Fathers for Change: A New Approach to Working with Fathers Who Perpetrate Intimate Partner Violence

Abstract

Legal and social service systems rarely acknowledge the status of men as fathers in the conceptualization and delivery of interventions for intimate partner violence (IPV). Large percentages of men who are arrested and mandated to intervention programs for IPV are fathers who continue to live with or have consistent contact with their young children despite aggression and substance use. There are currently no evidence-based treatments that address co-morbid substance abuse and domestic violence perpetration with emphasis on paternal parenting for fathers. This paper will describe the components of a new intervention, Fathers for Change, which addresses the co-morbidity of substance abuse, domestic violence, and poor parenting for fathers of young children. Fathers for Change is unique in its focus on the paternal role throughout treatment. Acase example and initial feasibility of the intervention will be described to provide an understanding of the key ingredients and the gap this intervention could fill in the field once tested in efficacy trials.

Introduction

There are 5.8 million victimizations of women by intimate partners in the United States each year resulting in 2 million injuries [1] demonstrating a major public health issue that is in dire need of effective intervention and prevention. Approaches that have been developed to intervene with men who perpetrate intimate partner violence (IPV) through legal, criminal action have been largely ineffective [2–4]. This broad lack of efficacy highlights the urgency for the development of alternative approaches to intervention for men following an initial incident of IPV.

There is a need for integrated treatment to address the issues faced by families impacted by IPV that targets violence, overlapping substance use and the perpetrator’s role as co-parent and father. Research has demonstrated a clear association between the issues of IPV and substance abuse. Meta-analytic studies report high co-occurrence rates of IPV and both alcohol [5] and drug abuse [6]. There is significant evidence of the deleterious effects of witnessing IPV and the often co-occurring substance abuse on children (see key findings in [7–12], and children exposed to IPV are at increased risk for child abuse [13]. These data together suggest many families impacted by IPV are also struggling with substance use and negative parenting behaviors. Yet, little work on integration of intervention approaches has been done. This paper is meant to describe the rationale and components of an integrated approach to IPV intervention for men who are fathers called Fathers for Change. Case material will illustrate key ingredients of the treatment. Initial implementation feasibility with a small number of pilot cases will be described to support further research evaluation on the efficacy of the intervention.

Why focus on Fatherhood in an IPV Intervention

Research has shown that men with IPV histories continue to play an important role in their children’s lives [14, 15]. Women take an average of 8 years to leave a violent relationship and 68% of women exiting domestic violence shelters return to live with the perpetrator [16, 17]. In a community sample of IPV victims, 80% still lived with or had contact with the perpetrator due to shared children 6 months after a domestic dispute that was reported to the police, and 68% of victims stated their child was attached to their aggressive father [18]. A study of preschool aged children who had limited or no contact with their previously violent fathers had higher levels of depression and anxiety than children who had frequent (at least weekly) visits. The effects of father contact were significant even when controlling for the severity of violence exposure [19]. In addition, preschool aged children, especially boys, who saw their fathers more regularly had fewer negative representations of their mothers [20]. These data highlight the reality that perpetrators often continue their presence within the family following domestic violence and the important role they play with their children.

One approach to improve IPV interventions for offenders may be to develop intervention programs that are specifically designed for men who are fathers. Several scholars have argued that (a) men who perpetrate family violence who recognize the impact of their violence and interparental conflict on their children can reduce the transmission of IPV across generations [21] and (b) men’s concern about the impact of IPV on their children may be a powerful motivating factor in seeking and remaining in treatment [22].

Studies suggest fatherhood may be a potential motivator for change for men who perpetrate IPV. Rothman and colleagues [14] surveyed men entering batterer intervention programs and found most men believed that their violence negatively affected their parent–child relationship and more than half (53%) of biological fathers worried about the long-term impact of IPV on their children. Another large scale survey of 3,824 men attending a court-ordered evaluation subsequent to being convicted of assault against an intimate partner revealed that 66% of the men had some type of fathering role with children under the age of 18 and in most cases, these relationships continued following their arrest. The majority of the men acknowledged that their children had been exposed to interparental conflicts, but fewer perceived that their children had been affected by the arguing [15]. Interventions that build on fathers existing commitment to their children may be an effective approach with a subset of these men.

Several qualitative studies have emphasized that not all men who perpetrate violence against a spouse/partner adopt unhealthy attitudes regarding their fathering role. In their study of interparentally violent fathers, Perel and Peled [23] concluded that most fathers desired more warm, involved, and connected relationships with their children. This is consistent with an interview study by Fox and colleagues [22], which revealed that men experienced a significant amount of shame, guilt, and remorse when thinking about the harm they may have caused their children. There is also evidence that many fathers wish to shield and protect their children from their anger [24].

IPV and substance abuse are intergenerational problems. Research studies have highlighted the continuation of aggression, alcohol/substance use and maladaptive parenting from one generation to another within a family [25]. An intervention that emphasizes the multigenerational nature of these issues, allows a father to begin to have an understanding of how his own childhood experiences impact his current behaviors and choices and provides him tools to cope and co-parent his own child differently, could have substantial impact.

An integrated approach may require a change to the current parameters on IPV interventions for offenders. States often prohibit inclusion of partners or families in court mandated programs for male offenders [26, 27]. This is despite mounting evidence nearly half of IPV cases are bidirectional and perpetrated by men and women at equal rates [28–31]. Additionally, for men with co-occurring IPV and substance issues, their partners often report using violence in the relationship and abusing substances at the outset of treatment and continue this behavior while their partners are in treatment[32]. A lack of assessment of the family system and inclusion of partners can hinder progress in treatment. While the unwillingness to treat couples or families appears justified in the most extreme cases of violence, coercion/control and maltreatment, fathers who perpetrate mild to moderate IPV could benefit from couples intervention. Especially given several interventions for IPV have shown good outcomes with the implementation of a couple component to treatment [33–36]

Description of the Intervention

Fathers for Change is designed to be offered individually to fathers who have young children (under 10 years) with a history of IPV, defined as threatened or actual sexual or physical violence against an intimate partner. The Fathers for Change intervention includes 16 topics to be delivered in 60 minute sessions of individual or dyadic treatment over the course of four to six months. The intervention combines psychodynamic, family systems and cognitive behavioral theory and techniques and builds on previous interventions like Behavioral Couple Therapy (BCT) [34, 37] and Substance Abuse Domestic Violence CBT (SADV) [33] with the goals of: 1) decreased violence and aggression; 2) decreased alcohol and substance abuse when indicated; 3) improved co-parenting; 4) decreased negative parenting behaviors; 4) increased positive parenting behaviors; 5) increased positive family interactions and activities; and 6) decreased child symptoms.

Following assessment, treatment progresses first to individual sessions followed by co-parenting sessions and ending with father-child sessions. The areas of focus for each of the three phases of Fathers for Change are: 1) abstinence from aggression and substance abuse; 2) co-parenting; 3) parenting/father-child relationship. Fathers for Change is designed to allow for optional co-parent participation in a portion of the sessions. If parents are living together and/or both want to participate in the treatment, the appropriateness of this should be determined during the course of an assessment/evaluation. Fathers must successfully move through the early session components, be active participants, and take some responsibility for their previous behaviors in order for treatment to move into co-parent or dyadic treatment sessions. Fathers for Change is unique in its focus on the paternal role throughout treatment, both in terms of the father-child and the co-parenting relationships. The central premise is that focus on men as fathers and increasing their feelings of competence and meaning within their parenting role, will provide motivation to change maladaptive patterns that have led to use of aggression and substances to control negative or inefficacious feelings.

Phases of Treatment with Case Example

Pre-Treatment Assessment

Thorough assessment of the father and the family context by a clinician is the first step in the program. The specific needs of a particular father and his family must be carefully assessed and considered when determining appropriateness of the intervention. Appropriate risk assessment is of particular concern and use of the Danger Assessment Scale [38] and the methods developed by Hilton and colleagues [39, 40] are an integral part of the Fathers for Change intake evaluation. Other areas of assessment and measures used include: severity of substance use (Addiction Severity Index [41], Michigan Alcohol Screening Test [42, 43], urine toxicology), severity of violence (Conflict Tactics Scale-Revised; CTS2 [44], Timeline Followback Calendar [45]), psychiatric symptoms (Brief Symptom Inventory [46], Beck Depression Inventory, Posttraumatic Checklist [47]), parenting behaviors (Adult-Child Relationship Questionnaire [48, 49], IOWA Family Interaction Scale [50], Parenting Alliance Inventory [51], Parental Acceptance Rejection Questionnaire; PARQ [52]), motivation for change, trauma history (Childhood Trauma Questionnaire [53, 54]) and willingness to take responsibility for previous violent behavior. Last, arrest and child protective services records are requested and reviewed with written permission from the father.

Prior to involvement of the child in treatment, mothers must consent to their child’s participation. Whenever possible, collateral information is gathered from the mother to gain a fuller picture of the family dynamics and issues. This assessment session with mothers is done individually and separately from the assessment of the father. She completes a similar set of measures to those of the father described above with a particular emphasis on risk assessment and her report his violence and substance abuse. Last, children must be assessed to determine that dyadic treatment with the father is appropriate and not contraindicated at the present time (e.g. child is extremely symptomatic and treatment with his/her father could exacerbate present symptoms). This is done via interview with each parent about symptoms of the child using the Child Behavior Checklist [55] and by observing the child with the father in a dyadic play assessment.

Zane¹ was a young adult father of two year old Greg. Zane was referred to Fathers for Change following two arrests for domestic disputes in rapid succession. Child Protective Services (CPS) was involved with the family prior to the domestic disputes because Amanda had a significant drug history and was in recovery. The CPS worker referred Zane to the program because she was concerned about his drinking and aggression in the home. She reported that she had observed Zane’s strong commitment to Greg and generally good parenting behaviors.

Assessment of Zane and his family revealed that Zane had a significant history of exposure to domestic violence, psychological abuse and community violence growing up. He currently was abusing alcohol to deal with stress, but was not alcohol dependent. He was not abusing any other drugs. He had a full-time job and worked double shifts to support Greg and Amanda. He reported some moderate trauma related symptoms and anxiety. He became quite angry and animated when he talked about Amanda and her addiction problems. He felt strongly that she needed to keep it together for Greg and had little empathy for her ongoing struggles to remain clean. He clearly took responsibility for his aggressive behavior. He was worried about his son and what he was witnessing in the home. Interview with Amanda provided corroboration of the reported levels of hostility and aggression in the relationship and Zane’s commitment to parenting Greg. A play assessment with Zane and Greg revealed that Greg was developmentally on target and interacted nicely with his father.

Phase I: Individual Sessions with the father

Individual sessions focus on two areas: 1) Helping the father to examine how he was parented, how his childhood experiences impact his parenting, and his wishes about the kind of parent he wants to be to his own child; and 2) Coping skill building to aid the father in his affect regulation. These sessions serve to motivate fathers by focusing on their roles in their children’s lives. What does it mean to them to be a father? What is a father supposed to do? What have been their experiences of being fathered? What did they most want from their fathers as children? Use of genograms and discussion of multigenerational transmission of IPV, substance abuse and parenting problems are discussed with each father to help him begin to recognize the ways in which he has not been prepared to have healthy relationships with his co-parent or his child. Exploration of the unique impact of witnessing IPV and parental conflict on his children is emphasized in these early sessions to increase his motivation to change these behaviors. These first 4 sessions pave the way for a series of coping skills sessions that utilize cognitive behavioral therapy techniques used in other treatment approaches for aggression and substance use (e.g. [33]). Cognitive Behavioral Therapy skills such as relaxation, feelings identification and regulation and cognitive processing are each reviewed in relation to the father’s use of aggression, substances, and negative parenting behaviors. Skill modules used in other CBT treatments have been adapted to focus more specifically on parenting and relationship cognitions and their association with substance use and aggression [33].

Initial individual sessions with Zane focused on what being a father meant to him. He described two areas: 1) being there for his son (unlike his own father), and 2) providing financially for the family. Exploration of other important contributions fathers make to their children’s development and what he hoped to teach Greg about how to be a good partner and father were emphasized. This was contrasted with his experiences in his own family of origin where he experienced loss, abuse and witnessing IPV. Zane was able to reflect on what he wanted from his parents as a child and begin to think about the emotional needs of his son in addition to his physical needs.

Zane was now quite motivated to change his behaviors and attended sessions without fail. He actively participated in CBT coping skills sessions focused on relaxation skills, feelings identification and modification (especially anger) and cognitive coping. He typically had negative and paranoid thoughts about Amanda. Zane and his therapist explored these negative thoughts and alternative more positive ways of thinking that would lead to less conflict and anger toward Amanda. It was clear that Zane was thinking these negative thoughts on his way home each day (e.g. “She probably didn’t clean the house or look for a job today,” “She probably sat around all day and the house will be a mess.”). He would enter their apartment hostile and would only see negatives. Replacing his negative thinking on the way home was hugely helpful to Zane. He would think about how well Amanda was taking care of Greg or how happy he would be to see Gregg when he got home. This would allow him to arrive home in a positive state of mind and resulted in far fewer arguments in the evenings.

Structured focus on the importance of co-parenting

The second phase of treatment focuses on the importance of and improvement of the co-parenting relationship. These sessions may be implemented individually or as dyadic sessions with his child’s mother. Concrete definitions of co-parenting, common co-parenting pitfalls, and methods of strengthening co-parenting distinctly and separately from the intimate or romantic relationship are emphasized. Communication and problem solving skills are introduced and practiced in session similar to other models that work with aggressive and substance abusing couples [33, 36, 37]. Communication practice is focused on co-parenting issues (e.g. visitation exchanges or disagreements about discipline). The focus on co-parenting is important because positive co-parenting even in the context of a conflicted intimate relationship can be protective and result in better child adjustment [56]. Additionally, co-parenting has been shown to have a much stronger influence on parenting and child adjustment than other aspects of the couple relationship [51, 57–59]. Focus on the importance of each parents’ roles in teaching their children about how to be in relationships and how they can expect to be treated by their partners and people they love in the future is a key component of these sessions.

Co-parenting sessions began with a focus on the difference between co-parenting and intimate relationships and the importance of Zane and Amanda’s co-parenting roles beyond the success or failure of their intimate relationship. Zane’s concerns about Amanda’s addiction issues and desire for her to move out and focus on her recovery were discussed with them together. Following two dyadic co-parent sessions, Zane’s fury at Amanda about a relapse to use prompted him to request an emergency session with his clinician. He was able to talk through his anger at Amanda. This anger was primarily a result of his worries about Greg and his son’s need for a mother. Given the previous work on the importance of maintaining a co-parenting relationship with Amanda, he was able to focus on Greg’s needs and how he could talk with him about his mother moving out. Zane needed help with what language to use and how to help Greg cope. The therapist worked with Zane on how to manage his angry feelings at Amanda, while focusing on Greg’s need to see his mother, facilitate positive visits and minimize conflict in front of Greg.

Father-child relationship enhancement and modeling of parenting skills

The third phase of treatment is dyadic father-child sessions. These sessions are with both father and child present and utilize aspects of Child-Parent Psychotherapy [60, 61]. Studies have shown that dyadic treatments with mothers and young children have a positive impact on the parent-child relationship and decrease symptoms for both mothers and young children [60, 62]. Inclusion of parenting and direct work with fathers and their children is a unique aspect of Fathers for Change. The clinician who has been working with the father through the first two phases of treatment now works with the father to develop goals for the dyadic sessions. These goals are determined by the specific needs of the father-child pair. Typical goals include: 1) the father taking responsibility for his previous negative behaviors, apologizing and explaining in age appropriate terms the work he is doing in treatment to learn new ways of coping with his feelings; 2) the father gaining greater understanding of the meaning of his child’s behavior; 3) improved father-child play interactions; and 4) improved implementation of parent management strategies.

Father-child sessions focused on helping Zane use age appropriate language to explain to Greg why the parents were not living together and the schedule for visits with his mother. Zane now understood Greg’s need to see his mother and the importance of reducing conflict during visitation exchanges. The therapist also focused on Zane’s reflective capacity with regard to Greg’s feelings and why he might be worrying about being separated from his father. Child directed play was modeled and implemented during father-child sessions to highlight for Zane how important this was for Greg.

At the conclusion of the program, Zane had not had any physically violent incidents with Amanda over the 4 months of treatment. He had reduced his alcohol use to an occasional drink every few weeks when he went out with friends. He had a solid understanding of the important role he was playing not only as a financial but emotional provider for his son. Zane reported that without help from the program, he was certain he would have become aggressive with Amanda around the time of her relapse. He would not have focused enough on the needs of his son or the impact of his behavior toward Amanda on Greg.

Preliminary Feasibility

Ten fathers have completed the Fathers for Change program. Fathers in this pilot implementation of the program were referred by Family Relations Counselors from the court or Child Protective Services as a result of an arrest for IPV. Fathers were 70% Hispanic and 30% African American with an average age of 25 years. Twenty percent of fathers were married to their youngest child’s mother, 30% were in a live-in relationship with the mother, 30% were in a relationship but not living with the mother, and 20% were single. Men had an average of two children and 50% had current involvement with Child Protective Services. At the time of intake assessment, 50% of fathers were abusing alcohol with an average of 12 days of drinking per month. One father met criteria for alcohol dependence. The other 50% of fathers were abusing marijuana with an average of 8 days of use per month. One father met criteria for marijuana dependence. Mean CTS2 Physical Aggression scores were 8.5(6.88) and Psychological Aggression Scores were 19.8(17.35). PARQ Parenting Hostility scores averaged 18.75(2.63). Ninety percent of the fathers reported experiencing childhood abuse or neglect or exposure to IPV as a child.

Men completed weekly logs during treatment of their aggression and substance use using methods developed by Fals-Stewart and colleagues [45] and post-treatment satisfaction surveys to provide information about what components of the intervention were helpful. All 10 who completed the program remained non-violent during treatment and reduced their substance use. Eighty percent became abstinent during treatment. One was referred to a higher level of substance use treatment due to his inability to abstain from marijuana and another had reduced his alcohol use from multiple days per week to two times per month.

Drop-out rates were low with 15 fathers initially referred. Of these, two were found inappropriate based on assessment, and three dropped out within the first two sessions. This drop-out rate of 20% is well below the 40–50% reported in the IPV intervention literature [63]. Those who completed the program unanimously found it helpful, would recommend the program to their friends or family, and found all three phases of the program helpful. Based on these promising pilot results, Fathers for Change is now being tested in a small randomized trial funded by the National Institute of Drug Abuse. A written manual and training material have been developed for use in the trial [64]. Efficacy in a research trial is the next step in the development of this intervention, as we cannot draw conclusions about the broad applicability of Fathers for Change based on this small sample.

Conclusions

Fathers for Change has shown initial feasibility with a small pilot sample and now requires further study to determine its effectiveness in working with fathers with a history of IPV and substance abuse. Focus on men’s roles as fathers and their wishes for their children may be a powerful motivator for change. Flexibility and working with men in an individual fashion can allow for more specific tailoring of intervention needs, which could result in better outcomes for the men and their families. If research evaluation finds Fathers for Change to be an effective intervention to reduce IPV and substance abuse, examination of current state policies around domestic violence interventions will be needed to allow for more individually focused intervention approaches that may include partners and children.