1. If it IS Broke, Why NOT Fix It?
Using ACT to Treat Intimate Partner Violence
Erika Lawrence, Ph.D.
Director of Translational Science
The Family Institute, Northwestern University

2. Existing Theories and (Lack of) Effectiveness
Existing theories guiding treatments
Feminist/patriarchal theory: Duluth model
Social learning theory: Cognitive-Behavior treatment
Hundreds of peer-reviewed studies and meta-analyses
5% improvement at best
Limitations
Target reasons for initial violence not violence maintenance
Narrowly focused on 1-2 contributors
Attempt to change thoughts and feelings in order to change behavior
(Didactic and confrontational)
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3. The New Intervention: ACTV
Developed from 20+ years of basic biobehavioral research on development of violence
Based on Acceptance and Commitment Therapy (ACT)
Developed for mental health problems (Hayes, Stroshal, & Wilson, 1999)
Success with substance abuse, smoking, other behavioral problems (e.g., Gifford et al., 2004; Wilson & Byrd, 2004)
First time ACT applied to externalizing problem
First treatment to focus on function rather than content of thoughts and emotions to reduce violence
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4. Acceptance and Commitment Therapy (ACT)
Avoidance vs. Acceptance
Avoiding internal experiences
Contact with Present Moment
Thoughts of past or future
dominate
Cognitive (De)Fusion
Believing/dominated by unhelpful thoughts
Values
Unclear values,
living for avoidance
Psychological
(In) Flexibility
Start with psych flex then to two processes
How different from CBT
Self-as-Context
Attachment to
unhelpful self-concepts
Committed Action
Persistent inaction, impulsivity or avoidance
(Hayes et al., 2006)

5. The New Intervention: ACTV
Cognitive Fusion
Cognitive Defusion
Being “hooked” by thoughts, rules and beliefs and letting them determine what you do in your life, even when they are not helpful in terms of moving you in the direction of your values and goals
Stepping back from the thoughts, emotions, memories and body sensations that pose as barriers and noticing them as thoughts, emotions, memories, and body sensations that need not determine what you do
Experiential Avoidance
Emotional Acceptance
Escaping from, avoiding, or trying to control one’s own experience such as thoughts, emotions, memories, and body sensations
Being willing to have whatever thoughts, emotions, memories, and body sensations show up when moving in a valued direction
To accomplish this goal in the new intervention, here are 2 of the processes we target in the new intervention: how participants respond their thoughts (known as cognitive fusion vs. cognitive defusion) and how participants respond to their emotional, environmental and physiological experiences (known as experiential avoidance vs. acceptance). Dozens of component studies on the effects of cognitive defusion27-29, acceptance30-32, and values33 indicate a variety of therapeutically desirable results34,35. Further, interventions emphasizing these processes show impressive outcomes across a broad range of problems. Indeed, these interventions were recently designated as “empirically supported,” the highest designation a behavioral intervention can achieve.
In sum, the new intervention is based on a CBS approach, an approach that has demonstrated efficacy with other harmful behaviors. This is the first intervention in which this approach has been adapted to reduce IPV.

6. Applying the ACT Model to Violence
Emotion Dysregulation
Stimulus
Interpersonal conflict
(2) Emotions, thoughts, urges, bodily sensations
Using the theory underlying ACT as a guide, I adapted a clinical model to aggression
Hypothesized to facilitate a practical advantage in conceptualizing and treating aggression
Model includes processes linked to intervention mechanisms
(3) Psychological or Physical Aggression
(4) Escape or relief from aversive emotional arousal

7. Achieving Change through Value-Based Behavior (ACTV)1
Multiple Contributions to Violence Maintenance 2
ACT Processes: Awareness, Values
3-4
Barriers to Change: Substance Use; Mood, Anxiety & Stress Management
5-8
ACT: Emotion (Dys)regulation, Experiential Avoidance , Emotional Acceptance 9
10-13
ACT Processes: Cognitive Fusion to Cognitive De-Fusion 14 15 16
Psychologically, Physically and Sexually Aggressive Behaviors
17-21
Practicing Behavioral Skills: Communication & Conflict Resolution Skills 22
23-24
Barriers to Change: Effective Parenting; Employment & Financial Stress 
How intervention is set up
Now link ACT linked to violence
Point out how applied – build up to certain skills
Contextualize act skills in other domains
Show how EA in this slide
We do a lot of other sessions, cover other things
Next I’m going to tell you about an efficacy study I did. Not all 24 sessions, just ACT processes sessions

8. Achieving Change through Value-Based Behavior (ACTV)1
Multiple Contributions to Violence Maintenance 2
ACT Processes: Awareness, Values
3-4
Comorbid Phenomena: Substance Use; Mood, Anxiety & Stress Management
5-8
ACT: Emotion (Dys)regulation, Experiential Avoidance vs. Acceptance 9
10-13
ACT Processes: Cognitive Fusion vs. Cognitive De-Fusion 14 15 16
Psychologically, Physically and Sexually Aggressive Behaviors
17-21
Practicing Behavioral Skills: Communication & Conflict Resolution Skills 22
23-24
Contextual Factors: Effective Parenting; Employment & Financial Stress 
How intervention is set up
Now link ACT linked to violence
Point out how applied – build up to certain skills
Contextualize act skills in other domains
Show how EA in this slide
We do a lot of other sessions, cover other things
Next I’m going to tell you about an efficacy study I did. Not all 24 sessions, just ACT processes sessions

9. Feasibility Testing
Can DOC employees learn the concepts and techniques?
Can these concepts and techniques be adapted to address IPV?
Can this population learn the new concepts and techniques?
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10. Feasibility Testing
Findings (qualitative data from facilitators and participants):
Participation and retention rates were higher in ACTV than TAU
Group facilitators able to learn the new conceptual model and employ the new techniques within the context of IPV
Participants were able to learn the new skills and implement them in their own lives when taught in the context of IPV
Qualitative data extremely positive
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11. Two Randomized Controlled Trials
Efficacy Study
Testing the ACT processes as applied to intimate partner violence
Feasibility and pilot studies with the Department of Corrections
Effectiveness Study
Testing the full intervention through the Department of Corrections
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12. Efficacy: Do ACT Skills Reduce Aggression?
Community volunteers in relationships (N = 101)
Criteria: 2 or more acts of physical aggression in 6 mos.
Random assignment: per group
12 sessions of ACT or support/discussion control group
Self-report questionnaires
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13. Do ACT Skills Reduce Psychological Aggression?
Post Intercept: b = 1.15, SE = .68, t(97) = 7.43, p < .01
6 Mos. Intercept: b = 2.05, SE = .71, t(97) = 8.33, p < .01
Slopes: b = 2.21, SE = .74, t(97) = 3.59, p < .05
ACT
MDEAS, 28 items

14. Do ACT Skills Reduce Physical Aggression?
Post Intercept: b = 1.45, SE = .59, t(97) = 7.11, p < .01
6 Mos. Intercept: b = 2.21, SE = .65, t(97) = 8.19, p < .01
Slopes: b = 2.35, SE = .89, t(97) = 6.22, p < .05
Control
ACT
Community couples
CTS2, 12 items

15. Do ACT Skills Account for Group Differences in Aggression?
ACT or Control
Study 1 establishes the feasility of thes ideas
Operates the way we expecgecd it ot operate
Next steps: go after all 24 sessions and apply iot to a much more severe sample
Partial Mediation in Psychological Aggression
Direct Effect: γ = , SE = .004, t(99) = -2.19, p < .05
With mediator: Z = 1.98, SE = .005, p = .08
Partial Mediation for Physical Aggression
Direct Effect: γ = , SE = .006, t(99) = -3.39, p < .05
With mediator: Z = 1.67, SE = .005, p = .08

16. Two Randomized Controlled Trials
Efficacy Study
Testing the ACT processes as applied to intimate partner violence
Feasibility and pilot studies with the Department of Corrections
Effectiveness Study
Testing the full intervention through the Department of Corrections
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17. Achieving Change through Value-Based Behavior (ACTV)1
Multiple Contributions to Violence Maintenance 2
ACT Processes: Awareness, Values
3-4
Barriers to Change: Substance Use; Mood, Anxiety & Stress Management
5-8
ACT: Emotion (Dys)regulation, Experiential Avoidance , Emotional Acceptance 9
10-13
ACT Processes: Cognitive Fusion to Cognitive De-Fusion 14 15 16
Psychologically, Physically and Sexually Aggressive Behaviors
17-21
Practicing Behavioral Skills: Communication & Conflict Resolution Skills 22
23-24
Barriers to Change: Effective Parenting; Employment & Financial Stress 
How intervention is set up
Now link ACT linked to violence
Point out how applied – build up to certain skills
Contextualize act skills in other domains
Show how EA in this slide
We do a lot of other sessions, cover other things
Next I’m going to tell you about an efficacy study I did. Not all 24 sessions, just ACT processes sessions

18. Recidivism One Year Post-Treatment
Violent offenses only
Most re-offend within 3 months

19. Summary
ACTV significantly reduces recidivism compared to standard treatment
First IPV intervention to:
Focus on function rather than content of thoughts/emotions
Target reasons why violence continues rather than why some men become violent initially
Conducted in collaboration with state policy makers or DOC
Iowa became the 1st state to disseminate a statewide, court-mandated, empirically supported intervention for IPV
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20. What Are We Doing Now? Adaptations Replicate and extend
IA, MN, MO, AZ, IL, NY
Bogota, Colombia (Spanish language versions)
Longer-term follow-up, level of risk
Test change mechanisms; indirect outcomes for victims, relationships, children
Educate stakeholders
PEW Institute recognized for cost effectiveness and (actual) effectiveness
APA awarded Distinguished Contribution to Family Psychology
Disseminating across the U.S.
Adaptations
Piloting BREAK - for adolescents in juvenile detention
Piloting CERB – for college students who engaged in sexual misconduct
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21. Thank you!
Questions?
“Far and away the best prize that life has to offer is the chance to work hard at work worth doing.”
- Theodore Roosevelt