Introduction

Violence against women has increasingly been recognized as a serious problem affecting large numbers of women (Levensky et al., 2003). Data from a National Survey indicates that approximately 35 percent of women were the victim of domestic violence in the United States (Black et al., 2011). Data also suggests that once a woman is battered, she is likely continue to be battered by the same partner; and this violence tends to escalate in frequency, intensity, and severity (e.g., Fritz et al., 2004). Furthermore, women who have experienced emotional, sexual and/or physical abuse often exhibit increased individual distress: they frequently report depression, anxiety, post-traumatic stress disorder, and higher suicide risk (Black et al., 2011).

Emotion regulation difficulties have been identified as core problems of intimate partner abuse victims (Iverson et al., 2009). Emotion dysregulation is defined as deficit of one’s ability to experience, express and manage emotions (Fruzzetti et al., 2003; Gross et al., 2006) and this appears to lead to dysfunctional coping responses such as poor decision making, interpersonal problems, impulsivity, psychological distress, and substance abuse (Linehan, 1993a).

Dialectical Behavior Therapy (DBT) was originally developed to treat chronic emotion dysregulation problems of borderline personality disorder to help them to use emotion regulation, mindfulness, and interpersonal and distress tolerance skills (Linehan, 1993a). Researchers have shown that DBT is effective not only to treat suicidality and self-harm behaviors, but also other problems related to emotion dysregulation including depression, substance abuse, and eating disorder (e.g., Linehan et al., 1991; Telch et al., 2001; Chapman, 2004). Considering pervasive emotion regulation difficulties of intimate partner abuse, the Domestic Violence Treatment Program at University of Nevada, Reno was developed specifically to treat female victims of domestic violence. The program is a group format, is free, and lasts for 12 sessions. This program teaches Dialectical Behavior Therapy (DBT) skills to help victims to learn skills related to emotion regulation. Five factors of comprehensive DBT are mindfulness, distress tolerance, validation, interpersonal effectiveness, and emotion regulation skills. Women are taught those skills in order to manage their emotions, maintain safety, and make effective decisions. Domestic violence victims who completed the program reported significant decrease on depression, hopelessness, and general psychiatric distress and significant increase on social adjustment and emotional well-being. Consumer satisfaction with the treatment was also high (Iverson et al., 2009).

Despite the utility of our group treatment for female victims of domestic violence, the drop-out rate between intake and completion range from 50% to 70%. Even among victims who are court-ordered for group treatment after experiencing domestic violence, only about 50% attend the first session. High drop-out rates are a consistent problem among similar treatment programs across the country (e.g., Van Minnen et al., 2002). Unfortunately, the literature does not specify which approach works best for what population to decrease dropout rate.

1. Enhanced commitment strategy

In DBT, commitment is a key concept of therapy and targeted to be reinforced throughout treatment. Commitment strategy needs to be covered both before beginning treatment and consistently after treatment starts (Linehan, 1993a). For this study, commitment strategies were developed to target drop-out rate of domestic violence victims based on DBT principles. Researchers have identified that certain commitment strategies are more effective than others in terms of psychotherapy in DBT. For example, the use of pros and cons, cheerleading while generating hope, and principles of shaping including the devil’s advocate technique, foot-in-the-door, and door-in-the face are known as effective (e.g., Ben-Porath, 2004; Lew et al., 2006). Not only including those strategies, we also added problem solving regarding attending treatment sessions. This is due to their high dropout rate related to chaotic lives regardless how much women victims wanted to attend the treatment. Lastly, we emphasized validating emotions to build rapport considering intimate partner abuse victims’ common emotional experiences of shame. One of the authors with more than 20 years of DBT experience with intimate partner abuse victims developed commitment strategies following literature and treatment experience. In this study, commitment strategies largely address 1) increasing mindfulness of the client’s goals vis-à-vis treatment by highlighting pros and cons of treatment, 2) exploring client’s previous treatment experiences including what was helpful, and what was not helpful, 3) solving potential barriers to attending sessions, and 4) noticing and validating any emotional difficulties clients might have that could interfere with participation including anxiety, fear, or shame. The therapist adds appropriate skills coaching at each level how to manage potential/current difficulties (Table 1). This intervention can help clients to be mindful about their goals of getting treatment and to reduce any potential problems. Therefore, client can be more engaged in getting treatment and is more likely to attend consistently.

Table 1

Enhanced commitment strategies.

Goal setting	Contrast pros and cons
	Increasing mindfulness of goals
Evaluation of previous treatment	Whether client has previous treatment experiences
	Evaluate what was helpful and not helpful
	Evaluate what got in the way to participate
Potential barriers	Anticipate what gets in the way of participating
	Problem-solving and rehearsal
Focus on emotion	Therapist validates clients’ emotions and increases self-validation
	Therapist helps client manage emotion that might get in the way

Materials and Methods

1. Participants

Participants were women who call seeking services from a domestic violence treatment program. Because many agencies refer clients to this program regularly, there was no active recruitment specifically for this study. Participants were referred from crisis centers, local domestic violence shelters and agencies for domestic violence victims, protection order offices, and city and county courts.

2. Measures

The impact of the enhanced commitment strategies was evaluated by tracking the following dependent measures.

1) Mean number of session attendance

Participants’ mean attendance rate was recorded.

2) Overall group attendance

This is sum of the sessions attended for each participant during the 12 session program.

3. Procedures

When potential participants contacted the clinic, all were given the standard initial screening over the telephone. The selection criteria for participation in this study were: 1) to initiate/agree to participate in the women victims of domestic violence program; 2) be at least 18 years of age; 3) not be currently suicidal (if suicidal, women were referred for other, more intensive services); and 4) fluent in reading and speaking English. Participants who met eligibility requirements were randomly assigned in order to the “Standard Assessment” (SA) condition or the “Enhanced Commitment” assessment (EC).” EC group participants received a brief enhanced commitment intervention during their intakes. Once the intakes were complete, the intervention component of this study was complete. All participants then entered the same treatment and no further differences in procedures or care were employed (Fig. 1).

Fig. 1

Procedures of the study.

4. Standard assessment procedure

1) Phone screening

If participants meet the criteria of this study during the initial phone conversation, they were randomly assigned to either the SA or EC conditions. In the remaining few minutes on the telephone, they were asked to provide brief information, including, 1) phone number and 2) address as a way to keep contact information. The therapist finished this brief phone conversation after scheduling an in-person intake appointment with participant and answering any questions she might have had.

2) Campus intake

When participants showed up for their campus intake, therapist asked participants about: 1) demographic information including their age, race, education, employment status and annual income, 2) how they heard about this program, 3) their abuse history (e.g., type, perpetrators, duration, and severity), 4) presenting problems (still in relationship? if not, any remaining issues including divorce, childcare problems), 5) previous counseling experiences, 6) participant’s current coping strategies, 7) social support system, 8) academic/work functioning, and 9) medical problems, 10) psychological difficulties, and 11) current or pending legal issues. Specific details about the group treatment including its goals, structures, session schedule, and contents were given to the participants, and campus intake was completed after participants had a chance to have their questions answered.

5. Enhanced commitment strategies procedures

1) Phone screening

Subjects in the EC condition received the same phone intake protocol.

2) Campus intake intervention

In this study, to establish domestic violence victims’ better treatment engagement, a very brief intervention (typically less than 10 minutes) based on DBT commitment strategies (Linehan, 1993) was developed. When participants attended their campus intake, brief and specific commitment strategies were added at the end of standard intake to increase the likelihood that clients would attend treatment sessions. Individualized goal setting, previous treatment experiences (if relevant), and potential barriers to attending treatment were addressed.

First of all, the therapist oriented participants to identify reasons for seeking treatment and goals of participating in the program. Participants could then be mindful of their goals and perhaps more able to anticipate barriers to participation, hence more likely able to reduce those barriers and achieve their goals. Participants were also asked about advantages and disadvantages of joining the group treatment (pros and cons), and some attention was paid to highlighting pros and trying to problem- solve cons to minimize their potential for interference. It was rare for participants to identify more disadvantages (such as time and effort, and/or feeling overwhelmed in their life with one more obligation). However, in those cases, the therapist normalized their feelings about these disadvantages and helped clients to see the big picture, including their own goals. Of course, women were supported in whatever decision they wanted to make, and the option of participating at a later date was always available.

The second topic was to evaluate participants’ previous treatment experiences. Some participants had received prior psychological treatment, including individual therapy, couples counseling, or support groups for victims of domestic abuse. It was important to know what had been helpful and had not been helpful in order to help participants engage actively in the current treatment. Similarly, if participants had never encountered any psychological treatment it was possible that they had inaccurate ideas about what treatment would involve, and the content and the processes of the treatment program were explained as needed.

Therapists and participants also worked on identifying potential problems that might interfere with participation. Typically, there were two types of potential problems: 1) practical environmental problems such as lack of reliable child care or transportation, and time conflicts with other activities; and 2) negative emotional reactions or experiences, including fear related to their partners (e.g., “how would he react if he found out I am attending a women victim’s group?”), social anxiety about a new environment and meeting new people, ordinary depression, suspicion about trying treatment, shame about herself or her situation (including self-invalidation by minimizing her own difficulties and suffering), or worrying about being labeled as a victim. By orienting them to a wide range of possible problems, participants were able to become mindful about potential difficulties, hopefully with less stigma, and the therapists helped them to solve the problems and minimize interference whenever possible. For example, when a participant had some practical concerns like child care, the therapist helped her to find a baby sitter from her family, friends, and neighbors, or gave her community resources. Role playing or imaginal rehearsal was employed to help make their efforts more effective. In cases in which women had emotional barriers (e.g., anxiety, fear, shame, and depression), the therapist noticed and validated their emotions and helped them both to be aware of their emotional experiences and to validate themselves (and not judge or criticize themselves). Of course, emotional support and validation were used through the whole intervention for all women (regardless of their randomized group). But, during this intake process, therapists paid extra attention to participants’ negative emotions (e.g. shame, anxiety, and sadness) and tried to normalize and validate them. Commitment strategies ended with summarizing goals of participants, possible difficulties, and solutions.

Although there were many possible ways to try to enhance commitment, in practice most women only identified one or two barriers, if any. Hence, the time spent in the intake process on commitment was typically only a few minutes (always less than 10 minutes).

Results

1. Demographic information

Demographic information and abuse history of those 47 women who participated in this study are described in Table 2. Among those 47 women, 49% reported physical abuse (with concomitant psychological abuse); 4% reported sexual (and psychological) abuse; 21% reported psychological abuse only; and 26% reported all of the above. The age range for this sample was from 20 to 60 years old, with 30.9% in their 40s, and 29.4% in their 30s. Seventy-five percent were Caucasian, and 16.2% were Hispanic. About 69.6% of women earned less than $10,000 annually. Women who had some college education was 39.7%, and 32.4% had high school degree. Additionally, 20.6% reported having been in an abusive relationship for less than 1 year and 41.2% reported having been with abusive partners for 1-5 years and. The percentage of women who reported being abused by a current or former husband was 64.7%. Fifteen percent was still with the abusive partner (reported they are safe in the relationship) and 85% (n=40) had already left their abusive partner, regardless of legal status (e.g. even though they are married legally). There was no significant difference on homogeneity between standard and EC group on age, income, period of abuse, and waiting period for treatment (see Table 3).

Table 2

Demographic information and abuse history of participants.

Age		Race		Annual income		Education
20 s	27.9%	Caucasian	75%	<$10,000	69.6%	Some high school	39.7%
30 s	29.4%	Hispanic	16.2%	$10,000~$15,000	3%	High school degree	32.4%
40 s	30.9%	Asian	4.4%	$15,000~$20,000	8.8%	GED	10.3%
50 s	11.8%	African American	1.5%	$20,000~$25,000	14.7%	Some college	39.7%
		Native American	1.5%	≤$25,000	3%	College	10.3%
						Graduate level degree	1.5%
Abuse type		Abuser		Period of abuse		Current status
Physical and Psychological	49%	Current or former husband	64.7%	<1 year	20.6%	With the abusive partner	15%
Sexual and Psychological	4%	Boyfriend or ex-boyfriend	31%	1~5 years	41.2%	Left the abusive partner	85%
Psychological only	21%			6~10 years	14.7%
All of the above	26%			11~15 years	13.7%
				≤15 years	1.5%

Table 3

Comparison of pre-treatment homogeneity between standard and EC group on age, income, period of abuse, and waiting period for treatment.

	Group	N	Mean (SD)	Levene test for	t-test for
				equality of variance	equality of means
				F	t
Age	Standard	36	37.70	.392	−.185
	EC	32	38.16
Income (1=$5,000)	Standard	36	2.35	2.271	1.136
	EC	32	1.87
Period of abuse (years)	Standard	36	6.30	.449	.394
	EC	32	5.62
Waiting period for treatment (week)	Standard	36	5.22	2.106	1.102
	EC	32	4.04

2. Attendance

Out of 47 women, 25 women (53.2%) participated in the first group treatment session. Six women did not attend the first session, but did attend one or more later sessions. Thus, 31 women (65.9%) attended at least one session, and the drop-out rate between campus intake and treatment completion was 34.1% overall (see Table 3).

There were no significant differences between the SA and EC groups regarding mean numbers of sessions attended (χ² (1, N=47)=.72, ns 5.5 vs. 5.5) during the 12 week treatment program. Overall completion rate (with completion defined as attending at least 2/3 of sessions) from among those who attended any session(s) (n=31) was 27.8% (n=5 out of 18) in SA, while those in EC completed the program 46.2% (n=6 out of 13) of the time. Perhaps due to the modest sample size (n=31), this difference was not statistically significant (χ² (1, n=31)=1.11, ns). Nevertheless, 72% of SA dropped out and 54% of EC dropped out, suggesting a trend toward a greater completion rate in EC.

Table 4

Completion rate of standard and EC intervention.

		Campus intake	Completion out of intake	Completion out of attending at least one session
Standard	N=36	N=25	5/25=20%	5/18=27%
EC	N=32	N=22	6/22=27%	6/13=46%

3. Barriers to attendance

During their intake evaluation, therapists helped participants in the EC group to identify further potential barriers and problem- solve them using any resources available to them. Reasons and goals were further highlighted, and those who had high negative emotional arousal were given ideas and strategies for managing these emotions Out of 23 women in the EC condition who attended an intake, 9 anticipated no problems coming to sessions regularly; 3 (33%) out of these 9 did not attend the first session. The other 14 women identified at least one problem during the EC intervention and tried to reduce or solve whatever problems they identified. However, 8 (57%) of them did not show up for the first session. A few women who dropped out stated that they had unexpected problems even though a difficulty they identified did not get in the way. One moved out of state unexpectedly, one reported no money for gas (although free bus passes were available), one reported being too busy with her divorce process, and one could not get a baby sitter. These kinds of factors reflect the ordinary but chaotic lives of women with domestic violence. The other participants who dropped out could not be contacted for further assessment because they had changed their phone numbers or did not return to therapists’ calls.

Discussion

This study used enhanced commitment strategies only during the intake (a very brief intervention, less than 10 minutes) to attempt to increase participation and overall retention rates (reduce drop-out). Limiting commitment interventions to the intake was done to avoid cross-group contamination of effects (women in both SA and EC attended the same groups). Although there were no statistically significant differences between two groups regarding average number of sessions attended and overall completion rates, participants in EC condition who attended any sessions showed a higher completion rate compared to participants in SA (46% vs. 28%, respectively). This does suggest some potential benefits of the EC procedures.

At least three issues are relevant in understanding these results: 1) modest statistical power; 2) the brevity of the intervention; and 3) the high levels of chaos and significant number of both instrumental and emotional challenges that abused women face. We will discuss each in turn.

The first issue is statistical power. The finding of 28% completion (SA) vs. 46% completion (EC) among those women who attended any sessions may reflect a meaningful difference, possibly obscured by the modest sample size (31 women attended at least one session). Thus, there is not yet enough power to demonstrate this difference reliably. However, given that the number of sessions did not differ between groups, nor did overall completion rates, this emerging difference must be viewed with caution. The interventions in this study should be further evaluated with a larger sample size.

Perhaps more important is the question of the sufficiency of the intervention itself. The “dose” of the intervention (just a few minutes during the intake evaluation) might be too weak or insufficient, and a more sustained attempt at enhancing commitment may be more effective. Intervention which takes less than 10 minutes during the intake just may not have been enough to make a difference throughout 12 sessions.

Thus, one remedy might be to construct the intervention to be somewhat bigger initially perhaps adding a commitment telephone call between sessions extending the intake so that more systematic attention is focused on the three commitment areas (practical barriers, emotional barriers, and awareness of goals and values). In addition, rather than limit attention to commitment to the intake period, each group could include a few minutes of commitment- focus. This could be done on a rotating basis (a couple of participants per group, then different ones the following session, etc.), or could be modeled and done as an exercise, with women broken down into pairs or sets of 3, to target increasing or maintaining commitment for a few minutes together. In addition, one of the group therapists could utilize commitment strategies between sessions, especially for women who have missed a session. A subsequent study should address each of these “dose enhancements,” either separately or as a package, with the hope that the mildly promising trend in this study could be enhanced into more meaningful increased participation and lowered dropouts, allowing more women to benefit from the intervention program.

In addition, participants’ chaotic lives could be a significant interfering factor with any attempts to increase attendance. This may be exacerbated by the small dose of commitment offered in the present study. Because unexpected problems came up quite often, and women in the program report consistently high levels of instrumental and emotional difficulties, it is important to recognize how disempowered these women likely experience themselves. For example, more than 2/3 of women in the study earned less than $10,000 annually, and only 3% earned more than $25,000 annually. Many women who participated no longer lived with their abusive partner. However, in many of these cases one consequence of this was extreme financial hardship and including genuine poverty. And, one of the common ways that abusive partners exert control is financially (e.g., controlling access to bank accounts, controlling what bills get paid, controlling money for transportation, child care, and so on). We should not underestimate the effects of not having a safe place to live, not being able to live independently, having so few financial resources that housing, childcare, and transportation cannot be relied upon, and other consequences of having few resources and/or living in an abusive environment. Future studies should evaluate these barriers explicitly, to begin to understand the experience of women in these situations, which may help develop interventions that are more effective in helping them to participate in needed services.

In summary, results from the present study do not provide any conclusive evidence that the enhanced commitment DBT interventions decreased drop-out rates overall for women victims of domestic violence. Although this study did not show statistically significant effects from the intervention, findings do suggest that the current intervention may be helpful in decreasing drop-out rate and increase completion rate, especially if they are made more substantive and are offered not just briefly during the intake procedure, but throughout the intervention program. The commitment interventions are both simple and cost-effective, and could be expanded throughout the treatment program with little additional expense. With refinement, this could be a very cost-effective intervention tool, broadly applicable to economically impoverished and psychologically distressed women to help them receive needed interventions.

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Figure & Data

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