Time for Dyadic Treatments for Low-Level Partner Aggression

See article by Hayes et al

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

The partner violence field has become stagnant with the common use of “power and control” interventions for men in relationships characterized by intimate partner aggression (IPV), though such interventions have received only marginal support.1 Thus, it is time to admit that “one size does not fit all” in the treatment of partner abuse2 and that there are alternatives. Interventions for low-level physical aggression and psychological aggression against partners can be successfully implemented in diverse settings with relationship dyads as well explicated in this treatment evaluation with veterans and their partners (see Hayes et al, this issue3). It is this very group—dyads with low levels of physical aggression and significant psychological aggression—that seems most appropriate to target at this stage of intervention development. With research designs and random assignment to interventions, the field will be able to meet standards that will enable researchers to document an intervention that meets American Psychological Association standards for empirically supported treatments.4 Further, a number of empirical evaluations of dyadic interventions have shown that psychological and physical aggression can be reduced in couples who were selected so that the wife was not injured and was unafraid to be in a therapeutic situation with her partner.5 Additionally, some such dyadic interventions do not directly target the IPV. Let us now address these above points in more detail.

Lack of Empirical Support for Commonly Used Interventions

Very little evidence exists to justify the current legal system practice of mandating all perpetrators of domestic violence to attend psychological interventions addressing power and control issues. In fact, numerous empirical reviews have questioned the continued use of intervention programs that emphasize power and control. Such reviews suggest that these treatments add little to simply placing the men on probation without any psychosocial intervention or treatment.6 Even more recent evaluations affirm that empirical support for “power and control” domestic violence programs is lacking, and dropout rates are very high.2

One Size Does Not Fit All

Men with diverse levels of partner aggression are often mandated to programs called batterer intervention programs, but this practice appears to be outdated. It seems illogical to have the same intervention for (1) men who are in relationships characterized by low levels of physical aggression and in which both the men and women engage in such aggression (often referred to as mutual or reciprocal aggression) and (2) men who repeatedly hit their wives with their fists and who engage in unilateral aggression. There are numerous ways in which researchers have attempted to classify men who engage in aggression, such as: (1) family only aggressive, generally antisocial/violent, and borderline/dysphoric7; (2) family only versus generally violent,8 (3) reactive versus proactive,9 and (4) common couple versus intimate terrorism.10 All classification systems for individuals in physically aggressive relationships take the position that there are important differences in the men and women who are in such relationships. Further, it logically follows that interventions should address these important differences.

Dyadic Interventions Can Be Safely and Successfully Implemented

Interventions for low levels of physical aggression and considerable psychological aggression can be implemented safely and successfully as is illustrated by the treatment outcome study by Hayes et al.3 These investigators excluded individuals with higher levels of physical aggression who might pose a danger to partners (“severe” physical aggression on the revised Conflict Tactics Scales and/or substance abuse), and the selection procedure was in accord with recommendations about individuals for whom dyadic interventions are appropriate.11 The Hayes and colleagues’ intervention3 showed significant reductions in psychological aggression as reported by veterans and their partners, and the 10-week intervention led to reductions in depressive and PTSD symptomatology. However, the low levels of physical aggression did not change, though the levels at preintervention were an average of 1 act of aggression in a 3-month period. One would hope that a longer program and a program that would address physical aggression, per se, would lead to significant reductions in physical aggression. This will be a continuing challenge of the Strength at Home Friends and Family intervention; but it should be noted that women are often more concerned about psychological aggression, and such aggression was reduced. Further, there were no significant increases in relationship satisfaction as measured by the Dyadic Adjustment Scale for the veteran (mean prescore of 100), though there were significant increases in the DAS scores of the loved one. In interpreting this outcome, it is important to note that, technically, neither the veteran nor his/her partner had scores in the distressed range on the Dyadic Adjustment Scale at pretreatment.

Dyadic Intervention for Low-Level Partner Aggression Will Allow Development of Empirically Supported Treatments

Dyads with low levels of physical aggression and significant psychological aggression can be randomly assigned to varied interventions and even wait-list control groups, and it is only with such research that the field will be able to document to professionals and the public that there are interventions for IPV that meet standards of the American Psychological Association’s criteria for empirically supported treatments. Alternatively, a series of experimental single-case study designs can be used to establish empirically supported treatments. However, in therapeutic intervention research with adults, random assignment to interventions and wait-list control groups (with treatment-on-demand caveats) are the most convincing methods of developing empirically supported treatments. In fact, given the positive outcomes of the Strength at Home intervention, random assignment of dyads to wait list and alternative interventions seems clearly in order.

Dyadic Interventions Can Reduce Partner Aggression in Diverse Ways

There are a number of dyadic interventions that address IPV, and the target of intervention may not be IPV, per se, as was the case for the trauma-focused dyadic treatment for veterans and their partners.3 Further, in a large federally funded marital treatment outcome study in which individuals were excluded because of severe aggression against a partner, there was no evidence that the presence of low levels of physical aggression moderated the increases in marital satisfaction.12 Another form of intervention that leads to reduction in physical aggression against a partner is a substance abuse treatment for the substance abuser and his or her partner.13 Finally, dyadic interventions that focus directly on physical aggression can also reduce physical and psychological aggression.5

Author affiliation: Psychology Department, Stony Brook University, Stony Brook, New York.

Potential conflicts of interest: None reported.

Funding/support: None reported.

REFERENCES

1. Babcock JC, Green CE, Robie C. Does batterers’ treatment work? a meta-analytic review of domestic violence treatment. Clin Psychol Rev. 2004;23(8):1023-1053. PubMed doi:10.1016/j.cpr.2002.07.001

2. Cantos AL, O’ Leary KD. One size does not fit all in treatment of intimate partner violence. Part Abuse. 2014;5(2):204-236. doi:10.1891/1946-6560.5.2.204

3. Hayes MA, Gallagher MW, Gilbert KS, et al. Targeting relational aggression in veterans: the Strength at Home Friends and Family intervention. J Clin Psychiatry. 2015;76(6):e774-e778.

4. Chambless DL, Ollendick TH. Empirically supported psychological interventions: controversies and evidence. Annu Rev Psychol. 2001;52(1):685-716. PubMed doi:10.1146/annurev.psych.52.1.685

5. Stith SM, McCollum EE, Rosen KH. Couples Therapy for Domestic Violence: Finding Safe Solutions. Washington, DC: American Psychological Association; 2011. doi:10.1037/12329-000

6. Feder L, Wilson D. A meta-analytic review of court-man dated batterer intervention programs: can courts affect abusers’ behavior? J Experimental Crim. 2005;1(2):239-262. doi:10.1007/s11292-005-1179-0

7. Holtzworth-Munroe A, Stuart GL. Typologies of male batterers: three subtypes and the differences among them. Psychol Bull. 1994;116(3):476-497. PubMed doi:10.1037/0033-2909.116.3.476

8. Boyle DJ, O’ Leary KD, Rosenbaum A, et al. Differentiating between generally and partner-only violent men: lifetime antisocial behavior, family of origin violence, and impulsivity. J Fam Violence. 2008;23(1):47-55. doi:10.1007/s10896-007-9133-8

9. Chase KA, O’ Leary KD, Heyman RE. Categorizing partner-violent men within the reactive-proactive typology model. J Consult Clin Psychol. 2001;69(3):567-572. PubMed doi:10.1037/0022-006X.69.3.567

10. Johnson MP. Patriarchal terrorism and common couple violence: two forms of violence against women. J Marriage Fam. 1995;57(2):283-294. doi:10.2307/353683

11. O’ Leary KD. Couple therapy and physical aggression. In: Gurman AS, ed. Clinical Handbook of Couple Therapy. New York, NY: Guilford; 2008:478-498.

12. Christensen A, Atkins DC, Berns S, et al. Traditional versus integrative behavioral couple therapy for significantly and chronically distressed married couples. J Consult Clin Psychol. 2004;72(2):176-191. PubMed doi:10.1037/0022-006X.72.2.176

13. Fals-Stewart W, Kashdan TB, O’ Farrell TJ, et al. Behavioral couples therapy for drug-abusing patients: effects on partner violence. J Subst Abuse Treat. 2002;22(2):87-96. PubMed doi:10.1016/S0740-5472(01)00218-5

Submitted: October 9, 2014; accepted October 14, 2014.

Corresponding author: K. Daniel O’ Leary, PhD, Psychology Department, Stony Brook University, Stony Brook, NY 11794-2500 (daniel.oleary@stonybrook.edu).

J Clin Psychiatry 2015;76(6):e824-e825 (doi:10.4088/JCP.14com09582).

© Copyright 2015 Physicians Postgraduate Press, Inc.