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Kristen Moeller-Saxone, Elise Davis, Donna E. Stewart, Natalia Diaz-Granados, Helen Herrman, Promoting resilience in adults with experience of intimate partner violence or child maltreatment: a narrative synthesis of evidence across settings, Journal of Public Health, Volume 37, Issue 1, March 2015, Pages 125–137, https://doi.org/10.1093/pubmed/fdu030
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Abstract
People who have experienced intimate partner violence (IPV) or child maltreatment (CM) are at risk of having lower resilience and adverse psychological outcomes. In keeping with the social and environmental factors that support resilience, there is a need to take a public health approach to its investigation and to identify existing initiatives in particular settings and populations that can guide its deliberate promotion.
This narrative synthesis examines quantitative and qualitative studies of interventions with resilience-related outcomes in specified health and other settings. Clinical RCTs are excluded as beyond the scope of this review.
Twenty studies were identified for review in several settings, consisting of 14 quantitative studies, 2 review studies, 2 qualitative studies and 2 mixed-methods studies. Three quantitative studies produced strong evidence to support: a home visitation program for at-risk mothers; a methadone program for women and a substance abuse program. This review reveals that few studies use specific resilience measures.
The topic has been little studied despite high needs for public health interventions in countries of all types. Interventions and research studies that use specific resilience measures are likely to help measure and integrate what is currently a disparate area.
The participation of people with IPV or CM history in program and research design and implementation is indicated to support advocacy, innovation and sustainable interventions. This is especially pertinent for interventions in LAMIC and indigenous settings where continuing programs are sorely needed.
Introduction
Resilience is defined as ‘a dynamic process in which psychological, social, environmental and biological factors interact to enable an individual at any stage of life to develop, maintain or regain their mental health despite exposure to adversity’.1 People who have experienced intimate partner violence (IPV) or child maltreatment (CM) at the hands of others (IPV and CM history) are found in high prevalence at all life stages worldwide.2 IPV is defined by the World Health Organization as the exposure to physical, sexual or emotional abuse inflicted by a current or past intimate partner such as a spouse.2 CM is defined as any act of omission or commission by a parent or other caregiver that results in harm, potential for harm or threat of harm to the child and often includes physical, sexual and/or psychological abuse, neglect and witnessing IPV as children or adolescents.2 In North America, 25–45% women are exposed to IPV during their lifetime and 6–16% are exposed to IPV in the past year.3,4 In middle-to-high-income countries participating in the World Mental Health Surveys, the prevalence of CM exposure among adults was 5.3–10.8% for physical abuse, 0.6–2.4% for sexual abuse and 4.4–5.2% for neglect.5
People with this background are at risk of having lower resilience through mechanisms such as the damaging effect of increased cortisol on brain development3 and the adverse impact of abuse on social support and wellbeing.4 They are at greater risk for a host of negative mental health sequelae including depression and anxiety disorders,5,6 as well as death, injury, physical ill-health and functional impairment.7 While women and girls report higher exposure and more serious lifetime physical and mental health consequences, IPV and CM affect adults and children of both genders. Given this, there is growing realization of the need to consider interventions that promote resilience for people with this background in addition to the necessary interventions to reduce the risk of violence occurring.
There are comparatively few studies and reviews to guide and encourage such interventions.7 However, recent clarification of two key ideas about resilience gives an impetus to the development of effective clinical and public health actions: the dynamic or interactive nature of resilience throughout the lifespan; and the interaction of resilience with major domains of life function, including intimate relationships and attachments. While positive stress is important for healthy development, resilience is more likely to be acquired or present when a child or adult can avoid strong, frequent or prolonged stress, or when the effects are buffered by supportive relationships.8 Effective clinical care and public health work to develop resilience requires partnerships across health and other sectors. Clinical and public health interventions each have a role in improving the chances of resilience among children and adults affected by maltreatment and interpersonal violence and other sources of severe adversity.7,8
In keeping with the social and environmental factors that support resilience, it is highly relevant to take a public health approach to its investigation among these vulnerable groups: and identify existing initiatives in particular settings and populations that can guide its deliberate promotion. This review examines quantitative and qualitative studies of simple and complex interventions with outcome measures relevant to resilience in specified health and other settings. Clinical RCTs are excluded. They are the subjects of a separate review in progress of the effect of treatment interventions on resilience among adults with IPV and CM history who present to health-care settings; it notes a paucity of studies examining resilience outcomes following clinical interventions with adults.
Systematic reviews of mixed study methods are emerging as an effective approach to investigating complex public health needs such as this.9,10 The Cochrane Research Methods Review Group noted that meta-analyses and systematic reviews may not provide clear guidance for policy and practice, nor address the translation of research evidence into local practice. The Group advocates narrative synthesis as a way of addressing these needs while maintaining the necessary transparency and replicability using systematic review methods.11
The relevant studies are expected to have varying designs and quality of evidence. The review aims to synthesize qualitative and quantitative evidence to address the types and effectiveness of programs that promote resilience among adults with IPV and CM history; provide insight into promising new interventions and provide additional evidence for effective interventions.
Method
This review used the PRISMA Guidelines for systematic reviews that recommends the PICOS framework for developing research questions and identifying studies to include. PICOS refers to the main components of study design—Patient, Intervention, Comparator, Outcome and Study design. Therefore, this review sought to examine studies that: In this review ‘Comparator’ is optional because it aims to assess all studies that report on interventions that influence resilience in this vulnerable group including studies without a comparator.
assessed adults who had experienced IPV or CM (Patient);
assessed the impact of any intervention, program or variable associated with resilience, whether controlled or naturally occurring (Intervention) on resilience or resilience-related constructs;
consistent with the definition of resilience given above, assessed the effect of interventions, excluding individual clinical interventions, that sought to address mental health status, including addiction (Outcome);
reported any study design other than randomized controlled clinical trials of any variation (e.g. cluster, double-blind, etc.), which were beyond the scope of this review.
Exclusion criteria
Studies were excluded from the review if they used a randomized controlled trial design, where participants were children or adolescents or were adults with no history of IPV, or did not report an intervention or the intervention did not aim to promote resilience or resilience indicators.
Search terms
Combinations of PICOS terms were searched. ‘Patient’ terms—‘resilience’, ‘family violence’, ‘spousal abuse’, ‘domestic assault’, ‘battered women’, ‘child maltreatment’; ‘Intervention’ terms—program, intervention; and ‘Outcome’ terms—‘self-esteem’, ‘quality of life’, resilience, mastery, ‘social support’, suicide, violence, depress*, anx*, somat*, addiction, prison (Fig. 1).
The search was conducted using the following databases: Medline, CINAHL, Science Direct, Science Citation Index, Education Research Complete, National Criminal Justice Reference Service Abstracts and Global Health. This broad cross section of databases elicited a large number of initial hits (4766) which were scanned for eligible articles and guidance regarding search terms. Eighty-one abstracts were downloaded for assessment. Duplicates and articles that did not meet the PICOS criteria were removed and 26 full-text articles were assessed for eligibility. Six full-text articles were further assessed as not meeting the PICOS criteria. The remaining 20 articles were included in this review.
Assessment of the quality of studies
The Quality Assessment Tool for Quantitative Studies (QATQ) was used for assessing the quantitative studies.12 The QATQ rates studies on selection bias, study design, confounders, blinding, data collection methods, withdrawals and drop outs, intervention integrity and analyses to give an overall rating of strong, moderate or weak. A systematic review of assessment tools rated the QATQ as one of the ‘top tools’ available.13 Qualitative studies were assessed using Daly et al.'s14 hierarchy of evidence for assessing qualitative health research. This hierarchy rates studies on the basis of theoretical framework, sampling and data collection, data analysis and research conclusions from which four levels are derived. Level one evidence is produced by generalizable studies where sampling is focussed by theory with clear implications for practice or policy. Level two evidence is produced by conceptual studies where sampling is guided by theoretical concepts but the sample is limited and further research is needed before practice recommendations can be developed. Level three evidence is produced by descriptive studies which can be a theoretical and sampling is driven by practical rather than theoretical issues. This research identifies the existence of phenomena in particular groups and identifies practice issues. Level four evidence is provided by case studies of single cases that alerts readers to the existence of new or unusual phenomena but has the least transferability to practice. Mixed-methods studies were assessed using the Mixed Methods Appraisal Tool (MMAT).15 The MMAT separately assesses the quality of the qualitative and quantitative aspects of studies, as well as the quality of the integration of the respective methodologies. The MMAT is a promising tool that has been found to be reliable in preliminary testing.16 Studies are scored out of 100%.
Two assessors (K.M.S. and E.D.) independently reviewed the studies and discrepancies were resolved through discussion. The different types of evidence were integrated into a public health theoretical structure, focussing on settings.
Results
Twenty studies reported on resilience-related outcomes of interventions that included or were designed for people with a history of CM or IPV (see Table 1). A range of mental health, social functioning and personality measures of resilience-related outcomes were included in the review (see Table 1). Measures of mental health as an indicator of resilience promotion are justified with reference to the literature on the long-term mental health effects of CM. Herrman et al.7 note that ‘exposure to stressful events in childhood and adolescence is consistently shown to produce long-lasting alterations in the HPA axis, which may increase vulnerability to mood and anxiety disorders’. An important aspect of the need for this review is to attempt to integrate the disparate terms and measures that are used in discussing resilience promotion in this group.
Study . | Sample/group . | Intervention . | Resilience outcome . | Study design and level of evidence . | Learning and recommendations . | Challenges and issues for review . |
---|---|---|---|---|---|---|
IPV settings | ||||||
Beeble et al. (2009)19 Main, mediating, and moderating effects of social support on the wellbeing of survivors of IPV across 2 years | 160 survivors of IPV receiving support from community domestic violence programs. Women must have experienced IPV in preceding 4 months and had young children | Assessment of whether perceived social support affected the Quality of Life (QOL), depression over time | Depression, and QOL social support | Experimental design—Quality Assessment Tool for Quantitative studies (QATQ): Moderate | QOL related to psychological abuse, not physical. High levels of abuse and low social support have more severe and adverse sequelae over time | No intervention, however, this study shows the effect of ‘naturally occurring’ social support on resilience over time |
Ford-Gilboe (2011) A theory-based primary health-care intervention for women who have left abusive partners | 50 women accessing housing program for abused women (secondary reporting of pilot study of 30 women) | Intervention for Health Enhancement After Leaving (iHEAL) is a 6-month intervention that aims to strengthen the capacity to limit intrusion | Intrusion, health (including Post-Traumatic Stress Disorder—PTSD) and QoL measured | Descriptive review of program development and narrative reporting of two pilot projects. No assessment needed | Early pilot projects show promise. ‘Intrusion’ is a concept that workers found helpful. iHEAL may help with PTSD symptoms | Descriptive rather than conclusive evidence of effectiveness |
Gerlock (2004) Domestic violence and post-traumatic stress disorder severity for participants of a domestic violence program | 62 male veterans or active military who were perpetrators of IPV. Significant correlations between IPV in family of origin of perpetrator and current PTSD | IPV cognitive-behaviorally oriented rehabilitation program offered to military veterans. Groups include 4 weeks orientation, 26 weeks rehabilitation, maintenance 6 months of weekly meetings | Program completers had lower levels of stress and post-traumatic stress, higher self-ratings of relationship mutuality | Experimental design—QATQ: Weak | 61% dropped out of the program. Program completion linked to improved resilience outcomes. PTSD in military veterans related to IPV in family of origin and decreased likelihood of program completion | Male IPV perpetrators likely to also be victims of CM. Non-completion of year-long programs that increase resilience is troubling |
Gustafson (2005)20 Exploring treatment and trauma recovery implications of facilitating victim-offender encounters in crimes of severe violence: lessons from the Canadian experience | 1 case study reported of male victim of child sexual abuse | VOM program | Lower (symptom severity) PTSD scores | Qualitative study Level IV evidence | VOM reduced feelings of shame and embarrassment. Explanations for effect include neurophysiological factors | VOM appears effective in reducing offending. Small body of work on CM survivors. Research appears to be focussed prior to 2002 |
Jung and Steil (2011)23 and Steil, et al. (2011)22 The feeling of being contaminated in adult survivors of childhood sexual abuse and its treatment via a two-session program of cognitive restructuring and imagery modification: a case study | Pilot study with 9 female participants | Cognitive restructuring intervention | Reduction in ‘Feeling of Being Contaminated’ (FBC), PTSD severity and distress | (Case study) and Pilot study using cohort design. QATQ: weak | Effective on PTSD as well as FBC in small pilot. No dropouts indicate acceptability and safety. These results indicate promising intervention that needs large studies to generalize findings | |
Welfare/employment program settings | ||||||
Thompson Martin et al. (2012) Perceptions of self-esteem in a welfare-to-wellness-to-work program(USA) | Participants (n = 33) in employment program. 54.5% had the history of domestic violence, 49% addictions and 64% referred for mh counseling | Welfare-to-wellness-to-work program that emphasizes + self-esteem, increased self-care and wellness along with life skills | Self-esteem score(Rosenberg's Self-Esteem scale) and interviews | Mixed methods: Mixed Methods Appraisal Tool (MMAT)—50% | Increased self-esteem and positive reports about program. Mainly female participants (88%) | Descriptive article that evaluates factors that contribute to welfare program outcomes |
Precin (2011)24 Challenges of welfare-to-work programs (USA) | Participants (n = 1553) in welfare-to-work program for long-term unemployed with disabilities. Both intervention (41%) and control group (39%) reported PTSD/mental health with child abuse and domestic violence | Detailed assessment, training in life skills, basic education, work ‘soft’ skills, English, job skills, goal setting. Psycho-education support groups taught symptom management | Getting and retaining work | Experimental design—QATQ: weak | Article focussed on describing the experience of program. Revealed many cases of undiagnosed PTSD (frequently as a result of DV and CA) that received treatment | Highlights the complex factors that influence success rates of employment programs |
LAMIC and indigenous settings | ||||||
Apondi (2007)26 Home-based antiretroviral care is associated with positive social outcomes in a prospective cohort in Uganda | Participants (n = 1006) of Home-Based AIDS Care project. 46% experienced physical abuse by spouse/sexual partner | Antiretroviral treatment with weekly home visits by trained counsellors | Increased community support, family support and relationship strengthening. Non-significant increase in physical abuse | Experimental design—QATQ: weak | Home-based counseling service strengthens relationships at all levels. Increase in abuse may have been attributable to improved health as a result of treatment | Program not designed for IPV or CM samples, but IPV or CM history is common in this group |
Kermode et al. (2007)25 Empowerment of women and mental health promotion: a qualitative study in rural Maharashtra, India | 32 women associated with Primary Health Care project—16 Village Health Workers (VHW) and 16 village women | Comprehensive Rural Health Project (CRHP) trains volunteer VHWs and this processes empowers individuals and communities | Increased civic and social engagement; reduced discrimination and increased access to economic resources due to participation in CRHP | Qualitative study: Level III Descriptive | Due to the external nature of resilience factors (eg. Dependable husband, sex of children), mental health usually outside individual control. CRHP increased personal control by improving freedom of movement and economic participation | |
Tsey et al. (2007)27 Empowerment-based research methods: a 10-year approach to enhancing indigenous social and emotional wellbeing | Individuals and communities of indigenous Australians | Family Wellbeing Program developed through Participatory Action Research with a group of stolen-generation indigenous people and university partner. Includes counseling, addressing grief and loss | Personal empowerment—enhanced sense of self-worth, resilience, active community efforts to address family violence, substance misuse and other mental health issues | Experimental design—QATQ: weak | Program developed by community members better than programs imported from outside the indigenous community. Creates personal change that leads to community change | Review article that quotes evidence from publications outside the parameters of this review. Commentary rather than evidence in this article |
Prisons and violence program settings | ||||||
Thompson and Harm (2000) Parenting from prison: helping children and mothers | 104 female prisoners | 15-week Parenting From Prison (PFP) program that covers child development, communication and self-esteem | Index of Self-esteem (ISE), Adult Adolescent Parenting Inventory (AAPI) classifies parent potential for child abuse, frequency of visits and letters from children | Experimental design—QATQ: weak non-random sample, no control group | SE significantly improved—mediated by frequency of visits and letters from children. When the history of cm considered, SE improved but remained clinically low and improved, but non-sig. AAPI scores | |
Tollefson and Gross (2006)28 Predicting recidivism following participation in a treatment program for batterers | 197 batterers (84% male) who participated in a domestic violence treatment program. 31% of whom were victims of child abuse and 43% experienced DV in families of origin | Psycho-educational program that incorporates cognitive and skills-based interventions and feminist approach. 20 weekly group sessions | Reoffending rates | Experimental design: QATQ—moderate | Client characteristics—substance abuse, history of abuse and psych. diagnosis more important than program in determining reoffending. History of abuse related to psychiatric diagnosis | Batterer programs not effective and should incorporate treatment for substance, child abuse and psychiatric diagnosis |
Zust (2009)29 Partner violence, depression, and recidivism: the case of incarcerated women and why we need programs designed for them | Groups of 10–12 incarcerated women— (previous studies reviewed to provide evidence of effectiveness) | INSIGHT cognitive therapy group program | Reduced depression, hopelessness, increased empowerment, self-esteem. Narrative analysis reported ‘rescuing self’, returns to study and employment | Review article—no rating | IPV-related depression high in incarcerated women. Prison-based treatments favor medication due to funding constraints, yet group programs are more effective | Review draws together evidence from different groups, etc. and argues for widespread program application |
Drug and alcohol treatment settings | ||||||
Wright et al. (2012)19 Implementation and evaluation of a harm-reduction model for clinical care of substance using pregnant women (USA) | 213 substance using women (132, pregnant, 97 delivered) 55% history of CM, 62.5% history of IPV. Focus on methamphetamine users | Perinatal clinical and social services emphasis on harm minimization | Abstinence and relapse, depression, infant outcomes, maternal reproductive outcomes | Experimental design: QATQ—weak | History of domestic violence most important predictor of poor infant outcomes (AOR 5.7). Program resulted in low levels of post-partum depression; retaining custody of infant and low repeat pregnancy rates | Drug treatment improved infant and maternal outcomes; however, IPV related to poor infant outcomes |
Bartholomew et al. (2005)30 Sexual abuse history and treatment outcomes among women undergoing methadone treatment (USA) | 98 women receiving no fee outpatient methadone treatment, 40% had a history of sexual abuse and 60% no history of sexual abuse | Methadone program including counseling, medication and case management | Psychological status (incl. depression, anxiety, suicide, violence), self-esteem, drug use, family cohesion | Experimental design: QATQ—strong | Women with a history of sexual abuse more likely to report higher depression, anxiety, hostility and lower self-esteem. No differences between crime, employment and drug use | Methadone programs do not improve mental health resilience for women with a history of sexual abuse |
Morrissey et al. (2005)31, Evaluations of the WCDVS study (US) (Also refers to Cocozza et al. (2005), McHugo et al. (2005), etc. for larger study information) | 2087 women receiving treatment for substance abuse and trauma | Trauma-informed services compared with treatment as usual | Global Severity Index (GSI) from Brief Symptom Inventory for mental health status; post-traumatic symptoms severity (PSS) at 6 and 12 months | Quasi-experimental cohort analytic design: QATQ—moderate (no blinding indicated) | Both control and experimental groups improved at 6 months. PSS significant improvement, GSI non-significant improvement. Both PSS and GSI significant improvement at 12 months | Integrating counseling into services appears to have a significant effect, whereas receiving more services associated with less improvement |
Pirard et al. (2005)18 Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes | 163 (out of original 700) substance users (male and female) seeking treatment for substance use | Day treatment or residential programs to address substance abuse (but no specific trauma treatment) | Addiction Severity Index (ASI), Global Assessment of Functioning (aka DSM-IV, Axis V) | Experimental design: QATQ—strong | Participants with a history of IPV report more psychiatric treatments in 12 month follow-up after substance abuse treatment. Both groups improved drug outcomes | Substance abuse treatment addresses only addiction and does not assist with mental health resilience outcomes |
Community mental health settings | ||||||
Waitzkin et al. (2011) Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression (New Mexico) | 120 patients at Community Health Centres (CHC) with depression enrolled to receive support from Promotoras (3 trained) | Promotoras identify depression, assist patients to manage contextual sources and follow-up | Depression related to history of violence | Mixed-methods study: MMAT—75% | No statistically significant effect of Promotoras on depression, but significant implementation issues may have impeded quant. assessment | |
Min et al. (2012) Low trait anxiety, high resilience, and their interaction as possible predictors for treatment response in patients with depression (Korea) | 178 outpatients at Mood and Anxiety Disorder Clinic with depressive disorders | Standard medication treatment administered through outpatients clinic | Depression (BDI), State anxiety (SAI), Trait anxiety (TAI), Alcohol use problem (AUDIT), Perceived Stress (PSS), Resilience (CD-RISC) | Experimental design: QATQ—weak (unclear whether confounders were assessed) | Interaction between trait anxiety and resilience significant predictor of treatment outcome within 6 months. Dep. patients with both high resil. and low TA 10 times more likely to achieve treatment response. History of trauma did not influence treatment response | This study quantifies the impact of resilience on outcomes and draws attention to the role of anxiety independent of depression as a mediator of resilience |
Ammerman et al. (2009)17 Changes in depressive symptoms in first-time mothers in home visitation (USA) | 806 at-risk first-time mothers in a HVP at enrolment and at 9 months | HVP delivered by nurses and social workers provides psycho-education and case management to prevent CM and improve child outcomes. Also provides support and mental health treatment to mothers | Depression (BDI-II), Trauma Inventory (TI) to measure the history of maternal trauma; social support (SPS) and current violence | Experimental design: QATQ—strong | 74% of sample had history of IPV and 14% had concurrent IPV. History of IPV associated with higher depression scores and stable or worsening symptoms over time. Minority receive mental health treatment and HPV often only mental health treatment received | IPV and CM complicate evaluation of HVPs. HVPs should improve assessment and treatment of IPV and history of CM in mothers |
Study . | Sample/group . | Intervention . | Resilience outcome . | Study design and level of evidence . | Learning and recommendations . | Challenges and issues for review . |
---|---|---|---|---|---|---|
IPV settings | ||||||
Beeble et al. (2009)19 Main, mediating, and moderating effects of social support on the wellbeing of survivors of IPV across 2 years | 160 survivors of IPV receiving support from community domestic violence programs. Women must have experienced IPV in preceding 4 months and had young children | Assessment of whether perceived social support affected the Quality of Life (QOL), depression over time | Depression, and QOL social support | Experimental design—Quality Assessment Tool for Quantitative studies (QATQ): Moderate | QOL related to psychological abuse, not physical. High levels of abuse and low social support have more severe and adverse sequelae over time | No intervention, however, this study shows the effect of ‘naturally occurring’ social support on resilience over time |
Ford-Gilboe (2011) A theory-based primary health-care intervention for women who have left abusive partners | 50 women accessing housing program for abused women (secondary reporting of pilot study of 30 women) | Intervention for Health Enhancement After Leaving (iHEAL) is a 6-month intervention that aims to strengthen the capacity to limit intrusion | Intrusion, health (including Post-Traumatic Stress Disorder—PTSD) and QoL measured | Descriptive review of program development and narrative reporting of two pilot projects. No assessment needed | Early pilot projects show promise. ‘Intrusion’ is a concept that workers found helpful. iHEAL may help with PTSD symptoms | Descriptive rather than conclusive evidence of effectiveness |
Gerlock (2004) Domestic violence and post-traumatic stress disorder severity for participants of a domestic violence program | 62 male veterans or active military who were perpetrators of IPV. Significant correlations between IPV in family of origin of perpetrator and current PTSD | IPV cognitive-behaviorally oriented rehabilitation program offered to military veterans. Groups include 4 weeks orientation, 26 weeks rehabilitation, maintenance 6 months of weekly meetings | Program completers had lower levels of stress and post-traumatic stress, higher self-ratings of relationship mutuality | Experimental design—QATQ: Weak | 61% dropped out of the program. Program completion linked to improved resilience outcomes. PTSD in military veterans related to IPV in family of origin and decreased likelihood of program completion | Male IPV perpetrators likely to also be victims of CM. Non-completion of year-long programs that increase resilience is troubling |
Gustafson (2005)20 Exploring treatment and trauma recovery implications of facilitating victim-offender encounters in crimes of severe violence: lessons from the Canadian experience | 1 case study reported of male victim of child sexual abuse | VOM program | Lower (symptom severity) PTSD scores | Qualitative study Level IV evidence | VOM reduced feelings of shame and embarrassment. Explanations for effect include neurophysiological factors | VOM appears effective in reducing offending. Small body of work on CM survivors. Research appears to be focussed prior to 2002 |
Jung and Steil (2011)23 and Steil, et al. (2011)22 The feeling of being contaminated in adult survivors of childhood sexual abuse and its treatment via a two-session program of cognitive restructuring and imagery modification: a case study | Pilot study with 9 female participants | Cognitive restructuring intervention | Reduction in ‘Feeling of Being Contaminated’ (FBC), PTSD severity and distress | (Case study) and Pilot study using cohort design. QATQ: weak | Effective on PTSD as well as FBC in small pilot. No dropouts indicate acceptability and safety. These results indicate promising intervention that needs large studies to generalize findings | |
Welfare/employment program settings | ||||||
Thompson Martin et al. (2012) Perceptions of self-esteem in a welfare-to-wellness-to-work program(USA) | Participants (n = 33) in employment program. 54.5% had the history of domestic violence, 49% addictions and 64% referred for mh counseling | Welfare-to-wellness-to-work program that emphasizes + self-esteem, increased self-care and wellness along with life skills | Self-esteem score(Rosenberg's Self-Esteem scale) and interviews | Mixed methods: Mixed Methods Appraisal Tool (MMAT)—50% | Increased self-esteem and positive reports about program. Mainly female participants (88%) | Descriptive article that evaluates factors that contribute to welfare program outcomes |
Precin (2011)24 Challenges of welfare-to-work programs (USA) | Participants (n = 1553) in welfare-to-work program for long-term unemployed with disabilities. Both intervention (41%) and control group (39%) reported PTSD/mental health with child abuse and domestic violence | Detailed assessment, training in life skills, basic education, work ‘soft’ skills, English, job skills, goal setting. Psycho-education support groups taught symptom management | Getting and retaining work | Experimental design—QATQ: weak | Article focussed on describing the experience of program. Revealed many cases of undiagnosed PTSD (frequently as a result of DV and CA) that received treatment | Highlights the complex factors that influence success rates of employment programs |
LAMIC and indigenous settings | ||||||
Apondi (2007)26 Home-based antiretroviral care is associated with positive social outcomes in a prospective cohort in Uganda | Participants (n = 1006) of Home-Based AIDS Care project. 46% experienced physical abuse by spouse/sexual partner | Antiretroviral treatment with weekly home visits by trained counsellors | Increased community support, family support and relationship strengthening. Non-significant increase in physical abuse | Experimental design—QATQ: weak | Home-based counseling service strengthens relationships at all levels. Increase in abuse may have been attributable to improved health as a result of treatment | Program not designed for IPV or CM samples, but IPV or CM history is common in this group |
Kermode et al. (2007)25 Empowerment of women and mental health promotion: a qualitative study in rural Maharashtra, India | 32 women associated with Primary Health Care project—16 Village Health Workers (VHW) and 16 village women | Comprehensive Rural Health Project (CRHP) trains volunteer VHWs and this processes empowers individuals and communities | Increased civic and social engagement; reduced discrimination and increased access to economic resources due to participation in CRHP | Qualitative study: Level III Descriptive | Due to the external nature of resilience factors (eg. Dependable husband, sex of children), mental health usually outside individual control. CRHP increased personal control by improving freedom of movement and economic participation | |
Tsey et al. (2007)27 Empowerment-based research methods: a 10-year approach to enhancing indigenous social and emotional wellbeing | Individuals and communities of indigenous Australians | Family Wellbeing Program developed through Participatory Action Research with a group of stolen-generation indigenous people and university partner. Includes counseling, addressing grief and loss | Personal empowerment—enhanced sense of self-worth, resilience, active community efforts to address family violence, substance misuse and other mental health issues | Experimental design—QATQ: weak | Program developed by community members better than programs imported from outside the indigenous community. Creates personal change that leads to community change | Review article that quotes evidence from publications outside the parameters of this review. Commentary rather than evidence in this article |
Prisons and violence program settings | ||||||
Thompson and Harm (2000) Parenting from prison: helping children and mothers | 104 female prisoners | 15-week Parenting From Prison (PFP) program that covers child development, communication and self-esteem | Index of Self-esteem (ISE), Adult Adolescent Parenting Inventory (AAPI) classifies parent potential for child abuse, frequency of visits and letters from children | Experimental design—QATQ: weak non-random sample, no control group | SE significantly improved—mediated by frequency of visits and letters from children. When the history of cm considered, SE improved but remained clinically low and improved, but non-sig. AAPI scores | |
Tollefson and Gross (2006)28 Predicting recidivism following participation in a treatment program for batterers | 197 batterers (84% male) who participated in a domestic violence treatment program. 31% of whom were victims of child abuse and 43% experienced DV in families of origin | Psycho-educational program that incorporates cognitive and skills-based interventions and feminist approach. 20 weekly group sessions | Reoffending rates | Experimental design: QATQ—moderate | Client characteristics—substance abuse, history of abuse and psych. diagnosis more important than program in determining reoffending. History of abuse related to psychiatric diagnosis | Batterer programs not effective and should incorporate treatment for substance, child abuse and psychiatric diagnosis |
Zust (2009)29 Partner violence, depression, and recidivism: the case of incarcerated women and why we need programs designed for them | Groups of 10–12 incarcerated women— (previous studies reviewed to provide evidence of effectiveness) | INSIGHT cognitive therapy group program | Reduced depression, hopelessness, increased empowerment, self-esteem. Narrative analysis reported ‘rescuing self’, returns to study and employment | Review article—no rating | IPV-related depression high in incarcerated women. Prison-based treatments favor medication due to funding constraints, yet group programs are more effective | Review draws together evidence from different groups, etc. and argues for widespread program application |
Drug and alcohol treatment settings | ||||||
Wright et al. (2012)19 Implementation and evaluation of a harm-reduction model for clinical care of substance using pregnant women (USA) | 213 substance using women (132, pregnant, 97 delivered) 55% history of CM, 62.5% history of IPV. Focus on methamphetamine users | Perinatal clinical and social services emphasis on harm minimization | Abstinence and relapse, depression, infant outcomes, maternal reproductive outcomes | Experimental design: QATQ—weak | History of domestic violence most important predictor of poor infant outcomes (AOR 5.7). Program resulted in low levels of post-partum depression; retaining custody of infant and low repeat pregnancy rates | Drug treatment improved infant and maternal outcomes; however, IPV related to poor infant outcomes |
Bartholomew et al. (2005)30 Sexual abuse history and treatment outcomes among women undergoing methadone treatment (USA) | 98 women receiving no fee outpatient methadone treatment, 40% had a history of sexual abuse and 60% no history of sexual abuse | Methadone program including counseling, medication and case management | Psychological status (incl. depression, anxiety, suicide, violence), self-esteem, drug use, family cohesion | Experimental design: QATQ—strong | Women with a history of sexual abuse more likely to report higher depression, anxiety, hostility and lower self-esteem. No differences between crime, employment and drug use | Methadone programs do not improve mental health resilience for women with a history of sexual abuse |
Morrissey et al. (2005)31, Evaluations of the WCDVS study (US) (Also refers to Cocozza et al. (2005), McHugo et al. (2005), etc. for larger study information) | 2087 women receiving treatment for substance abuse and trauma | Trauma-informed services compared with treatment as usual | Global Severity Index (GSI) from Brief Symptom Inventory for mental health status; post-traumatic symptoms severity (PSS) at 6 and 12 months | Quasi-experimental cohort analytic design: QATQ—moderate (no blinding indicated) | Both control and experimental groups improved at 6 months. PSS significant improvement, GSI non-significant improvement. Both PSS and GSI significant improvement at 12 months | Integrating counseling into services appears to have a significant effect, whereas receiving more services associated with less improvement |
Pirard et al. (2005)18 Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes | 163 (out of original 700) substance users (male and female) seeking treatment for substance use | Day treatment or residential programs to address substance abuse (but no specific trauma treatment) | Addiction Severity Index (ASI), Global Assessment of Functioning (aka DSM-IV, Axis V) | Experimental design: QATQ—strong | Participants with a history of IPV report more psychiatric treatments in 12 month follow-up after substance abuse treatment. Both groups improved drug outcomes | Substance abuse treatment addresses only addiction and does not assist with mental health resilience outcomes |
Community mental health settings | ||||||
Waitzkin et al. (2011) Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression (New Mexico) | 120 patients at Community Health Centres (CHC) with depression enrolled to receive support from Promotoras (3 trained) | Promotoras identify depression, assist patients to manage contextual sources and follow-up | Depression related to history of violence | Mixed-methods study: MMAT—75% | No statistically significant effect of Promotoras on depression, but significant implementation issues may have impeded quant. assessment | |
Min et al. (2012) Low trait anxiety, high resilience, and their interaction as possible predictors for treatment response in patients with depression (Korea) | 178 outpatients at Mood and Anxiety Disorder Clinic with depressive disorders | Standard medication treatment administered through outpatients clinic | Depression (BDI), State anxiety (SAI), Trait anxiety (TAI), Alcohol use problem (AUDIT), Perceived Stress (PSS), Resilience (CD-RISC) | Experimental design: QATQ—weak (unclear whether confounders were assessed) | Interaction between trait anxiety and resilience significant predictor of treatment outcome within 6 months. Dep. patients with both high resil. and low TA 10 times more likely to achieve treatment response. History of trauma did not influence treatment response | This study quantifies the impact of resilience on outcomes and draws attention to the role of anxiety independent of depression as a mediator of resilience |
Ammerman et al. (2009)17 Changes in depressive symptoms in first-time mothers in home visitation (USA) | 806 at-risk first-time mothers in a HVP at enrolment and at 9 months | HVP delivered by nurses and social workers provides psycho-education and case management to prevent CM and improve child outcomes. Also provides support and mental health treatment to mothers | Depression (BDI-II), Trauma Inventory (TI) to measure the history of maternal trauma; social support (SPS) and current violence | Experimental design: QATQ—strong | 74% of sample had history of IPV and 14% had concurrent IPV. History of IPV associated with higher depression scores and stable or worsening symptoms over time. Minority receive mental health treatment and HPV often only mental health treatment received | IPV and CM complicate evaluation of HVPs. HVPs should improve assessment and treatment of IPV and history of CM in mothers |
Study . | Sample/group . | Intervention . | Resilience outcome . | Study design and level of evidence . | Learning and recommendations . | Challenges and issues for review . |
---|---|---|---|---|---|---|
IPV settings | ||||||
Beeble et al. (2009)19 Main, mediating, and moderating effects of social support on the wellbeing of survivors of IPV across 2 years | 160 survivors of IPV receiving support from community domestic violence programs. Women must have experienced IPV in preceding 4 months and had young children | Assessment of whether perceived social support affected the Quality of Life (QOL), depression over time | Depression, and QOL social support | Experimental design—Quality Assessment Tool for Quantitative studies (QATQ): Moderate | QOL related to psychological abuse, not physical. High levels of abuse and low social support have more severe and adverse sequelae over time | No intervention, however, this study shows the effect of ‘naturally occurring’ social support on resilience over time |
Ford-Gilboe (2011) A theory-based primary health-care intervention for women who have left abusive partners | 50 women accessing housing program for abused women (secondary reporting of pilot study of 30 women) | Intervention for Health Enhancement After Leaving (iHEAL) is a 6-month intervention that aims to strengthen the capacity to limit intrusion | Intrusion, health (including Post-Traumatic Stress Disorder—PTSD) and QoL measured | Descriptive review of program development and narrative reporting of two pilot projects. No assessment needed | Early pilot projects show promise. ‘Intrusion’ is a concept that workers found helpful. iHEAL may help with PTSD symptoms | Descriptive rather than conclusive evidence of effectiveness |
Gerlock (2004) Domestic violence and post-traumatic stress disorder severity for participants of a domestic violence program | 62 male veterans or active military who were perpetrators of IPV. Significant correlations between IPV in family of origin of perpetrator and current PTSD | IPV cognitive-behaviorally oriented rehabilitation program offered to military veterans. Groups include 4 weeks orientation, 26 weeks rehabilitation, maintenance 6 months of weekly meetings | Program completers had lower levels of stress and post-traumatic stress, higher self-ratings of relationship mutuality | Experimental design—QATQ: Weak | 61% dropped out of the program. Program completion linked to improved resilience outcomes. PTSD in military veterans related to IPV in family of origin and decreased likelihood of program completion | Male IPV perpetrators likely to also be victims of CM. Non-completion of year-long programs that increase resilience is troubling |
Gustafson (2005)20 Exploring treatment and trauma recovery implications of facilitating victim-offender encounters in crimes of severe violence: lessons from the Canadian experience | 1 case study reported of male victim of child sexual abuse | VOM program | Lower (symptom severity) PTSD scores | Qualitative study Level IV evidence | VOM reduced feelings of shame and embarrassment. Explanations for effect include neurophysiological factors | VOM appears effective in reducing offending. Small body of work on CM survivors. Research appears to be focussed prior to 2002 |
Jung and Steil (2011)23 and Steil, et al. (2011)22 The feeling of being contaminated in adult survivors of childhood sexual abuse and its treatment via a two-session program of cognitive restructuring and imagery modification: a case study | Pilot study with 9 female participants | Cognitive restructuring intervention | Reduction in ‘Feeling of Being Contaminated’ (FBC), PTSD severity and distress | (Case study) and Pilot study using cohort design. QATQ: weak | Effective on PTSD as well as FBC in small pilot. No dropouts indicate acceptability and safety. These results indicate promising intervention that needs large studies to generalize findings | |
Welfare/employment program settings | ||||||
Thompson Martin et al. (2012) Perceptions of self-esteem in a welfare-to-wellness-to-work program(USA) | Participants (n = 33) in employment program. 54.5% had the history of domestic violence, 49% addictions and 64% referred for mh counseling | Welfare-to-wellness-to-work program that emphasizes + self-esteem, increased self-care and wellness along with life skills | Self-esteem score(Rosenberg's Self-Esteem scale) and interviews | Mixed methods: Mixed Methods Appraisal Tool (MMAT)—50% | Increased self-esteem and positive reports about program. Mainly female participants (88%) | Descriptive article that evaluates factors that contribute to welfare program outcomes |
Precin (2011)24 Challenges of welfare-to-work programs (USA) | Participants (n = 1553) in welfare-to-work program for long-term unemployed with disabilities. Both intervention (41%) and control group (39%) reported PTSD/mental health with child abuse and domestic violence | Detailed assessment, training in life skills, basic education, work ‘soft’ skills, English, job skills, goal setting. Psycho-education support groups taught symptom management | Getting and retaining work | Experimental design—QATQ: weak | Article focussed on describing the experience of program. Revealed many cases of undiagnosed PTSD (frequently as a result of DV and CA) that received treatment | Highlights the complex factors that influence success rates of employment programs |
LAMIC and indigenous settings | ||||||
Apondi (2007)26 Home-based antiretroviral care is associated with positive social outcomes in a prospective cohort in Uganda | Participants (n = 1006) of Home-Based AIDS Care project. 46% experienced physical abuse by spouse/sexual partner | Antiretroviral treatment with weekly home visits by trained counsellors | Increased community support, family support and relationship strengthening. Non-significant increase in physical abuse | Experimental design—QATQ: weak | Home-based counseling service strengthens relationships at all levels. Increase in abuse may have been attributable to improved health as a result of treatment | Program not designed for IPV or CM samples, but IPV or CM history is common in this group |
Kermode et al. (2007)25 Empowerment of women and mental health promotion: a qualitative study in rural Maharashtra, India | 32 women associated with Primary Health Care project—16 Village Health Workers (VHW) and 16 village women | Comprehensive Rural Health Project (CRHP) trains volunteer VHWs and this processes empowers individuals and communities | Increased civic and social engagement; reduced discrimination and increased access to economic resources due to participation in CRHP | Qualitative study: Level III Descriptive | Due to the external nature of resilience factors (eg. Dependable husband, sex of children), mental health usually outside individual control. CRHP increased personal control by improving freedom of movement and economic participation | |
Tsey et al. (2007)27 Empowerment-based research methods: a 10-year approach to enhancing indigenous social and emotional wellbeing | Individuals and communities of indigenous Australians | Family Wellbeing Program developed through Participatory Action Research with a group of stolen-generation indigenous people and university partner. Includes counseling, addressing grief and loss | Personal empowerment—enhanced sense of self-worth, resilience, active community efforts to address family violence, substance misuse and other mental health issues | Experimental design—QATQ: weak | Program developed by community members better than programs imported from outside the indigenous community. Creates personal change that leads to community change | Review article that quotes evidence from publications outside the parameters of this review. Commentary rather than evidence in this article |
Prisons and violence program settings | ||||||
Thompson and Harm (2000) Parenting from prison: helping children and mothers | 104 female prisoners | 15-week Parenting From Prison (PFP) program that covers child development, communication and self-esteem | Index of Self-esteem (ISE), Adult Adolescent Parenting Inventory (AAPI) classifies parent potential for child abuse, frequency of visits and letters from children | Experimental design—QATQ: weak non-random sample, no control group | SE significantly improved—mediated by frequency of visits and letters from children. When the history of cm considered, SE improved but remained clinically low and improved, but non-sig. AAPI scores | |
Tollefson and Gross (2006)28 Predicting recidivism following participation in a treatment program for batterers | 197 batterers (84% male) who participated in a domestic violence treatment program. 31% of whom were victims of child abuse and 43% experienced DV in families of origin | Psycho-educational program that incorporates cognitive and skills-based interventions and feminist approach. 20 weekly group sessions | Reoffending rates | Experimental design: QATQ—moderate | Client characteristics—substance abuse, history of abuse and psych. diagnosis more important than program in determining reoffending. History of abuse related to psychiatric diagnosis | Batterer programs not effective and should incorporate treatment for substance, child abuse and psychiatric diagnosis |
Zust (2009)29 Partner violence, depression, and recidivism: the case of incarcerated women and why we need programs designed for them | Groups of 10–12 incarcerated women— (previous studies reviewed to provide evidence of effectiveness) | INSIGHT cognitive therapy group program | Reduced depression, hopelessness, increased empowerment, self-esteem. Narrative analysis reported ‘rescuing self’, returns to study and employment | Review article—no rating | IPV-related depression high in incarcerated women. Prison-based treatments favor medication due to funding constraints, yet group programs are more effective | Review draws together evidence from different groups, etc. and argues for widespread program application |
Drug and alcohol treatment settings | ||||||
Wright et al. (2012)19 Implementation and evaluation of a harm-reduction model for clinical care of substance using pregnant women (USA) | 213 substance using women (132, pregnant, 97 delivered) 55% history of CM, 62.5% history of IPV. Focus on methamphetamine users | Perinatal clinical and social services emphasis on harm minimization | Abstinence and relapse, depression, infant outcomes, maternal reproductive outcomes | Experimental design: QATQ—weak | History of domestic violence most important predictor of poor infant outcomes (AOR 5.7). Program resulted in low levels of post-partum depression; retaining custody of infant and low repeat pregnancy rates | Drug treatment improved infant and maternal outcomes; however, IPV related to poor infant outcomes |
Bartholomew et al. (2005)30 Sexual abuse history and treatment outcomes among women undergoing methadone treatment (USA) | 98 women receiving no fee outpatient methadone treatment, 40% had a history of sexual abuse and 60% no history of sexual abuse | Methadone program including counseling, medication and case management | Psychological status (incl. depression, anxiety, suicide, violence), self-esteem, drug use, family cohesion | Experimental design: QATQ—strong | Women with a history of sexual abuse more likely to report higher depression, anxiety, hostility and lower self-esteem. No differences between crime, employment and drug use | Methadone programs do not improve mental health resilience for women with a history of sexual abuse |
Morrissey et al. (2005)31, Evaluations of the WCDVS study (US) (Also refers to Cocozza et al. (2005), McHugo et al. (2005), etc. for larger study information) | 2087 women receiving treatment for substance abuse and trauma | Trauma-informed services compared with treatment as usual | Global Severity Index (GSI) from Brief Symptom Inventory for mental health status; post-traumatic symptoms severity (PSS) at 6 and 12 months | Quasi-experimental cohort analytic design: QATQ—moderate (no blinding indicated) | Both control and experimental groups improved at 6 months. PSS significant improvement, GSI non-significant improvement. Both PSS and GSI significant improvement at 12 months | Integrating counseling into services appears to have a significant effect, whereas receiving more services associated with less improvement |
Pirard et al. (2005)18 Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes | 163 (out of original 700) substance users (male and female) seeking treatment for substance use | Day treatment or residential programs to address substance abuse (but no specific trauma treatment) | Addiction Severity Index (ASI), Global Assessment of Functioning (aka DSM-IV, Axis V) | Experimental design: QATQ—strong | Participants with a history of IPV report more psychiatric treatments in 12 month follow-up after substance abuse treatment. Both groups improved drug outcomes | Substance abuse treatment addresses only addiction and does not assist with mental health resilience outcomes |
Community mental health settings | ||||||
Waitzkin et al. (2011) Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression (New Mexico) | 120 patients at Community Health Centres (CHC) with depression enrolled to receive support from Promotoras (3 trained) | Promotoras identify depression, assist patients to manage contextual sources and follow-up | Depression related to history of violence | Mixed-methods study: MMAT—75% | No statistically significant effect of Promotoras on depression, but significant implementation issues may have impeded quant. assessment | |
Min et al. (2012) Low trait anxiety, high resilience, and their interaction as possible predictors for treatment response in patients with depression (Korea) | 178 outpatients at Mood and Anxiety Disorder Clinic with depressive disorders | Standard medication treatment administered through outpatients clinic | Depression (BDI), State anxiety (SAI), Trait anxiety (TAI), Alcohol use problem (AUDIT), Perceived Stress (PSS), Resilience (CD-RISC) | Experimental design: QATQ—weak (unclear whether confounders were assessed) | Interaction between trait anxiety and resilience significant predictor of treatment outcome within 6 months. Dep. patients with both high resil. and low TA 10 times more likely to achieve treatment response. History of trauma did not influence treatment response | This study quantifies the impact of resilience on outcomes and draws attention to the role of anxiety independent of depression as a mediator of resilience |
Ammerman et al. (2009)17 Changes in depressive symptoms in first-time mothers in home visitation (USA) | 806 at-risk first-time mothers in a HVP at enrolment and at 9 months | HVP delivered by nurses and social workers provides psycho-education and case management to prevent CM and improve child outcomes. Also provides support and mental health treatment to mothers | Depression (BDI-II), Trauma Inventory (TI) to measure the history of maternal trauma; social support (SPS) and current violence | Experimental design: QATQ—strong | 74% of sample had history of IPV and 14% had concurrent IPV. History of IPV associated with higher depression scores and stable or worsening symptoms over time. Minority receive mental health treatment and HPV often only mental health treatment received | IPV and CM complicate evaluation of HVPs. HVPs should improve assessment and treatment of IPV and history of CM in mothers |
Study . | Sample/group . | Intervention . | Resilience outcome . | Study design and level of evidence . | Learning and recommendations . | Challenges and issues for review . |
---|---|---|---|---|---|---|
IPV settings | ||||||
Beeble et al. (2009)19 Main, mediating, and moderating effects of social support on the wellbeing of survivors of IPV across 2 years | 160 survivors of IPV receiving support from community domestic violence programs. Women must have experienced IPV in preceding 4 months and had young children | Assessment of whether perceived social support affected the Quality of Life (QOL), depression over time | Depression, and QOL social support | Experimental design—Quality Assessment Tool for Quantitative studies (QATQ): Moderate | QOL related to psychological abuse, not physical. High levels of abuse and low social support have more severe and adverse sequelae over time | No intervention, however, this study shows the effect of ‘naturally occurring’ social support on resilience over time |
Ford-Gilboe (2011) A theory-based primary health-care intervention for women who have left abusive partners | 50 women accessing housing program for abused women (secondary reporting of pilot study of 30 women) | Intervention for Health Enhancement After Leaving (iHEAL) is a 6-month intervention that aims to strengthen the capacity to limit intrusion | Intrusion, health (including Post-Traumatic Stress Disorder—PTSD) and QoL measured | Descriptive review of program development and narrative reporting of two pilot projects. No assessment needed | Early pilot projects show promise. ‘Intrusion’ is a concept that workers found helpful. iHEAL may help with PTSD symptoms | Descriptive rather than conclusive evidence of effectiveness |
Gerlock (2004) Domestic violence and post-traumatic stress disorder severity for participants of a domestic violence program | 62 male veterans or active military who were perpetrators of IPV. Significant correlations between IPV in family of origin of perpetrator and current PTSD | IPV cognitive-behaviorally oriented rehabilitation program offered to military veterans. Groups include 4 weeks orientation, 26 weeks rehabilitation, maintenance 6 months of weekly meetings | Program completers had lower levels of stress and post-traumatic stress, higher self-ratings of relationship mutuality | Experimental design—QATQ: Weak | 61% dropped out of the program. Program completion linked to improved resilience outcomes. PTSD in military veterans related to IPV in family of origin and decreased likelihood of program completion | Male IPV perpetrators likely to also be victims of CM. Non-completion of year-long programs that increase resilience is troubling |
Gustafson (2005)20 Exploring treatment and trauma recovery implications of facilitating victim-offender encounters in crimes of severe violence: lessons from the Canadian experience | 1 case study reported of male victim of child sexual abuse | VOM program | Lower (symptom severity) PTSD scores | Qualitative study Level IV evidence | VOM reduced feelings of shame and embarrassment. Explanations for effect include neurophysiological factors | VOM appears effective in reducing offending. Small body of work on CM survivors. Research appears to be focussed prior to 2002 |
Jung and Steil (2011)23 and Steil, et al. (2011)22 The feeling of being contaminated in adult survivors of childhood sexual abuse and its treatment via a two-session program of cognitive restructuring and imagery modification: a case study | Pilot study with 9 female participants | Cognitive restructuring intervention | Reduction in ‘Feeling of Being Contaminated’ (FBC), PTSD severity and distress | (Case study) and Pilot study using cohort design. QATQ: weak | Effective on PTSD as well as FBC in small pilot. No dropouts indicate acceptability and safety. These results indicate promising intervention that needs large studies to generalize findings | |
Welfare/employment program settings | ||||||
Thompson Martin et al. (2012) Perceptions of self-esteem in a welfare-to-wellness-to-work program(USA) | Participants (n = 33) in employment program. 54.5% had the history of domestic violence, 49% addictions and 64% referred for mh counseling | Welfare-to-wellness-to-work program that emphasizes + self-esteem, increased self-care and wellness along with life skills | Self-esteem score(Rosenberg's Self-Esteem scale) and interviews | Mixed methods: Mixed Methods Appraisal Tool (MMAT)—50% | Increased self-esteem and positive reports about program. Mainly female participants (88%) | Descriptive article that evaluates factors that contribute to welfare program outcomes |
Precin (2011)24 Challenges of welfare-to-work programs (USA) | Participants (n = 1553) in welfare-to-work program for long-term unemployed with disabilities. Both intervention (41%) and control group (39%) reported PTSD/mental health with child abuse and domestic violence | Detailed assessment, training in life skills, basic education, work ‘soft’ skills, English, job skills, goal setting. Psycho-education support groups taught symptom management | Getting and retaining work | Experimental design—QATQ: weak | Article focussed on describing the experience of program. Revealed many cases of undiagnosed PTSD (frequently as a result of DV and CA) that received treatment | Highlights the complex factors that influence success rates of employment programs |
LAMIC and indigenous settings | ||||||
Apondi (2007)26 Home-based antiretroviral care is associated with positive social outcomes in a prospective cohort in Uganda | Participants (n = 1006) of Home-Based AIDS Care project. 46% experienced physical abuse by spouse/sexual partner | Antiretroviral treatment with weekly home visits by trained counsellors | Increased community support, family support and relationship strengthening. Non-significant increase in physical abuse | Experimental design—QATQ: weak | Home-based counseling service strengthens relationships at all levels. Increase in abuse may have been attributable to improved health as a result of treatment | Program not designed for IPV or CM samples, but IPV or CM history is common in this group |
Kermode et al. (2007)25 Empowerment of women and mental health promotion: a qualitative study in rural Maharashtra, India | 32 women associated with Primary Health Care project—16 Village Health Workers (VHW) and 16 village women | Comprehensive Rural Health Project (CRHP) trains volunteer VHWs and this processes empowers individuals and communities | Increased civic and social engagement; reduced discrimination and increased access to economic resources due to participation in CRHP | Qualitative study: Level III Descriptive | Due to the external nature of resilience factors (eg. Dependable husband, sex of children), mental health usually outside individual control. CRHP increased personal control by improving freedom of movement and economic participation | |
Tsey et al. (2007)27 Empowerment-based research methods: a 10-year approach to enhancing indigenous social and emotional wellbeing | Individuals and communities of indigenous Australians | Family Wellbeing Program developed through Participatory Action Research with a group of stolen-generation indigenous people and university partner. Includes counseling, addressing grief and loss | Personal empowerment—enhanced sense of self-worth, resilience, active community efforts to address family violence, substance misuse and other mental health issues | Experimental design—QATQ: weak | Program developed by community members better than programs imported from outside the indigenous community. Creates personal change that leads to community change | Review article that quotes evidence from publications outside the parameters of this review. Commentary rather than evidence in this article |
Prisons and violence program settings | ||||||
Thompson and Harm (2000) Parenting from prison: helping children and mothers | 104 female prisoners | 15-week Parenting From Prison (PFP) program that covers child development, communication and self-esteem | Index of Self-esteem (ISE), Adult Adolescent Parenting Inventory (AAPI) classifies parent potential for child abuse, frequency of visits and letters from children | Experimental design—QATQ: weak non-random sample, no control group | SE significantly improved—mediated by frequency of visits and letters from children. When the history of cm considered, SE improved but remained clinically low and improved, but non-sig. AAPI scores | |
Tollefson and Gross (2006)28 Predicting recidivism following participation in a treatment program for batterers | 197 batterers (84% male) who participated in a domestic violence treatment program. 31% of whom were victims of child abuse and 43% experienced DV in families of origin | Psycho-educational program that incorporates cognitive and skills-based interventions and feminist approach. 20 weekly group sessions | Reoffending rates | Experimental design: QATQ—moderate | Client characteristics—substance abuse, history of abuse and psych. diagnosis more important than program in determining reoffending. History of abuse related to psychiatric diagnosis | Batterer programs not effective and should incorporate treatment for substance, child abuse and psychiatric diagnosis |
Zust (2009)29 Partner violence, depression, and recidivism: the case of incarcerated women and why we need programs designed for them | Groups of 10–12 incarcerated women— (previous studies reviewed to provide evidence of effectiveness) | INSIGHT cognitive therapy group program | Reduced depression, hopelessness, increased empowerment, self-esteem. Narrative analysis reported ‘rescuing self’, returns to study and employment | Review article—no rating | IPV-related depression high in incarcerated women. Prison-based treatments favor medication due to funding constraints, yet group programs are more effective | Review draws together evidence from different groups, etc. and argues for widespread program application |
Drug and alcohol treatment settings | ||||||
Wright et al. (2012)19 Implementation and evaluation of a harm-reduction model for clinical care of substance using pregnant women (USA) | 213 substance using women (132, pregnant, 97 delivered) 55% history of CM, 62.5% history of IPV. Focus on methamphetamine users | Perinatal clinical and social services emphasis on harm minimization | Abstinence and relapse, depression, infant outcomes, maternal reproductive outcomes | Experimental design: QATQ—weak | History of domestic violence most important predictor of poor infant outcomes (AOR 5.7). Program resulted in low levels of post-partum depression; retaining custody of infant and low repeat pregnancy rates | Drug treatment improved infant and maternal outcomes; however, IPV related to poor infant outcomes |
Bartholomew et al. (2005)30 Sexual abuse history and treatment outcomes among women undergoing methadone treatment (USA) | 98 women receiving no fee outpatient methadone treatment, 40% had a history of sexual abuse and 60% no history of sexual abuse | Methadone program including counseling, medication and case management | Psychological status (incl. depression, anxiety, suicide, violence), self-esteem, drug use, family cohesion | Experimental design: QATQ—strong | Women with a history of sexual abuse more likely to report higher depression, anxiety, hostility and lower self-esteem. No differences between crime, employment and drug use | Methadone programs do not improve mental health resilience for women with a history of sexual abuse |
Morrissey et al. (2005)31, Evaluations of the WCDVS study (US) (Also refers to Cocozza et al. (2005), McHugo et al. (2005), etc. for larger study information) | 2087 women receiving treatment for substance abuse and trauma | Trauma-informed services compared with treatment as usual | Global Severity Index (GSI) from Brief Symptom Inventory for mental health status; post-traumatic symptoms severity (PSS) at 6 and 12 months | Quasi-experimental cohort analytic design: QATQ—moderate (no blinding indicated) | Both control and experimental groups improved at 6 months. PSS significant improvement, GSI non-significant improvement. Both PSS and GSI significant improvement at 12 months | Integrating counseling into services appears to have a significant effect, whereas receiving more services associated with less improvement |
Pirard et al. (2005)18 Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes | 163 (out of original 700) substance users (male and female) seeking treatment for substance use | Day treatment or residential programs to address substance abuse (but no specific trauma treatment) | Addiction Severity Index (ASI), Global Assessment of Functioning (aka DSM-IV, Axis V) | Experimental design: QATQ—strong | Participants with a history of IPV report more psychiatric treatments in 12 month follow-up after substance abuse treatment. Both groups improved drug outcomes | Substance abuse treatment addresses only addiction and does not assist with mental health resilience outcomes |
Community mental health settings | ||||||
Waitzkin et al. (2011) Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression (New Mexico) | 120 patients at Community Health Centres (CHC) with depression enrolled to receive support from Promotoras (3 trained) | Promotoras identify depression, assist patients to manage contextual sources and follow-up | Depression related to history of violence | Mixed-methods study: MMAT—75% | No statistically significant effect of Promotoras on depression, but significant implementation issues may have impeded quant. assessment | |
Min et al. (2012) Low trait anxiety, high resilience, and their interaction as possible predictors for treatment response in patients with depression (Korea) | 178 outpatients at Mood and Anxiety Disorder Clinic with depressive disorders | Standard medication treatment administered through outpatients clinic | Depression (BDI), State anxiety (SAI), Trait anxiety (TAI), Alcohol use problem (AUDIT), Perceived Stress (PSS), Resilience (CD-RISC) | Experimental design: QATQ—weak (unclear whether confounders were assessed) | Interaction between trait anxiety and resilience significant predictor of treatment outcome within 6 months. Dep. patients with both high resil. and low TA 10 times more likely to achieve treatment response. History of trauma did not influence treatment response | This study quantifies the impact of resilience on outcomes and draws attention to the role of anxiety independent of depression as a mediator of resilience |
Ammerman et al. (2009)17 Changes in depressive symptoms in first-time mothers in home visitation (USA) | 806 at-risk first-time mothers in a HVP at enrolment and at 9 months | HVP delivered by nurses and social workers provides psycho-education and case management to prevent CM and improve child outcomes. Also provides support and mental health treatment to mothers | Depression (BDI-II), Trauma Inventory (TI) to measure the history of maternal trauma; social support (SPS) and current violence | Experimental design: QATQ—strong | 74% of sample had history of IPV and 14% had concurrent IPV. History of IPV associated with higher depression scores and stable or worsening symptoms over time. Minority receive mental health treatment and HPV often only mental health treatment received | IPV and CM complicate evaluation of HVPs. HVPs should improve assessment and treatment of IPV and history of CM in mothers |
Three studies reported strong evidence of effectiveness against their stated aims, being: a home visitation program (HVP) for at-risk mothers;17 a methadone program for women17 and a substance abuse program.18 However, strong evidence did not necessarily relate to successful resilience outcomes for people with a history of IPV or CM. Indeed history of IPV or CM was frequently associated with poorer outcomes that suggest a need to adapt programs to best serve these groups. We discuss our findings below by setting.
IPV survivor support settings
One study of 160 women who were survivors of IPV and receiving support through community domestic violence programs produced moderate evidence for the association of social support with quality of life and depression.19 Women with high levels of social support reported higher QOL and lower depression than those with low levels of social support. They also reported greater improvement in depression over time. This suggests that social support may buffer the effects of abuse, particularly psychological abuse. It could also reflect lower levels of support when psychological abuse occurs over longer periods, though this was not assessed in the study. Interventions that strengthen social supports, including those that complement clinical interventions, may have important resilience benefits.
Studies from the legal literature include a case study of a VOM program.20 There is evidence that VOM programs lead to reduced offending.21 This article describes the possible mechanisms by which VOM assists victims of CM. There is, however, little follow-up literature to confirm its efficacy as an intervention that increases resilience for people with a history of CM.
A cognitive restructuring intervention for adult survivors of CM recruited to a post-traumatic stress disorder (PTSD) outpatient clinic was described in a case study and small follow-up study.22,23 These studies described a phenomenon known as ‘feeling of being contaminated’ that led to distressing behavioral and emotional consequences for survivors of CM. Cognitive restructuring was found to be effective at reducing distress, symptoms of PTSD and feelings of being contaminated (ibid).
Welfare/employment settings
Welfare to work programs for example in the USA aim to find employment for long-term unemployed people. IPV and CM history has been associated with poor program outcomes for participants. For example, in one study of a large welfare-to-work program for people with disabilities it was found that longer support times were needed to achieve employment outcomes than were expected. Symptoms of post-traumatic stress among participants with a history of IPV or CM were identified by program staff as impeding participation in employment24 and psycho-education groups and mental health treatments were incorporated into the program. Precin suggested that incorporating assessment and treatment for PTSD stemming from a history of IPV and CM may assist in developing more successful programs (ibid). However conclusions from these studies must be treated with caution as these studies had a strong emphasis on program development reporting rather than study design and produced only a weak level of evidence.
Low- and middle-income countries and indigenous settings
No studies from low- and middle-income countries (LAMIC) and indigenous settings produced strong evidence. One qualitative study of women's mental health in the Indian state of Maharashtra produced descriptive evidence that training volunteer village health workers improved the personal control of women.25 Because resilience was largely constrained by factors external to women, such as having a dependable husband and the sex of children, mental health was usually outside the direct control of women. By increasing economic participation and freedom of movement, the rural health project that included training village health workers facilitated increased civic and social engagement and reduced discrimination, according to the women interviewed. Other LAMIC and indigenous studies also emphasized the external nature of resilience factors and indicated a need for interventions to increase the capacity for personal and local community action.26,27 This setting represents a substantial gap in knowledge about programs that increase resilience for people with a history of IPV and CM.
Prisons and violence program settings
Moderate evidence supported the findings of a program for ‘batterers’ who participated in a domestic violence prevention program.28 Thirty-one percent of ‘batterers’ had a history of CM and 43% experienced IPV in their family of origin. Eighty-four percent of batterers were men. This program found that history of IPV and CM was the most important predictor of recidivism and the authors recommended that ‘batterer programs’ need to incorporate treatment for substance abuse, and psychiatric diagnosis to improve outcomes.
A review of a cognitive therapy program for incarcerated women found that the prevalence of depression related to a history of IPV was high in this group. Treatment programs tend to favor medication-based treatments due to the prison setting; however, evidence suggests that group activity programs are more effective.29
Drug and alcohol treatment settings
Bartholomew found that a methadone program improved substance abuse remission rates, employment outcomes, crime and HIV risk behaviours for women both with and without a history of sexual abuse.30 However, participants with a history of sexual abuse were more likely to report higher depression, anxiety and hostility and lower self-esteem before and after the program than participants with no such history. Therefore, while the methadone program was effective at improving some aspects of resilience, mental health and self-esteem were not improved. Another study found that treatment for substance use among men and women who had a history of physical and sexual abuse improved substance abuse outcomes, but also found that uptake of psychiatric treatments increased following treatment.18 These studies indicate that while substance abuse treatments successfully address addiction outcomes they have little impact on mental health. The resilience of substance users is therefore only partially supported by these substance use treatment programs.
Morrissey et al.31 evaluated the large US Women, Co-occurring Disorders and Violence Study that aimed to develop new approaches to treat women with mental health and substance abuse disorders who have a history of IPV or CM. This study demonstrated a moderate level of evidence for the integration of counseling for substance abuse, mental health problems and history of trauma into a comprehensive treatment program. Mental ill-health and PTSD symptom severity both improved as a result of the program. However, no significant effect for substance use outcomes, as measured by the Addiction Severity Index, was found.
Wright et al.32 studied a program that aimed to improve birth outcomes and developmental outcomes of the children of mothers using drugs and or alcohol during pregnancy. Resilience outcomes from the program included lower levels of post-partum depression, more women retaining custody of infant compared with previous pregnancies and low repeat pregnancy rates compared with controls. Poor infant outcomes were almost six times more likely among pregnant drug users with a history of IPV than those without a history of IPV.
Community mental health settings
Strong evidence supported a study of HVP for at-risk mothers.17 This study found that a history of IPV, along with young maternal age, being African American and clinically significant symptoms predicted worsening or lack of improvement of depressive symptoms in participants enrolled in the program. Ammerman et al. suggested that HVPs should consider the complex mental health issues faced by mothers and the knowledge that HVPs may be the only source of mental health support that at-risk, first-time mothers access (ibid). Assessing the mothers for a history of IPV, along with the other variables mentioned above, is important in providing services to this group.
Discussion
Taking a settings approach advocated in public health reveals a range of initiatives that potentially or actually promote resilience for people with a history of IPV and CM. These settings address specific aspects of resilience such as overcoming addictions, finding work, parenting skills and reduced recidivism and offending.
The main finding of this study
A key finding of this review is that recognizing both the presence of a substantial sub-group of people with experience of IPV and CM and the importance of acknowledging and addressing this experience and its consequences would likely strengthen the outcomes for programs and participants.
What this study adds
The review also identifies new trends and gaps in the literature such as research in LAMIC and indigenous settings. Economic participation and increasing the capacity for personal and local community action to control stressors appear to improve resilience. Training volunteer village health workers improved workers' personal control. The research designs in these settings are largely qualitative and so far have not tested interventions. However, the work has a strong participatory focus using research studies to explore research questions through empowerment models. Welfare and employment settings have also recently identified IPV and CM history as a factor that affects program outcomes. A range of initiatives and specific interventions incorporated into these programs may improve resilience and other outcomes. Precin24 proposed that integrating treatment for PTSD within welfare-to-work programs is indicated. High-quality studies are needed to support and extend innovative recommendations such as these. The need and potential to adapt existing programs for people with IPV and CM history in settings where vulnerable people are found has been under-recognized.
What is already known about this topic
The identified studies from the prisons and violence programs have focused on programs for male perpetrators of IPV. The studies of these programs indicate that while recidivism can be reduced among men in this group, a personal history of experiencing (or witnessing) IPV and CM from others is associated with worse outcomes. This observation suggests a need for programs in prisons and other relevant settings that seek to address a history of IPV and CM among male perpetrators as one way to reduce recidivism. It is also recommended that treatment programs for substance abuse and psychiatric disorders be integrated to improve outcomes. This concurs with the recommendations proposed by the welfare and employment programs described here that integrating treatments is likely to lead to more successful outcomes.
Innovative research conducted in ‘IPV survivor support settings’ indicates that supporting social networks for women who experience IPV may be particularly important in ameliorating the effects of psychological abuse. Cognitive restructuring appears to assist women who experience feelings of being contaminated, and may be a promising approach to interventions in non-health settings. Introducing to prisons and substance abuse treatment settings trauma-focussed non-pharmacological interventions is a promising area for future programs and research. VOM may assist adult survivors of CM, although preliminary findings need replication.
Limitations of this study
The review was designed to examine the public health approach to promoting resilience in various settings and hence excluded clinical RCTs as beyond the scope of the study. Preliminary work on a companion review of clinical RCTs reveals a paucity of studies. This review integrates mixed-method study designs and therefore conclusions about effectiveness are limited. Instead, the review aims to consider explanations for facilitators and barriers to successful implementation of resilience programs. Another limitation is the set of tools available for reviewing studies of different types. For example, the MMAT is one of the first mixed-methods tools to demonstrate adequate validity and reliability. However, because the tool is still under construction, caution must be used in interpreting results.
This review reveals that the topic has had little investigation despite high needs for public health interventions in countries of all types. Few studies use specific resilience measures. Interventions and research studies that use resilience measures such as the Resilience Scale for Adults,33 the Brief Resilience Scale34 and the O'Connor Davidson Resilience Scale35 are likely to help the measurement and integration of a currently disparate area36 and improve outcomes for people with a history of IPV and CM. Finally, the participation of people with a history of IPV and CM in program and research design and implementation in these various settings is strongly indicated to support advocacy, innovation and sustainable interventions.37 This is particularly pertinent for interventions in LAMIC and indigenous settings where continuing programs are sorely needed.