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Dialectical Behavior Therapy for Women Victims of Domestic Abuse: A Pilot

Study

Article  in  Professional Psychology Research and Practice · June 2009

DOI: 10.1037/a0013476

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Professional Psychology: Research and Practice © 2009 American Psychological Association
2009, Vol. 40, No. 3, 242–248 0735-7028/09/$12.00 DOI: 10.1037/a0013476

Dialectical Behavior Therapy for Women Victims of Domestic Abuse:

A Pilot Study

Katherine M. Iverson Chad Shenk

University of Nevada, Reno Cincinnati Children’s Hospital Medical Center

Alan E. Fruzzetti
University of Nevada, Reno

This article describes a brief, 12-week dialectical behavior therapy program modified for female victims
of domestic abuse and provides a preliminary examination of this intervention. Dialectical behavior
therapy is a comprehensive cognitive– behavioral treatment, which was originally developed to treat
multiproblem clients with severe and chronic emotion dysregulation, and was adapted for this study to
treat female victims of domestic abuse. From pretreatment to posttreatment, participants (N ⫽ 31)
showed significant reductions in depressive symptoms, hopelessness, and general psychiatric distress as
well as increased social adjustment. Additionally, participants reported high levels of consumer satis-
faction with the treatment. Findings support the possible utility of dialectical behavior therapy for
enhancing psychological and social well-being in female victims of domestic abuse.

Keywords: domestic abuse, women victims, dialectical behavior therapy, group therapy, emotion
regulation

Domestic abuse against women is widespread and refers to Goodman, 2001; Sullivan, Tan, Basta, Rumptz, & Davidson,
physical, sexual, psychological, and/or verbal abuse in the context 1992) for victims of domestic abuse. Fewer investigations have
of an intimate partner relationship. Approximately 22% to 29% of described interventions that specifically focus on enhancing emo-
American women will be assaulted by an intimate partner in their tional well-being, although some recent research has demonstrated
lifetime (Tjaden & Thoennes, 2000). Domestic abuse is associated the efficacy of cognitive– behavioral interventions in treating
with numerous mental health consequences, including heightened PTSD symptoms (Johnson & Zlotnick, 2006; Kubany et al., 2004).
rates of posttraumatic stress disorder (PTSD), depression, psychi- Although PTSD clearly represents an important treatment target
atric distress, social adjustment problems, and increased suicide for this population, the psychological sequelae of chronic abuse
risk (see Campbell, 2002). needs to include an understanding that is not limited to PTSD
Research has suggested the utility of interventions that enhance (Becker-Blease & Freyd, 2005; Mechanic, 2004) but also includes
social support (Constantino, Kim, & Crane, 2005; Tutty, Bidgood, other forms of psychological distress and interpersonal difficulties
& Rothery, 1996), marital interventions (Stith, Rosen, McCollum, (Cloitre, Stovall-McClough, & Levitt, 2004; Ford, Courtois, van
& Thomsen, 2004), and advocacy-based interventions (Bell & der Hart, Nijenhuis, & Steele, 2005). Similarly, although physical

Editor’s Note. This is one of six accepted articles received in response to ALAN E. FRUZZETTI received his PhD in clinical psychology from the
an open call for submissions on interventions for intimate partner violence/ University of Washington. He is associate professor of psychology and
domestic violence.—MCR. director of the Dialectical Behavior Therapy and Research Program at the
University of Nevada, Reno. His research interests include understanding
the relationships between emotion dysregulation and couple and family
KATHERINE M. IVERSON received her PhD in clinical psychology from the
interactions, developing and evaluating effective treatments for problems
University of Nevada, Reno, and is currently a postdoctoral fellow in the
such as borderline personality and related disorders, depression, and family
Women’s Health Sciences Division of the National Center for Posttrau-
violence, and training and dissemination of effective treatments.
matic Stress Disorder in the Boston Veterans Affairs Healthcare System.
THE PROGRAM DESCRIBED IN THIS ARTICLE was supported by grants from the
Her interests are in the conceptual understanding and treatment of survi-
vors of interpersonal trauma, as well as innovative approaches to the U.S. Department of Justice and the State of Nevada Office of the Attorney
dissemination of cognitive– behavioral therapies. General, awarded to Alan E. Fruzzetti. A special thank you is extended to
CHAD SHENK received his PhD in clinical psychology from the University the many therapists who worked in this program, often in a pro bono
of Nevada, Reno. He is currently a postdoctoral fellow in the Division of capacity, including Hillary LeReux, Kirsten Lowry, Brie Moore, Megan
Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hos- Oser, Heather Pierson, and Alethea Varra.
pital Medical Center. His areas of research interest include emotion dys- CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Alan E.
regulation, adolescent psychopathology, family interactions, psychother- Fruzzetti, Department of Psychology (298), University of Nevada, Reno,
apy outcome, and the developmental sequelae of childhood maltreatment. NV 89557. E-mail: [email protected]

242
 DIALECTICAL BEHAVIOR THERAPY FOR DOMESTIC ABUSE 243

and psychological abuse covary, more empirical work has focused ficulties making decisions, shame and self-blame, and interper-
on women victims of intimate partner physical assault. Research- sonal difficulties. Moreover, when feeling persistent emotions,
ers and clinicians have begun to focus on the consequences of the such as sadness or shame, the abused woman may experience the
psychological abuse of women (Follingstad, 2007) because it is associated action urge to isolate from others and/or may experi-
likely to precede and co-occur with physical abuse (Fritz & ence irritability, either of which reduce opportunities for social
O’Leary, 2004) and to have detrimental emotional effects, such as support (and even increase invalidation from others), which may in
anxiety, shame, and guilt, even in the absence of physical abuse turn maintain or exacerbate depression and anxiety disorders. In
(Street & Arias, 2001). other words, women who have been in abusive relationships may
Difficulties in regulating or managing emotion have increasingly develop significant and persistent difficulties related to regulating
received attention as central components of a variety of psychological their emotions. Such difficulties may occur in some specific situ-
problems (Barlow, Allen, & Choate, 2004). Emotional regulation ations and not in others, which has been referred to as apparent
difficulties may lead to dysfunctional coping responses, such as sub- competence (Becker & Zayfert, 2001; Linehan, 1993a). For exam-
stance abuse and problematic interpersonal behaviors, and may neg- ple, a woman may be able to cope extremely well in her work
atively affect emotional well-being (Gross, Richards, & John, 2006) environment where she is safe, feels less anxiety, and is more
and vice versa. Given the multiple emotional problems that result for confident, but she may experience difficulties asserting her needs
many women as a result of domestic abuse, emotion regulation may in interpersonal relationships where she feels more anxiety and has
be an important treatment target for this population. Moreover, be- a history of invalidation.
cause abused women are at risk for revictimization in future intimate Linehan’s (1993a) transactional model provides a way to con-
relationships (Dutton, Kaltman, Goodman, Weinfurt, & Vankos, ceptualize the problems associated with domestic abuse as prob-
2005), skills to help women discriminate between safe and unsafe lems related to emotion dysregulation (Fruzzetti, 2006). Thus,
partners (e.g., mindfulness) are necessary in treatment (Follette, Pis- emotional dysregulation resulting from invalidating transactions
torello, Murphy, & Iverson, 2007). can account for the common co-occurrence of emotional and
Linehan (1993a) and others (e.g., Fruzzetti & Iverson, 2006; behavioral problems across various forms of domestic abuse and
Fruzzetti, Shenk, & Hoffman, 2005) have proposed a transactional the heterogeneity of mental health consequences observed among
model for the development of disorders of pervasive emotion abuse victims. This model suggests that domestic abuse increases
dysregulation. According to the transactional theory, emotion dys- emotional arousal and susceptibility to the development of distress
regulation problems result from an ongoing transaction between an and psychological disorders. Victims may learn to engage in
individual’s emotional vulnerability and invalidating social re- escape behaviors, such as substance abuse, self-harm, or quick
sponses from others. A transaction can begin with either or both entry into a new (and sometimes dangerous) relationship, as a way
components, and it is possible that the pervasive invalidation to cope with their intense negative and dysregulated emotions.
received from an abusive partner initiates the cycle, creating in- These responses work in the short run because of their negatively
creased vulnerability (e.g., heightened emotional sensitivity and reinforcing qualities (immediate reduction in negative emotional
reactivity) in the abused partner, resulting in increased emotion arousal), but they do not resolve problems in the long run.
dysregulation and distress. Dialectical behavior therapy (DBT; Linehan, 1993a) was ini-
Invalidation may be a core component of the many forms of tially developed to treat the problems of emotion dysregulation;
domestic abuse because it communicates nonacceptance (or rejec- thus, modifying DBT to treat victims of domestic abuse is a logical
tion), criticism, disrespect, contempt, and/or disregard for a part- step. In addition, although DBT was originally developed to treat
ner’s personal worth and often results in increased emotional emotional dysregulation problems among chronically suicidal
arousal and distrust of one’s partner and one’s own feelings women with self-harm behaviors, borderline personality disorder,
(Fruzzetti & Iverson, 2004). An abusive partner may overtly and a host of co-occurring problems (e.g., depression, anxiety,
and/or subtly punish (or even pathologize) the other partner’s valid eating disorders), both the transactional model and the treatment
thoughts, wants, emotions, beliefs, values, behaviors, and goals. have been successfully applied to other problems, such as sub-
Thus, crazy-making behaviors, such as lying, blaming the victim stance abuse, binge eating, chronic depression in older adults, and
for the aggression, degrading comments, or chastising the victim couple distress (Chapman, 2006; Feigenbaum, 2007; Fruzzetti &
for ordinary daily events, result in shame, grief, fear, anxiety, and Iverson, 2006), and with trauma populations more generally
self-blame. All of these are forms of invalidation. (Becker & Zayfert, 2001; Follette, Iverson, & Ford, in press;
In these situations, women may logically develop increased Wagner & Linehan, 2006). In the current study, we have extended
sensitivity to their partners as a result of partners’ abusive behav- and modified DBT skills and interventions to the problems that
iors, becoming hypervigilant to his moods and behaviors as a women experience as a result of domestic abuse.
means of trying to stay safe. Similarly, these women may develop DBT integrates behavior change principles and strategies with
faster and more extreme reactions, which are also normative under acceptance principles and strategies (Linehan, 1993a). Compre-
circumstances of dangerous and unpredictable partner behaviors. hensive DBT involves addressing five different functions in treat-
Given the stressful environment of an abusive relationship, it may ment: (a) enhancing client skills and capabilities (mindfulness,
also be difficult and take longer for women to relax and return to emotion regulation, distress tolerance, and interpersonal effective-
their personal emotional baseline, which may lead to chronically ness skills); (b) generalizing those skills to everyday life; (c)
high levels of negative emotion (sadness, fear or anxiety, shame, increasing client motivation to use these skillful alternatives to
etc.). These difficulties may generalize well beyond the abusive reduce previous problematic behaviors and distress; (d) ensuring
relationship and may persist even after getting out of an abusive that the family and social environment do not impede treatment
relationship, manifesting as depression, anxiety, hopelessness, dif- (and, ideally, facilitate it); and (e) enhancing therapist skills and
244 IVERSON, SHENK, AND FRUZZETTI

motivation to provide treatment effectively (Linehan, 1993a). The Table 1

challenge in adapting and extending DBT to treat women victims Outline for Dialectical Behavior Therapy Modified for Women
of domestic abuse is how to maintain the comprehensive nature of Victims of Domestic Abuse Program
the therapy while creating an easily accessible, and readily export-
able, treatment program. Time Topic
This modification of DBT is a specialized, time-limited group Pretreatment Diary card
program in which all of the functions of DBT are accomplished as Phone information sheet
part of a 12-session group program. Specifically, as in standard Schedule
DBT skills groups, skill training (including homework review) is Guidelines for group
Safety planninga
provided in a group format, typically in the 2nd hr of the 2-hr
Week 1 Mindfulnessb
group. Targeting (identifying primary and secondary targets), Wise mind
chain and solution analysis and other aspects of problem solving, “What” skills: Observe, describe, participate
along with validation (client motivation to use skills to solve Establish treatment targets
problems) also occur within the group, typically in the 1st hr of Week 2 Mindfulnessb
“How” skills: Nonjudgmentally, one mindfully,
group. Skill generalization and motivation are promoted through effectively
the use of diary cards, which include identifying skills that women Options for attention
practiced throughout the week, in-group generalization planning, Letting go of judgments
as well as the option of calling one of the group therapists to Understanding your chain (chain analysis, problem solving)
Week 3 Distress toleranceb
receive coaching on skills (one component of generalization).
Self-soothing
Phone calls are especially encouraged during the early weeks of Pros and cons
treatment, particularly if an individual has a tendency to engage in Practice observing breath
mood-dependent behavior that may interfere with effective deci- Radical acceptance
sions (e.g., contemplating missing group because she is feeling Changing your chain (included weekly throughout
treatment)
anxious or depressed). Finally, therapists meet weekly as part of an Week 4 Validation and self-validationa
ongoing DBT consultation team. What is validation?
For readers who are unfamiliar with skills training in DBT, the Why is it important?
skills used in this program were largely those in the DBT skills Effects on emotions and so forth
Emotion regulationb
training manual (Linehan, 1993b), along with additional skills
Primary and secondary emotions
developed for this program. Mindfulness is the core skill in DBT Ways to describe emotions
and refers to awareness, acceptance, and participating fully and Week 5 Self-validationa
deliberately in the present moment without judgment (Linehan, How to validate yourself
1993b). Mindfulness and self-validation skills are particularly im- Getting validation from others
Learning to identify and affiliate with people who are
portant for women victims of domestic abuse because they are validatinga
likely to have difficulty labeling and expressing their emotional Week 6 Invalidation recovery and validating othersa
experiences accurately (and assertively) as a consequence of in- What is invalidation?
validation. Therefore, accurate expression is self-validating. Mind- Recovering from invalidation
How to validate othersa
fulness and self-validation skills also may be useful for increasing
Self-validation, continueda
awareness of danger-related cues, thus reducing the chance of Week 7 Validation review and practicea
future revictimization. Other skills include those to help regulate Reducing vulnerability (sleep, diet, exercise, etc.)b
emotion, tolerate distress (without escape into impulsive behav- Self-carea
iors), and improve relationships (e.g., assertion, support, self- Behavioral activationa
Week 8 Interpersonal effectivenessb
respect). A complete list of skills used in this modification of DBT Goals of interpersonal effectiveness
is presented in Table 1. DEARMAN (focus on objectives)
There is utility to the group structure of a treatment program Factors that interfere
(e.g., Heron, Twomey, Jacobs, & Kaslow, 1997; Ney & Peters, Week 9 Interpersonal effectivenessb
GIVE (more validating)
1995). Not only may abused women benefit directly from exposure
FAST (self-respect)
to other women with similar problems, but they may benefit from Week 10 Mindfulness review: Discuss progress/problems with
observing and participating in the solutions to those problems. In mindfulnessb
other words, women use mindfulness in every group session. For Relationship mindfulnessa
example, women victims of domestic abuse often engage in self- Using self-validation and relationship mindfulness to
find healthy relationshipsa
blame and are judgmental about themselves in a variety of other Week 11 More emotion regulationb
ways, which can lead to shame, guilt, sadness, and other negative Mindfulness of current emotion
emotions. When one woman goes through her chain leading to Identifying emotions/cycles
isolating herself, drinking, or passively responding to potentially Changing negative emotion and reducing suffering
Week 12 Wrap up, review, establish new targets, postassessment
beneficial situations, the group members can likely identify and
can help her solve this problem with skills. In effect, her solution Note. DEARMAN ⫽ skills to achieve objectives (Describe, Express,
is virtually every participant’s solution. Thus, it is possible to Assert, Reinforce, stay Mindful, Appear confident, Negotiate); GIVE ⫽
satisfy the comprehensive nature of DBT even in a group setting. relationship skills (be Gentle, Interested, Validate, have an Easy manner);
Furthermore, the group format provides validation, normalization, FAST ⫽ self-respect skills (be Fair, make no Apologies [for feelings,
objectives, etc.], Stick to your values, be Truthful).
a
Skills developed specifically for this modification of dialectical behavior
therapy for women victims of domestic abuse. b Traditional dialectical
behavior therapy skills (Linehan, 1993b).
 DIALECTICAL BEHAVIOR THERAPY FOR DOMESTIC ABUSE 245

and support of client experiences, which in turn may further help al’s overall social functioning across several domains, such as
them recover (Kaslow et al., 1998). Perhaps most important, employment, family, social and leisure, marital, and parenting
excellent outcomes have been reported for DBT adapted in mul- relationships. This measure has been shown to be psychometrically
tifunction group format for other homogeneous populations (e.g., sound (e.g., Weissman et al., 1978).
those with eating disorders; Telch, Agras, & Linehan, 2001). Symptom Checklist–90 –R. The Symptom Checklist–90 –R
Finally, groups are resource efficient, making it more likely that (Derogatis, 1994) is an instrument widely used to assess both
resource-limited treatment facilities could offer a program for domain-specific (e.g., anxiety, psychosis) and broad levels of
female victims of domestic abuse if the treatment has demon- individual distress. The Global Severity Index of the Symptom
strated utility. Checklist–90 –R was selected for analyses so that changes in
Despite the considerable amount of data supporting the effec- general levels of distress could be assessed at pretreatment and
tiveness of DBT for a variety of problems related to emotion posttreatment phases.
regulation (e.g., Chapman, 2006), DBT has not been evaluated as
a treatment for female victims of domestic abuse. This study Procedures
provides the first such evaluation of this program. We hypothe-
sized that women who completed the DBT group intervention Potential participants called the Women Victims of Domestic
would exhibit significant improvements on measures of depressive Abuse Program and completed a brief phone screening. There were
symptoms, hopelessness, general psychiatric distress, and social only two inclusion criteria for this study: The participants had to (a)
adjustment from pretreatment to posttreatment. We also expected be female and (b) report that they were a victim of domestic abuse by
that participants would report high levels of consumer satisfaction. an intimate relationship partner at any time in their life. Women who
reported a history of childhood abuse but not domestic abuse from an
intimate partner were excluded from the study and referred to appro-
Method
priate alternative services. Women who were actively suicidal were
Participants referred to more intensive DBT services or other established treat-
ments. During the phone screening, an intake assessment appointment
Data reported in this study were collected sequentially as part of was scheduled. At this appointment distress was assessed through the
an ongoing treatment program. Potential participants were referred self-report measures listed previously, and a general clinical interview
to the program through brochures, local women’s shelters, crisis was conducted. Details about the group, such as its meeting time,
centers, and municipal and state-affiliated agencies assisting content, structure, and overall length, were given to the participant at
women victims of domestic abuse (e.g., the city attorney’s office, this time. After the interview, the participant was assigned to the next
the temporary protection order office). Intervention was provided available open group.
at no cost to participants. The total number of women we intended For this study, we conducted seven groups, which were held at
to treat in the current study was 46, and the total sample size different times of the day or evening to accommodate work, child
completing the treatment program was 31. Thus, the total number care, or other scheduling challenges participants faced. Groups in-
of women who started but did not complete the program was 15, cluded 6 to 8 women and followed a structured, 12-week, closed-
reflecting an attrition rate of 33%. The average number of sessions group format. Each 2-hr session included the following: (a) new skills
attended for the 33% of participants who left the treatment pro- were taught and practiced, (b) the use of previously learned skills was
gram early was three sessions (range ⫽ 1–7 sessions). reviewed and encouraged, (c) problems in applying skills to daily life
The age range for this sample was 22–56 years, with an average were analyzed and practiced again (targeting, chain analysis, problem
age of 40.7. Of the women, 97% were Caucasian, 81% earned less solving, commitment), (d) opportunities for engaging in more effec-
than $30,000, and 72% had some high school or some college tive and skillful behaviors in the coming week were planned (gener-
education. In addition, 54% reported being in an abusive relationship alization included regular practice focused on treatment targets rele-
for1 to 5 years, 77% reported being abused by a current or former vant to daily life), and (e) support, encouragement, and validation
husband, and 26% still lived in the same home as their abuser. were provided both by the therapists and by other group members.
As noted, Table 1 includes a more detailed description of the
weekly topics of the group and the DBT skills used. Skills training
Measures
included all four skill modules in Linehan’s (1993b) skill-training
Beck Depression Inventory–II. The Beck Depression manual, DBT relationship skills (Fruzzetti & Iverson, 2006), and
Inventory–II (Beck, Steer, & Brown, 1996) is a widely used additional self-validation skills and skills for domestic abuse recovery
self-report instrument consisting of 21 items designed to measure developed specifically for this program. Eight master’s-level thera-
the presence and severity of depressive symptoms across several pists provided treatment, with two therapists per group. Each had
domains of individual functioning. taken part in extensive DBT training prior to coleading groups and
Beck Hopelessness Scale. The Beck Hopelessness Scale participated in a weekly 2-hr DBT consultation group, which empha-
(Beck, Weissman, Lester, & Trexler, 1974) is a psychometrically sized adherence to the DBT treatment. These consultation groups
sound 20-item instrument intended to measure the severity of were structured as outlined by Fruzzetti, Waltz, and Linehan (1997),
negative attitudes about the future. This scale was used to assess and therapists were supervised by a DBT supervisor with 20 years of
the extent of hopelessness and has been shown to be predictive of DBT experience (Alan E. Fruzzetti). Thus, the ordinary procedures
suicide risk (e.g., Glanz, Haas, & Sweeney, 1995). that are central to DBT were woven throughout the program, includ-
Social Adjustment Scale–Self-Report. The Social Adjustment ing the following: (a) clear treatment targets in a hierarchy, with safety
Scale–Self-Report (Weissman et al., 1978) measures an individu- at the top, (b) detailed chain analyses of targets, (c) the use of daily
246 IVERSON, SHENK, AND FRUZZETTI

diary/self-monitoring cards, (d) validation, (e) skill building and gen- severity of distress (either high or low severity) did not appear to
eralization, (f) balancing acceptance and change, (g) an emphasis on be a significant factor responsible for attrition. Additionally, there
practicing new skills and activities in daily life, and (h) ongoing were no significant differences between those who did not com-
therapist consultation. plete the group and those who did complete on length of the
Following the final group meeting, we asked participants to com- abusive relationship or severity of presenting symptoms at pre-
plete the same battery of questionnaires they completed during the treatment, ps ⫽ ns. Finally, women who were living with their
initial assessment. In addition, we asked participants to complete a abuser during the program (26%) were no more likely to drop out
satisfaction survey to provide us with client satisfaction data concern- of treatment, nor did they report greater distress on the Beck
ing the group format, components, and overall program. Depression Inventory–II, Beck Hopelessness Scale, Symptom
Checklist–90 –R, or the Social Adjustment Scale–Self-Report at
Results posttreatment, ps ⫽ ns.
A comparison of demographic variables showed that there were
Our main hypothesis was that women who completed the treat- differences only on levels of education between completers and
ment group would demonstrate statistically significant differences noncompleters. An independent-sample t test revealed that women
on outcome measures at postintervention when compared with who ended their participation early had fewer years of education,
their own preintervention scores. A within-subjects repeated mea- t(40) ⫽ ⫺2.94, p ⬍ .01, than women who completed the group.
sures analysis of variance (ANOVA) was conducted on all self- Level of income and whether there were children in the home did
report measures to assess treatment effects for the women who not significantly differ between women who did and did not
successfully completed the group (n ⫽ 31). There were significant complete the program, ps ⫽ ns. Women who left early (n ⫽ 15)
main effects for time on all within-subjects comparisons of self-report were asked what factors were for responsible for their dropout,
measures. Specifically, preintervention and postintervention effects with the most frequent response being that they were unable to
were as follows: Beck Depression Inventory–II, F(1, 30) ⫽ 12.97, consistently attend sessions during the arranged time/day of the
p ⬍ .001, d ⫽ .54; Beck Hopelessness Scale, F(1, 30) ⫽ 5.88, p ⬍ group.
.05, d ⫽ .42; Symptom Checklist–90 –R, F(1, 30) ⫽ 14.82, p ⬍ Finally, we were able to collect some posttest data on the overall
.001, d ⫽ .78; and Social Adjustment Scale–Self-Report, F(1, functioning of women who left the program prior to completion.
30) ⫽ 7.67, p ⬍ .01, d ⫽ .53. See Table 2 for descriptive statistics Given the small size of this subsample (n ⫽ 5), extreme caution
related to these results. should be taken when making inferences about these data. Posttest
In addition, 93% of our participants (completers) reported being means and standard deviations for this subsample are as follows:
very satisfied with our program (the highest rating), and 7% Beck Depression Inventory–II: M ⫽ 11.00, SD ⫽ 14.93; Beck
reported being satisfied (the second highest rating). Thus, no Hopelessness Scale: M ⫽ 3.33, SD ⫽ 3.21; Symptom Checklist–
participant reported less than adequate levels of satisfaction. 90 –R: M ⫽ 34.67, SD ⫽ 14.29; Social Adjustment Scale–Self-
To rule out possible selection bias due to dropout in our sample, Report: M ⫽ 2.01, SD ⫽ 0.66 (the reader may compare these
as well as to identify specific factors contributing to attrition, scores to those of completers, found in Table 2).
preintervention data were compared for women who did and did
not complete the group. First, a two-tailed, independent sample t
test showed that there were no significant differences between Discussion
groups at pretest on any of the clinical outcome measures of This study examined the feasibility and effectiveness of DBT
interest (all ps ⬎ .05). These results suggest that level of individual adapted for female victims of domestic abuse in a relatively brief
distress was evenly distributed across all participants and that (12-session) group format. Results support the feasibility and
possible effectiveness of this approach. The group that completed
treatment showed significant improvements on all of the outcome
Table 2 measures; participants reported reduced depressive symptoms,
Pretreatment and Posttreatment Means and Standard Deviations hopelessness, and psychiatric distress and reported increased social
for Treatment Outcome Measures adjustment from pretreatment to posttreatment.
Not only were changes from pretreatment to posttreatment sta-
Measure M SD F d tistically significant, the magnitude of changes was generally in the
moderate-to-large range of effect sizes. In fact, participants’ scores
Beck Depression Inventory–II
Pretest 18.3 15.0
on standardized outcome measures generally reached the normal
Posttest 10.2 11.4 12.97ⴱⴱⴱ .54 range at posttest. For example, depressive symptoms decreased
Beck Hopelessness Scale significantly, with the average score of participants in the moderate
Pretest 5.1 6.0 range of depression at pretreatment and with the majority of
Posttest 2.6 3.0 5.88ⴱ .42 participants reporting no elevations or only mild mood distur-
Symptom Checklist–90–R (Global
Severity Index Scale) bances at posttreatment (Beck et al., 1996). At the pretreatment
Pretest 44.7 11.8 assessment, nearly 25% of the sample met criteria for high suicidal
Posttest 35.5 13.3 14.82ⴱⴱⴱ .78 risk, according to established cutoffs (Glanz et al., 1995). How-
Social Adjustment Scale–Self-Report ever, at posttreatment, only 7% met criteria for high suicidal risk.
Pretest 2.2 0.57
Posttest 1.9 0.50 7.67ⴱⴱ .53
Similarly, at pretreatment, the participants’ average social adjust-
ment score was nearly 2 SDs above the community sample mean
ⴱ ⴱⴱ ⴱⴱⴱ
p ⬍ .05. p ⬍ .01. p ⬍ .001. (lower scores indicate better adjustment), whereas at posttreat-
 DIALECTICAL BEHAVIOR THERAPY FOR DOMESTIC ABUSE 247

ment, the group was nearly 2 SDs below this community mean domestic abuse experienced. In addition, the outcome variables
(Weissman et al., 1978). examined in this study are not exhaustive. Future investigations
Despite the stress that is characteristic of an abusive environ- should include a broader range of mental health measures, such as
ment and the demands of participating in treatment, participants’ measures of PTSD, self-esteem, and safety in future relationships (and
satisfaction with the treatment program was consistently very high. quality of those relationships), to capture more fully the range of
These high levels of satisfaction suggest that the program was difficulties that women victims of domestic abuse experience.
meeting many of the needs of its participants, and this high Approximately 33% of women who were appropriate for the
satisfaction complements the formal assessment data. program and agreed to participate did not complete the entire
This modification of DBT has a number of advantages that treatment. Post hoc data analyses showed similarities in pretreat-
make further development and evaluation important. First, given ment measures between those who completed the study and those
that participants reported improvements across all of the domains who dropped out, although women who dropped out had some-
evaluated, it appears that the group format is a practical mode for what less education than did women who completed the program.
treatment delivery. Many existing treatments for emotional well- This may reflect greater difficulties in the format for less educated
being among this population are individual focused. Although women (e.g., materials designed to help learn skills may have
these treatments are often effective (Johnson & Zlotnick, 2006; been, in fact, too difficult) or a variety of other possibilities. Future
Kubany et al., 2004), they carry significant limitations in avail- research should examine whether DBT commitment strategies
ability and access. For example, individual treatments are time (Linehan, 1993a) or other interventions, such as motivational
consuming for therapists and expensive for clients or mental health interviewing techniques (Miller & Rollnick, 2002), may enhance
systems and likely result in lower access for middle and lower program engagement and reduce attrition.
income women (such as those in this study). Of importance, this In conclusion, results from the present study justify a more
intervention is quite cost-effective; as many as 8 women attended rigorous examination of the efficacy and effectiveness of DBT as
the group treatment together. Furthermore, at just 12 weeks, treat- a treatment for women victims of domestic abuse. Although this
ment was efficient. study is preliminary, findings suggest that the current intervention
Limitations of this pilot study must be acknowledged. For two may be helpful in alleviating at least some forms of emotional
reasons, we did not include a control condition in this study. First, distress. In addition, it is both efficient and accessible, both essen-
in keeping with treatment development considerations, we decided tial qualities if such a program is to be useful to women victims of
to start with a basic pre- and posttest design to establish the domestic abuse who have few resources. Thus, this adapted DBT
treatment’s initial effectiveness. Second, given the absence of any program appears to help break down treatment barriers and holds
treatment standards, the only viable control condition would have potential for women who need assistance making the transition to
been either a wait list or individual treatment. In light of the a safer and healthier well-adjusted postabuse life.
substantial needs of this population, we ruled out a randomized
wait list. Given the costs and multiple confounds, we ruled out References
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Johnson, D. M., & Zlotnick, C. (2006). A cognitive– behavior treatment for Received November 2, 2007
battered women with PTSD in shelters: Findings from a pilot study. Revision received June 9, 2008
Journal of Traumatic Stress, 19, 559 –564. Accepted June 16, 2008 䡲

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