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Abstract

Despite systematic reviews calling for more research to determine which batterer intervention programs (BIPs) work, the Swedish Prison and Probation Service (SPPS) officially claims that their CBT (cognitive behavioral therapy)-based programs are successful. In order to find a plausible explanation for the discrepancy between what the service claims and what is reasonable to claim, a qualitative content analysis of the SPPSs’ use of evidence in the accreditation of BIPs and the treatment with these programs is conducted. The study first addresses the manifest content, which refers to the SPPS claims of scientific evidence that BIPs have a positive effect and the internal application of Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for the accreditation of their programs. The results show that despite the SPPSs’ efforts to keep up to date with research and public claims that treatment programs reduce recidivism, there is no independent scientific evidence that the treatment methods used are effective. The interpretative analysis of the latent content indicates that the concept of evidence is used rhetorically to convince the public that the activities are conducted successfully, scientifically and cost-effectively. The state of knowledge is uncertain, and a more realistic approach is required as the public has a right to know that treatment of IPV offenders is often based on uncertainty.

Keywords

Cognitive behavioral therapy perpetrators of intimate partner violence soft evidence Swedish prison and probation service

Introduction

Sweden is known for being a progressive country that strives for the most effective solutions to social problems (Government Offices of Sweden, 2017) and for having a prison system based more on restorative rehabilitation than on repressive punishment (Swedish Prison and Probation Service, 2024). SPPS’s mission as a state authority is to use prisons and probation services to enforce the sanctions imposed by the courts. The tasks include responsibility for remand centers, prisons and probation services, for recruitment and training, and for the logistics systems required for the operation of these units. Within the SPPS, the Scientific Advice Board also has primary responsibility for ensuring that treatment activities are conducted on a scientific basis. The SPPS must keep up to date with international research, develop new, more effective treatment programs, and continuously evaluate the effectiveness of existing programs. Accredited evidence criteria will guide the Scientific Advice Board in assessing whether or not treatment programs prevent relapse.

The SPPS (2024) official website presents cognitive behavioral therapy (CBT) as a universal treatment method for the prevention of recidivism in all types of criminal behavior: “Most of our treatment programs are based on cognitive behavioral therapy because it is the method that research has shown to be most successful in treatment work that focuses on criminal behavior.” The SPPS (2024a) further claims that the treatments have proven efficacy and reduce recidivism: “International research supports the fact that CBT-based treatment programs for prison clients have positive effects and reduce the risk of reoffending and substance abuse. The Prison and Probation Service’s own evaluations of its own treatment programs also support this.” https://www.kriminalvarden.se/behandling-och-vard/behandlingsprogram/ In the following, when quoting texts in Swedish, the translation is my own.

Overview of research on the effectiveness of CBT-based batterer intervention programs (BIPs)

There are currently no BIPs—including CBT, psycho dynamic therapy (PDT), and hybrid treatments (i.e., integrations of CBT and PDT)—that have been shown in a formal systematic review to have a sustained effect on recidivism. BIPs are considered controversial since the treatment effects are questioned. In Europe, cognitive and psychoeducational approaches to CBT-based BIPs predominate. It has historically been dominating forms of therapy and has been subject to several major systematic evaluations that revealed unclear and/or negative effects on the recurrence of intimate partner violence (IPV) (e.g., Nesset et al., 2019; Karakurt et al., 2019; Stover et al., 2009; McMurran, 2009; Smedslund et al., 2007; Babcock et al., 2004; Wathen, 2003). Recently, Wong & Bouchard (2021) has explored the literature on CBT approaches in IPV interventions and concluded that, as little research has examined how CBT principles are operationalized across program curricula, there is currently insufficient information from which to make recommendations for model CBT approaches in IPV interventions. The uncertainty about how to reduce IPV among men who use substances with CBT treatment is even higher (Stephens-Levis et al., 2019). One explanation is that BIPs are generally very difficult to evaluate systematically and that the few large systematic reviews that have been conducted have shown negative, unclear, or inconclusive results. The two pilot BIPs used in the SPPS have not yet been scientifically evaluated, and the likelihood of these BIPs being evaluated in the near future through a systematic review and/or compared with non-CBT-based methods is very low. The overview below includes both large systematic reviews and smaller studies and serves as a theoretical reference point to relate to the SPPSs use of BIPs.

According to Stuart et al. (2007), the historical development of BIPs in the United States has been characterized by the enactment of mandatory arrest laws by states in the 1980s for probable cause of IPV. These laws have brought more men arrested for IPV into the criminal justice system. In the rush to meet the needs of battered women, states began launching BIPs to reduce recidivism in IPV. Unfortunately, the overwhelming demand for and expansion of these programs has outpaced research efforts to assess their effectiveness. As an increasing proportion of women are arrested for IPV and required to participate in BIPs, attention should be directed toward evaluating and improving programs for women, who may need different types of interventions. The need for research-adapted BIPs is also highlighted by Sotirof et al. (2024) who address the importance of adaptations to perpetrators in LGBTQ + relationships, female-identifying perpetrators with a transgender identity, perpetrators located within relationships with bi-directional violence, and perpetrators with a trauma history.

In Sweden, the use of BIPs has undergone a similar historical development with the difference that courts do not impose BIPs as punishment but the treatment of IPV has taken place within prisons and in the community on a voluntary basis. Within SPPS, mainly one CBT-based BIP has been used in the form of the “Integrated Domestic Abuse Programme” (IDAP, based on the Duluth model) which gradually been replaced by “Preventing Domestic Violence” (Predov) and the Relationship Violence Programme (RVP) which is more individualized BIPs that is somewhat in line with the research reported here. In the following, an overview of research on CBT-based BIPs will be provided, including both larger meta-reviews and research within or related to a prison context.

Impact studies of traditional and alternative batterer intervention programs

Babcock, Green, and Robie’s (2004) research shows that treatment design has little impact on recidivism. There are no measurable differences in efficacy between the Duluth model and other CBT treatments for violent offenders. Beyond the effect of being arrested and thus prevented from committing violent crimes, the effect of the treatments was small, with minimal impact on reducing recidivism. Stover et al. (2009) support the view that existing interventions have limited effects on repeat violence and therefore provide minimal benefits compared to arrest alone. However, the minimal effects should not be underestimated, according to Sartin et al. (2006), who were early critics of the development of a norm based on the assumption that successful BIP treatments mean a permanent end to all domestic violence, which is unrealistic as the intention of the treatment is primarily to reduce the severity and extent of violence.

Evaluations that have only studied traditional pro-feminist BIPs—that is, treatment programs organized around the critique of patriarchal society and men’s power over women—also show mixed results. Cranwell et al. (2007) argue that traditional feminist-oriented BIPs have succeeded in getting participants to report a positive change in attitudes toward their violent behavior and toward stereotypical attitudes toward women. Despite the positive trends, several findings remain contradictory as men continue to claim that the abuse of women occurs because they are insecure or jealous and/or under the influence of alcohol and drugs. Research by Bowen et al. (2008) shows, on the one hand, that pro-feminist psychoeducational rehabilitation programs lead to a number of significant psychological changes in terms of attitudes toward violence against women, anger, control, and interpersonal dependency, but that the level of psychological change achieved cannot be related to recidivism in violent crime. Feder, Wilson, and Austin’s (2008) review shows that feminist-oriented BIPs of the Duluth model originating from the women’s shelter movement lack a statistically significant effect on recidivism and therefore there is no evidence that the programs are effective. Findings such as these raise questions about the effectiveness of the type of BIPs that are often court-ordered and the importance of developing new approaches to address this important social problem. Eckhardt et al. (2013) refer to a review of the effectiveness of traditional BIPs including studies of alternative formats of BIPs. The review shows that BIPs have equivocal results in terms of their ability to reduce the risk of IPV and that available studies had many methodological flaws. For example, the confrontation that is often part of treatment in the Duluth model can lead to dropout, which reduces the effectiveness of the therapy.

Effectiveness studies of alternative BIPs show uncertain results. According to Gondolf (2011), the debate on the ineffectiveness of BIPs has led to the emergence of alternative BIPs. However, the evidence is weak or insufficient that alternative treatments really work. The uncertain results concern psycho dynamic treatment (PDT) for attachment disorders, differentiated programs for different types of addicts, motivational techniques to increase willingness to change, specialized counseling for African-American men, and couples counseling for mutual violence. Mills, Barocas, and Ariel’s (2013) study of Restorative Justice programs in the form of Circles of Peace shows that they are as successful as traditional BIPs, but not more effective. Gondolf, Bennett, and Mankowski’s (2019) evaluation and critical review of Acceptance and Commitment Therapy (ACTV) reveals limitations that call into question the effectiveness of ACTV compared to CBT.

The conflicting results of BIP evaluations have had a negative impact on policy makers (Velonis et al., 2016). Policy makers and justice officials are currently unsure whether BIPs are the best way to address IPV and whether recommending and funding BIPs is the most rational approach. Research on BIPs by Aaron and Beaulaurier (2017) shows that they have been ineffective in preventing reoffending and that trust and support from the courts tends to decline. Cheng et al. (2021) confirm the contradictory state of research. Meta-analyses show that BIPs were effective within the context of criminal justice system measures in reducing IPV recidivism and general offense recidivism, but not when recidivism was assessed by victim survivors.

The importance of tailoring BIPs to subtypes of batterers such as: substance dependence, trauma experiences, type of violence, demographic position, and personality characteristics.

Taft et al. (2003, 2004) highlighted early in their studies how the quality of the working alliance between practitioner and client was affected by various factors at the individual and group level. They found that personality and interpersonal characteristics, motivation and readiness to change, and demographic factors such as being married, older age, and higher income were strong predictors of positive working alliance quality. Psychopathic and borderline personality traits and interpersonal problems were negative predictors of a good working alliance. Hanson and Wallace-Capretta (2004) also highlight the importance of demographic factors. The variables associated with recidivism were similar to those for recidivism in other criminal groups, such as an unstable lifestyle, substance abuse, and criminal history. According to Babcock et al. (2004), to address the specific problems, BIPs should be adapted to specific subtypes of offenders as well as individual characteristics such as: minority groups, chemically dependent offenders, offenders in different motivational phases, and to the types of violence used by offenders.

The integration of treatment for substance dependence and trauma experiences into BIPs has been shown to be particularly important for treatment effectiveness. Stover et al. (2009) point to the benefits of integrating empirically validated substance abuse and trauma treatments into BIPs. Couple treatments for substance abuse and aggression are found to have the lowest relapse rates. Manualized trauma treatments for children are also effective in reducing symptoms in children exposed to IPV. Yorke, Friedman, and Hurt’s (2010) study on the importance of integrating substance abuse treatment into BIPs also shows positive effects. They examined the effects of a BIP implemented within a substance abuse program at a state prison to see if the therapeutic interventions in the institutional setting affected offenders’ ability to recognize their violent behavior as abusive and to take personal responsibility for their actions. After the interventions were implemented, there was an increase in self-report of IPV and in the proportion of empathic responses showing greater realization that power and control damage relationships. Aaron and Beaulaurier (2017) stress the importance of better methods to identify the personality traits of perpetrators, especially traumatized individuals, and the types of violence that characterize their relationships. Karakurt et al. (2019) subgroup analyses showed that interventions that included abuse and/or trauma components produced better treatment outcomes than BIPs without these components.

Velonis et al. (2016) argue that in order to move forward and increase the effectiveness of BIPs, a realistic review is needed. It should identify the theories that underpin different programs, highlight the mechanisms that change participants’ behavior, and finally explain why these BIPs help some individuals reduce their use of violence and under what circumstances they are effective or ineffective. According to Aaron and Beaulaurier (2017), it is important to identify the types of violence used by different perpetrators. Differentiated treatment approaches have the advantage that they can be tailored to suit the offender and their particular types of violence. Programs, according to Morrison et al. (2017), should challenge the behavior of individual clients, but this must be done in a safe and secure environment where violence can be talked about openly and through adaptation to the unique clients. Recent studies by Mach et al. (2020) confirm the importance of thinking in terms of subtypes of IPV perpetrators in order to improve treatment response.

Increasing the impact of BIPs through working alliances and motivation that reduces dropout

Babcock and Steiner (1999) demonstrated early on the importance of batterers completing their IPV treatment. Abusers who completed IPV group treatment had fewer recidivism rates for IPV offenses at follow-up, and abusers in prison without treatment had more recidivism rates than those who did not complete IPV treatment.

One way to increase the proportion of offenders who complete treatment is through working alliances. Taft et al. (2003, 2004) show that a collaborative therapeutic environment produces better outcomes without recidivism. The quality of the working alliance between therapist and client may partly predict treatment outcome and it is therefore important to increase group cohesion and motivation of clients in BIPs. Hanson and Wallace-Capretta (2004) also show that maintaining a positive relationship with the therapist was related to reduced recidivism. According to Sartin et al. (2006), minimizing the number of dropouts is thus central to successful treatment. According to their research, dropouts can be reduced primarily through a therapeutic alliance, adaptation of BIP to different types of offenders, and less confrontation that risks reducing motivation to participate. The importance of tailoring treatment to different types of offenders is emphasized by Jewell and Wormith (2010) who show that variables such as employment, age, income, education, marital status, race, referral source, prior IPV, criminal history, and substance use distinguished those who completed treatment from those who dropped out. According to Morrison et al. (2017), the adaptation of an optimal BIP structure is key, where group size and program length should be adjusted to best promote change and interaction. For example, those leading the treatment should have the required IPV training.

Motivation can never be underestimated. Connors et al. (2013) show in their research that a positive improvement in motivation, whether assessed by the participant or the facilitator, was associated with improved program outcomes. According to Mach et al.’s (2020) research, offenders with high scores on “stake in conformity,” who directed their violence solely at the family, and attended more treatment sessions were more likely to complete the program.

In short summary, the overview shows that the evidence for unequivocal positive effects of CBT-based BIPs is weak, and it also applies to alternative forms of BIPs. Comparative program evaluations of BIPs are hampered by methodological ambiguities in how the intervention is carried out and differences in scientific design between different studies. Treatment design has been shown to have little influence on the effect of a CBT-based BIP beyond the effect of being arrested. Despite the small effects of treatment, the reduction in violence is important for those who are spared violence as a result of a treatment intervention. The literature assumes that treatment success means a permanent end to all IPV, but the intent of treatment is to reduce the severity and amount of violence. Dismissing current treatment interventions simply because violence has not been completely eliminated is illogical. Subtypes of perpetrators of different types of IPV need differentiated BIPs. For example, those who have directed violence solely at their family are different from those with borderline issues and those who are generally violent. The success of BIPs depends on whether they target specific groups such as minorities, chemically dependent abusers, and abusers at different stages of motivation. Subgroup analyses support that incorporating substance abuse and/or trauma components into BIPs yields more positive results than interventions without these components. Working alliances with client-therapist collaboration increase motivation and predict better treatment outcomes as well as reduced risk of dropout and relapse to violence.

The Swedish context

Despite unclear research support, the general attitude of the Swedish authorities toward CBT as a universal treatment method remains positive for both mental illness (Swedish Agency for Health Technology Assessment and Assessment of Social Services; SBU, 2005) and treatment of violent offenders (National Board of Health and Welfare; NBHW, 2020). SBU’s reports have influenced Swedish authorities’ policy on knowledge evaluation. After NBHW standardized evaluability as an evidence-based criterion for mental health, the position of CBT as a treatment method for IPV offenders has been strengthened within SPPS. As only CBT-based treatment methods are used within the SPPS, comparisons between CBT and alternative forms of treatment are impossible. In the municipalities’ voluntary treatment activities for IPV perpetrators—where PDT and hybrid treatment methods dominate—it is difficult to achieve corresponding representative data for systematic evaluations that are possible in SPPS. The possibility of gaining knowledge about the effectiveness of these methods is hampered by the fact that they are not admitted to the SPPS (Jansson and Saxonberg, 2022). CBT is, for example, difficult to individualize as the treatment is manual-based and conducted in group form (Hofmann et al., 2013; Daleflod and Lardén, 2004) and childhood traumas that have shaped the cognitive functions that control attribution and rational ability also risk remaining untreated (Jansson and Gunnarsson, 2024).

According to the SPPS (2024), there are currently two programs for convicted IPV perpetrators, all of which are CBT-based. RVP and Predov are new and created within the SPPS and have not yet been scientifically evaluated either internally or through independent studies or systematic reviews. The SPPS and the NBHW are currently conducting a scientific follow-up of Predov and RVP on behalf of the government. The assignment will be finalized in 2026. IDAP, which is being replaced by the Predov and RVP pilot programs, has been used since 2004 for the treatment of IPV (SPPS, 2011). IDAP is based on the Duluth Model (The Duluth Model, 2005) and CBT-based. IDAP is the only program for IPV offenders within SPPS, in good company with correctional services internationally, which has been the subject of several large independent systematic reviews showing that the treatment method is ineffective and/or is difficult to evaluate (e.g., Nesset et al., 2019). Although several studies indicate that IDAP lacks evidence, the method has been used within the SPPS until 2024. Predov and the RVP have toned down the feminist approach which is at the core of IDAP and consider the causes of violence as more complex and represent a better adaptation to the findings of research as described above. RVP is CBT-based and focuses on the role of drugs in partner violence and how drugs can be related to increased risks of IPV. RVP works with risk factors such as poor emotion regulation, lack of self-control, attitudes that support violence, jealousy, communication, conflict resolution problems, and antisocial behavior. Predov is CBT-based and is very similar to RVP but is less comprehensive and more focused on the main drivers of IPV such as attitudes that support violence, poor emotion regulation, communication, and conflict resolution. Both approaches address the role of drugs in IPV where appropriate. However, consideration of people with trauma experiences is missing from what can be inferred from the SPPS presentation. Furthermore, the importance of the therapeutic alliance is not emphasized very clearly. PDT and hybrid BIPs are not used within SPPS and will not be used under the current policy.

The SPPS Scientific Advice Board, represented by Swedish clinical researchers, recognizes most probably that CBT-based BIPs are used without evidence and that international scientific reviews show uncertainties, ambiguities, and sometimes negative results. At the same time, the SPPS (2024) officially claims that all their CBT-based treatments including BIPs are effective against reoffending. One possible explanation for the SPPS rhetoric may be that it strengthens the legitimacy of the SPPS. Expert knowledge, evidence-based policies, and a scientifically organized treatment structure strengthen the SPPS claim to government resources, as well as supporting already established policy positions (Benoit and Herzog, 2017; Yanovitzky and Weber, 2020).

Evidence-based decision-making is considered the highest standard for decision-making in policy and practice. However, it is considered rare and often misinformed (Oliver et al., 2014). The demand for evidence among consumers, patients, and policy makers has, for instance, been highlighted by the Sense About Science (2024) activities. The main thesis is that citizens have the right to demand scientific evidence behind public claims. Evidence-based policies (EBPs) have gained a lot of traction in public institutions and policies that use evidence as a basis for decisions. One problem with this type of model is that the evidence in evidence-based decision-making is often taken for granted and more attention needs to be paid to the evidence itself and what is meant by “evidence” (Raman, 2014). The meaning of evidence also has different meanings for different actors (Yanow, 1996). For policy proposals to be successful, they often need to be in tune with the EBP landscape. Policy-based evidence is an offshoot of EBP contaminated by political ideology that excludes and includes various forms of evidence with a political purpose (Marmot, 2004). According to Yanovitzky and Weber (2020), there are several methods for tracking the use of evidence in public decision-making. However, the tools have limitations as they only track evidence but have more difficulty in capturing whether and how evidence is used. This applies to what we have discussed above about how evidence is used for political purposes, for example, for persuasion, negotiation, and self-presentation. How the arguments are presented can say something about whether evidence is used instrumentally as facts or whether it has a symbolic function. In this case study, the analysis will focus on an interpretation of both the instrumental and symbolic meaning. We will come back to how the meaning of an argument can be examined through a content analysis of manifest and latent meanings after examining the conditions for evidence within the SPPS below.

Unclear concepts of evidence for assessing treatments for IPV perpetrators

Evidence is a complex concept in treatment that requires clarity. Evidence can exist for positive, negative, and absent effects and in many cases, it is not even possible to examine evidence scientifically. According to Ben Mrad et al. (2013), the concepts of hard and soft evidence can be used as a simplification to clarify the difference in degree between different types of evidence. Hard evidence is verified evidence that a specific variable has a specific value, for example, that a specific treatment intervention leads to a positive change in a person’s behavior. Soft evidence, on the other hand, refers to verified evidence that the true value of a variable cannot be measured with certainty, such as not knowing whether the treatment intervention leads to positive change or not. Currently, as discussed above, there is weak evidence from research reviews that CBT-based BIPs, in good company with alternative treatment methods (Gondolf, 2011) reduces recidivism among IPV offenders, which is consistent with soft evidence. In the Istanbul Convention, this resignation to the difficulties of evaluating IPV interventions has been reinterpreted as the value of doing anything at all (GREVIO, 2019; Hester and Lilley, 2014). The systematic reviews conducted of CBT-based BIPs have demonstrated different variants of soft evidence while hard evidence that the treatments have a solid and verified impact on the clients has been absent (e.g., Nesset et al., 2019; Feder et al., 2008; Babcock et al., 2004). In order to develop more effective treatment programs, researchers and practitioners have called for the integration of evidence-based practices under the name Principles of Effective Interventions (i.e., PEI). Initial empirical studies of PEI in BIPs are promising but have not been tested in larger systematic studies (Radatz et al., 2021). The problem of proving what is effective treatment in SPPS is shared by the social work profession, which wants to achieve scientific status through evidence-based interventions. Social work clients are in open systems with no control over external influences, making it difficult to determine what has caused deterioration or improvement (Murdach, 2010). The closed system of the SPPS facilitates the control of external influences as long as the closed treatment of IPV offenders is ongoing, while the control of external influences, such as demographic factors, on former IPV offenders is more difficult in the open system of the community, which influences recidivism.

SPPS has excluded methods other than CBT which precludes an open and unbiased pursuit of the best possible knowledge. In the absence of hard evidence from reviews verifying that CBT-based BIPs reduces recurrence of IPV, the SPPS risks becoming more exposed to its authority and reputation, which has rhetorical significance but lacks objective scientific value. The lack of evidence that treatment interventions prevent relapse to IPV warrants an interpretative content analysis of how the concept of evidence is used by the SPPS, to which we will return. Below we will look at how evidence is defined and graded and the basis on which the Scientific Advice Board can accredit BIPs for use in the SPPS.

Evidence grading in the SPPS

SPPS uses GRADE (Grading of Recommendations Assessment, Development, and Evaluation) (SPPS, 2014). The SPPS (2024c) accreditation criteria state that: “The assessment takes into account any previous intervention studies (including those conducted outside the Swedish correctional system) on the treatment program in question. If such studies exist, the assessment should primarily be based on the GRADE evidence grading model and the requirement is that at least level ++ (limited scientific evidence) should be achieved. As long as accreditation is based on levels ++ (limited scientific evidence) to +++ (moderately strong scientific evidence), the prison service is required to present a plan for the future evaluation of the current treatment program, even after accreditation with evidence in Swedish correctional services.”

GRADE is a transparent framework that provides a systematic approach to making recommendations for clinical practice by developing and grading the quality of evidence. According to Guyatt et al. (2011), the grades of quality of evidence should be assessed as follows: The strongest evidence ++++ means that the estimated effect of the treatment is very close to the true value, which is close to the concept of hard evidence (Ben Mrad et al., 2013) and corresponds to verified evidence that a particular variable has a particular value. In the case of moderately strong support +++, the estimated effect is likely to be close to the true value but may differ significantly. In case of limited scientific evidence ++, there is a risk that the estimated effect may differ even more from the expected effect. Insufficient scientific evidence + means that it is not possible to determine whether the treatment leads to a reduced or increased risk. SPPS (2024b) assures that they use the second lowest level ++ or +++ when previous evaluations are available.

Purpose and procedure

The aim of the study is to examine what constitutes evidence in SPPS’s treatment activities for IPV offenders and how the agency uses it as part of its public treatment policy. Part of the analysis focuses on the manifest content of the claims SPPS makes about the evidence for BIPs and the application of the GRADE accreditation rules. The SPPS application of evidence is related to the evidence produced by systematic research reviews, other scientific studies, and to how the GRADE evidence criteria should be applied. Another part consists of an interpretative analysis of how the SPPS rhetorically uses the concept of evidence internally within its treatment activities and externally in relation to the public and the state via statements in public documents on its website. The purpose of this sub-analysis is to investigate whether there is a latent content.

Method

The object of the case study is SPPS, a CBT-based treatment institution for IPV offenders and other convicted criminals. Qualitative content analysis (Graneheim and Lundman, 2004) is used as the main method of analysis to interpret the manifest and latent content of publicly available documents.

Unit of analysis

The data are based on secondary data from the official SPPS website (2024) and available documents (https://www.kriminalvarden.se/). The results have not been triangulated through interviews with SPPS staff. The official database on the SPPS website consists of subsections and contains both introductory and in-depth descriptions of treatment methods for IPV perpetrators, summaries of scientific evaluations, and accreditation criteria for evidence formulated by the Scientific Advice Board. The manifest content refers to the SPPS approach to evidence as demonstrated by statements about evidence on the official website, how evidence is used in the accreditation of BIPs within the SPPS via the GRADE criteria. The latent content analysis is based on an interpretation of how SPPS uses evidence internally and toward the public and government and whether a deeper rhetorical meaning can be discerned. Only BIPs are included in the study. The material presented by SPPS on its official website is considered authentic and representative of SPPS treatments of IPV perpetrators. The SPPS activities are internationally recognized and there is interest in showing the activities openly. SPPS states that the treatments described in the available documents are active forms of treatment. To prevent the study from being based on outdated data, initially collected data have been continuously updated to include changes made by the SPPS. The reference to research reviews of CBT-based BIPs is based on the above overview of research on the effectiveness of CBT-based BIPs. The use of citations and links to relevant documents is intended to enable intersubjectivity and facilitate replications.

Data sampling

Reporting of IPV treatment programs has during 2024 been taken from the main section on treatment and care [behandling och vård] on SPPS (2024) official website (https://www.kriminalvarden.se/behandling-och-vard/) and the subsection on treatment programs [behandlingsprogram] (https://www.kriminalvarden.se/behandling-och-vard/behandlingsprogram/). Only those BIPs available for the treatment of IPV are addressed in the results. The BIPs in question are the RVP and Predov. RVP has been approved by the SPPS Scientific Advice Board but still lacks evidence from evaluations: “During the years 2020–2026, the RVP will be evaluated in terms of effect and process. The evaluation is led by the Swedish Prison and Probation Service’s R&D activities” (https://www.kriminalvarden.se/behandling-och-vard/behandlingsprogram/rvp/). Predov is a new program that has not yet been evaluated but has been approved by the SPPS Scientific Advice Board: “Predov is developed in the Probation Service and in line with the latest research on effective treatment methods for partner violence. The program was accredited by a scientific panel in December 2020 and was thus approved for implementation in the regular activities of the Prison and Probation Service.”

https://www.kriminalvarden.se/behandling-och-vard/behandlingsprogram/predov/ Evaluations of the violence treatment programs have been taken from the main section for research and statistics [forskning och statistik] (https://www.kriminalvarden.se/forskning-och-statistik/) and subsection of statistics and facts [statistik och fakta] (https://www.kriminalvarden.se/forskning-och-statistik/statistik-och-fakta/) and furthermore from the subsection of SPPSs research and evaluation [Kriminalvårdens Forskning och Utvärdering] (https://www.kriminalvarden.se/forskning-och-statistik/kriminalvardens-forskning/). The reporting of the SPPS treatment programs for intimate partner violence has been taken from [behandlingsprogram] (https://www.kriminalvarden.se/behandling-och-vard/behandlingsprogram/). The basis for the analysis of [ackreditering] accreditation of treatment programs has been taken from (https://www.kriminalvarden.se/behandling-och-vard/behandlingsprogram/ackreditering/).

Analysis methods

Graneheim and Lundman (2004) treat text-based content analysis from two aspects. One aspect concerns the manifest content consisting of the visible and obvious components. As we have seen above, it refers to the public claims that the SPPS makes about its treatments, the scientific status of the evidence used by the SPPS, and how the GRADE criteria are applied internally by the Scientific Council (the manifest content also includes lack of evidence). The presented review of research on the effectiveness of CBT-based BIPs provides a theoretical framework to which SPPS’ use of BIPs is related and forms the basis for a critical analysis of the manifest content of the activity. The latent content is based on a relational aspect and refers to an interpretation of whether it is possible to discern an underlying meaning in claiming to the public and the state that there is evidence for the treatments when the analysis of the manifest content shows that there is none. It is not possible to prove that a latent content is used for a specific purpose, but to suggest a reasonable interpretation of why the SPPS generally portrays its activities as successful, when there is no concrete evidence of this. This is particularly true for RVP and Predov, which have not yet been scientifically evaluated. Both manifest and latent content require interpretation, but they vary in depth and level of abstraction. Content analysis is a balancing act where the researcher must let the text speak and not uncritically attribute meanings to it that confirm the researcher’s perspective. Results and sources should be presented openly and objectively so that the reader can search for alternative interpretations, which is a prerequisite for credibility. In this case, the manifest content can be substantiated with references to documents, while the latent content refers to an interpretation of why there is a discrepancy between what the SPPS claims about evidence for its BIPs and what is possible to substantiate scientifically. The study reveals a discrepancy between what the SPPS claims about the evidence for its treatments and what can be scientifically proven. The manifest content forms the basis for justifying a latent content in the form of rhetorical meaning intended for the public and the state. Ample citations and references to SPPS sources are used to allow for replication of the study and for the results from the Swedish context to be compared with other countries.

Scott’s (1990) four criteria for evaluating the quality of official documents further concretize the content analysis in the study. The content is interpreted with a focus on four characteristics: authenticity, representativeness, credibility, and meaningfulness. Authenticity refers to whether the material is genuine, and representativeness refers to whether the material is typical of the category to which it belongs. These aspects of the material are easier to assess due to the high availability of the SPPS public website and are preliminarily categorized as manifest content according to Graneheim and Lundman (2004). Credibility refers to whether the material contains errors and/or distortions that mislead the reader. Meaningfulness refers to whether the material is clear, understandable, and easy to draw conclusions from. The dimensions of credibility and meaningfulness are assumed to contain latent aspects related to how SPPS uses evidence to present itself to others as a government agency. Another starting point is the organizational identity which, according to Sillince and Brown (2009), is rhetorically formed in three tensions. As effective or ineffective organizations, as organizations integrated into society or separated from society, and as progressive or non-progressive organizations. All the tensions outlined above have both manifest and latent dimensions in relation to the public and the state. How evidence is used is further analyzed based on Yanovitzky and Weber (2020), interpreting the presentation of the arguments if they are primarily seen as instrumental facts or if they fulfill a symbolic function. If the evidence is presented first, followed by claims and reasons, this indicates that the arguments are logically derived from evidence. When arguments are structured with a conclusion first and evidence follows, it indicates that the use is symbolic or tactical as evidence is used to suggest a particular conclusion rather than the conclusion being logically derived from evidence.

Results

The manifest aspects of the SPPS use of evidence (the scientific status of used evidence)

The SPPS (2024) only uses accredited CBT-based BIPs: “The Swedish Prison and Probation Service’s treatment programs are accredited. This means that the programs have undergone a scientific test and that there is support in the research for the program to reduce the risk of recidivism or abuse” (https://www.kriminalvarden.se/behandling-och-vard/behandlingsprogram/ackreditering/). However, this means more precisely that the program has passed a scientific review by the SPPSs Scientific Advice Board, but not that a scientific test of the effectiveness of the method has been carried out nor that there is support from formal independent systematic evaluations that these treatment programs have a positive effect on relapse. According to the SPPS (2024a) subsection, Accreditation treatments are accredited according to six criteria. Criterion 1. A clear model of change. There must be a model that describes how the treatment program intends to achieve relevant changes in clients. Criterion 2. Client selection. It must be stated which clients the treatment program is intended for, and which selection methods are used. Criterion 3. Change in dynamic risk factors. The program must be focused on dynamic risk factors and there must be support for that the methods used are expected to affect the risk factors that are addressed. Criterion 4. Intensity and susceptibility. The scope of the efforts must be linked to the clients’ needs and, in addition, receptivity factors must be managed. Criterion 5. Treatment integrity. High treatment integrity is a prerequisite for the possibility of influencing the risk of recidivism and Criterion 6. Evidence in Swedish Prison and Probation. Accredited treatment programs that are rolled out in the SPPS must be evaluated. According to criterion 6: “A treatment program that is accredited and conducted properly should provide treatment effects. However, if the program is not evaluated, it is impossible to know whether the application of the initiative is effective in the Swedish Prison and Probation Service.” To meet criterion 6 on evidence in the SPPS, it is further required that: “At least one intervention study with a positive result in Swedish prison service is presented” and that “The accreditation panel assesses that the study/studies’ design and results mean that there is sufficient scientific evidence for the treatment program to be considered to have evidence in the Swedish Prison and Probation Service.”

However, a detailed look into the accreditation regulation shows that there is no absolute stipulation that treatment must reduce relapse: “After completing the intervention study, the results are presented to the Scientific Advice Board, which then assesses a possible positive result in combination with an assessment of the methodological aspects enough for the treatment program to be accredited with evidence in SPPS. If negative results are presented, it is the task of the accreditation panel to decide if the treatment program shall maintain its status as a nationally accredited program” (https://www.kriminalvarden.se/globalassets/behandling/ackrediteringsordning-2023.pdf).

The SPPS approach to accreditation contains several question marks. SPPS (2024) currently uses two CBT-based treatment approaches for IPV offenders. IDAP, which has been discontinued, is the only program for IPV offenders that has been tested in major external systematic reviews. The evaluations with the highest scientific status show that there is no evidence that IDAP reduces recidivism. This corresponds to an insufficient scientific basis according to GRADE+. The two BIPs currently in use, Predov and RVP, have not been scientifically evaluated and there is no hard evidence on whether they lead to a reduction or increase in risk, which is equivalent to GRADE+. Although research shows some support for BIPs with similar content to Predov and RVP, there is no evidence higher than the lowest level of evidence of GRADE + that they have a positive effect. The SPPS uses GRADE’s accreditation criteria, which have high standards for what can be categorized as evidence. If SPPS uses an externally developed program, a minimum of GRADE ++ or +++ is required. However, the requirements for an internally produced treatment program to be categorized with evidence in SPPS are low. According to SPPS (2024b) accreditation criteria, support for a positive effect is needed in only one completed intervention study within SPPS, but in cases where negative results exist, the Scientific Advice Board can still accredit the treatment with evidence within SPPS. GRADE + refers to when there is insufficient scientific basis to examine whether the estimated effect of the treatment is close to the actual value. The SPPS internal application of what constitutes evidence thus deviates from the internal requirements of its treatment programs. In conclusion, the interpretation of the manifest content shows that SPPS is currently not working with evidence requirements higher than GRADE + which is equivalent to non-existent evidence. In the light of the SPPS’ internal approach to evidence scientifically, together with public positive statements on evidence, it is reasonable that it fulfills latent functions in relation to the public and the state, which we will explore further in the following section.

The latent aspects of the SPPS use of evidence (how evidence is used)

The discrepancy between what is scientifically possible to claim, how BIPs are accredited by the Scientific Advice Board through an internal application of GRADE, and what is said publicly about the effectiveness of the treatments suggests that there is latent content that can be interpreted. Related to that, Scott (1990) warns that various forms of distortion and inaccuracy can threaten the credibility and legitimacy of the organization. Lack of clarity in the SPPS’s internal use of the accreditation criteria GRADE can threaten the state and the public’s confidence in the SPPS’s activities, which, in addition to enforcing sentences, should reduce recidivism in IPV. In order to meet public and government expectations of SPPS as an effective, well-integrated, and progressive organization (e.g., Sillince and Brown, 2009), a more positive rhetoric for evidence seems to be formulated than is supported by the manifest content in terms of facts. When you can control how evidence criteria are applied and which BIP you accredit, you have the freedom to construct a picture of success. If evidence from systematic reviews, other empirical research and GRADE were consistently applied, treatment activities would be difficult to justify as evidence-based. The more inhumane punitive function would then emerge more clearly as a more real purpose of SPPS activities. The SPPS is supposed to base its activities on science but finds itself in a political context where it is necessary to refer to evidence in order to access funding and to support the political structure of which the SPPS is a part. Therefore, it is likely that the SPPS approach to evidence has a latent sympathetic meaning that is intended to give the organization legitimacy in relation to expectations from the outside world (e.g., Strassheim and Kettunen, 2014; Yanovitzky and Weber, 2020).

Discussion and conclusion

All authorities seem to be forced to legitimize their raison d’être to the public and the state but this has risks. The questionable scientific status of the evidence cited by the SPPS seems to be compensated by rhetorically communicating to the public an overconfidence in its own treatment methods. The SPPS’s dilemma is that there is currently no hard evidence that the SPPS’s BIPs fulfill any higher function beyond enforcing the sentences for IPV offenders imposed by the courts. The public has every right to demand scientific evidence for the claims made by the SPPS and other authorities. If there is no hard evidence, an authority must be honest with the facts and communicate this, otherwise the credibility of both authorities and science is eroded. The absence of evidence that the SPPS BIPs have any scientific support should lead the SPPS to adopt a more open, humble, and unpretentious attitude toward the public and be honest with the truth about the situation that there is currently no evidence that BIPs have a positive effect. The SPPS has underestimated the rhetorical importance of publicly stating what can be proven, for example, that many types of BIPs can cure a few offenders and/or reduce the severity of violence in some. Realism gives society an honest chance to develop long-term support programs that follow up former IPV offenders after sentencing in the open community and the SPPS should be open to testing other treatment methods as well.

Limitations

No triangulation with interviews of staff has been conducted as validation. The review of CBT-based BIPs is not formal but corresponds to a selection of studies that are central to the debate on the effectiveness of BIPs. The research studies of CBT-based BIP conducted in the United States are also relevant to Sweden, with the reservation that some interventions are not available in the Swedish context and that the treated population is more heterogeneous in the United States.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Peter M. Jansson

Author biography

Peter M. Jansson is a senior lecturer in social work and sociology at Dalarna University, Sweden. His area of expertise is the relationship between male violence, masculinities, and emotions and how treatment programs should be designed to reduce recidivism. His research on the subject has been published in journals such as Child and Youth Services Review, Deviant behavior, Partner Abuse, and Aggression and Violent behavior.

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Can we trust that CBT-based batterer intervention programmes are effective?—Use of evidence for the treatment of IPV offenders in the prison and probation service

Abstract

Keywords

Introduction

Overview of research on the effectiveness of CBT-based batterer intervention programs (BIPs)

Impact studies of traditional and alternative batterer intervention programs

Increasing the impact of BIPs through working alliances and motivation that reduces dropout

The Swedish context

Unclear concepts of evidence for assessing treatments for IPV perpetrators

Evidence grading in the SPPS

Purpose and procedure

Method

Unit of analysis

Data sampling

Analysis methods

Results

The manifest aspects of the SPPS use of evidence (the scientific status of used evidence)

The latent aspects of the SPPS use of evidence (how evidence is used)

Discussion and conclusion

Limitations

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

Author biography

References