Client Beliefs About a Multicouple Group Service for Intimate Partner Violence

Abstract

Despite the ongoing debate about intervention best practices for intimate partner violence (IPV), few researchers have elicited the perspectives of clients themselves about what interventions most effectively decrease violence and increase safety. Using qualitative narrative analysis methodology, the researchers conducted 48 client participant interviews and 5 staff interviews to better understand couples’ perspectives of a multicouple conjoint treatment program for IPV. Several recurring themes included (a) group purpose and general service characteristics, (b) motivation for participation, (c) comparison with other services, (d) benefits of, (e) disadvantages of, and (f) suggestions for Couples Achieving Relationship Enrichment. Important research implications for community intervention are discussed.

Keywords

conjoint couples therapy intervention intimate partner violence multicouple group service

The rising acceptance of violence-focused conjoint couples therapy occurs amid ongoing concern about its danger and appropriateness (Bograd, 1992; Bograd & Mederos, 1999; Goldner, Penn, Sheinberg, & Walker, 1990; Harris, 2006; La Taillade, Epstein, & Werlinich, 2006; Stith, Rosen, McCollum, & Thomsen, 2004). A small body of evidence suggests that, under certain circumstances, conjoint couples therapy for intimate partner violence (IPV) can be safe and effective and is often preferred by couples (McCollum & Stith, 2008; Stith et al., 2004; Todahl, Linville, Tuttle Shamblin, Ball, & Skurtu, 2013). A study comparing violence-focused multicouple group treatment with gender-specific treatment found similar outcomes across conditions: Both groups reported lower rates of psychological and physical aggression. Female participants in the multicouple condition did not report higher rates of fear during sessions, did not disproportionately assume blame for the violence, and did not report being put at increased risk during their participation (O’Leary, Heyman, & Neidig, 1999). Participants in a qualitative study that examined experiences with a conjoint treatment program for domestic violence reported similar experiences about the service (Todahl et al., 2013). A quasi-experimental investigation of Domestic Violence-Focused Couples Treatment (DVFCT), also a multicouple intervention, determined that physical violence rates were significantly lower at 6-month follow-up for the multicouple group (25%) than for the individual couple therapy comparison group (66%; Stith et al., 2004). Finally, a random assignment behavioral couples therapy (BCT) intervention that centered around substance abuse reduction concluded that intimate partner physical violence was significantly less likely 12 months following services in the BCT condition relative to an individual treatment control (Fals-Stewart, Kashdan, O’Farrell, & Birchler, 2002; O’Farrell, Fals-Stewart, Murphy, Stephan, & Murphy, 2004).

Only four groups of peer-reviewed experimental studies investigating the efficacy and safety of conjoint couples therapy have been published (McCollum & Stith, 2008), and only two qualitative studies have explored participants’ overall attitudes and perceptions of violence-focused conjoint couples therapy (Allen & St. George, 2001; Todahl et al., 2013). Based on their summary of existing empirical research, Stith and McCollum (2009) concluded that couples-based interventions are at least as effective in reducing violence as controls and “in none of the studies was there any evidence that a dyadic intervention increased danger to either partner” (p. 238). Moreover, Johnson (2008) contended that conventional batterer intervention (BI) programs are ineffective for the majority of individuals who use violence, given the argument that most IPV behavior is situational, mutual (bilateral), intermittent, mild to moderate, and not likely to occur in the context of a coercive or fear-based relationship. Therefore, several researchers have suggested that individuals who meet these criteria may be best served in conjoint formats that thoroughly screen clients, directly address the violence, and build in regular safety monitoring (Hamel, 2008; Stith et al., 2004).

Violence-focused conjoint couples therapy intervention models, although somewhat varied (e.g., solution-focused vs. cognitive-behavioral strategies; individual vs. group formats), tend to include (a) violence screening and inclusion/exclusion criteria, (b) treatment goals that directly address ending all forms of violence, (c) a gender-specific program component prior to conjoint work, (d) safety planning, (e) ongoing monitoring of violence levels throughout the program, (f) psychoeducation, and (g) coordination with local services (Stith & McCollum, 2009). Moreover, established models tend to manage risk by (a) ensuring that providers are very familiar with their community’s coordinated response to interpersonal violence, (b) using an assessment and screening protocol that includes individual interviews, (c) using safety-based inclusion and exclusion criteria, (d) giving explicit attention to violence reduction strategies, and (e) assessing and planning for safety throughout the course of services.

Emerging data suggest that violence-focused conjoint couples therapy can be safe and effective with certain populations; however, client descriptions about the service itself are not adequately represented in the literature. Specifically, what do clients experience as useful or unhelpful about violence-focused conjoint couples therapy? As couples-based interventions gain acceptance, there is an important need to better understand which elements of the service are particularly beneficial and which are benign or even harmful. Clients who participate in these emerging treatment approaches offer important insights regarding the elements of the model that they find useful, their perceptions of change, and the factors that led to changes that may have occurred. Stith, Rosen, and McCollum (2003) urged the use of qualitative methodologies to examine these questions:

Little is known about how women experience domestic violence-focused couples therapy. It is important to know what conditions help them feel safe to participate fully in couples sessions and what conditions lead them to hold back. In addition, philosophical concerns must mesh with empirical ones. If couples treatment decreases violence and improves relationships but leaves women feeling more to blame and in danger, it would clearly be a mistake to judge such a treatment successful. Qualitative methods can certainly make a contribution in understanding women’s experience. (p. 421)

Given the need to better understand client beliefs about violence-focused conjoint couples therapy, this study investigated participants’ ideas about the most and least useful aspects of violence-focused couples therapy. Adult male and female clients participating in a multicouple group domestic violence program at an agency in the Pacific Northwest were interviewed individually about their experiences with this organization and its services. Researchers asked participants about the characteristics of the service, their motivation for participation in Couples Achieving Relationship Enrichment (CARE), a comparison of CARE with other BI and counseling services, the advantages and disadvantages of multicouple group work, and their recommendations for CARE services. The researchers focused on the following guiding research question: How do male and female clients in a violence-focused multicouple group feel and think about the service, especially with regard to (a) the general characteristics of the service, (b) what is and is not useful about conjoint couples therapy for IPV, (c) how it compares with other violence-focused services, and (d) participants’ recommendations for such services?

Method

Research Design

Narrative qualitative research methods and inquiry (Connelly & Clandinin, 1990; Creswell, 2002; Polkinghorne, 1988; Riessman, 2007) were used to explore the overall meanings and subjective experiences of individuals who had participated in a multicouple group treatment for domestic violence. We used narrative methods to collect data for the purpose of research through storytelling and our approach was discovery-oriented (Connelly & Clandinin, 1990). In keeping with the goal of narrative methods, we aimed to generate stories from the individual narratives (Bingley, Thomas, Brown, Reeve, & Payne, 2008), viewing participants as coresearchers and experts on their subjective experiences with conjoint treatment for domestic violence. Of interest with narrative inquiry is not what happened, but what meaning did participants derive of what happened. Narrative methods were particularly relevant for this study because we wanted to better understand participants’ meaning-making around the usefulness of conjoint services for domestic violence. In addition, narrative methods were appropriate given the highly personal and sensitive nature of the subject matter.

Site-Specific Information

This study occurred in the context of Christians as Family Advocates (CAFA), a not-for-profit, faith-based counseling agency that also provides state-approved BI services. Providing BI services since 2001, CAFA employs 15 therapists, most with master’s-level social work and family therapy training, and serves approximately 360 clients in the BI program at any given time. Male batterers are referred to the agency by county probation and parole officers. Client motivation for participation in CAFA, at least in part, is related to state law that prohibits offenders from seeing their partners for 1 or more years (e.g., 2 or more years if convicted of a felony) after the incident occurred. The program was created in response to females who wanted to reunite with their partners prior to the judge-imposed separation period and without the threat of legal prosecution.

Following attendance at a multicouple domestic violence-focused training provided by Sandra Stith and Eric McCollum in 2005, CAFA’s Executive Director decided to implement a similar model. In the program dubbed “CARE”, couples meet in a multicouple open-group format. A rotating, 10-week, solution-focused curriculum emphasizes self-awareness, self-soothing and emotion regulation, attachment theory, interpersonal processes, the process of “outgrowing power and control,” brain anatomy and physiology, and self-mastery. Approximately 80% of male CARE participants had been mandated to a 52-week BI program; these individuals are disallowed contact with their partner. CARE is not a replacement for BI, nor does CARE participation count toward the 52-week BI attendance requirement. For those individuals who freely wish to reunite, CARE participation is a prerequisite for reunification. Conjoint couples therapy, provided concurrently with BI, is disallowed in the state, though it has been approved to occur at this organization on a monitored trial basis.

To participate in CARE, female participants voluntarily initiate contact with the organization. A CARE intake coordinator then meets individually with the prospective female client and collaborates directly with the probation or parole officer to evaluate eligibility and to conduct a safety assessment. Although CARE participation is fully voluntary for female clients, prior to CARE participation, females are required to attend a 6-week female-only support and education group led by CARE staff. This extends the safety assessment, creates a supportive relationship with CARE staff, and assists the female in determining whether she wants to pursue CARE participation. CARE female participants are included in the service only on a voluntary basis and only if they express a desire to reunite or to consider reunification with their partner. Male CARE participants are typically not screened in or out due to the nature of their violent behavior (e.g., mild, moderate, severe) or legal status (e.g., mandatory vs. nonmandatory BI involvement); inclusion and exclusion criteria center on an assessment of (a) the BI participant’s ability to accept influence, and (b) the woman’s sense of safety. Approximately 60% of male CARE clients are unemployed, 95% have received at least one no-contact order, and their violent behavior ranges from severe (e.g., threats with a gun directed at partner and/or self, physical injury leading to hospitalization) to relatively mild physical violence (e.g., pushing that did not lead to injury).

Although CARE participation involves staff and client input, the ultimate decision for CARE participation is made by the probation or parole officer. The probation or parole officer, in collaboration with CARE staff, works directly to establish and review individually tailored safety plans. On average, the safety plan is reviewed on four separate occasions with each individual while involved in CARE. CARE staff and probation and parole officers are in “very frequent contact”; the relationship between CARE, probation and parole, and CARE clients is “transparent,” and probation and parole is “supportive, including collaborative decision-making” (Carolyn Rexius, personal communication, August 22, 2010).

Prior to each multicouple group, a therapist meets individually with each party to assess safety and goal-based progress. When information collected during the safety assessment indicates it is unsafe to meet conjointly (e.g., a female partner expresses fear of retribution), each member of the couple meets individually with a therapist. These meetings focus specifically on safety planning and motivational readiness. On average, couples attend 14 to 16 CARE meetings. Each meeting is 90-min long. CARE participants generally attend one meeting each week. Completion of CARE occurs in collaboration with CARE staff, clients, and probation and parole officers and is evaluated per predetermined goals and objectives.

The first author of this study has worked collaboratively with the agency’s Executive Director on several local domestic violence-related committees and projects, and the agency has served as an internship placement for family therapy graduate students. The fourth author participated in a 1-year internship with the agency; she did not interview any of her clients for the purpose of this study. None of the authors is otherwise affiliated with the CARE program and its agency.

Participants

Participants were recruited among individuals presently receiving CARE services. A study brochure was distributed and an oral invitation was given during a CARE multicouple meeting by the lead therapist at four different time points across a 28-month period. Clients who expressed an interest in the study anonymously provided their names to a CARE staff member who was subsequently contacted by a researcher. Study participants represent approximately 51% of all eligible clients during the study recruitment period. The researchers also interviewed five CARE staff to better understand CARE philosophy, objectives, and provider attitudes.

Confidentiality and Consent

This study received approval from the Institutional Review Board. In addition, participants were informed that a Certificate of Confidentiality (COC) had been acquired through the National Institutes of Health. Although limits to confidentially (e.g., child abuse, duty to warn) remained and were disclosed to all participants, the COC assured participants that “the researchers cannot be forced to disclose information that may identify you, even by court subpoena, in any federal, state or local civil, criminal, administrative, legislative, or other proceedings.” Participants were also informed that information provided to the interviewer by one member of the couple would not be shared with the other member of the couple. Participants were also assured that their personal information would not be shared with CARE staff. Prior to and following each interview, researchers asked all participants whether they were concerned about their safety or their ability to behave in a safe manner at that time.

Data Collection Procedures

The researchers conducted a total of 53 participant semistructured interviews, 42 of which were first interviews with clients; 6 were member-checking interviews and 5 were interviews with CARE staff. CARE staff members were interviewed solely for the purpose of understanding the CARE context and conjoint multicouple service. Researchers experienced in entering into conversations with individuals who had experienced domestic violence conducted interviews at the treatment facility in confidential rooms. As Mishler (1999) suggested, the interviews were co-constructed and involved dialogue. All interviews were audio-recorded and transcribed verbatim; they served as an ideal data collection method for understanding insider perspectives on conjoint couples treatment for domestic violence. All interviews were with individuals and ranged between 45 min and 90 min. Participants’ views about the impact of participation in CARE (i.e., personal and interpersonal changes), drawn from this same data set, have been reported elsewhere (Todahl et al., 2013). Table 1 lists the initial and follow-up member-checking interview questions for this study.

Table 1.

Questions: Initial and Follow-Up Member Checking.

Initial questions

Please briefly describe the CARE group and your participation.

What is most useful about your participation in the CARE group?

What is least useful about your participation in the CARE group?

Have you been involved in counseling or a group like CARE before? If so, was there anything particularly unique about CARE?

What do you believe CARE can do to improve its usefulness?

Member-checking example

Participants were read a narrative summary of each of the main narrative themes (e.g., attitudinal change). Following each summary, participants were asked:

Is this consistent with your overall observation?

Please explain briefly.

Note. CARE = Couples Achieving Relationship Enrichment.

Narrative Analysis

Three interpreters coded for themes across the narratives that demonstrated the complexity of the stories and gave insight into the meanings and actions of the participants. The interpreters engaged in a reciprocal process in which they coded independently and then came together to discuss and gain consensus on the emerging codes and themes. They then organized the codes into a sequence that emphasized the key events and meanings. The interpreters aimed to establish the trustworthiness of the study by including multiple coders and consensual qualitative research procedures, member checking, and by detailing an audit trail throughout the study. The interpreters analyzed using the following process. First, all of the interpreters became immersed in the data by reading all of the transcripts. Second, the interpreters used five interview transcripts to identify major themes across the narratives. Then interpreters confirmed each of these major themes by reading and jotting notes in the margins of the 2 to 3 transcripts. Interpreters would ask the following question: “Do any of the themes need to be renamed, condensed, eliminated or added?” Next, the interpreters met to discuss major themes; interview transcripts were split in half so that two interpreters could identify material/exemplars related to each theme to create a set of narratives. To create an audit trail, researchers labeled each illustrative quote with the following information: a transcript code, the line of the transcript, the gender of the participant, and the role of the participant in the violence (perpetrator, survivor or both). At this point, we identified and summarized each narrative and then integrated the storylines to create a summative narrative. To ensure trustworthiness of the narratives, we conducted six member-checking phone interviews. The researchers read the summative narratives to the six participants and asked if they made sense to them and to explain what fit and did not fit with their experiences. Through this member-checking process, participants confirmed that the integrated narrative made sense to them and captured the true essence of their experiences.

Results

The researchers identified several themes related to participants’ views of CARE services. They included (a) group purpose and general service characteristics, (b) motivation for participation, (c) comparison with other services, (d) benefits of CARE, (e) disadvantages of CARE, and (f) suggestions for CARE. These themes recurred throughout the narratives, suggesting similar experiences across couples.

Theme 1: Group Purpose and General Service Characteristics

Many participants expressed that group involvement was for the purpose of reunifying couples who have had IPV in their relationship, especially when there is some associated level of legal involvement. Some participants shared that, without group participation, couples could not legally have contact with one another. It was also indicated throughout the research findings that prior approval by probation officers was a necessary component before starting group participation and beginning the reunification process. When describing the purpose of the group, a female participant said,

CARE group is a couples’ group. I know it’s mainly for people who have had domestic violence situations who have been separated and they have no-contact orders, and this allows them to go through a safety plan so that they can receive contact again with the children and the spouse.

In addition, a male participant emphasized that, for him, one key purpose of the group is to facilitate reunification with his partner:

It’s been a transitional stage. This is what they call the reunification process, and this was just one piece of it. It’s channeled through the probation office, and she ultimately has the final decision. CAFA has tremendous input in that decision-making process, but ultimately, it is the probation officer. We had no contact whatsoever for a couple of months.

The most common group characteristics discussed by participants seemed to focus on the group as a positive, helpful tool for reunifying couples and for providing couples with new skills to better manage difficult situations or conflict within their relationships. When asked about some of the most important details of the group, many participants noted that the group leader was a significant and positive component of group participation. The group leader was described by participants as knowledgeable, informative, and willing to use her life experiences to help group participants learn. One female participant stated that the group leader “is wonderful because she is schooled in the dynamics of marriage. She offers information on different structures [of relationships] . . . how it works, and where conflicts might arise.” In addition, nearly all participants discussed at length the importance of how they were treated by CARE staff; for example, one male participant said,

They recognize who you are. They say your name. They’re all personable. Even people that I know have had a really rough, rough time and have ended up in prison—they’re all treated with respect. The program is about, as far as what I can see, respect; learning to respect and care for yourself and respecting and caring for others. You don’t find that very often in one place. So, it’s been real positive. It’s been a good thing.

Participants also consistently reported that the group setting was a supportive place for couples to learn new relationship skills. A female participant stated, “It’s letting you take responsibility for yourself. They’re giving you the tools to be able to get out of that area of your life.” Many participants shared that the group offers teaching points for couples to consider, along with a supportive environment so that couples are able to apply new knowledge to their relationship. In a previous report drawn from this same data set, participants indicated that, in particular, CARE helped them to become more self aware, to “think, not just react,” to slow down conversation to better understand their partner and resolve conflict, to self-soothe, and to better understand human behavior, human development, and brain functioning to more skillfully manage conflict (Todahl et al., 2013).

Participants also expressed awareness of CARE’s relationship with the probation and parole system. A male participant commented on this relationship:

They [CARE] share liability with the parole and probation department, from what I understand. CAFA is very much intertwined with the court system—with the probation officers especially. They have a little more control over people like me who need to answer to a probation officer.

Theme 2: Motivation for Participation

Participants discussed their motivation for participating in the group. The key motivational factors found in the participants’ narratives related to goals of becoming reunified and keeping the family together, a sense of commitment to one’s relationship, and interest in learning tools to help improve the quality of participants’ relationships. Indicating commitment to his relationship as well as a strong desire to be reunified with his partner, one participant stated, “If it wasn’t for this program, my partner and I would not be able to see each other. Like I said before, we have been together 10 years, and that’s just not going to happen.” The desire to reunite with his partner motivated this participant to learn as much as possible from the group:

But with this we get phone contact, and we get date nights and then church on Sundays. Of course, I want a lot more than that, but that’s enough for me to want to follow the rules and pay attention and really get something out of this while I’m here.

One female participant described that she felt there was no choice other than participation, considering the circumstances she and her partner were facing:

I would say that if you really want to get back together as a family, it’s your only option. Otherwise, you’re looking at a lot longer time. So, there is no other choice for me at this point in time.

Participants shared that motivation to continue attending the group came from the opportunity to spend time face-to-face with their partners to resolve relationship difficulties in healthier ways than had previously been used. Participants described the group as empowering by allowing couples to take control of their circumstances in a way that was not possible before. Participants indicated that their motivation for participation generally increased with group attendance. This seemed to be related to their belief that group attendance was contributing to useful change. For example one male participant stated, “I come to class to learn to manage the way I handle situations and to learn how to communicate a little bit better.” A female participant described her motivation for participating in this way:

It has just basically kept our family together. [The group] has definitely shown me that [my husband’s] got a side to him that I’ve never seen before. He’s just a different person now. It has made our relationships more loving. Without it, we wouldn’t be where we are.

A number of participants described their appreciation for learning new tools and new ways of thinking about things within their relationship. For example, one mandatory participant shared,

I like paying attention and learning about what they are teaching me. Maybe they’ll focus on the problem and throw it out there another way until I get it. Then I am shaking my head going, “yeah, I understand now.”

Theme 3: Comparison With Other Services

Participants were asked to share stories about how CARE group experiences compared with other therapeutic services they had participated in previously. Participant narratives gave strong indication that the CARE group was a unique experience for couples. Many participants discussed that the CARE group was more relaxed, comfortable, flexible, and supportive than other therapies received. In addition, participants talked often about how CAFA was a unique program in that it created change in relationships, change that did not take place as readily during other treatment they had experienced. One male participant directly compared CARE with other programs:

I am also enrolled in another program, and they are pretty much cut and dry, with a cookie cutter approach. But there are so many types of individuals with different problems. CAFA, I think, is more flexible with their programs and can identify the needs of particular couples rather than “this is the way that we do it and no way else.” We have a lot more flexibility at CAFA.

A female participant shared her perception of the uniqueness of CARE:

I’ve never had anything like this before. I think it’s unique because of the change it’s made in my husband. They’re [group leaders] so caring, and they are very interested in helping you.

Most participants indicated they felt much less judged by CARE staff than by staff at other BI programs they have participated in. A male participant discussed his experience with the CARE group after sharing that in a different domestic violence group he had felt judged:

I don’t feel like I’m being persecuted for the bad decisions I have made. I think there is a really bad misconception that people have about folks that get involved with domestic disputes. It’s that they’re bad people, and that’s simply not true. I made a mistake, yeah I did, and here I am, but I am not a bad person because of it. In the CARE group, I feel like I am being presented with an awareness that will help me to prevent anything like this happening again. So, it’s a positive thing, not a negative.

Another male participant shared a similar experience:

Well, listening to the other couples in there . . . there used to be a couple of other groups around (conventional BI services). And, it sounds like they almost used strong-arm tactics . . . though, you know, these people here are very comfortable, open. They seem not to judge anybody; they just listen to your problems and, if they can, help you or steer you in the right direction.

Another male participant expressed his appreciation of CARE staff’s attitudes compared with those of other groups:

I notice in all the meetings they know everyone by name. They go out of their way to do so. [Other classes] I’ve been to, as well as the ones I’ve heard about, they really don’t care to know you by name, and they tend not to treat you like the individual you are. They just group you with a blanket policy: this is what we do for everybody, and this is where you fall into this. And that’s what I didn’t see here.

Appreciation for CARE staff’s attitudes emerged in another male participant’s response:

What I’ve noticed in this particular group is they like to reinforce your positive image. Obviously, it’s a really touchy situation when any kind of violence is involved, domestic violence especially. You feel bad, and you feel horrible about yourself. You’ve already beaten yourself up pretty good. When you realize that what you’ve done is incorrect and against the law, this program makes you aware of that fact but realizes you’re still a human being and you make mistakes, that you’re still a good person.

Theme 4: Benefits of CARE

Participants discussed a wide range of group benefits, with emphasis on how the group allows couples with similar experiences to feel understood and to more fully face their conflicts in a nonjudgmental format. Many described this as an environment that creates an important context for change and growth. One male participant shared appreciation that “You’re allowed to be with each other in the group, and you’re allowed to share individually and freely without judgment or reprisal from other individuals in the group.”

When asked to describe why having both partners in the same group was a benefit of participation, many shared that both partners hear and learn about the same things simultaneously, and this allows couples to cooperatively and more readily work new skills into their lives. A female participant stated,

The advantages to working as a couple are the fact that both people get to be there, both people get to learn the styles of relating to each other and communicating with each other, and to practice them, and observe other people doing it. As well as they get to realize there is something greater than negative violence, even better than negative arguments. There are a lot of benefits. You also get to see other people in a series of their progression and to realize where you sit in the group and how well you’re doing as a couple . . . [You realize] that it could be worse, and you often see that it could be better. So, there is always something to strive toward in the group.

Participants also continually shared that a group benefit achieved by having both partners present was the support and accountability given to couples by group leaders and other participants. In fact, participants consistently identified that attending group as a couple each week promoted group cohesiveness and a desire to be accountable as a group member and as an example to leaders and other couples. Group members shared appreciation that they could all relate to one another’s experiences and developed a feeling of community and of not being alone as a couple in a difficult situation. A female participant shared her perspective that the group “gives a really good opportunity for people to actually get together and talk about what led up to our troubles that got us here.” A male participant supported this idea by sharing his belief that “The group overall is great because you are around other people who are dealing with the same situations. It’s not threatening.”

A predominant theme that emerged in participant narratives when they were asked to consider group benefits was that the group provides opportunities for couples to learn new skills and insight and to improve their relationships and quality of life. A male participant articulated this idea: “You’re given a lot of information to make decisions. They encourage you to think through your problems before you react.” A female participant shared that the group “gives us some tools that, if applied correctly, are really beneficial.” Another female participant discussed the new skills and outlook learned in CARE:

One of the greatest group benefits are the teachers and the knowledge they are passing down. They give you a different outlook on life and what you want; how to think differently. There was one incident when we were shown an example of a guy who was very: “I want my wife to be this way and if she’s not this way, I deserve to hit her.” Coming here gives our partners the outlook that they can’t think like that. I think it’s for the good, including for my boyfriend.

A very common theme present throughout these narratives was the belief that benefits associated with meeting in a group format were magnified by the conjoint (i.e., both members of the couple present) nature of the service. A female participant discussed that a positive aspect of the group, compared with other groups, was that the male and female were present (both partners in the couple relationship). She said, “That way, we are striving to work toward one goal.” Participants expressed appreciation for the CARE group format and for their ability to learn and create change in the group environment. These characteristics were described as different from previous therapy experiences.

Theme 5: Disadvantages of CARE

Most participants indicated that they did not see any disadvantages to CARE. When asked to discuss disadvantages, several participants provided the following answers: “There is nothing that I find wrong”; “No disadvantages that I can see”; “I can’t even think of something that’s not useful”; “I can’t find anything that is not useful about it. I think it’s the greatest thing that happened to us”; and “I have nothing negative to say about it.” Similar experiences include the following:

I honestly don’t know if there was anything that was not useful. I don’t ever remember feeling any kind of regret or I didn’t get anything out of this. (male participant)

That’s a hard question. I can’t even think of something that is not useful. I really don’t. I haven’t had anything. Every class that I have gone to, I’ve learned something so it’s nothing. (female participant)

A few participants did identify disadvantages, although there were no predominant themes among those listed. Several participants were frustrated that the group did not allow for more direct conversation about their unique conflicts or circumstances, including that CARE is too general in its approach:

Basically, we don’t talk about a lot of personal issues in the class; we just talk about how the brain works or how people, in general, work. We don’t discuss more personal experiences. (female participant)

A few participants expressed concern that CARE was provided in the context of a faith-based organization:

I understand this is a Christian-based group, but not everybody believes as they believe in religion. And I’m not a religious person. I don’t believe how they believe. And I don’t appreciate the religious aspect being put into it. (female participant)

Other disadvantages identified by participants included cost of the group, group size (too large), and a lack of flexibility with group scheduling.

Two participants, a male and a female, indicated that they were not benefiting from the group. The male reported that, due to CARE’s relationship with probation and parole, he was very reluctant to fully express himself:

They [CARE] share liability with the parole and probation department, from what I understand. CAFA is very much intertwined with the court system, with the probation officers especially. They have a little more control over people like me who need to answer to a probation officer. In that aspect, I don’t say what I want to say and I’m quiet. I’m not learning anything. I’m grateful that I can see my wife. I’m grateful there’s a class that allows me to do that. I just wish it was a little more personal and a little more active with each other on talking because we don’t talk to each other in class. We sit there and listen to each other talk, but I don’t think there’s much dialog back and forth.

The female participant indicated that she was not benefiting from CARE because it did not provide new or useful information for her: “I don’t know maybe it’s just a matter of where I am, the age I am doing this, and maybe it will help them in the long run . . . I think I’m above what they’re teaching.”

Theme 6: Suggestions for CARE

Many participants urged CARE to expand to other locations and settings: “Because it has helped me so much, and I see so much in it, I would like it to be available to more people than it currently is” (male participant) Another male participant stated, “It does help . . . Try to span out more. If they had more locations around Oregon, I mean all over the place. I think the program would be good to just take all over the place.”

Group participants repeatedly addressed the value of providing participants with private couples counseling, corresponding with group meetings. Participants indicated that private couples sessions would allow couples to work through specific, personal struggles within their relationships. Participants discussed that couple issues could be addressed more closely and in depth through private couples counseling. One female participant stated, “I think they need another portion of the program where they can meet with the couple and say, what problems arose, what can we do about them, and how do we resolve them? I think that would help.” This suggestion was identified as a way to provide more intimacy and to tailor solutions for individual couples as they learn and apply new skills through group participation. Another female participant put it this way:

Sometimes I think that the group counseling should intermix a little more with some one-on-one stuff throughout the whole course of things. You know, it’s available if we want it. All we have to do is pick up the phone and call and say, “I really think we need to come in and talk. When can we meet?”

Other suggestions included reducing costs for group attendance, speeding up the reunification process, providing more structure in the group environment, developing a “non-religious” group, providing the service for people in jail and prison, having fewer participants in each group, and making each group meeting longer.

Discussion

This exploratory study examined client perceptions of the components of multicouple conjoint services for IPV. Several limitations should be considered. For instance, despite efforts to limit risks of participation (e.g., the COC, clear description of the limits of confidentiality, individual interviews), it is not known whether or to what extent participants overstated the benefits of CARE services and understated its risks. We also cannot be certain of the impact of sampling bias, that is, the extent to which study participants represent the total population of CARE service recipients or the experience of participants in other, similar IPV service programs. In short, we do not know how the findings of this study may have varied if all CARE service recipients had participated. And undoubtedly, everything that could be said about the complexities of multicouple group work for IPV—even among the participants in this study—is not captured in this data set. In addition, participants were quite homogeneous—all identified as heterosexual, all couples included a male who had been identified as the primary aggressor, and nearly all identified as Caucasian and low-to-middle income. All data are based on self-report, and no longitudinal data were collected. Although client participant and CARE staff participant beliefs about CARE and its impact were largely consistent, data collection strategies were based on self-report alone. Therefore, client reports of safety and the benefits of CARE, for instance, were not verified via multiple data collection strategies (e.g., validated instruments, rearrest rates, structured observation). Moreover, we do not know the extent to which some participants may have overstated the benefits of CARE to protect their reunification interests. Despite these limitations, this study is the most extensive qualitative investigation of clients’ perspectives about the components of multicouple conjoint services for IPV to date and offers a focal point for further examination.

Participants overall were very positive about their experiences with CARE and pointed to several aspects of the service that they found to be beneficial. Participants reported that they believed that the service was safe for themselves and for other group members, that they acquired useful new skills, and that they valued the cooperative learning that occurred in the context of the group—all findings that are consistent with the small body of IPV conjoint and multicouple group outcome literature (McCollum & Stith, 2008; Stith & McCollum, 2009). Many participants pointed to the multicouple feature of CARE as particularly beneficial for them. This included “group process factors” (Stith et al., 2004, p. 316), such as colearning and accountability in a group context, exposure to similar information so that partners engage in a process of mutually understood change, and an opportunity to notice one’s change relative to the change of others. These findings are further detailed in a companion publication (Todahl et al., 2013).

Participants also highlighted their appreciation for the group leaders’ attitudes. Participants cited group leaders’ respect for each individual, their caring and nonjudgmental attitudes, and their practice of referring to CARE participants on a first-name basis as very important features of CARE. Participants were emphatic in pointing out that being treated in a respectful manner by providers was particularly important because they had felt very disrespected, dismissed, and misunderstood by previous providers. Moreover, many participants appeared to be quite grateful for the service, even advocating for its expansion. For instance, one male participant encouraged staff to expand their services:

I talked to Carolyn about this a couple times because she is such a major asset. I asked her whether she was training others to pass on what you’ve learned because she understood what she was trying to give and it helped me personally so much. Therefore, the only question I had is if she can train others.

Additional participants highlighted positive characteristics of CARE: useful curriculum content (e.g., brain functioning, attachment theory, characteristics of healthy relationships) and attention to skill acquisition (e.g., self-soothing) to help participants more effectively deal with their personal reactions and interpersonal conflict. Many female participants cited their voluntary involvement, their ability to withdraw from services at any time, and the pre-CARE women’s group as additional benefits; all of these factors contributed to reasonably ensuring their safety. Participants reported very few disadvantages or disappointments with CARE.

Nearly all participants identified reunification as a key motivator for participation. Although participating in CARE services is technically voluntary, one female participant suggested that given the alternative of extended separation from her partner, she felt little choice but to participate. One male participant indicated that although the courts disallowed contact with his partner, he would have contacted her anyway. For him, CARE became a legal avenue for contact with his partner and a major motivator for participation. The extent to which this is true for other participants and its impact on service participation and change are not known. There is some indication, however, that although reunification was a primary motivator for many participants, many of those same participants recognized a secondary gain—that is, personal and interpersonal growth as a result of CARE—and this realization enhanced their motivation for further participation.

Exploring participant motivation for change was not an explicit objective of this study, yet resulting themes suggest a dynamic interaction between participants’ intrinsic motivation and the supportive approach of the CARE program. Participants’ motivation for reunification as well as their positive experience of the cooperative group-learning process may be best explained by the transtheoretical model (Norcross, Krebs, & Prochaska, 2011; Prochaska, 1999). The transtheoretical model posits different stages of change for clients within an overall process of change that attends to levels of motivation (Norcross et al., 2011). The conjoint format of CARE may leverage participants’ emotional distress of separation and inherent motivation for reunification toward greater engagement in the program and therapy process. The respectful tone of CARE and cooperative group-learning environment may also accommodate varying levels of participant motivation for change, a research-supported approach toward support positive treatment outcomes (Norcross et al., 2011). Overall, the findings suggest that the structure of the CARE program amplifies participants’ inherent motivation for change and facilitates the change process.

Research Implications

This study points to several questions for further inquiry. First, participants were very positive about CARE. Beyond leaders’ nonjudgmental, respectful attitudes, and their practice of referring to clients on a first-name basis, it is important to identify the most important factors that contribute to participants’ favorable attitudes about CARE and its providers. This is particularly pertinent given the contentious relationship that can naturally occur between providers and BI service recipients. In addition, how might the largely mutually affectionate relationship reported by CARE providers and clients contribute to change? For example, it will be useful to understand whether clients who give CARE providers high favorable scores are more likely to reduce violence, to sustain those changes, and to engage in help-seeking behavior when warranted.

Further investigation of “batterer intervention systems” (Gondolf, 2002) as they relate to multigroup couples services and key partners, such as probation and parole officers is essential. Understanding the kind of relationship between services such as CARE, probation and parole officers, and their clients would be useful (Hamel, 2009). How does this relationship best manifest itself at the level of referral decision-making (e.g., inclusion and exclusion criteria, instrumentation), safety planning, progress check-in during services, termination criteria, and after care/follow-up? Participants’ readiness for change and provider responsiveness to participants’ motivation level are both relevant considerations for future research. Finally, research is needed toward a better understanding of how services should be adapted for diverse populations. For example, what mechanisms may need to be altered to best serve same-sex couples, ethnically diverse populations, and couples with females as primary aggressors?

Most participants urged CARE to offer adjunctive couples therapy services. Feld and Straus (1989) indicated that because reciprocal violence occurs between partners, these relational processes need to be addressed to meaningfully reduce violence. Goldner (1998) also highlighted the notion that change is often enhanced by conjoint work:

[Although] violence is not caused by the relationship . . . it is, nonetheless, woven into the confusing melodrama of the couple’s involvement. [Therefore] . . . the relationship must be addressed if second-order change around the violence is to occur. This cannot be done by seeing each separately since it is only by observing the particular, idiosyncratic “pull” of the relationship in statu nascendi that its power . . . comes into focus. (p. 265)

Further research is needed that examines the unique benefits of “here and now” relational work toward meaningful and lasting change.

Research is needed that investigates whether the benefits of CARE reported by participants in this study are sustained longitudinally. If these changes are sustained, among which populations and how do these sustained changes compare with those resulting from traditional BI services and other formats? Does tailored and concurrent couples therapy bolster multicouple group services and, if so, for which couples? And which postgroup interventions and activities are best suited to consolidate, reinforce, and perpetuate those gains? By examining these questions, we will have a better understanding of which of the reported positive changes in this study are due to short-term circumstances and which activities are most likely to perpetuate change across time.

Footnotes

Acknowledgements

Special thanks to Carolyn Rexius, CAFA Executive Director, for allowing access to research participants and for her important work to reduce violence in our community.

Declaration of Conflicting Interests

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

Funding

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

Author Biographies

Jeffrey L. Todahl is an associate professor in the Couples and Family Therapy Program at the University of Oregon and Director of the Center for the Prevention of Abuse and Neglect.

Deanna Linville is an associate professor in the Couples and Family Therapy Program. Linville’s research interests include obesity and eating disorder prevention and intervention, collaborative family healthcare/medical family therapy and couples issues (intimate partner violence and new parent couples).

Abby F. Tuttle Shamblin is a licensed family therapist in private practice in Eugene, Oregon and is employed with the Oregon Social Learning Center.

Angela Skurtu is a licensed family therapist in private practice in St. Louis, Missouri.

David Ball is a licensed family therapist in private practice in Eugene, Oregon and is employed with Looking Glass Counseling.

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