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Cognitive Trauma Therapy for Battered Women (CTT-BW)

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Sarah Chavez

on 6 November 2013

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Transcript of Cognitive Trauma Therapy for Battered Women (CTT-BW)

Cognitive Trauma Therapy for Battered Women (CTT-BW)
Issues in Referral and Methods of Engagement
CTT-BW was designed for women who are no longer in abusive relationships, who do not intend to reconcile with an abusive partner, and who are, for the most part, safe.
Complicated by: attachments to abusive partners, risk for revictimization by subsequent partners, vulnerability to guilt and shame*
if following assessment PTSD and *trauma-related guilt are present

Treatment Plan & Goal
TREATMENT PLAN:Although no "treatment plan" is explicitly outlined, there are 20 modules that can be tailored in order and use for particular client's need

GOAL: CTT-BW is aimed at alleviating PTSD, depression, guilt, and shame, and at elevating self-esteem in formerly battered women
What is CTT-BW?
CTT-BW is a combination of:
cognitive-behavioral therapy (exposure therapy, cognitive restructuring)
relaxation training

A multi-component, cognitive-behavioral intervention aimed at alleviating PTSD, depression, guilt, and shame, and at elevating self-esteem in formerly battered women.

Continuum of Care: Treatment (current PTSD Sxs and Prevention (future abuse)
The course treatment includes fifteen modules that are used with all clients, five optional modules addressing issues that may be less relevant for some clients and a closing module used with all clients. Some module topics include:
psychoeducation about PTSD
stress management (including relaxation training and homework practice)
self-monitoring of maladaptive thoughts and speech
talking about the trauma and imaginal and in vivo exposure homework.
Engagement and Client Diversity
The authors, Kubany & Ralston, believe CTT-BW is tailored "meet the needs of the great majority of women" and has been proven successful "regardless of ethnicity or level of education" (Kubany & Ralston, 2008)

However, typically conducted in a one-on-one format it may also be used in group settings, which could complicate efficacy

Assessment Framework
• Telephone Screening:
Hx of partner abuse and how long she’s been out of an abusive relationship
PTSD symptoms, particularly *abuse-related guilt

• If screening reveals she is not experiencing PTSD symptoms or is currently involved in an abusive relationship, she ordinarily is not accepted for CTT-BW treatment.

Secondary Modules
(1) psychoeducation on coping strategies that promote self-advocacy in specific areas of functioning (e.g., placing oneself first, decision-making that promotes personal happiness)
(2) assertiveness
(3) managing unwanted contacts with former partners
(4) identifying potential perpetrators and avoiding revictimization
Assignments include:
(1) studying PTSD symptoms
(2, 3) identifying harmless trauma reminders that are distressing or avoided, and imaginal and in-vivo exposure to these reminders
(4) self-monitoring and self-regulating negative self-talk
(5) listening to audiotapes of the sessions
(6) listening to a relaxation audiotape
(7) practicing relaxation techniques when stressed
(8) reading a brief article on "thinking errors, faulty conclusions, and cognitive therapy for trauma-related guilt" (Kubany, 1997)
(9) writing about the personal relevance of 25 cognitive and behavioral coping strategies directed at self-advocacy and self-empowerment
Assessment Framework, contd.
• Two additional instruments are considered essential to the practice of CTT-BW:

the Traumatic Life Events Questionnaire (TLEQ): assesses prior exposure to a broad range of traumatic events.

the Attitudes About Guilt Survey (AAGS): 7-item questionnaire used to assess the presence and magnitude of guilt and guilt cognitions
Contracting Issues
Manualized - Has a linear structure
Later modules build upon preceding ones
Individual Tx lends itself to flexibility

Core Intervention Phase
Sessions 5-10: "Cognitive Tx for Trauma-related Guilt" consists of 3 phases:
Guilt-issue assessment - During guilt-issue assessment, partner-abuse-related guilt issues are identified by means of a structured interview, which probes about specific sources of guilt
Guilt-incident debriefing exercises
Cognitive therapy
Modules within Core Phase
Cognitive Tx for Trauma-related Guilt Modules include:
• Mini-module on challenging "guiding fictions" or "supposed to" beliefs.

• Assertiveness module

• Module on how to identify potential perpetrators and avoid revictimization

"Supposed to" Values or "Guiding Fictions" Mini-module
Assertiveness Module
Goals: (1) to increase speech awareness and (2) learn how to respond assertively
Focus is on *style* of assertive message, not content
Thx and client take turns reading aggressive statements and assertive replies
i.e. "You're selfish."
"I don't deserve to be talked to that way."
Module on How to Identify Potential Perpetrators and Avoid Revictimization
Learn ways to identify potentially abusive men

Signs: possessiveness, jealousy, rushing into serious relationship, unreliability, always wanting to know gf's whereabouts, overcontrolling re. who, how, where she spends her time, microaggressions, imposing opinions and world views, known to have been physically aggressive or have a "bad temper", hx of heavy alcohol or drug use
Strategies to Assess for Potential Abusive Behavior
Clients are taught to provoke conflict
Saying "No" w/o saying why
Wanting to talk about his prior relationships and why they didn't work out
Express disagreement
Insist on something she would like
Being available only infrequently for the first several weeks or even months of a relationship

When provoked or confronted w/ conflict, bf will reveal his "true colors"
Culturally Competent Tx
The authors indicate that the flexibility of modules allows for individual Tx tailoring based on presenting symptomatology

Research indicates that children and adolescents-of-color from lower SES are at an increased risk for trauma exposure and later development of PTSD
Emphasis on trauma-related guilt modules considers the likelihood that presenting PTSD Sx may be a result of early childhood trauma --> is addressed in module
Tx ends following the final module: Coping strategies
Review coping strategy homework assigned at first session and second to last session
Cognitive shifts are demonstrated and can be seen homework juxtaposition
Clt no longer meets criteria for PTSD
Treatment-outcome assessment
(a) the Distressing Event Questionnaire measuring PTSD
(b) the Beck Depression Inventory,
(c) the Trauma- Related Guilt Inventory,
(d) the Sources of Trauma-Related Guilt Survey--Partner Abuse Version,
(e) the Rosenberg Self-Esteem Scale,
(f) the Personal Feelings Questionnaire, which includes scales of guilt and shame proneness.
Issues in Worker-Client Relationship
Research indicates sexual assault trauma plays a significant role in repeat traumatization --> Avoid victim-blaming

Childhood sexual abuse trauma can interfere with social development, which affects the worker-client relationship
May require additional attention with developing interpersonal and emotional regulation skills (may be evidenced in worker-client relationship)
Methods of Follow-up
No follow-up built in to Tx implementation

Follow-ups conducted at 3- and 6-months were the same used in treatment-outcome assessments
Role as Social Worker
Understanding unique stresses of the public social service and assistance system as a potential additional barrier (person-in-environment)
A non-judgmental approach to working with survivors of abuse in order to communicate genuine empathy, thus increasing the therapy’s success
Related value judgments, w/ Freudian or Psychodynamic undertones, include references to the women as in denial or codependent, labels with pejorative connotations
Treatment-Outcome Assessment:
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