From Resistance to Invitations: How Men Voluntarily in Therapy for Intimate Partner Violence May Contribute to the Development of a Working Alliance

Abstract

The high drop-out rate and modest outcome for men in treatment for intimate partner violence (IPV) have highlighted the question of how therapists can establish an effective working alliance with these clients. The aim of this study was to conceptualize the variety of ways in which male clients using violence against a female partner might present themselves to form a working alliance that might appeal to them. We studied how 20 men voluntarily in individual IPV treatment contributed at the beginning of therapy to forming an alliance with therapists skilled in such treatment. The first therapy session in 10 drop-out and 10 completed cases was transcribed verbatim and analyzed qualitatively, following guidelines drawn from the constructionist grounded theory. The analysis resulted in a conceptual model of gateways and invitations to an alliance. Gateways are themes that have the potential to open a path toward collaboration on personal change. Each of the three gateways identified, comprised solide and weak invitations to an alliance: (a) presenting reasons for seeking treatment—as their own choice, as avoidance, or as a mistake; (b) presenting notions of change—as their own need to change their violent behavior, as ambivalence toward the project, or as a need to change the partner; and (c) disclosing and describing violence—as a personal narrative, as a scene, as a fragment of their life, or as something else. Implications for therapists’ understanding of clients’ motivational goals, negotiation of alliance, and disclosure of violence early in therapy are discussed.

Keywords

intimate partner violence working alliance clients’ contribution motivational goals qualitative analysis

It can be challenging to create a viable alliance with men in therapy for the use of violence against their female partner. Therefore, it is important to gain knowledge on alliance development in intimate partner violence (IPV) treatment.

Research on IPV treatment has shown that the drop-out rates are quite high (e.g., Daly & Pelowski, 2000; Jewell & Wormith, 2010), and the treatment outcomes are described as modest in range (Babcock, Green, & Robie, 2004) or equivocal (Eckhardt et al., 2013; Feder & Wilson, 2005). This does not imply that there is evidence for no effect, but rather that we simply do not know whether the IPV interventions have positive, negative, or no effect (Smedslund, Dalsbø, Steiro, Winsvold, & Clench-Aas, 2011). These findings, and especially the high drop-out rate, emphasize that there are many challenges in developing interventions that can succeed in helping male clients stay in treatment and end violent behavior.

Psychotherapy research, in general, has found the client’s evaluation of the working alliance to be the best predictor of psychotherapy outcome (Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000; Orlinsky, Rønnestad, & Willutzki, 2004), particularly when the alliance is evaluated in the early stages of treatment (Horvath & Symonds, 1991). Furthermore, in the field of IPV treatment, clinicians and researchers have argued that a strong alliance is crucial in motivating abusive men to undergo treatment and in enhancing the possibilities for behavioral change (Scott, King, McGinn, & Hosseini, 2011; Taft & Murphy, 2007). In a study of men dropping out of group treatment for partner violence, the reason most frequently provided by the men was that their goals for treatment were not being met by the therapists (Brown, O’Leary, & Feldbau, 1997). In addition, abusive men’s rating of the alliance has been shown to predict dropout (Rondeau, Brodeur, Brochu, & Lemire, 2001), and observer ratings of the men’s alliance with the therapist has also predicted outcome (Brown & O’Leary, 2000).

The working alliance is conceptualized as the client and the therapist’s agreement on the goals and tasks of treatment, and the bond (trust, liking, and attachment) between them (Bordin, 1979, 1994). The clients’ motivation for changing their violent behavior may influence the development of a working alliance (Taft, Murphy, Musser, & Remington, 2004), in particular the agreement on goals and tasks for treatment. Numerous qualitative studies of how men relate to and explain their use of violence have revealed that these men often deny or minimize the severity of their violent acts and externalize responsibility for such acts (Adams, Towns, & Gavey, 1995; Cavanagh, Dobash, Dobash, & Lewis, 2001; Flinck & Paavilainen, 2008; Goodrum, Umberson, & Anderson, 2001). Thus, they are often more externally than internally motivated when entering treatment (Daly & Pelowski, 2000). Collectively, these studies suggest that there may be particular difficulties in forming a positive working alliance with abusive and aggressive men.

Safran and Muran (2000) argue that Bordin’s conceptualization of the alliance “highlights the fact that at a fundamental level the patient’s ability to trust, hope, and have faith in the therapist’s ability to help always plays a central role in the change process” (p. 13). Following Safran and Muran’s argument, one might claim that therapists have to intervene in a manner that enhances the client’s trust in the service the therapist has to offer. Several studies have examined how motivation-enhancing interventions (Miller & Rollnick, 2002) affect clients’ participation in and outcomes of IPV treatment (e.g., Crane, Eckhardt, & Schlauch, 2015; Kistenmacher & Weiss, 2008; Scott et al., 2011). Results showed that such interventions improved the clients’ readiness to change and decreased the extent to which they blamed their violence on external conditions (Kistenmacher & Weiss, 2008). Other studies have found that clients who received motivation-enhancing interventions completed treatment at a higher rate, attended more sessions, and showed lower drop-out rates than control participants (Crane et al., 2015; Scott et al., 2011). The Gassmann and Grawe (2006) study of psychotherapy in general showed that the therapist’s exploration and elucidation of the client’s resources, such as his key life goals, interpersonal skills, or values as a husband, are more often found in successful than in unsuccessful therapies. In addition, when therapists were instructed in the activation of clients’ resources before the therapy session started, resource activation in the sessions increased and therapy outcome improved (Flückiger & Grosse Holtforth, 2008).

Taken together, this body of research shows the importance of gaining more knowledge on what men using IPV might ask for or respond to when they enter treatment. In this study, the steps taken by the client to get some kind of response from the therapist in terms of being understood “correctly” and assisted “properly” are analyzed as invitations to form a working alliance. We might assume that a client seeking treatment voluntarily has some expectation that the treatment will be helpful. As such, the first therapy session can be considered a gateway for establishing a working alliance. To explore these ideas, we studied how men who participated voluntarily in individual treatment for IPV contributed in the first session to forming a working alliance with therapists skilled in such treatment.

Our aim was to introduce the concept of clients’ invitations to a working alliance. As such, invitations appear in the first session. We aspired to develop a language for therapists that might help them understand different ways in which their clients might open up and pass through gateways to an alliance. Conceptualizing these variations may provide ideas as to how to enhance alliance formation.

Method

The present analysis draws upon data from a naturalistic outcome and process study named Alternative to Violence Treatment Study (ATVT Study).¹ All the men who sought treatment at the outpatient clinic Alternative to Violence (ATV) during a period of a year and a half were asked to participate in the study. The participants were informed both orally and in writing about the study, and they gave their written consent.

ATV is a non-governmental organization (non-commercial foundation) that receives mainly public funding. It is a low-fee clinic specializing in treating domestic violence offenders. Clients who suffer from psychosis or severe drug or alcohol addiction do not receive treatment at ATV. The treatment is voluntary in the sense that the clients are not court-mandated.

The individual treatment provided at ATV focuses specifically on changing the men’s violent behavior and uses psychotherapeutic principles from behavioral, cognitive, emotional, and attachment approaches. The goals of the treatment are for the clients to stop using violence and expand existing or develop new relational skills. The tasks of the therapy are for the clients to disclose and acknowledge their violent behavior and practice behavioral assignments to regulate their anger and violent behavior. Further tasks are to investigate, clarify, and elaborate on the clients’ experiences throughout their life that relate to their violent behavior and, finally, to explore the clients’ understanding of the implications of violent acts for themselves and for those who are exposed to such violence (Råkil, 2002).

Data Selection

In the ATVT study, 84 men received individual therapy. Forty-eight of these therapies had ended by the time our analysis was conducted. Of these accessible cases, we selected a sample of 20 therapies. The composition of this sample followed the strategy of purposive sampling (Flick, 2009), with 10 therapy cases where the clients had completed treatment with a good outcome and 10 cases where they had dropped out of therapy early. This was done to provide data rich in variations and nuances in terms of the phenomenon (clients’ contribution to alliance formation) we aimed to study. The clients in the two groups were selected such that the groups were similar with regard to how the clients reported (at the beginning of treatment) on mental health (Outcome Questionnaire-45 [OQ-45]; Lambert et al., 1996), traumas in life (Traumatic Experiences Checklist [TEC]; Nijenhuis, Van der Hart, & Kruger, 2002), and partner violence (Violence, Alcohol, and Substance Abuse Questionnaire [VAS]; Askeland, Lømo, Strandmoen, Heir, & Tjersland, 2012).

In the completed cases, the therapists reported that they had come to a joint decision with the clients to end the therapy. The designation as a good outcome was based on the answers to the VAS questionnaire at the end of therapy, whereby the men reported no violence or a considerable reduction in violence. Furthermore, they had a low score on OQ-45, indicating no or very few symptoms of clinical significance. In the ATVT study, partner reports on IPV were also used as an outcome measure. As very few of these partner reports were available when we selected the sample, they were not used to define the outcome of a case. The therapy process was defined as a drop-out case if the therapist found the client had suddenly discontinued an unfinished therapy.

Participants

Clients

The average age of the 20 men was 38.4 years (range = 22-60) and the mean level of years of education after high school was 4.5 years (range = 0-14). Sixteen men were employed, 11 were married or cohabitating, and 17 were fathers. Four of the men had an ethnicity other than Norwegian (Asian, African, Eastern European, and Western European). In pretreatment assessment, all the men reported perpetrating one or several types of violent acts against their partner during the year prior to treatment. Use of physical violence was reported by 16 of the men, the same number reported the use of psychological violence, and 15 reported property violence. There were 14 men who related that the use of violence had injured their partner. Twelve men reported having symptoms of clinical significance on OQ-45 (range = 20-117). The mean level of traumatic experiences was 9.4 (range = 4-17) out of 29 potential traumatic experiences.

Therapists

Six male and five female therapists participated in the present study. They were all licensed clinical psychologists, and the average years of experience as psychotherapists was 9.9 years (range = 3-23). The average years of experience with IPV treatment was 7.4 years (range = 1-23). Furthermore, they were experienced and skilled in the ATV treatment approach. They received training in this specific model and the phenomenon of IPV, and they participated in group and individual supervision of their clinical work with clients using IPV.

Data Analysis

The qualitative analysis focused on what had taken place in the first session. The verbal interaction between the therapist and client in each of the 20 cases had been audiotaped and transcribed verbatim. The first author listened to all the audiotapes while reading the transcripts for the first time to prevent the possible loss of tone and emotional expressions in the conversation.

The first step in the analysis was to get a detailed and sequential understanding of what themes were brought forward and addressed—in particular, how the client presented himself and appealed for some kind of understanding and sympathy from the therapist. Presentations and appeals could be initiated by the client or occur as responses to the interventions of the therapist. Either way, the close reading kept track of what the client had to say that could in any way be relevant for how this particular client and the therapist could build an alliance, and how they found ways to work together and address problems attached to the client’s experiences of anger and use of violence. In this sense, the concept of alliance was used as a sensitizing device for a fairly broad search of the ongoing interaction for relevant content (Hsieh & Shannon, 2005; Kohlbacher, 2006).

The first author took the lead in this reading and rereading, paying careful attention during a session every time the client indirectly or directly touched upon reasons for coming or not coming, and possible and impossible ways of working with his therapist toward some type of change. Issues that pertained to the clients’ own initiative to come and to their willingness to come back were addressed in many different ways. The first author made written annotations for all transcripts correspondingly and sorted and labeled the clients’ contributions thematically. Examples of themes were as follows: talk about change, perceptions of treatment, relation to therapist, and comprehension of violence. The second and the third authors worked independently of each other and read some cases with an open mind, searching for the clients’ contributions in terms of collaborating with the therapist. The first author then met with each of the two others separately for comparisons and discussions regarding annotations and interpretations. These procedures followed guidelines drawn from the constructionist grounded theory (Charmaz, 2003). The third author was blind to the outcome of the cases. This was done to test whether the knowledge of an outcome influenced the interpretation of the clients’ contributions. Such influence was not found.

Thus, we arrived at a way of sorting the interactions in the sessions into three “gateways to an alliance”: reasons for seeking treatment, notions of changes, and ways of disclosing violence. The purpose of the next step in the analysis was to determine whether it was possible to collect and sort the rather specific aspects of the ways in which each client spoke about himself to his therapist into these broader categories. By doing so, we were able to identify a set of subcategories that could represent and cover the observed variations as to how these clients were interacting with the therapist. Taken together, these variations appeared as constituents in a set of invitations from the client to build a working alliance that might appeal to him.

In the results section, we will present the systematic variation in more detail and document and illustrate the subcategories with examples from the interactions in the sessions. Details in the excerpts from the therapies have been changed to provide anonymity.

Results

The analysis of the men’s contributions in the first session with the therapist resulted in three gateways to an alliance offered by the client. Within each gateway, we found both strong and weak invitations to a working alliance. The invitations that appeared as weak were difficult both to perceive as an invitation to collaborate on personal change and to build on to form a working alliance. Most of the drop-out cases expressed weak invitations to an alliance, while the completed cases expressed stronger invitations. However, there were also overlaps between the two groups (see Table 1). Under each heading in the following presentation of the results, we will first present the subcategories that most clearly invited a working alliance.

Table 1.

Gateways to an Alliance as Offered by 20 Men in Intimate Partner Violence Treatment.

Gateways and Invitations With Numbers of Men From Completed (C) and Drop-Out (D) Therapies	Examples of Client Invitations to a Working Alliance
Seeking therapy
As one’s own choice (7C, 4D)	It (psychological violence) shall not affect my children or my partner. So coming here is for my own sake.
As avoidance (3C, 3D)	She wants to leave me, but she knows I want to change. All I want to know is that I have a chance to continue to be with her . . .
As a mistake (3D)	I really don’t remember [If I was the one calling this clinic]. It may be me, but it’s not important. Eh I’m here but not because I find it right, absolutely not.
Notions of change
I want to stop using violence (9C)	It is unwanted behavior. I want to get rid of it. I must learn to deal with my anger. I have some dammed up anger inside of me.
Violence is not acceptable, but . . . (1C, 6D)	I have been physical when others are physical. When you’re a guy of 90 kg and you’re together with a girl of 45 kg, there is no excuse for throwing her to the floor . . . I have used violence. But it has been adequate violence. I have not been the one to escalate it.
My partner is the problem (4D)	I’m not a violent man, because I use my head to think. My wife has beaten me but I can’t report her to the police, you see. Ehh, I’m sorry but I have to say this, we’re sitting here because she also needs help.
Disclosure of violence
As a personal narrative (4C)	I need a lot of attention. I’m very insecure, so I go on asking: “Do you want this, is something wrong?” Then, she gets tired of me asking and it turns into a discussion, then I get frustrated and have to throw something onto the floor or I hit her arm or pull her by the hair or push her down into a chair . . . things like that. And then I feel everything is very sad.
As a scene (2C, 1D)	It was an episode at Easter. I call it physical . . . I’ve been more short-tempered, more acute anger. I do not kick her, I do not hit her in the face either, but I have hit her shoulder. Not with full force but, smack, here. I have never thought of hitting her in the face.
As a fragment of their life (3C, 4D)	I have kind of thrown her to the ground and . . . She has kicked me and scratched and it has sort of been . . . but in a way it has never been violence, it’s been more frustration.
As something else (1C, 5D)	A lot of words are coming out of me. I often get eager, so to speak. But she tells me that we should not discuss when alcohol is in the picture, but she will never discuss.

Seeking Therapy

Seeking out therapy is the client’s first step toward creating a working alliance with the therapist. During the first session, both clients and therapists took the initiative to elaborate on the process that led the client into therapy.

Even though all of the men spoke of being referred, pressured, or forced into treatment—“But if I hadn’t gone [to therapy], then I think she would have gone, or moved. She hasn’t said those words, but it’s implied”—they also disclosed their own reasons for coming, such as “Nothing is more important than this [being a good father],” “I want us [me and partner] to be able to speak together,” or “but I don’t want to, if I meet someone else [a new partner], and then something like this [violence] should happen again. That’s not me.” It seems as if the men resolved the dilemma of being passive respondents to others’ demands and being active agents of change of their own right. The analysis resulted in three subcategories describing how the men carried and attributed meaning to the process of seeking treatment in their initial negotiation with the therapist.

One’s own choice

The first way the men balanced the dilemma was to explain that it was, first and foremost, their own choice to seek treatment:

Eh . . . it was uh . . . at the urging of my better half, but, but uh, I had actually come to the same conclusion before she put her foot down, so to speak, but, but uh . . . uh, there was an episode where I uh . . . uh . . . simply crossed the line.

This type of invitation highlighted that the urging of significant others corresponded with what the client believed were the necessary steps to take. In such invitations, the men either described how they actively began to investigate different treatment options, or they implicitly demonstrated that therapy was their own objective by focusing on their own experiences and expectations for treatment.

Choosing therapy of their own accord was also connected to certain significant events that represented a shift in how the men perceived their lives. For instance, when their violent actions caused injuries, they saw it as being severe and expressed a need for help.

Avoidance

The second way of handling the dilemma in their encounter with the therapist was to assign great significance to the opinions or demands of others in choosing treatment: “Yes, that is, there is also zero tolerance [for violence] from her side of things, and I completely respect that.” Such invitations also emphasized an urgent need to change their own behavior:

So I feel that something has to happen, otherwise I feel like I could sort of just start burying myself. Now I want to really take hold of things. I hope, among other things, to receive help for that here, because now I actually see it so very clearly, what’s wrong.

Inviting in this way, the men described how violence had led to a breakup in the relationship with their partner or children and expressed a need to change to increase the possibility of maintaining these relationships: “Now I’m sort of very committed to saving the relationship and grabbing a hold of the things that I can grab hold of.” It seems as if this particular type of invitation was more oriented toward avoiding negative consequences (e.g., separation) than exploring their own violent actions.

Mistake

The third way of balancing the dilemma was by either explicitly or implicitly describing the fact that they were forced to seek therapy and that they viewed this as being a mistake. In such invitations, the men were either very uncertain about whether their behavior should be characterized as violent or totally convinced that it should not be. Thus, they invited the therapist to realize that therapy was the wrong intervention in their particular case:

Because it is totally wrong that I’m here. Yes, so [let us] spend some time on that instead. I think, you know, that instead of wasting lots and lots of time, so if, if you had said “ok, it’s wrong that you’re here” . . . but not for my sake. For I know myself that there’s no reason for me being here.

It seems as if this was an invitation for the therapist to make an assessment that the client did not, in fact, need treatment.

Seeking therapy as a gateway to an alliance varied from invitations emphasizing therapy as being their own choice, to choosing therapy to prevent negative consequences, and, finally, to ending up in therapy by mistake. If the client characterizes his decision to seek out therapy as his own choice, he invites collaboration. Conversely, if he characterizes this decision as a mistake, he is, in effect, asking for exemption from such therapy.

Notions of Change

For all the men, seeking therapy seemed relevant for one reason or another, but this was not necessarily connected to the perception of violent behavior as a personal problem. The notion of changing their own violent behavior as a gateway to an alliance is described below by three types of invitations that represent different starting points for establishing an alliance.

I want to stop using violence

This notion of change explicitly expressed the need to master difficult situations without using violence. “I do not want to get angry the way I do.” “I am here so that it [violence] will not happen again.” Such invitations contained reflections about what the process of moving away from violence toward a better way of solving conflicts should entail. Furthermore, this type of invitation expressed the need to learn mechanisms and tools to achieve more control, and to expand the repertoire of responses and emotions. Inviting in this manner, some of the men also described more specifically what skills they needed to master, which they viewed as being in contrast to the use of violence:

[I need] to, uh, identify some mechanisms that can help me to never get to the place where one goes so far, that one is simply able to stop in time and instead look at it rationally. I want to learn to talk about things. I have to teach myself to think better of [laughs a little] her [his wife] and uh, of course, others. There must be a, a, a radical change in mind-set.

In these invitations, the men explained that they had a bad temper or insecure personality, that they were aggression-inhibited, or that they suffered from the aftereffects of childhood traumas. These reasons were presented to explain not only the use of violence but also as conditions that needed to be changed if violent acts were to cease.

What seemed to be most relevant in such invitations was to stop the use of violent behavior toward the partner. The tasks for therapy were to work with their own traits or incompetence, by practicing new skills and working through difficult experiences or emotions.

Violence is not acceptable, but . . .

The second way of relating to change was by emphasizing the desire to not use violence, but at the same time presenting violence as understandable and inevitable. In such invitations, the client explained that it was not acceptable to use violence: “I have a tendency to throw her off me, but she thinks that is the same as hitting, and that’s something I am in agreement with because I should not use my superior strength in that way.” Statements such as “Because I do not want to, because I have promised that I will never lay a hand on her again, I will never yell at her again” appeared as an invitation to collaborate in changing their own violent behavior. However, when the therapist followed up on this invitation by investigating specific violent events, the focus was directed at external conditions, such as the behavior of the partner, as the main problem. “But it [the incident], with the nose and all [the partner is teasing the client by touching his nose], I felt was much undeserved [laughs]. It was a provocation, and it’s just like she’s tried to get me to cross the line.”

Similar to the invitations that emphasized the need to change their own violent behavior, this type of invitation stressed the men’s short temper or tendency to meet aggression with aggression. However, these conditions were presented as bad luck or as more individual deterministic traits and not as a starting point for therapeutic change. What seemed most relevant in such invitations was to stop acting violent due to a change in their partner. By simultaneously denouncing and defending the use of violence, the clients somewhat invited the therapist into their contradictory perception of their violent acts and their relationship with their partner.

My partner is the problem

The third way of relating to change was to explain that the partner or other family members represented the problem. In this type of invitation, the clients did not explicitly state that the partner had to change. However, by describing her as the problem, this was the impression given: “I can give you examples of what, that is, she says that I’m using psychological terror. She is Russian but she does not understand the Norwegian terminology and then she calls it psychological terror. It is absolutely ridiculous.”

Even though the men had reported the use of violence against their partners in the pretreatment interview and met with therapists who would have been aware of their use of violence, in this type of invitation, they did not present themselves as subjects who abused their partner. This notion of change contained no reflections on the drawbacks of their own way of thinking, feeling, or behaving, and no expressions of accepting any responsibility for violent acts. Such invitations stressed their own feelings of being violated and misunderstood, and this seemed to prevent the adoption of a more reflective view of their violence.

To summarize notions of change as a gateway to an alliance, we found a gradual transition from the invitations that emphasized an integrated perception of violence as a personal problem, to those having an emerging sense that violence was a problem, and finally, to the invitations where the treatment goal was located outside the client. These three invitations point to a relationship between the motivation for change and taking responsibility for violence. There were clear-cut differences between the notions that pointed toward the need to change their own violent behavior and the notions that solely highlighted that the partner had to change. The category “Violence is not acceptable, but . . .” emphasized some responsibility for violence, but it wavered in this regard when concrete violent acts were investigated.

Disclosure of Violence

The third gateway to an alliance observed in the present study was how the men engaged in disclosing violence. Four types of invitations represented the variations in this gateway. These invitations describe narratives in which the men positioned their violent acts in different ways.

Violence as a personal narrative

One way of disclosing violence was to present a narrative where the client’s use of violence toward the partner was the main focus:

Eh, the missus ran out of the house to escape, uh, and I ran after her and uh, and I tried to get her inside. Then, her son came and was trying to get me to let go, and so I pushed him away and he went down and stumbled over so eh . . . he broke his arm, it was not good. Yeah . . . and uh, I squeezed the missus’s arm so hard and pushed her so hard that she got bruises from it. . . . When I look back uh, it, it’s in no way viable to act in that way. So it’s pretty scary to think that one, one, that one has crossed such a boundary. Because I had basically never thought I’d cross that boundary where uh, and, and it is . . . that, when that trust is broken then it is . . . extremely difficult.

When violence was disclosed as a personal narrative, such invitations were characterized by two different meta-perspectives. First, the clients reflected on their own and others’ intentions when the violent event took place, and how both parties perceived the effects of the violence. These reflections were connected both to the immediacy of the violence and to its long-term consequences on their relationship with their partner and children. Second, they focused on the meaning of violent behavior in their life. They described what was typical and unusual when using violence and how they understood violence in the present compared with the past—highlighting change and development.

Violence as a scene

Another way of disclosing the use of violence was by mainly taking an outside position:

Yes, then I take her by the breast or the arms, like that, and then I throw her more or less over me so she lands on the floor. And then she hits her chin, lies there, and cries. The kid is sleeping.

The context where the violence took place, their own actions, and interactions with the partner were described in detail. However, such invitations offered no reflections upon the meaning of such violence for the clients and for their relationship with their partner and children. In addition, these invitations contained reluctance to provide further disclosure of violence. Therapist: “You want to explore the content [context and violent acts], if I understand you correctly?” Client: “No, I’m not sure if I want to do that.” The answer gave the impression that such invitations excluded exploration of violence as a meaningful task.

Violence as fragments of their life

There were two ways of disclosing violence as a fragment of their life. On one hand, the violent acts were not integrated as a part of the client’s personal narrative; for example, it was impossible to remember the violence because of alcohol intoxication. On the other hand, the violent acts became fragments of their life because they were not assigned an important position in the story the men told the therapist:

Yes, because sometimes she gets right up in my face and is so rude that I’ve not heard anything like it, and I just ask, “now you have to stop,” and some of the violent episodes is that I have. . . . Other times where I’ve pushed and “get away from me,” and stuff. It’s sort of like that, “get away from me, I do not want you here now because then even more foolish things could happen.”

In such invitations, violent acts were described in a referential manner. It was more like a confession than a disclosure of violence as a personal problem. These invitations emphasized the client’s intention to care for himself and his partner.

Violence as something else

The last way of disclosing violence was either through the use of metaphors or a denial of having used violence. This approach did not contain any descriptions of concrete violent acts: “Then, there was, you know, a snap when she arrived, then everything shuts down. So what happened, I said that she should get out of the car if she wasn’t able to drive. Then, she blew up and left.”

The metaphors referred to different ways of losing control of their emotions and actions. “Then, the Lego bricks collapse, and then I hit bottom.” Such disclosure of violence could be interpreted as an incipient invitation to explore their own difficulties. The invitations where the use of violence was denied appeared to be a desire for the therapist to understand the client’s effort to help the partner or to protect themselves against her accusations or attacks.

Disclosure of violence as a gateway to alliance varied from invitations offering a narrative of violence to those describing violence that took place through an isolated, concrete act or a metaphor. Furthermore, the disclosures of violence ranged from containing reflections upon the meaning of the violence for the clients and those who were affected by it to a lack of such reflections. The variation in transparency invites a collaboration based on exploring and understanding violence as a personal problem, based on understanding violent acts as exceptions or misunderstandings, and based on understanding violence as protection of the self and of the intimate relationship.

Discussion

We conducted this study with the aim of conceptualizing the variety of ways in which 20 men using violence against female partners presented themselves during the first therapy session to form a working alliance that might appeal to them.

The analysis of the clients’ contributions to an alliance, either initiated by the client or elicited by the therapists, resulted in a conceptual model of gateways and invitations to an alliance. Gateways are themes that have the potential to open a path toward collaboration on personal change. The analysis identified three gateways to an alliance: How the men were seeking treatment, what notions of change they presented, and, finally, how they organized the disclosure of violence. Within each gateway, the clients presented different invitations. The gateway “seeking treatment” included invitations presenting treatment as their own choice, as a means to avoid a negative consequence, and as a mistake. The gateway “notion of change” involved invitations emphasizing the need to change their own violent behavior, that violence was not acceptable, but inevitable or understandable, and that the partner represented the problem. Finally, the gateway “disclosure of violence” comprised invitations presenting violence as a personal narrative, as a scene, as a fragment of their life, and as something else. Looking across all cases, we observed how invitations within each specific gateway varied from weak to gradually stronger. For instance, the gap between externalizing (partner is the problem) and internalizing (I want to stop using violence) the treatment goal was filled by the invitation presenting an emerging sense of violence as a personal problem (violence is not acceptable, but . . .). The 10 invitations forming the three gateways covered all the observed variations within the data.

Implications for Therapists and Professionals

The conceptual model of gateways and invitations applied to early alliance formation has the potential to increase therapists’ awareness of what they may encounter and will have to address as invitations from the clients in the first session. Such awareness is especially important in a context where alliance building is difficult, but crucial. Our point here has not been to assess who is fit or unfit for therapy, but rather to specify the ways in which particular challenges and possibilities might appear as early invitations.

The conceptual model is somewhat similar to the concepts stages of change and readiness to change described in the Transtheoretical Model of Change (TTM) by Prochaska and DiClemente (1982). The variation from weak to strong invitations resembles the TTM stages of change—precontemplation, contemplation, preparation, and action. While the TTM emphasizes the clients’ stage in the change process, our findings describe themes and variations on these themes that may serve as gateways to an alliance as they occur in the therapeutic interaction.

One particular invitation, for example, disclosing violence as something else, took on different meanings if it was combined with either strong or weak invitations in the other gateways. It has been stated that one reason to minimize violent behavior toward a partner is that the client needs to appear socially desirable or wants to avoid the feeling of shame and possible rejection or condemnation by the therapist (Henning, Jones, & Holdford, 2005). Shame might be a suitable explanation when violence as something else occurred together with strong invitations. In these cases, an exploration of violent acts could help the client move into a more explorative state where new understanding, corrective experiences and actions, or mastery-coping may develop (Goldfried, 1980; Grawe, 1997; Hill & O’Brien, 1999). In combination with weak invitations, we would suggest that disclosing violence as something else just adds to the picture of the clients’ mistrust of other people. This is in line with a study where denial and minimization were found to overlap with the clients’ focus on the unfairness of the justice system (Levesque, Velicer, Castle, & Green, 2008). The client’s expressions of mistrust and unfairness could also be understood within the framework of traumatization. The relationship between experiencing violence in the family of origin and perpetrating IPV as a male adult is well documented (e.g., Askeland, Evang, & Heir, 2011; Smith-Marek et al., 2015). In addition, studies have shown that childhood trauma and hostile attitudes toward people are linked (Jin, Eagle, & Keat, 2008). Being exposed to violence by parents is thought to lead to hypervigilance regarding aggressive cues and broad negative assumptions about the world (Dodge, Bates, & Pettit, 1990; Dutton, 2000; Janoff-Bulman, 1992). If the therapist insists on exploring violence early in the treatment in such cases, the client might perceive this as too confrontational.

This study’s results can further provide guidelines on how to turn weak invitations into stronger ones. In the strongest invitations, the clients were both task-focused by searching for alternatives to violent behavior and inward-focused by reflecting upon their own, and their respective partners’, understanding of and reactions to violent behavior. Such interactions are examples of productive thinking (Bohart, 2002; Bohart & Tallman, 1999). This type of openness on the part of the client is an important predictor of change in psychotherapy (Grosse Holtforth & Castonguay, 2005; Orlinsky et al., 2004). One way for therapists to enhance the clients’ productive thinking is by searching for the motivations underlying the gateways. Examples of such motivations may be the need to be attached and to avoid separation or to appear as a worthy man/partner and avoid the label “violent man.” These motivations can be described as approach (satisfy psychological needs) and avoidant motivational goals (avoid negative experiences) (Grosse Holtforth, 2008; Grosse Holtforth & Castonguay, 2005; Grosse Holtforth, Grawe, & Castonguay, 2006). The weak invitations in each gateway could be interpreted as the client’s effort to avoid negative self-esteem or separation, while the connecting invitations in each gateway seem to entail both approach and avoidant motivational goals.

Previous research has highlighted that the activation of the client’s approach motivational goals fosters a working alliance and enhances the outcome of therapy, while activating the avoidant goals early in treatment can lead to ruptures (Caspar, Grossmann, Unmussig, & Schramm, 2005; Flückiger & Grosse Holtforth, 2008; Gassmann & Grawe, 2006). In our sample, this means always searching for and exploring the strongest invitations the clients offer. An exploration of the statement “violence is not acceptable,. . . ” would probably more easily lead to the clients’ key values than an investigation of “. . . but I’ve not been the one to escalate it.” This is in line with another study that advises therapists to access the clients’ remorse about their violent acts because this might clarify how the use of violence conflicts with their values or self-image (Whiting, Parker, & Houghtaling, 2014). In addition, the Blagden, Winder, Gregson, and Thorne’s (2014) study highlighted that the use of denial in interpersonal interactions (e.g., treatment) presented an opportunity for the offender to maintain a viable self. Furthermore, by assessing the offenders’ personal constructs and worldviews, they identified issues that were relevant as treatment targets. This was done without confronting the denial. Treatment approaches relying on motivation-enhancing interventions (Miller & Rollnick, 2002) have shown promising results by reducing dropout and defensive in-treatment behavior and increasing treatment completion and readiness to change (Crane et al., 2015; Eckhardt et al., 2013; Kistenmacher & Weiss, 2008; Scott et al., 2011). This method matches the therapist’s interventions to the client’s readiness to change and avoids confrontation of denial or rationalizations of violent acts, which is argued to increase the clients’ resistance to treatment (see Murphy & Baxter, 1997; Murphy & Eckhardt, 2005; Taft & Murphy, 2007). Taken together, to foster openness and an early working alliance, all these research results emphasize the importance of being attuned to the clients’ specific key psychological needs and not to confront defensive behavior.

Several limitations need to be considered in evaluating this study’s results. First, the model was developed by studying men voluntarily in IPV treatment. Even though the analysis revealed weak invitations (feeling pressured to enter therapy) that are similar to resistance shown in court-ordered samples, court-mandated treatments are closely linked to punishment which may raise other challenges to alliance development than found in our sample. In addition, gender and treatment context may present further limitations to our findings. For instance, other gateways and invitations to an alliance would probably be found if one studied women who abuse their male or female partner or abusive men who were referred for reasons other than violent behavior to mental health clinics where therapists are not trained in the specific challenges of IPV treatment. However, we would argue that the analytic position taken in this study would also be useful in the understanding of other client populations where therapists struggle to develop a working alliance.

Another limitation is the position of the researchers of the present study. Our background as psychotherapists with a special interest in alliance formation has, of course, contributed to the analytic focus of this study and guided us in our reflections and understanding of the material. We have exerted ourselves in interpreting client contributions as alliance invitations and might have seen invitations where others would not. However, the use of this analytic focus was useful in organizing how the clients contributed to alliance formation, thereby increasing therapeutic awareness of where to find gateways that can lead to a working alliance with these clients and of how to identify the therapeutic possibilities in the range of invitations.

Considering the high drop-out rate in IPV treatment, it is important to explore the process of alliance formation with these clients from different perspectives. Further research should study how therapists take initiatives and respond in the initial phase of treatment both in drop-out and completed cases. Similarities and differences in patterns of therapist interventions in contrasting cases may shed light on effective and ineffective alliance interactions. The investigations of the early phase of treatment have increased our knowledge of the way in which therapists can encourage the clients to undergo treatment (see Murphy & Ting, 2010). All this research may show that client motivation and collaboration in therapy are necessary but not sufficient to promote behavioral change (Scott et al., 2011). Therefore, a study of the entire process of good outcome cases could add knowledge regarding characteristics of the client–therapist interactions in successful change processes. Analysis of clients’ evaluations of treatment sessions would also add to such knowledge.

Conclusion

Instead of focusing on the particular challenges that men perpetrating violence against their female partner may represent at the beginning of therapy, we suggest that their contributions should be interpreted as potential gateways and invitations to an early working alliance. The detailed exploration of the client–therapist interactions in the first session of therapy brought forward several strong invitations to an alliance in a population most often described as resistant. In addition, even the weak invitations provided direction as to where the therapist could connect with the client without compromising the treatment goal to develop alternatives to violent behavior.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Bente Lømo, Cand. psychol., educated at the Department of Psychology, University of Oslo in 1993. She is a specialist in clinical psychology and a researcher at the Norwegian Centre for Violence and Traumatic Stress Studies. Central in her research is working alliance in intimate partner violence treatment, qualitative analysis of process, and outcome. She has worked as a clinical psychologist for several years, with both perpetrators and survivors of domestic violence, and adults with substance abuse.

Hanne Haavind, PhD, professor emeritus in clinical psychology, educated at the Department of Psychology, University of Oslo, and has since 1992 been a professor at the same department. She is a specialist in clinical psychology. For approximately 15 years full-time, she has worked as a clinical psychologist with children, youths, adults, and families. Central in her practice and research are personal development and sociocultural change, child care and social changes in parenting and family life, analyzing gendered meanings, and interpretative methods in clinical and social psychology.

Odd Arne Tjersland, PhD, professor in clinical psychology, educated at the Department of Psychology, University of Oslo in 1974. He is a specialist in clinical child psychology (1986) and in clinical family psychology (1995). For approximately 15 years full-time, he has worked as clinical psychologist with children, youths, couples, and families. Central in his practice and research are family conflicts connected to separation, concerns about sexual abuse, violence, and substance abuse.

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