Individual Versus Group Cognitive-Behavioral Therapy for Partner-Violent Men: A Preliminary Randomized Trial

Abstract

A randomized clinical trial tested the hypothesis that a flexible, case formulation–based, individual treatment approach integrating motivational interviewing strategies with cognitive-behavioral therapy (ICBT) is more efficacious than a standardized group cognitive-behavioral approach (GCBT) for perpetrators of intimate partner violence (IPV). Forty-two men presenting for services at a community domestic violence agency were randomized to receive 20 sessions of ICBT or a 20-week group cognitive-behavioral therapy (CBT) program. Participants and their relationship partners completed assessments of relationship abuse and relationship functioning at baseline and quarterly follow-ups for 1 year. Treatment uptake and session attendance were significantly higher in ICBT than GCBT. However, contrary to the study hypothesis, GCBT produced consistently equivalent or greater benefits than ICBT. Participant self-reports revealed significant reductions in abusive behavior and injuries across conditions with no differential benefits between conditions. Victim partner reports revealed more favorable outcomes for group treatment, including a statistically significant difference in psychological aggression, and differences exceeding a medium effect size for physical assault, emotional abuse, and partner relationship adjustment. In response to hypothetical relationship scenarios, GCBT was associated with greater reductions than ICBT (exceeding a medium effect) in articulated cognitive distortions and aggressive intentions. Treatment competence ratings suggest that flexible, individualized administration of CBT creates challenges in session agenda setting, homework implementation, and formal aspects of relationship skills training. Although caution is needed in generalizing findings from this small-scale trial, the results suggest that the mutual support and positive social influence available in group intervention may be particularly helpful for IPV perpetrators.

Keywords

domestic violence batterers intervention/treatment violent offenders

Intimate partner violence (IPV) is a pervasive social problem with extensive negative health consequences (Lawrence, Orengo-Aguayo, Langer, & Brock, 2012; Mitchell & Anglin, 2009). Psychosocial rehabilitation programs for perpetrators of IPV, or Abuser Intervention Programs (AIPs), are widely available (Price & Rosenbaum, 2009), yet the efficacy of these interventions remains in question (Eckhardt et al., 2013). Meta-analyses of controlled studies report small average effect sizes relative to minimal intervention or case monitoring control conditions (Babcock, Green, & Robie, 2004; Feder & Wilson, 2005).

These results have stimulated interest in program modifications that may improve clinical outcomes (Stuart, Temple, & Moore, 2007), including flexible treatment modalities tailored to the unique characteristics of individual offenders (Murphy & Eckhardt, 2005). Most AIPs deploy “one-size-fits-all” psychoeducational approaches grounded in a feminist analysis of social institutions that support men’s expression of power and control over women in the domestic sphere (Adams & Cayouette, 2002; Pence & Paymar, 1993). Many programs include cognitive-behavioral therapy (CBT) interventions that target hostile cognitive biases, emotion dysregulation, and skill deficiencies in assertiveness, communication, and problem solving (e.g., Sonkin, Martin, & Walker, 1985; Wexler, 2013).

Our literature review identified mixed results for prior controlled investigations designed to isolate the unique benefits of group CBT interventions for partner-violent men. Three studies failed to find significant benefits of CBT in reducing abusive behavior. Comparison conditions for these studies included a process-psychodynamic treatment with narrative analysis of painful childhood experiences for community IPV offenders (Saunders, 1996), supportive group counseling for community IPV offenders (Morrel, Elliott, Murphy, & Taft, 2003), and rigorous monitoring by case managers for U.S. Navy personnel (Dunford, 2000).

In contrast, three other studies have shown significant benefits of CBT interventions in reducing partner abuse. One study found greater reductions in physical and emotional abuse for a trauma-informed group CBT treatment in contrast to enhanced treatment as usual for U.S. Veterans receiving care from the Veterans Administration (Taft, Macdonald, Creech, Monson, & Murphy, 2016). A second study reported significant reductions in self-reported violence for a volunteer sample of Norwegian IPV offenders relative to a wait-list control (Palmstierna, Haugan, Jarwson, Rasmussen, & Nøttestad, 2012). A third study examined Acceptance and Commitment Therapy (ACT), a variation of CBT, and found greater reductions in abusive behavior relative to supportive group treatment for a self-referred sample from a community mental health center (Zarling, Lawrence, & Marchman, 2015). These positive findings are consistent with process research showing greater reduction in IPV for individuals who are more compliant with CBT homework assignments (Taft, Murphy, King, Musser, & DeDeyn, 2003) and with prevention research showing positive effects of CBT interventions in preventing IPV (e.g., Markman, Renick, Floyd, Stanley, & Clements, 1993; Wolfe et al., 2003).

One possible explanation for the inconsistent findings regarding the efficacy of CBT in reducing partner abuse is that many partner-violent offenders in community IPV programs display inadequate collaboration and compliance to benefit from CBT interventions that require active efforts to achieve behavior change. Most partner-violent men begin treatment in early stages of change, unprepared to engage in active interventions (Alexander & Morris, 2008; Eckhardt, Holtzworth-Munroe, Norlander, Sibley, & Cahill, 2008). Protherapeutic attitudes and compliance with CBT interventions can be substantially improved with motivational enhancement therapy prior to group treatment (Crane & Eckhardt, 2013; Kistenmacher & Weiss, 2008; Musser, Semiatin, Taft, & Murphy, 2008). These findings highlight the need for interventions that combine motivational and CBT strategies.

In addition, almost all prior AIP research has relied on the group treatment format. Group interventions have a number of positive features (Yalom & Leszcz, 2005). They are cost-effective, provide opportunities for positive peer influence, and allow therapists to observe client behavior and intervene in a social context. In general, the efficacy of group approaches is comparable with individual approaches for many mental health and behavioral problems (Burlingame, MacKenzie, & Strauss, 2004). However, group interventions for IPV perpetrators also have several potential limitations. The group format creates challenges in addressing individual needs that vary as a function of motivations for engaging in abuse, readiness for change, and comorbid problems such as anger dysregulation and substance abuse. In addition, group treatment may support peer contagion of abuse-promoting attitudes and behaviors (Murphy & Meis, 2008).

In light of prior research, the goal of the current project was to evaluate a flexible, empirically informed individual therapy for partner-abusive men that combines motivational and CBT treatment strategies. The treatment manual (Murphy & Eckhardt, 2005) instructs therapists to use motivational interviewing (MI) to reduce client hostility toward treatment, promote a collaborative alliance, and resolve ambivalence about change. MI strategies are complemented by a flexible application of CBT interventions designed to challenge abuse-maintaining beliefs and develop alternative relationship skills to supplant abusive behavior. Therapists help clients to progress at their own pace through phases addressing the following: (a) motivation to change, (b) safety and life stabilization, (c) relationship skill enhancement, and (d) trauma recovery and relapse prevention. Therapists are given a high level of autonomy to adapt intervention strategies to the needs of individual clients using a case-formulation approach.

A randomized clinical trial compared individual CBT (ICBT) to a standard group CBT intervention (GCBT), delivered in 20 weekly sessions at a community-based domestic violence agency. ICBT was expected to confer several advantages, including greater flexibility to define and address individual change targets, enhanced ability to pace and time interventions relative to the client’s readiness to change, and reduced potential for negative peer interactions. We hypothesized that ICBT, relative to GCBT, will lead to higher rates of desistence from partner violence, greater reductions in physical and emotional abuse perpetration, greater reductions in distorted and problematic cognition, and greater improvements in communication and relationship adjustment.

Method

Participants

The sample consisted of 42 men presenting at a community-based domestic violence agency who met the following criteria: (a) age 18 or above, (b) currently involved in an intimate relationship of at least 6-months duration, (c) participant self-reported physical partner assault in the prior 6 months or severe partner assault at any time in the history of the current relationship on the revised Conflict Tactics Scale (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996), and (d) participant provided written informed consent for study participation and partner contact. Potential participants were excluded if they displayed any of the following on the Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 1996) at intake: (a) current psychotic symptoms, (b) lifetime history of one or more manic or mixed episode, (c) current diagnosis of major depressive disorder with suicidal ideation, or (d) current substance dependence disorder (excluding caffeine or nicotine) that had not remitted for at least 6 months. Participants were enrolled in the trial between November, 2003, and December, 2005. Their relationship partners were contacted by phone and asked to complete research assessments. Participants and their partners were compensated US$30 for the baseline and quarterly follow-up assessments.

Figure 1 provides details on sample recruitment and retention, and Table 1 provides demographic details by treatment condition. The sample consisted primarily of non-Hispanic White (45.2%) and African American (42.9%) men. Overall, 71.4% of the sample were court referred, 19.0% were self-referred while awaiting adjudication, and 9.5% had no court involvement.

Figure 1.

Consolidated standards of reporting trials (CONSORT) flow diagram.

Table 1.

Background Characteristics for the Intent-to-Treat Sample by Treatment Condition.

Variable	Individual CBT (n = 21)	Group CBT (n = 21)
Age, M (SD), years	36.86 (7.12)	31.90 (6.07)
Education, M (SD), years	12.76 (1.73)	13.19 (2.40)
Past year income, M (SD), US$	28,571 (21,988)	31,071 (23,738)
Race, number (%)
Asian/Asian American	1 (4.8)	0 (0)
Black/African American	10 (47.6)	8 (38.1)
Hispanic/Latino	1 (4.8)	1 (4.8)
White/Caucasian	7 (33.3)	12 (57.1)
Other	2 (9.5)	0 (0)
Referral status, number (%)
Deferred prosecution	3 (14.3)	3 (14.3)
Condition of probation	12 (57.1)	5 (23.8)
Civil court referral	3 (14.3)	4 (19.0)
Court case pending	3 (14.3)	5 (23.8)
No legal involvement	0 (0)	4 (19.0)
Relationship status, number (%)
Married	11 (52.4)	11 (52.4)
Cohabiting	6 (28.6)	6 (28.6)
Other	4 (19.0)	4 (19.0)

Note. CBT = cognitive-behavioral therapy.

Measures

Partner-abusive behavior was assessed with the CTS2 (Straus et al., 1996) and the Multidimensional Measure of Emotional Abuse (MMEA: Murphy, Hoover, & Taft, 1999). Participants and their relationship partners reported item frequency on a scale from never to more than 20 times for the 6 months prior to baseline and each quarterly follow-up interval. The primary outcome indicators (and internal consistency estimates at baseline for the current sample) were three CTS2 subscales: Psychological Aggression (eight items; α = .69 and .72 for client and partner reports, respectively), Physical Assault (12 items; α = .67 and .94 for client and partner reports, respectively), and Injury (six items; α = .62 and .66 for client and partner reports, respectively), and the total emotional abuse score from the 28-item MMEA (α = .92 and .94 for client and partner reports, respectively). Behavior frequency scores were estimated for each scale at each assessment by recoding response options to category means and summing across items. Both the MMEA and CTS2 have adequate psychometric properties and have been used in prior clinical research with partner-violent offenders (e.g., Taft et al., 2003; Zarling et al., 2015).

Relationship adjustment was assessed with the Dyadic Adjustment Scale (DAS; Spanier, 1976). Participants and their partners completed the DAS at each assessment. Extensive evidence of reliability and validity are available for this widely used 32-item measure (Spanier, 1989). For the current sample, Cronbach’s alpha at baseline was .84 for client reports and .86 for partner reports.

Participant communication difficulties were assessed by partner report on the 27-item Spouse Verbal Problem Checklist (VPC; Haynes, Chavez, & Samuel, 1984) at each assessment. VPC items reflect common communication problems (e.g., “interrupts you when you are talking”) with response options on a 5-point scale from never to always. Spouse reports on the VPC are internally consistency (α = .93 in the current sample) and correlate with observer ratings of negative communication during dyadic problem solving (Haynes et al., 1984).

The Articulated Thoughts in Simulated Situations (ATSS) paradigm (Zanov & Davison, 2010) was used at each client assessment to assess cognitive responses to challenging relationship scenarios. The participant listened to a computer-administered audio-recorded conversation between two women and was instructed to imagine that he was overhearing a conversation between his relationship partner and her friend. During each vignette, the audio stopped 4 times and the participant was prompted to say what was going through his mind during a 30 s pause before the next segment began. In one vignette, the woman speaks about her relationship partner in a highly pejorative fashion and reveals unflattering personal details about him. In the other, the woman reveals behaviors that she has been hiding from her partner. The vignettes were adapted from prior assessments of relationship cognition in partner-violent individuals (Eckhardt, Barbour, & Davison, 1998; Holtzworth-Munroe, Jacobson, Fehrenbach, & Fruzzetti, 1992). Both vignettes were administered at baseline, and one vignette was administered at each quarterly follow-up in an alternating fashion. Participant verbalizations were recorded, transcribed, and coded for articulated cognitive distortions, irrational beliefs, aggressive intentions, and hostile attributions (Eckhardt, 2007) by a trained research assistant who was blind to treatment condition. In prior research, partner-violent men displayed more irrational and distorted cognition during the ATSS than nonviolent men (Eckhardt et al., 1998).

Criminal justice outcomes were evaluated through review of a publicly available electronic state database for 1 year from the individual’s first day of treatment, or 1 year from the date of first intake for those who enrolled but did not enter treatment. Two dichotomous indicators were analyzed: (a) any arrest on domestic abuse–related charges and (b) any new domestic abuse–related civil court petition.

Procedure

Study procedures were approved by institutional review at the University of Maryland, Baltimore County.

Assignment to conditions

After completing a two-session agency intake, eligible participants were invited to enroll. Those who completed informed consent attended an additional baseline assessment session and were assigned to condition with an urn randomization procedure (Stout, Wirtz, Carbonari, & Del Boca, 1994) that included two dichotomous balancing factors: (a) high versus low scores on the self-report component of a validated Treatment Prognostic Scale (Murphy, Morrel, Elliott, & Neavins, 2003) and (b) high versus low CTS2 psychological aggression scores.

Therapists

Five therapists delivered ICBT: three doctoral clinical psychologists (who treated 1, 2, and 8 cases, respectively) and two doctoral students in clinical psychology (who treated 4 and 6 cases, respectively). The first author provided training and supervision to ICBT therapists, which included review and discussion of the treatment manual, weekly case supervision, and periodic review of audio-recorded sessions. GCBT groups were conducted by cotherapy teams consisting of a clinical psychology graduate student trainee and an agency staff member (three doctoral clinical psychologists and two master’s level clinical psychologists).

Treatments—ICBT

ICBT (Murphy & Eckhardt, 2005) was delivered in 20 weekly 1-hr sessions. The manual instructs therapists to use MI strategies (Miller & Rollnick, 2002) to resolve ambivalence, establish alliance, and stay on pace with the client’s change process. It includes case conceptualization guidelines for flexible application of CBT interventions, including education about healthy relationships, targeted problem solving for life difficulties, safety promotion, cognitive restructuring of abuse-maintaining beliefs and negative relationship schemas, and relationship skills training to promote active listening, negotiation, compromise, and assertiveness. Therapists were encouraged to work collaboratively with each client to establish treatment goals, set session agendas, and devise homework tasks.

Treatments—GCBT

The group intervention constituted treatment as usual at the agency research site delivered in 20 weekly 2-hr sessions. GCBT promotes behavior change through supportive group interactions and structured psychoeducational intervention. Each session included a review of a structured practice assignment, presentation of structured psychoeducational content, group discussion and/or role plays, and unstructured time to discuss personal situations and concerns. The groups began with 8 to 10 members and were conducted in a closed-ended format. The structured psychoeducational content addressed, in sequence: (a) motivation to change abusive behavior, (b) crisis management and anger self-regulation, (c) relationship communication and problem-solving skills, (d) focused discussion of common problems (e.g., substance use, parenting), and (e) planning for continued change. Following standard agency practice, group members were offered individual therapy after group. One GCBT participant accepted that offer and attended 11 additional sessions. GCBT participants were in seven distinct treatment groups, two groups contained one study case, two groups contained two study cases, and three groups contained three study cases. Due to participation in treatment-as-usual groups with other agency clients, treatment fidelity data were not available for GCBT.

Treatment integrity

Treatment integrity was evaluated for the ICBT condition using a therapy competence rating scale developed for the current project. Using audio recordings, the first and third authors rated therapist performance at the session level on a 7-point scale for 11 skill areas assessing core competencies in four categories: case conceptualization, structuring skills, motivational applications, and CBT applications. Additional ratings address client hostility toward treatment, client problem complexity, phase-of-treatment focus, and the use of 27 specific CBT techniques and change targets. A total of 40 sessions were coded (with 1/3 double coded for reliability). Sessions were selected to reflect early, middle, and late phases of treatment across cases and therapists. Rater agreement, assessed as mean competency category ratings, was good (Spearman correlations ranged from .83 to .92 across the 11 rating items).

Given that no training standards exist for ICBT, competency ratings provided a general check on adherence to the treatment principles and descriptive information to aid in the interpretation of findings. For specific skill areas, adequate performance was defined as average competency ratings above the midpoint on a 7-point scale, where 1 reflects poor performance and 7 reflects excellent performance. Average competency ratings were lower for structuring skills (M = 3.6, SD = 1.2) than for case conceptualization (M = 5.4, SD = 0.9), MI applications (M = 5.3, SD = 0.7), and general CBT applications (M = 5.1, SD = 0.8). Only one of the five ICBT therapists attained an average rating above the scale midpoint on structuring skills. All five ICBT therapists received average ratings above the scale midpoint for all other competency categories. These ratings suggest that session agenda setting and homework implementation were the most challenging elements of this highly flexible CBT approach.

Data analysis

Analyses compared the frequency of abusive behavior during the 6-month period prior to treatment initiation (assessed at baseline), the 6-month period of scheduled treatment (pooled reports from assessments conducted 3 and 6 months after baseline), and the 6 month period after treatment (pooled reports from the 9 and 12 month assessments). This method created frequency variables that could be directly compared for change across three equal time intervals. The DAS, VPC, and ATSS were likewise pooled for analysis across these three time intervals. ANOVAs examined treatment condition as a between-subjects factor and time as a within-subjects factor. When the assumption of sphericity was violated, the Greenhouse–Geisser correction was used to adjust degrees of freedom. Violence cessation was examined using a dichotomous physical assault/no assault variable at each quarterly follow-up and dichotomous criminal justice outcomes for the 12 months of follow-up. Due to low statistical power for this small-scale trial, treatment effects were interpreted if they met conventional significance levels (p < .05) or exceeded the cutoff for a moderate effect size, designated as a phi coefficient (Φ) ≥.30 for categorical outcomes (Cohen, 1988) or an eta squared (η²) ≥.06 for continuous outcomes (Cohen, 1988). Initial screening of frequency distributions for abusive behavior revealed a high degree of positive skew and platykurtosis. Variables distributed with skew ≥2.0 or kurtosis ≥7.0 were considered to deviate substantially from normality (West, Finch, & Curran, 1995) and were log transformed prior to hypothesis testing. To enhance interpretability, means and standard deviations are presented for raw frequency scores.

Results

Table 1 displays demographic characteristics for the intent-to-treat sample. Average age was significantly higher in ICBT than GCBT, F(1, 40) = 5.89, p = .020. No significant condition differences were present in education F(1, 40) = 0.44, p = .511, or income, F(1, 40) = 0.13, p = .715. Analysis of contingency tables revealed no overall significant condition differences in race, referral status, or relationship status (all p values >.10). Table 2 provides descriptive data on the frequency of abusive behavior and indicators of relationship functioning at the pretreatment assessment for the intent-to-treat sample. Analyses revealed no significant differences between conditions for participant self-reports of physical assault, F(1, 40) = 1.40, p = .244, injury, F(1, 40) = 0.00, p = .965, psychological aggression, F(1, 40) = 0.20, p = .655, emotional abuse, F(1, 40) = 2.01, p = .164, or relationship adjustment, F(1, 40) = 0.07, p = .794, and no significant differences in partner reports of physical assault, F(1, 37) = 2.53, p = .120, injury, F(1, 37) = 0.86, p = .359, psychological aggression, F(1, 37) = 1.86, p = .181, emotional abuse, F(1, 37) = 1.24, p = .273, verbal problems, F(1, 33) = 0.00, p = 956 or relationship adjustment, F(1, 33) = 0.23, p = .637.

Table 2.

Means and Standard Deviations of Study Variables by Treatment Condition.

Variable	Individual CBT			Group CBT
	M (SD)			M (SD)
	Pretreatment	During Treatment	Posttreatment	Pretreatment	During Treatment	Posttreatment
Partner reports
CTS2 physical	4.35 (5.71)	10.30 (23.30)	4.00 (5.72)	14.05 (26.79)	12.00 (34.90)	4.83 (14.30)
CTS2 psychological	32.10 (31.28)	56.85 (54.04)	68.47 (72.97)	45.01 (27.61)	47.92 (64.91)	25.58 (40.19)
CTS2 injury	1.85 (3.34)	2.45 (4.11)	1.89 (4.03)	3.79 (7.45)	3.67 (10.88)	1.42 (4.06)
MMEA total	91.70 (97.45)	181.00 (216.82)	168.33 (230.41)	129.42 (138.54)	111.50 (155.23)	40.25 (61.95)
DAS	93.39 (29.94)	87.08 (36.22)	82.25 (41.88)	97.47 (19.28)	97.46 (28.42)	109.65 (26.47)
VPC	47.17 (22.94)	43.63 (22.21)	41.99 (27.34)	46.76 (19.98)	38.88 (20.69)	31.88 (20.59)
Client self-reports
CTS2 physical	4.35 (4.88)	1.40 (3.52)	0.95 (3.58)	3.67 (5.96)	1.53 (2.92)	1.50 (4.78)
CTS2 psychological	23.00 (24.11)	19.00 (17.06)	12.05 (15.84)	24.85 (23.59)	25.07 (41.03)	23.86 (49.57)
CTS2 injury	0.90 (1.70)	0.70 (1.87)	0.20 (0.70)	0.81 (1.47)	0.67 (2.09)	0.00 (0.00)
MMEA total	49.83 (54.24)	41.50 (50.60)	26.95 (35.86)	80.34 (97.98)	26.60 (30.90)	30.50 (67.77)
DAS	103.45 (26.93)	100.36 (22.38)	100.89 (24.65)	105.11 (10.56)	105.81 (16.57)	105.70 (20.91)
Articulated thoughts in simulated situations
Cognitive distortions	3.33 (4.07)	4.95 (7.00)	7.00 (9.64)	3.95 (4.59)	3.20 (5.23)	2.92 (6.01)
Irrational beliefs	8.24 (5.62)	8.16 (6.60)	6.75 (8.81)	7.57 (6.31)	6.60 (7.40)	3.50 (4.83)
Aggressive intentions	1.67 (2.92)	1.37 (3.35)	2.19 (3.66)	1.10 (1.87)	1.67 (4.58)	0.17 (0.39)
Hostile attributions	0.19 (0.60)	0.16 (0.69)	0.00 (0.00)	0.43 (1.03)	0.00 (0.00)	0.00 (0.00)

Note. CBT = cognitive-behavioral therapy; CTS2 = Revised Conflict Tactics Scale; MMEA = Multidimensional Measure of Emotional Abuse; DAS = Dyadic Adjustment Scale; VPC = Verbal Problem Checklist.

Six individuals (14%), all of whom were assigned to the group condition, dropped out between baseline assessment and the beginning of treatment. Efforts to complete follow-up with the first three of these cases were received unfavorably, and we therefore limited follow-up to participants who attended at least one treatment session after baseline. Criminal justice outcomes were gathered on the entire intent-to-treat sample. Those who dropped out prior to treatment did not differ significantly from those exposed to treatment in age, education, income, race, referral status, baseline client reports of physical assault, psychological aggression, or injury or baseline partner reports of physical assault, injury, psychological aggression, and total emotional abuse (all p values > .10). However, those who dropped out had higher baseline client reports of emotional abuse (on the MMEA) than those who attended treatment, F(1, 40) = 5.16, p = .029.

Treatment Attendance

For the intent-to-treat sample, treatment uptake was higher in the ICBT condition, as evidenced by attendance of one or more treatment sessions (100% in ICBT; 71% in GCBT), χ² = 7.00, N = 42, df = 1, p = .008, Φ = .41, completion of a credible dose of treatment (attending at least 15 of 20 core treatment sessions: (90% in ICBT; 62% in GCBT), χ² = 4.72, N = 42, df = 1, p = .030, Φ =.34, and average number of sessions attended (ICBT: M = 19.62, SD = 3.61; GCBT: M = 12.19, SD = 9.12), F(1, 40) = 12.07, p = .001, η² = .232. Among those who attended at least one treatment session, completion of a credible dose was similar across conditions (90% in ICBT; 87% in GCBT) but voluntary uptake of sessions beyond the core treatment was higher in ICBT (33%) than GCBT (7%), χ² = 3.60, N = 362, df = 1, p = .058, Φ = .32.

Partner Abuse and Relationship Functioning

Partner reports

As revealed in Tables 2 (descriptive data) and 3 (significance tests), partner reports of CTS2 psychological aggression declined over time in GCBT but increased in ICBT, yielding a significant treatment by time interaction. The treatment by time interaction met the cutoff for a medium effect size ( $η_{p}^{2}$ ≥ .06) for three additional partner report variables. Greater reductions were observed in GCBT versus ICBT for partner reports of CTS2 physical assault. Total emotional abuse (MMEA) increased over time in ICBT and decreased in GCBT, and partner relationship adjustment improved over time in GCBT condition and declined in ICBT. Figure 2 displays these findings. A significant main effect of time for partner reports of physical assault and verbal problems, and a medium effect size for total emotional abuse (MMEA) were also present, reflecting a decline in abusive behavior and communication problems across conditions.

Figure 2.

Plots of treatment condition by time interactions for partner reports of physical assault, psychological aggression, emotional abuse, and relationship adjustment.

Client self-reports

Client self-report data revealed significant reductions over time across conditions in CTS2 Physical Assault, Psychological Aggression, and Injury, and total emotional abuse (MMEA). No significant change over time was observed in client reports of relationship adjustment, and there was no evidence of differential change across treatment conditions (see Tables 2 and 3).

Table 3.

Repeated Measures ANOVA for Treatment Outcome Variables.

Variable	Main Effect of Time			Treatment × Time Interaction
Variable	F (df)	p	$η_{p}^{2}$	F (df)	p	$η_{p}^{2}$
Partner reports
CTS2 physical^a	4.18 (2,58)	.020	.126	2.80 (2,58)	.069	.088
CTS2 injury^a,b	1.59 (1.6,58)	.217	.052	0.77 (1.6,58)	.444	.026
CTS2 psychological	1.23 (2,58)	.299	.041	4.76 (2,58)	.012	.141
MMEA total^a	2.32 (2,56)	.108	.076	3.03 (2,56)	.057	.098
Dyadic adjustment^b	0.06 (1.4,46)	.880	.003	3.52 (1.4,46)	.057	.133
Verbal problems	7.72 (2,54)	.001	.222	1.43 (2,54)	.247	.051
Client self-reports
CTS2 physical^a,b	5.91 (1.7,64)	.013	.139	0.46 (1.7,64)	.595	.014
CTS2 injury^a	4.29 (2,64)	.018	.118	0.20 (2,64)	.821	.006
CTS2 psychological^a	31.26 (2,64)	.001	.494	0.05 (2,64)	.952	.002
MMEA total^a,b	10.37 (1.6,64)	.001	.245	0.94 (1.6, 64)	.381	.028
Dyadic adjustment^b	0.01 (1.4,62)	.964	.000	0.08 (1.4,62)	.854	.003
Articulated thoughts in simulated situations
Cognitive distortions^a	0.86 (2,52)	.430	.032	2.04 (2,52)	.141	.073
Irrational beliefs^a,b	5.18 (1.6,52)	.015	.166	0.16 (1.6,52)	.856	.006
Aggressive intentions^a	1.14 (2,52)	.328	.042	2.09 (2,52)	.134	.074
Hostile attributions^a,b	2.64 (1.4,52)	.103	.092	0.56 (1.4,52)	.511	.021

Note. CTS2 = Revised Conflict Tactics Scale; MMEA = Multidimensional Measure of Emotional Abuse.

Scale scores were log transformed prior to hypothesis tests.

Greenhouse–Geisser correction applied due to violation of the assumption of sphericity.

Assault prevalence at quarterly follow-ups

Table 4 displays the prevalence of any client-to-partner physical assault as reported by either the client or partner on the CTS2 at each of the four quarterly follow-up assessments. The recurrent assault rate was higher in ICBT than in GCBT at each assessment, although these differences were not statistically significant. The difference met the cutoff for a moderate effect size at the 6-month follow-up assessment.

Table 4.

Client-to-Partner Physical Assault Prevalence by Either Self- or Partner-Report.

Assessment	ICBT (n = 21) (%)	GCBT (n = 15) (%)	Odds Ratio	Phi	χ²	p
3 month	52.4	33.3	2.2	.19	1.29	.257
6 month	57.1	26.7	3.7	.30	3.29	.070
9 month^a	33.3	14.3	3.0	.21	1.60	.207
12 month	38.1	33.3	1.2	.05	0.09	.769
Assault during treatment (at 3 or 6 months)	61.9	46.7	1.9	.15	0.82	.364
Assault posttreatment (at 9 or 12 months)	52.4	40.0	1.6	.12	0.54	.463
Assault at any assessment	71.4	53.3	2.2	.19	1.24	.265

Note. ICBT = individual cognitive-behavioral therapy; GCBT = group cognitive-behavioral approach.

No follow-up data were available for one participant in Group CBT at the 9-month assessment.

Criminal justice outcomes

A review of the state criminal justice information database revealed that 93% of participants in the intent-to-treat sample had a positive pretreatment history of domestic abuse-related justice system involvement. Five individuals (12%) generated new charges for domestic abuse-related crimes during the 1-year study period, four (19%) in the ICBT condition and one (5%) in the GCBT condition. This difference reflected a small, nonsignificant effect, χ² = 2.04, df = 1, N = 42, p = .153, odds ratio = 4.7, Φ = .22. Six individuals (14%) had civil court involvement for domestic abuse-related petitions during the 1-year study period, four (19%) in ICBT and two (10%) in GCBT. This difference reflected a small, nonsignificant effect, χ² = 0.78, df = 1, N = 42, p = .378, odds ratio = 2.2, Φ = .14. The higher comparative rate of ongoing legal involvement in ICBT for the entire sample randomized to treatment is directly contrary to the hypothesis and consistent with results from the repeated measures analyses.

ATSS

A significant main effect of time reflected a reduction in Irrational Beliefs across conditions (see Table 3), and the main effect of time exceeded a medium effect size for Hostile Attributions. For both cognitive biases and aggressive intentions, the treatment by time interaction exceeded the threshold for a medium effect, reflecting a greater reduction in problematic articulations in GCBT than in ICBT.

Discussion

The findings failed to support the hypothesis that a flexible, individual version of CBT would be more effective than a structured group CBT program for partner-abusive men. Contrary to hypotheses, group CBT produced outcomes consistently equal to, or better than, individual CBT. This difference was statistically significant for partner reports of participant’s psychological aggression and exceeded a medium effect size for partner reports of physical assault and emotional abuse, partner relationship adjustment, and client cognitive distortions and aggressive intentions in response to hypothetical relationship scenarios.

Other findings suggest positive change over time across treatment conditions, including client self-reports of physical assault, psychological aggression, emotional abuse, and injury, partner reports of client communication problems, and client articulations of irrational beliefs and hostile attributions. Using a “zero-tolerance” model of violence outcome, reports of any physical assault revealed lower rates (although not statistically significant) at each follow-up assessment for the GCBT than ICBT condition. Data on the entire randomized sample also showed lower rates (again nonsignificant) of criminal justice involvement for partner violence during the follow-up year for participants in GCBT versus ICBT.

In contrast, treatment uptake, attendance, and voluntary continuation were higher in ICBT than GCBT. Many participants may prefer individual treatment over group in an attempt to avoid embarrassment from public disclosure of abuse and out of fear that other group members will be highly violent and dangerous. In our experience, these negative expectations tend to be rapidly disconfirmed by supportive group facilitators who respect client autonomy.

The results raise vexing questions as to why the individual treatment was less effective than group. The flexible nature of ICBT places high demands on therapists to develop a sound case formulation, devise a collaborative change agenda, motivate client engagement, and deliver targeted interventions. Treatment competency analyses revealed low average ratings for structuring the session agenda and administering homework assignments, both key elements of CBT. These patterns were quite consistent across therapists, regardless of experience level or training. In addition, informal CBT interventions were frequently used (e.g., discussing general relationship themes, problem solving for specific relationship events, suggesting alternative attributions for partner behaviors), whereas more formal CBT interventions were less frequently used (e.g., shaping and role-playing specific relationship skills, eliciting and evaluating alternative cognitions). Thus, more extensive therapist training may be needed to support competent delivery of ICBT. However, a need for more extensive training may impose significant barriers to widespread dissemination in AIP practice.

For some ICBT cases, the development of a collaborative change agenda and homework tasks remained persistent challenges as a function of low client motivation to change. Although one-on-one MI can help alleviate initial hostility and enhance assumption of personal responsibility for abuse (Musser et al., 2008), the group may facilitate greater subsequent engagement through role modeling and positive social influence. Ambivalence may be more readily resolved through observation of group members experiencing benefits from their change efforts rather than through protracted MI with an individual therapist.

It is interesting to note that the physical assault recidivism rate was high in both conditions. Almost half of participants engaged in assault during the 6 months after treatment. This rate is 2 to 4 times higher than prior clinical findings from the same research site (Morrel et al., 2003; Musser et al., 2008). Several factors may account for this difference. First, the current study used quarterly follow-up assessments rather than twice yearly assessments and may have detected recidivist incidents that would not be recalled with a more lengthy assessment window. Second, our prior studies relied exclusively on victim partner reports. In the current study, 7% of clients reported perpetrating physical assault when their partners did not report experiencing assault. Finally, the requirement that participants were in a relationship at the time of study recruitment may increase recidivism risk. High overall rates of reassault (41%-74%) have been reported in other clinical investigations that selected for intact relationships (O’Leary, Heyman, & Neidig, 1999; Stith, Rosen, McCollum, & Thomsen, 2004).

The trial had a number of positive features, including recruitment of a racially and socioeconomically diverse sample, careful treatment specification, random assignment to conditions, use of multiple data sources, and high sample retention for those exposed to treatment. However, some key limitations warrant consideration. First, six participants dropped out before treatment in the group condition and had no follow-up data other than criminal justice records. Although dropout may have biased findings in favor of the group condition, this seems unlikely in light of criminal justice outcomes, which revealed higher recidivism in the individual versus group condition in the intent-to-treat sample with odds ratios similar to those observed in analyses combining all available data from participants and partners.

Second, the sample was relatively small, derived from one agency site, and restricted to male IPV perpetrators with no major psychiatric or substance use problems who are involved in a committed heterosexual relationship. These features limit generalization of findings to other treatment contexts and other samples, including women, individuals in gay or lesbian relationships, and men who have separated from their relationship partners. This highly select sample may minimize the influence of factors that can impede intervention success (e.g., substance abuse) and factors that may operate independent from treatment to reduce or end violence (e.g., lack of access to a relationship partner).

Third, as in many comparative treatment studies, it is not possible to isolate which aspects of the different treatment conditions may account for observed findings. Most notably, to remain faithful to standard clinical practice, group sessions were twice as long (2 hr) as individual sessions (1 hr). Therefore, greater treatment contact may explain the favorable outcomes observed for group treatment. However, participants in ICBT attended about seven sessions more, on average, than those in GCBT. As a result, the differences in total clinical contact time were not dramatically different between conditions. Similarly, it is possible that therapists experienced greater confidence in delivering GCBT, as this is the standard intervention at the agency. Individual treatment required additional training and support, and may require a higher level of therapist skill to deliver effectively. In addition, individual treatment was delivered by a relatively large number of therapists with varied levels of experience, each of whom treated a relatively small number of cases, raising the prospect of differences in treatment outcome across therapists that could not be assessed due to sample limitations. Finally, the cotherapist model in GCBT may provide more options for participants to establish rapport, more flexibility in how therapists can deliver CBT interventions, and more opportunities to model supportive and respectful interactions.

These study limitations highlight important priorities for future research in this area, including the need to develop and evaluate more highly structured versions of individual CBT to address concerns about variable and flexible implementation. In addition, recent studies highlight the potential value of addressing additional change targets, including strategies to enhance emotion regulation through increasing mindfulness or mind–body awareness (Tollefson & Phillips, 2015; Zarling et al., 2015). Recent controlled trial research has provided encouraging support for trauma-informed approaches in reducing IPV, although this work to date has focused only on military veterans (Taft et al., 2016). Finally, although CBT can address a range of abuse-promoting beliefs and relationship skill deficiencies, further research is needed to adapt these interventions to the needs of specific cultural, racial, and ethnic groups (Waller, 2016).

In the final analysis, our hypothesis that a flexible individual version of CBT would produce greater change than a standard group CBT approach was clearly not supported. The results indicate greater success from the group treatment approach, yet greater challenges in promoting group treatment uptake. In light of the small, highly select sample and unique features of the CBT treatments under investigation, the current findings should be seen as preliminary, and applications to practice and policy must be made with considerable caution. Nevertheless, within the constraints of the current sample and design, the current findings indicate that the group format may have important advantages over individual treatment in efforts to reduce and end IPV using CBT strategies.

Footnotes

Acknowledgements

The authors thank the staff of HopeWorks of Howard County, Maryland, for their support of our clinical research efforts and acknowledge the dedicated efforts of the following research assistants and project therapists: Theresa Schmitz, Fabio van der Merwe, Cynthia Eaves, Manu Singh Looney, Jeffrey Elliott, Tiffany Sim, Peter Musser, Christina Watlington, and Danielle Black.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant from the National Institutes of Health (R21 MH64562) to the first author.

Author Biographies

Christopher M. Murphy, PhD, is professor and chair of psychology at the University of Maryland, Baltimore County. His research focuses on cognitive-behavioral, motivational, and trauma-informed interventions for perpetrators of intimate partner abuse; the role of alcohol and drug use in intimate partner violence and its treatment; and the prevention of intimate partner abuse in emerging adulthood.

Christopher I. Eckhardt, PhD, is professor of psychological sciences and director of clinical training at Purdue University in West Lafayette, Indiana. His research examines the cognitive and affective correlates of intimate partner violence, the effects of alcohol on these processes, and how risk factor research may inform interventions for intimate partner violent offenders.

Judith M. Clifford, PhD, is licensed clinical psychologist in practice with My Mental Health, LLC in Annapolis, Maryland. She specializes in the treatment of traumatic stress, anxiety and mood disorders, and adaptation to chronic illness. Her research has examined treatment for intimate partner violence and the influence of self-esteem on commitment to abusive relationships.

Adam D. LaMotte, MA, is a graduate student in the human services psychology doctoral program at the University of Maryland, Baltimore County. Before graduate school, he was a research technician at the VA Boston Healthcare System. His research interests include intimate partner violence, posttraumatic stress disorder, and the influence of traumatic experiences on intimate relationships.

Laura A. Meis, PhD, is a clinical research psychologist at the Minneapolis VA Health Care System and an assistant professor of medicine at the University of Minnesota. Her research focuses on intimate relationship functioning among individuals with symptoms of posttraumatic stress disorder (PTSD) and improving the effectiveness of psychosocial treatments for PTSD, with an emphasis in understanding how family relationships can influence use of mental health care. Additional areas of interest include developing and testing couple therapies for mental health conditions, understanding behavior change, understanding the nature of PTSD, and improving mental health care for underserved populations.

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