INTIMATE PARTNER VIOLENCE: ESTABLISHING THE NEEDS AND OPINIONS OF STAKEHOLDERS REGARDING SUPPORT THROUGH EHEALTH
A Qualitative Research Study
Anne Dijkers
University of Twente – Stichting Transfore
Supervisors:
dr. Y.H.A. Bouman dr. S.M. Kelders
H. Kip, Msc.
Date: 21-11-2017
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Samenvatting
Achtergrond: Partnergeweld kan een enorme invloed hebben op het leven van partners die partnergeweld ervaren. Tevens leidt het tot hoge maatschappelijke kosten. Ondanks dat er
verschillende behandelingen mogelijk zijn in forensisch psychiatrische instellingen voor plegers van partnergeweld, is het recidive cijfer voor deze verschillende behandelingen nog steeds te hoog. Door middel van de volgende drie factoren zou de effectiviteit van de behandelingen verhoogd kunnen worden: door partners van plegers meer te betrekken bij de behandeling, door het aanbieden van een eHealth technologie die partners vanuit huis ondersteuning zal bieden en door deze eHealth
technologie aan te laten sluiten op stage of change waarin de partners zich bevinden. Omdat er nog niet veel bekend is over het gebruik van eHealth voor deze specifieke doelgroep, is het doel van dit onderzoek om te onderzoeken wat de behoeften en meningen van de stakeholders: plegers, hun partners en hun behandelaar van De Tender, zijn ten opzichte van eHealth technologieën die de partners zullen helpen om toekomstig partnergeweld te voorkomen.
Methode: Er zijn semigestructureerde interviews afgenomen met zes behandelaren van De Tender.
Tijdens deze studie zijn ook plegers van partnergeweld en hun partners benaderd om deel te nemen aan dit interview, maar dit wilden zij niet. De respondenten zijn bevraagd over: hun mening met betrekking tot de huidige situatie rondom het betrekken van partners van plegers bij De Tender, hun mening over de benodigde ondersteuning van partners in de verschillende stages of change, hun mening met betrekking tot de verschillende manieren waarop eHealth aangeboden kan worden om zodoende partners te ondersteunen om toekomstig partnergeweld in hun relatie te voorkomen.
Resultaten: Alle behandelaren in deze studie waren enthousiast over de ontwikkeling van een nieuwe eHealth technologie om plegers van partnergeweld en hun partners te ondersteunen om zodoende toekomstig partnergeweld in hun relatie te voorkomen. Door de meeste behandelaren werd
aangegeven dat er extra ondersteuning voor beide partners nodig is in de action en maintenance fase omdat de meeste partners niet meer zo vaak naar therapie komen als ze deze fasen bereikt hebben.
Monitoring was de hoogst gewaardeerde vorm van eHealth volgens de behandelaren. Een effectieve eHealth technologie voor plegers van partnergeweld en hun partners dient, volgens de behandelaren, op maat gemaakt te worden voor ieder individu maar dient ook rekening te houden met de interactie dynamieken tussen ieder koppel.
Conclusie: Volgens de behandelaren is de ideale eHealth technologie, voor plegers van partnergeweld en hun partners om hen ondersteuning te bieden om toekomstig partnergeweld in hun relatie te
voorkomen, een mix tussen monitoring en gepersonaliseerde feedback. De technologie moet passend zijn voor beide partners en moet extra ondersteuning bieden aan partners in de action en maintenance fase. Omdat partnergeweld vaak ontstaat door een storing in de zelf regulerende processen, benoemen de behandelaren dat het goed zou zijn als er een manier wordt gevonden waardoor het ontstaan van het geweld gemeten kan worden in elk individu zodat het systeem de gebruikers kan waarschuwen als zij
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zich geïrriteerd of gefrustreerd voelen en hen zodoende kan helpen om hun zelf regulerende processen te herstellen.
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Abstract
Background: Intimate partner violence (IPV) can have an enormous influence on the lives of partners experiencing IPV; it also comes with high societal costs. There are different types of treatment for IPV perpetrators in forensic psychiatric outpatient centers. However, the recidivism rates of all these types of treatment are still high. The treatment effectiveness for IPV perpetrators can be increased by the following: by involving partners from perpetrators in the therapy, by offering an eHealth technology which will support partners in their homes and by tailoring the technology to the stage of change in which the partners are. Since there is not much known about eHealth for this specific target group so far, this research aims to investigate what the needs and opinions of stakeholders: perpetrator, their partner and their therapist at De Tender, are regarding eHealth to support the partners in order to prevent future violence in their relationship.
Method: Semi structured interviews were conducted with six therapists of De Tender. During this study perpetrators and their partners were also requested to participate but they didn’t want to participate. The respondents were asked about: their opinion regarding the current involvement of partners from perpetrators at De Tender, their opinion regarding the needed support for perpetrators and their partners in the different stages of change, their opinion regarding different ways to offer eHealth to perpetrators of IPV and their partners in order to prevent future violence in their relationship.
Results: All therapists in this study were enthusiastic about the development of a new eHealth
technology to support perpetrators of IPV and their partners in order to prevent future violence in their relationship. A majority of the therapists mentioned that especially in the action and maintenance phase additional support would be needed for both partners, since mostly partners are not going to therapy as much as they used to when they reach these phases. Monitoring was a form of eHealth which was most liked by all the therapists for this target group. An effective eHealth technology for this target group has to be tailored to the needs of each individual user but also to the interaction dynamics of each couple, according to the therapists.
Conclusion: According to the therapists, the ideal eHealth technology to support IPV perpetrators and their partners in preventing future violence is a mix between monitoring and personalized feedback.
The technology needs to be suitable for both partners and the technology has to offer support to the partners in the action and maintenance phase. Since often IPV occurs due to failure in self-regulatory processes, the therapists mentioned that it would be nice if there would be a way to measure the construction of violence in each individual so that the system could warn the users when they start to feel angry or frustrated and could help restore the self-regulatory processes.
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1. Introduction
Intimate partner violence is a big problem in the Netherlands. Every year a hundred people in the Netherlands lose their lives because of intimate partner violence (IPV) (Janssen, 2015). No less than 12% of the Dutch population has experienced violence at some time committed by a (ex)partner (Oosten, Vlugt, & Brants, 2009). In 2012 the Dutch police registered 60.000 incidents of domestic violence (Ferwerda & Hardeman, 2013). From all these reportings, 72,4% concerns IPV. IPV is a type of domestic violence, in which one or both (ex)partners use violence against each other. There are different definitions of violence with regards to IPV. A commonly used definition of violence is that it includes both moderate and severe forms of physical violence, threats and intimidating gestures, destruction of property, denigration and humiliation, hostile withdrawal and efforts to monitor and limit the partners activities and social contacts (Murphy, & Eckhardt, 2005). IPV occurs in heterosexual as well as homosexual relationships and in relationships between adolescents as well as in relationships between adults. IPV is not only a problem in the Netherlands, but a worldwide problem. In the UK IPV is reported to occur in one of four households and in Canada fifty percent of the women of 16 years and older reported at least one incidence of IPV (D’Ardenne & Balakrishna, 2001). It can be concluded that IPV is a serious and widespread problem.
IPV has societal-, as well individual consequences. For example, the societal costs that are the consequence of IPV are high. In the Netherlands in 2009, the costs that were the consequences of domestic violence were approximately €400.000.000 (Zalm, 2009). These societal costs include medical costs, mental health care costs, costs for the treatment of the perpetrator, costs for the deployment of the police, justice and rehabilitation (Janssen, 2015). IPV also leads to many individual consequences for the victim: from bruisings to bone fractures, from headache to spontaneous abortion or miscarriage, from stomach-, muscle- and joint pains to hearing deficits (Groenen, Jaspaert, &
Varvaeke, 2011). Besides these physical health problems as a consequence of IPV, victims also report more psychological problems than non-victims of IPV. The most important psychological consequences are depression and posttraumatic stress disorder (Groenen, Jaspaert, & Varvaeke, 2011).
It can be concluded that IPV is a big problem wherefore effective interventions need to be created.
1.1 The emergence of IPV
A question that arises is: how can IPV perpetrators cause this much pain to the one person they choose to spend their lives with? According to the I³ Theory from Slotter and Finkel (2011), IPV is most likely to occur when instigating triggers and impelling forces are strong and inhibiting forces are weak, see Figure 1 (Finkel, 2008, p. 276). Instigating triggers are events which trigger the individual to aggress, these triggers are precedent to the violence (Kleespies, 2016). The perpetrator might perceive the victim to be the one who started the conflict that led to the occurrence of the violence, might perceive someone other than the victim to be the one who started the conflict or might be provoked to use violence because of some aggression-related cues in the immediate environment.
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Impelling forces are factors that increase the likelihood that the individual will experience an aggressive impulse in response to the afore mentioned instigating trigger. These factors can be the characteristics of the perpetrator, the characteristics of the relationship between victim and perpetrator, cognitive, affective or physiological experiences that are momentarily activated. Finally, the inhibiting forces are the factors which increase the likelihood that an individual will override the aggressive impulses rather than act upon them. For example, this can be empathy for the partner or relationship commitment (Slotter & Finkel, 2011). This means that IPV occurs when there is an event which triggers the individual to behave violent, there are factors that make the individual experience an aggressive impulse and there are no factors that make the individual overcome these aggressive impulses.
Figure 1. Reprinted from ``Intimate partner violence perpetration. Insights from the science of self- regulation, by Finkel, E. (2008) Social relationships: Cognitive, affective and motivational processes, p. 276.
1.2 Types of IPV
Based on research it turned out that not all IPV perpetrators are the same. There are different theories which establish different types of IPV (Graham-Kevan & Archer, 2003; Holtzworth-Munroe, Meehan, Herron, Rehman, & Stuart, 2000; Johnson, 2010). In this study the four different types of IPV established by Johnson (2010) will be discussed since they focus more on the share of both partners in the escalations than do the other theories.
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According to Johnson (2010), four different types of IPV can be distinguished based on these different reasons why perpetrators act violent towards their partner. Each type of IPV contains different dynamics of partner violence and different kinds of context in which the violence occurs. Regarding the I³ Theory all perpetrators have strong impelling forces, strong instigating triggers and weak inhibiting factors, but the impelling forces and instigating triggers differ for perpetrators of different types of IPV (Slotter & Finkel, 2011). The first type is situational couple violence, in this type aggression occurs in the context of a specific argument in which one or both the partners lash out physically. Aggression here is not a form of power or control. In case of situational couple violence, the violence is situationally stimulated, the emotions or tensions of a particular event lead someone to react with violence (Johnson, 2010). Often the escalation is caused by a problem in the communication between both partners. Mostly in situational couple violence both partners have a share in the escalations and in most cases both use violence impulsively (Johnson, 2006). When IPV occurs because both partners have a share in the occurrence of the violence this is also called dyadic behavior (Capaldi & Langhinrichsen-Rohling, 2012). The second type of IPV is mutual violent control, in which both the partners are controlling and violent. Two intimate terrorists are battling for control.
This type of IPV is rare and not much is known about it (Johnson, 1999). In case of this type of IPV, the violence also occurs because of dyadic interactions between the couple (Capaldi &
Langhinrichsen-Rohling, 2012). The instigating trigger for situational couple violence and mutual violent control could be the partner who is starting a conflict and the impelling force could be bad communication skills or jealousy between both partners (Finkel, 2007). The third type is ‘intimate terrorism’, here the violence is used as a form of control and power. The perpetrator wants to control his/her victim by using violence. The perpetrator of this form of IPV uses physical violence combined with a variety of other control tactics to exercise general, coercive control over the partner (Johnson, 2010). Intimate terrorism contains more severe violence than situational couple violence. The main difference between intimate terrorism and situational couple violence is that in case of situational couple violence both partners have a share in the escalations, while in case of intimate terrorism one partner causes the violence (Johnson, 1995). In case of intimate terrorism, the instigating trigger could be activation of the desire to control the behavior of the partner and the impelling force could be attachment anxiety (Finkel, 2007). The final type of IPV is violent resistance, in this category both partners are violent but only one of the partners is controlling (Johnson, 2010). In this case, it might be that the primary victim of intimate terrorism is fighting back. The instigating trigger for violent resistance could be the aggressiveness of the other partner and the impelling force could be pain (Finkel, 2007). All these different types of IPV require different types of treatment to prevent future violence in relationships (Kelly & Johnson, 2008).
1.3 Effectiveness of treatments
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There are different types of treatment for IPV perpetrators in forensic psychiatric outpatient centers.
Worldwide, the most common form of treatment for men who committed IPV is group therapy with other IPV perpetrators (Dutton, 1995; Sonkin, 2000). This group therapy is comparable with the batterer intervention programs in the United States. Batterer intervention programs are generally considered a combination of rehabilitation and punishment, with an emphasis on the safety of the abused partner. The majority of the batterer intervention programs focus on heterosexual male perpetrators and take place in a group (Stuart, Temple, & Moore, 2007). Two meta analyses by Levesque and Gelles (1998) and Babcock, Green, Robie (2004) reveal that most batterer intervention programs for perpetrators of IPV only had a moderate effect on declining recidivism of IPV. The difference in recidivism between the group perpetrators who received a treatment and the group perpetrators who didn’t receive treatment was only 5% (Babcock, Green, & Robie, 2004). In addition, Daly and Pelowski (2000) state that researchers have consistently noted that between 40% and 90% of men who were mandated by the court to attend batterer intervention programs did not attend or complete such programs.
Different studies have proven that, compared with these group therapy sessions with other IPV perpetrators, individual couple therapy and multi couple therapy were more effective. Individual couple therapy is based on issues that the couple brings to the session and the content of the multi couple therapy addresses the needs expressed by each member of the group (Stith, Rosen, &
McCollum, 2004). Studies by Smith Stover, Meadows, Kaufman (2009) and Stith, Rosen, McCollum (2004) show that these types of therapy had the lowest rates of recidivism and treatment dropouts. The added value of couple therapy and multi couple therapy in comparison with the other types of treatments is that the underlying relationship dynamics that may play a part in the maintenance of the violence get addressed. Even though couple therapy and multi couple therapy were more effective than group therapy sessions with IPV perpetrators, the recidivism rates six months after treatment were still high, namely 43% for the individual couple therapy and 25% for the multi couple therapy, compared to 67% in the comparison group (Stith, Rosen, & McCollum, 2004).
In the more complex cases individual therapy is often offered. For example, when the perpetrator has a borderline disorder or if the battering includes control, subjugation, and intimidation.
In these cases, conjoint therapy will place the victim at risk for more frequent and severe violence afterwards (Stith, Rosen, & McCollum, 2004). However, studies haves found that these individual therapy sessions are also less effective than individual couple therapy or multi couple therapy in preventing IPV from reoccurring (Stith, Rosen, & McCollum, 2004). To conclude, the effectiveness of all types of treatment needs to get improved since the recidivism rates are high.
1.4 Improving treatment effectiveness
There are different reasons why the current treatment for perpetrators of IPV is not highly effective.
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Three reasons will be discussed, namely: only little or no involvement of partners in most current therapies, regular therapy has to be scheduled and often takes place in an institution while violence occurs in the home of both partners and does not occur on scheduled times and treatments are not tailored to the stages of change. First the low level of current involvement of partners from perpetrators of IPV in therapy will be discussed.
Although situational couple violence is the most common form of IPV people still think too dichotomous in terms of ‘victim’ and ‘perpetrator’ (Bogaerts, Henrichs, & Klerx-van Mierlo, 2011).
In most cases of IPV both partners have a share in the occurrence of the violence but the person who is perceived to be the perpetrator and the other partner who is often perceived to be the ‘victim’ receive separate forms of treatment. After IPV gets reported the perpetrator is send to a forensic psychiatric outpatient center while the other partner gets referred to social work or doesn’t receive treatment at all (Oosten, Vlugt, & Brants, 2009). Different studies have shown that these separated forms of treatment are not always successful in preventing IPV from reoccurring and in some cases, even worsen the problem (Babcock, Green, & Robbie, 2004; Feder & Wilson, 2005; Stith, Rosen, & McCollum, 2003).
A study by Pan, Neidig, O’Leary (1994) showed that disagreement in a relationship was the most accurate predictor of physical aggression against a partner, therefore both the partners have a share in the occurrence of the violence. According to the I³ Theory, the partner is in this case the (dyadic) trigger, who triggers the perpetrator to use physical violence (Slotter & Finkel, 2011). To prevent violence from reoccurring it is therefore important to involve both partners in therapy (Johnson, 2010).
Cessation of IPV by one partner is highly dependent on whether the other partner also changes its behavior, that in the past, has led to escalation (Jacobson, Gottman, Waltz, Rushe, & Holtzworth- Monroe, 1994; Magdol, Moffitt, Caspi, Newmann, & Fagan, 1997). So, to prevent violence in relationships from reoccurring and to improve the treatment effectiveness, it is important to involve both partners in the treatment.
A second reason why current treatment for IPV perpetrators is not highly effective, might be that face-to-face therapy with a therapist has to be scheduled and takes place in an institution, while IPV occurs in the home of both partners and not on scheduled times. Technology, such as apps, wearables, web-based applications, electronic health records, health sensors, domotics (the use of electronics for automating domestic processes), video communications, robotics (electronic, mechanical machines driven by specialized software that perform certain tasks) (Van Gemert-Pijnen, Peters & Ossebaard, 2013), can be used to involve both partners and it can be placed where the problem really occurs, in the home of the partners. This is often referred to as eHealth, which is defined as ‘’the use of information and communication technologies, internet-technology in particular, to support or improve health and health care.’’ (Van Gemert-Pijnen, Peters & Ossebaard, 2013, p.14).
In the Netherlands, only a few eHealth technologies have so far been developed specifically for IPV perpetrators and their partners. For example, Minddistrict developed an eHealth module to stop violence and improve the relationship of adult partners with relational symmetric violence. Both the
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partners work through this module individually. In every session, the user gets information, reads experiences from example patients and works on one or more exercises. Every session also consists of movies in which a therapist or patient talks about their experiences (Minddistrict.com, 2016). Another eHealth technology specifically developed for this target group was a mobile application, the Time Out! App, which was developed by the Lumens Group. When one of the partners felt that a fight was escalating, this partner could click on the ‘Time Out’ button. The application then suggested the partners a beforehand agreed calming assignment (e.g. go outside walk with the dog). The application controlled the location of the phones from both the partners and checked if both partners stayed away from each other. If this was not the case, then the application called one of the contact persons of the couple. The application also automatically suggested a time out for both the partners if it detected noise (huiselijkgeweld.nl, 2016). According to H. de Bruijn (personal communication, 19-09-2016), the Lumens Group stopped using this application for two main reasons. First, the application was working on a server which required signing up and connection, this turned out to be a threshold.
Second, the application foresaw in an escalation model in the social network of the patient, but most patients did not want their problems to be known in their social network. These kinds of design issues can be prevented by using a proper development process (Van Gemert-Pijnen, Peters & Ossebaard, 2013; Limburg et al., 2011). This way the technology is more likely to fit to the needs of the end-users and design failures can be tackled to ensure a decent uptake, long-term sustainability and effectiveness. An example of a framework to guide the development, implementation and evaluation is the CeHRes Roadmap. According to the CeHRes Roadmap, stakeholders have to be involved in the designing process and eHealth technologies have to be developed together with the users, also called participatory development. This way the eHealth technology will relate to the perspective of the user and this makes the technology more useful (Kelders, Oinas-Kukkonen, Oörni & Van Gemert-Pijnen, 2016). The CeHRes Roadmap offers a holistic approach to eHealth development, see Figure 2 (Limburg et al., 2011). In order to develop an eHealth technology which fits the needs of the stakeholders, the first two steps of the CeHRes Roadmap are most important to start with in this study.
In the first step, the contextual inquiry, the stakeholders’ needs and problems are being identified and described. In the value specification, the second step, the stakeholders address the added values they want to achieve by means of the eHealth technology. After this information is all gathered the next steps will focus on how this might fit into a technology and how this technology could be implemented in practice (Van Gemert-Pijnen, Peters & Ossebaard, 2013). To conclude, E-Health intervenes directly at moments when and where it is needed. Therefore, the second way to improve the effectiveness of treatments is to use eHealth as a supplement to the existing therapy for perpetrators of IPV and their partners. Since there are not much eHealth technologies available for perpetrators of IPV and their partners in the Netherlands, a new eHealth technology has to be developed. In order for it to be effective, the steps of the CeHRes Roadmap have to be followed during the development of this technology.
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Figure 2. CeHRes Roadmap (Van Gemert-Pijnen et al., 2011)
A third reason for the high recidivism rates in treatment for IPV perpetrators (Stith, Rosen, &
McCollum, 2004) might be because treatment is not tailored to the stage of change in which the perpetrator or the partner from the perpetrator is. If the perpetrators of IPV and their partners are not aware of their own share in the occurrence of the violence and they do not believe in the therapy process, then they will not be motivated to actively participate in the therapy and to change their behavior. If they are not motivated to participate in the therapy chances are that they will drop out early and that the intervention will not be effective (Sonkin & Liebert, 2008). According to the Transtheoretical Model of Behavior Change (TTM), there are six stages through which people go to before reaching the desirable behavior (Prochaska & Clemente, 1982). First there is the precontemplation stage in which the IPV perpetrator and the partner have no intention of changing their behavior. Second, the contemplation stage in which the IPV perpetrator and the partner think about changing their behavior. In the preparation stage the IPV perpetrator and the partner are planning to change their behavior in the short term and they will take steps to get ready for the change.
In the fourth stage: action, the IPV perpetrator and the partner recently changed their behavior. In the fifth stage of maintenance, they have performed the new behavior, their confidence in continuing their changes has increased and they are less tempted to relapse. The last stage is termination, the IPV perpetrator and the partner feel no more tempted to relapse into their violent behavior and they feel 100 percent confident in maintaining the new behavior (Prochaska, Redding, & Evers, 2015). A study by Levesque, Ciavatta, Castle, Prochaska and Prochaska (2012) showed that an intervention for domestic violence offenders that tailored to the Stages of Change improved the treatment outcomes.
However, this study only focused on the perpetrators and did not involve the partners in the treatment.
When using an eHealth technology to support IPV perpetrators in order to prevent future violence in
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their relationship, it is important that this technology also tailors to the stage of change in which both partners currently are at.
1.5 Aim of the study
The aim of this study is to investigate in what way eHealth technology could support partners who experienced IPV to prevent future violence in their relationship, according to the stakeholders. This makes the value specification the central point of this study. The partners and therapists who treat partners that experienced IPV at De Tender are the target group of this study. It is important to involve the therapists in this value specification since their attitude towards eHealth is typically less positive than the attitude of clients or help seekers towards eHealth (Gun et al., 2011; Kaltenthaler et al., 2008;
Waller & Gillbody, 2009). Since therapists are the primary source of health information and treatment recommendations, it is necessary to make them feel more positive towards eHealth interventions (Eichenberg, Wolters & Brähler, 2013). Involving them in the development process might accomplish this change in attitude. Besides, the therapists have considerable expertise with partners who experience(d) IPV and are familiar with the situation in which the technology has to be implemented.
To create a successful eHealth intervention, it is also important to tailor eHealth to the needs of the partners in the different stages of change (Sonkin, & Liebert, 2008). The stakeholders will therefore also be questioned about their opinion regarding the need for support, of partners who experience(d) IPV, in the different stage of change and how technology can be used to deliver this type of support in order to prevent future IPV.
The main question of this research project is: How can eHealth technologies support the partners, from the perpetrators of IPV, to prevent future violence in their relationship according to the therapists and the partners? The following sub questions will lead to an answer on the main question:
- What does the current treatment situation for perpetrators of IPV and their partners look like at De Tender, according to the stakeholders?
- What kind of support do the partners, from perpetrators of IPV, need in the different stages of change to prevent future IPV, according to the stakeholders?
- What are the requirements of an eHealth technology to support IPV perpetrators and their partners in order to prevent future IPV, according to the stakeholders?
- What are the advantages and disadvantages of different elements in existing eHealth technologies in order to support partners to prevent future IPV, according to the stakeholders?
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2. Method
The aim of the study is to gather ideas and opinions, through interviews, of stakeholders on new eHealth interventions to support partners of perpetrators of IPV in order to help them prevent future violence. A qualitative research method was therefore warranted. The aim of the study was not to gather valid knowledge but to gather valuable ideas which can be tested on validity at a later stage.
The study was conducted at several forensic psychiatric outpatient facilities, all part of De Tender, Transfore. This study is part of a larger project which aims to develop eHealth applications for forensic psychiatric patients and their significant others; a collaboration between University of Twente, Erasmus University and Transfore. This study is a first step in that process to check whether there is a need for support through eHealth and to find out what preferences there are.
2.1 Participants
The target group of this study contained perpetrators of IPV, their partners and their therapists from De Tender. The perpetrators of IPV and their partners did not necessarily have to be in therapy. The researcher recruited participants through convenience sampling at De Tender. Participants were excluded if they did not approve the researcher recording the interview. Patients and their partners were excluded if they were too vulnerable to participate in this study or if the relationship between them was too vulnerable to participate in this study according to the therapist. The aim was to reach 5- 7 participants. This study aimed not at creating a representative sample of the population but to gather as much information as possible from a broad population, since this is an exploratory study.
Eventually, only one couple that was in therapy at De Tender for experiencing IPV agreed to participate in this study. Of the eleven therapists who were working at De Tender and were requested to participate in this study, six of them agreed to participate.
2.2 Instruments
The perspectives from therapists regarding support through eHealth in order to prevent future violence in the relationship of IPV perpetrators and their partners was investigated by the use of a semi- structured interview scheme (see Appendix III ‘Interview scheme therapists’). Also, an interview scheme for patients and an interview scheme for partners were created (see Appendix IV ‘Interview scheme patients’ and Appendix V ‘Interview scheme partners’). These interview schemes were developed by the researchers and are based on the research questions, the TTM of behavior change (Prochaska & Clemente, 1982), and existing eHealth interventions. A description of these eHealth interventions which were used as an example during the interview are displayed in the interview schemes. In these interview schemes, some generally formulated questions were stated but during the interview the researcher could deviate from these questions to react on the answers of the participant.
The interview consisted of 17 open ended questions accompanied by probes. All the research
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questions were answered by means of the interviews. In Table 1, the content of the interview scheme for the therapists is displayed.
Table 1. Content of the interviewscheme for therapists
Question Content Example question
1 - 4 The need for support in the different stages of change – Transtheoretical Model and the current situation at De Tender regarding involvement of partners
Do you think that partners are in need of additional support in the precontemplation phase: in order to get to know more about the occurrence of the relational violence? If yes, then how? If no, why not?
5 About their knowledge on eHealth Before we continue with the
following questions about eHealth, do you have some questions about the meaning of eHeatlh?
6 About the experiences the stakeholders have with using eHealth Do you offer eHealth to partners who experience(d) IPV during therapy? If yes: what are your experiences with using eHealth for this target group? If no: why not?
7 – 13 About the opinion of the stakeholders regarding (already existing) eHealth technologies:
- Minddistrict Module - Time Out App - Fitbit - Virtual Coach - Red light
What do you like about this kind of eHealth technology?
14 About the different ways in which eHealth could offer support, namely: psycho-education, monitoring and feedback.
Do you think that technology could help partners who experience(d) IPV to get to know more about the occurrence of the violence (psycho-education). If yes, then how?
15 Ideas of stakeholders regarding an eHealth technology for IPV perpetrators and their partners
How does the ideal eHealth technology for partners who experience(d) IPV in order to help them prevent future violence in their relationship look like, according to you?
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2.3 Procedure
This research study was approved in advance by the ethical commission of the University of Twente.
This study was also approved by the ‘Centrale Commissie Mensgebonden Onderzoek’ from the Dimence Group.
Participants were recruited at De Tender through convenience sampling. Prior to recruiting participants, the researcher made an appointment with the therapists of De Tender in order to introduce the aim and procedure of this study. The therapists were asked to give verbal information about the content and practical matters of the study to their patients who were in therapy for experiencing IPV and of whom they thought the patient was not too vulnerable. The researcher also provided the therapists with an information letter which they could hand over to their patients (see Appendix I
‘Information letter’). If both the patient and the partner approved to participate in this study they could contact the researcher to schedule an appointment via E-mail.
Therapists were also sampled via a convenience sample. The therapists who helped with recruiting patients and partners were asked to participate in this study. An E-mail with the request to participate in an interview was send to eleven of the therapists. Six of these therapists agreed to participate in this study and an appointment with them was scheduled by phone or E-mail.
It turned out to be very difficult to recruit patients and their partners to participate in this study. Only one couple agreed to participate. At the day the appointment was scheduled only the patient was present. The patient explained that his wife was too nervous to participate in this study.
The interview with the patient only took 10 minutes because the patient was in a hurry. This patient did not deliver any valuable information relating to the content, but only answered the questions with:
‘yes’ and ‘good’. Therefore, the data of this patient is left out of the data analyses, only the interviews with the therapists were analyzed.
The appointments with the participants were scheduled at one of the outpatient facilities from De Tender. Before the interview started, again the purpose of the interview was explained to the participant verbally. The researcher also explained that the participant could stop the interview at any time and that the participant was not obliged to answer any question. The interview started after the participant signed the informed consent (see Appendix ‘Informed consent’). The minimum duration of the interview was 45 minutes and the maximum duration of the interview was 60 minutes.
If the participant asked for access in his/her own data afterwards, a summary of the interview was send to the participant.
2.4 Analysis
All the interviews with the participants were audio-recorded and transcribed verbatim. The researcher transcribed the interviews and then imported the text files into ATLAS.ti 7.5.10, this is a qualitative analysis software program. Then the interviews were coded in order to analyze the results.
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The first, second, partially the third and final research questions were deductively coded. Prior to the analysis four codes were created for the first research question: treatment type, involvement, the share of both partners in IPV and use of eHealth. The codes for the second research question were created based on the five stages of change of the Transtheoretical Model. For the third research question a combination of deductive and inductive coding was used. Three codes were already established before the analysis and were based on the three forms of technology that were assessed in the interview: psycho-education, monitoring and feedback. The other codes were created through inductively coding. For the final research question the codes were based on the five eHealth examples which were shown to the respondents during the interview; Minddistrict Module, Time Out App!, Virtual Coach, Fitbit, Red light.
For the third research question, also inductive coding was used. First the researcher started coding inductively by reading through all the transcripts and by selecting fragments that were relevant for answering the main-, and sub question of this study. In this so-called open coding, there were no predetermined codes or categories, but the codes were based on the material (Boeije, 2014). Based on the fragments, preliminary codes were created. These preliminary codes formed the first version of the code system, which was developed with help of ATLAS.ti. During the second step, axial coding, the researcher reread the transcripts, made connections and created structure between codes (Boeije, 2014). This way the preliminary codes from the first phase got ordered and a subdivision from main codes and sub codes were created. The researcher elected the most important codes and searched for differences and relations between each code. Codes were perceived important if they contained the opinion of the respondents regarding different ways how eHealth can offer support to IPV perpetrators and their partners. Also, overlapping codes were combined, or broad codes were subdivided into separate codes. The coding process was an iterative process. In this second step the code system was adapted until saturation of categories was reached and every important fragment received a code. In the final step, selective coding, the researcher determined which topics were the most important regarding the main-, and sub questions of this research and how these topics related to each other (Boeije, 2014). To assure interrater reliability, a second researcher also coded the first two interviews.
Both raters then reviewed each other’s text codes and discussed the discrepancies to reach a consensus. Finally, the researcher interpreted the analysis into an answer on the research questions.
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3. Results
In this chapter the results of the interviews are displayed in four different paragraphs. Each paragraph represents one of the research questions. All quotes used in this section were translated by the
researcher from Dutch to English. All original quotations and the translated quotations are displayed in Appendix VII ‘Translated quotes’.
3.1 Current treatment situation for perpetrators of IPV and their partners at De Tender This paragraph displays the results of the first research question based on the following four main codes: treatment type, involvement, the share of both partners in IPV and the use of eHealth. This paragraph ends with an overall conclusion.
Treatment type
According to the respondents, De Tender offers four different types of treatment for perpetrators of IPV and their partners, which are shown below in Table 2. A combination of two or more different types of treatment is also possible, this depends on each specific situation. All respondents are positive towards the couple therapy and couple therapy in a group. The prevention group for male perpetrators evokes some negativity in one of the respondents. This respondent experienced some negativity in the partners from perpetrators who participated in this prevention group. According to these partners, the perpetrator changes his behaviour but the situation at home does not benefit from it. The respondent mentioned that the prevention group is not a systematic approach, the partners are unaware of topics that are being discussed in this prevention group.
Table 2. Types of treatment available for perpetrators of IPV and their partners at De Tender, according to the respondents
Type of treatment Treatment content
Individual therapy for the perpetrator To treat contra-indications
Couple therapy System therapy, to find out what should change in the
communication pattern of both partners.
Couple therapy in a group Eight meetings in which communication dynamics are being
discussed.
Prevention group for male perpetrators only Talking about domestic violence for those whose partner doesn’t want to come to therapy or who don’t have a partner anymore.
Involvement of partners
Three out of six respondents mentioned that De Tender offers enough support for the partners of IPV perpetrators, because the perpetrator can always bring his/her partner to therapy.
Also mentioned by three respondents is that not all partners find it necessary to get involved in the treatment of the perpetrator. They said that some of the partners just don’t want to get involved because then they will be constantly confronted with the violence. They also mentioned that there are
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some partners who just blame their partner and don’t see their own share in the occurrence of the violence. One of these three respondents also said that if the partner is just a victim, he or she is not at the right place for support at De Tender.
One of the respondents mentioned that there is room for improvement regarding involvement of partners at De Tender. This respondent claims that the attention is particularly with the perpetrator. ``It often happens in the beginning that the partner comes along with the patient to look what kind of organization this is and what will happen. Then it sometimes happens that we let this partner sit in the waiting room to do the intake individual’’. This respondent said that they should pay more attention to the partner, already at the intake. ``To also hear what has it done to you? And is there enough
attention for? Did you already receive help? What does it look like?’’.
The share of both partners in IPV
All the respondents said that in most cases both partners have a share in the occurrence of IPV. They claim that violence mostly occurs because both partners have a problem in communicating with each other. One of the respondents said that relational violence occurs because of a lack of communication, the feeling of not being understood by each other, and being humiliated by one another. Two of the six respondents said that having a share in the occurrence of the violence is not the same as guilt.
According to these respondents, guilt is a legal question. All respondents also explain that in some excessive cases only one partner causes the violence.
Use of eHealth
All the respondents mentioned that they never used eHealth during the regular therapy for perpetrators of IPV and/or their partners. Reasons they gave for not using eHealth blended for this target group were: not enough time, unfamiliarity with eHealth and difficult target group because of the interaction between two partners. Two out of six respondents said that they did sometimes suggest the use of an eHealth module to perpetrators and partners of IPV but that they never used it blended. One of these two respondents also said that his experiences with offering eHealth is that the response rate is not high.
To conclude, the majority of the respondents is satisfied with the amount of support offered by De Tender for partners of perpetrators of IPV. All the respondents were positive about the couple therapy and couple therapy in a group sessions offered by De Tender for perpetrators of IPV and their partners.
None of the respondents ever used eHealth for IPV perpetrators and/or their partners.
3.2 Needed support in the different Stages of Change for perpetrators of IPV and their partners This paragraph displays the results which give an answer to the second research question. The main codes that will be discussed are: precontemplation phase, contemplation phase, preparation phase,
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action-, and maintenance phase and the most common phase for partners at De Tender. This paragraph ends with an overall conclusion.
Precontemplation phase
Two of six respondents mentioned that the precontemplation phase is not the first step in treating IPV.
They meant that during therapy they do not start with making the partners aware of their own share in the occurrence of the violence but the first step is to stop the violence from occurring. When the situation of both partners is safe enough the therapists can start informing partners and perpetrators about interactions and patterns which can lead to violence. All six respondents mentioned that in the precontemplation phase it is important to use psycho-education to inform the perpetrators and partners about communication patterns, physiological processes and cooling down techniques. There are different manners how this psycho-education can be delivered to the perpetrators and partners, the respondents mentioned: in a meeting with the therapist (n=3), on paper (n=1), in a movie (n=2), through eHealth (n=2) or in a role play (n=1).
Contemplation phase
All the respondents mentioned that in this phase it is important to shift the focus from general
information about IPV to specific dynamics of the couple. In this phase, according to the respondents, it is important to make the partners aware of what triggers the perpetrator and which role the partner plays in it (n=4). Then, it is important to offer both partners guidance in how they can change their behavior (n=3). Also, one of the respondents mentioned that in this phase it is important to assure the partners that it is okay to talk about the violence.
Preparation phase
All respondents acknowledge the importance of this phase, that the partners prepare and take steps to get ready for the change. Five out of six respondents mentioned that in this phase the attention should be on helping the partners applying the newly learned skills. The respondents mentioned different ways in how to help the partners apply these skills namely: in the presence of the therapist (safe environment) (n=1), by giving them examples of other couples who were in the same situation (n=1), by pointing out that the chance of a relapse is becoming smaller when the partner also participates in therapy (n=1) and by giving them instructions about new skills (n=2). One of the respondents points out that in this phase it is important to reflect on the application of newly learned skills afterwards.
Action and maintenance phase
All six respondents said that support in the action and maintenance phase is very important since in most cases partners are no longer in therapy at De Tender when they reach these phases. Two of the six respondents said that it is difficult to offer the needed support in these phases in regular therapy.
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Different forms of support were mentioned by the respondents: less intensive support than in previous phases but still keeping them alert on what they learned and make sure they keep applying these skills (n=2), somebody they can call when they need some support (n=1), letting them experience the positive effects of applying the learned skills in practice and reflect on it (n=1), by preparing themselves mentally on what skills they have to use when things will get out of hand in the future (n=1), continues coaching on their weak points (n=1).
Most common phase for partners at De Tender
All respondents find it hard to say in which phase most partners at De Tender are because it differs.
Four out of six respondents said that most partners are not aware of their own share in the occurrence of the violence, and are therefore in the precontemplation phase. One of these respondents said that at the intake most partners are in the first or second phase, they have no idea how the violence occurs or how to cope with it. According to this respondent, it differs in which phase the partners are when therapy is finished. A few partners are able to learn but regularly partners barely get out of the first two phases.
Overall, according to the respondents, each of the five stages of change require different support. A majority of respondents mentioned that it is especially important to offer additional support to
perpetrators and partners of IPV in the action and maintenance phase, since in most cases the partners are no longer in therapy when reaching these phases.
3.3 Requirements of an eHealth technology to support IPV perpetrators and their partners This paragraph displays the results of the interviews which give an answer to the third research question of this study. The main codes that will be discussed in this chapter are: psycho-education, monitoring, feedback, tailoring, as a supplement on existing therapy and finally eHealth examples thought of by respondents. For all the main codes a table was created which displays the sub codes and in some cases also the variations belonging to each main code. This paragraph ends with an overall conclusion.
Psycho-education
Table 3 displays all the subcodes and variations for this main code psycho-education. Most respondents said they think it is possible to offer psycho-education to partners by using technology.
Only one of the respondents is more negative about offering psycho-education to partners through technology, this respondent said that some partners will not finish psycho-education when it is offered on a computer, like the Minddistrict Module. The reason he mentioned is that this asks for too much time investment of the user; the module consist of too much text and exercises.
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Four respondents mentioned examples on how psycho-education can be delivered through eHealth, these examples are displayed in Table 3. A majority of the respondents thought off offering psycho- education through eHealth as an added value to regular therapy. One of the most mentioned reasons for this is that it saves them time during regular therapy (n=5). This way they can focus on instant problem solving in order to prevent partner violence during therapy sessions.
Table 3. Subcodes and variations for main code Psycho-education.
Subcodes Variations
Time investment (n=1)
Tension increasing exercises (n=1) Application with general information (n=1) Movies and pictures (n=2)
Added value (n=5) • Time saving during regular therapy (n=5)
• Can be done in own time (n=2)
• Writing down emotions and behavior might be easier (n=2)
Examples (n=4) • Creating an application which offers general information
(n=1)
• Showing movies and pictures of what happens to the body before violence occurs, so that partners can learn to feel it coming before it is too late (n=2)
• Observing or experiencing tension increasing experiences to make partners aware of their own stress level (n=1)
Monitoring
In Table 4 an overview is given of all the subcodes and variations belonging to this main code monitoring. Five out of six respondents said they could imagine that technology could be helpful in monitoring violence in relationships, especially since technology is available 24/7 and can be present where the violence occurs. One of the respondents mentioned the following: ``All of a sudden I am angry, that is what they say but that is not true. It increases, so I kind of find it [monitoring] a nice idea. If they get literally reminded of the fact that apparently, they are becoming more angry. I think that that would be nice, if you give certain warnings’’. Five respondents came up with various examples how monitoring could help partners in order to prevent future violence in their relationship.
These examples are shown in Table 4.
One of the respondents found it hard to imagine how technology can help monitor violence in relationships. This respondent said that this has to be done through regular therapy by asking the couples what the conflict looked like and what the cause was. According to this respondent, technology can’t adapt to each couple, only a therapist can. This respondent mentioned that it differs per person when someone is going to explode, therefore it is hard to develop a technology which
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measures when violence is about to occur: ``It seems to me that it is very difficult to determine when someone is going to explode, when someone is going to use violence since that differs per person’’ . Even though most therapists were positive about the possibilities of monitoring through eHealth for this target group they also came up with some struggles for monitoring perpetrators of IPV and their partners. Two respondents mentioned that mostly when violence is measurable it is already too late:
``…only it seems to me that the toughest with these kind of things is that they only react when it is already too violent. And actually, then it is already too late’’.
The lack of privacy is also mentioned by a majority of the respondents as a probable disadvantage of monitoring through eHealth (n=5).
Table 4. Subcodes and variations for main code Monitoring.
Subcodes Variations
Available 24/7 (n=6)
Present where violence occurs (n=6)
Difficulties measuring different perpetrators (n=1) Already too late when violence becomes measurable (n=2)
Lack of privacy (n=5) • External control (n=2)
• Loss of sensitive information when loosing technology (n=1)
• Visibility of technology for environment (n=3)
Examples (n=6) • Use technology to make partners reflect on their day,
every evening, with help of the following five points:
experience, thoughts, feelings, behavior and consequences (n=1)
• Use technology by offering the partners an electronic diary (n=1)
• Record a fight between the partners, so that they can see their own posture and can hear the volume of their voices
• Use technology to ask the partners informing questions about the conflicts. For example: What was the conflict about and how long did it take? (n=1)
• Use technology to give partners insight in their physiological responses so that over time the user can recognize these responses without the technology (n=1)
• Use technology to discover patterns (n=1)
• Use technology to make the results and progress visible for therapists (n=2)
Feedback
Table 5 displays all the subcodes and variations belonging to this main code Feedback.
All respondents could imagine that technology can be used to offer feedback to partners in preventing relational violence from occurring. Five of the respondents said that it is important to give personally relevant feedback and no general advices. For example, one of the respondents said: ``I think that if it is so standard, people will recognize it and think well yea and now you probably going to say that I need to take some distance. I think that it will evoke that reaction pretty soon and that after that you will lose interest in it’’. These respondents suggested that the therapist discusses, during therapy, what the partner needs when this partner is having a hard time and then imports this feedback in the system.
Mentioned by three respondents is the importance of delivering feedback before a conflict escalates into violence. When the couple is already in a conflict then it is too late for an eHealth device to
