Intimate partner violence: A group cognitive-behavioral therapy model
By Kacey Sax, MA
The Centers for Disease Control and Prevention (CDC) defines intimate partner violence (IPV) as physical, sexual, or emotional/ psychological abuse as well as threats of violence between two people in a close relationship. It “exists along a continuum from a single episode of violence to ongoing battering” (CDC, 2012, p. 1). Effective treatments and standards of care are necessary for victims of IPV as research has shown that such violence can have long-term effects on the physical and emotional well-being of the individual. Additionally, the CDC reports that IPV can directly affect the well-being of society; namely, in 2003, $8.3 billion was spent on the medical and mental health care of victims of physical and sexual assault. Additionally, victims of this type of violence lose 8 million days of paid work and 5.6 million days of household productivity on average every year (CDC, 2012). According to the findings of the National Violence Against Women Survey funded by the National Institute of Justice and the CDC in 2000, IPV is the most common type of violence against women. This survey found that 7.7 percent of women were sexually abused and 22.1 percent were physically assaulted by either a current or former intimate partner at some point in their lives. This report projected that over a 12-month period, 201,394 women are raped and 1.3 million are physically abused by a romantic partner (Tjaden & Thoennes, 2000). The current study will focus on a treatment program that may be useful for victims of IPV that have already left the dangerous environment.
Research has found that group therapy can be a useful means for treatment with a population of women who have endured IPV. Walker (1991) stated that “[outpatient groups] are often a useful adjunct to individual psychotherapy as the woman can learn from others’ experiences as well as her own. Participation in the group also helps rebuild the woman’s trust in other women and makes it easier to re-establish friendships” (p. 27). Additionally, women learn that they do not have to be dependent on or give in to others to feel safe. Beyond that, group therapy techniques such as role play educate women on how to take control in a relationship without use of manipulation. Techniques used in group therapy are effective in promoting successful expression of anger, teaching women that they can express themselves without being abused or judged (Walker, 1991).
While individual counseling is effective for women who have experienced IPV, being around others who genuinely understand their pain will likely prove beneficial in their treatment progress and perceived feelings of support (Johnson & Zlotnick, 2009). Many—if not all—individuals who suffer from a traumatic experience such as abuse can benefit from knowing that they are not alone in their struggle.
Key Aspects of Group Cognitive Behavioral Therapy Designed for Victims of Intimate Partner Violence
There are several research studies that report the effectiveness of utilizing Cognitive-Behavioral Therapy (CBT) to address the development of Post-Traumatic Stress Disorder (PTSD) and related mental health symptoms that often result from IPV and related traumas. Specifically, Ehlers and Clark (2000) found that targeting clients’ core beliefs is crucial to understanding how they are currently coping with the trauma they have experienced. Further, studying how the individual negatively appraises the trauma also provides important information for their symptoms. Therapeutic interventions that address one’s core beliefs about herself and her trauma are effective in decreasing the effect of the trauma on the client’s daily functioning. Specifically, modification of cognitive appraisals and addressing maladaptive coping strategies (such as manipulation) have been found to reduce PTSD symptoms (Ehlers & Clark, 2000). This CBT approach also increases the clients’ ability to process information successfully, which then enhances the formation of a healthy belief about the self and the future (Ehler & Clark, 2000).
Johnson and Zlontnick (2009) used a CBT approach to promote client safety, empowerment, coping skills, and interpersonal relationships. The intervention, “Helping to Overcome PTSD Through Empowerment (HOPE),” was provided to women living in domestic violence shelters. By targeting a client’s sense of control, power, safety, self-esteem, and intimacy, the intervention was able to decrease the severity of the client’s PTSD and depression symptoms as well as increase personal and social resources for the client. These results were maintained for six months after the CBT intervention was complete.
There are several facilitation issues that could arise when implementing group therapy with such a vulnerable population. Care should be taken when choosing group facilitators. If a male facilitator is selected, there may be issues regarding the female group members building rapport with and establishing trust in the group facilitator. There will likely be resistance towards opening up to a male specifically because they have been abused by males in the past. Another potential issue to consider is that women in the group could become more dependent on male leaders. They may try to be what they perceive the therapist wants or expects them to be in order to avoid potential abuse. Female clients may also feel as though they have to manipulate male facilitators to gain control, since this is what they have learned to do in the relationship with their abuser (Walker, 1991).
If a male facilitator is able to take the time to form a trusting relationship, a very powerful therapeutic alliance could occur between the woman and that facilitator. For example, she may learn that she can express anger without being abused. Also, a trusting relationship with a man would provide the woman a safe place to practice taking control by using adaptive communication techniques.
Although the focus above is on the potential difficulties with male facilitators, women who have experienced IPV may also have a difficult time trusting women group leaders as well. There will likely be clinical resistance to opening up and letting anyone into their lives given the heightened vulnerability and fear of this group. Each group member has been in a relationship where her control and safety were taken away. It will be difficult for a facilitator of either gender to gain the trust of the clients.
It may also be a potential challenge to facilitate trust and rapport between the group members. In this regard, it will be important for the group facilitators to create a safe place for the women to express themselves and practice new skills.
Overview of the Proposed Treatment Group
The purpose of the group discussed in this paper seeks to promote the short-term safety and long-term functioning of female victims who have experienced intimate partner violence. In broad terms, the group will address the following areas: the victim’s tendency towards manipulation; control; interpersonal issues; and mood-related factors such as anger, anxiety, and depression. More specifically, the group will be focused on increasing feelings of safety, goal-setting behaviors, and coping skills. Additionally, the group will move towards increased social support and trust in others, and will learn new communication skills to enhance their ability to effectively express and control anger.
There are several goals that are hoped to be achieved as a result of the group work. The primary goal is for the group members to gain a better understanding of IPV and its effects. Second, it is anticipated that group work will promote selfunderstanding so the women do not return to an unsafe environment. Overall, it is expected that, after the 15-session group therapy experience, the group members will report decreased PTSD symptoms, decreased depressive symptoms, increased social support and a greater awareness of themselves (e.g., strengths, weaknesses, interests, core beliefs and fears).
Group members. The group will include 10-15 women between the ages of 25 and 45. Having a small group of adult females with similar trauma experiences will help to achieve the goal of helping the clients work to create rapport and trust in group members. Additional inclusion criteria are as follows: 1) women who have left their abuser for more than one month, 2) women who are currently living in a women’s shelter or similar agency, and 3) women who meet DSMIV- TR criteria for PTSD. Women will also be screened for other mental health issues such as depression or other anxiety disorders; these women will be included in the group as long as they also meet the criteria for PTSD. Women who present with psychotic features, severe dissociation, or bipolar with active manic symptoms will not be included in the group. Additionally, women will be screened for other potential risk factors such as socioeconomic status, number of children, level of social support, education level, and employment status. This will not have a bearing on whether they are included in the group. Instead, these variables will be important to note so that it does not confound the results when an effectiveness study is performed after the group’s termination.
Group facilitators. Each therapy group will have two master’slevel facilitators who will run the weekly sessions. In each group there will be both a male and female facilitator so as to 1) make the clients feel more comfortable easing into the therapeutic experience with a woman and 2) help them to develop trust in the opposite sex. The facilitators will receive weekly training and supervision from doctoral-level clinicians to ensure that all therapeutic protocols are being met.
The initial objective of the group facilitators is to create group cohesion so the women feel comfortable sharing their stories. They will demonstrate a non-judgmental attitude to maintain a safe place for the women to discuss painful memories and emotions. At the beginning stages of treatment, they will provide psychoeducation to the clients regarding the development and maintenance of PTSD symptoms as well as information about IPV and related outcomes. Further, facilitators will teach coping skills and communication techniques, and allow appropriate space for women to discuss and practice with other group members. As treatment progresses, facilitators will be responsible for executing therapeutic techniques; for example, they will create role play situations between group members to increase ability to express anger, desensitize the previous trauma, and create trusting relationships. Most importantly, after the facilitators teach relevant skills, they will allow the group members to interact without much interference, as it will be important for them to learn effective interpersonal skills.
PTSD Symptom Scale—Interview (PSS-I; Foa, Riggs, Dancu, & Rothbaum,1993). The PSS-I is a 17-item questionnaire measuring re-experiencing, arousal, and avoidance on a Likert-type scale ranging from 0 (not at all) to 3 (5 or more times per week); 0 = not at all, 1 = once per week, 2 = 2-4 times per week, and 3 = 5 or more times per week.
PTSD Symptom Scale—Self-Report (PSS-SR; Center for the Treatment and Study of Anxiety, University of Pennsylvania. (n.d.). The PSS-SR is a 17-item questionnaire measuring reexperiencing, arousal, and avoidance on a 0-3 Likert scale; 0 = not at all, 1 = once per week, 2 = 2-4 times per week, and 3 = 5 or more times per week.
Post Traumatic Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997). The PDS is a 49-item self-report measure recommended for use in clinical or research settings to measure severity of PTSD symptoms related to a single identified traumatic event.
The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996). The BDI-II will be used to measure severity of depression symptoms.
The Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988). This scale measures perceived adequacy of social support from three different sources: family, friends, and significant others. The MSPSS consists of 12 items that are rated on a 7-point Likert-type scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). Four items are dedicated to measuring perceived social support from each source, and the MSPSS measures the adequacy of support from three sources: family (items 3, 4, 8, 11), friends (items 6, 7, 9, 12) and significant other (items 1, 2, 5, 10).
Self-Understanding and Personal Growth Scale (Sax & Treadwell, 2012) . This scale was designed by the group facilitators and supervising clinicians, to be administered to the women regarding their level of self-understanding based on core concepts that were the focus of the group therapy. A greater understanding of strengths, weaknesses, interests, core beliefs, and fears will be measured using a 5-point Likert scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree).
In order to determine the effectiveness of the group treatment, these seven measures will be given at the beginning of the first session, post-treatment (Session 15), and three months following the completion. During Session 15, group members will also be asked to give any feedback to the group facilitators regarding aspects of the groups they liked or disliked and whether there were specific skills or symptoms that were not targeted by the current group.
Group format. The group will meet twice per week for a total of 15 sessions. Each session will be 1 hour and 30 minutes in length to allow time for every member of the group to practice learned skills. Over the course of the 15 sessions, the group facilitators will work with clients from creating preliminary treatment goals at Session 1 to creating a discharge plan at Session 15; the group members and facilitators will be an active part of each stage of the group therapy experience.
Treatment techniques. This group for women who have suffered from IPV will utilize CBT-based techniques to increase important skills and insight. Walker (1991) found that addressing a victim’s manipulation and control issues, dissociation, anger, issues with intimacy, and feelings of vulnerability are crucial to her treatment. CBT techniques such as thought-stopping, Automatic Thought Records (see Greenberger & Padesky, 1995), and role playing will allow the facilitators to address the woman’s core beliefs about herself, challenge dysfunctional thinking, and modify the cognitive appraisals associated with the trauma. Lastly, CBT will allow the group to identify maladaptive coping strategies and replace them with healthy coping and communication strategies.
Treatment format. This group therapy will follow a similar format to the HOPE program referenced in Johnson and Zlonick (2009). Session 1 will focus on rapport building between group members and group facilitators. As a way to promote empowerment and control over her treatment, each group member will share why she is in group and her individual goals for treatment. Continuing on the work from Session 1 regarding the promotion of group rapport and trust, during Session 2 the group members will begin to work in groups of 3 to discuss their personal experience with trauma. Additionally, Session 2 will focus on creating a detailed safety plan for each individual. The facilitator will first discuss the important aspects of an effective safety plan. According to the National Center of Domestic and Sexual Violence (NCDSV), safety plans should be personalized and contain detailed information regarding multiple different scenarios that could occur. For more details on safety planning, please visit the NCDSV website. Members of each small group will give and receive help in creating the safety plans for each member.
Sessions 3 and 4 will focus on empowering the group members by providing psycho-education about the development of PTSD and other short- and long-term effects of IPV. Knowledge is viewed as power; the better the women understand their current situation, the more control they have over it. The clients will be given relevant handouts and worksheets regarding symptoms and effects related to IPV. It is intended that this educational component will have a secondary effect of providing group cohesiveness so members do not feel like they are the only one suffering from previous trauma.
During Sessions 5 through 8, facilitators will utilize CBT techniques to teach the group members about schemas, core beliefs and how these concepts can affect one’s emotions and behaviors. Facilitators will teach group members how to complete Automatic Thought Records (Greenberger & Padesky, 1995) as an effective way of challenging negative beliefs about themselves and their traumas. It is likely that most of the women in the group will endorse core beliefs that they are unlovable, do not deserve to be happy, or feel that they are too weak to leave a relationship, so facilitators will point out these beliefs to the group. Facilitators will also highlight any themes that arise regarding cognitive appraisals of the traumatic event, such as victim thinking.
Small group work and large group facilitation will be utilized throughout these sessions to further increase the group’s comfort with one another and with the facilitators.
Sessions 9 through 10 will focus on having the facilitators and group members work toward identifying what triggers memories, flashbacks, and anxiety or avoidant behaviors. From there, group facilitators will identify which maladaptive coping strategies group members have used in the past to deal with these triggers. Effective coping strategies and communication techniques will be taught during these sessions, and the group members will have the opportunity to discuss with the group their success in using these coping strategies outside of the sessions.
Sessions 11 through 13 will capitalize on the feelings of trust and safety the group members have developed over previous sessions. These sessions will focus on role-playing techniques to address healthy expression of anger and other relevant emotions such as pain and resentment. Each group member will have a chance to role play with other members of the group. As the group dynamics develop over the previous 10 sessions, the facilitators will make a judgment regarding an issue each client should work through in a role play; however, to promote control and empowerment, the ultimate decision about the role play will be left up to the individual client. The client is able to make the decision about what emotion or situation they would like to address as well as which group members they would like to use. Psychodramatic techniques will be utilized in the role-playing sessions (see Karp, Holmes, & Tauvon, 1998). Group members will play several roles, including client doubles, client alter-egos, client life-roles, and important people in the client’s life. Each client will have the opportunity to utilize effective coping strategies and communication techniques to express their emotions and work through their issues.
Sessions 14 and 15 will be the termination sessions. Clients will have the opportunity to express what they feel they have gained from the group therapy experience. The facilitators will praise the clients for the growth and point out their newly found strengths in order to promote control and confidence in their abilities. Each client will review their safety plan and make changes as needed. Facilitators will make any necessary referrals if a client should need additional support or treatment. Facilitators will perform a review of what the group members accomplished throughout the course of group treatment, and will provide a packet of worksheets and resources so the women can continue their progress after termination. Lastly, each client will discuss their long-term goals and how they plan to attain those goals. Facilitators will stress the importance of setting manageable goals and objectives as an effective way of promoting confidence and maintaining motivation to continually progress. Before the client leaves the group, she must identify at least one group member in whom she feel she can trust and confide. Additionally, each member must identify at least one way she plans to increase her social support in her community (i.e., job opportunity, volunteering, church group).
To conclude, IPV is a growing issue in the United States. Finding effective treatment modalities for women leaving their abusers has important implications for personal as well as societal well-being. This paper details a group therapy technique to address Posttraumatic Stress Disorder symptoms that have developed as a result of violence in the group member’s romantic relationships. This intervention will use CBT techniques such as thought-stopping, automatic thought records, and role playing in order to help the women safely re-enter their community.
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