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Cognitive – behaviour group therapy for men voluntary seeking help for intimate partner violence TOM PALMSTIERNA , GRETHEMOR HAUGAN , STIG JARWSON , KIRSTEN RASMUSSEN , JIM AAGE N Ø TTESTAD
Palmstierna T, Haugan G, Jarwson S, Rasmussen K, N ø ttestad JA. Cognitive – behaviour group therapy for men voluntary seeking help for intimate partner violence. Nord J Psychiatry 2012;66:360–365.
Background: Domestic violence is a major problem in society. In spite of this, there are few studies on the treatment of men who voluntarily seek help to stop their violent behaviour towards intimate partners. Most studies are performed on court-ordered individuals. Aim: The objective of this study was to evaluate results of a manualized cognitive – behaviour group therapy for voluntarily treatment-seeking men, aware of and willing to change their abu- sive behaviour. Methods: Thirty-six men recruited on a voluntary basis were offered a 15-week manualized group therapy. After initial assessment but before group therapy sessions they were randomly selected for immediate treatment or treatment after 4 months on a “ waiting list ” . All 26 who started group therapy treatment fulfi lled the programme. Changes in violent behaviour, before and after treatment, were assessed by self-reports using the Confl ict Tactic Scales. Also, the men on the waiting list were compared after 4 months without treatment with the men receiving treatment immediately. Results: All kinds of self-reported partner related violence were signifi cantly reduced by treatment, but being on a waiting list for 4 months did not reduce violent behaviour compared with those immediately receiving treatment. The results indicate that that the group treatment had an effect in itself beyond the wish and intention from the men to reduce their partner violence.
• Cognitive – behaviour therapy , Domestic violence , Group therapy.
Tom Palmstierna, Programomr å de Social- och R ä ttspsykiatri, Karolinska Institutet, Box 4044, SE-141 04 Stockholm, Sverige, E-mail: tom.palmstierna@ki.se; Accepted 6 February 2012.
Violence in the home, at the workplace, at schools, and in the community is a recurrent theme in both scientifi c and popular forums. The question of how to
reduce violent behaviour has long been of great concern,
and many studies have been carried out on violence in
general and on violence in intimate relationships in par-
ticular. The fi rst and most comprehensive nationwide sur-
veys on violence in intimate relationships were conducted
in the USA in 1975 (1). This investigation, “ The National
Family Violence Survey ” , was the fi rst attempt to assess
the prevalence of intimate partner violence in a nation-
ally representative sample. It was found that in the year
prior to the 1975 survey, 12.1% of women were victims
of their husbands ’ physical aggression and that 3.8%
were victims of severe violence. These proportions were
very similar 10 years later where it was found that 11.3%
were victims of their husbands ’ violence and 3.0% were
victims of severe violence (2). Similar studies have been
performed in the Nordic countries. A Norwegian study
(3) found that 27% of the women surveyed had been
exposed to violence from an intimate partner since the
age of 15, of which 21% had been exposed to physical
violence. In Sweden (4) it was found that 35% of the
women surveyed had been exposed to violence by an
intimate partner, and in Finland (5) it is found that 33%
of the women surveyed had been exposed to violence
from a partner using the same defi nition of violence as
in the Swedish study, i.e. physical violence, threats of
violence and sexual violence since the age of 15.
A number of therapeutic approaches have emerged to
reduce men ’ s violence towards their female partners, e.g.
couple counselling, neuropsychological treatment, dialec-
tical counselling, psychodynamic or emotive approaches,
stress management and cognitive – behaviour therapy
(CBT) (6). Since the early 1960s, cognitive therapy (CT)
and CBT have been used (7, 8).
© 2012 Informa Healthcare DOI: 10.3109/08039488.2012.665080
CBT FOR PARTNER VIOLENCE
NORD J PSYCHIATRY·VOL 66 NO 5·2012 361
desire for change, without formal or legal coercion to
participate.
Methods and participants Participants Men abusing their female partners were recruited by
advertising in public media and spreading information
about the programme to general practitioners in the area
of Trondheim, a city in Norway with about 168,000
inhabitants. During a 12-month period, 37 men were
recruited, none of them subject to formal coercion by
authorities or court order. Exclusion criteria were severe
alcohol or drug abuse, psychotic disorder, or lack of fl u-
ency in the Norwegian language. All participants had a
fi rst appointment within a week for initial assessment and
information about the treatment. All but one came to the
fi rst appointment. At the initial assessment, the remaining
36 men were randomly assigned either to immediate
treatment or to a waiting list. Clients were consecutively
randomized into blocks of 10. The clients who served as
waiting-list controls waited for 4 months from random-
ization before the commencement of treatment. At the
beginning of the therapy, nine men did not show up for
treatment and one was immediately referred to psychia-
tric treatment. Of the remaining 26 individuals, 15
belonged to the immediate treatment group and 11
belonged to the waiting list group. The mean age for the
whole group was 36 years (standard deviation � 9.7, range 19 – 55). In all, 28 (76%) of the men were in regu-
lar work, 21 (57%) had a college degree and 19 (51%)
had an annual income of US $ 42,000 or more. Of the
nine drop-outs, four were initially assigned to the waiting
list group and fi ve to the group treated immediately.
There were no signifi cant differences between completers
and drop-outs, apart from a trend towards higher age
among the drop-outs ( P � 0.074) (Table 1).
Treatment description After receiving a reference by letter or telephone, clients
were offered contact with a therapist from the pro-
gramme. The initial contact starts with three or four indi-
vidual sessions. In the individual sessions, the client
learns the rationale of the method and the procedure in
the group sessions. In these sessions, emphasis is put on
three main aspects. The fi rst aspect concerns the aspect
of the client – therapist relation where the therapists reas-
sure that they are meeting the client with respect, warmth
and as being an “ equal human being ” . The second aspect
of the individual sessions concerns the mutual assessment
of the violence problem, creating a shared picture on the
problem. Here the Confl ict Tactic Scales (CTS) assess-
ments are part of the sessions. A third aspect of these
individual sessions is refl ections on the client ’ s readiness
to change with emphasis of the client ’ s acknowledgement
Research on the effectiveness of treatment programmes
for men violent to their female partners has yielded
mixed fi ndings. Gondolf & Jones (9) noted that earlier
meta-analyses had found little or no treatment effect,
whereas their own meta-analysis of three well-established
programmes using cognitive – behavioural approach sug-
gested that cognitive – behavioural approaches reduced the
likelihood of re-assault between 44% and 64%. A recent
review from the Cochrane Institute (10) stated that in
spite of many studies on treatment of men violent to
their female partners, the evidence of controlled studies
is insuffi cient to draw conclusions on the effects. In this
review, six trials with a total of 2343 participants meeting
their criteria were found. The report noted that most stud-
ies focused on treatment of court-ordered clients and that
many studies lacked a description of the actual content of
the therapy. In another review of 22 studies, the relative
impact of the so-called Duluth model, CBT, and other
types of treatment on subsequent recidivism of violence
were compared (11). It was found that there were no dif-
ferences in effect sizes in comparing Duluth model with
CBT-type interventions. However, it is diffi cult to sepa-
rate the Duluth model from CBT-inspired treatment mod-
els since the Duluth model, which has at its core beliefs
linked to masculinity and patriarchy, often has incorpo-
rated several issues from CBT. Since the publication of
these reviews, other studies have come forward, e.g. Alex-
ander et al. (12) who found no differences in self-reported
aggression in their study comprising 528 male batterers
randomly assigned to either a motivational interviewing
approach or standard CBT gender re-education showed no
differences in self-reported aggression. However, this
study also (12) showed that signifi cantly fewer partners of
men assigned to the stages-of-change motivational inter-
viewing treatment approach reported having experienced
physical aggression at follow-up. This fi nding is of impor-
tance since partners ’ reports are considered more valid
than the reports from the subjects of treatment (11).
Overall, the effects of treatment in most studies were
in the small range, meaning that the interventions had
just a small impact on reducing recidivism beyond the
effect of being arrested.
It could thus be argued that the controversies regard-
ing the effect of CBT could be because of insuffi cient
descriptions of the treatment programmes and that many
of the effect studies are based on court-ordered popula-
tions, i.e. populations of abusers with severe problems,
more or less forced into treatment and thus also probably
have less motivation and ability to change than the aver-
age male abusive partner.
Aim The aim of this study was to evaluate the effects of man-
ualized group CBT for men who have abused their female
partners and voluntarily seek treatment with an expressed
T PALMSTIERNA ET AL.
362 NORD J PSYCHIATRY·VOL 66 NO 5·2012
behaviour. The rest of the group participates by helping
the client to defi ne an acceptable alternative behaviour.
When an acceptable alternative behaviour enabling with-
drawal from a diffi cult situation is found, the client is
told to practise it at home. The client is also asked to
generalize the new violence-avoidant behaviour to other
violent situations.
The second part (about seven or eight sessions), the
cognition modifi cation phase, starts when all the clients
in the group are judged by the therapists to have the
skills to control their behaviour. The participants are now
able to avoid violence and to recognize vulnerable situa-
tions. In this phase, the task is to reach an understanding
of the clients ’ automatic thoughts and beliefs. During the
sessions, the clients learn about their core beliefs in order
to recognize them, question them and acquire techniques
for challenging them. Cognitive distortions forming core
beliefs and ways of addressing them are identifi ed by
using rehearsal and homework. At the end of the 15 ses-
sions, the group members evaluate each other and iden-
tify areas where they need to be cautious in the future.
of personal responsibility of his own behaviour. If wished
by the client and his partner, a fourth session together
with the partner, refl ecting on these themes, is offered.
After these initial sessions, the client either went on to
the waiting list or entered directly the treatment group
consisting of six to eight clients, led by two therapists
(one male and one female). The treatment phase lasted
for 30 h (15 weeks with 2-h sessions per week). The
treatment was based on the principles of Aaron Beck ’ s
cognitive therapy (13) with a treatment manual con-
structed by two of the authors (14) consisting of two
equal parts.
In the fi rst part (about seven or eight sessions), the
behavioural modifi cation phase, all sessions start with
each client describing how the week has passed with
regard to their violent behaviour. From this round, a cli-
ent is chosen based on the seriousness of the violence
used. The clients are then taught how to use anger-
avoiding behaviours to prevent new violent episodes.
Using Socratic questions, the therapists encourage the
clients to come up with constructive alternatives of
Table 1 . Demographics.
Mean age
Completers ( n � 26) 35
Drop-outs ( n � 9) 40
P 0.074
Test statistics
t -test n % n %
Education
Primary school 4 15 2 22 0.89 χ 2 College 15 58 5 56
High School/university 7 27 2 22
Work
Regular work 21 81 7 78 0.18 χ 2 Unemployed 1 4 1 11
Receiving social benefi ts 0 0 1 11
Student 4 15 0 0
Annual income (US $ )
0 – 14000 2 8 0 0 0.30 χ 2 14000 – 28000 5 19 3 33
28000 – 42000 6 23 0 0
42000 – 13 50 6 67
Ever violent while intoxicated
Yes 20 77 4 44 0.30 χ 2 Never 6 23 5 56
Family status
Single 2 8 0 0 0.51 χ 2 Married 3 12 2 22
Cohabitant 18 69 7 78
Non-cohabitant couples 3 11 0 0
Previous sentence for violence
against partner
Yes 1 4 0 0 0.55 χ 2 No 25 96 9 100
Previous sentence for other violence
Yes 7 27 2 22 0.78 χ 2 No 19 73 7 78
Previous mental health problems
Yes 15 42 3 33 0.47 χ 2 No 11 58 6 67
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NORD J PSYCHIATRY·VOL 66 NO 5·2012 363
sessions, only 15 of the 26 previously violent men
reported violence of any kind. Only four of the 21 men
who had reported a history of physical violence still
reported such behaviour, whereas six of the 19 men
who had reported verbal aggression still reported such
behaviour. A reduction in violence towards property
was also reported. All these changes were signifi cant
(Table 2).
Signifi cant differences were revealed by comparing
the reassessment of the 11 men in the waiting list
before entering treatment with those who were assessed
after treatment starting immediately after the fi rst
assessment in order to exclude a “ waiting list ” effect.
At follow-up without treatment, 10 of the 11 men in
the waiting list still exhibited some kind of partner-
related violent behaviour before treatment as compared
with only seven of the 15 men receiving immediate
treatment ( P � 0.036, Fischer ’ s exact test). There was also a signifi cantly lower rate of men reporting physi-
cal violence in the treatment group compared with the
untreated waiting list group. Two (13.3%) of 15 men
in the treatment group reported physical violence after
treatment compared with eight (72.7%) of 11 men in
the follow-up of the waiting list group before treatment
( P � 0.004, Fischer ’ s exact test). The same pattern was observed with self-reported verbal aggression. Only
three (20%) of the 15 men in the treatment group
reported such behaviour, whereas nine (81.8%) of the
11 men in the waiting list group still reported such
behaviour at follow-up before treatment ( P � 0.004, Fischer ’ s exact test). Self-reported violent behaviour
towards property showed the same difference between
the groups; two (13.3%) of the 15 men in the treat-
ment group reported such behaviour, whereas nine
(81.8%) of the 11 men in the waiting list group
reported such behaviour at follow-up before treatment
( P � 0.001, Fischer ’ s exact test). The only client characteristics listed in Table 2
related to some kind of violent behaviour after treat-
ment was age, which was signifi cantly and negatively
correlated to exercise of physical violence after treat-
ment (Spearman ’ s rho � � 0.52, P � 0.007). All four men still physically violent after treatment were below
the age of 28.
Measures Data on violent behaviour was collected from the partici-
pants before and after treatment using an extended ver-
sion of the CTS (15). The CTS consists of a list of actions
that a family member might use in confl ict with another
family member, friend or stranger. The original CTS
is intended to measure three constructs: “ Reasoning ” ,
“ Verbal Aggression ” and “ Physical Aggression ” / “ Violence ” .
In our study, the “ reasoning ” items from the CTS were
dropped and a section on material violence was added.
In this study, domestic violence is defi ned as the use
of physical violence, verbal aggression or material vio-
lence of one adult towards another or towards a member
of the household to cause harm, injury or fear. Physical
violence items involve throwing something, pushing,
grabbing, shoving, slapping, spanking, kicking, biting,
punching, hitting, trying to hit with an object, beating
up, choking, threatening with or using weapons. Verbal
aggression involves interrogating a partner when she has
been out, calling her obscene names or frightening her
with threatening body language in intense jealousy. Ver-
bal aggression also includes shouting, using verbal or
symbolic means of hurting such as insults or threats.
Material violence was defi ned as behaviours such as
pounding a wall or table as well as destruction of prop-
erty. The violent acts were registered with the options
one, two or three times or more during the past year, or,
in the follow up interviews, the last 4 months.
All participants were assessed at the fi rst appointment
and after treatment. Those in the waiting list group were
reassessed when entering treatment after 4 months on the
waiting list, thus serving as a control assessment to com-
pare with the assessments after treatment in the group
having immediate group therapy treatment.
Ethics The study was approved by the Regional Committee for
Research Ethics (REK).
Results Follow-up interviews of all 26 men who had undergone
treatment indicated that most of the men had reduced
their self-reported violent behaviour. After the treatment
Table 2 . Self-reported violence among 26 men participating in group cognitive – behaviour treatment.
The year before treatment After 15 weeks of treatment
n % n %
Any violence at all 26 100.0 15 57.7
Any physical violence 21 80.7 4 15.4
Any verbal aggression 19 73.1 6 23.1
Any material violence 22 84.6 4 15.4
All differences are signifi cant with Wilcoxon ’ s signed matched pair test ( P � 0.001).
T PALMSTIERNA ET AL.
364 NORD J PSYCHIATRY·VOL 66 NO 5·2012
A limitation of the study is the small sample, which
could mask real differences between drop-outs and com-
pleters. However, the only difference between the com-
pleters and the drop-outs was a trend toward older age
among drop-outs. In line with our fi ndings, this would
indicate loss of participants with more positive outcome
predictors of treatment. Also, because of some minor
alterations of the CTS, the results might not be totally
comparable with other studies. Another limitation is that
collateral information on participants ’ violent behaviour
was not collected. However, the loss of true information
from the participants because of denial is probably less
important in this study, as all of the clients already had
identifi ed themselves as violent by seeking treatment vol-
untarily. Also, the short follow-up time limits conclu-
sions of sustainability of the treatment. Larger samples
and longer follow-up periods are needed to establish the
effect of this treatment programme.
However, in spite of these shortcomings, our results
of CBT in a voluntary treatment-seeking group are prom-
ising since, if replicated in larger samples with longer
follow-up periods, this treatment method could possibly
offer a solution for a larger group of violent men will-
ing, but not able by themselves to stop their violence,
and thus be of societal importance beyond the small
group of convicted individuals who constitute a minority
of batterers.
Declaration of interest: The authors report no confl icts
of interest. The authors alone are responsible for the con-
tent and writing of the paper.
References Strauss MA, Gelles RJ, Steinmetz SK. Behind closed doors: 1. Violence in the American family. New York: Doubleday; 1980. Strauss MA, Gelles RJ. Societal change and change in family 2. violence from 1975 to 1985 as revealed by two national surveys. J Marriage Family 1986;48:465 – 79. Haaland T, Clausen ST, Schei B. Couple violence — Different 3. perspectives. Results from the fi rst national study in Norway. Oslo: Norwegian Institute for Urban and Regional Research (2005:3); 2005. Lundgren E, Heimer G, Westerstrand J, Kalliokoski AM. 4. Captured queen. Men ’ s violence against women in “ equal ” Sweden — A prevalence study. Stockholm: Fritzes Offenliga Publikationer; 2002. Heiskanen M, Piipsa M. Faith, hope, and battering. A survey of 5. men ’ s violence against women in Finland. Helsinki: Statistics Finland/Council for Equality; 1998. Gondolf EW. Evaluating batterer counselling programs: A diffi cult 6. task showing some effects and implications. Aggression Violent Behav 2004;9:605 – 31. Ellis A. Reason and emotion in psychotherapy. New York: Lyle 7. Stuart; 1962. Beck JS. Cognitive therapy: Basics and beyond. London: Guilford 8. Press; 1995. Gondolf EW, Jones AS. The program effect of batterer programs 9. in three cities. Violence Victims 2001;16:693 – 704. Smedslund G, Dalsb ø TK, Steiro A, Winsvold A, Clench-Aas J. 10. Cognitive behavioural therapy for men who physically abuse their female partner. Cochrane Database of Systematic Reviews 2007,
Discussion Even though this is a small study with only 26 partici-
pants, the results showed that a 15-week manualized
group-based CBT programme signifi cantly and substan-
tially reduced self-reported violent behaviour. The wait-
ing list men wished to change their behaviour but were
not able to do so by themselves, which is illustrated by
the absence of any reduction in violent behaviour in the
waiting list group prior to treatment compared with the
men immediately entering the treatment group. These
fi ndings indicate that the treatment as a whole, including
the initial individual sessions, was effective by itself.
This is in line with the results of Musser et al. (16) who
found enhanced response of the group CBT by introduc-
tory intake sessions using the techniques of motivational
interviewing. The results are also in line with for exam-
ple Gondolf & Hanneken (17), who emphasize the desire
to change as the most important variable in changing
behaviour. At inclusion, the clients were, by seeking vol-
untary, aware of their problematic behaviour, i.e. being
in preparation stage of motivation (18). Even so, the
waiting list results in our study illustrate that readiness
and motivation to change were not enough.
There is currently a lack of studies investigating what
motivates abusive men to stay in treatment. In this light,
it is interesting that all the men who started up in the
group sessions in our study also completed the pro-
gramme. The high completion rate among our subjects
may seem out of the ordinary in view of other studies
fi nding that non-court-ordered men attend fewer sessions
than court-ordered (19, 20). Whereas most studies fi nd
more drop-outs among younger men, the trend in our data
for drop-outs to be older is, however, in line with Ger-
lock ’ s fi ndings (20). This difference could be related to
the assumption that voluntary treatment seekers have few
people to confi de in and discuss what to do about their
problem with violence. It could also not be ruled out the
specifi c procedure of the initial individual sessions includ-
ing both a reassurance of respect together with emphasis
on the clients individual responsibility could have had an
impact on the willingness to complete the programme.
This together with a possible feeling in the group ses-
sions of being respectfully connected to others with simi-
lar problems, offering a relief of being in the “ same boat ”
could also be a reason for the high completion rate.
The treatment was least effective for the youngest
men. This might be because of a lack of readiness to
change related to their low age, or they might constitute
part of another population of batterers who will develop
more violent behaviour as they grow older, increasing
the likelihood of entering court-ordered treatment in the
future. It could also refl ect an interaction between age
and type of programme. Cognitive programmes typically
involve cognitive issues that demand a great deal of self-
refl ection, possibly less present among younger men.
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NORD J PSYCHIATRY·VOL 66 NO 5·2012 365
Gerlock AA. A profi le of who completes and who drops out of 20. domestic violence rehabilitation. Issues Mental Health Nursing 2001;22:379 – 400.
Tom Palmstierna, M.D., Ph.D., Ass. Prof., St. Olav ’ s Hospital, Forensic Department and Research Centre Br ø set, Norwegian University of Science and Technology, Trondheim, Norway, and Program for Social and Forensic Psychiatry, Centre of Psychiatric Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. Grethemor Haugan, R.N. Cand. Polit., St. Olav ’ s Hospital, Forensic Department and Research Centre Br ø set, Norwegian University of Science and Technology, Trondheim, Norway. Stig Jarwson, R.N., St. Olav ’ s Hospital, Forensic Department and Research Centre Br ø set, Norwegian University of Science and Technology, Trondheim, Norway. Kirsten Rasmussen Ph.D., Professor, St. Olav ’ s Hospital, Forensic Department and Research Centre Br ø set, Norwegian University of Science and Technology, Trondheim, Norway, and Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway. Jim Aage N ø ttestad, Ph.D., Ass. Prof., St. Olav ’ s Hospital, Forensic Department and Research Centre Br ø set, Norwegian University of Science and Technology, Trondheim, Norway.
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