The Challenges of Working With Men Who Perpetrate Partner Violence: Perspectives and Observations of Experts Who Work With Batterer Intervention Programs

Abstract

Batterer intervention programs (BIPs) constitute the primary treatment for perpetrators of intimate partner violence (IPV). Systematic evaluations of BIPs, however, have yielded modest results in terms of these programs’ ability to reduce perpetration. Descriptive studies, which can provide information on the contexts and process associated with BIPs, can provide insights into the underlying mechanisms that might promote change among BIP clients, and as such are important to improving efficacy measures for BIPs. To date, however, limited research exists on what challenges BIPs encounter in working with clients, and how those challenges present barriers to behavioral change among perpetrators at the intervention level. As part of a 2-year ethnographic study, we conducted 36 individual semistructured interviews with professionals working with BIPs. We identified six themes related to challenges to promoting behavioral change among men who perpetrate violence: (a) social acceptance of IPV, (b) hypermasculine attitudes, (c) emotional problems, (d) childhood exposure to violence, (e) co-morbid mental health issues, and (f) denial, minimization, and blame. Our results have implications for thinking about some of the contextual factors that may impede BIPs ability to produce desired outcomes and for identifying areas in which programs can be tailored to improve the overall client experience. Our results also point to the need for a more coordinated community response to IPV, and in particular to helping provide resources that support BIPs sustained, safe, and as effective as possible work.

Keywords

intimate partner violence battering prevention domestic violence offender/perpetrator intervention exposure to violence

Introduction

Intimate partner violence (IPV) is a significant social and public health issue that affects nearly 12 million Americans in the United States each year (Black et al., 2011). IPV victimization is associated with a host of negative physical, psychological, and social outcomes, the most severe of which is death (Centers for Disease Control and Prevention, 2011; Sugg, 2015), and translates into high health costs and burdens for victims (Bonomi, Anderson, Rivara, & Thompson, 2009; Centers for Disease Control and Prevention, 2003). Although women and men can both experience victimization, women continue to be disproportionately affected by IPV. In the United States, at least one in three women has experienced some form of IPV (e.g., rape, physical violence, or stalking) in their lifetime, and one in four has experienced severe physical violence by a partner (Black et al., 2011). Women are more likely to be killed by a partner than any other class of individuals (Catalano, 2012; Stöckl et al., 2013), more likely to be injured than men due to violence from a partner (Catalano, 2012), and suffer greater noninjury-related health burdens as the result of IPV from male partners (Garcia-Moreno et al., 2011).

Furthermore, research continues to suggest that IPV is a gender-based issue that is often rooted in gender inequities and power imbalances between men and women (Reed, 2008). Women are at a greater risk of IPV victimization at the hands of their male partners due to structural, economic, and other inequalities that limit their power in their relationships, families and communities and put them at risk of victimization (Jewkes, 2002). Although prevalence of male perpetration is unclear, a recent study by Singh, Tolman, Walton, Chermack, and Cunningham (2014) found that one in five men reported lifetime IPV perpetration toward their current partners. Furthermore, Black et al. (2011) found that across all violence types, 97% of female victims reported a male intimate partner perpetrator. Thus, to diminish the social and health costs of this epidemic and eliminate IPV altogether, efforts at reducing perpetration—and in particular perpetration by male partners—are needed.

Batterer Intervention Programs (BIPs)

BIPs are currently the most utilized type of intervention and treatment for male IPV perpetrators. Since the 1980s, these programs have become an integral part of the criminal justice response to IPV (Price & Rosenbaum, 2009) and an estimated 1,500 to 2,500 BIPs exist today in the United States. Furthermore, roughly 80%-90% of IPV perpetrators are court mandated into a BIP in lieu of incarceration (Price & Rosenbaum, 2009). The goal of BIPs is ultimately to stop abusive behaviors through strategies designed to promote prosocial behavioral change (Mederos, 1999). Although various models for BIPs exist, (two of the most common continue to be the Duluth and Emerge models) in general most programs utilize feminist-psychoeducational or cognitive behavioral therapy approaches (or some combination of the two) that are designed to promote perpetrator accountability, expand their knowledge and understanding of abuse, challenge masculinity/gender norms, and provide perpetrators with tools for deescalating anger, and enacting nonviolent methods of conflict resolution (Saunders, 2008).

Systematic evaluations of BIPs, regardless of the model used, however, have yielded modest results in terms of these programs’ ability to reduce perpetration. Although some studies have shown promising results (Boots, Wareham, Bartula, & Canas, 2016; Kelly & Westmarland, 2015; Lila, Oliver, Catalá-Miñana, & Conchell, 2014; Mills, Barocas, & Ariel, 2012), most have found mixed results, or best minimal reductions in recidivism or perpetrator behaviors among the individuals involved in such programs (Aldarondo, 2012; Arias, Arce, & Vilariño, 2013; Carter, 2010; Eckhardt et al., 2013; Haggård, Freij, Danielsson, Wenander, & Långström, 2017; Herman, Rotunda, Williamson, & Vodanovich, 2014; Murphy & Ting, 2010). Systematic evaluations of BIPs are also admittedly limited in terms what such studies can tell us about how BIPs “work” (Holtrop et al., 2017; Sheehan et al., 2012); or rather, the underlying processes occurring in BIPs that might be associated with behavioral change (i.e., efficacy) among men who attend them. Thus, while such evaluations of BIP efficacy are important, so too are studies which can identify and describe the BIP contexts and processes that promote change among perpetrators. Recognizing the need for more descriptive information on BIPs, a steadily growing body of qualitative research has emerged (Boira, del Castillo, Carbajosa, & Marcuello, 2013; Chovanec, 2012; Gray et al., 2016; Gray, Lewis, Mokany, & O’Neill, 2014; Holtrop et al., 2017; Morrison et al., 2017; Morrison et al., 2016; Parra-Cardona et al., 2013; Shamai & Buchbinder, 2010; M. E. Smith, 2011). In particular, qualitative studies of BIP facilitators’ and clients’ experiences have identified various components of the group process (e.g., intergroup dynamics, support, critical feedback and peer discussions) that seem to promote change and may be effective for reducing perpetration (Gray et al., 2014; Holtrop et al., 2017; Parra-Cardona et al., 2013).

An area that has yet to be fully explored in the literature, however, are the reasons why BIPs are not effective (Stuart, Temple, & Moore, 2007); or rather, some of the factors that impede change among BIP clients, and/or BIPs’ ability to promote change among their clients. To capture the BIP process, and describe how BIPs “work,” a consideration of the full range of contextual factors and circumstances in which BIPs function is needed, including descriptions of the various challenges and barriers such programs encounter in trying to accomplish their missions. The objective of this analysis, therefore, was to describe what challenges BIPs encounter in working with clients, and how those challenges present barriers in terms of effecting behavioral change among men who perpetrate IPV. Such research is important for understanding how BIPs negotiate the change process with their clients, what factors impede their efficacy, and how to refine programs to optimize their potential to reduce perpetration. To our knowledge, this is the first study to qualitatively explore the perspectives of those individuals who work with perpetrators on what challenges BIPs encounter in trying to promote prosocial behavioral change.

Method

Parent Study

We conducted a 2-year ethnographic study of two community-based BIPs for male IPV perpetrators in an urban area in the United States. The parent study included observations of BIP group sessions, debriefing interviews with BIP facilitators immediately after session observations, semistructured interviews with various professionals whose work brings them into direct or indirect contact with perpetrators and BIPs, and semistructured interviews with BIP clients. The current study uses the methodology described in full in Morrison et al. (2016).

Current analysis

This analysis draws on in-depth, semistructured interviews with a range of professionals who work directly with BIPs and their clients, or whose work either relies on BIPs, or brings them into close proximity to BIP clients as a part of their daily or regular job responsibilities, including BIP group leaders or facilitators, administrators and auxiliary staff, IPV victims’ advocates, members of the criminal justice system (e.g., probation officers, law enforcement officers, lawyers, and judges), county health department service providers and officials, state and county policy makers, and other relevant community leaders (i.e., individuals who work in other kinds of community services that IPV victims and perpetrators access). In brief, this study was conducted in partnership with two community-based BIPs. At the time of data collection, both programs had over 10 years of experience providing intervention to male perpetrators of IPV, had at least five locations where programs were held, and represented the two largest BIPs in the area. Each served over 100 clients annually, the majority of which were court-mandated. One utilized the Emerge (Adams & Cayouette, 2002) model as the basis for its program; the other utilized an adaptation of the Duluth model (Pence & Paymar, 1993).

Data collection occurred between 2013 and 2015. We used snowball sampling to recruit participants, starting with two BIP facilitators who served as consultants on the study. From there, potential participants were identified and recruited by already participating individuals who helped to facilitate contact. To ensure confidentiality and anonymity among our participants who work in a relatively small community, we do not include demographics related to participants’ specific roles or professions in the study. Instead, we divided participants into three professional domains related to IPV work: BIP experts/ IPV victims’ advocates, judicial and legal professionals, and policy/human services professionals.

The interview guide for these participants broadly explored their perspectives on the challenges or barriers to batterers’ intervention, what factors facilitate effective intervention and/or what “best practices” exist for intervening with men who perpetrate violence, what factors contribute to perpetration behaviors, and how BIPs can be improved to maximize outcomes and improve efficacy. Questions relevant to this analysis included the following: (a) What are the key challenges to working with men who perpetrate violence? (b) What barriers exist to intervention with male perpetrators of IPV? (c) What barriers exist to promoting behavioral change among perpetrators? All interviews were conducted by the first author, a PhD-trained anthropologist, in a private location of the participant’s choosing. Each interview lasted between 45 min to 1.5 hr. Verbal consent for participation was obtained prior to each interview. The institutional review board at the University of Pittsburgh approved this study.

Current Data Analysis

All interviews were audio-recorded and transcribed verbatim and entered into Atlas.ti (Muhr, 2004) for data management, organization, and analysis. Analysis took a two-coder iterative approach, focusing on content and global coding of thematic and subthematic categories. We began our approach to data analysis by reviewing all transcripts and identifying and labeling all aspects of the interviews that addressed the primary topics addressed in our interview guide: barriers, facilitators, best practices, factors contributing to IPV perpetration, and suggestions for improvement. For each of these key topics, we then performed more detailed coding and examined codes for categories within each topic, as well as themes and subthemes. When we performed our coding for the theme of barriers/challenges, we noted that the participants described two categories of barriers—those related to the operational elements of BIPs and external factors and those related to the clients. Preliminary codes, categories, and themes were then presented to participant stakeholders for feedback and refinement, resulting in a draft codebook. Realizing the complexity and richness of this overall topic, we chose to separate the analyses—first focusing on the theme of operational challenges described in Morrison et al. (2016). For this current analysis and paper, the first author and research assistant recoded the transcripts using the draft codebook with specific focus on the theme of participants’ perspectives on client-related challenges. Under this theme, coders identified six main subthemes (described below) and met once more compare subthemes for this analysis and further refine each. The refined codebook was again presented to the participant stakeholders for any additional feedback. The two coders then independently recoded the transcripts a third time using the final codebook, and met once more to reconcile any differences if needed. However, no differences in interpretation were noted. We also reviewed themes and subthemes with available interview participants to corroborate our findings and noted good corroboration (Crabtree & Miller, 1999; Patton, 1990).

Results

Thirty-six semistructured interviews with participants were conducted. A majority of participants were Caucasian (75%), female (70%), had 5 or more years of professional experience in IPV, and were employed as BIP experts/IPV advocates (52%), 12 of whom were BIP group facilitators (i.e., the service providers who run BIP group sessions and work directly with BIP clients, providing group counseling). Under the theme of BIP client challenges, six subthemes arose consistently across the majority of participants, including (a) social acceptance of violence, (b) hypermasculine attitudes, (c) emotional issues, (d) childhood exposure to violence, (e) mental health and substance abuse, and (f) denial, minimization, and blame.

Notes on the presentation of results: First, for the sake of clarity, we have presented each of our findings as a unique theme. However, it is clear that each of these challenges is potentially interrelated among some perpetrators. Second, identification of participants by professional domain or role would risk breaching confidentiality as our work was conducted in a relatively small community. Thus, exemplary quotes are presented using only participants’ numerical study ID, as well as indicators for individuals who work directly with BIPs and their clients (WD), and for those individuals whose work either relies on BIPs, or brings them into close proximity to BIP clients (WI) as a part of their daily or regular job responsibilities.

Social Acceptance of IPV

Participants identified societal acceptance of violence as one barrier to change for BIP clients. In general, they felt that society is permissive of violence against women. For example, when asked about the barriers to change for BIP clients, one participant stated, “People are accepting of it. It is ‘ok’ to be abusive. Probably that is one of the biggest challenges. You know, ‘What is the big deal? It shouldn’t even be illegal’” (13, WD). Similarly, another participant stated, “This is the thing about violence. It is a social thing. That is how society is. If enough people say that is ok, then you can do it” (22, WD). When asked how societal views on violence specifically presented a barrier, participants asserted that such attitudes contributed to BIP clients’ impression that abusive behaviors are acceptable,
Well one challenge is that there is so much social approval of violence. So, these men are not monsters, but they’re supported by a society that approves of violence (18, WD).

Societal acceptance of violence, therefore, presented a challenge in terms of BIPs’ ability to underscore to clients why their behavior was problematic, ‘They don’t see it as a problem in our society. It is hard to convince them of that because in our culture there is so much support for violence against women.’ (16, WI)

Moreover, participants felt that clients’ peers, in particular, played a “supporting role” in this area. For example, one participant, in describing how peers contributed to barriers to change for BIP clients, stated, “Men who are abusive, who are making jokes about it, people will still accept them, not confront them, hang out with them, still be friends with them. It’s a barrier in terms of them [clients] believing they need to change” (2, WD). Another participant similarly described how the negative feedback BIP clients received from friends challenged their ability to make positive behavioral changes by reinforcing the status quo “It’s hard for men to change and keep having their same group of friends. It’s so frightening for men to be considered a sissy, that they’ll do what they can to maintain the semblance of control” (4, WI). Thus, participants felt that the social messages that BIP clients received about abuse, particularly from their peers, served to undermine any progress clients make toward change. One participant described a BIP client’s struggle between his desire to enact the changes he had made and the need to conform to peer norms (3, WD):
One guy said it was so hard for him because as a salesperson, the places he went to sell were just so misogynistic. He would hear repeatedly a lot of anti-woman talk. He didn’t believe in it anymore, but he had to choose whether to make a sale or say something about it.

Another participant summarized, “I think it’s ubiquitous for a lot of men that make some changes, they no longer believe it, don’t agree and don’t want to mistreat their wives, but don’t know how to challenge it when they see it elsewhere” (5, WD).

Hypermasculinity

Participants also identified the hypermasculine attitudes BIP clients’ display as a barrier to promoting behavioral change. For example, when asked about barriers to intervention BIP clients, one participant described what she saw as the hypermasculine attitudes that perpetrators may bring to groups, “They have to keep that rough stuff. That ‘I’m the man. I have to be badder [sic] than you, you got to be badder [sic] than the next one, and he’s the badest [sic] guy on the block (22, WD).’” Another participant similarly stated, “The men bring that, ‘We’re men. We’re strong. We have to take charge’ mentality with them. Sensitive men are ‘gay’ or ‘not a real man.’ So for them to show vulnerability in group is a sign of weakness (6, WI).” Thus, some participants felt that hypermasculine attitudes had the potential to limit clients’ active participation in the BIP. One participant described what she had observed in a BIP in terms of clients’ inability to show vulnerability around other men, “A challenge for some is knowing that it’s okay to feel upset in group, you don’t always have to prove that you’re a man, some men can’t really like accept that” (26, WD). Thus, participants felt that clients’ who expressed these attitudes were often unwilling to admit they have a problem and ask for help. Another participant summarized,
Most of them do not feel at all ok about themselves and cannot admit that. It is hard to measure up to be a real man. Impossible. I can’t be human and be a real man. Because as a real man, I’m in charge. I’m always right. I’m never vulnerable. I don’t need help. (1, WD)

Emotional problems

Participants also described some of the underlying emotional problems that BIP clients exhibit as a barrier to engaging them in the group process. Some participants described what they saw as a deep-seated form of anger that BIP clients bring with them to such groups. One participant in describing why BIP clients are challenging to engage in intervention stated, “They’re angry. They have a lot of deep-seated anger. A lot of them are really angry” (31, WD). Others described what they saw as a kind of emotional detachment among men mandated to BIPs. Similarly, another participant stated, “Most of the guys that I see aren’t able to say how they feel. I think they are missing a lot on a fundamental level” (25, WI). Either way participants felt that such issues hindered clients’ ability to participate in the activities or other therapeutic approaches that BIPs use to promote emotional knowledge and awareness. One participant described her observations from a BIP group exercise on feelings where the clients could not identify any feeling other than anger, “. . . an exercise on feelings. There is probably 100 different feelings on that paper, most of the men, in their brain they are angry, they don’t think about frustration, confusion, or the many different feelings out there” (17, WD). Thus, participants felt that such underlying emotional issues presented a barrier in terms of engaging clients in some of the psycho-educational activities that make up part of the BIP process. Another participant described what she saw as the challenges of getting BIP clients to address their emotional issues within the context of a BIP:
A lot of them are not able to express themselves. So how to address that and get them to identify, ‘I’m upset right now’ and then, ‘Okay you’re upset, and it’s okay to be upset, it’s okay to be angry, but how do you express that without being violent?’ (20, WI)

History of exposure to violence

Participants also identified the previous exposure many BIP clients had to violence as children as barrier to effectively promoting behavioral change. Clients often arrive at BIPs having witnessed, or been the victim of, violence as children. One participant, therefore, when asked what challenges exist in terms of BIP clients’ ability to change, described the trauma she had observed among this population, “These guys, I mean they are coming with baggage, all the things from their childhood, they were abused themselves, all of that” (18, WD). Another participant made a similar observation about BIP clients, “Many have been physically, sexually, emotionally abused. Tortured by fathers, grandfathers, uncles. We don’t talk about the men in this country that have experienced abuse. That is a huge hidden problem that many of these men are carrying” (12, WI). Thus, participants felt that BIP clients often have their own unaddressed trauma from childhood experiences with violence that they brought to the groups, “One of the challenges is that most of these guys are coming in with—yes, they were the abusers—but most of them were abused themselves and they have never addressed that” (19, WI).

Participants recognized that while clients’ trauma was no excuse for perpetration behaviors, it nonetheless factored into their behavior. One participant emphasized the need to put BIP clients’ behaviors in this context to understand why some men might be resistant to behavioral change, “Looking at the men, very often they’ve had traumatic backgrounds too. It’s not excusing behavior but it’s putting it in a context” (4, WI). Participants felt, therefore, that BIP clients are often desensitized to abusive behavior and see their behavior as normal. Thus, because of this, it is hard to get clients in a BIP to see their behavior as abusive. As one participant stated, “As I stated before, a challenge is they grew up in it and they don’t know any different. That’s what is normal, so getting them to see it is not easy” (27, WD). Such normalization of violence presented a barrier, therefore, in terms of promoting self-awareness of abusive behaviors among clients in BIP groups. One participant similarly described the challenges BIPs face in working with their clients, “They think yelling at you is not abusing you. They really don’t get it. You’re trying to undo what they experienced in their home” (33, WI). Another participant similarly describing the challenges to working with clients in a BIP summarized:
One challenge is that is what dad did. The longer someone experiences that as part of his environment the more likely it is that he’s going to grow up to be an abuser. If they don’t work on that [trauma], and work on themselves, they really don’t get it. It is not an excuse. He is still accountable for what he does, but it is a challenge. (14, WI)

Mental health and substance abuse

Participants also recognized the ways in which mental health or substance abuse issues further complicated clients’ behavior and general engagement in the group. Participants felt that many BIP clients arrive at programs with untreated mental health or substance use issues. One participant described what he saw among clients court-mandated to a BIP, “A lot of the men are on drugs, have just so many issues like that, and mental health problems too that need treatment. So that’s a barrier” (26, WD). Again, though such issues were not viewed as an excuse for violence, participants nonetheless understood how they contributed to clients’ behaviors. Another participant described how drugs and alcohol fueled violent behavior among BIP clients, “I think you have a lot of un-medicated folks with you know depression or anxiety that come in that just are really easily tripped” (15, WD). Getting clients to see how those issues affected their behavior, therefore, was a challenge for BIPs. One participant described how such issues affected BIPs’ ability to get clients to understand and address their behaviors, “The other part is recognizing they have a drug or alcohol issue, and having them recognize how those things impact their ability to make wise decisions. That is a challenge” (14, WI). Furthermore, participants saw such issues as a challenge that impeded BIPs’ ability to engage their clients in the groups, “Sometimes you probably suspect that they are using drugs or have a mental health issue, but they’re not diagnosed and that can be difficult to engage them in group” (2, WD). Thus, participants who endorsed this theme sometimes felt that intervention is limited to the extent to which clients are able to address their comorbid mental health or substance use issues. Another participant in describing what she saw as a key challenge for BIPs and their ability to promote prosocial behavioral change among clients summarized, “At least 60-65% of the men probably have a dual-diagnosis. It would be ideal that they would deal with the mental health or substance use while they go to group, but most don’t see a need for it” (19, WI).

Denial, minimization, and blame

Finally, participants identified denial, minimization, and blame as a set of interrelated beliefs that created resistance among BIP clients toward the program. Denial, minimization, and blame among BIP clients are unsurprising and a generally expected response perpetrators have when entering a program. However, participants described the complexity of these beliefs and the difficulty they presented in terms of engaging BIP clients in the process. Participants recognized that BIP clients arrive at programs in varying degrees of denial. Some described the way in which BIP clients willfully display denial, “I think everything comes back to they refuse to think they did anything wrong. So that’s a challenge to trying to even get them to want to change their behavior” (28, WD). Others participants described how BIP clients might try to deny their behavior by reframing the narrative of their abuse as “something other than violence.” One participant explained using the example of how one client framed the incident that lead him to be court-mandated to a BIP group:
He said, ‘I don’t need to be here. I’ve never been in a physical fight,’ and I said, ‘You have been in one.’ So he said, ‘I stand corrected. You are right; I am here because of the one physical fight.’ To him that wasn’t violence, that was something else. He saw it as something in his relationship that was wrong. (7, WI)

Other participants described how BIP clients minimize or downplay their violence, “They minimize their behavior. There is a lot of minimizing that takes place from the perspective of the abuser. He only slapped her, or he was drunk and he doesn’t know how that happened” (8, WI). Still other participants described how clients in BIPs try to excuse their behavior by blaming the victim or external factors, “A lot of batterers will blame 50 other things for why they act the way they do. Most notably they will blame the victim” (25, WD).

Furthermore, participants saw denial, blame, and minimization as a challenge because these beliefs fostered resistance among BIP clients, and limited their “buy in” to the program. One participant described what they saw as how clients’ denial promoted resistance to the BIP:
Challenges for the men. The belief they did not do anything wrong. You know, the victim blaming, the “she hit me first.” They look at it as only one incident or minimize it. So the whole denial system is a barrier. You know, the belief they don’t need it [the BIP]. (24, WD)

Another participant similarly described the resistance to the BIPs she saw among clients, “I just think the system of denial is very complex and I just don’t see many of these guys saying ‘I want to change. I realize that this is not working well.’ I mean they really don’t see it” (9, WI). Such “denial systems,” therefore, presented a barrier in terms of getting clients “on board” with the program. It also, however, presented a challenge in terms of getting clients to take responsibility for their actions. One participant described overcoming resistance and achieving accountability within the short time frame BIPs have with clients was a barrier, “The biggest challenge is the constant minimizing, denying and blaming. I think it is challenging to work with that, and we have very limited time to get them to see how they are responsible for their behavior” (35, WI). Thus, participants saw denial, minimization, and blame as barrier to working with BIP clients, and in particular as a challenge in terms of how to achieve client “buy in” and promote accountability in the limited time programs have. Another participant summarized,
I think just to get the men to be accountable is the biggest challenge. When you go around the groups, the resistance, the ‘I didn’t do nothing,’ ‘She did this or she did that’ and all the excuses. Just getting them to that point where they can, in the time we have, understand that this is wrong, that is a challenge. (23, WD)

Discussion

In our ethnographic study of two BIPs, professionals who work directly with, or whose work brings them in close proximity to, BIPs and their clients reported a range of challenges related to working with male perpetrators of IPV, and how such challenges presented barriers to the BIP process. Participants described issues at the individual, interpersonal, and societal level that impeded clients’ ability to recognize and accept responsibility for their behaviors, engage in the BIP process and enact behavioral change. Understanding what barriers BIPs face in terms of intervention with clients is vital to improving intervention methods for working with clients, and ultimately identifying ways to maximize BIPs’ potential for promoting prosocial behavioral change among perpetrators.

We found that participants identified ways in which gender norms at both the interpersonal and societal level presented a barrier to behavioral change. Gender norms, and in particular, inequitable gender beliefs about women, have traditionally underscored etiological explanations of IPV; thus, why BIPs have favored feminist-psycho-educational models (Barner & Carney, 2011; Gondolf, 2015). However, research has demonstrated men’s perceptions of masculinity, and how other men perceive them, also play a role in their perpetration behaviors, their willingness to intervene as bystanders, and the resistance they show toward changing their behaviors (Carlson, 2008; Catlett, Toews, & Walilko, 2010; Neighbors et al., 2010). Likewise, our study found that masculinity scripts, or rather clients’ beliefs about how men “should act,” their desire to conform to masculinity gender scripts in front of their peers, both in and out of group, and to not appear “weak” or somehow “un-masculine” served ultimately to undermine progress. Thus, our study suggests that intervention approaches for men who perpetrate violence may need to include a “positive masculinity” framework (United Nations Population Fund, 2010) in addition to addressing inequitable gender beliefs about women to be more effective. Such “gender transformative” programming is not widespread in the United States. (Katz, 1995; Miller et al., 2012), nor is it clear from the research on BIPs how many groups may already incorporate such strategies into their programs. However, early research of prevention mechanisms utilizing such an approach with younger boys and men have shown promising results (Miller et al., 2013) and thus, an exploration of these approaches in BIPs should be supported.

We also found that exposure to violence as children was perceived as a barrier in terms of promoting self-awareness of abusive behaviors among BIP clients. There is strong support for the relationship between exposure to violence as a child and adult perpetration behaviors (Lee, Reese-Weber, & Kahn, 2014). There is also evidence to suggest that witnessing of violence and/or victimization as a child often leads to the desensitization and justification of violence in later adulthood (Wood & Sommers, 2011). Undoubtedly, trauma plays a role in both these processes (Taft, Schumm, Orazem, Meis, & Pinto, 2010; Wood & Sommers, 2011). Although evidence suggests that many male perpetrators of IPV may have been exposed to at least one traumatic event in their lives (Maguire et al., 2015), addressing trauma as a part of the BIP process remains a largely unexplored and somewhat contentious issue (Browne, Saunders, & Staecker, 1997; Saunders, 1996). In general, psychotherapeutic models are thought to be “not confrontational enough” for the BIP context, and as allowing perpetrators to excuse and rationalize their violence (Maiuro & Eberle, 2008). As such, these approaches are labeled as “inappropriate” by most state standards (Maiuro & Eberle, 2008). However, there is no empirical support in the literature yet for the efficacy of one treatment modality over another (Gelles, 2001; Maiuro & Eberle, 2008). There is also evidence that some BIP clients may actually benefit from more psychodynamic approaches (Saunders, 1996). Thus, it is perhaps premature to rule out any one particular kind of treatment. Either way, our study suggests that at the intervention level, working with individual clients who have trauma associated with childhood exposure to violence may be difficult in the BIP context and thus, finding safe ways to address and treat trauma may be vital to improving overall outcomes for BIPs and their clients.

Participants also reported a host of mental health issues that presented barriers to engaging clients in the BIP process. The relationships between substance abuse and other mental and emotional health issues and IPV perpetration is well-documented (Shorey, Febres, Brasfield, & Stuart, 2012; P. H. Smith, Homish, Leonard, & Cornelius, 2012). Others have shown as well that mental health issues, including substance abuse, are associated with risk of recidivism post-BIP, and poor outcomes for perpetrators (i.e., attrition) (Jewell & Wormith, 2010; Lila et al., 2014; Tollefson & Gross, 2006). Furthermore, Lila et al. (2014) have found that perpetrators with low pretreatment levels of impulsivity (a characteristic of many mental and emotional health disorders) have less risk of recidivism; thus, suggesting that perpetrators with a greater degree of such issues are again, less likely to make gains from the therapeutic experience. Despite the recognition that such issues contribute to IPV, there is very little exploration as to the efficacy of alternative approaches that combine and/or mandate concordant treatment for IPV and other mental health problems (Arias et al., 2013; Gondolf, 2009; Timko et al., 2012; Timko, Valenstein, Stuart, & Moos, 2015). Thus, it is unclear to what extent treating perpetrators for both IPV and other ongoing mental health issues would improve BIP outcomes. Nonetheless, our study highlights how mental health issues may impede clients’ ability to “work the process” or engage effectively in a BIP. More descriptive information on how mental health issues intersect with IPV intervention would help identify areas where BIPs may improve their strategies for working clients who are struggling with these issues, as well as establish “best practices” for treating clients experiencing both problems.

Perhaps unsurprisingly, we also found that participants reported denial, minimization, and blame as a key barrier to promoting change among BIP clients. These cognitive distortions are characteristic of IPV perpetration (Catlett et al., 2010; Lila, Herrero, & Gracia, 2008; Whitaker, 2014). However, our participants also identified complexity of denial, minimization, and blame behaviors, and the challenges that these distortions present in terms of promoting client “buy in” and accountability. Such a finding is especially salient given that a primary intervention goal for BIPs is the promotion of accountability for abusive behaviors among perpetrators (Maiuro & Eberle, 2008). The underlying theoretical perception is that perpetrators who own their behaviors are less likely to recidivate or re-assault (Adams & Cayouette, 2002; Pence & Paymar, 1993). However, the relationship between denial, minimization and blame, and recidivism is not well understood (Henning & Holdford, 2006; Lila et al., 2008). Furthermore, there is limited research on how BIPs’ overcome denial to achieve accountability with perpetrators (Catlett et al., 2010; Chovanec, 2012), or what practices (e.g., length of time for treatment, treatment modality; Muldoon & Gary, 2011) are best for overcoming resistance. Our study suggests that perpetrator “buy in” to programs is perhaps dependent on BIPs’ ability to overcoming resistance, something that may prove difficult and require more time than programs have with clients. To ensure better outcomes for BIPs, some consideration may need to be given to assessing clients’ level of denial, and to tailoring the number of sessions “prescribed” to clients on a case-by-case basis. Furthermore, research is needed to better understand how BIPs promote “buy in,” and what strategies might be most effective at minimizing resistance among clients.

Finally, the challenges presented here that BIPs face in working with clients are arguably not issues that can, nor should, be resolved by one agency alone. Thus, our study also suggests that efforts to promote an integrated and coordinated community response to reducing perpetration are needed (Aaron & Beaulaurier, 2017). And in particular, we need to seek ways to truly incorporate BIPs into the broader framework of community resources for IPV and utilize multiple strategies to reduce perpetration behaviors and improve BIPs clients’ ability to make changes. As others have argued, however, BIPs are often not considered in coordinated community responses to IPV despite recognition that reducing perpetration is integral to such approaches (Gover & Richards, 2017; Kelly & Westmarland, 2015). One study in particular, by Kelly and Westmarland (2015) in the United Kingdom, found that while in general BIPs are viewed as part of a coordinated community response to IPV, lingering suspicions toward BIP work, funding contentions, and policy obscure the visibility of BIPs and their role in holding perpetrators accountable. As such, BIPs are often viewed as “secondary activities” to women’s programs or other IPV work (Kelly & Westmarland, 2015). The work by Kelly and Westmarland (2015) is important in that it highlights the need to better integrate BIP work into coordinated community approaches to IPV to maximize the potential that BIPs have for reducing perpetration behaviors and more broadly inform the work that IPV advocates and others in the field do. Such coordinated approaches would also serve to help connect perpetrators with services to address the issues such as trauma, substance abuse, or mental health problems that may impede their ability to make prosocial behavioral changes.

Limitations

Our study was with only two BIP organizations, and did not include professionals who may work with perpetrators in individual or other settings (e.g., independent psychotherapy). Thus, it is unclear to what extent our findings are generalizable to all BIPs, or all practitioners who work with perpetrators. Furthermore, our study was conducted in a relatively small, urban area. Thus, to what extent these findings reflect the challenges and barriers faced by other BIPs in other regions or countries is unclear. However, we included many BIP experts and community stakeholders from other parts of the United States in discussions of our findings and noted that these external experts corroborated our findings. In addition, our study included a diverse group of community stakeholders, both individuals who work directly with, or whose work relies on BIPs regularly. This sampling strategy did not allow us to make comparisons between the professional domains of participants. Differences may exist in the thoughts and perspectives between those individuals who work as BIP experts/IPV victims’ advocates, as judicial and legal professionals, and as policy/human services professionals that we were not able to capture. Had we focused on one group (e.g., solely BIP facilitators) we may have generated different findings. However, we chose a heterogeneous sample purposely as we were interested in commonalities across these groups. Finally, our community-based BIPs served only adult male perpetrators. Other BIPs that serve diverse populations (e.g., LGBTQ, women) likely face a different constellation of challenges and barriers.

Conclusion

The challenges and barriers BIP encounter in working with perpetrators that impede their ability to promote behavioral change are complex. To improve the efficacy of BIPs, therefore, more attention needs to be given to how to address these issues within the BIP context, if possible. Moreover, however, more effort needs to be paid to facilitating a more coordinated community response to perpetration, one that includes combined or coordinated treatment for some of the comorbid psycho-social issues that perpetrators may be experiencing. Community judicial, mental health, human services, and other agencies that can help provide coordinated care and support BIPs in sustained, safe, and as effective as possible work will be vital to overcoming these challenges and reducing perpetration. Furthermore, more observational research is needed to highlight the challenges BIPs face in working clients that impede their process and ultimately, their ability to be effective.

Footnotes

Acknowledgments

The authors would like to thank the Pennsylvania Coalition against Domestic Violence and the Women’s Center and Shelter of Greater Pittsburgh for their support.

Author’s Note

Study conception and design was done by all authors; acquisition of data was done by Penelope Morrison; analysis and interpretation of data by Penelope Morrison and Judy Chang; title page with author information; drafting of manuscript were done by Penelope Morrison, Judy Chang, and Elizabeth Miller; and critical revision by all authors.

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: Support for this work was made possible by grant funding from the Pennsylvania Commission on Crime and Delinquency and, in part, under a grant with the Pennsylvania Department of Health. The Department specifically disclaims responsibility for any analyses, interpretations or conclusions.

Author Biographies

Penelope K. Morrison, PhD, MPH is an assistant professor of Biobehavioral Health at the Pennsylvania State University – New Kensington. Dr. Morrison has utilized her expertise in qualitative methods to broadly explore issues related to gender and sexuality, with a focus on improving health services for underserved, vulnerable populations of women and children. Her research domains include intimate partner violence, opioid dependency and pregnancy, and adolescent substance use and sexual and reproductive health risk-taking.

Lynn Hawker, PhD, is formerly of the Women’s Center and Shelter of Greater Pittsburgh. Dr. Hawker has over 20 years’ experience working with intimate partner violence as a women’s advocate. She has developed and led workshops on a variety of women’s issues, and continues to consult on intimate partner violence research.

Patricia A. Cluss, PhD, is the director of STANDING FIRM. Recently retired from her position as Associate Professor in the Department of Psychiatry at the University of Pittsburgh School of Medicine, she continues her professional work as a licensed psychologist and consultant for several regional nonprofit and health-related organizations. She is also an expert member of the Allegheny County District Attorney’s Intimate Partner Violence Homicide Review Team and a consultant for a PA Commission on Crime and Delinquency-funded research project at the University of Pittsburgh that is describing the methodology and impact of batterer intervention programs in the region.

Elizabeth P. Miller, MD, PhD, is chief of Adolescent Medicine at Children’s Hospital of Pittsburgh of UPMC, and Associate Professor of Pediatrics at the University of Pittsburgh School of Medicine. Dr. Miller’s research has included examination of sex trafficking among adolescents in Asia, teen dating abuse, and reproductive health, with a focus on underserved youth populations including pregnant and parenting teens; and foster, homeless, and gang-affiliated youth. Her current research focuses on the impact of gender-based violence on young women’s reproductive health.

Rhonda Fleming, MSOL, is the Education & MEN/S Program Director at Women’s Center & Shelter of Greater Pittsburgh. Ms. Fleming has 20+ years of experience training others both nationally and internationally in the area of intimate partner violence. Her expertise includes identifying warning signs of abuse, safety planning, teen dating violence, effects on children and understanding the batterer’s perspective.

Terry Bicehouse, BA, is formerly of the Women’s Center & Shelter of Greater Pittsburgh. Mr. Bicehouse has over 35 years of experience working with men who batter, both through private practice and as a batterer intervention program facilitator. He continues to share his expertise though training and consultations related to intimate partner violence.

Donna George, MS, is an AOD Program Director at California University of Pennsylvania. Ms. George has over 20 years of experience as an advocate and facilitator, working with both men and women in the area of intimate partner violence.

Jessica Burke, PhD, is an associate professor and associate chair of Behavioral and Community Health Sciences, at the Graduate School of Public Health, University of Pittsburgh. Dr. Burke’s work aims to improve the health and wellbeing of women and children by addressing complex community health issues including intimate partner violence, HIV/AIDS and racial disparities in birth outcomes.

Kalem Wright, MSW, LCSW, is a clinical social worker and therapist. Mr. Wright specializes in intimate partner violence, trauma, mood disorders, grief and loss, and relationships. He also has expertise and extensive experience as a batterer intervention program facilitator.

Judy C. Chang, MD, MPH, is an associate professor in the Department of Obstetrics, Gynecology & Reproductive Sciences, Department of Medicine, University of Pittsburgh. Dr. Chang’s work has been primarily focused on violence against women, specifically on issues regarding health care screening and interventions for intimate partner violence. She has participated in multiple collaborative groups exploring various topics in women’s health services and outcomes, and is currently expanding her research to examine patient-provider communication in women’s health and obstetrics/gynecology.

References

Aaron

S. M.

Beaulaurier

R. L.

(2017). The need for new emphasis on batterers intervention programs. Trauma, Violence, & Abuse, 18, 425-432. doi:10.1177/1524838015622440

Adams

Cayouette

(2002). Emerge—A group education model for abusers. In Aldarondo

Mederos

(Eds.), Programs for men who batter: Intervention and prevention strategies in a diverse society, (pp. 4.1-4.32). New York: Civic Research Inc.

Aldarondo

(2012). Evaluating the efficacy of interventions with men who batter. Family & Intimate Partner Violence Quarterly, 4, 246-266.

Arias

Arce

Vilariño

(2013). Batterer intervention programmes: A meta-analytic review of effectiveness. Psychosocial Intervention, 22, 153-160.

Barner

J. R.

Carney

M. M.

(2011). Interventions for intimate partner violence: A historical review. Journal of Family Violence, 26, 235-244.

Black

M. C.

Basile

K. C.

Breiding

M. J.

Smith

S. G.

Walters

M. L.

Merrick

M. T.

. . . Stevens

M. R.

(2011). The National intimate partner and sexual violence survey. Atlanta, GA: Centers for Disease Control and Prevention.

Boira

del Castillo

M. F.

Carbajosa

Marcuello

(2013). Context of treatment and therapeutic alliance: Critical factors in court-mandated batterer intervention programs. The Spanish Journal of Psychology, 16, E4, 1 -13.

Bonomi

A. E.

Anderson

M. L.

Rivara

F. P.

Thompson

R. S.

(2009). Health care utilization and costs associated with physical and nonphysical-only intimate partner violence. Health Services Research, 44, 1052-1067.

Boots

D. P.

Wareham

Bartula

Canas

(2016). A comparison of the batterer intervention and prevention program with alternative court dispositions on 12-month recidivism. Violence Against Women, 22, 1134-1157.

10.

Browne

Saunders

Staecker

(1997). Process-psychodynamic groups for men who batter: A brief treatment model. Families in Society: The Journal of Contemporary Social Services, 78, 265-271.

11.

Carlson

(2008). I’d rather go along and be considered a man: Masculinity and bystander intervention. The Journal of Men’s Studies, 16, 3-17.

12.

Carter

L. S.

(2010). Batterer intervention: Doing the work and measuring the progress—A report on the December 2009 experts roundtable. Washington, D.C.: Family Violence Prevention Fund & National Institute of Justice.

13.

Catalano

(2012). Intimate partner violence, 1993–2010. Washington, D.C.: Office of Justice Programs.

14.

Catlett

B. S.

Toews

M. L.

Walilko

(2010). Men’s gendered constructions of intimate partner violence as predictors of court-mandated batterer treatment drop out. American Journal of Community Psychology, 45, 107-123.

15.

Centers for Disease Control and Prevention. (2003). Costs of intimate partner violence against women in the United States. Atlanta, GA: Author.

16.

Centers for Disease Control and Prevention. (2011). National intimate partner and sexual violence survey: 2010 summary report. Atlanta, GA: Author.

17.

Chovanec

M. G.

(2012). Examining engagement of men in a domestic abuse program from three perspectives: An exploratory multimethod study. Social Work with Groups, 35, 362-378.

18.

Crabtree

B. F.

Miller

W. L.

(1999). Doing qualitative research. Sage.

19.

Eckhardt

C. I.

Murphy

C. M.

Whitaker

D. J.

Sprunger

Dykstra

Woodard

(2013). The effectiveness of intervention programs for perpetrators and victims of intimate partner violence. Partner Abuse, 4, 196-231.

20.

Garcia-Moreno

Watts

(2011). Violence against women: An urgent public health priority. Bulletin of the World Health Organization, 89(1), Article 2.

21.

Gelles

R. J.

(2001). Standards for programs for men who batter? Not yet. Journal of Aggression, Maltreatment & Trauma, 5(2), 11-20.

22.

Gondolf

E. W.

(2009). Outcomes from referring batterer program participants to mental health treatment. Journal of Family Violence, 24, 577-588.

23.

Gondolf

E. W.

(2015). Gender-based perspectives on batterer programs: Program leaders on history, approach, research, and development. Lanham, New York: Lexington Books.

24.

Gover

Richards

(2017). A review of state standards for batterer intervention treatment programs and the Colorado model. Court Review, 53, 36-41.

25.

Gray

Broady

Gaffney

Lewis

Mokany

O’Neill

(2016). “I’m working towards getting back together”: Client accounts of motivation related to relationship status in men’s behaviour change programmes in New South Wales, Australia. Child Abuse Review, 25, 171-182.

26.

Gray

Lewis

Mokany

O’Neill

(2014). Peer discussion and client motivation in men’s domestic violence programs: An Australian qualitative interview study. Australian Social Work, 67, 390-404.

27.

Haggård

Freij

Danielsson

Wenander

Långström

(2017). Effectiveness of the IDAP treatment program for male perpetrators of intimate partner violence: A controlled study of criminal recidivism. Journal of Interpersonal Violence, 32, 1027-1043.

28.

Henning

Holdford

(2006). Minimization, denial, and victim blaming by batterers: How much does the truth matter? Criminal Justice and Behavior, 33, 110-130.

29.

Herman

Rotunda

Williamson

Vodanovich

(2014). Outcomes from a Duluth model batterer intervention program at completion and long term follow-up. Journal of Offender Rehabilitation, 53, 1-18.

30.

Holtrop

Scott

J. C.

Parra-Cardona

J. R.

Smith

S. M.

Schmittel

Larance

L. Y.

(2017). Exploring factors that contribute to positive change in a diverse, group-based male batterer intervention program: Using qualitative data to inform implementation and adaptation efforts. Journal of Interpersonal Violence, 32, 1267-1290.

31.

Jewell

L. M.

Wormith

J. S.

(2010). Variables associated with attrition from domestic violence treatment programs targeting male batterers: A meta-analysis. Criminal Justice and Behavior, 37, 1086-1113.

32.

Jewkes

(2002). Intimate partner violence: Causes and prevention. The Lancet, 359, 1423-1429.

33.

Katz

(1995). Reconstructing masculinity in the locker room: The mentors in violence prevention project. Harvard Educational Review, 65, 163-175.

34.

Kelly

Westmarland

(2015). Domestic violence perpetrator programmes: Steps towards change: Project Mirabal final report. London and Durham: London Metropolitan University and Durham University.

35.

Lee

Reese-Weber

Kahn

J. H.

(2014). Exposure to family violence and attachment styles as predictors of dating violence perpetration among men and women: A mediational model. Journal of Interpersonal Violence, 29, 20-43. doi:10.1177/0886260513504644

36.

Lila

Herrero

Gracia

(2008). Evaluating attribution of responsibility and minimization by male batterers: Implications for batterer programs. The Open Criminology Journal, 1, 4-11.

37.

Lila

Oliver

Catalá-Miñana

Conchell

(2014). Recidivism risk reduction assessment in batterer intervention programs: A key indicator for program efficacy evaluation. Psychosocial Intervention, 23, 217-223.

38.

Maguire

Macdonald

Krill

Holowka

D. W.

Marx

B. P.

Woodward

. . . Taft

C. T.

(2015). Examining trauma and posttraumatic stress disorder symptoms in court-mandated intimate partner violence perpetrators. Psychological Trauma: Theory, Research, Practice, and Policy, 7, 473-478.

39.

Maiuro

R. D.

Eberle

J. A.

(2008). State standards for domestic violence perpetrator treatment: Current status, trends, and recommendations. Violence & Victims, 23, 133-155.

40.

Mederos

(1999). Batterer intervention programs: The past and future prospects. In Shepard

M.F.

Pence

E.L.

(Eds.), Coordinating community responses to domestic violence: Lessons from Duluth and beyond, (pp. 127-150). London: Sage.

41.

Miller

Tancredi

D. J.

McCauley

H. L.

Decker

M. R.

Virata

M. C. D.

Anderson

H. A.

. . . Silverman

J. G.

(2012). “Coaching boys into men”: A cluster-randomized controlled trial of a dating violence prevention program. Journal of Adolescent Health, 51, 431-438.

42.

Miller

Tancredi

D. J.

McCauley

H. L.

Decker

M. R.

Virata

M. C. D.

Anderson

H. A.

. . . Silverman

J. G.

(2013). One-year follow-up of a coach-delivered dating violence prevention program: A cluster randomized controlled trial. American Journal of Preventive Medicine, 45, 108-112.

43.

Mills

L. G.

Barocas

Ariel

(2012). The next generation of court-mandated domestic violence treatment: A comparison study of batterer intervention and restorative justice programs. Journal of Experimental Criminology, 9, 65-90. doi:10.1007/s11292-012-9164-x

44.

Morrison

P. K.

Cluss

P. A.

Miller

E. P.

Fleming

Hawker

Bicehouse

. . . Chang

J. C.

(2017). Elements needed for quality batterer intervention programs: Perspectives of professionals who deal with intimate partner violence. Journal of Family Violence, 32, 481-491.

45.

Morrison

P. K.

Hawker

Miller

Cluss

P. A.

George

Fleming

. . . Chang

J. C.

(2016). The operational challenges for batterer intervention programs: Results from a 2-year study. Journal of Interpersonal Violence, 1 - 23 doi:10.1177/0886260516662307

46.

Muhr

(2004). Atlas.ti: The knowledge workbench: V5.0 user’s guide and reference. Scientific Software Development. Berlin: Atlas.ti.

47.

Muldoon

Gary

(2011). Enhancing treatment compliance among male batterers: Motivators to get them in the door and keep them in the room. Journal of Mental Health Counseling, 33, 144-160.

48.

Murphy

C. M.

Ting

L. A.

(2010). Interventions for perpetrators of intimate partner violence: A review of efficacy research and recent trends. Partner Abuse, 1, 26-44.

49.

Neighbors

Walker

D. D.

Mbilinyi

L. F.

O’Rourke

Edleson

J. L.

Zegree

Roffman

R. A.

(2010). Normative misperceptions of abuse among perpetrators of intimate partner violence. Violence Against Women, 16, 370-386.

50.

Patton

M. Q.

(1990). Qualitative evaluation and research methods. Sage.

51.

Parra-Cardona

J. R.

Escobar-Chew

A. R.

Holtrop

Carpenter

Guzmán

Hernández

. . . González Ramírez

(2013). “En el grupo tomas conciencia (in group you become aware)”: Latino immigrants’ satisfaction with a culturally informed intervention for men who batter. Violence Against Women, 19, 107-132.

52.

Pence

Paymar

(1993). Education groups for men who batter: The Duluth model. New York, NY: Springer.

53.

Price

B. J.

Rosenbaum

(2009). Batterer intervention programs: A report from the field. Violence & Victims, 24, 757-770.

54.

Reed

(2008). Intimate partner violence: A gender-based issue? American Journal of Public Health, 98, 197-198.

55.

Saunders

(1996). Feminist-cognitive-behavioral and process-psychodynamic treatments for men who batter: Interaction of abuser traits and treatment models. Violence & Victims, 11, 393-414.

56.

Saunders

(2008). Group interventions for men who batter: A summary of program descriptions and research. Violence & Victims, 23, 156-172.

57.

Shamai

Buchbinder

(2010). Control of the self: Partner-violent men’s experience of therapy. Journal of Interpersonal Violence, 25, 1338-1362.

58.

Sheehan

K. A.

Thakor

Stewart

D. E.

(2012). Turning points for perpetrators of intimate partner violence. Trauma, Violence, & Abuse, 13(1), 30-40.

59.

Shorey

R. C.

Febres

Brasfield

Stuart

G. L.

(2012). The prevalence of mental health problems in men arrested for domestic violence. Journal of Family Violence, 27, 741-748.

60.

Singh

Tolman

Walton

Chermack

Cunningham

(2014). Characteristics of men who perpetrate intimate partner violence. Journal of the American Board of Family Medicine, 27, 661-668.

61.

Smith

M. E.

(2011). A qualitative review of perception of change for male perpetrators of domestic abuse following Abuser Schema Therapy (AST). Counselling and Psychotherapy Research, 11, 156-164.

62.

Smith

P. H.

Homish

G. G.

Leonard

K. E.

Cornelius

J. R.

(2012). Intimate partner violence and specific substance use disorders: Findings from the national epidemiologic survey on alcohol and related conditions. Psychology of Addictive Behaviors, 26, 236-245.

63.

Stöckl

Devries

Rotstein

Abrahams

Campbell

Watts

Moreno

C. G.

(2013). The global prevalence of intimate partner homicide: A systematic review. The Lancet, 382, 859-865.

64.

Stuart

G. L.

Temple

J. R.

Moore

T. M.

(2007). Improving batterer intervention programs through theory-based research. Journal of the American Medical Association, 298, 560-562.

65.

Sugg

(2015). Intimate partner violence: Prevalence, health consequences, and intervention. Medical Clinics of North America, 99, 629-649.

66.

Taft

C. T.

Schumm

Orazem

R. J.

Meis

Pinto

L. A.

(2010). Examining the link between posttraumatic stress disorder symptoms and dating aggression perpetration. Violence & Victims, 25, 456-469.

67.

Timko

Valenstein

Lin

P. Y.

Moos

R. H.

Stuart

G. L.

Cronkite

R. C.

(2012). Addressing substance abuse and violence in substance use disorder treatment and batterer intervention programs. Substance Abuse Treatment, Prevention, and Policy, 7(1), Article 37.

68.

Timko

Valenstein

Stuart

G. L.

Moos

R. H.

(2015). Substance abuse and batterer programmes in California, USA: Factors associated with treatment outcomes. Health & Social Care in the Community, 23, 642-653.

69.

Tollefson

D. R.

Gross

E. R.

(2006). Predicting recidivism following participation in a treatment program for batterers. Journal of Social Service Research, 32(4), 39-62.

70.

United Nations Population Fund. (2010). Engaging men and boys in gender equality and health: A global toolkit for action. New York, NY: Promundo.

71.

Whitaker

M. P.

(2014). Motivational attributions about intimate partner violence among male and female perpetrators. Journal of Interpersonal Violence, 29, 517-535. doi:10.1177/0886260513505211

72.

Wood

S. L.

Sommers

M. S.

(2011). Consequences of intimate partner violence on child witnesses: A systematic review of the literature. Journal of Child and Adolescent Psychiatric Nursing, 24, 223-236.