Introduction

Violence against women by their intimate partners is a problem of epidemic proportions in America and the rest of the world as well (Heise, Ellsberg, & Gottemoeller, 1999). Nearly twenty-five percent of American women have been raped and/or physically assaulted by an intimate partner at some time in their lifetime (Tjaden & Thoennes, 2000). Approximately 1.5 American women are raped and/or physically assaulted by an intimate partner each year. (Tjaden & Thoennes, 2000)

This book was written for you if you are suffering from the after effects of having been physically and/or psychologically abused by your husband, boyfriend, or other intimate partner. These aftereffects include symptoms that may continue long after you have left an abusive relationship. Examples of some of these symptoms include:

• heart palpitations or breaking into a cold sweat when you see violence on TV
• waking up in a state of panic from dreams of being chased by your abuser
• cleaning obsessively to avoid thinking about the abuse
• not answering the phone because you think it might be your abuser
• not taking pleasure in activities you used to enjoy
• not feeling close to anyone
• not being able to walk down the street without looking around and worrying that you will run into your abuser
• not being able to get more than four or five hours sleep, and not restful sleep at that
• trying to read and finding yourself stuck on the same page for twenty minutes
• yelling at the kids for little things
• feeling guilty that the children witnessed the abuse or are being deprived of their father
• feeling guilty about not having been able to get your partner to change
• feeling guilty about not having broken off the relationship sooner

These kinds of aftereffects are quite predictable and often occur as a collection of symptoms called Posttraumatic Stress Disorder or PTSD.

This book is intended primarily for women who were previously abused by an intimate partner but are now safely out of the relationship. The book may also be helpful for women suffering from posttraumatic stress related to any kind of traumatization—including rape, incest, serious accidents, or the sudden, unexpected death of a loved one.

We are aware that intimate partner abuse can and does occur in same-sex relationships as well as in heterosexual relationships. In fact, we have conducted Cognitive Trauma Therapy with several clients who were abused by a same-sex partner. However, for ease of communication, we always refer to the perpetrator as “he” or “him” and the victim or survivor as “she” or “her.”

Finally, this book may also be useful for victim services providers in their work with battered women. For example, many of the exercises in this workbook can be easily adapted for use in a group format, in support groups or at shelters for battered women.What Does It Mean to Say that a Woman Has Been Battered?

A woman is considered to be a battered woman if she was traumatized by physical violence (or threat of violence) and/or psychological abuse by her husband, boyfriend, or other romantic partner. To be traumatized means that a person has experienced an intensely negative emotional reaction during a stressful event (American Psychiatric Association, 1994). Hence, a woman is a battered woman if she experienced intense fear, helplessness, or horror during violence or abuse by an intimate partner. The intensity of the reaction to the violence is very important because only stressful events that evoke extremely strong negative reactions are likely to produce chronic depression and long-term stress reactions, as in PTSD (American Psychiatric Association, 1994).

Most battered women with partner-abuse-related PTSD have been traumatized by repeated acts of physical violence. Many of these women have also been traumatized by acts of psychological abuse including: death threats; stalking; sex abuse or coercion to have unwanted types of sex; kidnappings; physical restraint; badgering; harassment, or repeated pressure to engage in a variety of other unwanted behaviors; verbal cruelty; mistreatment of pets; financial control; property damage; and social isolation.

In fact, some women are traumatized and develop PTSD in response to psychological abuse even if there has been no physical violence in the relationship. In our treatment-outcome study with 125 battered women, nine women with partner-abuse related PTSD had not been physically abused by their intimate partners but had been terrorized and traumatized by their intimate partners in other ways (Kubany et al., 2004). Among these nine women, seven had been threatened with death or serious bodily harm, five had been stalked, and three had been sexually abused by their partners.

Are Men Also Battered?

Unfortunately, many people, including many police officers, think that domestic violence is a mutual kind of thing, where both husbands and wives contribute equally to the violence and are equally affected or unaffected. And maybe it is mutually reciprocal when most couples “fight” verbally or where physical aggression is very limited or mild (such as rare instances of pushing, holding, or throwing of objects). But this is not the case in truly abusive relationships, where men purposely use threats, verbal abuse, physical violence, and their strength to control their partners. For example, if the police respond to a complaint of domestic violence and see blood on both the husband and his wife when they arrive at the door, it is not the same! The woman may be hysterical and appear out of control (because she is terrified), whereas the man is often calmer (because he is not afraid) and may even appear rational to the police. Unfortunately, the husband’s and wife’s demeanor may be falsely interpreted by police that the woman is the primary aggressor. In fact, women are likely to be terrified and horrified when they are abused by their partners, but men are rarely traumatized when their wives fight back.

Going back to the definition of battered, relatively few men are battered because relatively few men experience intense fear, helplessness, or horror in response to physical aggression by their wives or girlfriends. Most men are bigger than their female partners, do not get frightened if their wives or girlfriends become aggressive, and do not feel helpless or out of control because they know they can stop their partner’s violence by physically restraining her or by escalating their aggression toward her. In addition, men are much more likely than women to utilize aggression as a way of dominating and controlling their partner in the relationship. Women are much more likely to utilize aggression to fight back or as a way of defending themselves.

We conducted a study at a substance abuse treatment program which illustrates that men and women do not engage in the same kind of partner aggression and are affected or impacted differently by the aggression (Tremayne & Kubany, 1998). Many of the men as well as the women in this program indicated that they had been slapped, punched, or otherwise physically hurt by an intimate partner. However, this is where the similarity ended. Compared to the men:

• women were far more likely to have been threatened with death or serious bodily harm by an intimate partner
• women were far more likely to have been stalked by an intimate partner
• women were far more likely to have been sexually abused by an intimate partner.
• women were far more likely to have PTSD than the men.
In addition, other research indicates that male violence against women does much more damage than female violence against men; women are much more likely to be injured by partner aggression than are men (Bureau of Justice Statistics, 1995).

Getting Your Wants and Needs Met

Getting personal wants and needs satisfied has not been a high priority for most of our battered woman clients when they started therapy. If you are like most of our new clients, you have been spending most of your time taking care of other people and placing the needs of others above your own. You have probably considered other people’s needs more important than your own needs. Similarly, most of our new clients have been placing a high priority on anticipating and avoiding disapproval and keeping other people from getting mad or angry. Advocating for their own needs is foreign to many abused women when we first meet them, and many equate self-advocacy or assertiveness with being “rude,” “aggressive,” “bitchy,” or “unfeminine.” When our clients placed themselves first or stood up for their rights, they often felt selfish and guilty. They were also intimidated by and fearful of interpersonal conflict. One reason for this is that arguments, disagreements, and raised voices are reminders of the abuse; and women with abuse-related PTSD do not like being reminded of the abuse. Much of this workbook focuses on helping you take your power back and establishing you as you own strongest advocate.

Exposing Yourself To Trauma Reminders as an Avenue of Recovery

Almost anything that will remind a woman with PTSD of her abuse (or her abuser) will be avoided—because avoidance is one of the hallmark symptoms of PTSD. Learning about the symptoms of PTSD may bring up painful memories that you don’t want to think about. However, in order for you to fully recover from PTSD, it is necessary to stop avoiding memories of the abuse. While you may not want to think about what happened, facing and reprocessing memories of past abuse is essential to take the emotional charge out of these memories. In fact, “avoidance busting” is one of the royal roads to your recovery from PTSD.

While the idea of deliberately exposing yourself to reminders of the abuse and your abuser may seem to be a difficult, if not intimidating, challenge at this point, we think that you can do it, and we will support you if you are willing to give it a try. We will not “assign” exposure exercises until you get to Chapter 14, and by then you may be far better prepared to face your memories than you are right now. If you can get to the place where you no longer become disturbed when you think about what happened and are no longer intimidated by images of your abuser or situations that remind you of him, you will be liberated and empowered.

Most of the women who have completed our program of therapy—which included having them confront reminders and memories of the abuse and their abusers—no longer have PTSD, have had their self-esteem restored, and feel very empowered. They are now able to walk down the street without fear, know what to do if they run into their former abusers, sleep well at night, and are engaging in and enjoying activities they used to enjoy.

Translating a Successful Therapy for PTSD into a Self-Help Format

Most of the content, exercises, handouts, and assignments in this workbook were drawn from an educationally oriented intervention for battered women called Cognitive Trauma Therapy (CTT). In fact, the chapters in this book parallel or correspond with the various modules or topics covered in CTT.

Two studies have been conducted to evaluate the effectiveness of CTT (Kubany, Hill, & Owens, 2003; Kubany et al., 2004). CTT has resulted in substantial reductions in posttraumatic stress, depression, guilt, and shame, and substantial increases in self-esteem. Because the intervention is based on a learning or educational model, the approach is highly amenable to a self-help format. We believe that many battered women will be able to make significant positive changes in their well-being and quality of life by reading this book, by doing the exercises and “homework” assignments, and by practicing the recommended “self-advocacy strategies” on an ongoing basis.

How to Use this Book

This book was not written to be read passively. That’s why it’s called a workbook. We want to actively engage you in an interactive process with us. We are going to challenge you to think critically, and to do this, we are going to ask you a lot of questions. Teaching by asking repeated questions is called the Socratic Method. This type of teaching challenges the “student” to think critically and is a hallmark characteristic of the way cognitive-behavioral therapy (CBT) is conducted (e.g., Beck, 1976). It is also a hallmark characteristic of the way we conduct CTT. We want to encourage you to think critically too. Critical, rigorous, and logical thinking will facilitate your recovery from PTSD.

The Importance of Writing out Your Answers When We Ask You Questions

In this workbook, whenever we provide spaces for you to write out your answers, it is extremely important that you put your answers in writing. The act of responding to the questions by writing your answers in the spaces provided will help you organize and articulate your thoughts and will be helpful in and of itself. Writing your answers is much like writing in a journal or diary, which can help a person clarify her thinking on certain issues and something she can come back to later and reflect upon. You will get much less out of this book if you do not write down your answers to the questions posed. We also suggest that you keep a journal to accompany your reading of this book. When your answers are too long to fit in the spaces provided, we recommend that you write the page number in your journal and expand on your answer in your journal. Sometimes we ask questions without providing blank spaces for you to write an answer. When we ask you questions this way, we still want you to answer them. It might even help to answer these questions out loud or to write out the answer in your journal.

The Importance of Doing the Homework

In CTT, we give clients lots of homework to supplement what goes on in the sessions themselves. In this workbook, the homework assignments correspond to the homework assignments in CTT. To get the most out of this workbook you will need to place a high priority on diligently doing this homework. In the very first session in CTT, we tell clients that, “What you do in between sessions is just as important—and eventually becomes even more important—than what happens during the sessions themselves.” Clients who diligently do their homework are far more likely to recover from their PTSD than clients who do not do their homework diligently, on a regular basis.

We strongly encourage you to make every effort to complete the homework as a top priority. If you find that you did not complete an assignment, ask yourself, “How can I find a way?” As your advocates on this road to your recovery, we encourage you to focus on looking for ways that problems—such as completing homework—can be solved rather than coming up with reasons why your problems can’t be solved. Keep asking yourself, “How can I find a way?”
The Importance of Taking Your Time
In this book, we give you a great deal of information, and there is a lot to absorb and reflect upon. Therefore, we encourage you to only read one chapter per day and to take at least one month to finish the book. Also, many of the homework assignments are meant to be completed on a daily basis over an extended period of time. For example, the relaxation exercises and the exercise for monitoring the way you talk to yourself are meant to be implemented daily, for at least a month.

If you are the “impatient” type or get so absorbed in reading this book that you want to read it all in one or two days, that is okay—IF you go back and re-read the chapters one day at a time.

In CTT, we tape-record all sessions and give our clients audio cassettes of the sessions for “listening homework.” Many of our clients find this homework very helpful, and some clients listen to the tapes of their sessions more than once to reinforce what they have learned or to gain additional insights about what they have learned. Many readers of this workbook may find that re-reading the chapters (or even re-reading them more than once) may also be helpful. Some former CTT clients have told us that they re-listened to the tapes of the sessions much later for therapy “booster shots” or to reflect upon how much they had changed. Therefore, it might also be a good idea for you to re-read this book six months or a year from now to reflect upon how you and your life have changed since completing this workbook program.

It may seem to be a daunting challenge, but if you take this program one paragraph at a time, one question at a time, exercise at a time, and one chapter at a time, the task will be less intimidating than you may think it will be. You have been through a lot, and it may take a while for you to increase your self-confidence and realize that you do have the capabilities to overcome obstacles, perform difficult tasks, and make significant changes in your life. If you are like almost all the women who have completed CTT, you can successfully complete this workbook program.

An Overview of This Workbook

In Chapter 1, you will learn about symptoms of PTSD and can evaluate whether you may be suffering from PTSD. You will also learn that PTSD is a normal reaction to extreme stress and why trauma produces the same kinds of symptoms/reactions in everyone.

In Chapter 2, we discuss self-advocacy and how you can empower yourself by becoming your own strongest advocate. We will ask you to evaluate the strength of your beliefs about twenty-five self-advocacy strategies, which can empower you and will be important for you to adopt.

Chapter 3 is about anger. We discuss several reasons why holding onto anger is not in your best interest and that “letting go” of anger involves a conscious decision or choice.

In Chapter 4, you will learn a technique for monitoring or keeping track of your negative self-talk, which you can use as a tool for breaking these habits. In Chapter 5, we will then try to maximize your motivation for breaking negative self-talk habits by providing many reasons why these bad habits drag you down and interferes with your ability to think clearly.

In Chapter 6, you will learn about stress, several reasons for keeping muscle tension in your body at a low level, and how you can control how you feel by relaxing your muscles.

In Chapter 7, you will learn more about PTSD and why thinking and talking about what happened are essential to your full recovery. You will learn that avoiding memories and other reminders of your trauma provide only temporary relief and that behaviors which provide relief are usually not in your best interest.

In Chapter 8, you will learn about learned helplessness, which explains why many formerly battered women often “feel overwhelmed” and believe they are unable to overcome obstacles in their lives. You will learn about the importance of adopting a solution-oriented attitude, which focuses on ways problems can be solved rather than on reasons why they can’t be solved.

Chapters 9 and 10 focus on guilt and may be the most important chapters in this book. In Chapter 9, you will learn that guilt can be best understood by breaking it apart and examining each of its parts separately. In Chapter 10, we will help you get rid of your guilt. We will identify and help you correct numerous thinking errors, which have led you to experience guilt.

In Chapter 11, we will ask you to critically challenge several “supposed to” beliefs, which lead many battered women to stay in an abusive relationship. In Chapter 12, you will learn about assertiveness and how to discriminate disrespectful or aggressive speech in others. You will learn how to get your wants and needs met by being assertive and how to not tolerate disrespect from anyone. Chapter 13 is an extension of the assertiveness chapter. You will learn how to effectively manage stressful and unwanted interactions with former partners.

In Chapter 14, we will assign you exercises for exposing yourself to abuse- and abuser-reminders, which will enable you to overcome your fears and to grieve your losses (such as the loss of a marital dream).

In Chapter 15, you will learn how to identify potential perpetrators and avoid revictimization. You will learn about numerous “red flags,” which indicate a suitor has the potential to become abusive. Then, you will learn how to determine whether someone is a potential abuser—early in the relationship—when he is charming and may seem too good to be true.

In Chapter 16, you will complete the self-advocacy exercise for a second time and see how you have changed since you started this book. If you are like most of the women who have completed CTT, you will find that self-advocacy strategies are no longer foreign to you and that advocating is empowering and feels good.

Whom This Book Can Help

This book is for formerly battered women. Many of the things that we teach and recommend women to do could conceivably jeopardize the safety of women who are in an abusive relationship. For example, we recommend that women “selfishly” advocate for getting their own wants and needs satisfied as a top priority and to not tolerate disrespect. This kind of self-advocacy could be potentially dangerous in an abusive relationship where the woman has previously placed her partner’s needs above her own and where the dominant strategy for “keeping the peace” has been to avoid conflict. On the other hand, assertive and self-advocacy strategies are good for women who are out of abusive relationships or may be in the early stages of a relationship with a new man. Such strategies can help you avoid ever being victimized again.

It would be difficult, if not impossible, to eliminate PTSD in a woman who is in an ongoing abusive relationship, even if the abuse only occurs once in a while. People do not get over PTSD if the threat of retraumatization looms or if retraumatization occurs. We will illustrate with an example of combat trauma. Let’s say a soldier was traumatized and developed PTSD after his unit was ambushed and several of his buddies killed. Let’s say we pull him off the front lines, provide him with rest and recreation, treat his posttraumatic stress, and then send him on another combat mission, in which more people in the unit get killed. Do you think his PTSD will go away or not come back? Not very likely! If trauma or the threat of trauma is ongoing, it may be extremely difficult to help someone get over their PTSD; it may not even be adaptive to “recover.” It may be more adaptive to remain emotionally “shut down” in order to reduce the emotional impact of subsequent trauma than to “open up” and experience the full emotional hurt of subsequent trauma.

A cautionary note: Our intervention research has focused on women who are no longer in an abusive relationship and are relatively safe. This workbook is based on that research. If you are trying to implement our strategies while you are in a relationship with an abusive or potentially abusive person, it is extremely important that the individual also be in contact with a victim services provider and have a safety plan.

Cognitive Trauma Therapy (CTT): Development, Procedures, Effectiveness

As we mentioned in Chapter 1, the chapters in this workbook correspond to the agenda and topics that are covered in Cognitive Trauma Therapy, which is the subject of this chapter (see Kubany & Watson, 2002). This chapter was written primarily for therapists and victim services providers. The chapter was meant to be informative but was not written with the intention of assisting battered women in their self-help efforts to recover from PTSD. Therefore, this chapter is written in a somewhat more technical and less user-friendly way than the rest of the book In this chapter, we will:

(1) briefly discuss how Cognitive Trauma Therapy was developed and how the various modules or treatment components were assembled,
(2) describe the procedural outlines in Cognitive Trauma Therapy, and
(3) describe and discuss two studies that were conducted to evaluate the effectiveness of Cognitive Trauma Therapy
Development of Cognitive Trauma Therapy for Battered Women
Based on a review of the literature on battered women, Kubany and Watson (2002) identified several issues or problems faced by many battered women—in addition to PTSD—which may complicate their treatment. First, many battered women have guilt and shame issues that are unique to the population—for example, guilt and shame related to a “failed” marriage, effects of the violence on the children, and guilt and shame related to decisions to stay in or leave the relationship. Battered women may require special cognitive interventions that target and facilitate the reprocessing of these complicated cognitive issues. Second, many treatment-seeking battered women have experienced prolonged, repeated trauma. Not only are they likely to have been repeatedly traumatized by intimate partners in multiple ways (threats, stalking, sexual abuse), but many also have histories of exposure to other forms of interpersonal violence, such as childhood physical and/or sexual abuse. Such repeated and multi-method abuse may contribute not only to the severity of PTSD but also to related problems, such as deficits in assertiveness and tolerance of disrespect from others. Self-advocacy and empowerment or self-efficacy issues may be particularly important to address as a therapeutic theme in treatments for battered women (e.g., Ozer & Bandura, 1995). Third, the lives of many formerly battered women remain enmeshed with their ex-partners because these men are fathers of the children, and continuing contacts are a frequent source of stress. Many formerly battered women could benefit from interventions that enable them to efficaciously manage stressful contacts with former partners. Fourth, many battered women are at risk for re-victimization by subsequent intimate partners. A module on ways to identify potentially abusive suitors and prevent re-victimization may be important to include in comprehensive trauma recovery programs for battered women.

Cognitive Trauma Therapy, which we refer to as CTT in this chapter, includes several treatment components adapted from existing cognitive-behavioral treatments for PTSD, including: (1) psychoeducation about PTSD, (2) stress management (including relaxation training), and (3) talking about the trauma and exposure homework. CTT also includes specialized procedures for (1) assessing and correcting irrational guilt-related beliefs and (2) reducing negative self talk—related to guilt and shame, in particular. Irrational guilt-related beliefs are identified and corrected in a systematic, semi-structured format. Negative self-talk habits are addressed directly by teaching clients to observe their mental life by means of self-monitoring homework and to break habitual bad habits of using negatively evaluative words in thoughts and speech.

CTT also includes modules that address issues which may complicate the treatment of battered women. These modules focus on self-advocacy and empowerment and include: (1) psychoeducation on cognitive and behavioral self-advocacy strategies, (2) assertive communication skill building, (3) managing unwanted contacts with former partners, and (4) how to identify potential perpetrators and avoid revictimization.

Procedural Outlines in CTT

In our funded studies of CTT (Hill, Kubany, & Owens, 1998), CTT has been conducted in a 1.5-hour session format that takes 10-12 sessions to complete with most clients. In the “real world” of private practice, it usually takes about 20 50-minute sessions (plus or minus up to 5 sessions) to complete CTT. The procedural outlines for conducting CTT in a 1.5-hour session format are described below.

Session 1
The purpose of Session 1 is to establish rapport, obtain an account of clients’ most distressing experiences of partner abuse, inquire about other significant traumatic experiences (based on experiences reported on the Traumatic Life Events Questionnaire; Kubany, Haynes et al., 2000), and to provide an overview of our theoretical orientation and topics that will be covered. At the end of Session 1, clients are given a homework handout, in which they are to write what they believe about 25 sets of self-advocacy strategies. We have found that giving this assignment at the beginning of CTT gives clients meaningful objectives of what they want to accomplish, highlights issues that will be addressed in CTT, and often appears to have immediate positive effects on client optimism and symptom level. Clients are given the assignment again prior to the last session, when the self-advocacy strategies module is conducted.

Session 2
During Session 2, we (1) provide psychoeducation on negative self-talk and assign homework to monitor self-talk, (2) provide psychoeducation on stress management, and (3) provide progressive muscle relaxation training. Clients are given a 20-minute audiotape of the relaxation exercises (in the therapist’s voice), with instructions to listen to the tape twice a day. Clients are also instructed to do a “body scan” (i.e., systematically “scan” or attend to the different muscles in their body so as to identify loci of tension) when experiencing stress and to over-tense and then release tension in the muscles affected by the stressor (to attempt to return to their level of arousal prior to the stressor’s onset). Starting with Session 2, clients are loaned audiotapes of the sessions for “listening homework” and asked at each subsequent session what they learned from listening to the tape over and above what they got out of the session itself.”

Session 3 and 4
During Sessions 3 and 4, we (1) complete the trauma history exploration if it was not completed during the first session, (2) provide psychoeducation about PTSD and the rationale for exposure homework, (3) assign exposure homework, and (4) provide psychoeducation on learned helplessness and the importance of a solution-oriented attitude—as opposed to an attitude which focuses on reasons why problems can’t be solved.

Session 5 to Session 7 or 8
Two to three sessions are usually devoted to addressing guilt. Cognitive Therapy for Trauma-Related Guilt (Kubany & Manke, 1995) includes three phases: (1) guilt assessment, (2) guilt incident debriefings, and (3) cognitive therapy proper, which involves “exercises in logic” for correcting thinking errors that lead to faulty conclusions associated with guilt. The thinking errors are addressed in the context of four separate, semi-structured exercises in which clients are taught to distinguish what they knew “then” from what they know “now” and for reappraising perceptions of justification, responsibility, and wrongdoing (in light of beliefs held and knowledge possessed when the trauma occurred). Cognitive Therapy for Trauma-Related Guilt includes considerable psychoeducation, particularly in its early stages. In later stages of this intervention, therapist and client are actively involved in assessing the client’s beliefs and considering alternative explanations.

Sessions 7 or 8 to Session 10
Latter CTT modules focus on self-advocacy issues and empowerment. These modules involve: (1) training in how to differentiate between assertive and aggressive speech and how to be assertive in response to verbal aggression, (2) how to identify potential perpetrators, (3) how to handle or manage interpersonal harassment or unwanted contacts with anyone (including former abusive partners), and (4) psychoeducation on self-advocacy strategies.

Session 11 and 12
If the core CTT curriculum has not been completed in 10 sessions, Sessions 11 and 12 are used to complete the core curriculum. If the core curriculum has been completed in 10 sessions, Sessions 11 and 12 will be used to expand on completed modules and/or used to conduct optional modules. Optional modules address (1) decision making (e.g., related to employment, moving, etc.); (2) trauma-related anger management; (3) how to address an old or persistent interpersonal problem (e.g., how to confront a relative who molested the client as a child; conflict with a work supervisor or co-worker; chronically negative phone conversations with a parent), and (4) additional grief work, which includes critical incident debriefings. Which optional modules are covered will depend upon relevance to the client.

Effectiveness of CTT

Study 1 (Kubany et al., 2003)
In an initial study to examine the efficacy of CTT, 37 ethnically diverse, formerly battered women were randomly assigned to an immediate CTT group or to a delayed CTT group (Kubany et al., 2003). There were no significant reductions in PTSD or depression symptoms among women in the delayed CTT condition over the six-weeks between the first and second pre-therapy assessment. Dr. Kubany was the therapist for all 37 women. Eighty-six percent of the 37 women completed the CTT protocol. Of the 32 women who completed CTT, PTSD was removed as a diagnosis in all but two of them—with an average 83% reduction in PTSD symptom severity. Compared to pre-therapy assessments, there were also substantial reductions in depression (83% on average), trauma-related guilt (83% on average), trauma-related guilt cognitions (82% on average), and shame (72% on average). Self esteem scores increased an average 92%. All gains were maintained at three-month follow-up assessments.

Study 2 (Kubany et al.,2004)
Study 2 utilized the same design as Study 1. Participants were randomly assigned to an immediate CTT group or to a delayed CTT group, who were assessed twice prior to receiving CTT (with a 6-week delay). The sample size was considerably larger in Study 2 than in Study 1 (125 participants versus 37 participants). Study 2 employed seven therapists versus only one in Study 1. In addition, follow-up assessments were conducted at six months as well as three months post-therapy in Study 2.

Characteristic of the Women Who Participated in Study 2

While the characteristics of the samples in Studies 1 and 2 were similar, we will describe the Study 2 sample in some detail to give you a more complete picture of the profiles of the women we have treated. Our participants’ levels of education ranged from 5th grade to a doctorate, with an average of 13.5 years of educational attainment. Participants’ ethnic backgrounds were diverse, including White (66), Native Hawaiian (11), Filipino (9), Japanese (8), Black (6), Samoan (6), American Indian (2), and other or mixed ethnicity (17). All participants had been physically, sexually, and/or psychologically abused (e.g., threatened, stalked, badgered, and/or humiliated) by an intimate or romantic partner. Sixty-eight percent of the sample reported having been physically hurt by intimate partners more than five times, and half had been physically hurt by more than one intimate partner. Even the small number of participants who did not report being physically hurt by an intimate partner were traumatized by other forms of partner abuse. For example, of the nine women who were not physically hurt by an intimate partner, three were sexually abused, five were stalked, and seven were threatened with death or serious bodily harm.

Most participants had been in long-standing relationships with their abusive partners; the average period of time from the first to the last incident of abuse was 6.3 years. Among participants who had been physically abused by an intimate partner, the last incident of abuse occurred an average 5.0 years prior to entering the study.

Most participants reported histories of multiple traumatizations in addition to partner abuse. Participants reported experiencing intense fear, helplessness, or horror in response to an average 9.0 types of events listed on the Traumatic Life Events Questionnaire. More than half the women had witnessed family violence while growing up, and more than half had been physically abused while growing up. In addition, more than half the women had been sexually abused before age 13. Finally, one-fourth of the women had had miscarriages that were traumatic, and more than one-third had had abortions that were traumatic.

Women qualified for participation if they (1) had been out of an abusive relationship for at least 30 days with no intention of reconciling, (2) had not been physically or sexually abused or stalked by anyone for at least 30 days, (3) met diagnostic criteria for partner-abuse-related PTSD, (4) had moderate or greater abuse-related guilt, (5) were not currently abusing alcohol or drugs, and (6) did not have schizophrenia or bipolar disorder. While participating in the study, women were not required to discontinue other services (e.g., other therapy, support groups) or prescription medication. Therapists and Therapist Adherence to CTT Procedures

CTT was conducted by Dr. Kubany and six other individuals—one man and five women (including Ms. McCaig)—whom were trained to conduct CTT-BW by Dr. Kubany. The man is a clinical psychologist with postdoctoral training in PTSD. Among the women, two have advanced degrees in nursing, one has a Masters degree in counseling psychology and works as a victim witness advocate (Ms. McCaig), and two have bachelor degrees and several years of experience in the field of domestic violence as counselors and educators. All the therapists had completed multi-day workshops on domestic violence.

The therapists were provided intensive training and ongoing supervision in conducting CTT from Dr. Kubany. CTT was conducted following a preliminary 55-page procedural manual and 30-page therapist-client workbook. Therapists used and followed the manual and workbook in therapy sessions. All therapy sessions were tape-recorded. Using CTT therapist-adherence rating scales, therapist adherence ratings were obtained for 60 randomly selected therapy sessions. The adherence ratings indicated that all seven therapists reliably adhered to CTT procedures.

Treatment Outcomes in Study 2

The result of study 2 were very similar to those obtained in Study 1. For example, PTSD and depression among women in the Delayed CTT condition did not diminish over the six weeks between their first and second pre-therapy assessments. However, 87% of women who received post-therapy assessments after completing CTT no longer met diagnostic criteria for PTSD—with corresponding reductions in depression, guilt, and shame, and significant increases in self-esteem. Therapeutic improvements were maintained at 3- and 6-month follow-up assessments.

Discussion of Studies 1 and 2

There were several findings—in addition to the overall results—which may add to the significance of Studies 1 and 2, considered together. First, 94% of women who completed CTT in Study 1 no longer met the DSM-IV PTSD numbing/avoidance criterion (criterion C) at the post-therapy assessment. And 85% of the women who completed CTT in Study 2 no longer met criterion C at the post-therapy assessment. These findings are noteworthy because PTSD treatments have in general been most successful in reducing intrusive symptoms but have been less successful in eliminating numbing and avoidance symptoms (e.g., Solomon et al., 1992; Blake & Sonnenberg, 1998).

A second additional finding that may enhance the significance of this research is that CTT resulted in positive outcomes across an educationally and ethnically diverse group of women. For example, CTT worked as well with ethnic minority women as it did with White women. In Study 1, all 14 ethnic minority participants and 16 of 18 White participants no longer met diagnostic criteria for PTSD at the post-therapy assessment. In Study, 2, 86% of ethnic minority participants and 88% of White participants who completed CTT-BW no longer met diagnostic criteria for PTSD at the post-therapy assessment. Kubany et al. (2003) speculated that CTT-BW may have been efficacious across ethnic groups because (1) PTSD is a universal problem with similar manifestations across ethnocultural contexts, (2) male dominance and female disempowerment is a problem in virtually all cultures (Heise, Ellsberg, & Gottemoeller, 1999), and (3) the individual therapy format of CTT-BW may have minimized the effects of cultural factors that would be accentuated in a group therapy format (e.g., related to willingness to self-disclose highly personal guilt- or shame-related experiences in a public or group setting).

A third additional finding that may enhance the significance of this research is that excellent outcomes were achieved by therapists with no formal psychotherapy training, and two of the therapist have only bachelor’s degrees. These findings may have important public health implications because the majority of victim services providers who counsel and conduct support groups for battered women are paraprofessionals with no formal training in psychological or psychiatric counseling. Such individuals represent a large potential pool of individuals who could be trained to conduct CTT.

Finally, excellent outcomes were obtained by the male therapists as well as the female therapists. In most treatment-outcome studies of PTSD in abused women, the therapists have all been women (e.g., Resick et al., 2002). Our findings suggest that male therapists may not be sufficiently utilized in PTSD programs for women (some women may actually prefer and do better with a male therapist), and call for research that examines the effects of therapist gender in treatments of abused women.