An Expanded Approach to Batterer Intervention Programs Incorporating Neuroscience Research

Introduction

Over the past decade, neuroscience research has made significant contributions to the mental health arena. Of particular importance is the nature of emotional regulation impairments subsequent to childhood neglect and abuse.

Although few studies have focused exclusively on intimate violence, interventions that incorporate neuroscience research findings have been steadily gaining recognition in the treatment of substance abuse, posttraumatic stress disorder (PTSD), and populations with borderline personality disorders (BPD).

In light of the high rates of comorbidity among these diagnosis, and the strong representation of these disorders in perpetrators of intimate violence, it is reasonable to question whether neuroscience findings that inform intervention and prevention in related areas can be useful in the field of intimate partner violence (IPV; Klostermann, Kelley, Mignone, Pusateri, & Fals-Stewart, 2010; McKinney, Caetano, Ramisetty-Mikler, & Nelson, 2008).

Concerns regarding the efficacy of existing approaches to Battering Intervention Programs (BIPs) have been eloquently and repeatedly stated (Aguirre, Lehmann, & Patton, 2011; Corvo & Johnson, 2003; Dutton & Corvo, 2006; Scott, 2004; Stover, Meadows, & Kaufman, 2009). The great majority of existing programs have demonstrated poor outcome, resistance to change, and a high drop-out rate (Babcock, Green, & Robie, 2004; Eckhardt, Murphy, Black, & Suhr, 2006). Research supported by the National Institute of Justice recommends the need to improve the models that guide batterer intervention programs, and expand approaches based on emerging research on batterer profiles and causes of battering (Barner & Carney, 2011). In the collective effort to consider alternative and more selectively responsive approaches to BIP, progress made in related areas may provide useful strategies for invigorating existing treatment approaches to IPV. This article will explore the relationships among childhood trauma, emotional regulation and IPV, and recent contributions based on neuroscience research that may provide a rationale for the incorporation of expanded strategies in BIPs.

Linking Trauma Research and IPV

The research regarding emotional regulation and cognitive changes that result from childhood trauma are particularly relevant to individuals who engage in partner violence, given the statistical relationship between battering and childhood exposure to family violence. While not all batterers were victims of physical abuse, the majority witnessed or experienced parental violence, community violence, or multiple traumas (Briere, 2002; McKinney et al., 2008). Busby, Holman, and Walker (2008) address the complexity in understanding the relationship between violence in the family of origin and aggression between adult partners, as children who were directly victimized, witnessed parental violence, and/or perpetrated violence themselves have different statistical outcomes. However, subjects who reported relationship violence in the family of origin had significantly higher rates of partner violence, with almost one third of the group who reported family of origin violence engaging in intimate violence as a perpetrator, victim, or both. Moreover, batterers who report abusive childhood experiences have higher rates of anger, personality disturbances, and substance abuse (Eckhardt, Samper, & Murphy, 2008).

It is also suggested that children who witness family violence may be as deeply affected as children who have experienced direct victimization (Holt, Buckley, & Whelan, 2008; Strauss & Gelles, 1980). Children who experience emotional abuse have been identified as a high-risk group for continued difficulties with emotion regulation, and it is not surprising that they are overrepresented in populations of IPV (Burns, Jackson, & Harding, 2010).

Researchers struggle to distinguish the differing consequences of specific forms of trauma, as exposure to different levels and combinations of violence tend to cooccur (Graham-Bermann, Gruber, Howell, & Girz, 2009; Whitfield, Anda, Dube, & Felitti, 2003). Research conclusions are also difficult to substantiate and replicate given weak methodological design (Thornberry, Knight, & Lovegrove, 2012). It is also important to consider the range of ongoing moderating factors such as exposure to community violence and ongoing stress that may be particularly potent to survivors of childhood trauma (Wolf & Buss, 2010). Garrido, Culhane, Petrenko, and Taussig (2011) suggest that adolescents who experience parental violence as well as observed IPV have the most serious impairments. Those who eventually develop symptoms of PTSD demonstrate difficulties processing emotions, insecure attachment patterns, and cognitive-processing problems that are activated by anxiety (Bremner, 2003; Cohen, Perel, DeBellis, Friedman, & Putnam, 2002).

Children raised in homes with domestic violence (DV) and who have experienced multiple forms of trauma are more likely to repeat DV in their own adult relationships (Bensley, van Eenwyk, & Simons, 2003; Coid et al., 2001; Dutton, 2000; Franklin, Menaker, & Kercher, 2011). They are also disproportionately represented in clinic populations treated for psychiatric problems and substance abuse (Klostermann et al., 2010; Overlien, 2010; Turner & Kopiec, 2006). Despite discrepancies in research findings, childhood abuse is generally regarded as creating enduring effects that create ongoing difficulties controlling anger and higher risk of perpetrating IPV (Anda et al., 2006). Unfortunately, it is estimated that at least 30% of American youth are exposed to IPV in any given year (McDonald, Jouriles, Ramisetty-Milder, Caetano, & Green, 2006).

Neurobiology of Trauma

While early efforts to explain the heritability of family violence gave consideration to genetic predisposition, modeling, and faulty parenting due to stressful marital dynamics, understanding the consequences of family violence shifted radically with the introduction of brain-imaging research (Crawford & Wright, 2007; Gunnar & Fisher, 2006). Although interpretation is not yet fully refined, there is a substantial body of research that documents differences in brain structure and neural networks that are believed to be consequences of exposure to trauma in childhood (Caffo & Belaise, 2003; Cicchetti, 1996; Gollan & Coccaro, 2005; Heim & Nemeroff, 2001; Maughan & Cicchetti, 2002; Schore, 2003; Van der Kolk, 2003; van der Kolk, van der Hart, & Marmar, 1996; Yates, 2007). A growing body of research points to changes in right brain function, particularly in adults with PTSD who, as children, were sexually or physically abused. Schore (2003, p. 20) suggests that the implications of right brain impairment leads to an inability to “sense, attend to and reflect on changes in subjective self states, leading to high levels of reactivity or dissociation as an escape from overwhelming affect.”

Summary papers highlight neural consequences of childhood trauma exposure in the hypothalamic–pituitary–adrenal (HPA) axis, neural networks, and functionality of different areas of the brain (Twardosz & Lutzker, 2010; Yates, 2007). Other findings from brain-imaging studies of children who experienced family abuse indicate a reduction of corpus callosum, an essential area of nerve fibers that connect the left and right hemispheres of the cortex (De Zulutta, 2006). These kinds of impairments can lead to problems establishing unified perceptions and memories. Other research suggests that exposure to unbearable stress creates synaptic pruning that alters the processing of emotional states. Damage in the right-hemispheric cortical and subcortical limbic circuits has been noted as a factor leading to difficulty regulating emotions (De Zulutta, 2006; Teicher et al., 2002).

Neuropsychiatry research has also been assisted by more sophisticated methodology in studies of neurobiology. Traumatized children show disruptions in the endogenous opiate system, which leads to difficulty being comforted. Changes in the dopamine and norepinephrine–epinephrine systems are also implicated in producing maladaptive response to threat (Cohen et al., 2002). Persistent changes in neurotransmitter systems may predispose adult survivors to mood, anxiety, and personality disorders (Mead, Beauchaine, & Shannon, 2010). These findings support a belief that childhood trauma has the potential to create chronic PTSD symptoms that can result in compromised cognitive and psychosocial functioning, and contribute to maladaptive functioning in traumatized children who may not present with full-blown PTSD symptoms (DeBellis, 2001; El-Shiekh, Cummings, Kouros, Elmore-Stanton, & Buckhalt, 2008; Gewirtz & Edleson, 2007; Saxe, Ellis, & Kaplow, 2007).

Researchers are also interested in factors that ameliorate or reduce the consequences of family violence on the developing brain, as not all children who have been exposed to family violence develop these kinds of problems. For example, maternal warmth has been identified as one factor that can serve as a buffer that allows children to manage stress in a way that promotes health (Gagne & Drapeau, 2007; Morris, Silk, Steinberg, Myers, & Robinson, 2007). However, there is sufficient research to conclude that for some adults, exposure to childhood stress that was generated through witnessing or experiencing family violence has led to neural responses that may have initially offered short-term coping adaptation, but altered the capacity to experience and regulate emotions in the long run. It is thus reasonable to surmise that there is a subgroup of batterers who have been affected by exposure to early trauma who may have developed impairments that compromise emotional regulation (Howard, 2012).

Unfortunately, few brain-imaging studies on IPV populations exist. Neurochemistry studies to date have produced mixed findings regarding baseline differences among types and levels of male batterers, but have not controlled for exposure to childhood trauma (Pinto et al., 2010). Animal studies have demonstrated biological roots in the transgenerational transmission of IPV (Cordero et al., 2012). Adult male rats exposed to fear-inducing experiences during the peripubertal stage of development displayed more aggression toward female partners than control males who had not been stressed. The female partners of the stressed males showed decreased body weights during cohabitation, as well as altered HPA axis function, depression-like behavior, and enhanced fear responses to mild aversive stimulation. The male offspring of stressed pairs demonstrated aggressive behaviors, leading the authors to conclude that aggressive behavior linked to early traumatic stress emerges independently of cultural and social learning factors and that male offspring reproduce the patterns of aggressive fathers.

Howard’s (2012) review of the neurobiological aspects of violence notes that abusive men have higher incidences of head injury than males in the general population. Head injuries involving the orbitofronal and anterior temporal lobe regions are particularly common and are believed to contribute to emotional lability, impaired social insight, and poor impulse control. A history of head injury or traumatic brain injury has been noted as a risk factor for interpersonal violence, as perpetrators have a higher prevalence than the general population (Cohen et al., 2002; Farrer, Brock Frost, & Hedges, 2012; Rosenbaum, Geffner, & Benjamin, 1997).

Cognitive-Processing Impairments

As a significant proportion of IPV takes place within a context of interpersonal conflict, the mechanisms linking cognitive interpretation and emotional response in relational interaction is an important area of focus for understanding partner violence. Emotions are responses to triggers that involve cognitive appraisal, physiological changes, and feedback loops throughout multiple areas of the brain (Lewis, 2007; Lewis & Todd, 2005). The meaning that is assigned to the trigger is a vital aspect of this process, as personal history and revived emotional memories can serve to increase or diminish the appraisal of danger and other triggers (Phelps & LeDoux, 2005; Suvak & Barrett, 2011). Implicit cognitive beliefs, executive function, and trauma memories may all coalesce in a complex interaction that contributes to intimate aggression (Jouriles, McDonald, Mueller, & Grych, 2012).

Awareness of emotionally based physiological responses may be delayed or constricted in ways that contribute to unrecognized feelings. The exposure to childhood trauma in the absence of family security and attunement leaves some individuals compromised in their ability to decipher and manage emotional triggers. For example, individuals with BPDs have difficulty processing emotional information related to self or others and are less able to integrate conflicting or ambiguous emotional states (Baird, Veague, & Rabbitt, 2005; Levine, Marziali, & Hood, 1997). While not all individuals with this disorder were abused during childhood, perceived lack of attunement is a common complaint, and there is some statistical support for higher incidences of early trauma exposure (Cloitre, Cohen, & Koenen, 2006; Linehan, 1993). Many victims of violence become reactive to threatening facial and vocal expressions and may be more likely to interpret a partner’s expression of frustration or annoyance as an attack (Schore & Schore, 2008). Lack of self-awareness regarding gradual changes in emotional states and restricted tolerance of feeling states may lead to confusion about causation, as an internal state of distress may be perceived as being inflicted by a partner. Cognitive distortions and inaccurate appraisal increase the release of stress hormones and emotional memories that culminate in an overwhelming state of emotional distress (Wolf, 2007).

Implications for Practice

In general, there is consensus that the most effective BIPs will offer treatment that is tailored to the differences in kinds of violence and underlying disorders (Cavanaugh & Gelles, 2005; Kelly & Johnson, 2008; Langhinrichsen-Rohling, 2005). Emotional intensity and loss of emotional control have been frequently described in typologies that distinguish different kinds of batterers (Cavanaugh & Gelles, 2005; Fowler & Westen, 2011; Scott, 2004). If emotional dysregulation defines a discrete subgroup or is an important dimension found in different subgroups of IPV populations, then interventions tailored to that dynamic hold promise for BIPs. Because difficulties processing trauma-related stimuli have been noted in studies of PTSD as well as partner abusive men, interventions aimed at developing awareness, tolerance, and management of emotions and triggers could be an important focus of intervention.

Screening for emotional dysregulation could include a self-reported history of witnessing parental violence, being subjected to physical, emotional, or sexual abuse, or having a history of significant or accumulated trauma. In addition, questions could be posed to the perpetrator and/or victim regarding the context and nature of the violence, in an effort to confirm a pattern of escalating emotionally driven interactions. Several instruments have been developed to assess emotional regulation, including relatively brief inventories (Bradley et al., 2011; Killiam, 2012). Cognitive impairments such as splitting can be measured by the Splitting scale or the Dyadic Splitting scale (Siegel & Spellman, 2002). Previous studies that have explored state/trait anger have also successfully identified subgroups of batterers with different emotional responses (Eckhardt et al., 2008). These assessment tools could be added to the existing cadre of measures in an effort to expand and clarify the typologies of IPV populations and the efficacy of proposed interventions.

Although studies of possible triggers related to partner violence are in their infancy, work with trauma survivors suggests that specific interpersonal cues, reminders, and cognitive mechanisms are related to emotional dysregulation in other trauma populations (Cloitre et al., 2006; Saxe et al., 2007). While there is a need to further study the nature and incidence of the emotional triggers such as rejection sensitivity and cognitive processes such as rumination, dissociation, and splitting in IPV populations, clinical reports suggest that techniques to challenge cognitive distortions have been well received (Siegel & Forero, 2012).

Models that incorporate emotional regulation strategies have been steadily gaining popularity in the treatment of PTSD (Cloitre et al., 2006; Cloitre, Koenen, Cohen, & Han, 2002; Kinniburgh, Blaustein, & Spinazzola, 2005). Several of these approaches incorporate aspects of dialectical behavioral therapy (Linehan, 1993; Robins & Chapman, 2004) and emphasize strategies to reduce emotional intensity as well as strengthen self-awareness (De Rosa & Pelkovitzm, 2008; Najavits, 2002; Robins & Chapman, 2004; Saxe et al., 2007; Vermilyea, 2000). Interventions typically work toward helping individuals reduce the intensity of emotional reactivity through employment of mindfulness, thought substitution, acceptance, grounding, or relaxation techniques. However, they also introduce skills that strengthen awareness of emotional states within self and others, and incorporate ways of tolerating and working productively with emotional reactions (Baer & Huss, 2008; Moses & Barlow, 2006). While medication may be recommended in certain cases, therapies that provide emotion regulation have been found to reduce symptoms, facilitate psychological adjustment, and strengthen interpersonal relationships in clinic populations with severe symptoms (Tamir, 2011; Thompson, Arnkoff, & Glass, 2011).

Affect regulation techniques have been studied and demonstrated to be effective in several established trauma approaches such as addictions and trauma recovery integration model (Miller & Guidry, 2001), trauma adaptive recovery group education and therapy (Ford & Russo, 2006), and seeking safety (Cohen et al., 2002; Najavits, 2002). Models incorporating emotional regulation techniques are also proving effective in treatment of traumatized children (Saxe et al., 2007). Strategies to regulate emotions have also been introduced in clinical work with substance abusers, as emotional regulation has been found to be relevant in predicting use as well as recidivism (Aldao, Nolen-Hoeksema, & Schweizer, 2010; Berking et al., 2011; Fox, Hong, & Sinha, 2008).

Briere (2002), Briere and Rickards (2007), Briere and Spinazzola (2005), and Gunnar and Fisher (2006) support the goal of reducing the experience of stress by focusing on specific mechanisms that improve regulation of the HPA axis.

Strategies that incorporate mindfulness have been successfully used with a range of problem areas that include personality disorders, aggressive behavior, and substance abuse (Baer & Huss, 2008; Baird et al., 2005; Burke, 2009; Keng, Smoski, & Robins, 2011; Macklem, 2010). Thompson, Arnkoff, and Glass (2011) suggest a role for mindfulness in both treatment and building resilience to trauma. Aggressive behavior in adolescent boys was diminished after an intervention that involved monitoring emotions and raising awareness (De Castro, Bosch, Veerman, & Koops, 2003). Mindfulness practices have also been effective in work with traumatized children in foster care (Coholic & LeBreton, 2009).

Although few studies have investigated BIPs that incorporate mindfulness or specific strategies to strengthen emotional regulation, Finkel, DeWall, Slotter, Oaten, and Foshee (2009) have established the importance of self-regulatory failure in IPV. The authors note that violent impulses during conflictual interactions are quite common, but are typically regulated. Certain batterers may differ from nonbatterers in their ability to identify and control aggressive impulses. Although the authors suggest that factors related to self-regulation include dispositional self-control, cognitive-processing time, and depletion of self-regulatory resources, the literature on emotional regulation offers additional strategies that may improve emotional regulation skills ( Keng et al., 2011; Southam-Gerow & Kendall, 2002). Interventions based on emotional regulation have been successfully used in work with clinic populations in individual, couple, and group formats (Johnson & Williams-Keeler, 1998; Neborsky, 2003).

In addition to psychoeducation and techniques that raise emotional awareness and tolerance, treatment models that focus on emotional regulation emphasize the therapeutic relationship (Solomon & Siegel, 2003). Accordingly, most treatment goes beyond psychoeducation to include attunement to the client (Johnson, 2004; Lapides, 2011; Siegel, 2006a). Validation is a therapeutic aspect of emotional regulation (Linehan, 1993; Shenk & Fruzzetti, 2011) and a prerequisite for an atmosphere that allows for self-reflection and self-disclosure.

Although this aspect of treatment may appear to detract from the demand for accountability that is essential to protect the victim, it should be emphasized that the therapist’s validation of a feeling state does not imply agreement or approval of the batterer’s conclusions or aggressive tactics. Rather, the clinician assumes a dialectical stance that holds both the subjective experience of the batterer and an awareness of faulty cognitive processes and beliefs that have contributed to a dysregulated state. In providing an attuned response, the therapist is able to help calm turbulent emotions and achieve a more balanced perspective. Attunement also contributes to a strong therapeutic working alliance, a factor that has been identified as creating better outcomes in psychotherapy and interventions with abusers (Eckhardt et al., 2006).

Emotionally focused treatments are recognized as helping to stabilize moods, enhance interpersonal relationships, and build neural resilience, so that there is less emotionally driven reactivity to stress (Farb, Anderson, & Segal, 2012; Kung & Sloan, 2011). Batterers who have participated in qualitative studies probing self-identified strengths and strategies that have helped them create violent-free relationships note the importance of loving relationships and emotional stability (Aguirre et al., 2011). Sheehan, Thakor, and Stewart’s (2011) review of qualitative research on the turning points identified by reformed batterers includes the development of emotional regulation skills and improved relationships with the partner and other family members. Improved emotional regulation may also decrease substance use, which indirectly may help diminish IPV (Berking et al., 2011; Dass-Brailsford & Myrick, 2010; Haaga, McCrady, & Lebow, 2006). Emotional regulation skills thus have the potential to help control aggressive impulses, develop self and other awareness that may strengthen family relationships, and allow for more effective problem solving that may help prevent conflict escalation.

Conclusion

In response to the need for BIPs to integrate current research and incorporate trauma-based interventions, strategies that address emotional regulation and related cognitive mechanisms such as splitting may be helpful. Research on the neural consequences of psychological trauma has led to an expanded awareness of the importance of emotions, which, in turn, has informed treatment response to populations with high rates of cooccurrence with IPV (Briere, Hodges, & Godbout, 2010; Dass-Brailsford & Myrick, 2010; DeBellis, 2001). These strategies employ corrective emotional and cognitive strategies that are not currently employed in prevailing BIPs.

A focus on relationship building and emotional stability is compatible with the factors described by reformed perpetrators who have identified the catalysts and skills that helped them to change (Sheehan, Thakor, & Stewart, 2011). Aguirre, Lehmann, and Patton (2011) also note qualities such as pride in fatherhood, pleasure achieved from time with children and family, and the importance of family, faith, and friends as potential sources of strength to male batterers. Building on strengths and fulfillment of personal goals such as relationship success may be viewed as strength-affirming alternatives to interventions based on shame. By gaining skills in emotional intelligence, learning to better understand self and other, and improving self-regulation, the batterer may acquire strengths and resilience that support change. While it is imperative that any approach that incorporates emotional regulation be rigorously tested, there are theoretical grounds to suggest the potential efficacy of an expanded approach to BIP for batterers who experience emotional dysregulation.