435

Dialectical Behavior Therapy for D o m e s t i c Violence: Rationale a n d P r o c e d u r e s

A l a n E. F r u z z e t t i a n d E r i c R. L e v e n s k y , University o f N e v a d a , R e n o

Domestic violence is a significant social problem with significant psychological and medical consequences for its victims and their
children. In part because treatments for domestic violence are often not effective, and in part because of the hypothesized similarities
between the problems of chronically aggressive men and chronically suicidal women (e.g., emotion dysregulation), a rationale for ap-
ptying Dialecticat Behavior Therapy (DBT) to domestic violence is p~)vided. This new application of DBT, designed to treat aggres-
sion and violence in families, is described. Aggression assessment procedures and conceptualization issues are presented, along with
a case to illustrate treatmentprinciples and intervention strategies. Typically targeting men who batter theirpartners, this new appli-
cation includes the four essential functions of DBT, including attending to client motivation, skill acquisition, skill generalization,
and team~therapist consultation. In addition, a number of new treatment developments are presented to target reducing and elimi-
nating aggression: validation and empathy skill training; a focus on reconditioning anger responses to be more normative (includ-
ing identifying alternative emotions and their associated effective coping responses); skills training on accurate interpersonal emo-
tional expression; and understanding the functions of aggression and teaching skills in how formerly aggressive partners can get
relationship and self-management needs met skillfully. A brief overview of the other strategies and components of DBT, and how they
are applied to treating domestic violence, is also provided. Particular attention is devoted to therapists maintaining a nonjudgmen-
tal stance by utilizing mindfulness practice and team consultation.

OMESTIC VIOLENCE (also r e f e r r e d to as p a r t n e r serving aggression a n d violence between parents a n d in-

D abuse, battering, aggressive o r violent behavior,
etc.) is a significant social p r o b l e m in the U n i t e d States.
Data f r o m a national survey indicate that 1 o u t o f 8 hus-
bands e n g a g e d in at least one violent act toward his wife
d u r i n g the year o f study, a n d 1.8 million wives are as-
saulted by their spouses o r partners each year (Straus &
Gelles, 1990). T h e National Institute o f Justice (1994) es-
timates that p a r t n e r abuse occurs in between 2.5 million
a n d 4 million h o m e s each year in the U n i t e d States, with
the vast majority o f violence p e r p e t r a t e d by m e n against
their female partners. Moreover, once b a t t e r i n g has be-
gun, it is likely to c o n t i n u e to occur, a n d will often esca-
late in frequency, intensity, a n d severity (Feld & Straus,
1989).
Domestic violence has e n o r m o u s negative conse-
quences for its female victims, who show b o t h increased
psychological p r o b l e m s (e.g., depression, substance
abuse, posttraumatic stress disorder, a n d h i g h e r suicide
risk) a n d increased physical health p r o b l e m s (e.g., over 1
million w o m e n seek m e d i c a l care for injuries related to
battering, a n d 20% o f all w o m e n ' s e m e r g e n c y r o o m visits
are the result o f battering; H o u s k a m p & Foy, 1991; Stark
& Flitcraft, 1982). In addition, significant p r o b l e m s have
b e e n identified in children, b o t h as a direct result of ob-
Cognitive and Behavioral Practice 7, 4 3 5 - 4 4 7 , 2000
1077-7229/00/435-44751.00/0
Copyright © 2000 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
[~ Continuing Education Quiz located on p. 526.
directly as a function of the o t h e r consequences (e.g., de-
pression, h e a l t h problems, jail) o f their p a r e n t victims
a n d perpetrators.
A p p l y i n g Dialectical Behavior Therapy to
D o m e s t i c V i o l e n c e : Rationale
Developing o r i m p l e m e n t i n g a new t r e a t m e n t for any
p r o b l e m is justified u n d e r the following circumstances:
(a) data show that existing treatments do n o t work well;
(b) data d e m o n s t r a t e b e t t e r o u t c o m e s with a new treat-
ment; (c) a new t r e a t m e n t is m o r e resource efficient t h a n
an old o n e (without d i m i n i s h i n g outcomes); o r (d) treat-
m e n t providers p r e f e r a new t r e a t m e n t (e.g., r e d u c e d
b u r n o u t ) , as l o n g as o u t c o m e s are n o t d i m i n i s h e d a n d
costs do n o t increase.
T h e rationale for applying Dialectical Behavior Ther-
apy (DBT) to p r o b l e m s o f aggression a n d violence in
families generally follows this logic: (1) O u t c o m e s for
existing treatments for battering (both recidivism a n d
d r o p - o u t rates) are generally poor; (2a) t h e r e are several
theoretical links between parasuicidal a n d b o r d e r l i n e be-
haviors successfully treated by DBT a n d aggressive a n d
violent behaviors of batterers; (2b) empirical findings
suggest that aggressive behaviors in batterers may be rein-
forced by both instrumental gains a n d d i m i n i s h e d nega-
tive e m o t i o n a l arousal, paralleling reinforcers for para-
suicidal behaviors o f b o r d e r l i n e clients; (2c) empirical
outcomes of DBT are strong with respect to relevant over-
l a p p i n g t r e a t m e n t targets ( o u t c o m e a n d t r e a t m e n t reten-
436 Fruzzetti & Levensky

tion); (3) DBT costs m u c h less than prison (and any suc- Babcock a n d Steiner (1999) evaluated 339 male batterers
cessful t r e a t m e n t likely would m e a s u r e u p well against who h a d b e e n c o u r t - o r d e r e d for b a t t e r e r g r o u p treat-
the social a n d individual costs o f battering), a n d (4) ment: Only 106 (31%) c o m p l e t e d the treatment.
stress a n d b u r n o u t a m o n g t r e a t m e n t providers is be-
lieved to be high, a n d DBT targets r e d u c i n g stress a n d Support for an Emotion-Dysregulation Model
b u r n o u t a m o n g providers. Most treatments for domestic violence (e.g., a n g e r
m a n a g e m e n t , general cognitive-behavioral interventions,
Problems With Existing Treatments role resocialization) are pragmatic. T h a t is, they have
Domestic violence t r e a t m e n t p r o g r a m s typically treat b e e n d e v e l o p e d in response to behaviors o f batterers that
male batterers using a weekly g r o u p f o r m a t for p e r i o d s are p r o x i m a l to their aggression (anger, attitudes a n d at-
r a n g i n g from 8 to 36 weeks. Most b a t t e r e r t r e a t m e n t pro- tributions, beliefs a b o u t roles). However, researchers
grams use cognitive-behavioral studying b a t t e r e r typology have f o u n d that batterers are a
interventions, with a curricu- h e t e r o g e n e o u s p o p u l a t i o n with respect to these vari-
Given the lum that includes core in- ables. Moreover, most studies that have m e a s u r e d appro-
difficulties with struction in a n g e r manage- priate variables have identified a subtype o f batterers who
dropout rates in m e n t (e.g., anger recognition, exhibit b o r d e r l i n e personality d i s o r d e r behavior traits o r
time-out, self-talk strategies, e m o t i o n regulation p r o b l e m s (e.g., H a m b e r g e r &
treating batterers, a n d relaxation training) a n d Hastings, 1986), a n d most batterers fit profiles in DSM-1V
the e m p h a s i s in violence cessation (e.g., time- Cluster B.
DBT that is placed outs, self-talk, relaxation). The Tweed a n d D u t t o n (1998) c o n d u c t e d a cluster analysis
c u r r i c u l u m may also include o f 79 batterers, a n d f o u n d that 38 (48%) o f the batterers
on orienting, interventions from a feminist fell into an "impulsive" cluster, 32 (41%) fell into an "in-
committing, and perspective, i n c l u d i n g sex- strumental" cluster, a n d 9 (11%) d i d n o t fit into either
collaboration m a y role education, resocialization, cluster. These authors f o u n d that the "instrumental"
a n d discussions of patriarchal, g r o u p was m o r e narcissistic, antisocial, a n d aggressive,
be effective for this mate power issues, a n d may a n d r e p o r t e d m o r e severe physical violence, whereas the
population of include training in skills to "impulsive" g r o u p was m o r e passive-aggressive, border-
clients. improve relationship function- line, a n d avoidant, a n d h a d h i g h e r chronic a n g e r a n d
ing, such as c o m m u n i c a t i o n fearful attachment. They suggest that instrumental bat-
a n d conflict resolution skills, terers use violence to maintain control o f their p a r t n e r s
social skills, a n d assertion skills (Holtzworth-Munroe, (for instrumental gain), whereas impulsive batterers en-
Beatty, & Anglin, 1995). gage in violence to r e d u c e their own aversive arousal a n d
Poor outcomes. Most p u b l i s h e d studies have f o u n d lim- negative affect.
ited if any r e d u c t i o n s in rates o f recidivism. F o r example, Rubio a n d Fruzzetti (2000) argue f u r t h e r that m a n y
Rosenfeld (1992) reviewed 25 o u t c o m e studies of batter- m e n who have antisocial personality d i s o r d e r o r a signifi-
ers' t r e a t m e n t p r o g r a m s a n d f o u n d that across the stud- cant subset of antisocial behaviors ( p a r t n e r abuse) may
ies, the average recidivism rate (defined as at least o n e act have disorders that overlap with b o r d e r l i n e personality
o f violence by the time o f the follow-up assessment) was disorder. They suggest that m a n y aggressive a n d violent
27%. Rosenfeld c o n c l u d e d that batterers who c o m p l e t e d m e n have the same psychological difficulties with emo-
t r e a t m e n t h a d only slightly lower rates o f recidivism than tion regulation (and related p r o b l e m s o f "self" such as
batterers who refused treatment, d r o p p e d o u t o f treat- b e i n g u n a b l e to identify emotions, wants, etc.) as d o
ment, or were arrested a n d n o t r e f e r r e d to treatment. chronically suicidal a n d parasuicidal b o r d e r l i n e women.
G o n d o l f (1997) evaluated the o u t c o m e s o f 840 batterers F u r t h e r m o r e , they argue that in a d d i t i o n to the f r e q u e n t
receiving t r e a t m e n t at four "well-established" cognitive- instrumental gains a c c r u e d by the use o r threat o f aggres-
behavioral b a t t e r e r t r e a t m e n t programs, finding that sion, such behaviors may also be negatively r e i n f o r c e d
39% reassaulted at least once d u r i n g the 15-month fol- by d i m i n i s h e d negative arousal following threats o r use
low-up, 70% e n g a g e d in verbal abuse, a n d 43% p e r c e n t o f aggression.
c o m m i t t e d threats o f violence d u r i n g that time.
High dropout rates. T h e d r o p o u t rate between initial Effectiveness of DBT
contact with b a t t e r e r t r e a t m e n t p r o g r a m s a n d p r o g r a m DBT is a t r e a t m e n t for e m o t i o n dysregulation a n d the
c o m p l e t i o n is often greater than 90% ( G o n d o l f & Foster, various behavioral difficulties associated with severe a n d
1991). Additionally, even a m o n g batterers who are court- chronic e m o t i o n dysregulation. DBT is the only treat-
o r d e r e d to treatment, 40% to 60% o r m o r e do n o t com- m e n t to date to have g a r n e r e d significant empirical sup-
plete the p r e s c r i b e d n u m b e r o f sessions. F o r example, p o r t for treating multi-problem, parasuicidal b o r d e r l i n e
 DBT for D o m e s t i c Violence
w o m e n (e.g., L i n e h a n , Armstrong, Suarez, Allmon, &
H e a r d , 1991). Moreover, the established efficacy o f DBT
in treating c o n c o m i t a n t p r o b l e m s (e.g., substance use, af-
fective disorders, o t h e r quality-of-life p r o b l e m s ) is impor-
tant in considering treating batterers, who also are likely
to have p r o b l e m s with substance use as well as o t h e r sig-
nificant behavioral problems.
DBT has d e m o n s t r a t e d an ability to k e e p suicidal a n d
self-laarming b o r d e r l i n e individuals in t r e a t m e n t to its
c o m p l e t i o n (16% d r o p o u t over 1 year; L i n e h a n et al.,
1991), despite the fact that this p o p u l a t i o n ( b o r d e r l i n e
w o m e n ) has a very high d r o p o u t rate in o t h e r treatments.
Given the difficulties with d r o p o u t rates in treating bat-
terers, the emphasis in DBT that is p l a c e d o n orienting,
committing, a n d collaboration may be effective for this
p o p u l a t i o n o f clients.
Finally, working with batterers is challenging a n d de-
m a n d i n g for t r e a t m e n t providers: D r o p o u t rates are
high, outcomes are p o o r (recidivism rates are high), cri-
ses are c o m m o n , a n d successes a n d reinforcers are rela-
tively infrequent. This parallels the difficulties of thera-
pists in treating m u l t i p r o b l e m , chronically suicidal a n d
b o r d e r l i n e clients. "Treating the therapist" is a tenet of
DBT (Linehan, 1993a), recognizing that motivating skill-
ful therapists is essential b o t h for their well b e i n g a n d for
i m p r o v e d outcomes in their clients. This a p p r o a c h seems
particularly a p p r o p r i a t e with providers o f b a t t e r e r treat-
m e n t as well.
D e s c r i b i n g DBT f o r D o m e s t i c Violence
DBT has b e e n comprehensively d e s c r i b e d elsewhere
(e.g., L i n e h a n , 1993a). Applying DBT to aggressive a n d
violent behaviors has b e e n a c c o m p l i s h e d primarily
t h r o u g h a systematic utilization of existing DBT princi-
ples, structures, a n d strategies, with a few modifications.
T h e modifications to established DBT have b e e n devel-
o p e d specifically for the t r e a t m e n t targets a n d p r o b l e m s
o f this client population. In this section we will describe
each o f the essential c o m p o n e n t s o f DBT a n d their rele-
vant application to aggressive p a r t n e r behaviors.
Assessment
Assessment in DBT for domestic violence serves t h r e e
p r i m a r y purposes: to d e t e r m i n e a p p r o p r i a t e n e s s for the
treatment, to identify t r e a t m e n t targets, a n d to measure
the effectiveness o f the treatment.
Assessment to determine appropriateness for inclusion in the
treatment. This assessment simply identifies factors rele-
vant to inclusion a n d exclusion criteria: Does the client
have the kinds o f p r o b l e m s for which the t r e a t m e n t (and
the specific t r e a t m e n t p r o g r a m ) is i n t e n d e d ? Does the
client m e e t any exclusion criteria o f the t r e a t m e n t pro-
gram? These m i g h t include i m m i n e n t suicidal behaviors,
437
c u r r e n t threats toward others (e.g., with Tarasoffimplica-
tions), c u r r e n t severe psychosis that makes p a r t i c i p a t i o n
in t r e a t m e n t difficult o r impossible, c u r r e n t prison in-
m a t e status (unless the t r e a t m e n t p r o g r a m is o p e r a t e d
within the facility or the facility allows b r i e f furloughs for
t r e a t m e n t ) , a n d so on.
Assessing inclusion a n d exclusion criteria requires
clear p r o g r a m guidelines from the t r e a t m e n t team re-
g a r d i n g how it is applying DBT: F o r w h o m / w h a t be-
haviors is this t r e a t m e n t b e i n g offered? Are t h e r e any em-
pirically derived exclusions? Similarly, inclusion a n d
exclusion policies o f the clinic, agency, o r o t h e r setting in
which the t r e a t m e n t is b e i n g offered must be d e t e r m i n e d
a n d assessed. T h e m o r e specific these criteria are, the
easier they are to assess efficiently with questionnaires,
p h o n e screening, o r a face-to-face interview. Moreover,
inclusion a n d exclusion criteria can be h i g h l i g h t e d in
b r o c h u r e s o r advertisements to those m a k i n g referrals so
that a m i n i m u m a m o u n t o f time (for b o t h staff a n d those
who would be excluded) can be devoted to this phase o f
assessment.
Assessment to identify treatment targets to aid the delivery of
services. Identifying p r i m a r y t r e a t m e n t targets is espe-
cially i m p o r t a n t in DBT in general as well as in DBT for
batterers. Because the p r o b l e m s o f domestic violence are
within the set o f priority targets within DBT, these "first
stage" targets m u s t be assessed continuously (see Table
1). Because DBT is a behavioral treatment, the anteced-
ents a n d consequences o f these target behaviors must b e
Table 1
Stage 1 Treatment Targets
Decrease:
Life-threatening behavior: suicidal and parasuicidal behaviors,
thoughts, urges, actions; aggressive and violent thoughts,
urges, and actions; child neglect
Therapy-interfering behaviors
Quality-of-life interfering behaviors (that threaten stability,
individually or in the family)
• Criminal behaviors that may lead to jail
• Problematic sexual behavior (outside relationship, high
risk/unprotected)
• Seriously dysfunctional interpersonal behaviors
• Significant employment or school-related dysfunctional
behaviors
* Illness-related dysfunctional behaviors
* Housing-related dysfunctional behaviors
• Mental health-related dysfunctional behaviors (e.g., severe
DSM Axis I - IV disorders)
Increase: Individual Behavioral Skills and Self-Management
Mindfulness
Distress tolerance
Emotion regulation
Interpersonal effectiveness
Validation and empathy
438 Fruzzetti & Levensky
identified as intermediate or secondary targets for
change in order to influence primary targets.
There are, of course, a n u m b e r of ways to assess these
secondary targets (antecedents and consequences of ag-
gression). We have developed a semistructured interview,
the Domestic Violence Interview (DVI; Fruzzetti, Saedi,
Wilson, Rubio, & Levensky, 1999), that provides a func-
tional analysis of aggressive and violent behaviors vis-~t-vis
emotion dysregulation, couple intimacy and relationship
factors, and instrumental gains. In the DVI, the assessor
(usually the therapist in the first or second appointment)
guides the client t h r o u g h a behavioral analysis of the vul-
nerability factors, emotions, thoughts, actions, events,
etc., along the chain of behaviors toward a specific ag-
gressive episode. The target of the therapist is to be non-
judgmental and noncritical, eliciting as m u c h descriptive
data as possible from the client, utilizing cues (such as es-
tablishing c o n t e x t - - d a t e , day, time, place, room, temper-
ature, events of the day) to en-
hance reporting. This is, of
The assessor... course, typical of behavioral
or functional analysis in gen-
guides the client
eral. This strategy allows the
through a therapist to listen to the cli-
behavioral analysis ent's whole story without re-
sponding except to communi-
of the vulnerability
cate acknowledgment and
factors, emotions, understanding of the events
thoughts, actions, (including thoughts and feel-
ings) of the client. No at-
events, etc., along
tempts are made to suggest al-
the chain of ternative behaviors at this time,
behaviors toward a nor to engage in any thera-
peutic strategies other than as-
specific aggressive sessment per se. This affords
episode. the therapist with early targets
for intervention once a com-
mitment to treatment is estab-
lished. Of course, use of formal assessment protocol is
only one option and may not be necessary. However, care-
ful, comprehensive, and detailed behavioral analysis (in-
cluding a focus on identifying emotions along the chain
of behaviors) must be completed in some manner.
Assessment of outcomes to determine the effectiveness of the
treatment. There are at least four consumers of o u t c o m e
data that should be satisfied when considering which
outcomes to measure: (a) the client; (b) the therapist
(and other members o f the treatment team); (c) whom-
ever is paying for the treatment (this may be the client
exclusively, but often also includes third-party payers, the
public, etc.); and (d) administrators responsible for re-
source allocation, at all levels of care and administration
(i.e., from direct supervisors to agency heads, legisla-
tors). If the p r o g r a m has a research c o m p o n e n t , h u m a n
subject review boards and scientific peers must also be
considered.
In general, there are two types of relevant "data" (this
word is used loosely here to represent any kind of infor-
mation used to determine effectiveness) that should be
considered: primary outcomes and intermediate out-
comes. Most obvious is outcome on the primary target:
Has aggression and violence ceased? The longer the fol-
low-up period, of course, the more confidence we may
have in the effectiveness of the program. Thus, knowing
that the client has not battered during the 6-month pe-
riod of treatment would not be as useful as knowing
about recidivism over a 1- or 2-year (or longer) follow-up
period. The other kind of data relevant to understanding
outcomes involves measuring putative mediators of out-
come; these are often the secondary targets of treatment
n e e d e d to achieve success on primary targets. For exam-
ple, skill acquisition and generalization, client collabora-
tion, attendance, substance use, and other secondary tar-
gets of treatment are believed to predict long-term
outcome (e.g., primary target of decreasing aggressive
behaviors). By measuring these variables, treatment pro-
viders can tell whether or not the immediate targets are
affected, thereby increasing the likelihood that longer
term (primary) targets will be achieved in an enduring
way. O f course, measuring intermediate variables is only
useful when data support the model on which they are
predicated and the variables in question actually do pre-
dict outcomes empirically.
Measures of mediators and direct indices of outcome
can be collected during time intervals or continually
(daily or weekly) t h r o u g h o u t the treatment. Long-term
outcomes are collected at termination and at subsequent
posttermination intervals. We typically utilize quarterly
assessments (every 3 months), daily self-monitoring cards,
and therapist reports and ratings. During the initial and
quarterly assessments, data that can likely be collected re-
liably with interval sampling are assembled. This might
include questionnaire data (social support, alcohol and
drug use, skill acquisition, depression severity, attitudes
toward treatment, etc.) or interview data (covering simi-
lar topic areas). Daily self-monitoring cards include daily
recording of aggressive thoughts, urges, and action (and
suicidal thoughts, urges, and action if present in past
year), drug and alcohol use, sleep and other relevant vul-
nerability factors, skill practice, emotions, social contacts
made that day, and so on. As secondary targets are identi-
fied they are included on the diary card; as targets are
achieved they are removed.
In order to have high confidence in treatment effec-
tiveness, it may be important to have collateral sources of
data. For example, police and court records, and either
interview or questionnaire data from a current partner
 DBT for Domestic Violence
c o n c e r n i n g client conflict a n d o t h e r potentially aggres-
sive behaviors, may aid in u n d e r s t a n d i n g the true i m p a c t
o f the interventions p r o v i d e d (there are significant de-
m a n d characteristics o n the client's self-report in m a n y
cases). If p a r t n e r s a r e asked to provide any information,
it is essential that clients do n o t have access to it for obvi-
ous safety reasons. O n e easy way to d o this is to collect fol-
low-up data anonymously from partners. A l t h o u g h it may
be impossible to identify individual t r e a t m e n t successes
a n d failures, this m e t h o d maximizes safety for p a r t n e r s
a n d allows the overall i m p a c t o f the t r e a t m e n t p r o g r a m
to be evaluated in a m o r e valid manner.
Let us use a case e x a m p l e to illustrate how t r e a t m e n t
targets would be assessed a n d o r g a n i z e d initially with the
DVI. This case is a composite of typical behaviors o f mul-
tiple client presentations, a n d will be e m p l o y e d through-
o u t the rest o f this p a p e r to illustrate o t h e r c o m p o n e n t s
of DBT for aggressive a n d violent behavior.
Case example. Mr. A. is court-referred for t r e a t m e n t
while waiting for adjudication s u b s e q u e n t to b a t t e r i n g his
partner. In the most r e c e n t episode o f battering, neigh-
bors called the police late at n i g h t in response to l o u d
noises a n d screaming. Both p a r t n e r s were f o u n d with
bruises a n d facial lacerations, a n d the female partner's
eyes were swollen almost shut. She was t r e a t e d in the
e m e r g e n c y r o o m a n d released. H e was treated in the fo-
rensic unit a n d released on bail the n e x t day, a n d went to
live, temporarily, with his b r o t h e r across town. H e told
police that "she started the fight, I was only p r o t e c t i n g
myself," while she told police that h e escalated over the
course o f the evening, finally b e a t i n g h e r with his h a n d s
when she a t t e m p t e d to leave to go stay with a friend.
T h e domestic violence interview (see above) was. con-
d u c t e d a r o u n d this specific episode a n d d e t e r m i n e d the
following chain o f behaviors:
I. H e h a d b e e n late to work on that day, in part be-
cause he h a d driven his wife to work after h e r car
would n o t start;
2. H e was anxious arriving for work late ( r e p o r t e d
that his lateness is a f r e q u e n t p r o b l e m ) ;
3. H e tried to sneak in b u t his supervisor saw him;
4. H e felt "angry" a n d in the interview also identified
fear o f losing his j o b a n d e m b a r r a s s m e n t over get-
ting c a u g h t trying to h i d e his lateness;
5. H e felt angry at his wife all day ( r u m i n a t e d ) for
"making h i m late" to work;
6. H e f u r t h e r r u m i n a t e d a b o u t the effect o f his late-
ness on his employee evaluation, which would be
c o m p l e t e d later that m o n t h ;
7. H e was angry a n d u p s e t u p o n r e t u r n i n g h o m e for
the evening;
8. H e d r a n k "a couple o f beers" while waiting for
dinner;
4159
9. H e a r g u e d verbally with his wife d u r i n g d i n n e r ; he
was critical of h e r in m a n y ways which c o n t i n u e d
for several hours through the evening (she watched
television a n d generally i g n o r e d his criticisms);
10. A r o u n d 10:45 p.m. she yelled at him, called h i m
"irresponsible" r e g a r d i n g work, p o i n t i n g o u t that
he h a d b e e n late m a n y times previously because
h e h a d n o t set the alarm, n o t r e m e m b e r e d his
work schedule, a n d so on;
11. H e verbally t h r e a t e n e d her, telling h e r to "shut u p
o r I'll shut you up";
12. H e identified intense anger, which he called a
"white out";
13. H e g r a b b e d her;
14. She p u l l e d h e r a r m loose a n d yelled at h i m that
she h a d told h i m she would leave him if he threat-
e n e d h e r again;
15. She went to get h e r coat a n d keys;
16. H e g r a b b e d h e r by the arm again, they struggled,
p u s h i n g a n d scratching each other;
17. She again tried to get to the door;
18. H e k n o c k e d h e r down, knelt down on the floor
a n d s l a p p e d a n d p u n c h e d h e r r e p e a t e d l y in the
face;
19. She went into the b a t h r o o m ;
20. H e sat down o n the sofa;
21. T h e police arrived a n d he was arrested.
Let us t u r n o u r attention now to the t r e a t m e n t struc-
ture a n d hierarchy o f t r e a t m e n t targets to u n d e r s t a n d
which behaviors are addressed, in what order, in DBT for
domestic violence.
Treatment Hierarchy, or Structure o f Treatment
O n e o f the essential structures of DBT is its d e t a i l e d at-
t e n t i o n to a hierarchy o f t r e a t m e n t targets. Table 1 high-
lights the essence o f the t r e a t m e n t hierarchy, which is de-
scribed below.
O~enting and committing to treatment. After o n e o r m o r e
assessment sessions, b u t p r i o r to t r e a t m e n t p e r se, o n e to
two sessions are devoted to describing in detail what a cli-
e n t can e x p e c t if she or he participates in this t r e a t m e n t
(orienting) a n d evaluating the pros a n d cons o f partici-
pation, c u l m i n a t i n g in an active decision w h e t h e r o r n o t
to participate ( c o m m i t m e n t ) . Clients begin identifying
i n t e r m e d i a t e targets for treatment, c o m p l e t e a diary c a r d
daily to track relevant behaviors as they are identified,
a n d c o m p l e t e out-of-session assignments d e s i g n e d to
clarify a n d e n h a n c e c o m m i t m e n t .
This phase may be c o m p l i c a t e d by the fact that clients
may be c o u r t - o r d e r e d to treatment. It is essential for
these clients that the therapist h i g h l i g h t their f r e e d o m to
choose (or not) DBT, even given the a p p a r e n t absence o f
alternatives (they must a t t e n d some t r e a t m e n t o r be re-
m a n d e d to c o u r t o r jail). This has at least a couple o f ira-
440
plications: First, therapists must be knowledgeable con-
c e r n i n g alternative treatments available in order to
c o m p a r e a n d contrast them accurately with DBT. Espe-
cially relevant are any o u t c o m e data available, the struc-
ture a n d expectations of other programs, a n d so on. The
target here is n o t to dissuade s o m e o n e from participating
in a n o t h e r t r e a t m e n t or to convince s o m e o n e to partici-
pate in DBT per se, b u t rather to facilitate an active com-
m i t m e n t to t r e a t m e n t (DBT or other) or a n active
c o m m i t m e n t to n o treatment. The target is active com-
m i t m e n t to a course of action that will likely help the per-
son achieve the kind of life he or she desires, from a "wise
m i n d " perspective.
It is essential to highlight how DBT is likely different
from most other treatments for domestic violence (such
as a n g e r m a n a g e m e n t or more standard CBT, in o n e or
both of which m a n y clients will already have partici-
pated). In DBT:
• there is an e m o t i o n regulation focus, a n d n o t j u s t o n
anger as the precipitant for aggression;
• active skills are taught as the solutions to problems
(aggressive a n d violent behavior, of course, b u t
other problems that are in any way c o n n e c t e d to
aggression);
• mindfulness is a core skill in DBT (with emphasis o n
both the attention-focus a n d wise-mind aspects of
mindfulness);
• although there is a psychoeducational c o m p o n e n t
to DBT skills, the t r e a t m e n t involves a collaborative
a n d integrative application of these skills (including
attention to generalization);
° idiographic behavioral assessment (behavioral or
functional analysis, self-monitoring) a n d behavioral
i n t e r v e n t i o n s / b e h a v i o r therapy are the primary
change strategies (not insight or u n d e r s t a n d i n g , per
se);
• there is an assumption a b o u t the value of the client
as a h u m a n being, a n d that she or he has a reper-
toire that includes valuing the integrity of others
a n d valuing n o n v i o l e n t action with partners (the cli-
e n t also may have a repertoire that values the use of
aggressive a n d violent behaviors; the former reper-
toire t h e n would be the target for e n h a n c e m e n t ,
consistency, a n d reinforcement, the latter for reduc-
tion or elimination);
• it is assumed that treating aggressive a n d violent cli-
ents is d e m a n d i n g of therapists' t r e a t m e n t skills a n d
sometimes challenging emotionally, a n d that there-
fore therapists n e e d a team for s u p p o r t in order to
be effective.
Pros to be considered with a client trying to decide
whether to c o m m i t to DBT may include the following:
previous treatments may n o t have b e e n effective (i.e., en-
Fruzzetti & Levensley
tering repeatedly into a t r e a t m e n t that has n o t worked
may diminish motivation; DBT may n o t only be a new
t r e a t m e n t for batterers, b u t also directly addresses moti-
vation a n d c o m m i t m e n t in treatment); other parts of the
t r e a t m e n t hierarchy may be relevant to the client (e.g.,
depression, substance use, poor relationships, etc.; see
below); DBT is a d e m a n d i n g a n d comprehensive treat-
m e n t (involves skill training, behavioral analysis, general-
ization of skills, homework/practice) that operates
within a t r e a t m e n t hierarchy, so clients may be motivated
by t r e a t m e n t targets in addition to r e d u c i n g aggression;
t r e a t m e n t is very focused o n specified targets, so clients
are well-oriented participants in their therapy; t r e a t m e n t
is a collaborative enterprise; a n d so on. O f course, as a di-
alectical treatment, every o n e of these potential pros to
DBT may also be a reason not to participate in DBT: It is a
complicated a n d d e m a n d i n g treatment, is very focused,
requires active c o m m i t m e n t , participation, a n d collabo-
ration. After clients commit to DBT in principle, commit-
m e n t to specific aspects of treatment are continually mon-
itored a n d addressed as n e e d e d t h r o u g h o u t treatment.
Also with respect to c o m m i t m e n t , it is i m p o r t a n t to
clarify what role, if any, the therapist or t r e a t m e n t pro-
gram will take vis-gt-vis court-related matters. For exam-
ple, states or counties have different limits to confi-
dentiality with court-mandated clients t h a n for purely
voluntary clients. Also, DBT is an empirically m i n d e d ap-
proach to treatment, and, as such, we are loath to make
predictions a b o u t a client's future behavior unless an in-
dex or i n s t r u m e n t or assessment methodology has dem-
onstrated predictive i n c r e m e n t a l validity in m a k i n g such
predictions. Thus far, we are aware of n o such indices for
domestic violence a n d consequently we will agree to re-
port only what we observe directly. Thus, clients (even ap-
parently highly motivated or successful ones) should n o t
expect us to make predictions a b o u t the likelihood of
their recidivism. Rather, they should expect us to report
only the specifics of their participation in t r e a t m e n t a n d
any group aggregate o u t c o m e or follow-up data collected
in a particular agency:
Case example. Mr. A. a n d the therapist identified sev-
eral pros to t r e a t m e n t for him: He had b e e n t h r o u g h
other treatments (at least three); he desired a more
stable, n o n v i o l e n t life; he wanted to have children a n d
did n o t think raising them in a violent e n v i r o n m e n t was
healthy for them; a n d he expected his wife would leave
him again (he had moved back in with her a b o u t 3 weeks
after the most recent episode), possibly permanently, if
he battered again. T h e identified cons to t r e a t m e n t were
that it involved a lot of time a n d effort ( m i n i m u m 6
months, daily m o n i t o r i n g practice) a n d he "did n o t like"
the idea of focusing o n emotions other than anger. How-
eve1, he did c o m m i t to 6 m o n t h s of t r e a t m e n t as a pack-
age (i.e., all c o m p o n e n t s ) , a n d b e g a n t r e a t m e n t after
 DBT for Domestic Violence 441

these three sessions focusing on assessment, orienting, sion was identified, in proximal response to fears of his
and committing. wife leaving, shame about his own behavior, and hurt re-
Stage 1. This is the stage in which aggressive and vio- sulting from verbal, invalidating statements from his wife
lent behaviors are targeted (see Table 1). In this first (or others). Anger was identified as a generally secondary
stage of treatment, the highest-order targets are those on emotion, primarily function-
the c o n t i n u u m of life-threatening behaviors: suicidal/ ing as an escape from fear,
parasuicidal behaviors, aggression toward others, and shame, and hurt. Vulnerability In the first stage of
child neglect. Thus, assessing these behaviors in every ses- factors (earlier in the chain of treatment, the
sion via daily diary card and targeting these problem be- behaviors) such as p o o r work
haviors in session are the first order of business for the performance, social rejection, highest-order
therapist. A l t h o u g h n o t explicitly part o f the original p o o r sleep, and alcohol use targets are those
set of targets in DBT for borderline women (Linehan, were identified. T h e pri- on the continuum
1993a), aggressive and violent behaviors against partners mary reinforcers for aggres-
are clearly on the c o n t i n u u m of life-threatening behav- sion seemed to be: (a) it suc-
of life-threatening
iors in DBT. cessfully inhibited his wife behaviors: suicidal/
Even if a client has not been aggressive or violent in a from leaving, at least tempo- parasuicidal
given week, this may be targeted in session. The first goal rarily; (b) it did result in re-
in this stage of treatment is sufficient self-management that duced arousal from or aware- behaviors,
the person no longer engages in life-threatening behav- ness (albeit temporarily) o f aggression toward
iors (toward self or others, including threats and other fear, shame, or hurt. others, and child
verbal behaviors that may have the same function as ac- In this stage of treatment,
tual aggression). Thus, until e n o u g h of the pieces or assessment, skill training, be- neglect. Thus,
links of the chain o f behavior have been addressed that havioral analysis and behavior assessing these
the client has sufficient skills for comprehensive self- therapy, and multiple thera- behaviors in every
m a n a g e m e n t (no aggressive or suicidal actions, etc.), peutic strategies (validation,
prior episodes o f aggression (as well as current thoughts problem solving, recondition- s e s s i o n . . , and
or urges) continue to be examined and treated. ing emotional responses to targeting these
Self-management is approached behaviorally to estab- stimuli to make them more problem behaviors
lish intermediate targets (toward e n h a n c e d safety, re- normative, shaping, etc.) are
d u c e d - a n d ultimately no--aggression) in Stage 1: Is the used to identify links in the in every session
person able consistently to engage in reasonably safe be- chain toward aggressive be- are the first order
haviors (not harming self or others: having a reasonable haviors (antecedents) that can of business.
life expectancy, and predictable behavior such that be changed. In addition, rein-
others' behavior does not function to avoid harm from forcing consequences that can
the person)? Does the person participate actively in treat- be altered are identified and targeted, and the reinforce-
m e n t (come to sessions, come on time, collaborate in m e n t o f alternative, nonaggressive behaviors is empha-
treatment, complete practice exercises and daily self- sized. These processes will be described later regarding
monitoring) and not engage in other behaviors that in- Mr. A.
terfere with treatment? Does the person exhibit behav- Stage 2 and beyond. Just as with DBT for suicidal behav-
ioral control to a degree sufficient to maintain iors, once stability and self-control are established, the
a reasonable and stable quality of life (stable housing, targets may shift. Once a client is stable, treatment moves
stable and sufficient income for minimal standard of liv- to Stage 2 and may target other emotional and life prob-
ing, n o t in jail, substance use modest or less)? lems in continuing individual treatment (e.g., Linehan,
Case example. With repeated behavioral analyses (and 1993a) or may turn to focus more on improving couple
after learning emotion identification skills), Mr. A. iden- and family relationships in couples or fmnily therapy
tified hurt and shame in response to his wife's statements (Fruzzetti et al., in press). Because DBT as it is applied to
(that he was "irresponsible") during the episode de- treat aggressive and violent behaviors is the focus of this
scribed earlier. Later he also described shame regarding paper (and by definition are Stage 1 targets), please see
his own "completely pathetic" behavior, overwhelming these other sources for information about subsequent
fear that she would leave him, shame that he was harming stages o f treatment.
her in order to force her to stay, and "overwhelming" feel- In DBT, self-management (Stage 1 target) is achieved
ings of worthlessness prior to beating her. As prior violent by the comprehensive acquisition, application, and gen-
and current near-violent episodes were analyzed using eralization of skills. In the following section, a brief de-
the DVI format of behavioral analysis, a pattern of aggres- scription of these skills is provided.
442 Fruzzetti & Levensky

Mindfulness skills are essential to help reduce confu- gressive behaviors are negatively reinforced by subse-
sion about self, decrease (or inhibit increasing) cognitive quent reductions in negative emotional arousal, finding
and emotion dysregulation, increase attention-focus, in- nonaggressive means to reduce painful arousal, such as
crease contact with wise-mind values (core values), and distress tolerance, emotion regulation and interpersonal
enhance awareness of one's own behavior. Mindfulness skills (below), may be particularly important.
aids assessment in general and enhances client ability to Emotion regulation skills help stabilize and manage la-
recognize when they are on problematic chains of behav- bile emotions and decrease painful negative emotional
ior (the earlier on the chain they b e c o m e aware, the arousal. Clients are taught new ways to think about and
better), which makes successful changes (e.g., nonaggres- understand emotions and new strategies for managing
sive outcomes) more likely. In DBT mindfulness skills, cli- them, including decreasing emotional vulnerability, re-
ents are taught how to observe, describe, and participate ducing unnecessary emotional suffering, and strategies
in experiences in a nonjudgmental, effective way, focus- for changing painful emotions over time. In particular
ing attention on one thing at a time. The focus here is with batterers, we emphasize accurate identification of
both on obsmwing, describing, and participating in one's emotions (DBT H a n d o u t 4), reducing vulnerability to
own experience and on being able to observe and de- painful negative emotional arousal (DBT H a n d o u t 6),
scribe the actions, feelings, and so on of significant others and reducing emotional suffering (DBT Handouts 9 and
in a nonjudgmental way. We have augmented the stan- 10; Linehan, 1993b). We have augmented existing skills
dard DBT mindfulness handouts (Linehan, 1993b) with with additional focus on the following: (a) possible func-
skill focus on "relational mindfulness," or the ability to tions of anger as a secondary emotion (i.e., a secondary
observe and describe, nonjudgmentally (and empathi- emotion is hypothesized to function as to escape from or
cally), another person. Mindfulness is the foundation on block primary emotions such as fear/jealousy, sadness
which the other skills rest. Thus, we teach mindfulness and guilt/shame; it is assumed that stimuli that norma-
first, before going on to other skills, and then again prior tively elicit these other emotions have been conditioned
to teaching additional skill modules. to elicit anger instead, so reconditioning these stimuli to
Distress tolerance skills are integral to increasing safety elicit their normative emotional response is an important
and self-control, and are employed to forestall aggres- part of this treatment); (b) how to disclose emotions ef-
sive behaviors. Given research fectively (combined with interpersonal effectiveness
that has identified a subtype skills); and (c) understanding the links between emotion
Self-management of batterers as particularly im- and aggressive behaviors, including the reinforcing func-
in S t a g e 1 is pulsive, these skills may be es- tions of aggressive behaviors both privately (i.e., to re-
pecially important. Further- duce negative arousal) and publicly vis&-vis an intimate
achieved by the
more, they are used to reduce partner (e.g., to titrate intimacy; cf. Saedi & Fruzzetti,
comprehensive impulsive behaviors that likely 2OOO).
acquisition, lead to further dysregulation, Interpersonal effectiveness skills help reduce interper-
even if not aggressive per se sonal chaos and increase interpersonal effectiveness. In-
application, and
(rumination, substance use, cluded are skills designed to help balance (a) objectives
generalization of etc.), and to provide a "win- or goals in a specific situation, with (b) maintaining the
skills: m i n d f u l n e s s , dow" (a break from escala- relationship, and (c) maintaining (or enhancing) self-
tion) in which a client can uti- respect. Somewhat paradoxically, we use self-respect ef-
distress tolerance,
lize mindfulness (of current fectiveness (utilizing mindfulness) to reduce aggression
emotion regulation, status and where the current (increased respect of others) by targeting increased
interpersonal "chain" of behavior is likely to awareness of wise-mind values of nonaggression, nonco-
lead). This window, in which ercion, and fairness.
effectiveness, and
the client briefly tolerates dis- Validation skills are used to reduce one's own dysregu-
validation/ tress, allows him or her to ori- lation (self-validation), to improve relationships (validat-
empathy. ent to using skills to alter the ing others), and to enhance empathic understanding as a
trajectory of current behav- means of reducing aggressive behaviors (thoughts, urges,
iors, ultimately reducing dis- and actions). These skills include (a) understanding the
tress via more functional means (not t h r o u g h dysfunc- forms and functions of validation (including empathy)
tional escape behaviors, aggression, etc.). These skills and invalidation, (b) specific skills to identify targets
include many strategies for surviving crises, accepting re- (e.g., emotions, opinions, effective behaviors) for under-
ality, controlling arousing stimuli (inhibiting escalation standing and validation, (c) empathy and validation prac-
or fostering deescalation; e.g., time-out), and tolerating tice, and (d) the verbal and communication skills to vali-
distress to allow natural change. To the extent that ag- date others effectively. Part of validation necessarily
 DBT for Domestic Violence 44:$

includes understanding the impact of aggression and vio- consistent alternative (nonaggressive, nonaversive) be-
lence on others. This is a kind of "empathy" training that haviors of the client before they respond in trusting, rein-
involves integrating mindfulness of others (relational forcing, appreciative, reciprocal (all likely reinforcing)
mindfulness) with mindfulness of core values (wise ways. Until that time, the therapist must provide social re-
mind). The result is more empathic understanding of the inforcement and help the client finds ways to be rein-
impact of aggression, and this may function (via contin- forced by the intermediate success of behaving skillfully,
gency clarification) to decrease avoidance of emotion even if others do not yet respond in naturally reinforcing
and increase motivation not to use aggression. Thus, we ways.
practice understanding and validating the impact of ag- Client motivation. The essence of motivation from a be-
gression (empathy) not as a kind of aversive countercon- havioral viewpoint is, What are the controlling variables
ditioning, but more as a means of mindfulness practice for target behaviors? That is, what antecedent condi-
and recommitment to nonaggressive behavior. tions (discriminative stimuli, or
The first four modules mentioned (mindfulness, dis- sometimes conditioned stim-
tress tolerance, emotion regulation, interpersonal effec- uli) are necessary to elicit the B a t t e r i n g , like
tiveness) are adapted directly from Linehan's Skills Train- target behavior (e.g., aggres- parasuicidal
ing Manual (1993b). The last module (validation) is sive behavior) and what conse-
adapted both from Linehan (1997) and Fruzzetti (1995, quent stimuli reinforce it (or behavior, may be
1996), and is elaborated elsewhere (Fruzzetti, Hoffman, punish or extinguish alterna- difficult to c h a n g e
& Linehan, in press; Hoffman, Fruzzetti, & Swenson, tive, less problematic, behav-
b e c a u s e it m a y b e
1999). iors)? Client motivation (i.e.,
acting more skillfully and with extremely difficult
Modes and Functions of Treatment self-control) is enhanced via t o r e m o v e its
Linehan (1993a) has argued that DBT must include behavioral analysis, solution
reinforcers:
the following four functions: skill acquisition; skill gener- analysis, and tile application
alization; enhancing client motivation to change (behav- of skills (behavior therapy). aggressive
iorally defined); and enhancing therapist motivation and Battering, like parasuicidal behaviors may be
skills. At times, a fifth function, structuring the environ- behavior, may be difficult to
negatively
ment, is also important in DBT. As a direct application of change because it may be ex-
DBT, these four (and sometimes five) functions of treat- tremely difficult to remove its reinforced by
ment are considered essential in treating domestic vio- reinforcers. As noted above, subsequent
lence as well. However, the modes with which these func- these behaviors may be nega-
diminished
tions are achieved may vary from program to program. tively reinforced by diminished
Some of the options for delivering these services are de- negative emotional arousal, as negative
scribed below. well as positively reinforced emotional arousal,
Skill acquisition. Skills may of course be taught in tradi- by intermittent instrumental
as well as by
tional groups (cf. Linehan, 1993b), and this is perhaps gains. Thus, DBT strategies of-
the most common mode in which this function is ten must focus on changing intermittent
achieved (it is resource efficient). However, individual antecedent steps on the chain instrumental gains.
skill training, self-study, email or internet augmentation, of behaviors toward aggres-
video or CD-ROM formats, and so on, could be em- sion by identifying and rein-
ployed, consistent with other skill training approaches in forcing alternative, nonaversive means of reducing pain-
behavior therapy. ful negative emotional arousal. These antecedent steps
Skill generalization. DBT with batterers similarly em- include: (a) mindfulness of present state, including iden-
ploys the full behavioral array of strategies to bring skills tifying what "chain" (or pattern) of behavior the client is
into clients' daily lives: telephone skill coaching, general- currently participating; (b) awareness of the wise mind
ization programming, between-session practice exercises, commitment to getting off chains that could lead to ag-
in-vivo shaping, etc. It is essential to structure generaliza- gression; (c) using skills to decrease negative emotional
tion in small, achievable steps with considerable (albeit arousal, especially early in the chain; (d) using skills to
temporary) therapist reinforcement to enhance practice achieve goals, in ways that are consistent with the client's
and skills until the use of new skills is naturally reinforced wise-mind values (e.g., nonaggressive means; fairness);
in the client's life (i.e., under the control of natural rein- and (e) using skills to accept what is not possible, those
forcers). This is especially important to convey to clients: immediate goals that cannot be achieved skillfully (at
Because they have used aversive and aggressive control least not at that moment), within wise-mind values of
strategies in the past, others may require repeated and one's own behavior.
444 Fruzzetti & Levensky

T h e function o f e n h a n c i n g client motivation for skill- difficulties, a n d a focus on change. T h e way DBT instanti-
ful behavior may be a d d r e s s e d in individual t r e a t m e n t ates this dialectic of acceptance a n d c h a n g e is with the
(typical in DBT) o r in a g r o u p format. Either way, the fo- c o m p r e h e n s i v e application of behavioral principles a n d
cus is o n using the t r e a t m e n t hierarchy to establish tar- behavior therapy in the context o f a validating therapeu-
gets, use various assessment tools (especially diary cards) tic environment. Full discussion o f these strategies is be-
to m o n i t o r targets, to c o n d u c t behavioral analyses, solu- y o n d the scope o f this p a p e r (cf. L i n e h a n , 1993a). Never-
tion analyses (employing skills as solutions to p r o b l e m s ) , theless, a couple o f i m p o r t a n t points in applying DBT
a n d to plan generalization strategies in this p a r t o f the with batterers are e m p h a s i z e d below.
t r e a t m e n t (cf. L i n e h a n , 1993a). Behavior therapy. O n e o f the most i m p o r t a n t develop-
Motivation and skill enhancement of the therapist. Treat- ments o f the "new wave" o f behavior therapies in r e c e n t
ing batterers can be a d e m a n d i n g set o f tasks. N o t only years has b e e n the focus o n the role o f e m o t i o n in behav-
are clients themselves suffering, their behavior has often ioral analysis a n d therapy, from b o t h an o p e r a n t a n d a re-
had a very h a r m f u l i m p a c t on o n e o r m o r e people. Drop- s p o n d e n t perspective. This is especially true o f DBT, a n d
o u t rates are high a n d success rates low in this client with batterers this focus on e m o t i o n s is j u s t as important.
group, a n d can easily result in therapists b e c o m i n g de- Moreover, additional focus is p l a c e d o n the theoretical
moralized. Clients often do n o t i m m e d i a t e l y reinforce (and practical) difference between primary a n d second-
" g o o d therapy," a n d may in fact be quite critical o f the ary emotions. F o r example, m a n y batterers are able to
t h e r a p y o r the therapist. By definition, b a t t e r e r clients identify only a n g e r in the chain o f behaviors l e a d i n g
have violent histories, few skills for self-management in to aggressive action. F u r t h e r analysis may reveal instead
difficult e m o t i o n a l situations (like those that therapy may that a n g e r is a secondary e m o t i o n whose function is to
elicit), the therapist him- or block a different (primary) e m o t i o n such as shame, fear,
herself c o u l d legitimately feel sadness, o r hurt.
DBT strategies t h r e a t e n e d , a n d progress is Thus, the behavior therapy techniques e m p l o y e d with
often must focus often slow. This parallels treat- batterers include the full array o f intervention strategies
m e n t for chronically suicidal ( e x p o s u r e / r e s p o n s e prevention, skill acquisition a n d
on changing
w o m e n in DBT. F o r m a n y o f generalization, c o n t i n g e n c y m a n a g e m e n t a n d clarifica-
antecedent steps these reasons, " t r e a t m e n t of tion, stimulus c o n t r o l p r o c e d u r e s , cognitive modifica-
on the chain of the therapist" is an essential tion, etc.) with a focus on negative e m o t i o n a l arousal in-
p a r t o f DBT, b o t h as a means volving a variety o f emotions, n o t j u s t anger. We d o n o t
behaviors toward
o f e n h a n c i n g therapist skills assume that aggression is necessarily a "natural" response
aggression by a n d as a m e a n s of providing to a n g e r (an i m p l i e d r e s p o n d e n t m o d e l ) . Rather, we as-
identifying and therapists s u p p o r t to do diffi- sess its function, n o t only r e g a r d i n g external reinforcers
cult work (Fruzzetti, Waltz, & b u t especially vis-/t-vis negative emotions. And, as n o t e d
reinforcing
L i n e h a n , 1997). above, we target reconditioning stimuli to elicit a broader,
alternative, Typically, these functions m o r e normative range o f e m o t i o n s than simply anger,
nonaversive are m e t t h r o u g h weekly team teach how to identify a n d label these o t h e r emotions, a n d
meetings that consist of two how to m a n a g e t h e m effectively. Again, this is n o t differ-
means of reducing
o r m o r e therapists providing e n t from DBT with o t h e r client p o p u l a t i o n s p e r se, b u t
painful negative p e e r supervision a n d support. does r e p r e s e n t a d e p a r t u r e from m a n y o t h e r treatments
emotional arousal. Most therapists treating bat- for domestic violence.
terers already work with at least Validation. Similarly, validation in DBT for domestic
a cotherapist, so m a n y o f the violence is no different from DBT for o t h e r target behav-
s u p p o r t functions of the team naturally are met. How- iors. W h a t may be particularly difficult for therapists is
ever, targeting effective a n d a d h e r i n g t r e a t m e n t some- the activity o f finding the validity in aggressive a n d violent
times requires m o r e effort: Giving f e e d b a c k to peers may behaviors. T h a t is, we may be so against aggression that
be difficult, especially when the work is already d e m a n d - suggesting it has validity may be, particularly at first, dif-
ing. Nevertheless, i m p r o v i n g t r e a t m e n t delivery and pro- ficult. But how is it valid? First, it may be valid in the
viding s u p p o r t are essential in DBT, regardless of client sense that it "works," or is effective in some i m m e d i a t e
g r o u p o r target problems. sense (either instrumentally o r to diminish o r escape
aversive e m o t i o n a l arousal, o r b o t h ) . In addition, aggres-
Treatment Strategies sive behaviors may be valid responses given a p e r s o n ' s life
DBT with batterers employs the usual set o f DBT treat- history (that may have i n c l u d e d m o d e l i n g c o n d o n i n g o f
m e n t a p p r o a c h e s a n d strategies: a focus on b o t h accep- aggression). Moreover, o t h e r behaviors o f the client may
tance o f the client a n d h e r o r his c u r r e n t p r o b l e m s a n d be valid, a n d it is essential (from a shaping standpoint) to
 DBT for Domestic Violence 44S

identify even small valid behaviors along the chain to- of his wife. Because of the risk of harm, Mr. A. did agree
ward aggression in the service of reducing and eliminat- to move out of the house for at least 1 week following any
ing violence. subsequent physically threatening or actual physically ag-
Case example. After his initial c o m m i t m e n t to treat- gressive behavior (contingency management).
ment, Mr. A. then attended only four of the next eight After 5 months in treat-
skill groups and missed several appointments with his in- ment, Mr. A.'s wife shoved him
dividual therapist. ~Vhen he did come in for treatment, into the refrigerator during a While w e do not
he often had not completed his daily assessments or his conflict episode. H e got up
practice. Behavioral analysis of these therapy-interfering and left the house (he yelled
hesitate to
behaviors (e.g., missed sessions, noncompliance) showed at her that he was angry and highlight their
that Mr. A. had been quite ashamed of his behavior fol- that her behavior was "unfair" aggressive
lowing earlier behavior analyses, and had felt "horrible, because of all the work he put
miserable" for several days following earlier sessions. The in to being nonviolent). De-
behaviors, analyze
therapist validated how difficult this must have been and spite being angry and emo- t h e m behaviorally,
targeted ending the assessment and change phase of the tionally hurt, he was also and include a flank
session 20 minutes early, with the last part of the session pleased with his self-control.
devoted to using skills to manage difficult emotion that After the full 6 months of indi-
look at their
Mr. A. was feeling at that moment. In addition, a brief vidual treatment, Mr. A. grad- consequences
skill-coaching telephone call was scheduled for the day uated from Stage 1 and he (including natural
after sessions to assist with in-vivo assessment and subse- and his wife entered couples
quent skill generalization. Mr. A. subsequently missed therapy to work on reducing
consequences
fewer sessions and regularly completed his diary card, at their aversive conflict styles, such as jail,
least several days per week. increasing their constructive separation or
In addition to doing repeated comprehensive behav- conflict skills, and enhancing
ior analyses and solution analysis (with practice and re- support and intimacy in their
divorce), w e are
hearsal o f new skills) o f prior aggressive behavior, therapy relationship. Both partners re- c o m m i t t e d to
devoted increased time to current nonaggressive but ported no further violence at using positive
emotionally volatile conflict episodes between Mr. A. and the end of 6 months of cou-
his wife. Mr. A. learned to be mindful of her and the ples therapy.
c h a n g e strategies
larger context of their relationship and, whenever possi- as m u c h as
ble, his own hopes and goals for the relationship prior to Dialectics possible.
conflict situations--and to take a minute off from con- Dialectics is both a m e t h o d
flict to achieve this constructive orientation. Using inter- of argumentation and an ap-
personal skills, he was able to highlight what he was doing proach to ontological questions. In DBT, therefore, it is
and why for his wife, who was quite supportive of his the c o m p o r t m e n t of the therapist (approach to argu-
efforts. mentation and discourse with clients and on the team)
Significant therapeutic time was e x p e n d e d in expo- and an assumption about the nature of reality. Therefore,
sure and response prevention/learning alternative re- at least with respect to behavior, causation can be under-
sponses to stimuli that formerly elicited anger. For exam- stood from multiple, even apparently opposite, perspec-
ple, imaginal (and later, in vivo) exposure to criticism tives, and change is most likely to occur in the context of
targeted identifying hurt and defensive feelings, in addi- appreciating multiple perspectives and synthesizing them.
tion to angry ones, and Mr. A. practiced appropriate cop- Thus, a dialectical worldview in DBT balances and synthe-
ing responses (distress tolerance, emotion regulation, sizes n o t only acceptance (validation) and change (be-
and interpersonal skills). In addition, imaginal exposure havior therapy), but also other therapeutic strategies
to situations in which Mr. A. could not get what he (consulting to clients versus environmental intervention;
wanted, even with interpersonal skills, was targeted. In- reciprocal versus irreverent communication, etc.), multi-
stead of only responding with frustration and disappoint- ple team m e m b e r perspectives, and so on. DBT with bat-
ment, Mr. A. practiced identifying disappointment or sad- terers fully embraces this dialectical perspective, without
ness and their appropriate coping responses. Similar modification to standard DBT (Linehan, 1993a).
procedures were practiced with fear, shame, guilt, and
other stimuli that typically had elicited only anger (and Therapist Mindful Practice
concomitant aggressive urges) in the past. Again, DBT with batterers involves the standard target
There were several times over 6 months that Mr. A. re- of therapists taking a nonjudgmental stance. Although
ported urges to use violence, and twice "got in the face" this may at times be difficult in treating clients who have
446 Fruzzetti & Levensky
h a r m e d (and may c o n t i n u e to h a r m ) others, this remains
the o n g o i n g target. O f course this perspective is in-
f o r m e d by dialectics: It is essential to be completely com-
m i t t e d to c h a n g e (elimination o f aggression) while simul-
taneously c o m m i t t e d to b e i n g n o n j u d g m e n t a l a b o u t
aggressive behaviors a n d a b o u t the person.
Many b a t t e r e r clients have h a d experiences in treat-
m e n t o f b e i n g j u d g e d , chided, criticized, a n d so on re-
g a r d i n g their violent behaviors. While we do n o t hesitate
to h i g h l i g h t their aggressive behaviors, analyze t h e m be-
haviorally, a n d i n c l u d e a frank l o o k at their consequences
(including natural consequences such as jail, separation,
o r divorce), we are c o m m i t t e d to using positive c h a n g e
strategies as m u c h as possible, n o t using arbitrary aversive
c o n t r o l to effect c h a n g e (it is also n o t a very effective
means), a n d to r e m a i n i n g m i n d f u l o f the whole client
from a n o n j u d g m e n t a l perspective. Team s u p p o r t is es-
sential to m a i n t a i n this position, especially in cases o f re-
cidivism, client verbal abuse toward the therapist, r e p e a t e d
slips toward n o n c o m m i t m e n t to change, and so on.
Case example. T h e early phase o f M r A.'s treatment, as
n o t e d above, i n c l u d e d re-
p e a t e d missed sessions a n d
•.. "treatment of o t h e r treatment-interfering be-
t h e t h e r a p i s t " is a n havior (no diary cards, little
practice between sessions).
essential part of
Moreover, despite his clear
DBT, b o t h a s a c o m m i t m e n t early on to living
means of a life that h a d no r o o m for ag-
gression, he d i s c o u n t e d this
enhancing
desire later on ("Hey, every-
therapist skills and b o d y has to watch o u t for him-
as a means of self, i n c l u d i n g me. If I n e e d to
be a little r o u g h a r o u n d the
providing
edges to take care o f myself,
therapists support so be it") a n d was frequently
to do difficult critical o f the therapy ("these
skills are worthless") a n d the
work.
therapist ("What do you know
a b o u t this? You d o n ' t give a
shit a b o u t me. You're j u s t d o i n g your j o b [sarcastically]
a n d d o n ' t give a d a m n how it fucks m e over"). T h e ability
o f the team to s u p p o r t the therapist in observing limits
( r e d u c i n g verbal aggression in session was i m p o r t a n t to
this therapist) while simultaneously fostering a h u m a n e
attitude o f acceptance that the client was d o i n g the best
he could (and n e e d e d to do better) h e l p e d the therapist
m a i n t a i n balance. Thus, the therapist could recognize
that the t r e a t m e n t was very d e m a n d i n g for Mr. A.: Diary
cards a n d behavior analysis elicited a lot o f shame for
which he initially h a d few skills with which to cope effec-
tively. Similarly, t h e r e were m a n y factors in Mr. A.'s life
that could easily be u n d e r s t o o d to c o n t r i b u t e to his use o f
aggression. It was also true that his behavior h a d a very
negative i m p a c t on his wife a n d was in many ways r u i n i n g
his life. By m a i n t a i n i n g a n o n j u d g m e n t a l stance, the ther-
apist was able to balance these factors, validate his efforts
a n d potential to change, noticing even very small im-
provements in behavior (shaping) that m i g h t easily n o t
have b e e n r e c o g n i z e d without team s u p p o r t in the con-
text o f his considerable therapy-interfering behaviors.
Consequently, the t h e r a p e u t i c relationship was strength-
e n e d a n d the client expressed less a n d less hostility in ses-
sions over time, along with m o r e consistent skill practice
b o t h in a n d o u t o f session.
Summary and Conclusions
Developing a n d evaluating new treatments for domes-
tic violence are justified in general d u e to the high d r o p -
out rates a n d m o d e r a t e to p o o r o u t c o m e s r e p o r t e d for
existing treatments. DBT is p r o m i s i n g because o f its the-
oretical links to, a n d empirical s u p p o r t for, treating re-
lated targets in o t h e r client populations. Nevertheless,
only pilot cases have b e e n evaluated so far, b u t outcomes
have b e e n promising. D r o p o u t rates have b e e n low
(15%) a n d recidivism rates, at least at termination, have
also b e e n low (less than 10%). However, client samples
have b e e n quite limited. F o r example, few clients have
b e e n c o u r t - o r d e r e d (most have b e e n voluntary), so the
p r o m i s i n g results may n o t e n d u r e with m o r e court-
o r d e r e d clients. Similarly, the majority o f o u r clients so
far have b e g u n treatment in the context of wanting couple
or family treatment, a n d battering treatment has b e e n re-
q u i r e d (Stage 1) p r i o r to couple o r family interventions
(Stage 2 a n d beyond). Thus, p r e t r e a t m e n t motivation
may be particularly high in o u r samples. Finally, n o ran-
d o m l y c o n t r o l l e d study has b e e n c o m p l e t e d , so direct
comparisons with o t h e r treatments are n o t yet possible.
Nevertheless, DBT with batterers may be an a p p r o p r i -
ate choice for clients who have failed in o t h e r treatments,
a n d is a p p r o p r i a t e for f u r t h e r study. More systematic
study is n e e d e d specifically to test f u r t h e r the applicabil-
ity o f the u n d e r l y i n g m o d e l o f e m o t i o n dysregulation, to
d e t e r m i n e the overall effectiveness o f DBT for domestic
violence, a n d to try to identify client factors that m a k e
this t r e a t m e n t likely to be effective for some clients a n d
n o t others. F o r example, data may d e m o n s t r a t e that for
"instrumental" batterers (those for w h o m e m o t i o n regu-
lation does n o t seem to be a factor in aggression) DBT is
n o t effective.
T h e p r o b l e m s of domestic violence are big e n o u g h
such that no one t r e a t m e n t is likely to be effective univer-
sally. However, DBT does address factors that may have
c o n t r i b u t e d to p o o r outcomes in o t h e r treatments: T h e
DBT focus on c o m m i t m e n t to t r e a t m e n t may h e l p re-
duce d r o p o u t a n d e n h a n c e c o m p l i a n c e a n d practice; the
n o n j u d g m e n t a l c o m p o r t m e n t a n d focus o n validation by
 DBT With a n I n p a t i e n t F o r e n s i c P o p u l a t i o n 447

the therapist may e n h a n c e the t h e r a p e u t i c alliance a n d
help reduce dropout; and the focus on emotions other
t h a n a n g e r m a y allow o t h e r skills to b e l e a r n e d (e.g.,
e m o t i o n i d e n t i f i c a t i o n a n d r e g u l a t i o n ) to t r e a t skill deft-
cits likely to c o n t r i b u t e to a g g r e s s i v e a n d v i o l e n t b e h a v i o r .
References
Babcock, J. C., & Steiner, R. (1999). The relationship between treat-
ment, incarceration, and recidivism of battering. Journal ofFamily
Psychology, 13, 46-59.
Feld, S. L., & Straus, M. A. (1989). Escalation and desistence of wife
assault in marriage. Criminology, 27, 141-159.
Fruzzetti, A. E. (1995). The intimacy-distance]nvcess codingsystem:A func-
tional approachto coding coupleinteractions. Coding manual, Univer-
sity of Nevada, Reno.
Fruzzetti, A. E. (1996). Causes and consequences: Individual distress in
the context of couple interactions.Journal of Consulting and Clini-
cal Psychology, 64, 1192-1201.
Fruzzetti, A. E., Hoffman, E D., & Linehan, M. M. (in press). Dialectical
behavior therapy with couplesand families. New York: Guilford.
Fruzzetti, A. E., Saedi, N., Wilson, M. E., Rubio, A., & Levensky, E. R.
(1999). Domestic Violence Interview Manual. Reno: University of
Nevada.
Fruzzetti, A. E., Waltz, J. A., & Linehan, M. M. (1997). Supervision in
dialectical behavior therapy. In C. E. Watkins, Jr. (Ed.), Handbook
ofpsychotherapy supovision (pp. 84-100). New York: Wiley.
Gondolf, E. W. (1997). Patterns of reassault in batterer programs. Vio-
lenceand Victims, 12, 373-387.
Gondolf, E. W., & Foster, R.A. (1991). Pre-program attrition in batter-
ers'programs. Journal of Family Violence, 6, 337-349.
Hamberger, L. IC, & Hastings, J. E. (1986). Personality correlates of
men who abuse their partners: A cross validation study.Journal of
Family Violence, 1, 323-341.
Hoffman, P., Fruzzetti, A. E., & Swenson, C. R. (1999). Dialectical behav-
ior therapy-Family skills training. FamilyProcess,38, 399-414.
Holtzworth-Munroe, A., Beatty, S. B., & Anglin, K. (1995). The assess-
ment and treatment of marital violence: An introduction for mar-
ital therapists. In N. S. Jacobson & A. S. Gurman (Eds.), Clinical
handbook of marital therapy (pp. 317-339). New York: Guilford
Press.
Houskamp, B. M., & Foy, D. W. (1991). The assessment of posttrau-
mafic stress disorder in battered women. Journal oflnteepersonal
Violence, 6, 367-375.
Line han, M. M. (1993a). Cognitive-behavioraltreatment of borderline per-
sonality disorder..NewYork: Guilford Press.
Linehan, M. M. (1993b). Skills training manualfor treatingborderlineper-
sonality disorder..New York: Guilford Press.
Linehan, M. M. (1998). Validation and psychotherapy. In A. Bohart &
L. S. Greenberg (Eds.), Empathy and psychotherapy:New directions to
theory, research,and practice.Washington, De: American Psycholog-
ical Association.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H.
(1991). Cognitive-behavioral treatment of chronically suicidal
borderline patients. Archives of GeneralPsychiatry, 48, 1060-1064.
National Institute ofJusfice. (1994). Reporton victims of domesticviolence.
Washington, DC: U.S. Department of Justice.
Rosenfeld, B. D. (1992). Court-ordered treatment of spouse abuse.
Clinical PsychologyReview, 12, 205-226.
Rubio, A., & Fruzzetti, A. (2000). Borderlineand antisocialpersonalitydis-
orders: Genderedpublic versus similarprivate and self behaviors. Manu-
script submitted for publication.
Saedi, N., & Fruzzetti, A. E. (2000). Thefunction of aggression and vio-
lence in men who batter their partners. Manuscript submitted for
publication.
Stark, E., & Flitcraft, A. (1982). Medical therapy as repression: The
case of the battered women. Health and Medicine, 1, 29-32.
Straus, M. A., & Gelles, R.J. (1990). How violent are American fami-
lies? Estimates from the national family violence survey and other
studies. In M. A. Straus & R. J. Gelles (Eds.), Physical violence in
Americanfamilies (pp. 95-112). New Brunzwick, NJ: Transaction.
Tweed, R. G., & Dutton, D. G. (1998). A comparison of impulsive and
instrumental subgroups of batterers. Violenceand Victims, 13(3),
217-230.
Address correspondence to Alan Fruzzetti, Ph.D., University of Nevada,
Department of Psychology, # 298, Reno, NV 89557-0062.
Received: October20, 1999
Accepted: July 7, 2000

DBT With an Inpatient Forensic Population: The CMHIP Forensic M o d e l

R o b i n A. M c C a n n a n d E l i s s a M . B a l l , Institute f o r Forensic Psychiatry, Colorado M e n t a l H e a l t h I n s t i t u t e at Pueblo
A n d r e I v a n o f f , Columbia University

Implementation of Dialectical Behavior Therapy (DBT) in a forensic or criminal justice setting differs dramatically from standard
outpatient DBT. Forensic patients are multiproblem patients with violent histories and multiple diagnoses including borderline per-
sonality disorder (BPD), antisocial personality disorder (ASPD), and concomitant Axis I psychotic or mood disorders. D B T was se-
lectedfor this population because of its emphasis on treating life-threatening behaviors of patients and therapy-interfering behaviors
of both patients and staff The forensic inpatient DBT model described here includes modification of agreements, targets, skills train-
ing groups, and dialectical dilemmas. A n additional skills module, the Crime Review, was developed to supplement standard DBT.
Conclusions and recommendations for applying DBT in a forensic setting are presented.

Cognitive and Behavioral Practice 7, 4 4 7 - 4 5 6 , 2000 -~ORENSIC INPATIENT SETTINGS, i n c l u d i n g c r i m i n a l j u s -

107%7229/00/447-45651.00/0 rice a n d f o r e n s i c h o s p i t a l s , d i f f e r s i g n i f i c a n t l y f r o m
Copyright © 2000 by Association for Advancement of Behavior s t a n d a r d D B T o u t p a t i e n t settings. T h e p a t i e n t / i n m a t e
Therapy. All rights o f reproduction in any form reserved. p o p u l a t i o n is i n c a r c e r a t e d , m a l e , a n d c h a r a c t e r i z e d by
[~ Continuing Education Quiz located on p. 527. a n t i s o c i a l b e h a v i o r s . I n o n e study, 9 7 % o f c o r r e c t i o n a l in-