Aftercare Services for International Sex Trafficking Survivors

Increasingly, I've been hearing from human service providers in North Carolina communities that they are being asked to offer help to international sex trafficking survivors who have been rescued or escaped from traffickers. These providers include child protection workers, domestic violence advocates, sexual assault advocates, as well as social workers in many settings (e.g., health care, mental health, substance abuse). These providers also describe the challenge of trying their best to help vulnerable trafficking survivors with little guidance about best practices. Providers want to help survivors to recover and live safe, independent lives. However, providers are not always certain about what services to offer because survivors' problems are so complex and traumas so severe.

To help address these important information needs, Natalie Johns and I conducted a research study. This research was recently published in the journal Trauma, Violence and Abuse. You can find the article abstract here and download the article here.

Here I want to mention that when we worked on this research, Natalie was a graduate student in the UNC at Chapel Hill Schools of Public Health and Social Work. Natalie's interest in and passion about this topic helped to galvanize my own interest in and commitment to the issue of sex trafficking. So, this research also shows how creative and productive collaborations between faculty and students can be.

For this study, Natalie and I systematically reviewed and synthesized 20 documents addressing the needs of and services for international survivors of sex trafficking into the United States. Through this work, we found that trafficking survivors need a continuum of aftercare services to address their changing needs as they move from initial freedom to recovery and independence. From these research findings, we created a service delivery framework to help providers with developing programs for survivors. We hope that this framework will be useful for human service providers throughout the United States who are trying to develop new programs for trafficking survivors in their communities.

Our research findings also showed the many challenges human service providers will face in developing such programs. For example, we need increased policy attention about how best to fund all the aftercare services that trafficking survivors will need. Our study also showed how little research attention has been given to evaluating existing aftercare service delivery programs. We also encourage anti-trafficking advocates, service providers, and policy makers to collaborate with researchers to evaluate aftercare programs whenever possible.

The Survivor-to-Survivor Project

Partner violence is a complex, frightening and overwhelming problem. For those seeking safety, it can be difficult to know where to begin, what to do, and how best to seek help. Likewise, family and friends who are concerned about partner violence survivors often want to offer help, ideas and resources. However, like the survivors themselves, family and friends do not always know where to turn or what to do.

Fortunately, a new website can help survivors, as well as their family and friends with such information. The web-based, Survivor-to-Survivor project began because three North Carolina partner violence survivors wanted to ensure that others who are seeking safety would have readily accessible, helpful information. The Survivor-to-Survivor project aims to help survivors understand and navigate the complex systems that offer help and resources, including the court and legal systems, domestic violence shelters, and victims' compensation.

The Survivor-to-Survivor project is a documentary-style resource guide designed to provide a visual toolkit of North Carolina partner violence help and resources. The website provides information on safety planning, children and partner violence, and a detailed list of resources. The website also provides tailored information to specific groups of partner violence survivors, including survivors in military communities, survivors with disabilities, and Native American survivors, as a few examples.

Partner violence survivors, as well as North Carolina partner violence experts, helped to develop this web-based resource. However, without the outstanding work and dedication of its directors, this project would never have happened. Cynthia Hill, who is an award-winning Durham-based documentary filmmaker, directed the project. Janeen Gingrich, who is the Director of Development at Legal Aid of North Carolina, is the project's co-director. (Detailed information about the project directors, funders, and production team can be found here.)

A considerable challenge to ending partner violence is informing survivors about the available help and resources. The wonderful Survivor-to-Survivor project is another way that we can all spread the word that it is possible to live safely and free from violence.

 

Acknowledgments

In every published research article there is a space to recognize the people who helped make that particular research study possible: The Acknowledgments. Typically, the people that get a mention in the acknowledgements are colleagues who helped with the research by offering a good idea or by reading a draft of the article and providing feedback.

Interestingly, the people that rarely get a mentioned in this section of the paper are the people who participated in the research. So, the acknowledgements section of scientific article is an interesting and funny place. Of course, I should acknowledge my wonderful colleagues who help me with my research. However, without people who are willing to fill out my surveys, provide their opinions, or participate in my research interventions, my studies could never happen.

Often there are very good reasons not to name participants in the acknowledgements or in any part of a research article. Protecting participants' confidentiality and anonymity is critically important in most studies. Such protections are paramount in my research, which is concerned with violence, victimization and survivorship. Still, there are times when I wish I could publically say "Thanks!" to my participants. From my point of view, research participants are the unsung heroes of science.

Recently, I had one of those times when I wanted to acknowledge and say "thank you" to a group of participants. I had a research article published in the journal Violence Against Women. The article described the findings from an exploratory, qualitative study that provided information about helpful, promising practices in domestic violence and sexual assault services. The article reported on findings from 14 in-depth interviews with North Carolina domestic violence and sexual assault agency advocates and directors.

In these interviews, I asked advocates and directors their opinions about what services are most helpful for survivors. After analyzing the data, my research team and I determined findings about (1) critical services for survivors; (2) essential service delivery practices; (3) ideal services that are challenging to deliver because of funding and other barriers; and (4) areas of service delivery practice uncertainty due to a lack of best practices. If you are interested in this study and the research findings from this article, you can read the full piece here.

What I did not get to say in this article is how incredibly helpful and essential the 14 participants were to this research study. Clearly, I could not have conducted this research without the 14 advocates and directors who were willing to give me their time and opinions. Equally important was how welcoming and friendly each of the participants was to me. None of these research participants knew me well and most did not know me at all before I invited them to participate. However, they were all willing to give me their time, as well as their honest opinions and insights.

Beyond the findings presented in this research article, these 14 participants also gave me insights and understandings into their daily lives and their work. Before I conducted this study, my comprehension of what it takes to provide safety services day-in-and-day-out was limited at best. These study participants educated me about the challenging realities of their work, as well as the incredible sense of accomplishment that they have after a job well done.

I can never name or publically acknowledge these participants. As part of my research protocols, I promised all that their participation in this study would remain confidential. Nonetheless, I still would like to thank them here- as publically as possible- for their participation in this study. I would like to give every one of you heartfelt thanks for your participation in this research. Your time, insights and opinions enabled me to write this research article. More importantly to me personally, your participation helped me to understand how important our community-based domestic violence and sexual assault programs are. So thank you all very much.

 

Hope for Children

Ever have one of those weeks where the same challenging issue keeps coming up? For me, the question of how to best help children exposed to domestic violence came up in three different meetings this week. Unfortunately, I did not have a helpful to answer to offer the folks asking me this question.

Are there best practices and programs to help children who witness domestic violence in their families? Unfortunately, little research exists to help guide programs and practices to address this important need.

Why are programs and practices to help children exposed to domestic violence so important? Research shows that 1.3 million women in the U.S. experience physical violence from a partner each year. Much of this partner violence is occurring in families where there are children who are exposed violence. Children who witness their parents/caregivers violence perpetration and victimization are more likely (than children who have not had this experience) to have problems with their emotions, in their peer relationships, as well as problems at school. Specifically, other research shows that for children who are exposed to domestic violence nearly 63% fared worse in behavioral, academic, and social functioning than the average child who has not been exposed to such violence. So we need evidence about works to help keep children safe from domestic violence.

Though there isn't much research on this topic and though robust, evidence-based practices to help children exposed to domestic violence don't exist, there are programs and agencies across the U.S. offering innovative and promising programs to children and their families.

I had the terrific opportunity to collaborate with one these programs. In Wake County, North Carolina three agencies joined in a collaborative effort to provide services to children whose families have been affected by domestic violence. The three agencies are Interact, SAFEchild, and Triangle Family Services. These three agencies joined in a collaborative effort to provide services to children whose families are burdened with the problem of domestic violence. The three agencies shared a vision that children in Wake County could have access to a coordinated and comprehensive continuum of age-appropriate services to help them overcome the negative psychological, social, and emotional health effects that are caused by exposure to domestic violence. The agencies named this program Hope for Children.

I collaborated with these agencies to evaluate this innovative program. I've posted the full evaluation report on the web. I've also developed two short briefs based on the findings from this research. One brief highlights the practice and service findings from this research, and the other highlights the program development findings.

This research takes a step in the right direction. But much more work needs to be done before we have a good idea about what works to make a difference in the lives of children exposed to domestic violence.

Are there innovative, promising programs to address the needs of children in your community?

Challenges Facing the Anti-Domestic Violence & Anti-Sexual Assault Movements in North Carolina

Early in the anti-domestic violence and anti-sexual assault movements, advocates, researchers and movement leaders expressed concerns about whether grass-roots, community-based domestic violence and sexual assault programs would endure. The anti-domestic violence and anti-sexual assault programs that developed from the movements were founded on feminist and empowerment philosophies. As a result, these programs tend to: (1) focus on social change and social justice; (2) have nonhierarchical administrative and decision-making structures; and (3) rely extensively on volunteers.

Many advocates and movement leaders thought (and still think) that these programs characteristics were (and still are) positive. However, many also worried that these same positive program characteristics may also threaten service survival. That is, would the need for stable program funding from governmental agencies, for example, mean that these organizations would drift away from their social change and social justice missions? Or, would the need to develop program legitimacy mean that professional staff would be recruited to provide services to the exclusion and displacement of volunteers?

Since that time, these movements and the issues of domestic violence and sexual assault have evolved considerably. A key example of one such change is the federal Violence Against Women Act (VAWA), which provides increased funding for domestic violence and sexual assault services. Given the questions about programs' sustainability, as well as the changes that have occurred in the past 20-30 years since the beginning of the movements, my research team and I thought it was important to investigate the challenges domestic violence and sexual assault program face today. Are the anti-domestic violence and anti-sexual assault movements experiencing the challenges that the movement leaders predicted?

To help answer this question, my research team and I conducted an exploratory, qualitative study, including 7 focus groups and 12 in-depth interviews with North Carolina (NC) domestic violence/sexual assault agency directors, NC state-level funding staff, and NC state-level advocacy staff. Through this research, my team and I sought to identify the current challenges facing the NC domestic violence and sexual assault movements from the perspectives of agency directors, funding staff, and advocacy staff. The findings from this research have recently been published in the Journal of Interpersonal Violence and you can find our research paper describing the study and its findings here.

Briefly, our research found that the North Carolina anti-domestic violence and sexual assault movements are struggling with four challenges that were indeed anticipated by the leaders of the movements over 20 years ago. These four challenges are: (1) inadequate and inconsistent funding to sustain core services (e.g., crisis hotlines, advocacy); (2) program sustainability, which relates to the challenge of funding; (3) community norms that make it difficult to help violence survivors with safety; and (4) ongoing tension between grassroots versus professional service providers.

In addition to these four challenges, our research also discovered three additional, unanticipated challenges. These challenges are: (1) lack of attention to and resources for the problem of sexual assault; (2) the need for welcoming services for all survivors regardless of their racial, ethnic, and cultural backgrounds, sexual orientations, disabilities, and immigration statuses; and (3) the need for comprehensive services to help survivors with co-occurring mental illnesses and substance abuse problems.

This study was limited to North Carolina, but the findings leave me wondering if the movements in other states are experiencing similar challenges. If this is the case, and given the prevalence of the domestic/partner violence and sexual assault in the U.S., those of us who are actively working in the movements today have our work cut-out for us. I encourage those of you who are interested in addressing these challenges to read the full research article. Though the research participants identified many challenges, they also recommended many potential solutions. These possible solutions may lead to ideas for tackling the challenges we face today.

Though this study's findings were- in many respects- discouraging, I want to convey that I did not find this research completely grim. Rather, I was heartened by the people who participated in this study, including the domestic violence/sexual assault directors, advocates and funders. I found it uplifting to see so many dedicated women and men working steadily to end domestic violence and sexual assault even in the face of these ongoing challenges.

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.