Care of perpetrators of repeat family violence: an integrative literature review

Abstract

Objectives

Identifying the main articles in scientific literature on care of perpetrators of repeat family violence and presenting the most relevant successful experiences.

Methods

Integrative literature review consisting of a survey for articles published from 2008 to 2017 indexed in MEDLINE, CINAHL, and SciELO.

Results

Out of the 1,496 identified articles, 15 met all inclusion criteria. After analysis of all studies included, two categories were elaborated: intervening factors for intra-familial violence and successful measures for the treatment or rehabilitation of perpetrators of family violence.

Conclusion

Literature on the topic is scarce in emerging countries. Aspects such as intergenerational patterns and experience of violence in childhood may be intervening factors for aggressive family behavior. Mindfulness meditation, individual counseling, improvement in sleep pattern, participation in prevention programs, and forms of psychotherapy were shown to be successful measures for the care of perpetrators.

Domestic violence; Family health; Aggression; Delivery of health care

Resumo

Objetivo

Identificar as principais literaturas científicas sobre o cuidado prestado ao agressor familiar frequente e apresentar as experiências exitosas mais relevantes.

Métodos

Revisão integrativa da literatura, com busca de artigos publicados entre os anos de 2008 a 2017, nas bases de dados MEDLINE, CINAHL e SciELO.

Resultados

Dos 1.496 artigos identificados, 15 atenderam aos critérios de inclusão. A análise desses estudos revelou duas categorias: Fatores intervenientes à agressividade intrafamiliar e Medidas exitosas para cuidado ou reabilitação de agressores familiares.

Conclusão

Há escassez de produção sobre a temática em países emergentes. Aspectos como padrões intergeracionais e vivência de situações violentas na infância podem ser intervenientes para o comportamento agressivo contra a família. São apontadas como medidas exitosas para o cuidado do agressor familiar a meditação de atenção plena, o aconselhamento pessoal, a melhoria do padrão do sono, participação em programas de prevenção e em formas de psicoterapia.

Violência doméstica; Saúde da família; Agressão; Assistência à saúde

Resumen

Objetivo

Identificar las principales literaturas científicas sobre el cuidado ofrecido al agresor familiar recurrente y presentar las experiencias exitosas más relevantes.

Métodos

Revisión integradora de literatura, con búsqueda de artículos publicados entre 2008 y 2017 en las bases de datos MEDLINE, CINAHL y SciELO.

Resultados

De los 1496 artículos identificados, 15 cumplieron los criterios de inclusión. El análisis de estos estudios reveló dos categorías: factores intervinientes en la agresividad intrafamiliar y medidas exitosas para cuidado o rehabilitación de agresores familiares.

Conclusión

Hay escasez de producción sobre este tema en países emergentes. Aspectos como patrones intergeneracionales y vivencia de situaciones violentas durante la infancia pueden ser intervinientes en el comportamiento agresivo contra la familia. Se señalaron las siguientes medidas exitosas para el cuidado del agresor familiar: meditación de atención plena, consejos personales, mejora del patrón del sueño, participación en programas de prevención y tipos de psicoterapia.

Violencia doméstica; Salud de la família; Agresión; Prestación de atención de salud

Introduction

Violence is a complex experience affecting individuals from different social classes, physical characteristics, age groups, religions, and cultures. Due to the physical and psychological harm caused by violence, it is considered a serious health issue affecting individuals worldwide. Interactions among several factors may affect individuals’ behaviors, transforming them into victims or perpetrators of violence.¹,²

Family violence is defined as violence that occurs among members of a family, intimate partners, or individuals in an intimate relationship with or without blood ties. Thus, it is characterized as a harmful act performed by individuals who are intimate. Aggression begins with an imbalance in power between victim and perpetrator and it includes, but is not limited to, sexual and psychological abuse, physical aggression, negligence, abandonment.²,³It may compromise well-being, development, or physical integrity in the family and affect interpersonal relationships. It may be perpetrated by any given family member and it is often used as a tool for conflict resolution in the face of lacking communication skills. For example, in Brazil, most of non-lethal aggression events are estimated to take place within the households of victims.²-⁴

A literature review on psychological interventions for perpetrators of family violence has shown that most healthcare studies in the field of family violence are mainly victim-related, including topics such as humanizing care for victims (embracement), decrease in conditions of vulnerability, and mandatory reporting.⁵ Furthermore, there is a lack of research on approaches, treatment, care, and rehabilitation for perpetrators. A lack of training for healthcare providers — especially nurses — may reflect on the duration and effects of family violence, given perpetrators are likely to recur if they do not receive proper care nor understand the magnitude of their actions towards their victims. Given the reasons above, the authors of this study put forth the following question: what experiences have been successful in the care of perpetrators of family violence?

Thus, the objectives of this study were: identifying the main articles in scientific literature on the care of perpetrators of repeat family violence and presenting the most relevant successful experiences.

Methods

An integrative literature review was conducted to seek evidence on the care of perpetrators. This kind of study consists in analyzing the literature by synthesizing multiple studies, allowing for a deep understanding of a specific phenomenon.⁶ The following steps were used: elaborating the issue, collecting data, assessing, analyzing, interpreting, and presenting results.⁶

The PICO (patient or problem = perpetrator of family violence, intervention = treatment and/or care, control or comparison = not applicable, and outcome = successful measures) strategy was used to elaborate the main issue, resulting in the following question: what measures have been successful in the care of perpetrators of repeat family violence? Data were collected included scientific articles indexed in MEDLINE, CINAHL, and SciELO. Inclusion criteria were: articles written in Portuguese, Spanish, or English from 2008 to 2017. The following Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH)were used: aggression, family, treatment, delivery of health care. Databases were surveyed between February and March 2018.

For the combination of keywords, Boolean operators AND (restrictive combination) and OR (additive combination) were used. To combine keywords from the PICO strategy acronym, the OR operator was used; to combine keywords from different acronyms, the AND operator was used. A combined survey was conducted using the MEDLINE and CINAHL databases with terms family [MeSH Terms], AND aggression [MeSH Terms], OR violence [MeSH Terms], OR domestic violence [All Fields] AND treatment [All Fields] OR therapy [MeSH Terms], OR delivery of healthcare [MeSH Terms]. When using the SciELO database, the term family violence [All Fields] was added due to its presence in articles found during our survey, despite it not being a standard descriptor.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was used in this review.⁷ Articles were initially selected by title and abstract, read in their entirety, and then included in the study on the basis of their relevance to the study’s main question and concepts deemed relevant to the study’s objectives. Articles that were repeatedly featured in more than one database were analyzed only once. The following number of articles by database was obtained: MEDLINE 1,067, CINAHL 283, and SciELO 146. Articles that full text was not available and articles on the care of occasional perpetrators of family violence were excluded. Two reviewers read titles and abstracts independently, considering all inclusion and exclusion criteria. Conflicts between reviewers were resolved in discussions until a consensus was reached. Finally, a sample of 15 articles was obtained. Primary studies were classified by their level of evidence.⁸

The process of selecting articles based on grouping the descriptors used for database surveys, the survey results, and the number of articles included in this study are shown in figure 1.

Figure 1
Study selection chart illustrating the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) strategy

Results

For classifying the 15 articles selected, a synoptic panel was drafted with all significant variables: authors, year of publication, location, journal, study design, and results (Chart 1).

Chart 1
Synthesis of studies selected for integrative review

Authors	Year of publication/country of origin	Journal	Study design/level of evidence	Results
Kassis W, Artz S, Maurovic I, Simões C.(9)	2017 Austria, Germany, Slovenia, and Spain	Child Abuse & Neglect	Observational study/level VI	Chances of young people being free of violence and/or depression are significantly lower with increased exposure to family violence.
Mathias CW, Duffing TM, Acheson A, Charles NE, Lake SL, Ryan SR, Liang Y, Dougherty DM.(10)	2015 USA	Addictive Disorders & Their Treatment	Observational study/level IV	Family history of substance abuse is a predictor for early onset addiction and family aggression.
Dragioti E, Damigos D, Mavreas V, Gouva M.(11)	2012 Greece	International Journal of Caring Sciences	Observational study/level VI	High levels of hostility and aggression were observed among individuals exposed to traumatic family events.
Tanaka A, Raishevich N, Scarpa A.(12)	2010 USA	Journal of Interpersonal Violence	Correlational study/level VI	Family conflict was related to increased proactive but not reactive aggression in children with high levels of anxiety.
Karakurt G, Keiley M, Posada G.(13)	2013 USA	Journal of Family Violence	Correlational study/level VI	Individuals presenting higher levels of insecurity were more likely to be victims of persistent aggression in their relationships.
Ruddick L, Davies L, Bacarese-Hamilton M, Oliver C.(14)	2015 United Kingdom	Research in Developmental Disabilities	Observational study/level VI	Need for proper support and service to care for children with intellectual disabilities exhibiting aggressive and destructive behavior in the family.
Forster M, Dyal SR, Baezconde-Garbanati L, Chou CP, Soto DW, Unger JB.(15)	2013 USA	Ethnicity & Health	Observational study/level IV	Acculturative stress and little family cohesion were associated with bullying and aggressive responses, which in turn increase the connection between depression and smoking.
Levac AM, McCay E, Merka P, Reddon-D’Arcy ML.(16)	2008 Canada	Journal of Child and Adolescent Psychiatry Nursing	Qualitative study/level V	Group therapy led to a decrease in stress levels and an increase in confidence for parents and children, thus decreasing family violence.
Elmquist J, Shorey RC, Labrecque L, Ninnemann A, Zapor H, Febres J, et al.(17)	2016 USA	Violence Against Women	Observational study/level VI	Interventions such as meditation in programs for perpetrators of intimate partner violence increase capacity for emotional regulation.
Shorey RC, Anderson S, Stuart GL.(18)	2015 USA	Journal of Interpersonal Violence	Experimental study/level III	Negative relationship between mindfulness and aggression.
El-Sheikh M, Tu KM, Erath SA, Buckhalt JA.(19)	2014 USA	Journal of Family Psychology	Observational study/level IV	Sleep quality and efficiency may affect the association between negative parenting and intellectual capacity.
Seo JY, Lloyd DA, Nam SI.(20)	2014 South Korea	Journal of Family Violence	Experimental study/level III	Providing counseling to men in the military decreased chances of aggression and family conflict.
Connors AD, Mills JF, Gray AL.(21)	2013 Canada	Psychological Services	Experimental study/level III	A family violence prevention program with incarcerated offenders showed efficient outcomes.
Mohamed AR, Mkabile S.(22)	2015 South Africa	Journal of Intellectual Disabilities	Case study/level VI	Attachment-based therapy was effective in the case of a child with intellectual disabilities exhibiting highly aggressive behavior towards her family.
Zamudio SA.(23)	2011 Bolivia	Ajayu	Qualitative study/level V	Brief solution-focused therapy with family offenders was shown to be effective.

By analyzing these articles on the topic of care for perpetrators of family violence in light of successful experiences in rehabilitating these individuals, authors observed convergent or similar material that was grouped into the following categories: (1) intervening factors for intra-familial violence and (2) successful measures for the treatment or rehabilitation of perpetrators of family violence. The level of evidence of studies obtained can be considered low, given 46.6% of studies were classified as level VI evidence.⁸ Most articles were published in 2015 (33.3%) and 14 (93.3%) of them were published in English.

Discussion

The role of perpetrator of family violence may be fulfilled by different actors and at different times of a life cycle; at certain moments, men may be the perpetrators of some form of aggression, whereas in others, women or mothers may also cause harm. Even children, adolescents, and the elderly may act as grave offenders. Thus, perpetrators of family violence cannot be purely restricted to a single gender, age group, and social role.⁹-¹⁵ Additionally, at any given time, any individual may find themselves in the role of victim or witness. At others, one may find themselves in the role of the offender. Our first category, “intervening factors for intra-familial violence”, emphasizes how certain familial characteristics may contribute to a condition of violence and aggression within the family itself or within adjacent institutions, such as the school or work environments. A piece of data shown to be significant in these studies is the repetition of intergenerational patterns of violence. Young individuals exposed to family violence tend to behave aggressively in situations of stress or conflict.⁹ Experiences as victims or witnesses of intra-familial violence increase the likelihood of individuals becoming aggressive or developing early onset depression or substance addition. On the contrary, young individuals who have not been exposed to family violence tend to be more resilient in adverse situations, show protective mechanisms to confront conflicts, better conditions for self-acceptance and self-control, in addition to a more optimistic outlook on the future.⁹-¹¹

In families with an excessive amount of conflict, children exhibit a high level of anxiety that causes aggressive behavior. It is worth noting that aggression in children is not usually a response to stress, i.e., it is not usually reactive, but proactive.¹² Causes are still little known and further research is required, but a tendency for reproducing behavior learned in the family can be observed.

Another intervening factor for the perpetration of family violence is the presence of victim insecurity or fragility. A study including 87 North American couples showed that women who have seen violence perpetrated against their mothers in childhood tend to be more likely to become victims of violence themselves in adulthood. Additionally, attachment insecurity leads men and women to become both victims and perpetrators of violence, depending on how they perceive power in their partners.¹³ I.e., the incidence of aggressive behavior is higher when a partner is perceived as inferior or weak. This is not the case, however, with aggressive behavior in people with intellectual disabilities, as the aggressive condition may be due to aspects unrelated to power; nonetheless, there is need for care and specialized services, particularly in early childhood.¹³

External factors may also be intervening factors for aggressive behavior in the family and demand an increasingly complex intervention exceeding the individual capacities of a single healthcare provider, which would mainly involve public and educational policies against violence. A study conducted with immigrants of Hispanic origin in the State of California, USA, showed that acculturative stress generates tensions that often go unresolved, culminating in a high risk for alcohol consumption, smoking, and violence, mainly in response to individuals being made fun of or humiliated due to immigrant and family origins.¹⁶

Our second category, “successful measures for the treatment or rehabilitation of perpetrators of family violence”, sheds light on possible interventions for offenders. One study reports a significant improvement in children of parents attending group therapy, where they learn to reflect about the influence of their parenting on the behavior of their children, which leads them to a change of habit and, consequently, a positive response in their children and a minimization of aggression among family members.¹⁷

In the case of couples where the repeat perpetrator of violence is male, some measures have been indicated as successful for minimizing hostility. Special consideration may be given to the practice of mindfulness meditation, which allows offenders to reflect about the impact of their behavior on victims and witnesses.¹⁸

Additionally, mindfulness seems to allow the perpetrator of family violence to become aware of what is happening in their life at present. Thus, it leads them to understand their own personal capacities for conflict resolution. A North American study conducted with 116 male perpetrators of family violence showed evidence of decrease in verbal and psychological violence, even in individuals exhibiting alcohol and drug addiction.¹⁸The same study, however, showed little response in the cases of physical violence, generally associated with an intense violent drive that is harder for the perpetrator to control.

Another aspect that played a relevant role in the decrease in family violence is the sleep pattern of the repeat perpetrator. A long and high quality period of sleep was shown to be a protective factor against anxiety and depression, especially in young individuals and adolescents, who showed a decrease in aggression towards their parents and family members.¹⁹

Men in the military are more used to dealing with violence in response to the demands in their activities, and they may also become repeat perpetrators of family violence. A study conducted in South Korea with 293 male individuals in the military showed that 36.9% of participants were perpetrators of intimate partner violence, mainly verbal (33.4% of cases). The same study showed that individual counseling, either formal or informal, was useful and helped perpetrators reach a decrease in offensive practices.²⁰

A Canadian study conducted with 159 male offenders incarcerated due to serious crimes of domestic or family violence, including homicide, showed the implementation of a High Intensity Family Violence Prevention Program (HIFVPP) was highly effective in changing their pattern of behavior. The program consisted in psychological counseling of a cognitive behavioral approach with an approximate duration of 300 hours divided into 75 group sessions and at least 10 individual sessions, conducted by 2 trained professionals. After the program, an improvement was seen in these individuals’ dimensions, such as self-control, acknowledgment of distorted thinking, empathy, and a sense of accountability for one’s own actions.²¹

A case study with parents of an adolescent participant with intellectual disabilities and long term highly aggressive behavior towards her family showed a positive short term impact (between three and six months) of the use of attachment-based therapy.²² In this case, parents and family members were approached at first, and the adolescent was included later on in the process. Approaching the family as a whole allowed for the identification of the needs and potentials of each member individually, in order to maintain family homeostasis, removing their sole focus from the adolescent’s individual behavior and transferring it to the various forms family wound up producing a hostile conduct. A similar approach is used in solution-focused therapy,²³ which is centered around resilience and the search for solutions based on each individual’s understanding of their own problems. This form of therapy was shown to be equally efficient in the case of a long term repeat perpetrator of sexual family violence.

We consider a study limitation the fact that the survey was conducted including three electronic databases only, as there might be further studies indexed with different locations. Additionally, the timeframe for publication of 10 years increases the possibility of dealing with outdated data. This timeframe was deemed warranted after an initial survey attempt with shorter periods of time, such as three to five years. In light of the quantity and quality of data returned by this survey, a need for widening our timeframe was identified.

Issues concerning violence have been the focus of studies in the field of Nursing for several years, given both victims and witnesses need to be properly cared and aided within the context of health services. We believe this study brings forth an additional reflection: successful practices in the care of perpetrators. Thus, it contributes to health promotion and prevention of recurring violent behavior. Results arising from this review will contribute to the practice for nursing and other fields of healthcare, especially by showing that treatment for perpetrators of repeat family violence should involve the whole family system and include more holistic and less excluding practices in order to achieve satisfactory results.

Conclusion

Research on treatment for perpetrators of family violence is widespread in published literature from North American. In emerging countries, however, research is scarce; and no Brazilian articles were found on the topic. Intergenerational patterns, repeat exposure to violence, and external factors — such as adaptive stress — seem to be intervening factors for family violence. Additionally, repeat family conflicts in childhood and adolescence may predispose to persistent hostile behavior in some members within the family unit. Despite the eventual in nature, some measures have been successful in the care of perpetrators of family violence and in the decrease in harmful behavior, such as mindfulness meditation, improvement in sleep pattern, individual counseling, participation in intensive psychotherapy programs, and forms of family therapy. Thus, the authors suggest that new studies, mainly experimental ones, should be conducted to investigate multidisciplinary care and minimizing the existing research gap in the published literature.

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Publication Dates

• Publication in this collection
  29 July 2019
• Date of issue
  May-Jun 2019

History

• Received
  22 Oct 2018
• Accepted
  3 Apr 2019