Friday, August 14, 2009

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.


Michele said...

This is a great overview. But what if a survivor doesn't want to approach healing this way?

I'm wondering your thoughts on other methods, i.e. information processing therapies, or hypnosis and neuro-linguistic programming.

Any thoughts on these as viable and effective methods of healing trauma?

Rebecca J. Macy said...

Hello Michele. Thanks for reading my blog and thanks for posting! Great question and terrific comment!!

Unfortunately, there just has not been much research on treatments and interventions for survivors of violence. So we don't have much evidence about "what works" to help survivors heal from trauma, as well as overcome mental health problems that stem from violence.

What I've summarized here in this posting are some treatments with promising evidence based on rigorous research findings or the "gold standard" for research studies as far as academics (like me) are concerned. (By the way, both of these treatments emphasize trauma processing, which is a type of information processing therapy.)

That said, just because research has not been conducted on other forms of therapies (you listed some terrific ones, hypnosis and NLP as examples), doesn't mean that these therapies DON'T work for violence survivors. It just means that researchers (like me) have not conducted a study and published our findings yet.

Advocates, clinicians and other providers may use other therapies besides the ones I highlight with great success to help survivors. But we need more evidence about "what works." So I hope more researchers will collaborate with survivors and advocates to investigate promising practices that don't yet have evidence.

Also, though I do a pretty decent job of keeping on top of the new research, it is certainly possible that I've missed a newly published study on one of the therapies that you mention.

Your question also raises another important point. I agree that advocates and clinicians should always give survivors as much choice as possible over their own treatment. Ultimately, the survivor is the best judge of what works for her or him.

So though these therapies may be based on research and evidence, it does not mean they are the "right" treatments for every survivor. When we provide mental health treatments to survivors, we should offer different therapeutic approaches and let them survivor guide the treatment.

Again, terrific comment! Thanks for reading my blog. best wishes, Rebecca