Assessing Treatability in Abusive Men Lisa Buys, Ph.D., R.Psych Kierla Ireland, Industrial Intern 1 Overview Defining Treatability Review of treatment/treatment effectiveness Variables affecting Treatability: The Research Attrition Substance use Denial Readiness Personality type Variables affecting Treatability: Clinical Observations Summary 2 Treatability The likelihood that a treatment program will result in the reduction or elimination of abusive behavior in a given man Standard gender-specific group-based program Armchair decision Male violence against women 3 1
Why is Understanding Treatability Important Deeper understanding of abusive relationship behavior Better decisions about managing risk Better decisions about spending treatment dollars Lead to the development of different treatments for men who are not treatable through standard programs 4 Treatability Ultimate goal to stop violent recidivism, but there are many mediating processes Type of mediating process targeted often depends on theoretical perspective of the particular treatment program (often not evidence based) Recent arguments for targeting mediating processes based on an individualized assessment of the offender 5 Treatability is NOT Risk General notion that high risk men are in the most need of treatment Need to uncouple risk and treatability Some of the factors related to poor treatment outcome are also related to higher risk. (Low risk men are probably more treatable than high risk men-delete sentence) High risk men may or may not be treatable (Treatment may not be the best way to manage risk) 6 2
Prevailing Models of Treatment Pro-Feminist Model (Duluth Model) Cognitive-Behavioral Model Many programs adopt a hybrid approach Little difference in treatment efficacy across treatment types (Babcock et. al, 2004; Davis & Taylor, 1999) 7 Treatment Treatment programs may be more similar than different Examples of Common themes addressed: Power and Control Anger recognition Anger as a funnel emotion Communication Conflict resolution Crisis management (time-out) 8 Does Treatment Work? Reduced recidivism is the acid test of treatment effectiveness Results are inconsistent, effect sizes are generally small but positive Methodological problems A certain percentage of men will spontaneously stop being violent 9 3
Does Treatment Work Does one size fit all? Spousal violence offenders are heterogenous Which offenders benefit from the standard treatment programs? Are there alternate interventions that could help offenders less likely to benefit form standard programs? 10 The Research Review research that examines treatment outcome as a function of offender characteristics Treatment outcome refers to both treatment completion and treatment success (reduction in violence) 11 Treatment Completion Attrition: Number of men who were referred for treatment but do not complete treatment Between 22 and 99% of men drop out of treatment Men who drop out are more likely to recidivate 12 4
Attrition Demographic Variables Lower education Lower Income Lower employment status Unmarried, not living with partner No children together Prior criminal history Age (?) 13 Attrition - Dynamic Variables Psychopathology (especially personality disorders) Alcohol and Drug Problems Lower levels of marital conflict and lower levels of aggression Lower distress at intake Attrition rates higher for men who pay low monthly fees, do not travel far for sessions Wait list Motivation 14 Reducing Attrition Enhancing Motivation Increase therapeutic alliance (Augusta- Scott & Dankwort, 2002; Brown & O Leary, 2000) Taft et. al. (2001) Simple measures directed to increasing alliance significantly reduced attrition FACS Strategies to increase motivation prior to group have reduced drop-outs 15 5
Reducing Attrition Increasing Sanctions Some studies argue for increased monitoring and legal sanctions (Healey et. al., 1998) But being mandated is inconsistently related to attrition may depend on SES Gondolf (2000) found that a 30-day post referral court contact increased attendance for assessment from 64% to 95% - but did not predict program completion 16 Predicting Success: Substance Use Continued alcohol consumption is associated with more frequent and more severe violence More research needed about the nature of this relationship and the best way to intervene 17 Denial, Minimization and Blame Denial, minimization and blame are not associated with increased recidivism (Henning and Holdford, 2006) Clinically, extreme levels of denial indicate poor prognosis for group treatment (?recidivism) Extremely low levels of denial may indicate values condoning violence Why an offender is denying more important than whether or not he is denying 18 6
Readiness for Change Prochaska & DiClemente Transtheoretical Model Precontemplation Contemplation Action Maintenance Stage of change is a composite measure that encompasses motivation, efficacy (a belief that change is possible), insight/awareness and openness to seeking help 19 Readiness to Change Men in the contemplation/action stage at the beginning of treatment show greater treatment success than precontemplative men (Scott & Wolfe, 2003) Studied many measures of treatment success: self and partner rated abusive behavior, perspective taking, conflict management and emotional support skills Also related to attrition (Scott, 2000) 20 Readiness to Change May be useful to work with precontemplators to prepare them for group Calgary Counseling Centre Precontemplators show the greatest bias in self-report. As precontemplators move towards contemplation, they may look like they are getting worse (but they are being more honest) 21 7
Therapeutic Alliance Myth that the therapeutic alliance is unimportant or impossible to create in mandated populations Brown & O Leary (2000)- Man s alliance with therapist during first session was related to treatment success (although not treatment completion) Goal setting (Lee et. al., 2007) Hooking a client is important 22 Personality Pathology Individuals with higher levels of personality dysfunction are more likely to be abusive after treatment (Dutton et. al., 1997; Gondolf & White, 2001), Treatment leads to little change in personality variables 23 Typologies of Abusive Men Holtzworth-Munroe & Stuart, 1994) proposed three types of Batterers Family only (50-%) Dysphoric/borderline (25%) Generally violent/antisocial (25%) 24 8
Family Only Batterer Deficits in social skills in marital situations Low levels of psychopathology Less violence, less severe violence Lower levels of substance abuse 25 Dysphoric/Borderline Batterer Higher levels of psychopathology - Dependency, jealousy, borderline traits Preoccupied or fearful attachment abandonment fears Impulsive Substance abuse problems More serious violence than family-only Violence generally restricted to relationships (Less willing to acknowledge problems) deletre sentence 26 Generally violent/antisocial batterer Higher levels of psychopathology - antisocial personality traits Alcohol and drug problems Violent inside and outside of the home Genetic predisposition towards impulsivity and aggression 27 9
Other Classification Efforts Instrumental vs. impulsive violence (Tweed & Dutton, 1998) Form of abuse predatory, instrumental, affective (Stuart, 2005) Predatory, planned violence vs. impulsive violence following a period of build-up in a time of low self-restraint. 28 Typologies: The Research Family-only batterer group emerges regularly in the research. This group shows generally lower levels of psychopathology and is more willing to admit to an anger problem. They are less likely to respond with violence in a wide range of triggering situations External stress may be more important than personality and attitudinal characteristics in determining their violence 29 Typologies: The Research Type is stable over time (Holtzworth- Munroe et. al., 2003) Some studies have had difficulty distinguishing between the dysphoric/borderline and generally violent/antisocial groups Instrumental vs. impulsive violence Psychopathology scores 30 10
Typologies: Implications for Treatability Little research Saunders (1996) Dependent men: process-oriented psychodynamic treatment Antisocial men: Cognitive-behavioral treatment Results not replicated (Gondolf) Family only group is probably easiest to treat; their needs best met in standard programs (?) Need to develop tailored treatments for other groups (e.g., Dialectical Behavior Therapy) 31 Barriers to Treatability: Clinical Observations Substance use disorders Personality disorders Clinical depression Post-traumatic Stress Disorder Cognitive/neurological impairment Anxiety disorders (social anxiety disorder) Poor English skills 32 Treatability: Summary Stable characteristics of the offender Dynamic characteristics of the offender Therapeutic alliance Relationship Context 33 11
The Paradigm Shift Challenges to the Profeminist model All men who have engaged in violent behavior are batterers All abuse is caused by patriarchal values Anger does not play a central role Treat the alcohol problem first Never use couples therapy Childhood abuse issues should not be targeted until men have addressed current behavior 34 Throwing the baby out with the bathwater Importance of victim safety Partners are not your patient or client; therefore, clinicians must be careful abut how they communicate with spouses about the risks and benefits of treatment. Your primary duty is to your client and informing him/her of the risks and benefits of treatment 35 Questions/Discussion 36 12
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