A Life without Violence? Experience of Treatment for Perpetrators of Violence in Intimate Partner Relationships in a Small Nordic Welfare Society

In this study, the experiences of perpetrators of violence in intimate relationships in Iceland that took part in this program; “Peace at home” were explored. Also the experiences of survivors were examined, who had a spouse that took part in that treatment program. A qualitative method was used, interviews were taken with six perpetrators and six survivors. All of the participants were white Icelandic people, none of them had a different ethnic background. The interviews were transcribed and analysed. As a result of their participation in the treatment program, all the perpetrators experienced improvement in quality of life, in their relationships with their spouses and in their general well-being. The survivors experienced the time their spouse was in therapy as positive overall and that it made a difference in their own lives. In all cases the physical violence stopped. However, the emotional abuse did not cease in all cases or increased again. Thus, it seems that perpetrators might need more prolonged treatment or different emphasis in treatment, in order to work on patriarchal mentality and stress-provoking situations.


Introduction
Intimate partner violence is a serious and extensive problem which can have devastating consequences for the victims (Esquivel-Santoveǹa, Lambert, & Hamel, 2013;National center for injury prevention and control, 2003;Thoresen, Myhre, Wemtzel-Larsen, Aakvaag, & Hjermdal, 2015), as well as for the children if they are present (Freysteinsdóttir, 2006; National center for injury prevention and control, 2003; Thoresen et al., 2015). Consequences include, but are not limited to, the following; post-traumatic stress disorder (Kernsmith, 2005), fear (Zeelenberg, Wagenmakers, & Rotteveel, 2006), anxiety and depression (Thoresen et al., 2015), and serious health problems (Bonomi, Anderson, Reid, Rivara, Carrell, & Thompson, 2009). This phenomenon is not only painful for the direct (partners) and indirect (children) victims of violence, but it is also very expensive for societies, which is reflected through the social system, health care system and the judicial system (National center for injury prevention and control, 2003).
Even though it seems to be common that intimate partner violence is bidirectional (Straus, 2009), it has been argued that most of the violence that seems bidirectional is in fact gender asymmetric and becomes more and more unidirectional (Leonard, Winters, Kearns-Bodkin, Homish, & Kubiak, 2014).
It is evident that the difference in physical strength among the genders is great. Thus, women generally experience more severe consequences than men (Black et al., 2011). In the most serious cases when the violence results in injury or death, women are most often the victims (Daly & Wilson, 1990).
Furthermore, women who have a violent partner experience less personal control, whereas having a violent partner does not influence men's personal control in the same way (Umberson, Anderson, Glick, & Shapiro, 1998). In addition, it has been argued that men do not seem to be threatened by physical violence from a woman partner, since they are able to use physical force to end such violence (Nybergh, Enander, & Krantz, 2016). The power structure of a certain type of masculinity that identifies some men, allows male dominance over women (Hamber, 2016). Men, who have a sense of inadequacy, might assert their masculinity in order to feel more masculine (Edleson & Tolman, 1992).
In the beginning, the focus was on supporting women who were victims of intimate partner violence. In the late 1970's the main role of shelters was to provide support for women who were victims of violence. This role gradually changed and the staff at the shelters started to work with social services, health care services and law enforcement (Chang et al., 2005). In addition, the feminist movement demanded a response from the criminal justice system (Pandya & Gingerich, 2002) and the focus shifted from the victims to the treatment of perpetrators (Stover, 2005), which is important since the perpetrators are responsible for the violence they perpetuate against women which can have serious consequences.
The Duluth model, which is a psychoeducational treatment program was developed in 1981. The model suggests that men's violence against women has roots in patriarchal ideology, which is socially learned (Pence & Paymar, 1993;Stover, Meadows, & Kaufman, 2009 other men (Forbis, Addam-Curtis, & White, 2004). The so-called power and control wheel in the model reflects how patriarchal ideas influence violent relationships (Pence & Paymar, 1993;Stover et al., 2009). In treatment based on the Duluth model, group facilitators help perpetrators to replace power and control behaviour with other learning tools (Barner & Carney, 2011). The most common form of intervention with male perpetrators is group treatment (Pandya & Ginerich, 2002).
Later cognitive-behavioural interventions were developed as an alternative treatment approach to the Duluth model. The cognitive-behavioural approaches are more gender neutral and view violence as a result of thinking errors which therapists work on changing in treatment. These interventions emphasize anger management and skills training as well (Dutton, 2008;Dutton & Curvo, 2007).
However, it has been argued, that programs based on the Duluth model and on cognitive-behavioural ideology are getting similar, with both approaches addressing both irrational thoughts as well as attitudes regarding women (Babcock, Green, & Robie, 2004).
It could be argued that the Duluth model explains violence by looking at political power factors, whereas violence is explained by psychological factors by the cognitive-behavioural approach. Johnson (1995,2005) argued that there are more than one forms of intimate partner violence, including patriarchal terrorism and more gender-neutral conflict. The Duluth model might be more suitable for patriarchal terrorism violence and the cognitive behavioural model might fit perpetrators better that experience occasional outbursts when conflict escalates, in more gender neutral situations. According to a literature review study, neither of those treatment methods are very effective, since the recidivism rate is quite high or about a quarter (Stover et al., 2009).
In addition, the recidivism rate is even higher for perpetrators with combined borderline personality traits and antisocial personality traits with impaired empathy recognition (Martí nez, Lila, & Albiol, 2016a). Risk factors such as poor mental health and substance abuse are among factors that might be related to an experience of trauma (Devaney & Lazenbatt, 2016). One treatment program which emphasized reducing risk factors and is based on an ecological model, showed that empathy recognition did improve following the program, but perpetrators who consumed less alcohol showed more improvements than perpetrators who consumed more alcohol (Martí nez, Lila, Martí nez, Rico, & Albiol, 2016b).
It has been questioned, if one group-based program fits the needs of all perpetrators (Gondolf, 2012).
For example, Karakurt, Whiting, Esch, Bolen and Calabrese (2016) who reviewed studies on treatment, argued that couple therapy seems to be appropriate for particular issues related to gender neutral conflict. Perpetrators are not all alike and they are dealing with different problems. However, some similarities among them have been found. There is an empirical support for psychological problems among male perpetrators of violence. With higher frequency of violence, they show more depressive symptoms, irresponsibility and risk-taking behaviour, but less anxiety than men who do not use violence (Dowgwillo, Mé nard, Krueger, & Pincus, 2016). Furthermore, men who perpetuate violence against women have a lower empathy level than other men (Ulloa & Hammett, 2016). In addition, they are likely to have personality disorders or symptoms of such disorders (Freysteinsdóttir, in press;Dowgwillo et al., 2016). But it can be argued, that it is important for all perpetrators to feel motivation to enter treatment. Sheehan, Thakor and Stewart (2012) concluded after reviewing several studies, that the motive for change, was usually related to a turning point following a special event or situations.
Examples were criminal sanctions or fear of losing their family.
Since the problem of violence in intimate relationships and violence against women is extensive, it can be argued that treatment programs and an exploration of such programs for perpetrators are important.
Over a third of women in the 28 European Union countries have suffered from physical and/or sexual violence by their partner or former partner (European union agency for fundamental rights, 2014). This is slightly less than the frequency in Iceland, where this study was conducted. According to a recent study, about a quarter have been victims of violence there by a current or former partner (Elí sabet & Ásdí s, 2010). In addition, several women have died during the last decades in this small country as a result of intimate partner violence (Freysteinsdóttir, 2017).
There is only one official perpetrator treatment program in Iceland. It is called "Peace at home" [Heimilisfriður] and is only available in two areas in the country. The program is based on the program "Alternative to Violence" [Alternative til vold] (Heimilisfriður, n.d.) which was the first treatment town, which is the largest town outside of the capital city area. It offers four diagnostic interviews in the beginning of treatment. Following the interviews, it is evaluated if additional interviews or group therapy is suitable and how extensive the treatment will be. Partners of the perpetrators receive two interviews in the beginning of therapy and in the end of therapy. The purpose of those interviews is to evaluate the safety of the partners and of the children as well. Men can contact the program themselves, but they can also be referred to the program by institutions such as the social services, child protection authorities and the police (Heimilisfriður, n.d.).
A study where content analyses was used on available written material in this program, showed that the violence used by the perpetrators was most often emotional and physical but some had used sexual violence as well. Some of the perpetrators had used violence against more than one partner and many of the perpetrators had either been abused in their childhood, witnessed violence, or both (Freysteinsdóttir & Þórðardóttir, 2016 from their perspectives and from the perspectives of partners.

Method
This studyś objective was to deepen the understanding of the experience of treatment of violence in intimate relationships in Iceland. In order to achieve that goal an attempt was made to look into the world of both victims and perpetrators of violence in intimate relationships by using a qualitative research method. The purpose with using qualitative methods is to gain information of the experiences of particular groups regarding a particular subject (Neuman, 2006). The qualitative research method is best suited to analyse the interviewee's deepest feelings, problems, attitudes and behaviour in order to gain a deep understanding of the subject (Padgett, 2008). Interviews were conducted and analysed in order to identify themes in the narratives of the participants (Esterberg, 2002). Themes can be described as principles that reoccur and form relations among subsystems which give a particular cultural meaning (Spradley, 1980).

Participants
The participants were 12 in total, six women who had a partner who had been in treatment for men who are violent to their partner and six men who had been in that program. The men interviewed had been in the program for three to four months up to two years. The partners of the women interviewed had been in the program from few interviews up to two years. All of the participants were white, Caucasian people. The Research centre of children and families received a list of perpetrators who had been in interviews and/or in a group program for perpetrators. It also received a list of all registered victims of intimate partner violence who had been involved with the program. The participants were selected from those lists, contacted and asked to participate. The women who participated in this study, were 32-75 years old. Two of them were over 70 years old. Two women were still in a relationship with the perpetrator, four of them had ended the relationship. The men were 25-42 years old. Four of them were still with the same woman they had been with when in the treatment program. The participants were not couples.
Two of the men had completed a university education, three had finished apprenticeship or a comparable education and one men had only completed elementary school. All of them had a job.
Three of the women had a university education and one had completed secondary school. Two women only had an elementary education, were retired but had been working for many years. The participants were given fake names to maintain confidentiality. The names were listed alphabetically by series of interviews, the first respondent (woman) was renamed Arna, respondent two was renamed Bá ra and so on. The same method was used for the names of the men.

Data
Interviews were semi-structured interviews in order to explore the experiences and perceptions of survivors and perpetrators of violence in intimate relationships. Thus, an interview guide was created by the author of this article, with questions for the perpetrators and another interview guide was created for the victims. The interview guides included questions about demographics, the violence and the influences of therapy. Examples of questions in the interview guide were the following: 1) When did you first realize that you were using violence in the relationship (perpetrators)? 2) Can you describe the experience of being the victim of violence (survivors)? The objective of semi-structured interviews is to explore a subject in an open way and give the interviewee the opportunity to offer their views and ideas in their own words (Esterberg, 2002). Most of the interviews lasted for about an hour, but one of them was considerable longer and lasted for over two hours.

Procedure
The participants were selected by purposive sampling, which means that they were chosen by certain characteristics in order to give information that has been missing in this research area (Esterberg, 2002;Padgett, 2008). As noted before, the participants were selected from a list of participants in a program for perpetrators of violence against women. The research centre of children and families chose persons randomly from that list and called them and asked them to participate. On the average three interviews were booked for each interview that actually took place. Many were going to participate, but did not as little preconceptions about the research material as possible (Padgett, 2008).
All participants signed an informed consent. The ministry of social welfare which supported the batterer treatment program financially, reported the study to The Icelandic data protection authority.

Result
When the data was analysed with open coding and theme analysis, few main themes presented themselves from the interviews with the perpetrators and few main themes from interviews with the survivors. Only one of the themes is described in this paper: The experience of the influences of treatment and support.

Perpetrators Experience of the Influence of the Treatment
All six men were satisfied with the treatment of the treatment program. Their experience was positive and they thought that their frame of mind changed a great deal. However, it was a challenge for them to enter treatment and they entered it after they felt a pressing need to enter it. In some cases, the men did It seemed to be important that this resource was available and affordable as Einar noted. After his wife had pointed it out to him that he was perpetuating emotional violence, he used the internet to find a resource: … and then I scheduled an interview… I found out that it was not expensive… you know or very little… I was very pleased… and and… the pr… price was manageable for me.
But once the perpetrators had decided to enter the treatment program, it seemed to be very challenging for them to do that. Bragi described how difficult it was for him to enter the program: …it was, first I thought that this was just a program for men who were beating their wives, and that, and I thought that it was somehow distasteful to think about it, to enter something like that you see.
Bragi had perpetuated emotional violence towards his wife, but not physical violence. Arnar also described how challenging it was to enter the program: …then I go to [,,,] group work. I thought it was amazingly good. I was very apprehensive of this or like shy about this, you know, to sit there with a lot of men that I did not know, everybody discussing something that we were doing that we should not be doing, you see?
Gunnar expressed how difficult it had been to face his shortcomings in the treatment: Extremely difficult. Just to look yourself in the eye and go through this, through this work. But, but like, I also realized that this was, this was what I needed and so it was good to meet with this psychologist that, like, I saw. He definitely, you see… Yes, what can I say? No nonsense like guy, just entered things directly, asked difficult questions, threw excuses out of your hands and just took a firm grip around you. That, I think, was really good for me.
It seemed that group therapy was even more helpful for some of the men than interviews. It seemed to help them see more clearly what others were doing wrong which helped them to point it out to each other as Einar noted: "…But that did a lot, I think, I think it really had more effects than the private lessons, you know".
He further noted: … there are good psychologists that are there…. And the boys [the other perpetrators in the group] are… you know… they are… it is very good to be able to mirror yourself in them… because we are all really dealing with the same problems… However, the group therapy did not seem to suit all the men. Friðrik did not find it as helpful as the Bragi's marriage fell apart while he was in treatment. His wife moved to a different country for educational purposes and they got a divorce few months after that. However, Bragi who only had been to five or six interviews during a two-year period and not entered group treatment, thought that the interviews had helped them to go through the divorce in a positive manner: These interviews, I think that they had a very good influence on us, for example, just, like, we got a divorce and that went amazingly well… I just… we were able to go through this together and respect each other and, and, so I think these interviews have, for example helped me very much in all that, you see.
The participants described improvement in their relationships with others than their partners following the treatment. Arnar described improvements in the relationship between him and his son following the treatment: …there is much lighter [atmosphere] between us you see. We were a lot together despite these dull moments that were, like, that I was like that… But, now today I think he is just enjoying this more, you see, you know he does not have to be so alert.
Similarly, Gunnar managed to break an intergenerational transmission of violence following the treatment and was experiencing a more comfortable life and more joy in his family: …there was always supposed to be silence when the news was on and the news was always on you know, when we were having dinner and things like that, there was always news on the television [in his family of origin]. You know. I just stopped this, just, don't listen to the news and we just talk while we eat. We don't have the television on… More, more like, joy and so on… and yes intimacy, better family life.
He further added how he behaved in a different way towards people in general. He experienced himself as more open and more positive: Thus, I experience this change that I have maybe, made on myself, with this program, not just in communication with my partner, but also with my children, family, friends and also just strangers.
Gunnar described further how his relationships with other than his partner had benefitted from the treatment program: "I think I am a better friend and thus a more likable bloke now after I went into this program". In addition, the perpetrators expressed how they learned to replace the old behaviour for new by mirroring themselves in the accounts of other perpetrators in the group work. The men described how they ceased controlling with terror inside the home, they could control their own behaviour better, the other family members were less fearful and that there was a lighter atmosphere in the home. However, it seemed like some of the men had a tendency to resort to violence and needed to hold on to something that reminded them of different ways to manage stress like Einar mentioned: … I wish that I could say you know… that this is completely fixed you know… that this is all just gone… but this is such a problem that it will always… I think that I will always need to be conscious about this… and that I always need to be working on this, yes… because this is so strong… this is so rooted mmhmm… and so on, exactly yes.
From this quote it seems like at least some perpetrators might need long term treatment or continue in some kind of a post treatment, in order to prevent falling into old behaviour patterns. However, there were examples of a complete difference in views following the treatment. Friðrik described how his view had changed regarding conflict: … when we had a fight, I always thought that either of us would have to win… But you know it doesn't matter when you start fighting with someone. Neither of you is going to win the fight, it is just that, there is nothing more complicated than that you see. You know, the only way to win a fight, is to not get hooked into it.
Gunnar further added, how the treatment had changed his way of thinking and the way he felt on a daily basis: You know, I am not this arrogant, irritated, like, angry guy. You know, I am very different in the traffic, very different in the store. You know, there are not anymore just assholes and lunatics around you. I had somehow developed that kind of attitude.
He also noted that the treatment had help him gain insight into the influence of alcohol. In all cases where he had perpetuated violence towards a partner, he had been under the influence of alcohol: And thus, it opened my eyes for like… the interplay between alcohol and emotions. That, you know, alcohol makes people less inhibited and, and, magnifies and exaggerates emotions.

The Experience of the Survivors of Their Partner's Treatment and Support from the Environment
The experience of survivors when their spouse was receiving treatment varied. Overall, their experience was positive, the women were hopeful and satisfied with the fact that their partner was seeking help. However, one of the women thought that the therapists were sceptical, because they thought that the violence had been more serious than it really was and that her partner had not revealed all the violence incidents.
For all the women the physical violence stopped for some period of time following the treatment and the emotional violence stopped or was reduced, but then the emotional violence started to increase again. Erna said that her partner had become more open and it was easier to discuss matters with him.
He had also reduced drinking alcohol while he was in therapy. The physical violence had completely According to the women, the physical violence ended when their partners were in the treatment program, but the emotional violence continued even though it might have ceased for a while. They also described a better atmosphere when the emotional violence ceased. The women had sought various support during their relationships with the perpetrators. Some of the women had received support from the extended family, even from grown children. All of them had received support from professionals such as social workers, psychologists or priests.

Discussion
The perpetrators' experience of violence in intimate relationships and the experience of treatment for perpetrators had not been previously studied in Iceland when this study was conducted. The results show that even in a small Nordic welfare society, men can be found who have patriarchal ideas, are dealing with different risk factors and are violent towards their partners. The perpetrators described the violence as difficult experiences that have had major consequences on their lives. Others have been influenced by their behaviour as well, such as their partners, children, relatives, friends and even strangers.
The men described how the treatment had helped them change their thoughts and behaviour, so when something in the environment had triggered violence before, they were able to respond to those triggers differently. They seemed to be more aware of their responsibility for their reactions and their behaviour.
This experienced self-understanding seems to be similar to the results of other studies conducted by Pandya and Gingerich (2002) and Wansgaard (as cited in Silvergleid & Mankowski, 2006).
The perpetrators thought that their quality of life had improved and they experienced a closer and more fulfilling relationship with their partners after they took part in the treatment program. Some perpetrators had benefitted from individual treatment whereas others thought that group treatment was more helpful. It might be important to find out if personality characteristic of the perpetrators play a role in that. As noted by Silvergleid and Mankowski (2006), admitting a problem in a group is more influential than in a private session. They further noted that senior members in group therapy recognize how far they have become when new members enter the group. Thus, it is important to find out why group treatment does not seem to fit all men.
The perpetrators seemed to have needed a push from the outside in order to realize that they were being violent and that they needed to do something about it, something that really moved them. This is similar to the results of Sheehan et al. (2012).
The survivors in this study expressed that the physical violence had stopped following the treatment, but that the emotional violence had decreased but not stopped permanently. This is partly in accordance with Gondolf's (2007) study, stating that incidents of physical violence and other violence decreased dramatically or stopped in relationships were the men participated in treatment for perpetrators of violence in intimate relationships. Other older studies have shown decrease in physical violence following treatment but that verbal abuse continued following treatment (Saunders & Hanusa, 1986).
Thus, perpetrators might maintain their status of power by using verbal abuse and threats (Edleseon & Tolman, 1992).
However, in this study it seemed from the perpetrator's descriptions, that they were struggling with changing their attitudes and behaviour after years of maintaining a certain pattern, which was in some cases learned in childhood. Some of them wanted to be different from an abusive role model, which is similar to the findings of a study conducted by Silvergleid and Mankowski (2006). Furthermore, they seemed to be more aware of when they were using abuse. They wanted to stop being abusive and have better relationships with their families. These findings are similar to the findings of Schmidt, Kolodinsky, Carsten, Schmidt, Larson and MacLachlan (2007) and the findings of Silvergleid and Mankowski (2006).
What perpetrators have found helpful in treatment in supporting them changing their behaviour according to Wansgaard (as cited in Silvergleid & Mankowski, 2006) was respect and support from other group members as well as facilitators and group dynamics (Silvergleid & Mankowski, 2006). But not only support is important from facilitators, but also education, modelling and confrontation.
Confrontation is particularly important in order to help violent men to stop denying their abusive behaviour (Silvergleid & Mankowski, 2006). Another study showed that violent men who had completed a feminist orientated program showed more responsibility for their battering behaviour, had developed empathy for their partners, were less dependent upon their partners and had increased communication skills (Scott & Wolfe, 2000).
Since the emotional violence seemed to continue following treatment according to the survivors, it is important to find effective ways to reduce the emotional violence further, either by prolonging it or by changing the nature of it. Buttell (2001) has found that moral reasoning is low among batterers.
Because of that, they tend to prioritize self-interest higher than empathy. He argues that it is important to address moral reasoning in programs for perpetrators. Court ordered programs based on cognitive behavioural therapy are likely to reduce controlling and intimidating behaviour of perpetrators and increase quality of life of both perpetrators and victims (Dobash & Dobash, 2000).
In addition, one study showed that men's fear of losing their wives, the importance of their children or demands from the criminal justice system could all be factors motivating them to change their behaviour. Thus, it seems like the manhood they had learned needed to be changed into a new manhood (Silvergleid & Mankowski, 2006), since the old one did not seem to have been supporting them or their families. Thus, it might be speculated if it would be helpful for the treatment program in Iceland to add more feminist orientation to it. It could be argued that batterer programs for male perpetrators that do not include the feminist perspective are gender blind rather than gender neutral. All the facilitators are males, it might possibly be beneficial to have two group facilitators, both a man and a woman who might be important role models for respect and quality communication.
The treatment program for perpetrators in Iceland seems to be rather influential. However, other programs might be more successful. For example a program that includes both educational cognitive behavioural approach as well as self-help approach has shown better results than an approach which only includes educational cognitive behavioural approach or only self-help approach (Edleson & Syers, 1991). Furthermore, the domestic abuse intervention project in Duluth, Minnesota which combines cognitive-behavioural approach with feminist approach is believed to be the most prominent program for batterers (Edleson & Tolman, 1992;Gondolf, 2002). Furthermore, a follow up might be needed in order to maintain progress, especially regarding emotional violence.

Strengths and Limitations
This was a qualitative study which included few participants. The aim of the study was to explore how perpetrators and victims experience treatment for perpetrators. Thus, the results cannot be generalized to the wider population, which is a weakness of this study. However, the strength of this study is that both perpetrators and victims were interviewed, which gives information from a wider perspective.

Policy Implication of the Research Findings
The results of this study might be useful in increasing awareness among professionals regarding what perpetrators and survivors of intimate partner violence are experiencing. The results might help minimize the risk for victims and perpetrators to experience prejudice by professionals and lack of understanding of their situation which they might face (Eriksson, Bergbom, & Lyckhage, 2014;Swahnberg, Hearn, & Wijma, 2009). In addition, the results might help professionals to be more aware that this problem might exist when treating people of various kinds of consequences of violence (Swahnberg et al., 2009). Moreover, the results show the importance of the existence of treatment programs for those who need and want to seek help. This type of service is of course important not only in the capital and in the northern part of the country, but throughout the country. It is worth trying to reduce violence because of its far-reaching consequences, on those involved as well as on society. This study gives insight into how important such treatment programs are even in a small Nordic welfare society, for perpetrators, survivors and their children. In addition, it gives information on how it might be possible to improve the quality of treatment for perpetrators even further. However, more qualitative studies are needed to explore perspectives of perpetrators (Devaney & Lazenbatt, 2016) in order to improve treatment programs.