Tuesday, November 17, 2009

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.