Domestic abuse, which refers to physical, sexual, psychological, and verbal abuse between intimate partners, is a pervasive and distressing phenomenon. Studies estimate that between 22% and 29% of women will be the victim of an abuse relationship at least once in their lifetime (Tjaden & Thoennes, 2000). Sadly, a number of dangerous outcomes are associated with being the victim of domestic abuse, including post-traumatic stress disorder (PTSD), depression, general distress, difficulties in social adjustment, and elevated risk of suicide (Campbell, 2002).
Given this startling information, the need to develop treatments capable of assisting victims of domestic abuse is obvious, and today I would like to discuss an article published in Professional Psychology: Research and Practice by Katherine Iverson, Chad Shenk, and Alan Fruzzetti (2009) in which they examined the potential utility of a brief, 12-week version of dialectical behavior therapy (DBT) for this population. As you might recall from prior PBB articles, DBT is comprised of four components: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. The treatment was originally designed for the treatment of individuals with borderline personality disorder (BPD) and each of these components addresses core symptoms of that disorder. Recent research, however, has indicated that emotion regulation difficulties are at the core of numerous mental illnesses and, as such, DBT has been adapted for a number of other presentations and, in fact, is considered an empirically supported treatment for both bulimia nervosa and binge eating disorder (e.g., Telch, Agras, & Linehan, 2001).
Marsha Linehan, the creator of DBT, has proposed a biosocial model (also referred to as a transactional model) of BPD in which an individual's innate vulnerability to dysregulated emotions interacts with invalidating environments, resulting in the onset of BPD pathology. Iverson, Shenk, and Fruzzetti (2009) explained that this same model might be successfully applied to female victims of domestic abuse, as an abusive intimate partner represents a severely invalidating environment. As such, they believed that teaching such women skills to better manage their emotions and impulses and to better evaluate the value of particular interactions and assert their needs could potentially represent a successful method for improving the lives and psychological well-being of female abuse victims.
DBT in its truest form involves both group skills training (2-hours per group) and individual treatment and is intended to last two full years of weekly sessions, representing at least two complete cycles through the entire treatment protocol. The authors sought to drastically reduce this time requirement by revising the protocol such that the entire treatment consisted of weekly group skills training and lasted a total of twelve weeks. 46 women were initially involved in the study, although only 31 completed the entire protocol, representing a 33% attrition rate. I will address the attrition rate in more detail later, but obviously this represents one fairly substantial problem.
Participants ranged in age from 22 to 56, with an average age of 40.7. 54% of the participants had been in an abusive relationship for 1 to 5 years and 26% were still living in the same home as their abuser. Each participant was given a measure of depression symptoms, hopelessness, social adjustment, and overall psychological well-being both an pre-treatment and post-treatment. Each group consisted of 6-8 women. The first hour of each group meeting involved the discussion of diary cards and the description of how skills were successfully or unsuccessfully implemented into group members' lives (behavioral chain analysis). The second hour of each group meeting involved skills training, with the particular skills changing as the group advanced from one module to the next. Each week, the DBT clinicians met amongst themselves for a consultation meeting.
So, what did they find? For participants who remained in treatment, there were substantial (medium to large effect size) reductions in depression symptoms, hopelessness, suicidality, and general distress and a substantial increase in social adjustment. At the beginning of treatment, the average depression score for the overall group was in the moderate range; however, at post-treatment, the majority of participants reported either a complete absence of mood symptoms or only mild symptoms. At the beginning of treatment, 25% of the sample met criteria for severe suicide risk whereas at post-treatment, only 7% met that criteria. Additionally, 93% of the participants reported being very satisfied with the treatment program (highest possible rating) and 7% reported being satisfied (second highest rating).
What about that 33% that dropped out of treatment though? On average, those participants attended 1-3 sessions before stopping treatment. Obviously, this is a substantial portion of the sample, which raises questions as to whether severely ill participants were simply dropping out of treatment and thus inflating the impact of treatment for those who remained. As it turns out, however, this was not the case. Individuals who dropped out of treatment were no more severe on any of the clinical measures than were the individuals who remained in treatment. The only significant difference between those who remained in treatment and those who dropped out was education level, with those who dropped out reporting fewer years of education. The most common explanation for dropping out of the program was an inability to consistently attend sessions at the scheduled time and/or day. In other words, severity of illness and satisfaction with treatment had nothing to do with the dropout rate.
This study had a lot of obvious positives. First of all, it demonstrated positive effects on a range of outcome measures for a population in need of help. Secondly, it found these effects for a brief version of DBT, meaning that treatment can be provided efficiently and at lower costs and which is received positively by clients. Third, the study utilized a number of outcome measures representing a wide range of variables rather than focusing only on a limited set of outcomes.
Along with these positives, however, were a number of important limitations. Iverson and colleagues (2009) noted that this was a preliminary study aiming to establish initial evidence of utility and, as such, they were not aiming to conduct a large scale randomly controlled trial. Unfortunately, this means that, in addition to lacking a comparison to another active treatment, the study lacked a control group. As such, we can not tell whether or not the improvements experienced by participants were due to the treatment itself rather than common factors (e.g., therapeutic alliance) or the simple passage of time. Additionally, although the authors did assess a number of different outcomes, they only used self-report questionnaires, which while useful also involve many important limitations. The authors also provided no diagnostic information. In other words, we do not know how many participants met criteria for mental illnesses either pre- or post-treatment, which thus prevents us from knowing whether the treatment actually impacted diagnostic status. The authors only used two time points, so we do not know how quickly treatment gains occurred and whether or not all 12 sessions were even necessary. Finally, the authors did not conduct any follow-up assessments, so it is entirely unclear to what degree treatment benefits were maintained following treatment and whether or not treatment resulted in participants avoiding involvement in future abusive relationships.
On the whole, this study provided solid preliminary evidence for the utility of brief DBT in treating female victims of domestic abuse. Treating an outcome rather than a diagnosis is not the traditional approach of the empirically supported treatments paradigm, but that, in and of itself, is not a criticism. It simply means that the authors took an alternative approach to addressing a problem. Future studies that address the limitations mentioned above will be important, but readers who themselves are the victims of domestic abuse or who know others who are should feel encouraged by these findings and in the knowledge that there are researchers out there attempting to develop interventions aimed to precisely address this situation.
If you would like to learn more about dialectical behavior therapy, we recommend the following resources, all of which are available through our online store:
- Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan
- Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha Linehan
- Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings by Linda Dimeff and Kelly Koerner
- The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, & Validation by Alan Fruzzetti
- Dialectical Behavior Therapy for Binge Eating and Bulimia by Debra Safer, Christy Telch, and Eunice Chen