time outs weekly, until they demonstrate an ability to take real Time-Outs on a regular basis.

The Anger Journal

The “anger journal” (see Forms) is the second most important intervention in this program. This exercise is prescribed to the batterers in order for them to become more aware of their thought patterns and how they ultimately affect their emotions, such as anger, and behaviors, such as aggression. The anger journal is to be completed whenever a man feels any level of anger, frustration, or uncomfortable affect. Specific questions include:

1. What were the physical signs and behavioral signs of the anger?
2. Did the client take a time-out?
3. What was the positive self-talk?
4. What was the negative self-talk?
5. Did he direct his anger?
6. Were alcohol or drugs a factor?

An example of the anger journal is in the included forms. Ideally, the anger journal should be used daily; however, two entries a week are the required minimum. Depending on what issues need to be addressed, clients can share one or two of their entries as a part of their particular work in the group. Another important behavioral intervention is provided by the anger-sensitization exercises. These help the client learn to identify the physical (body) responses and their behavioral (action) responses to anger and other forms of arousal. The goal of these interventions is to help men learn to identify their anger while it is manageable, before the level of emotion reaches the point when it is difficult to control. The continual reworking of the anger-sensitization exercises is an important element in the anger journal.

Other Homework Assignments/Therapeutic Interventions

Focused topics of discussion in any particular group are like to generate homework assignments and educational material. Therapists are encouraged to utilize other therapeutic techniques and educational interventions for the group as a whole and for individuals to help keep the focus on partner abuse and violence prevention as well as a means to achieve any specific treatment goals for individual clients. The Time-Outs and the Anger Journal are a structure to provide clients an immediate alternative to violence.  However, the ultimate goal is for each client to find what methods work best within their particular life context Therefore, as treatment progresses, it is important that the therapist exposes the clients to a broad range of coping mechanisms, behavioral techniques and psychotherapeutic interventions so that clients may expand their repertoire coping mechanisms.

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