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A Case Study of Cognitive-Behavioral Psychotherapy With a Perpetrator of Domestic

Abuse
Michael Townend and Margaret E. Smith
Clinical Case Studies 2007 6: 443
DOI: 10.1177/1534650106295899
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A Case Study of Cognitive-Behavioral

Psychotherapy With a Perpetrator
of Domestic Abuse

Clinical Case Studies

Volume 6 Number 5
October 2007 443-453
2007 Sage Publications
10.1177/1534650106295899
http://ccs.sagepub.com
hosted at
http://online.sagepub.com

Michael Townend
Margaret E. Smith
University of Derby, UK

This is a case study of a male perpetrator of domestic abuse who voluntarily sought help for
abusive behavior toward his partner. The case is described, highlighting a 20-week treatment
plan underpinned by an interacting cognitive subsystem-based conceptualization. Evaluation
of the therapy is by self-report measures of aggression, assertiveness, and dysfunctional attitude that were administered pre- and posttherapy and at 9-month follow-up. The results are a
reduction in aggressive behavior and improved assertiveness, whereas dysfunctional attitudes
changed to a profile of greater psychological strengths. Implications for therapeutic intervention and development are also discussed.
Keywords:

domestic abuse; perpetrator; cognitive therapy; voluntary

1 Theoretical and Research Basis

Domestic violence is a major social problem, with estimates suggesting that one fourth
of all women and one sixth of men experience domestic abuse during their lifetime
(Mirlees-Black, 2004). This rate of abuse is important not only socially but also because of
the psychological and physical consequences of such abuse. The psychological consequences are reported to include depression, posttraumatic stress disorder (PTSD), alcohol
misuse, drug misuse, and chronic low self-esteem (Byrne, Byrne, Hillman, & Stanley,
2001). It is further estimated that physical injury because of perpetrator aggression is highly
significant, with pregnant women being at particular risk (Neggers, Goldenberg, Cliver, &
Hauth, 2004).
Domestic abuse can take both active and passive forms and can include physical and verbal
aggression, financial control, sexual abuse, emotional and psychological manipulation, and
neglect. A working definition is proposed by the British Home Office (2000):
Any incident of threatening behavior, violence or abuse (psychological, physical, sexual,
financial or emotional) between adults who are or have been intimate partners or family members, regardless of gender. (p. 1)

Despite prevalence of domestic abuse and its social and psychological consequences, there
is a paucity of studies for individual, one-to-one intervention programs. Most of the studies in the literature are based on group therapy, with recidivism rates ranging from 16% to
47% (R. M. Tolman & Edleson 1995). Babcock, Green, and Robie (2004) conducted a
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meta-analysis of the findings of 22 studies evaluating treatment efficacy. Studies reviewed

tested the relative impact of the Duluth model, cognitive-behavioral therapy, and various
other types of treatment. Recidivism was used as the main dependent variable. The effective
sizes overall, although significant in terms of a reduction of episodes of domestic abuse,
were small, with no differences being found in effectiveness among any of the interventions.
There are also reports where perpetrators of domestic violence have been mandated by
the courts to undergo psychological therapy. Tolman and Edleson (1995) report that perpetrators who are mandated to treatment are associated with lower recidivism than untreated
control groups. Palmer, Brown, and Barrera (1992) conducted a study with random assignment of batterers to treatment or to a no-treatment control group. In this study, 30 courtmandated batterers were assigned to a psychoeducational or a cognitive-behaviororiented
program. In this study, 10% of treated batterers and 30% of psychoeducation-only controls
recidivated. Results from these studies thus indicate a relatively poor outcome in terms of
offending behavior, with high drop-out rates being the norm (Barnish, 2004; Gondolf,
2002). This may be because of the high prevalence of personality disorders within courtmandated domestic abuse samples (Barnish, 2004; Gondolf, 2002).
Several suggestions have been put forward as contributing to the development of domestic abuse. These have included formative hostile family environments, observation of abuse
between parents, being bullied at school, bullying from siblings, unresolved loss, lack of
discipline, and overcontrolled environments during childhood (Aldarondo & Sugarman,
1996; Dutton, 1998, 2000). The evidence thus suggests an absence of a singular causative
factor as the origin of domestic abuse.
Although the emphasis in this case study will concern therapy for perpetrators of domestic abuse and aggression, it has not been our intention to ignore the needs of survivors of
domestic abuse. What is evident is that many survivors become entrapped within violent
and abusive relationships, and therefore without changing the unacceptable and abusive
behavior of perpetrators, the abuse in many cases is likely to continue. There is therefore a
clear need for both survivors and perpetrators who require help to have appropriate access
to psychological and social therapies to reduce the psychological, physical, and social longterm effects of abuse.
This article reports a case study within the context of a prevention of domestic abuse service funded by the National Lottery Commission in the United Kingdom, established to
research and develop a domestic abuse program for perpetrators and survivors of domestic
abuse. The model that underpinned this approach was based on ICS (interacting cognitive
subsystems; Teasdale & Barnard, 1993). This theory was chosen to underpin the program
because of research hypotheses concerning the importance of schema and behavioral factors in the maintenance of abuse cycles.
ICS theory differs in an important way from Becks model (Beck, Rush, Shaw, & Emery,
1979) of emotional disorders in that it specifies two qualitatively different levels of meaning. These different levels of meaning are assumed to play different roles in the production,
maintenance, and modification of emotion and recognize the distinction between cold or
intellectual thoughts (propositional) and hot or emotional beliefs (implicational).
ICS theory suggests seven input subsystems into the central engine of the model.
These subsystems are proprioceptive (feeling sense), imagery (visual images), visual (what

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the person can see in the environment), acoustic (what the person can hear), peripheral,
articulatory (movement), and morphonolexical (what is said to the person). These subsystems feed into the two main systems that are responsible for the management of meaning
the propositional (moment by moment verbal meaning) and schematic or implication
meaning. The central engine of the theory is thus the interplay between the propositional
and implicational levels of meaning.
The propositional level according to ICS is not directly linked to the generation of emotion but is characterized by a memory system of verbal, nonemotional representations of
meaning. Emotion, according to ICS, is generated through the activation of a generic and
holistic affect-related implicational beliefs system again stored within its own memory
structure. This implicational system stores holistic meanings, patterns of direct sensory
inputs, details of environmental events, and responses derived from a wide variety of inputs
(Gumley & Power, 2000).
The configuration of these multiple and multilevel elements in people who abuse others
and have anger-control problems leads to the perpetuation of idiosyncratic models, where
the self or others are viewed as weak, the environment or others becoming encoded as
threatening, the world being perceived or felt as an unpredictable place of injustice that is
beyond an individuals control. For example, anger might be triggered by any number of
elements within the overall configuration, such as being physiologically aroused. The emotive and behavioral responses are then maintained by an interlock (Barnard, 2004;
Teasdale & Barnard, 1993), which is a self-perpetuating loop among threat, injustice configurations that have been encoded, the individuals higher-order view of anger as a way of
coping with threat or perceived injustice, and the cognitive and sensory subsystems. The
distinction between propositional and implicational systems is particularly important as it
can explain the non-cognitive automatic arousal reported in many people with angercontrol problems (Power & Dalgleish, 1997), and the notion of interlock can be used to explain
ruminative processes found in people who engage in abuse and show poor anger control.

2 Case Presentation
Michael was a 36-year-old, White man who was seen at a specialist service for perpetrators of domestic abuse. The second author carried out the intake assessment and provided
all the therapeutic interventions. The second author is trained to the postgraduate level in
both integrative counseling and cognitive-behavioral psychotherapy. The assessment indicated that Michael was an appropriate candidate for the domestic abuse service on the
grounds that he was voluntarily seeking help and acknowledged his problem.

3 Presenting Complaints
Michaels presenting problem was physical and verbal aggressive behavior toward his second
partner. This usually consisted of screaming at his partner, followed by kicking or pushing her.
He was irritable and angry on a daily basis and was violent to his partner at least once per week.

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4 History
Historically, Michael was aware that he had previous problems during his first relationship
because he was jealous and mistrusting, but he was not aggressive at that time. He recognized
that his feeling of rejection had been established from early on in his childhood. Michael
described how he had been adopted before age 2 and that his adoptive father had rejected him.
He described him as cold and distant. He also felt that his adoptive mother was critical and
rejected him. He also believed that he had never lived up to her expectations. He had been
bullied at school because of his adoptive parents financial wealth in relation to the surrounding social environment and because of the color of his hair. Throughout his life, he had found
social relationships difficult to form. When seen for therapy, he was working as a charity
worker, and he was finding his job difficult because of being unable to assert himself within
his work place. Because of his early experiences, he felt that others had hostile intentions
toward him, that he was different from others in a fundamental way, and also that he was
unlovable. He had never been diagnosed with a mental health disorder. His first marriage had
ended in divorce after 3 years. He had been married to his second wife for 13 years, and they
had a 12-year-old son.

5 Assessment
The careful and systematic assessment of aggressive behavior in the context of domestic abuse is important both theoretically and clinically. Huesmann, Eron, Lefkowitz, and
Walder (1984), in a longitudinal study, showed that aggression predicted later antisocial
behaviors. Although this is an important predictor for development of domestic abuse,
aggression is also a multidimensional construct. Therefore, having an accurate understanding of the initial development, maintenance within contextual factors, and manifestations
of aggression is important both for researchers and clinicians. This is important in the field
of domestic abuse to develop knowledge of the idiosyncratic nature of the complex problems with which perpetrators of domestic abuse present.
At the initial intake interview, a detailed functional analysis of Michaels presenting
problems was undertaken. This included assessment of his beliefs about himself, his beliefs
about his partner and their relationship, beliefs by which he justified his behavior, and
behavioral, sensory, and cognitive maintaining factors. The functional analysis revealed
multiple triggering events to the aggression that were (a) when his partner told him that she
loved him, (b) when he interpreted his partner as accusing him of wanting a relationship
with another woman when he did not, and (c) when he blamed himself for his partners
emotional states. There was also a number of environmental and interpersonal antecedents
for his domestic abuse, such as his expectations of others not being met, frustration when
driving, minor accidents, stress from work, or drinking more than four units of alcohol.
Prior to episodes of domestic abuse, he would think that his wife did not love him and must
be planning to leave. Immediately after aggressive behavior, he would experience a release
in tension, with an almost immediate feeling of guilt.
His motivation was also assessed by asking him about his goals for therapy, which he
was able to describe as stopping abusive behavior. A full personal and life history was taken

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to contextually understand the presenting problem and form hypothesis as to the origins of
his unhelpful beliefs and abuse behavior patterns. He was also formally consented to participate in this case study research. His name and other factors that might lead to him being
identified have been changed to ensure his anonymity.
Case study research can also help to facilitate the development of new theory and interventions (Tolman & Dugard, 2001). Use of single case study methods confers a number of
distinct and important advantages over larger controlled studies as they enable a close
examination of the effects of particular interventions at an idiosyncratic level, which we
were interested in exploring through this case study.
The study method adopted with this case was a multiple baseline applied behavioral
analysis design. The overall baseline period of measurement was 4 weeks. This was followed by the manualized, ICS-based cognitive-behavioral intervention for 20 weeks with
follow-up at 3, 6, and 9 months.
The dependent measures used in this case study were the Aggression Questionnaire
(Buss & Perry, 1992). This measure is widely used in aggression research and consists
of 29 items divided among four scales: Physical Aggression (9 items, average score for
men = 24.3), Verbal Aggression (5 items, average score for men = 15.2), Anger (7 items,
average score for men = 17.0), and Hostility (8 items, average score for men = 21.3). The
overall scores can range from 29 to 145, with an average score for men of 77.5. This multivariate model of aggression is supported by relatively recent research (Bernstein & Gesn,
1997). Another dimension that we measured was assertiveness. In our experience,
assertiveness is an area with which many perpetrators of domestic abuse have difficulty.
Assertiveness is the ability to make appropriate requests; actively disagree with other people;
express personal rights or feelings on issues; initiate, maintain, or disengage from conversations; and stand up for oneself. Assertiveness was measured by the Rathus Assertiveness
Schedule (Rathus, 1973). The Rathus Assertiveness Schedule is a 30-item scale that is
designed to measure a range of assertive and nonassertive behaviors. Each item is scored
on a 6-point Likert-type scale ranging from 3 (very uncharacteristic of me) to 3 (very
characteristic of me). Total scores can thus range from 90 to 90. The scale has been shown
to have an internal consistency alpha of .77 and a test-retest reliability coefficient of .91
(Pearson, 1979; Rathus, 1973). Reactivity to provocation was another dimension that was
assessed. To assess reductions in this from the therapy, the Reaction Inventory (RI; Evans
& Strangeland, 1971), a 76-item scale, was used. Its authors report very good internal consistency for the overall scale (about .9). The authors offer no indication of validity. The
Dysfunctional Attitude Scale (Weisseman & Beck, 1978) was also used. This scale contains
six subscale profiles consisting of Approval, Love, Achievement, Perfection, Entitlement,
Omnipotence, and Autonomy. This scale has demonstrated good construct validity, internal
consistency, and test-retest validity (Power et al., 1994).

6 Case Conceptualization
Michaels abusive behavior and aggression within his second relationship were reported as
being triggered by a number of internal (felt) and external events. Michaels first marriage
had ended when his first wife had left him, saying that she no longer loved him. A speculative

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hypothesis was formed during the assessment that abusive and aggressive behavior had
occurred because of development of an implicational system related to further rejection. This
can be predicted by ICS theory (Barnard, 2004; Barnard & Teasdale, 1991), in which there
are seven subsystemsproprioceptive (feeling tense), imagery (images of being rejected),
visual (a frowning look), acoustic (a critical tone), peripheral, articulatory (a move away),
and morphonolexical (what is said). These all feed into the two main subsystems of momentby-moment meaning and the higher-order implication meaning.
This ICS interacting view is supported by the case conceptualization, as Michael would
often experience immediate hostile negative automatic thoughts that his second wife could
not love him. The thoughts were underpinned by implicational beliefs that she must be saying that she loved him as a ploy toward leaving him and that he would inevitably be rejected
because he could never be lovable. Once this implicational level of meaning had been triggered, the global sense of being unlovable and the fear of being rejected elicited an emotional response of fear and anger. This emotional response was accompanied by a
physiological response of increased heart rate, sweating, and tensing up of muscles. He
then would become preoccupied and ruminate about being rejected. Finally, this would lead to
an aggressive behavioral response. These aggressive responses would occur almost immediately in some situations and in others only after a period of rumination. Once the tension
had been released by the aggressive behavior, the implicational meaning structure was also
further reinforced as his partner withdrew from him, further reinforcing his hostile
appraisal of contemporary events. Michaels conceptualization is shown in Figure 1.

7 Course of Treatment and Assessment of Progress

The model of therapy developed to treat perpetrators of domestic abuse was based on the
theoretical premises of ICS. This theory was used to facilitate conceptualization and understanding of both rumination-provoked and automatic anger. These factors were hypothesized
as the keys to the maintenance of the domestic abuse. ICS can also be used to conceptualize both the distorted content and thinking processes exhibited by many perpetrators of
domestic abuse to justify their unacceptable behaviors.
The therapy developed incorporates learning self-control and regulation skills, followed
by cognitive and behavioral interventions to modify the unhelpful propositional and implicational systems. Homework, recognition of the problem by the client, and adherence were
integral aspects of the program.
The framework of the program followed a weekly structure of the following:
1. Pretherapy assessment: This included intrinsic motivation, risks posed, decision for suitability for the program, and measures completion.
2. Weeks 1 to 2: A full cognitive-behavioral assessment and individual conceptualization
and socialization to the ICS-based program were carried out.
3. Weeks 3 to 4: Identification of internal and external triggers for abusive behaviors through
assessment and self-monitoring diaries was carried out, with education and initial
conceptualization shared with full explanations regarding interlock-maintaining belief
systems and ruminative processes. Work also began at this stage on the identification and

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Figure 1
Idiosyncratic Conceptualization for Michael, a Perpetrator of Domestic Abuse,
Based on Interacting Cognitive Subsystems Theory

Sensory
Body State
Muscular
Tension

Bodily
Effects
Arousal

Sensory Loop
AngerSchematic Model
(implicational)
Im unloveable/ Ill be rejected with
increased vigilance and scanning

Cognitive Loop
Rumination and
Preoccupation

AngerRational Propositional
Meanings
Why is she telling me now? If
shes saying she loves me then she
must be planning to leave me

Rational
Negative
Meanings
(propositional)

4.

5.

6.

7.
8.

Kicking Partner
Screaming
ANGER

Negative
Automatic
Thoughts
(speech level)

challenging of thoughts and meanings that seek to justify or avoid taking responsibility
for the domestic abuse.
Weeks 5 to 6: This consisted of stimulus control and coping-strategy enhancement,
including early recognition of physical tension or arousal, flash points, and activation of
unhelpful thinking and bodily states.
Week 7: This included a more detailed identification and understanding of physiological
and ruminative responses to implicational system activation during abusive incidents,
with further coping-strategy management, including distress or trigger tolerance training
through real-life and imaginal exposure.
Weeks 8 to 10: Continuation of cognitive restructuring was carried out with links made to
implicational and abuse-justification schemas. Links were also made between physiological, behavioral, and environmental triggers and responses. The conceptualization was
subsequently updated according to specific targeted work.
Week 11: This focused on consolidation of therapy with a problem-solving focus and further homework to consolidate progress.
Weeks 12 to 13: During this phase, a review of propositional beliefs in relation to abusive
behavior took place. Further hypotheses were formed, and the conceptualization was
updated as to the structure and content of the implication system and its lifeline formation
through prior learning experiences. Current family or personal rules in relation to the

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historical family context were also hypothesized with the client. New models of thinking,
feeling, and responding were discussed, with a plan agreed to begin to develop a new
implicational system. This was achieved through cognitive and behavioral strategies, particularly behavioral experiments, positive data logging, and exposure.
9. Weeks 14 to 17: Continued work was carried out through the critical life events in childhood, adolescence, and adulthood in relation to implicational system development.
Positive data logging, challenging unhelpful beliefs, and rules were used to strengthen
new implication systems through a continuation and recording of behavioral experiments
and flash cards.
10. Weeks 18 to 20: This included development of maintenance strategies through the
medium of a relapse blueprint to consolidate the new implicational model and prevent
future reoccurrences of domestic abuse.

Michaels response to the program was very positive. This was probably because he
engaged with the therapeutic process because of an intrinsic motivation to change unacceptable behavior. Regular reviews with Michael indicated that he found the cognitive
focus of the program useful to develop his understandings of his own beliefs and responses.
He also indicated that the coping-strategy development, behavioral experiments, and exposure facilitated changes in his implicational system through new and more helpful experiences and interpretations. He also reported that the process of therapy itself was helpful,
with an accepting and understanding environment that accepts the person, demonstrates an
understanding of his or her behavior and distress, empathizes with the distress, and recognizes the possibility of change but does not condone or accept domestic abuse as an acceptable form of expression in any of its forms.

8 Complicating Factors
Michael did initially justify his actions on the grounds that his behavior was because of
provocation and that he could not help himself. But this quickly changed with cognitive
restructuring aimed at these beliefs and as he began to understand the nature of the therapeutic program.

9 Managed Care Considerations

The domestic abuse program developed for voluntary help seekers such as described in
this case study opens up the opportunity for a significant number of perpetrators who recognize and wish to change their problematic behavior. Such help is rarely available within
the United Kingdom despite the high prevalence of the problem and the associated costs to
society. This is, perhaps, surprising, as many of the problems associated with domestic
abuse and its consequences might be prevented with early intervention given the known
associations of domestic abuse with trauma, depression, anxiety, low self-esteem, and medical costs. There is also the huge and sometimes chronic and disturbing impact of domestic abuse on children and the wider family network.

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Table 1
Treatment Outcome Scores at Baseline, Posttreatment, 3-Month Follow-Up (3mfu),
6-Month Follow-Up (6mfu), and 9-Month Follow-Up (9mfu)
Clinical Measure
Aggression Questionnaire
Physical
Verbal
Anger
Hostility
Total
Reaction Inventory
Rathus Assertiveness Inventory
Dysfunctional Assumptions Scale
Approval
Love
Achievement
Perfection
Entitlement
Omnipotence
Autonomy

Baseline 1

Baseline 2

Posttherapy

3mfu

6mfu

9mfu

39
18
30
26
113
228
53

41
20
32
30
123
223
56

24
10
16
16
66
183
17

28
13
16
16
73
218
29

25
9
15
12
61
182
29

22
11
13
9
55
181
7

6
8
8
5
3
6
1

5
5
5
5
+1
5
4

+3
+3
+5
1
+6
+4
+8

1
1
4
5
1
+1
0

+1
2
0
2
0
2
0

+2
+1
3
3
+1
+4
+1

10 Follow-Up
Michael improved with cognitive-behavioral psychotherapy for domestic abuse following the 20-session format (see Table 1). The follow-up period was important, as any valuable intervention must be able to demonstrate maintenance or continued improvement after
the active intervention phase has been completed. The self-report measures of outcomes
suggested significant improvements in a number of areas at 9-month follow-up. There was
an apparent reduction in his aggression. His partner was also interviewed, and she independently confirmed this. His reactivity to provocation was also reduced on the RI,
although he did continue to report increased tension and a tendency to ruminate about
rejection at times of stress. Although not directly targeted for therapy, his assertive behavior and the appropriate expression of his emotions also improved. This, we hypothesized,
was because of the development of a new, more adaptive implicational system.

11 Treatment Implications of the Case

This case study is relevant because it demonstrates the effectiveness of psychological
therapy in the previously underresearched area of individual cognitive-behavioral therapy
for domestic abuse. The case study shows an improvement through a reduction in domestic abuse and aggression with an individual without a diagnosis for a preexisting personality disorder. The client was not mandated and sought out therapy, indicating a degree of
insight and motivation for change. Results from this study have the potential to assist further development of psychological therapy for perpetrators of domestic violence.

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12 Recommendations to Clinicians and Students

The ICS theory of the program of therapy underpinning this case study specifically targets meanings, sensory elements, and cognitive processes of anger and justification of
domestic abuse as a means to changing aggressive or other abusive behavior. The distinction between propositional and implicational meanings subsystems is important in conceptualizing domestic abuse and anger in terms of two important and sometimes puzzling
elements for both the clinician and the client, respectively. These are the tendency for the
abusive or aggressive behavior to occur immediately (directly via the implicational route)
or after a delay following rumination and preoccupation (indirectly via the propositional
route). It can also help clinicians to understand beliefs held by the client that are clearly distorted and seem to go without question by the perpetrator of domestic abuse to justify his
or her inappropriate behavior. This again can be conceptualized as a representation of the
implicational system and is therefore difficult for the client to articulate. Conceptualization
is at the heart of the therapeutic process, and when a comprehensive conceptualization is
developed in a way that seems to fit the presentation and responses of the client, then alternative implicational models can be built through cognitive restructuring, behavior changes,
and the development of adaptive coping.
A further implication for the clinician is the value of working with a systematic, manualbased therapy program. The conceptual component gives the clinician the flexibility to work
on an individualized basis with the client while ensuring that the chosen interventions have
research evidence that supports their utilization within the context of the case.
Our results are important in relation to effective evidence-based assistance for perpetrators
of domestic abuse. Further research is indicated and is ongoing for this significant psychological and social problem. This program is now being tested within a larger controlled trial.

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Michael Townend is a reader in cognitive behavioural psychotherapy and the program leader for the Msc in
cognitive behavioural psychotherapy and PG certificate in clinical supervision at the University of Derby. He
has 16 years experience in cognitive behavioural psychotherapy both in the NHS (inpatient, community, and
primary care) and in private practice. He has published in a number of cognate areas to cognitive behavioural
psychotherapy, including single case studies, clinical supervision, consumerism, interprofessional working, and
user involvement. His current research activities continue in these areas.
Margaret E. Smith is the program leader for the MA in integrative counselling practice at the University of
Derby. She worked in the banking and computer industries until 1989, prior to working in private counselling
practice in 1990. She has subsequently worked as a counsellor and trainer for an organisation she founded to
provide counselling and training in the field of domestic abuse following the completion of her masters degree
in 1996. Her PhD is in the efficacy of CBP for perpetrators of domestic abuse.

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