Thoughts on the Film Precious

I saw the film Precious a few weeks ago at the North Carolina Coalition Against Sexual Assault's special screening of the film. (You can find more information about NCCASA here.) For those of you who have not seen the film, an overview of the movie and plot can be found in the New York Times review by A.O. Scott here. (ALERT! THERE ARE "PRECIOUS" SPOLIERS IN THIS BLOG. If you don't want to know what happens, go watch the film first. Then come back and read the blog.)

I found the film both horrifyingly gut-wrenching and beautiful. For me, the film was about resilience in the context of incredible adversity. The film is also about how a writer finds her voice and then is able to tell her story of survival in a way that positively transforms her life, as well as the lives of those around her.

The way that Lee Daniels (the filmmaker) portrays Precious' life- by blending elements of visual escapism with the reality of the harrowing story- is innovative and creative. At key times of crisis in the plot, the main character Precious (as played by Gabourey Sidibe) escapes into a fantasy world of her own making. In this regard, I found the film to be one of the best creative representations of trauma symptoms of dissociation that I've ever seen. With the film's portrayal of the effects of the horrific violent trauma, as well as its portrayal of one survivor's path toward recovery and resilience, the film is well worth seeing. All that said, the violence is realistically disturbing. So I encourage readers to carefully consider the potential emotional impact of the film before going out to see it.

Since seeing the film, I've been following the debate in the media about the film's depiction of African Americans. Felicia Lee's New York Times article pithily sums up the core issues in the debate by asking this question about the film: "A reinforcement of noxious stereotypes or a realistic and therapeutic portrayal of a black family in America?" This debate is important, and the issues are significant. No matter how well intentioned and meaningful, the life story of a resilient violence survivor loses its significance if the story relies on clichés and racists stereotypes.

However, I find that one important aspect of this debate has been neglected in the articles and blogs I've read so far. Very little has been said about the importance of community and society for understanding why some groups of people are at great risk for family violence. Much of the debate focuses on how the individuals in the film are portrayed. Less has been said about Precious' victimization in relation to the community and social context in which the violence (and story) occurs. Given what the violence research says about the importance of this context, I find that it is impossible to understand Precious' story without considering the community and society in which Precious lives her life.

Though the research on community and social risk factors for violence is limited and more work needs to be done in this important area, the research is growing and shows that community and social factors play a key role in the prevalence of family violence. For example, Taft and colleagues' recent research emphasizes the importance of the social and cultural context for partner violence against African American women. Also, the Centers for Disease Control and Prevention's recommended framework for preventing sexual violence emphasizes community and social change strategies as much as it emphasizes individual change strategies for violence prevention. Thus, the violence research tells us that to fully understand Precious' victimization we must also consider the effects of racism and poverty in her life.

Both poverty and racism insidiously work to undermine the community and social resources that help protect people from violence. So when some groups of people in our society are burdened with oppressive social realties like racism and poverty, those groups tend to experience more problems of violence and victimization. For example, I was struck in the film by how isolated Precious and her mother were from any sources of social supports, such as neighbors, friends and family, who may have helped and protected Precious. Research shows over and over again how important positive, supportive social relationships can be for preventing and ending family violence. Unfortunately, such resources were not available to Precious.

I was also struck by how many professionals were involved in Precious' life- educators, social workers, child protection workers- and how little was done by any of these people to help protect Precious. Indeed, it took Precious' second pregnancy by her father before an educator and a social worker took an interest in helping her. In this way, the film did an excellent job of showing the problems of our communities' over-burdened and under-funded systems, such as schools, welfare, and child protection. As the film depicts, though these systems are charged with protecting the vulnerable members of our communities, too many people fall through the cracks in these systems never to receive help or support.

When these systems are so over-burdened and under-funded, the people who work in these systems (even the very well meaning ones) may be more unhelpful than helpful. A wonderful example of such a person was Mariah Carey as she portrayed Precious' social worker. Though the social worker does try to help Precious, the social worker's interventions are at best ineffective and at worst harmful. One of these harmful interventions as seen in the film was the counseling session that the social worker holds with Precious and her mother. Though this counseling session makes for a dramatic and pivotal moment in the story, it also makes for pretty poor- and potentially harmful- social work practice. (A note to social work educators here: This film could be an excellent teaching tool in what NOT to do to help clients.) The counseling session is a moment of empowerment and resilience for Precious because of her own inner resources and strengths, not because of anything the social worker does.

In the end, I feel positively about the film "Precious" because it addressed violence as a social justice issue. In this way, the film reminded me very much of Toni Morrison's The Bluest Eye. Both Morrison's and Daniel's work explore the issues of family violence, child abuse, incest leading to pregnancy, poverty and racism. And both works remind us that we cannot fully comprehend or address violence in its many forms without considering social inequalities. I'm hopeful that this film, as well as the controversy that the film sparked, will help bring awareness to the issues of family and sexual violence, as well as urge those of us who are working to prevent violence to address the gender, racial and socioeconomic inequalities that perpetuate violence.

Think Safe: Developing a Brief Cognitive Behavioral Therapy (CBT) for Partner Violence Survivors

Over the past several months, I've been working to develop a brief cognitive behavioral therapy (CBT) for partner violence survivors that could be delivered in community-based domestic violence programs. I'm calling this treatment Think Safe to emphasize both the cognitive and safety aspects of the service. Here, I overview the Think Safe treatment with the hope of both informing other violence advocates and service providers about this work, as well as with the hope of hearing others' ideas and suggestions about this work.

I decided to develop this therapy after completing a study of North Carolina's domestic violence and sexual assault services. During this project, I found that the staffs of domestic violence agencies are assisting increasing numbers of partner violence survivors who have mental health problems. Although agency directors want to provide both domestic violence and mental health services to their clients, they were uncertain of how their staff could best provide these interventions. In addition, program directors described considerable challenges in helping clients access community-based mental health services, including long waiting periods (i.e., many weeks to months) and denial of state-supported mental health services because survivors did not fit the diagnostic criteria of having "serious and persistent mental illnesses" such as bipolar disorder and schizophrenia.

The findings from this project showed a mental health care crisis for violence survivors. However, given that I also found that agency directors are motivated to address this service gap; this service delivery crisis also presents a unique opportunity to address the mental health needs of partner violence survivors in novel ways.

    Think Safe is grounded in the social cognitive theory literature, which applies social cognition to violence and trauma, coping with trauma, and the cognitive behavioral therapy (CBT) literature. The theory of change underlying the Think Safe treatment conceptualizes violence survivors as active agents with capacities to change their thoughts, feelings, and behaviors toward improving their mental health, creating meaning from their traumatic experiences, and achieving safety. Think Safe is brief and crisis-focused, consistent with the
primary goal of helping survivors in the immediate aftermath of partner violence. Think Safe consists of eight 90-minute individual therapy sessions between a client and a trained domestic violence staff member. Each session is structured with goals and activities, and ends with "Safety Work," which is a safety-focused homework activity on which the survivor can focus her efforts between sessions. The treatment was developed as a brief intervention: (a) because other brief cognitive behavioral therapies have been shown effective with violence survivors and; (b) because a brief treatment will be feasible for the "real-world" setting of a community-based domestic violence agency. Thus, if the findings from this program of research show Think Safe to be an effective treatment, the intervention will be feasible for delivery in other community-based domestic violence agencies.

 

The Think Safe treatment builds on research that demonstrated the efficacy of CBT for partner violence survivors. (Please see my earlier blog posting here for a full discussion of evidence-based cognitive-behavioral therapies for survivors.) However, Think Safe is unique because it focuses on women who are in crisis and who are still in, or have only recently ended, violent relationships. Research shows that the other existing forms of CBT (such a trauma exposure therapies) are appropriate for survivors who have already achieved their safety goals and are living violence-free lives. Partner violence survivors will likely benefit from trauma exposure therapies once their safety is secure. Until then, an initial mental health treatment may be helpful to help survivors while they are working toward the goals of escaping violence and securing safety. Think Safe was developed to be delivered in that transitional period–as survivors work toward living violence-free lives and until they are permanently safe from violence. In the development of Think Safe, my research team and I selected therapeutic change strategies for the distinct, yet overlapping, goals of mental health and safety promotion. Thus, the treatment helps partner violence survivors by using a three-pronged approach that includes cognitive restructuring, adaptive coping, and planning for safety.

1. Focus on positive cognitions. Think Safe works to alter maladaptive and inaccurate cognitions that undermine victims' mental health and safety actions. Using the well-established therapeutic technique of cognitive restructuring that has demonstrated effectiveness for many psychosocial problems, Think Safe ameliorates mental illness by modifying and replacing negative, unhelpful cognitions. Partner violence survivors may not only suffer from Post Traumatic Stress Disorder (PTSD) but also frequently struggle with negative cognitions (thoughts, beliefs), including powerlessness, entrapment, and vulnerability, which are supported and maintained by maladaptive cognitions and cognitive errors. Negative experiences and events, like partner violence, generate greater cognitive activity than positive events. The negative cognitive activity produced by a violent event generates complex, powerful, and stable cognitions. However, these trauma-based cognitions are not intractable, and can be modified or replaced using CBT. Through cognitive restructuring, Think Safe teaches survivors helpful ways of thinking about themselves, their relationships, and their futures. The treatment provider first helps victims identify maladaptive thoughts and beliefs, and then helps victims replace such thoughts with cognitions that are adaptive, helpful, and accurate. By addressing the cognitions that underlie and perpetuate PTSD, as well as cognitions that inhibit survivor's capacity to carry out safety actions, Think Safe helps survivors identify and assess existing resources and opportunities in themselves, their lives, and their communities; this knowledge helps survivors to navigate their way out of violent life circumstances.

    

2. Focus on adaptive coping. Adaptive coping includes (a) a search for meaning in the experience, (b) an attempt to regain a sense of mastery over the event and life, and (c) an effort to feel good about the self again. The outcomes of adaptive coping are a combination of (a) reduction of physiological reactions and psychological distress, (b) return to normative social functioning and routine activities, (c) enhancement of personal well-being, (d) maintenance of positive self-esteem, and (e) enhancement of perceived personal effectiveness. Think Safe improves survivors' adaptive coping skills by repairing their eroded capacities for work, relationships, and safety actions. When faced with a personally threatening event, human beings strategically engage in coping activities that focus on readjustment, management, and positive change.

 

Research on coping with trauma has established that, depending on the kind of coping used in response to violence, subsequent coping actions become either problematic or helpful mechanisms for a person's well-being. As Collins and her colleagues stated in a research article from Social Cognition, "the more an individual engages in active coping efforts such as cognitive reappraisal and behavior change, the greater will be the positivity of his/her belief change". In addition, active, adaptive coping efforts increase the likelihood that a person will find benefits and growth in a negative—even horrific—experience such as partner violence. This adaptive coping theory has been applied to a variety of stressors, threats, and challenges, and is supported by empirical evidence.

    Building from both trauma and coping research in general and partner violence-specific research, there is compelling theoretical and empirical support for the idea that adaptive coping strategies not only help victims maintain or improve their mental well-being in the aftermath of a violent assault, but that adaptive coping strategies also protect women from revictimization. The theoretical and empirical research suggests cognitive-behavioral interventions are useful in helping women to extract meaning from the violence, to gain or regain a sense of mastery over their lives, and to improve their self-concepts. Although working toward such positive adaptations (e.g., implementation of self-care behaviors such as taking a daily walk; behavioral changes to manage negative emotions such as meditation, deep breathing exercises, or guided imagery; positive reappraisals of the violence) is a critical first step for violence survivors, additional preparation will likely be needed to enable survivors to establish safe and violence-free lives.        

3. Focus on safety. To address the needs of survivors in crisis (i.e., those who have either recently ended or are trying to end a violent relationship), Think Safe focuses on safety planning (e.g., using legal remedies to address the violence, securing finances and economic resources independent from the perpetrator, securing housing independent from the perpetrator) throughout the treatment. The weekly treatment sessions use methods grounded in the CBT approach to enhance survivors' capacities for safety planning and action. At the beginning of each session, the provider will use a check-in strategy to help the survivor assess her/his current safety status and the efficacy of her/his safety planning efforts. At the end of each session, and consistent with CBT homework strategies, the survivor and provider will develop a "Safety Work" strategy (i.e., safety-focused homework activity).

    The cognitive changes and the adaptive coping strategies will build and enhance survivors' capacities to use safety actions in two ways. First, the cognitive and behavioral change strategies will improve survivors' cognitions and PTSD symptoms. In turn, improved mental health status will enhance survivors' capacities for safety actions. Second, the combination of cognitive and behavioral changes will directly enhance IPV survivors' capacity to learn and use safety actions. With improvements in cognitions (i.e., increased helpful, accurate cognitions) and behaviors (i.e., increased active problem solving and seeking support), survivors' capacities for safety actions (e.g., using legal remedies to address the violence, securing housing independent from the perpetrator) will also improve. Survivors receiving Think Safe should also receive domestic violence advocacy services, and the utility of those services will be enhanced by pairing them with Think Safe.

I've begun to develop a draft of the treatment manual based on (1) my research on the topic of partner violence; (2) my clinical experience working with partner violence survivors, treating clients with mental illnesses, and delivering CBT to clients; and (3) feedback from domestic violence directors, counselors, and advocates. The manual incorporates information on all aspects of Think Safe, including (1) treatment rationale; (2) conceptual framework; (3) change processes and essential elements of the treatment; (4) treatment goals; (5) intervention strategies; (6) session formats, including detailed guidance for eight sessions and guidance on homework strategies for clients; and (7) a discussion of therapeutic and clinical issues, including safety issues (e.g., what to do if partner violence lethality risk increases or a client becomes suicidal).

    To ensure that the treatment is acceptable to domestic violence service providers, an initial draft of the treatment manual was reviewed by three staff members of the North Carolina Coalition Against Domestic Violence and two staff members at a North Carolina domestic violence agency. Feedback obtained from these five domestic violence provider-experts was used to revise and enhance the manual.

I recently submitted a grant proposal to pilot test this treatment, and I hope that a preliminary test of this intervention will show promising results.

 

Preventing Partner Violence Deaths Requires Individualized Solutions

A recent article in the News and Observer, Wake Couple Had a Tumultuous Past, reports on the horrible death of Jammie Street, as well as the murder charge for her death that was filed against her boyfriend, Daniel Montgomery. The article describes the various legal remedies Street had (and had not) taken in the several months before her death. The article notes: the victim, Street, "stayed silent" about an assault charge pending against her boyfriend- Montgomery- during a court hearing against him; Street allowed a protective order against Montgomery to expire; and Street allowed Montgomery to move back into her home after an assault incident.

By highlighting these aspects of this sad, horrific event, the article draws our attention to the strategies that violence victims do (and do not use) in their efforts to seek safety, end violence, and protect their lives. It is all too easy for those of us on the outside of a violent relationship to ask "Why doesn't she just leave?" or "Why doesn't she call the police?" or "Why not take out and keep a protection order?" The average person who has not had experience with partner violence tends to think that anything that helps a victim leave a violent relationship should increase her safety. Sadly, the realities of partner violence are complex, and these easy questions do not fully capture the challenges of violence victims' lives.

Though I cannot speak to the realities of this horrible situation (I have no knowledge of the event beyond what I read in the paper online today), I can speak to what the research says about legal and safety strategies that seek to enhance safety, end violence, and prevent partner homicides.

Research on the effectiveness of safety services and legal remedies for partner violence is not clear-cut. For example, a 2003 report from the National Institute of Justice, authored by Laura Dugan, Daniel S. Nagin and Richard Rosenfeld, found that some interventions (e.g., restraining orders, arrest, or shelter protection) may result in angering or threatening an abusive partner without providing the victim with any additional protections. So the strategies that the average person tends to think are helpful may- in fact- make violence worse in some situations for some victims.

It is worth noting here that this same research also found that there are two policies that do seem to lower violence victims' exposure to retaliatory abuse from violent partners. These policies are warrantless arrest laws and higher AFDC benefit levels.

However, Dugan and her colleagues do not conclude that legal and safety services should be abandoned as strategies to prevent partner violence deaths. Rather, these researchers recommend that such prevention efforts should be tailored to victims' individual needs and risk situations. Therefore, though a protection order may be helpful for one victim, it may not be helpful for another victim. Likewise, a protection order that may have been helpful to a victim at one time, may no longer offer the same benefits with a change in the victim's circumstances or situation.

Research on partner violence also shows that victims are not only concerned with ending violence and securing safety, they must also grapple with employment, the financial realities of their lives, housing, parenting, as well as their responsibilities to friends and family (just to name a few examples). Taryn Lindhorst, Paula Nurius and I have written research on how the complex challenges of violence victims' lives can complicate or impede their efforts to seek safety. In this research, we also describe comprehensive safety planning strategies (for use by domestic violence advocates, counselors, social workers, and health care providers) that can help victims manage the complex realities of their lives as they work toward safety.

Another evidence-based strategy that can be useful in developing an individualized safety plan for victims is the Danger Assessment Instrument developed by Jacquelyn C. Campbell. (Detailed information on the instrument, including a web-based training can be found here.) Research shows that the risk of partner violence homicide is highest when a victim makes efforts to leave a violent relationship (see Dugan and colleague's research again on this point). Thus, this instrument can be useful in helping victims to assess the risk of their current situation. In turn, such risk information can help a health care provider, human service provider or advocate work with a victim to plan her safety and her family's safety.

Taken together, the research I described here shows that we should never second guess violence victims' actions. Further, this research makes me think that rather than asking what the victim should do differently, we should be asking what can our organizations and communities could be doing differently to help protect victims and prevent partner violence. In preventing partner violence homicides, the most helpful and most important questions to ask are the ones that we ask ourselves.

Prolonged Exposure Therapy, Is Reliving Past Trauma The Cure? – ELLE

In the latest issue of Elle, there is a terrific article on the cognitive behavioral therapy of prolonged exposure and its usefulness for treating Post Traumatic Stress Disorder "Prolonged Exposure Therapy, Is Reliving Past Trauma The Cure?" by Louisa Kamps. (I've blogged about prolonged exposure, and you can find that posting here.)

Kamps does a great service by informatively describing prolonged exposure, including the controversies about its use and its potential benefits for violence and trauma survivors. She also provides a brief, evidence-based explanation of why women are more likely to struggle with Post Traumatic Stress Disorder than men.

Kamps has wonderful quotes by leaders in the fields of prolonged exposure and Post Traumatic Stress Disorder, including Edna Foa, Stevan Hobfoll, and Patricia Resick.

Kamp's article is a terrific read for someone who does not know a lot about cognitive behavioral therapies, prolonged exposure or Post Traumatic Stress Disorder, but is interested in learning more.

Also, the article could be used when training sexual assault advocates and counselors. And therapists may find this article useful for educating survivors about prolonged exposure as a possible therapeutic strategy.

Violence Survivors Neglected in Health Care Debates

An important group of people who are often not mentioned in the health care debates (how health care should be delivered, who should receive it, and how it should be paid for) are violence survivors. As the controversy over health care increases, I worry about the lack of attention to survivors because research shows that women who have survived partner violence (also known as domestic violence) and sexual assault are far more likely to experience serious health problems than women who have not experienced violence.

(Note that the research shows that men who suffer violent victimization suffer fewer physical injuries than women. However, the research on the health effects of violence for men is limited. More research on this important topic is needed.)

For overviews of the research on the connections between health and violence, please see research by me and my colleagues, research by Dr. Jacquelyn Campbell, and this summary from the Centers of Disease Control and Prevention.

What are the health problems that survivors experience? Not surprisingly, partner and sexual violence often result in serious injuries, including broken bones, head trauma, and spinal cord injuries. Rape survivors are likely to have genital injuries. Even after such assault-related injuries have healed, survivors are likely to experience chronic pain disorders (migraines, pelvic pain, arthritis) and gastrointestinal disorders (stomach ulcers, spastic colon). Survivors also are likely to have reproductive health problems. And some research shows that survivors are at increased risk of hearing loss and heart disease. Survivors are also likely to have mental health problems, including depression, anxiety, posttraumatic stress disorder (PTSD), substance abuse, and suicidal ideations (thoughts about wanting to die or that life is not worth living).

With the many serious health problems survivors may experience, I'm concerned that so little attention is given to how survivors access health care and what types of health care are most helpful for survivors. For a research overview of the challenges that survivors face when they try to access health care see Dr. Stacey Plichta's excellent article. Plichta determined that partner violence survivors seek health care as much as other people, but survivors are less likely to receive the services that they need and more likely to have a poor relationship with their health care providers.

My worry about the neglect of survivors in the health care debate has been increased by a recent blog post reporting that domestic violence is a 'pre-existing condition' for insurers in some states (including my own state of North Carolina). Likewise, my colleague Dr. Sandy Martin and I have preliminary findings from a project to assess the needs of survivors who access domestic violence and sexual assault services. Our initial findings show that physical and/or mental health problems are a serious concern for nearly all the survivors. Further, these preliminary findings show that the majority of the survivors in this sample do not have health insurance.

Taken together, research shows that violence survivors are in need of health care but may not be able to access the services that they need because they lack the means and ways to pay for their health care. Personally, I find it outrageous that a person who experienced brutal violence may not be able to access needed health care. Beyond moral outrage, it seems to me that by not helping survivors with their health and safety, our society is likely incurring serious costs in the form of chronic health disabilities and lost productivity.

The Centers for Disease Control and Prevention report the costs associated with partner violence exceed 5.8 billion a year. I wonder how that number might be lowered if we were to ensure that every violence survivor received needed safety and health care services.

Trauma, Sleep Disorders and Treatments

I've been learning about how sleep disorders are often another health problem associated with violent victimization. To be honest, I had not thought much about how violent trauma may change survivors' sleep before now. Maybe this is true for others too? So I thought a brief summary of research on this topic may be useful to share with others here.

Though limited research has been conducted in this important area, the existing research shows an association among Post Traumatic Stress Disorder (PTSD), sleep disorders, and the experience of violence (see Kendall-Tackett's 2007 research). Violence survivors with PTSD are likely to struggle with sleep problems (see Caldwell's & Redeker's 2005 research).

Such sleep disorders may resolve once a survivor receives physical and behavioral care interventions that address disorders that underlie or exacerbate sleep difficulties such as chronic pain, substance abuse, depression, and PTSD. However, this resolution is not true for all survivors with sleep disorders, and many survivors will benefit from specialized sleep treatments.

When a violence survivor is identified in a physical or mental health care practice, Caldwell and Redeker recommened that the clinician should use a sleep hygiene checklist to assess the patient’s sleep. When paired with education about effective sleep hygiene, such assessments may improve a survivor’s sleep patterns. However, providers should also refer survivors to sleep centers if the survivor’s sleep patterns do not improve with either the implementation of sleep hygiene strategies or treatment for other health disorders.

Evidence-Based Mental Health Treatments for Violence Survivors

Advocates and human service providers may be interested to know that there are two behavioral therapies for violence survivors with Post Traumatic Stress Disorder (PTSD) that are supported with promising, positive findings from randomized controlled trials.

These two empirically supported therapies are based in cognitive-behavior therapy (CBT) theory. To help readers understand these therapeutic approaches, I provide a description of CBT.

Briefly, the theory of change underlying CBT posits that difficulties in human functioning stem from inaccurate, unhelpful beliefs or thoughts (i.e., cognitions) about the self, relationships, the world, and the future. A cognitive-behavioral therapist uses psychoeducational techniques, modeling, in-session therapeutic exercises, and between session homework to build a client’s cognitive change, emotional regulation, and behavioral skills in ways that address the client’s presenting problem. CBT has been widely researched and determined to be an effective practice with a range of presenting problems, including depression, anxiety, PTSD, chronic pain, and substance abuse.

Prolonged exposure is one of the most researched treatments for PTSD, and it has repeatedly demonstrated efficacy in the treatment of PTSD caused by various traumas, including women who have survived violent physical and sexual assaults (see Foa and colleagues’ research from 2005).

The prolonged exposure approach seeks to improve PTSD symptoms by using two therapeutic strategies. First, the therapist- in the context of a safe place and in a therapy session- has the survivor repeatedly imagine the traumatizing, violent event. Second, the therapist may have the survivor expose herself to real life situations that she tends to avoid because of the violent event. For example, the violence survivor avoids walking down a street in her community because that was the palce where she was attacked. This street would then become a site for real life exposure, either as part of a therapy session or as part of homework that the survivor would do outside of therapy sessions.

Prolonged exposure is usually delivered in 9 to 12 individual therapy sessions that are 1.5 to 2 hours in length. This therapeutic approach is implemented most effectively when (a) the therapist and client have established a strong therapeutic alliance; (b) the therapist has provided the client with a clear rationale for the treatment; (c) the therapist has successfully conveyed to the client both the potential usefulness of the treatment, and the therapist’s expertise in delivering the treatment; and (4) the treatment is tailored to the client’s situation and symptoms (see Hembree and colleagues 2003 article for how to implement this therapy). Moreover, prolonged exposure should be delivered when violence survivors are no longer in danger and are living safe, violence-free lives.

Second, Kubany and colleagues developed Cognitive Trauma Therapy for Formerly Battered Women (CTT-BW) based on the evidence regarding the effectiveness of CBT-based therapies for individuals with PTSD. Specifically, these researchers sought to develop this therapy because no such interventions specific to survivors of partner violence had been developed and rigorously evaluated.

CTT-BW is described as “a multi-component, cognitive-behavioral intervention aimed at alleviating PTSD, depression, guilt and shame, and elevating self-esteem in formerly battered women” (Kubany & Watson, 2002, p. 113). CTT-BW is usually delivered in 8 to 10 individual therapy sessions lasting 1.5 hours each. The sessions are conducted twice a week, and clients work on therapeutic homework between sessions. The therapeutic strategies of CTT-BW include (a) providing psychoeducational content about PTSD, (b) teaching stress management, (c) developing a woman’s cognitive skills to enable her to monitor and to modify unhelpful beliefs, and (d) imagined and in vivo exposure to the trauma.

Similar to prolonged exposure, CTT-BW is appropriate for women who are no longer in abusive relationships and who are relatively safe. Although the use of CTT-BW has led to improvements in PTSD symptoms among battered women in a randomized controlled trial (see Kubany and colleagues' 2004 research), limited experimental evidence exists for this therapy approach and additional research is warranted to establish the treatment’s efficacy.

This information may be helpful for advocates when they refer survivors to mental health therapist. Advocates may want to ensure that the therapists who they use as referal sources for survivors have training in evidence-based mental health therapies such as these.

Likewise, mental health therapist who work with violence survivors may want train in these therapies.

Sexual Violence in Adulthood: Connections to Women's Health

My colleague at the UNC School of Public Health, Dr. Sandy Martin, and I recently developed a research summary article for VAWAnet about the connections between sexual violence in adulthood and women's reproductive health, as well as the connections between sexual violence and high-risk health behaviors.

Sandy and I based this summary on the best available research published to-date. Advocates may find this summary helpful for their work with sexual violence survivors, program development, and/or grant writing.

You can download the entire summary either as a pdf or you can view it as a web page in html. A very brief summary of the article can also be found here.

I welcome comments or questions about this brief research summary.

Should the Locations of Domestic Violence Shelters Be Confidential?

A few weeks ago, a reporter with the Independent Weekly- Fiona Morgan- interviewed me about my research on domestic violence and sexual assault for an article she wrote about Interact's new model for safety and violence prevention. (You can find the article here.)

During the interview, Fiona asked me about whether it is a best practice to keep the location of a domestic violence shelter hidden. In other words, are survivors safer when the locations of domestic violence shelters are unknown to all except shelter staff and survivors?

On its face, the answer to this question seems like an easy "yes." However, I was surprised to learn that domestic violence advocates here in North Carolina have different opinions regarding what are best practices for handling information about where their shelters are located.

I recently conducted a project (funded by the North Carolina Governor's Crime Commission) to determine best practices for North Carolina domestic violence and sexual assault services. During this project I learned that some domestic violence shelters choose to have a confidential but not a hidden location. (A paper about this research is currently in press with the journal Violence Against Women.)

Having a confidential location means that though the shelter staff do not actively advertise the shelter location, the location is not kept completely hidden and secret.

Some domestic violence shelter advocates made a decision to have a confidential (rather than hidden) location for practical reasons.

In small and rural communities, it is difficult (or impossible) to keep the shelter hidden. Eventually people who live in a small community are going to find out where the shelter is located- no matter what staff and survivors do to keep the shelter hidden. Also, sheltered survivors may need to tell others about where they are living to go about their daily lives (for work, for education, to keep in touch with friends and family).

Some domestic violence shelter staff made the decision to have a confidential location for philosophical reasons. These advocates hold the belief that survivors should not have to "hide out" in their own communities. These advocates felt that having a hidden shelter implies that the survivor did something wrong, when in fact the perpetrator was the person in the wrong.

Though shelter staff decided to have confidential locations for many reasons, they all used similar strategies to maintain the safety of the survivors and staff at their shelters. Specifically, these shelters had strong security and safety protocols.

These advocates also looked toward their communities to help keep survivors safe and the shelter secure. As an example, the shelter staff developed positive, collaborative relationships with law enforcement. In these communities, police officers made it a point to drive by the shelter often on their regular rounds, as well as to respond quickly if they received a call from the shelter.

Interestingly, when I asked other domestic violence advocates about this idea of confidential shelter locations, I found strong disagreement. Some advocates feel strongly that shelters should make every effort possible to keep their locations hidden and secret for the safety of survivors and staff.

After my interview, I reflected on Fiona's important question. And I'm beginning to think that there may not be a one-size-fits-all approach to managing information about shelters' locations. It may be that in some communities survivors can only be safe when shelters are hidden. In other communities, survivors may be very safe even when the shelter location is widely known. I'm just not certain how to tell the difference between these types of communities.

Unfortunately, there is little research about what shelter-location strategies are best for keeping survivors and staff safe. Thus, this is a domestic violence service area in which advocates, researchers and survivors could usefully collaborate to help determine best practice guidelines for shelters.

What are others' ideas about this important issue? How does it work in your community?

HIV & Violence

I was recently invited to give a presentation on the connections between HIV and violent trauma. (You can find the power point presentation here.)

While putting this presentation together, I found that the latest research on HIV holds critically important information for those of working in the violence field. Overall, there are three connections between HIV and violent trauma.

First, violent victimization may trigger a risk pathway leading to HIV exposure. Though the precise risk mechanism is not known, there is a cluster of co-occurring risk factors for HIV, including victimization, risky sexual behaviors, and substance misuse (alcohol, drug).

Why are survivors of violence more likely to engage in risky sex and substance misuse? Those of working with survivors should always keep in mind that victimization often undermines a person's ability to cope with this trauma in helpful ways. Violent victimization may damage a survivor's ability to view the world in a positive way, to trust others, and to feel good about him or herself.

Once these positive views of the self, others and the world are taken away, a survivor may be less likely to use helpful ways of coping, such as seeking out the support of friends and family, or seeking help from healthcare providers or counselors. With fewer positive ways of coping available, a survivor may be more likely to use risky ways to manage the feelings and thoughts from the violence, such as substance misuse.

Second, survivors with HIV are challenged by Highly Active Antiretroviral Therapy (HAART) adherence. The "fallout" effects of violent victimization, including depression, anxiety, substance misuse, can get in the way of a survivor's ability to keep medical appointments and adhere to a medication regime. Also, survivors may be less likely to engage with health care providers because victimization undermines their positive views of others- including doctors, nurses, counselors and other providers- as helpful and trustworthy.

Third, violent victimization may accelerate HIV diesease progression because the psychological responses to violence affect survivors' immune functioning. Also, if a survivor is misusing alcohol and drugs, these substances may also erode immune functioning.

To best help survivors, we should be mindful of the context in which violence and HIV occur. As an example, the stigma of HIV is another stressor that survivors must manage. Also, survivors may be dealing with other forms of oppression (heterosexism, ablism, racism, gender discrimination). Some surviviors with HIV may also be struggling with poverty. Finally, most surviviors are trying to access HIV treatment from healthcare systems that are overburdened and overwhlemed.

How can violence advocates help surviviors with HIV? First, we should call for universal screening of violent victimization in healthcare settings. When violence survivors are identified, healthcare providers should be prepared to coordinate their services with their local domestic violence and/or sexual assault program. Here in my state of North Carolina these programs can be found through the North Carolina Coalition Againist Domestic Violence and the North Carolina Coalition Againist Sexual Assault.

Second, we should call for greater use of trauma-informed healthcare practices. Trauma-informed care means that healthcare systems and practices are adapted to account for patients' experiences of violence and trauma to help surviviors better engage with and fully benefit from their healthcare. Rather than expecting surviviors to adapt to traditional healthcare structures and practices, trauma-informed services are welcoming, accessible and managable for survivors. Such practices may significantly help survivors with HAART adherence, for example.

Third, we should encourage the use of evidence-based practices for violence surviviors, such as Seeking Safety and Prolonged Exposure Therapy wherever appropriate and relevent.

Preventing Family Violence: The Challenges of Collaboration

A couple of weeks ago I was asked to do a briefing on family violence prevention (by "family violence" I mean child abuse and partner/domestic violence, including psychological, physical and sexual abuse).

You can see the power point slide show at my slideshare page here. (Though it did not upload as cleanly as I would have liked, so email me if you'd like a copy of it.)

Since the presentation, I've been thinking about how challenging preventing family violence can be. I remembered a research interview I did with a director of a sexual assault agency here in North Carolina about some of these challenges.

The director and I were talking about her agency's prevention programs. One of the programs she thought was very successful for her community was a high school-based prevention program that used educational and interactive seminars with teenagers . (This was one of the rare communities where the sexual assault program had a collaborative relationship with their local high school.) The director told me how disappointing it was that the school recently told her that her agency's prevention staff could not have time with the students any longer because the school needed to spend more time working on the students' standardized testing skills.

I remembered this conversation as I developed my prevention briefing. This director's experience with the school underscores the challenge of family violence prevention. Preventing family violence is difficult because so many organizations and people- who have very different goals and priorities- have to work together to deliver prevention strategies and to make these strategies work successfully.

Research shows that there is no one-stop, quick, silver-bullet solution to family violence prevention. Effective strategies for preventing family violence take time and collaborative work from many people and organizations.

Research also shows that high schools are a great place to target family violence prevention efforts. The time when most of us first experience relationship/dating violence or sexual assault is in our adolescence. If we wait to deliver prevention programs to young adults after high school, we are too late to prevent anything.

Also, most promising prevention strategies for family violence are for teenagers. As a teenager you are just beginning to date and develop relationships for the first time. It's a perfect time to learn that it's not okay to hurt someone you love. It's also a perfect time to learn that if someone you love is hurting you, you do not have to live with the abuse and that you can get help to end the violence. So if we want to prevent family violence, our best best is delivering prevention strategies to high school and junior high school students.

Schools are a great place to deliver these preventions because the kids are there all in one place (for the most part). But- as the story above shows- delivering family violence preventions in high schools is challenging to do because it takes collaboration from other community organizations and because schools have other priorities and goals.

This not to say that these priorities and goals are not worthy ones. (Though improving a student's standardized testing skills may be debatable).

Nonetheless, research shows that a quarter of women in the U.S. will experience partner violence, and a quarter of U.S. adults (women and men) tell researchers that they experienced abuse when they were children. More and more research shows the horrible and grave costs of such violence. Given how widespread family violence is and given the serious costs, it seems that preventing family violence should be a priority, too.

We are unlikely ever to know fully what happened between Chris Brown and Rihanna. Still, I can't help but wonder if they both received family violence prevention information and skills in junior high or high school, would be hearing more about their music and less about their relationship now?

Sexual Violence Linked to the Many Forms of Human Misery

After reading a recent blog posting by Josh Ruxin on the growth of sex tourism and child sex trafficking in Mombasa Kenya, I've thinking about how sexual violence (including sex trafficking, which I see as yet another form of sexual violence) is inextricably linked to many forms of human misery, including catastrophe and disaster, war, poverty and tyranny.

Now comes another article from the New York Times by Barry Bearak that highlights the plight of women and children fleeing from Zimbabwe into South Africa to escape the disease and despair of their home country. Bearak reports that many of these children are orphaned because of the recent cholera epidemic in Zimbabwe, as well as the ongoing political instability there. He describes how, while trying to scrape together a meager subsistence in South Africa, these women and children are victimized by brutal gangs of "swindlers, thieves and rapists." Further, Bearak's article makes the point that many of the girls who find their way to South Africa may be swept up into prostitution and sex work to survive and because of their vulnerabilities (i.e., no food, shelter, protection).

Reading these articles, I find myself overwhelmed at the horror of children, as well as young women and men, struggling every day for survival who are also brutalized by sexual violence and sexual traffickers.

To offer some remedies for these problems, Ruxin describes the importance of government policies as a way to end sex trafficking. Ruxin argues that government policies that enable families to economically support themselves help prevent sex trafficking by protecting children and young adults from economic and social insecurities.

Further, Ruxin states that social and governmental corruption fuel the sex trafficking industry. Corruption exacerbates poverty, which in turn makes children and young people vulnerable to sex traffickers. I imagine that corrupt governments are more likely to turn a blind eye to sex trafficking, too.

Likewise, it is interesting to note in Bearak's article that the South African police are overwhelmed and have few solutions for how address the sexual violence and other crimes against the children from Zimbabwe who have fled to South Africa. Without the policies and laws in place that Ruxin recommends to protect these vulnerable refugees, it is likely that the Zimbabwe children in South Africa will continue to be sexually victimized even as they struggle to survive.

Certainly, these are just two recent examples of the connection sexual violence has to many forms of human misery. Clearly, anti-poverty programs and anti-corruption policies to promote stable, working governments are part of the answer to help address these various forms of human misery, including sexual violence and sex trafficking. However, it also seems that those of us working to end sexual and partner violence should play a bigger role in the development of anti-poverty and anti-corruption efforts locally in our own communities, as well as globally.

My impression is that those of us advocating for an end to sexual, partner and family violence are not always at the table when it come to developing programs and policies to end poverty and social instability. Yet these two articles show that violence is part and parcel of many forms of human misery.

Could those of us who are working to end violence also collaborate to develop solutions for these related problems of human misery? Perhaps we already are? If readers know of examples of such efforts, I would welcome the opportunity to learn more.

Dating Violence

The New York Times published an article last week by Elizabeth Olson about the rise in dating violence.

One important point about dating violence that was not raised in the article is that there is an evidence-based intervention to prevent dating violence. (Unfortunately, there are few evidence-based prevention programs for domestic violence and sexual violence). This prevention program is called Safe Dates and is listed on the SAMHSA registry of evidence-based programs. Dr. Vangie Foshee at the UNC School of Public Health has been the lead investigator in the efforts to develop and study this prevention program.

The description on the SAMHSA site states: "Safe Dates is a program designed to stop or prevent the initiation of emotional, physical, and sexual abuse on dates or between individuals involved in a dating relationship. Intended for male and female 8th- and 9th-grade students, the goals of the program include: (1) changing adolescent dating violence and gender-role norms, (2) improving peer help-giving and dating conflict-resolution skills, (3) promoting victim and perpetrator beliefs in the need for help and seeking help through the community resources that provide it, and (4) decreasing dating abuse victimization and perpetration."

Given the serious consquences of dating violence- as the Times' article highlights dating violence can result in young women's deaths- it is unfortunate that Safe Dates is not provided in more communities. Though I hear from advocates who provide prevention programs that it can be very challenging to gain access into schools to provide prevention programs like Safe Dates.

So I am wondering if others have had success in gaining access to schools to provide prevention programs like Safe Dates? If folks have had success, how was this accomplished?