Treatment Resistant Perpetrators of Intimate Partner Violence: Research Advances

Abstract

Intimate partner violence (IPV) is a worldwide social and public health problem, with serious consequences not only for the victims’ physical and psychological well-being, but also for their children, and the wider community (Campbell, 2002; Ellsberg et al., 2008; Guedes et al., 2016; Martín-Fernández et al., 2019, 2020; Okuda et al., 2011; World Health Organization [WHO], 2021). While women experience this form of violence to a greater extent than men and with more serious consequences (WHO, 2021), men can also be victims (Hines, 2015; Perryman & Appleton, 2016; Scott-Storey, 2023). Moreover, studies indicate that rates of IPV victimization can be as high or higher among sexual and gender minorities than heterosexual cisgender people (Badenes-Ribera et al., 2016; Gilchrist et al., 2023; Liu et al., 2021; Peitzmeier et al., 2020; Rollè et al., 2018). While research in the field of IPV perpetrators has advanced considerably in recent decades, significant challenges regarding intervention effectiveness remain. Intervention programs for IPV perpetrators emerged in the late 1970s in response to a growing recognition of IPV as a social problem (Mackay et al., 2015; Scott et al., 2011). Since then, several researchers have conducted studies and meta-analyses to evaluate their effectiveness (e.g., Arce et al., 2020; Babcock et al., 2004; Cheng et al., 2019; Karakurt et al., 2019; Smedslund et al., 2011; Travers et al., 2021; Wilson et al., 2021). This body of literature suggests that the scientific evidence supporting the effectiveness of IPV perpetrator programs is still limited. Major challenges hamper the effectiveness of intervention programs for IPV perpetrators, the most important of which include high dropout rates, low motivation to change, high levels of denial, minimization of responsibility and victim blaming, and dealing with high-risk and highly resistant participants (Carbajosa et al., 2017; Expósito-Álvarez et al., 2021; Jewell & Wormith, 2010; Lila et al., 2012, 2019; Martín-Fernández et al., 2018, 2022). Also, we must take into account that many intervention programs for IPV perpetrators function within the framework of the criminal justice system. A large number of IPV perpetrators are court-mandated to attend these programs and, consequently, they may not be self-motivated to attend, as they are ‘forced’ to undergo an intervention that they often feel is useless or unjustified (Eckhardt et al., 2013; Lila et al., 2018). Despite these constraints, researchers in this field consider that there is significant room to improve intervention strategies to increase the effectiveness of these programs (Babcock et al., 2016; Levesque et al., 2012). In this regard, recent studies and meta-analyses point out that perpetrator programs that include motivational strategies or adhere to risk-need-responsivity principles are more promising than the more traditional ‘one-size-fits all’ intervention approach (Eckhardt et al., 2013; Lila et al., 2018; Romero-Martínez et al., 2019; Santirso, Gilchrist, et al., 2020; Travers et al., 2021). In this special issue we aim to better understand the therapeutic needs, risk factors, and treatment resistance in IPV perpetrators to provide evidence-based responses to improve intervention programs. In the first manuscript of the special issue, Systematic investigation of meta-analysis data on treatment effectiveness for physical, psychological and sexual intimate partner violence perpetration, Ouztüzün et al. (2023) found that differences in the effectiveness of perpetrator programs that may exist depending on the type of violence they are working with. Using meta-regression analysis, these authors assess the effects that different treatment models have on physical, psychological and sexual IPV. From the thirteen studies included in their review, in which the effectiveness of sixteen intervention models is reported, it emerges that when self-reported physical IPV is higher pre-intervention, it is more likely that the intervention can demonstrate its effectiveness more clearly. However, when psychological and sexual violence are higher at the beginning of the intervention, the results of the intervention are less favourable. Among the practical conclusions drawn from this meta-regression, the authors highlight the fact that treatment may be more effective if the intervention program is tailored to the type and severity of violence reported at the start of the intervention. Perpetrators individual characteristics, such as substance use and mental health, have been shown to increase perpetrator program drop-out and recidivism (e.g., Bijlsma et al., 2022; Catalá-Miñana et al., 2013; Daly & Pelowski, 2000; Lila et al., 2019; Romero-Martínez et al., 2019; Tollefson et al., 2006, 2008); highlighting that treatment resistant perpetrators need interventions tailored to target their risk factors for IPV and recidivism (e.g. Arias et al., 2013; Butters et al., 2021; Travers et al., 2021). Indeed, recent reviews suggest that perpetrator interventions that address substance use and trauma could potentially be more effective in reducing IPV (Karakurt et al., 2019; Stephens-Lewis et al., 2021; Tarzia et al., 2020). Deficits in executive cognitive functioning due to head injury, trauma or prolonged substance use are also associated with IPV perpetration and recidivism (Horne et al., 2020; Humenik et al., 2020). As a result, perpetrator programs for men with such deficits should include skills-building (e.g. goal-setting, problem solving) to improve cognitive functioning, to enhance program engagement and improve outcomes (Horne et al., 2020; Humenik et al., 2020; Vitorira-Estruch et al., 2018). In the second manuscript in this special issue, Neuropsychological performance, substance misuse, and recidivism in intimate partner violence perpetrators, Romero-Martinez et al. (2023) compare neuropsychological variables among male IPV perpetrators with and without substance use problems to non-abusive men, and examine whether differences in IPV recidivism are due to neuropsychological performance. They found that IPV perpetrators with substance use problems had poorer cognitive performance than controls. IPV perpetrators who did not have problems with substance use reported poorer executive functioning than non-abusive men. In addition, IPV perpetrators with substance use problems had higher rates of recidivism than those without substance use problems. Recidivism in both groups was related to cognitive flexibility, verbal fluency, and worse attention functioning. The authors recommend perpetrator programs conduct neuropsychological assessments with potential participants to allow their neuropsychological needs to be addressed during the program. Similar to male IPV perpetrators, individual risk factors for women who perpetrate IPV include substance use, a history of trauma, poor emotional regulation, and mental health problems (Mackay et al., 2018; Stuart et al., 2006). Previous studies have highlighted the potential benefit from addressing alcohol concurrently with IPV among male perpetrators (see above). In the third manuscript in this special issue, Randomized clinical trial of a brief alcohol intervention as an adjunct to batterer intervention for women arrested for domestic violence, Brem et al. (2023) randomized women to receive the state-mandated perpetrator program with a brief alcohol intervention or to the perpetrator program alone. They found greater reductions in physical IPV perpetration and improvements in alcohol outcomes for women who received the perpetrator program plus the brief alcohol intervention. Authors conclude that, as reported in previous studies with men (e.g., Stuart et al., 2013), adding a brief alcohol intervention to perpetrator programs for women may also improve outcomes for women arrested for IPV. Male IPV perpetrators with substance use problems are a treatment resistant group, with targeted integrated intervention recommended for this group. In this special issue’s fourth manuscript, Expósito-Álvarez et al. (2023) conducted a systematic review titled Participants in court-mandated intervention programs for intimate partner violence perpetrators with substance use problems: A systematic review of specific risk factors. Their review includes 29 studies on the specific risk factors in male IPV perpetrators with and without substance use problems on entry to court-mandated perpetrator programs. They found higher clinical symptomatology (e.g., anger and impulsivity), personality disorders, poorer executive functions, experience of stressful life events and exposure to childhood trauma, lower intimate social support and higher responsibility attributed to the offenders’ personal context among those perpetrators with substance use problems compared to those without substance use problems. The authors believe that addressing these risk factors in IPV perpetrator programs could improve outcomes. The prevalence of IPV victimization is far higher among men partnered with men than men partnered with women (e.g. Liu et al., 2021; Rollè et al., 2018). The penultimate manuscript included in this special issue, IPV perpetration denial and underreporting in cisgender male couples, compares IPV perpetration denial (i.e. self-reported perpetration contradicts their partner’s reported victimization) across different types of IPV: emotional, monitoring/controlling, and physical/sexual among male couples using actor-partner interdependence models. Walsh & Stephenson report that 21% of men denied perpetrating monitoring/controlling IPV, 28% denied perpetrating emotional abuse and 36% denied perpetrating physical/sexual IPV. They found that depression was negatively associated with denying monitoring/controlling and physical/sexual IPV perpetration. Lower odds of denying perpetration of emotional IPV was reported when depression was discordant among both partners in the couple. Lower odds of denying perpetration of monitoring/controlling IPV were reported among men who used substances compared to those who did not. The authors conclude that these findings could inform prevention and intervention strategies. This special issue identified key targets and strategies for IPV perpetrator programs that could improve the outcomes for treatment resistant IPV perpetrators. However, further studies are needed to test whether these would increase effectiveness and reduce recidivism. As described earlier, studies evaluating the effectiveness of IPV perpetrator programs face many methodological issues. In this special issue’s final manuscript, Methodological challenges in group-based randomised controlled trials for intimate partner violence perpetrators: a meta-summary, Turner et al. (2023)review the methodological challenges described by the study authors in the design and conduct of 15 trials of perpetrator programs, including: source of outcome data, treatment modality, attrition and sample characteristics. The authors provide suggestions on how to reduce or address these methodological challenges to improve future studies on perpetrator program effectiveness. In summary, this special issue includes publications from some of the leading researchers in the field of IPV perpetration. Their manuscripts describe risk factors for treatment resistant or minoritized perpetrators to inform the tailoring and targeting of interventions approaches for this population. Through reviews of existing evidence, we see how addressing the intensity and types of violence, as well as knowing the specific risks that offenders who use substances present with, can be the basis for the design of intervention strategies that improve perpetrator program outcomes. Likewise, identifying the neurocognitive deficits and problems of at-risk populations participating in these programs is relevant for the design of tailored interventions to improve such cognitive deficits and as a result, intervention outcomes. In addition, interesting results are presented from studies that analyze less studied populations of IPV perpetrators (i.e., female IPV perpetrators with substance use problems and men who abuse their same-sex partners). Finally, a review of the main methodological problems faced by randomized clinical trials in assessing the effectiveness of these interventions is presented and possible solutions to these problems are provided. To improve the effectiveness of IPV perpetrator programs interventions should be more sensitive and responsive to participants’ risk factors and treatment needs.