Cognitive Behavioural Therapy for Men Who Physically Abuse their Female Partner

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Updated Systematic review.

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Synopsis

Cognitive behavioural therapy for men who physically abuse their female partner

Domestic violence is common and serious. Many convicted men are court-ordered to receive cognitive behavioural therapy (CBT) in order to end their violence. Most men do not voluntarily seek such therapy but participate either after being pressured by their partners or after being legally required to do so. The review sought all randomised controlled evaluations about the effects of CBT on physical violence worldwide, but found only six small trials with 2343 participants met the inclusion criteria. The evidence from the included studies is insufficient to draw any conclusions.

Background

Violent behaviour constitutes a serious problem in societies worldwide. Intimate partner abuse is especially problematic because it takes place in the private family sphere, making it a difficult arena for intervention and help. The physical abuse of women by their male partner is a serious concern because “it affects a distressingly high percentage of the population and it results in physical, psychological, social, and economic consequences” (CDCP 2003). The World Health Organisation (WHO) reported that “the overwhelming health burden of partner violence is borne by women at the hands of men” (WHO 2002). The WHO also provided evidence about the extent of the problem: in national surveys between 10 % and 34 % of the women reported being physically assaulted by an intimate male partner (WHO 2002).

Domestic violence occurs in the family and takes many different forms, including sexual, psychological, emotional and physical abuse. In this review the focus is solely on physical abuse. Domestic violence can occur between spouses/partners and between adults and children in the family. This review focuses only on partnership abuse, and specifically on men who physically abuse their female partner or ex-partner. The term domestic violence is therefore too broad to give meaning for this review, and more useful terms are physical abuse, battering, and intimate partner abuse. Another important limitation is that this review does not focus on the causes of violent behaviour. Several biological, psychological and sociological studies have attempted to find the one answer to what causes men to commit violent actions. In general there is now more focus on the correlation of different behavioural variables leading to violence. Therefore this review sets out to include more outcome variables than strictly physical violence, for example self-esteem, substance use and emotional problems.

US batterer intervention programmes were initially introduced as an alternative to incarceration for men arrested for domestic violence. This was a controversial strategy because many policy makers/advocates felt that this diversion sent the message that abuse was a mental health problem rather than a crime, and because funding these programmes may have diverted funds from programmes for abused women. The stated goals for the batterer intervention programmes differ widely, from statistically measurable reductions in violence, to holding men accountable to preparing men to take action against the woman battering culture.

One of the most frequently used treatment programmes for physically abusive men is a psychological intervention called cognitive behavioural therapy (CBT). CBT not only seeks to change behaviour using established behavioural strategies, but also targets the thinking patterns and beliefs that are thought to contribute to violence. CBT is “designed to help the patient test certain maladaptive cognitions and assumptions” (Beck 1979). CBT techniques aim to identify thoughts and beliefs that precede violent behaviour, challenging the patterns that violent men use to justify their violence after the event. The goal is to bring about changes in the way that physically abusive men think about violence and the circumstances which lead to violence, thereby interrupting the chain of events that lead to physical abuse. The CBT can be given in individual, couple or group format. A common intervention called the Duluth Model (Pence 1993) has many cognitive-behavioural components and is included in this review.

An American review of state and provincial programmes for intervening in spouse abuse cases reported simply “the jury remains out on the effectiveness of these programmes” (Arias 2002). When spouse abusers are sent on programmes, it is important to know the positive or negative effect. If a programme does not work or has adverse outcomes, we risk putting women in danger of future abuse.

The scope of this review is to determine the effectiveness of cognitive behavioural therapy delivered to men engaged in physical abuse, against their female partner. A previous review of cognitive therapy (Butler 2000) for violent offenders did not include physically violent spouse abusers, but concluded that the therapy had a beneficial effect for those with problems such as marital distress and anger. To date, we know of no systematic review of the effects of CBT for men who are physically violent toward their partners that has employed a search strategy aiming to locate every randomised controlled study worldwide regarding this question. Davis and Taylor (Davis 1999) reviewed the literature but did not report a search strategy. A later review (Babcock 2004) searched only PsychINFO and used only four search terms. The results from the present review are of importance for perpetrators and victims of this form of violence, and those who seek this form of treatment for the problem, and also for therapists, researchers, the judiciary, and the general public.

Objectives

To measure the effects of cognitive behavioural therapy (CBT) and similar interventions on men's physical abuse of their female partners.

Criteria for considering studies for this review

Search strategy for identification of studies

We searched the Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library Issue 4, 2006), MEDLINE (1966 to September week 3 2006), EMBASE (1980 to 2006 week 39), CINAHL (1982 to September 2006), PsycINFO (1806 to October 2006), ERIC (1966 to September 2006), C2-SPECTR (searched December 2006), Care Data/Social Care Online (searched September 2006), Sociological Abstracts (1963 to September 2006), Criminal Justice Abstracts (1968 to September 2003), Bibliography of Nordic Criminology (1999 to December 2006), and SIGLE (1980 to September 2003). Criminal Justice Abstracts and SIGLE were only searched until 2003 because we did not have access in 2006.

We handsearched Santé mentale au Québec, an online scientific journal, from 1976 to 2003. The review authors contacted field experts and the authors of retrieved studies in order to find additional studies. Conference papers were searched also, in order to minimise the threat of publication bias. Reference lists in included studies were searched for relevant literature. Studies were included regardless of language and country of origin.

Below is the search strategy used to search CENTRAL. The search strategies for the other electronic databases were modified to suit each database. They are included in Table 02, Table 03, Table 04, Table 05, Table 06, Table 07, Table 08 and Table 09.

Search strategy used in CENTRAL, The Cochrane Library Issue 4, 2006 (Sigrun Espelien Aasen)

#1MeSH descriptor Battered Women, this term only

#2MeSH descriptor Domestic Violence, this term only

#3MeSH descriptor Spouse Abuse, this term only

#4((familiy or domestic or conjugal or partner*) near/3 violence):ti,ab,kw

#5((abus* or batter*or beat* or assault*) near/3 (wom*n or partner* or spouse* or female* or wife or wives or domestic* or fiance or cohabitant* or live-in)):ti,ab,kw

#6((male* or men or man or partner* or spouse* or husband or fiance or cohabitant* or live-in) near/3 (batter* or perpetrator* or abus* or violen* or beat* or assault)):ti,ab,kw

#7(#1 OR #2 OR #3 OR #4 OR #5 OR #6)

#8MeSH descriptor Behavior Therapy, this term only

#9MeSH descriptor Cognitive Therapy, this term only

#10MeSH descriptor Psychotherapy, Rational-Emotive, this term only

#11(cognitive* near/3 (therap* or train* or techni* or question* or approach* or assessment*)):ti,ab,kw

#12((behavior* or behaviour*) near/3 (therap* or train* or modif* or experiment*)):ti,ab,kw

#13(rational* near/3 emotive*):ti,ab,kw

#14(cbt):ti,ab,kw

#15(schemas or schematas):ti,ab,kw

#16MeSH descriptor Imagery (Psychotherapy), this term only

#17(imager*):ti,ab,kw

#18((cognitive* or mental*) near/3 (map* or model*)):ti,ab,kw

#19(Socratic* near/3 (question* or method* or dialogue* or strateg* or sequence*)):ti,ab,kw

#20(dysfunctional near/2 (thought* or assumption* or rule* or appraisal* or belief* or attitude* or scheme*)):ti,ab,kw

#21(automatic near/3 (thought* or process*)):ti,ab,kw

#22(nat or nats):ti,ab,kw

#23(reattribution*):ti,ab,kw

#24((key or core) near/2 belief*):ti,ab,kw

#25(#8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24)

#26(#7 AND #25)

Methods of the review

Description of studies

Methodological quality of included studies

All included trials were reported as randomised and the method of randomisation was adequate in four out of the six studies. Concealment of allocation was judged as adequate in three studies (Bronx Exp. 2005; San Diego Navy 2000, Yale Study 2007). In four studies it was clear that there were no systematic differences in treatment between groups aside from the experimental intervention (low risk of performance bias). Detection bias was unclear in all studies except for Yale Study 2007, that is, it was not clear whether the persons collecting the results were blind to treatment group allocation. It should be noted, however, that this may not be important whenever the outcomes are written criminal justice records. There were high or unclear attrition in five out of six studies. Only the Navy (San Diego Navy 2000) managed to keep most of the participants in the intervention. Intention-to-treat was met in all studies. The randomisation was frequently compromised by judges overriding the allocation because they did not want certain of the defendants to be in the control group. In sum, all studies had a high risk of bias except for the San Diego Navy 2000 Experiment (San Diego Navy 2000) which we judged to have a moderate risk of bias.

Results

Discussion

There have been few randomised evaluations of cognitive behavioural therapy for men who physically abuse their female partner. All such studies have so far been conducted in the USA. The studies also have relatively small sample sizes, the largest study having 861 participants. This review has employed an extensive search strategy with no restrictions on publication language or geographical region. Because there were so few studies, we could not model sources of heterogeneity using e. g. meta-regression or stratified analyses. Only one meta-analysis was performed. The results were inconsistent and heterogeneous, but there was no clear evidence for publication bias (Figure 01). The number of studies in this funnel plot (N = 4) is, however, so small that great caution should be taken in its interpretation. The methodological quality of the included studies was generally low (Table 01). The concealment of the random allocation sequence was mostly unclear or not met. Furthermore, it was mostly unclear whether the assessors of the results were aware of group allocation. Finally, the attrition was either unclear or high. Unclear concealment of allocation and high attrition both contribute to high risk of selection bias, but blinding of the assessors is probably not of serious concern because criminal justice records are in written form.

Two anonymous peer-reviewers pointed to a number of issues pertaining to contemporary US debates which should be mentioned here. The partners of the male perpetrators were offered some support. This support might have made the partners more able to report new violence, independently of the effect of the interventions on the men. This review focuses exclusively on effects on physical violence. But even where interventions may have an impact on physical violence, perpetrators may continue or possibly increase the use of emotionally controlling behaviours (Dobash 2000). Reliance on criminal justice records is also problematic because much violence is never recorded by the police. Some authors have been worried about whether assignment to a batterer intervention programme actually sends an implicit message that contradicts its official aim, namely that battering will not be taken seriously. This raises another debate: although some form of monitoring for compliance was present in all of the studies reviewed, sanctions for noncompliance are very rare. Moreover, the issue of attendance versus drop-out raises the important issue of selection bias, namely whether men who complete programmes are more motivated to stop their violence than those who never attend or drop out. While randomised controls should eliminate selection bias, the poor ways in which compliance is monitored suggest this may not be so. This review focuses on behaviour change, but many programmes actually view behavioural change as unlikely. They focus more on message sending and re-education or education.

CBT is a broad category that encompasses many different approaches. The most widely used model in the US, the Duluth Model, is included in this review because it has components of CBT. Not to include this model would eliminate most batterer intervention programmes in the US. But the fact that it has such components does not mean that everyone recognises it as a form of CBT. The Duluth Model includes strong elements of anti-sexist messaging, for instance, whereas traditional CBT approaches do not.

Care should be taken when generalising the results of this review to other parts of the world. First, there may be different baseline risk of violence across populations. Second, the motivation to comply with the treatment might vary greatly across populations of violent men. Men have different reasons for being in therapy. Their wives might have threatened to leave them if they do not enter therapy, or the men might have been court-ordered to take part. The men differ in their degree of stake in conformity, and such variables (employment and age) have predicted both attendance at treatment and re-offending (Broward Exp. 2000).

Reviewers’ conclusions

Internal sources of support

Norwegian Knowledge Centre for the Health Services, NORWAY

External sources of support

Nordic Campbell Centre, DENMARK

Contribution of reviewers

Dalsbo and Smedslund wrote the protocol.

All reviewers independently screened literature, reviewed potential trials, and extracted data. Smedslund analysed the data. Smedslund wrote the text of the completed systematic review. Steiro, Winsvold and Clench-Aas contributed by giving comments, assessing studies and acting as mediators if necessary. Responsibility for updating the review is jointly shared between Dalsbo and Smedslund.

Acknowledgements

Many thanks to Torill Johme for contributing to the planning of the study, for literature screening, hand-searching, and for performing the initial searches in 2003.

Thanks to Sigrun Espelien Aasen for carrying out updated searches in November-December 2006. We also want to acknowledge the Norwegian Directorate for Health and Social Affairs, which housed us and funded us during the initial phase of the development of this review. We are also grateful for the support by Andy Oxman during the start-up. Last, but not least, we want to thank Jane Dennis, the review group coordinator of the Cochrane Developmental, Psychosocial and Learning Problems Group for her continuous support and help in dealing with a number of different review authors and with different drafts leading up to the final review.

This review is co-registered within the Cochrane Developmental, Psychosocial and Learning Problems Group (Cochrane Collaboration).

Potential conflict of interest

None known.

Characteristics of included studies

Characteristics of excluded studies