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Abusive Personality Violence and Control in Intimate Relationships
By Donald G. Dutton
The Guilford Press Copyright © 2003 The Guilford Press
All right reserved.
Chapter One The Treatment of Assaultiveness
If one conclusion stands out from the rest in the preceding chapters, it is that assaultiveness and abusiveness have a psychology. They are not merely the product of "bad attitudes," nor can they be narrowly defined as the robotic imitation of action. The actions of abusiveness are supported by ways of looking at and feeling about the world, about oneself, about intimate relationships, and about one's partner. These attitudes themselves emanate from personalities destined to destroy intimate relationships and to blame their demise on their female partner. The abusive male is easily shamed and tends therefore to externalize problems by blaming others. He experiences high levels of anxiety and depression. These dysphoric feelings become "evidence" for the partner's failures and generate substance abuse problems, which further exacerbate the marital conflicts. The man experiences but remains unaware of his "abuse cycles" comprised of collected tension, abusive "blowouts," and consequent contrition. In his mind the changes are not within himself but in external reality. Clearly, this will not represent a receptive client population. Given the tendency to shameeasily, abusive men must not be confronted too quickly or too strongly. (A form of treatment for borderline personality disorder [BPD] provides a method to remedy this therapeutic problem. We discuss Marsha Linehan's work below, given the centrality of borderline problems to abusiveness.)
On the other hand, given abusive men's well-established denial system and tendency to minimize the consequences of their abusiveness, some confrontation must occur. Similarly, given their isolation from other men, a group treatment format will seem intimidating; yet individual treatment, the alternative treatment approach, is expensive and frequently abandoned prematurely. Accordingly, before focusing on a treatment group regimen, it is important to put treatment in context.
As cited in their article on pharmacological treatment for assaultive males, Maiuro and Avery developed a three-stage program termed "biopsychosocial intervention." The biological aspect involves administering pharmacological treatment for problems such as depression, irritable temperament, hyperreactivity, emotional lability, pathological anxiety, obsessiveness, compulsiveness, and postconcussive or other related syndromes. The biological treatment results suggest that pharmacological agents such as antidepressants, anxiolytics, and serotonin reuptake moderators might aid in treating certain aspects of the abusive personality. Cocarro and Kavoukian have found low levels of serotonin to be associated with aggressive behavior in animals. Other pharmacological treatments such as depakote and Prozac have been useful in treating impulsivity and obsessiveness/depression, respectively. However, as the researchers point out, this form of intervention cannot be substituted for social change or psychological (group) treatment. Recall Bandura's analysis of the effect of hypothalamic stimulation in animals of differing social status (p. 16). Delgado had found that hypothalamic stimulation produced cowering in submissive female monkeys. As these females were "promoted" by successive entry into less aggressive tribes, they became progressively more assertive and aggressive themselves. After several such promotions, the same hypothalamic implant now produced aggression. Neurobiology, by itself, was not the complete answer.
Hence, even with drug treatment several targets for psychological treatment remain. The following were listed by Maiuro and Avery as potential psychological treatment targets: defenses against acknowledgment of responsibility (e.g., denial, minimizing, blame projection), anger management (detection and control of anger responses), personal acceptance or justification of violence, assertiveness, bargaining and communication skills, attitudes toward women, family-of-origin modeling influences, relationship enhancement skills (including nonviolent conflict resolution skills), and relapse prevention skills. I agree that these appear to be reasonable targets for psychological intervention, yet both the narrower biological and psychological interventions must be set within a social context of activism concerning general cultural acceptance of violence, violence toward women, women's safety, and male sex-role conditioning.
Treatment groups for assaultive males were developed in the late 1970s by Dr. Anne Ganley, then a psychologist at the Veterans Administration Hospital in Tacoma, Washington. Ganley's treatment model was based on the notion of abusiveness as a learned behavior, that is, a social learning model. We adopted her treatment model and, in line with our own experience, revised it somewhat. I outline this model here, including extended applications relating to BPD, psychopathy, attachment issues, and trauma. I then examine the outcome research on treatment effectiveness. The clinical goals of treatment are relatively simple: to get the man to recognize and to accept responsibility for his abusiveness, and to develop control over and to reduce the frequency of such behavior. The treatment program described below is simply one means of achieving these objectives.
SIXTEEN WEEKS IN A TREATMENT GROUP
Court-mandated treatment models arose in a number of locations in the early 1980s. The criminal justice system needed an effective way for judges to settle wife assault cases before them, and treatments were developed to meet that need. Many men who are sent by the courts for wife assault treatment have had no experience with psychotherapy. They imagine their worst fears and weaknesses being exposed; consequently, the experience is initially terrifying.
Robert Wallace and Anna Nosko have described the opening night ritual in such groups as a "vicarious detoxification" of shame. Men who come to group, assuming they are "normally" socialized, experience high levels of shame as a result of their violent behavior. Hearing other men in group discuss their own violence allows the man to "vicariously detoxify," that is, to face his own sense of shame. This sense of shame, were it not detoxified, would maintain the man's anger at a high level and preclude his opening up to treatment. The anger is maintained to keep the shame at bay. Anger allows blame to be directed outward, preventing shame-induced internalized blame.
For this reason, we start very slowly in our groups (see Figure 9.1), simply asking men on opening night to describe "the event that led to your being here" (e.g., the assault). Their stories provide them with a sense of mutual affliction and of shame detoxification that furthers the bonding process. Moreover, these stories provide us with an initial assessment of the man's level of denial and willingness to accept responsibility for his violence.
The only other thing we try to accomplish on opening night is to review the group rules with the clients. These rules are reproduced in Figure 9.2. Apart from commonsense rules such as attending consistently in a sober condition, these rules also outline the confidential nature of the group and the exceptions to this rule (such as disclosures of child abuse or of direct threats toward another person). As straightforward as these rules may be, they still trigger resentment concerning the criminal justice system's handling of the man's case. Many men feel poorly treated by the system and see therapists as extensions of that system. These feelings frequently surface during discussion of the participation agreement.
At the end of the first group session we ask men how they feel at this juncture. Generally, they express relief about "surviving" the first group and about being in a group composed of men with similar problems. Their relief generally has to do with not feeling judged; this aspect proves to be particularly important given the shame feelings often experienced by abusive males, as described by Wallace and Nosko. For this reason, I would not recommend confrontation on opening night.
Immediately following the beginning of group, therapists should interview each female partner to assess her safety plans, her perception of personal risk, the man's current level of abuse, and any feedback he may have brought home from his first group experience. One danger sign, for example, is the use of the group to minimize one's abuse: "You think I'm bad, you should hear these other guys in my group." The therapist should also ascertain what information can safely be fed back to the man. If the woman isn't comfortable with direct feedback (attributed to or traceable to her), present the issue during group in general terms. Ask the men if they have any lingering reactions to what they heard the preceding week and discuss "defensive social comparison," where one uses the group to deny or to minimize one's own abuse. The point should be that each man, regardless of his level of abuse, has to take responsibility for that abuse. It is irrelevant that someone else may be more violent than he is.
The second meeting should begin with addressing residual feelings from week 1. It is useful to get the clients to focus on and to describe such feelings; this begins a weekly "check-in" exercise that will initiate the group process for each week to come. It can also lead into a simple exercise for week 2: differentiating feelings from "issues" and actions. An example is presented in Table 9.1.
We present this as an exercise; men are asked, "What do you argue about?", "How do you feel after these arguments?", and "How do you act when you are arguing?" This exercise is again deceptively simple; it outlines some apparent distinctions between feelings and actions. At the same time, it again shows clients that other men share many of the same issues. This revelation furthers the bonding process in the group and facilitates shame detoxification. We tend not to confront men much during these initial few weeks. We describe what confrontation is and distinguish it from attack or putdowns. We explain that confrontation is a device to help someone change, whereas attack is simply done to make the attacker feel powerful. We warn men that we will later use confrontation as a part of treatment. If a group is particularly woman-blaming, however, it is important to initiate the confrontation process earlier, before a negative form of group cohesiveness develops, built on shared commiseration about how difficult women can be. Reorienting the men from an other-blaming orientation to a self-control orientation typically has to be repeated during early sessions. As the guiding philosophy, a self-control orientation emphasizes personal responsibility and control of self (along with negotiation with, rather than control over, others).
Week 3 begins with a feeling check-in again and deals with the question of what is meant by "abuse." The various forms of abuse (physical, sexual, emotional) are discussed, and the "power wheel," developed by a program in Duluth, Minnesota, is explained (see Figure 9.3). A working definition of abuse also includes the motive of harming the partner's self-esteem or restricting her autonomy. Men are informed that, for the duration of the group, they will be asked to report any abuse committed that fits the aforementioned definitions. One practical issue regarding the "check-in" exercise deserves mention: it can run for an hour and a half in a 10-man group, reducing group time for other exercises. If this begins to happen, get the men to respond succinctly to three questions: Was there any abuse this week (if so describe)? Did you handle your anger well on any occasion? Do you need any group time for special problems?
Week 4 examines the gains and losses each man experiences through the use of violence. This leads to asking the men to develop a personal "violence policy" for the following week. Each violence policy must be a response to this poser: "I believe it all right to be violent under the following circumstances...." Each man has to develop his personal policy as a homework exercise. (Again, from a process perspective, this is a test of the man's commitment to the groupwork.) Most men will cite self-defense or protection of family, while others may cite reactions to home invasion and the like as justifying violence. Few will cite violence as acceptable during arguments with their wives. It is important that this policy come from the client. This undercuts his erroneous conviction that actions and beliefs are being imposed on him. If it is his own policy, which the therapist will hold him to, there exists a greater feeling of co-authorship between the client and therapist. Men who have a policy that is at odds with the group philosophy will need to have their attitude identified and confronted directly. The role of the "proviolence" attitude in sustaining destructive behavior patterns must also be addressed. If the man refuses to change his attitude, the therapist must decide whether this is a "protest gesture" (against the therapist, who is seen as an extension of the criminal justice response, still angering the man) or a bona fide attitude that impedes the client's progress. This is a situation where confrontation by another group member or by a "catalyst" (a man returning from a prior group to co-facilitate and to act as a catalyst) is especially helpful. In the face of prolonged failure, however, men who refuse to change their pro-violence attitude may be asked to leave the group; their refusal to adopt a more constructive perspective is contradictory to a commitment to change.
Around this time in the group progress, friendships may begin to form. We capitalize on this by forming help triads. Men selfselect into groups of three. They realize that in making this choice, they are agreeing to be on 24/7 emergency helpline for each other and that the other two will also do it for them. Help triads are to be used when a time-out has failed, anger is escalating, and an overnight cooling off is called for. All that is expected is a place to stay and some support. Alcohol and drugs are forbidden.
Week 5 introduces the anger diary or anger log (see Figure 9.4). This anger diary is the basic tool to improve the men's ability to detect and manage their anger. It requires them to specifically state what triggered their anger as objectively as possible (under the "trigger" column), to list how they knew they were angry (what physical cues told them so?), to rate their anger severity on a scale where 10 is their own personal extreme, and to describe their "talk-up" (their thoughts as their anger escalates) and "talk-down" thoughts (their thoughts as their anger diminishes). Most clients have some initial difficulty with the latter. A list of talk-down statements is provided to help them with this (see Figure 9.5).
Excerpted from Abusive Personality by Donald G. Dutton Copyright © 2003 by The Guilford Press. Excerpted by permission.
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