Ensayo

A complexity-based approach to batterer intervention programmes

Programas de intervención con agresores por violencia doméstica desde la perspectiva de la complejidad

Venus E. Medina-Maldonado1 Rossana Medina-Maldonado2 y Germán Parada-Cores3

1 Universidad de Carabobo. Valencia, Venezuela. medinav@uc.edu.ve
2 Instituto Venezolano de Investigaciones Científicas. Los Teques, Venezuela. rossana_medina@hotmail.com
3 CIESI.org, Lima (Perú). Psicólogos Sin Fronteras. Madrid, España. german@cop.es

Received 3th May 2013/Sent for Modification 18th August 2013/Accepted 28th November 2013


ABSTRACT

This paper was aimed at providing opinion by adopting a complexity-based approach to coordinating nursing science and psychology concerning psycho-educational intervention for batterers regarding their partner or ex-partner. Improving both disciplines' interrelationship should facilitate implementing relevant action, thereby engendering motivation for change in participants and modifying sexist attitudes and beliefs. The document has analyzed the importance of coordinating scientific disciplines' action and defined guidelines for an approach involving intervention as well as highlighting implications for practice and research.

Key Words: Domestic violence, crisis intervention, public health, patient care team (sourse: MeSH, NLM).


RESUMEN

Con este ensayo pretendemos brindar nuestras reflexiones sobre las coordinaciones que podrían generarse en la enfermería y la psicología durante la intervención psicoeducativa a hombres que ejercen violencia hacia su pareja o ex pareja, desde la perspectiva de la complejidad. La tesis que aquí defendemos es que al optimizar la interrelación entre ambas disciplinas, se facilita la puesta en práctica de acciones que impactan positivamente la motivación al cambio en estos hombres, y en consecuencia, la modificación de actitudes y creencias sexistas. En el escrito se estiman dos fases: la primera plantea un análisis sobre la importancia de la articulación de acciones entre disciplinas científicas; la segunda fase delimita las pautas de actuación de cada disciplina en los procesos de intervención así como las implicaciones para la práctica profesional y la investigación.

Palabras Clave: Violencia doméstica, intervención en crisis, salud pública, equipo multidisciplinario (fuente: DeCS, BIREME).


Gender violence is one of the most serious problems affecting females around the world; 15 % to 70 % of women worldwide have experimented physical and/or sexual violence from their intimate partners during their lives (1). Some negative consequences of such abuse concerning women's health would include physical wounding, unwanted pregnancies, abortions, gynecological complications, sexually-transmitted diseases (including HIV/AIDS), post-traumatic stress disorders and depression (2).

As this issue is caused by several factors, different sciences have addressed gender violence as a complex problem involving individual, social and cultural variables. Several risk factors have contributed towards the incidence and severity of violence against women, i.e. alcohol and drug consumption, witnessing and experiencing violence during childhood, spousal conflicts, social norms giving men control over women's behavior and poverty (3).

It is clear that domestic violence affects women's right to a healthy life; worldwide governments have thus adopted action and initiatives aimed at promoting the eradication of violence against women, i.e. education and public awareness raising campaigns and prevention programmes for the general public, on-going professional training to provide assistance for gender violence victims, law reform, protection services for gender violence victims and batterer intervention programmes (the main content of this essay).

From a conceptual point of view, batterer intervention programmes refer to perpetrator re-education (particularly male perpetrators of any type of violence in relationships with their partners or ex-partners). Regarding gender violence as a public health problem, coordinating nursing science and psychology is presented as a means of preventing future exposure to violence as well as improving these populations' physical and mental health.

The importance of coordinating scientific disciplines

A discipline is understood to be an organizing category within scientific knowledge, involving the division and specialization of work and responding to the diversity of fields covering the sciences [4]. Such fragmentation of knowledge has historically led to an increasing trend towards specialization and has resulted in interrupting developing ties with the heritage of different sciences to deepen and understand a given phenomenon.

However, the course of mankind and criticism of the separation of disciplines has created the need to rethink the approach to social issues to produce complex solutions whose distinctive features are convergence and interdependence, thereby involving the crossing of disciplinary boundaries, the search for a common language and establishing lines of action considering the multiple dimensions of a specific situation.

The above provides a chance for inter-, multi- and/or trans-disciplinary-based dialogue. The former means that disciplines sit down at the same table where exchange and cooperation are involved. Multi-disciplinary dialogue is an association of disciplines for resolving concrete situations and developing common projects.

Trans-disciplinary, inter- and multi-disciplinary dialogue are more complex as knowledge transcends disciplines and the terms of cooperation are changed for coordination and common objects for common projects ("trans" denoting something going "through", "beyond" or "between" means an entity or idea that is broader in perspective and is even "transcendent" and also implying disruption or even dissolution of limits when used in words such as "transgressive") (5).

Inter-multi-trans-disciplinary intervention begins from a combined study from the perspective of each field, involving cooperation, dialogue and coordination of knowledge. These studies' common elements are discussed concerning social needs, the discipline's frameworks and established strategies for analysis and action. Ethical, pragmatic, epistemological and political elements are discussed since the participation of other actors influences decision-making when adopting a particular approach (6).

Problems require an approach from different disciplines in today's society, including violence. The spheres of philosophy, sociology, law, anthropology and medicine have reached agreement in stating that violence (particularly gender violence) is a social issue caused by the violation of human rights and thus triggering a public health problem (7).

From our point of view, gender violence has been connected to a network of interests allowing interest in it to evolve from the cooperation of scientific disciplines to the involvement of sectors of society and, although practical problems still remain regarding harmonious coordination being achieved between disciplines, it cannot be denied that progress has been made in this area.

Two theoretical links have thus been selected, considered organizing principles of knowledge, regarding intervention with males who have used violence towards their partners or ex-partners. One involves feminist epistemology which has contributed towards understanding, analysis and criticism of male domination, patriarchal organization of society and constraints concerning the construction of female identity, making it clear that violence by men forms more a part of a pattern of abusive behavior than isolated incidents (8).

The following nexus concerns the momentum which constructive epistemology has gained concerning the use of socio-constructivist and narrative approaches from a gender-based perspective, acknowledging the importance of therapeutic alliance and collaboration typical of psycho-therapeutic approaches and, at the same time, the consideration of socio-cultural and political context typical of a gender-based approach. This perspective considers subjectivity as incarnated in an individual and in relation to political and social aspects of gender, considering social and individual dialectic and assuming radical inter-subjectivity (9).

Other approaches, models and techniques have been and are used when working with males who have committed violent acts towards their partners or ex-partners. The above summary has been concerned with what actually happens to briefly illustrate how discipline-based knowledge converges in practice.

A complexity-based approach can integrate contexts in unison (10); complex coordination between nursing and psychology was thus considered feasible for addressing intervention concerned with males perpetrating violence towards their partners or ex-partners, thereby expanding our view of whether to interpret the problem or undertake the necessary and innovative action. Without falling into the trap of anything goes, or eclecticism which is only intended to be valid for a particular therapeutic process or moment [11], this approach implies accepting the challenge of checking both the aspects of a particular phenomenon and the empirical evidence for evaluating, exchanging, organizing and linking knowledge.

There is no doubt such integration must conform to coherent, solid and stable agreement between both disciplines regarding which moments should be set involving clearly delimited spaces, followed by other moments for greater integration and bi-directionality involving constricting a framework to bring together the perspectives of natural and objective sciences with assessments more associated with human and social sciences and other more individual perspectives with relational and social perspectives (12).

Guidelines for a coordinated approach to intervention with males using violence towards their partners or ex-partners

Psychologists try to build a bond and create a therapeutic space with males from the very beginning of their re-education where they do not feel judged nor threatened and are invited to transform their abusive behavior (12).

This space is used to promote males becoming aware of situations involving violence, the consequences for their victims and thus enable them to take responsibility for their actions.

However, given that people usually go there for legal or family conditioning, their motivation for completing any type of intervention programme will be low, involving them adopting a defensive, rejectionist attitude (13-15). There is no doubt about the difficulty of such task as it requires a readiness of empathy with those who are rarely willing to acknowledge such abuse and/or systematically deny and minimize violence (16).

Worldwide studies (17-19) have revealed that just a small percentage of offenders are mentally ill, although a certain rate of dual pathology is expected (20); this represents gender violence combined with health disorders, primarily involving alcoholism, drug addiction, pathological gambling and/or damage regarding neuropsychological function or psychopathology.

Furthermore, research into aggressors' profiles and types (21,22) has indicated that abusers have an inappropriate psychological state, or have non-specific psychopathological symptoms characterized by an inability for emotional expression, low self-confidence and/or low self-opinion, poor anger management, limited communication and problem-solving skills, relationship ambivalence or immaturity, jealousy and/or over-dependence.

Violence in an intimate partner-based relationship is not a disease and taking abusers as sick people implies that the responsibility is exogenous, making treatment difficult and providing relapse (23). Treatment thus does not involve exempting the aggressor of his responsibility and it is essential that further aggression be avoided (24). It thus becomes evident that adjusting many elements describing violent behavior is required and, consequently, simultaneous psychosocial- and health-based approaches are indispensable, involving psychologists having undergone high-level professional training, specialization and adequate handling of techniques for both motivating people to become engaged in a re-education programme and staying in it until the end.

In this regard, using motivational interviews is one strategy for increasing Batterer Intervention Programme success (25). Motivational Interviewing is used, based on respect for a patient, his beliefs and scale of values, seeking to stimulate his motivation and promote healthy habits, emphasizing his own point of view and freedom of choice (6).

An aggressor is asked during motivational interviews to name a person from his environment who can become involved in the intervention programme and report on the subject's conduct when such assistance is requested. Referred to as informant during the re-education process, she/he will be requested to supply information about the topics being addressed; moreover, this person becomes a point of connection with the subject's social environment (25).

Coordinated action converges at this point, since community health nursing should act as a link between informant, aggressor and Batterer Intervention Programmes. The usual field work carried out in this discipline enables communities to become associated with primary care level services; such practice allows assessment of a particular population's health situation and risk factors to enable subsequent planning, carrying out and evaluating of nursing care. The epidemiological outlook can thus be analyzed and action taken to promote health, prevent disease and support therapeutic treatment, as well as rehabilitation (27).

One of community health nursing's achievements has concerned it acting as an educational agent for change by adopting a participatory view-point. Such non-prescriptive work invites our focus (people, family, group or community) to reflect on and engage in critical thinking; decision-making thus involves shared dynamics seeking to stimulate knowledge, self-care and self-responsibility for health, as well as adopting healthy long-term behavior until they become part of our life-styles.

The above, regarding intervention programmes involving males who have used violence towards their partners and ex-partners, thus leads to stating that the role of community health nursing (as educational agent of change) would be to build alternative strategies for overcoming the use of violence jointly with aggressors and their social environment, along with promoting self-care and self-responsibility for their own health. Such role would also involve supporting the team in intra-home approaches and following-up cases. The latter action is very helpful concerning the evaluation of programmes' long-term effectiveness.

Implications for professional practice and research

Any practical convergence between nursing and psychology must be considered very carefully as optimizing such interrelationship facilitates action being taken which would have a positive impact on men's intrinsic motivation, thereby changing sexist attitudes and beliefs.

Such action simultaneously involves inter-multi-trans-disciplinary dialogue and adopting a complexity-based approach, thereby requiring a trained, integrated team. Incorporating a gender-sensitive approach in nursing matters is important, specifically regarding violence against women. Professional preparation and training will provide the tools for tackling such public health problem, not only by addressing the people who are the victims of violence but also those who carry it out.

Patient care teams must also have and be able to integrate additional skills, such as an appreciation of ethics, humility and professional versatility; such abilities are easily invoked when working with victims but using them can be more challenging when working with offenders. If the aim is to help men to end their abusive behavior, it is only reasonable to show them the qualities stimulating people to make changes in their lifestyles (28).

This is where incorporating a gender-based approach as a basis for professional reflection and sensitivity concerning social hierarchies becomes stronger to broaden our vision of the issue, accompanied by questioning of the ideological structure and power relationships entailing self-analysis regarding personal tendency towards violent behavior (11,29) based on constructing identity and exercising power regarding gender-based relationships.

If a facilitator is male, he must review his own gender roles, pre-conceived stereotypes or ideas about violence in a partnership. To what extent has he broken with these hegemonic patterns? Or otherwise, does he reproduce them in his personal and professional life? A female facilitator must also review topics such as what are her expectations regarding such men? How have their relationships with males and females been? Or, has she been a victim of violence?

The importance of the facilitator couple (so-called duo) should be noted to show the male group that it is possible to interact with the other sex on an equal power and hierarchy basis. In any case, a male or female facilitator must remain vigilant to the forms of violence and power relationships which may also have been expressed during re-education intervention so as not to duplicate the same interactive and relational patterns which the programme is aimed at changing.

The foregoing should provide a platform for a joint project involving both disciplines and coordinating them, in which scenario a more active health sector role may be seen referring to integrated support services regarding gender violence. Health research in this respect should involve two facets which should be subject to empirical verification, one related to the understanding between both disciplines and the way in which the links for developing intervention will be established whilst the other refers to the intervention itself and to anything regarding a complexity-based approach's appropriateness, effectiveness, solidity and stability.

Competing interests: The authors declare that they have no competing interests.


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Instituto de Salud Publica, Facultad de Medicina - Universidad Nacional de Colombia Bogotá - DF - Colombia
E-mail: revistasp_fmbog@unal.edu.co