This article describes an innovative treatment for interpersonal violence victims and perpetrators. The treatment consisted of 15 sessions, lasting 90 minutes each, with participants between the ages of 22 and 63. A follow-up was carried out six months after the end of the treatment. Throughout this article we describe theoretical foundations, clinical outcomes, and innovative aspects of the treatment technique in such an important field as domestic violence.
Why include victims and perpetrators in the same group? In literature we find forms of treatment that imply the participation of both the perpetrators and the victims in the same treatment group. In particular Knauss (2010) admitted two victims and two court convicted perpetrators into a group he was carrying out for the treatment of different pathologies. Other studies show positive results emerging from treating couples within a group (Dunford, 2000; O'Leary, Heyman, & Neidig, 1999). In this case, the advantage resulting from the participation of perpetrators and victims in the same group is to give the victim the opportunity to relate to the offender in the presence of a protective authority figure able to handle the oppressive nature of the abuse. The victim could use this experience as a model for future situations of conflict (Dunford, 2000). The presence in the same group of those who suffer and those who carry out violence is considered a fundamental element in order to allow the participants to realize the complementarity of roles assimilated through past experiences and later experiment more effective behavior through the interaction and the verbalization within the group. Furthermore, since one of the most frequent attitudes colluding offenders and victims results from the belief the aggressor’s violence is caused by a psychological condition (and is therefore to be understood and somewhat tolerated), it is stated that getting the victim to interact with offenders who recognize their fault, take full responsibility for their actions, and offer testimony of their own will to control the victim through violence, may help the victims overcome the above belief about the pathological cause of the aggressor’s violence. In such an interaction, proof of the victim’s pain is offered to the offenders, allowing them to experience empathy towards her or him.
As treatment of victims and perpetrators receiving treatment within the same group is so under researched and rarely described in literature we decided to implement a pilot experience within a public health center, in order to improve working patterns in that center and to contribute to research in the field of treatment and interpersonal violence.
For this purpose we chose to adopt the technique of analytical psychodrama (Lemoine, 1973, 1977). It is in fact well documented how psychodrama techniques have been proved effective in group treatment either for victims or for perpetrators (Smokowski & Bacallao, 2009; Karataş & Gökçakan, 2009; Réveillaud & Guyod, 2008; Avinger & Jones, 2007; Carbonell & Parteleno-Barehmi, 1999; Stith & McCollum, 2011).
Why is psychodrama so effective? Through analytic psychodrama, and in particular through psychodrama play techniques, it becomes possible to perceive emotions and feelings associated with the violence; which have not been processed and thus are difficult to communicate (Allen, Fonagy, & Bateman, 2010). Psychodramatic play, through role playing and dubbing (Miglietta, 1998), allows participants to grasp their dissociated inner components making it easier for the integration into the general personality. Such integration is moreover important in people who experienced trauma or violence either in childhood or later in their development. Psychodrama is a special tool for that purpose, through staged action and direct and intentional body involvement. Psychodrama group is a safe physical space, within a safe interpersonal context, where emotions may come out much more easily than through the mere verbal mean.
The people involved in the psychodrama group treatment were psychiatric public service users suffering from anxiety or depressive symptoms. They had not had any contact with each other until the time of insertion within the group. They requested help from the service due to one or more of these types of violence (as victims or perpetrators):
• Sexual and psychological violence within the family
• Incidents of Racial Discrimination
• Incidents of bullying;
• Physical and psychological violence within the couple
In most cases, participants were involved in more than one type of violence. The participants were aged between 22 and 63 years; five women and two men. There were two perpetrators, one man and one woman (the man also on a regimen of antianxiety meds). Another participant was a man who claimed to be the perpetrator of violence and who in turn suffered violence. The perpetrators of violence had no current legal proceedings or claims of separation that could influence the choice to adhere to treatment.
The treatment lasted for 15 meetings, fortnightly, at an hour and a half each session. Each of the seven selected participants was also offered anywhere from three to five individual sessions before the start of group treatment aimed at the analysis of the demand and expectations and the definition of individual targets. During the preliminary interviews it was made clear to participants that violence is never to be considered a pathological symptom. They were also asked for their consent for the inclusion of perpetrators of violence; it was stated that this inclusion was firstly functional for the effectiveness of the treatment for the victims, and only secondly for the perpetrators themselves.
The group was led by two psychotherapists who alternated in the role of conductor and observer. Each participant was also given the opportunity to take advantage of some individual interviews in the course of treatment. These interviews were intended to analyze urgent issues. The agreement with the participants was to find at a later time the space within the group to share at least part of these issues.
During each meeting, the participants spoke in turns following the free association rule; the leader chose from the stories that which would better represent the “emergent" of the group (Pichon-Riviere, 1985), after which psychodrama play took place. The person chosen by the leader was asked to pick out from the participants in the group those who could play the roles of their story. Once the choice of characters was made and the reasons for their choice provided, the story could be staged by the technique of role playing and “dubbing”.
After the psychodrama play, a session of group sharing and listening to the experiences of the "spectators" and "actors" took place. At the end, the task of the observer, silent throughout the session, was to recount what they grasped from the themes and deep emotions that emerged during the performance of the “psychodrama play" and, more generally, from the speeches of the participants.
All the participants showed gratification from the experience. The clinical observation has permitted to detect a significant improvement of mood and decreased anxiety in all cases. The follow-up one year after the end of treatment showed positive results, in particular with regard to the four women victims of violence. Among them: the youngest girl in the group applied to social services for protection of her little niece because the father was acting on her the same violence that she had suffered in the past; a woman has left the abusive partner and engaged in a loving relationship with another man; a woman is out of the treatment after four sessions in order to be followed by a women's refuge; and the oldest lady has maintained a relationship with her husband who inflicted psychological violence, saying that she didn’t want to break up as separation might make him dangerous, but she improved coping strategies (from strategies of blame and avoidance to more active strategies). The man perpetrator and victim of couple’s violence reported a significant improvement in the quality of the relationship with cessation of violence, either inflicted or suffered. The other man perpetrator has taken full responsibility for his choices of domestic violence which prior to treatment was blaming on his psychological problems. From external attribution (blaming the victim) he passed to the internal attribution of responsibility finally overcoming the hypothesis of psychological pathology as a mitigating factor for his responsibility and the consequent recognition of his anger and need for control as the primary motivation underlying the violence. In this case, while reducing levels of violence, verbal violence remained still, although sporadic.
One case that did not seem to have had the effects of the reduction of violence was that of the woman perpetrator. She inflicted psychological abuse on her daughter who had just turned eighteen and had shown from the outset of the treatment poor insight, an extremely rigid and stereotyped thinking, and very little ability to cognitive decentralization (ability to take the point of view of the victim).
In conclusion, the interventions in this field shift between Scylla and Charybdi: on the one hand the need to assist people who need help and on the other hand the need to avoid the risk of making the offenders feel less responsible and “pathologizing” the victims. Nevertheless, we believe that the technique of psychodrama is an innovative and effective tool in the treatment of these problems. The ability to identify with the "complementary" role allows each participant to achieve an awareness of one's position improving the capacity of decentralization and, more generally, improving the development of processing abilities and symbolic thinking. We also believe that the effectiveness of the group treatment, and in particular of the role playing, may promote:
– The development of more effective coping strategies in the relationships (eg, active strategies aimed at conflict management, demarcation and protection of personal space)
– The shift from acting-out to thinking and action
– A better contact with feelings and emotions such as impotence and guilt often split off and projected outside
– The transition from the guilt to taking responsibility
– Improved capacity for cognitive processing
In conclusion, although aware of the limitations that characterize this clinical experience, among them the lack of a measure of the effectiveness of treatment by scales and the consequent reliance on clinical observation as the sole source of assessment; we believe that the technique of psychodrama for treatment of perpetrators and victims of violence within the same group will constitute a new and effective tool in the field of psychotherapy and treatment of violence. We hope that future research in the same field can make the methodological rigor necessary to put in check the clinical efficacy of the results of this pilot study.
Acknowledgments: A special thanks to Dr. Pierluigi Boldri, Director of Centro di Salute Mentale Tiarini, Ausl Bologna.
Conflicts of interest: the author declares no competing financial interests.
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