Cognitive-behavioral therapy for psychological harm in domestically abused women: systematic rev= iew and meta-analysis

Terapia cognitivo-conductual para el dańo psicológico en mujeres maltratadas domésticamente: revisión sistemática y meta análisis<= /p>

= ¹=

Juan Andrés Guillermo-Anasicha

https://orcid.org/0000-0002-878= 9-243X=

<= /span>

Universidad Católica de Cuenca, Unidad Académica de Posgrado. Maestría en Psicología = Clínica mención en Psicoterapia, Cuenca - Ecuador.

juan.guillermo.55@est.ucacue.edu.ec

= ²=

Andrés Alexis R= amírez-Coronel=

https://orcid.org/0000-0002-699= 6-0443=

<= /span>

Universidad Católica de Cuenca, Laboratorio de Psicometría, Psicología Comparada y Etología (LABPPCE), Cuenca, Ecuador.

andres.ramirez@ucacue.edu.ec<= o:p>

= ³=

Pedro Carlos Ma= rtínez-Suárez=

https://orci= d.org/0000-0002-1441-3821=

<= /span>

Universidad Católica de Cuenca, Laboratorio de Psicometría, Psicología Comparada y Etología (LABPPCE), Cuenca, Ecuador.

pmartinezs@ucacue.edu.ec=

Artículo de Investigación Científica y Tecnológica

Enviado: 28/03/2022

Revisado: 01/04/2022

Aceptado: 07/04/2022

Publicado:05/07/2022

DOI: = https://doi.org/10.33262/cienciadigital.v6i3.216= 7

&n= bsp;

Cítese:=

&n= bsp;

Guillermo Anasicha, J. A., Ram= írez Coronel, A. A., & Martínez Suárez, P. C. (2022). Cognitive-behavioral therapy for psychological h= arm in domestically abused women: systematic review and meta-analysis. Ciencia Digital, 6(3), 61-83. https://doi.org/10.33262/cienciadigital.v6i3.2167

=

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CIENCIA DIGITAL, es una revista multidisciplinaria, trimestral, que se publicará = en soporte electrónico tiene como misión contribuir a la   formación de profesionales competent= es con visión humanística y crítica que sean capaces de exponer sus resultad= os investigativos y científicos en la misma medida que se promueva mediante = su intervención cambios positivos en la sociedad. https://cienciadigital.o= rg

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Esta revista está prote= gida bajo una licencia Creative Commons Attribution Non Commercial No Derivati= ves 4.0 International. Copia de la licencia: http://creativecommons.o= rg/licenses/by-nc-nd/4.0/.

Palabras claves: Terapia Cognitivo-Conductual, violencia doméstic= a, mujer, abuso, intervenciones

&n= bsp;

Resumen

Introducción= .

La violencia doméstica vulnera la salud física y mental de la víctima y de su entorno familiar; habitualmente las mujeres son las más afectadas, por razones culturales y sociales la violencia ha sido normalizada dentro del contexto familiar. Los perjuicios, sobre todo el dańo psicológico, es una de las consecuencias que perduran en el tiempo a menos que la víctima reciba una atención integral enfocada en sus principales necesidades. Objetivo. <= span style=3D'mso-spacerun:yes'> El objetivo fue valorar la evidenc= ia empírica actual de la Terapia Cognitivo-Conductual (TCC) para el tratamie= nto del dańo psicológico en mujeres violentadas domésticamente por su pareja.= Metodología. La revisión se realizó en la base de datos Scopus, PubMed y Web of Science, se utilizaron los lineamientos de la declaración Prisma y Consort para obtener la muestra final de los artículos seleccionados en base a los criterios de inclusión y exclusión propuestos= . Resultados. La mayor parte de intervenciones cognitivo-conductuales se han centrado e= n el abordaje de la sintomatología del TEPT, depresión o ansiedad, logr= ando resultados favorables para este tipo de población. Conclusión. La = TCC es eficaz para el tratamiento del dańo psicológico en mujeres violentadas domésticamente por su pareja. Sin embargo, la ausencia de especificidad de las intervenciones constituye una limitante importante al momento de repl= icar en la práctica clínica. =

<= /o:p>

Keywords: Cognitive-behavioral therapy, domestic violenc= e, woman, abuse, interventions.

Ab= stract

Introduction. Domestic violence violates the physical and mental health of the vi= ctim and her family environment; usually women are the most affected, for cult= ural and social reasons violence has been normalized within the family context. The damage, especially the psychological damage, is one of the consequenc= es that lasts over time unless the victim receives comprehensive care focuse= d on her main needs. Obj= ective. The objective was to assess= the current empirical evidence of Cognitive-Behavioral Therapy (CBT) for the treatment of psychological harm in women who have been domestically abuse= d by their partners. Methodology. The review was conducted in the Scopus, PubMed, and Web of Science databases, using the guidelines of the Prisma and Consort statements to obtain the final sample of articles selected based on the proposed inclus= ion and exclusion criteria. Results. Most cognitive-behavioral interventions have focused on addressing = the symptomatology of PTSD, depression, or anxiety, achieving favorable resul= ts for this type of population. Conclusion. In conclusion, CBT is effective for t= he treatment of psychological harm in women who have been domestically abuse= d by their partners. However, the lack of specificity of the interventions constitutes an important limitation at the time of replication in clinical practice.

Introduction

Domestic violence (DV) aga= inst women encompasses a series of violent attitudes and behaviors that occur wi= thin the family system (Sáenz, 2019). It is often exercised by the spouse or par= tner (man) through physical, psychological, sexual, social, and financial abuse = with the aim of dominating and subduing the victim (Labrador et al., 2017; Mayor & Salazar, 2019). In addition, DV can generate physical and mental harm that transgresses the rights and personal well-being of the woman and her family environment (Tullio et al., 2021).

Currently, due to the Covi= d-19 pandemic, Kofman & Garfin (2020) note an increase in DV cases from stay-at-home guidelines (confinements) and temporary disruptions of governm= ent and private support services; approximately 1/3 of women globally suffer fr= om DV (WHO, 2021). In South America, particularly in Ecuador, there has been a significant increase in violence against women compared to previous years (Gonzales & Molina, 2021; Valenzuela et al., 2021). Likewise, it is possible that the frequency and intensity of violence has increased in homes where it was occurring or has arisen in homes where it was not found before (Montero-Medina et al., 2020; PAHO, 2020; Vieira et al., 2020).<= /span>

Indeed, violence against w= omen is a social problem that demands the assistance of multidisciplinary sectors for a comprehensive and personalized approach; these should guarantee the rights of the victims as well as their physical and mental health. From a m= ental health perspective, there are currently various psychotherapeutic procedures for women victims of DV; however, most psychotherapies do not meet the immediate needs and objectives of the patients and their families and, in m= any cases, are conducted by professionals with a deficient level of updating, training and supervision, resulting in an iatrogenic practice. <= /span>

In relation to the exposed problematic, the importance of the present study lies in having scientific evidence on Cognitive Behavioral Therapy (CBT) in domestically abused women. Therefore, this research could contribute to the psychotherapeutic work sin= ce it can be applicable in clinical practice according to the clinician's judg= ment as well as to the characteristics and context of the patient. For this reas= on, the direct and indirect beneficiaries will be the mental health professiona= ls and the victims of this unfortunate reality.

It is widely accepted that mistreatment of women is the product of a complex combination of psychologi= cal, cultural, social, and contextual factors (Heise, 1998; Labrador et al., 201= 7); the result generates damage in the intrapersonal sphere and in areas of dai= ly functioning, often persisting over time even after the victim has ended the bond with the aggressor (Ellsberg et al., 2008). Women victims of DV present severe psychological damage compared to non-violated women (García-Moreno et al., 2013). In this regard, at the international level, a considerable amou= nt of evidence has been published on the psychological consequences of DV in women: Post Traumatic Stress Disorder (PTSD) depressive and anxiety disorde= rs, somatoform disorders, phobias, alcohol, drug or pharmaceutical abuse, suici= de attempts (especially women with a family history of mental illness), psycho= logical distress and low self-esteem (Chang et al., 2015).

That said, from the four b= asic models of psychotherapy (Psychodynamic, Humanistic, Systemic, and Cognitive-Behavioral) treatments for women victims of intimate partner viol= ence have been developed (Daneshvar et al., 2020).

Regarding CBT, it is indisputably a psychological treatment with solid scientific evidence for t= he care of various mental disorders (Díaz et al., 2017; Hofmann et al., 2012);= for this reason, in addition to its efficiency and effectiveness, CBT has been incorporated into the main intervention guidelines and is often the first choice over other therapy modalities (David et al., 2018). Fundamentally, C= BT is based on learning theory, classical conditioning, operant conditioning, vicarious or observational learning and the principles of cognitive behavior modification (Ibáńez-Tarín & Manzanera-Escartí, 2012). Moreover, states that dysfunctional thoughts underlie all mental disorders, which generate maladaptive manifestations at the emotional and behavioral level (Beck, 202= 1).

In this perspective, speci= fic interventions have been proposed to treat the traumatic stress of DV victim= s; for example, Cognitive Processing Therapy (CPT) and Cognitive Trauma Therapy (CTT-BW) have proven to be effective in the treatment of battered women (Ku= bany et al., 2004; Resick et al., 2008). Likewise, individual, group and self-he= lp protocols have been designed according to the sociocultural needs of the victims (Ayats et al., 2008).

Thus, the purpose of this = research is to assess the current empirical evidence of CBT for the treatment of psychological harm in domestically abused women. In addition, as secondary objectives, the aim is to identify the scientific evidence at international, regional, and local levels and to refer to the effectiveness of CBT in such cases.

Methodology<= /span>

The methodological approach adopted in this study is a systematic review based on the guidelines of the PRISMA Statement (Preferred Reporting Items for Systematic reviews and Meta= -Analyses) (Page et al., 2021).

Inclusion and exclusion criteria

To the research, a search = was performed in the following databases: PubMed, Scopus, and Web of Science. Therefore, the inclusion criteria that limited the search were: 1) studies = on CBT in domestically violent women; 2) adult and middle-aged participants; 3) research focused on pilot, experimental or randomized controlled clinical trials; 4) published in English and Spanish and 5) published in the last 5 years in peer-reviewed journals. Therapies other than CBT and populations outside the study objective were excluded from this systematic review. It should be noted that there was no restriction for longitudinal follow-up and therapies for the control group.

The research was conducted during February 1-2, 2022. The research strategy (keywords and search seque= nce) for each database was:

·         PubMed (3 results): (“Domestic Violence/psychology"[Majr] OR "Domestic Violence/therapy"[Majr])

·         Scopus (9 results): ( domestic AND violence  AND  = ;therapy )  AND  ( LIMIT TO ( PUBSTAGE ,  "final" ) )&n= bsp; AND  ( LIMIT-TO ( PUBYEAR , &n= bsp;2022 )  OR  LIMIT TO ( PUBYEAR ,  2021 )  OR &nb= sp;LIMIT-TO ( PUBYEAR ,  2020 )  OR=   LIMIT-TO ( PUBYEAR ,  2019 ) = ; OR  LIMIT TO ( PUBYEAR ,  2018 ) )  AND&= nbsp; ( LIMIT-TO ( DOCTYPE ,  "ar&q= uot; ) )  AND  ( LIMIT TO ( SUBJAREA ,  "PSYC" ) )&nb= sp; AND  ( LIMIT-TO ( EXACTKEYWORD ,&nbs= p; "Domestic Violence" )  OR  LIMIT TO ( EXACTKEYWORD ,  "Article" )&nb= sp; OR  LIMIT-TO ( EXACTKEYWORD ,  = "Adult" )  OR  LIMIT TO ( EXACTKEYWORD ,  "Psychotherapy"&nbs= p;)  OR  LIMIT-TO ( EXACTKEYWORD , = "Violence" )  OR  LIMIT TO ( EXACTKEYWORD ,  "Battered Woman" )  OR  LIMIT-TO ( EXACTKEYWO= RD ,  "Cognitive Behavioral Therapy" )  OR  LIMIT-TO ( EXACTKEY= WORD ,  "Treatment" )  OR &nbs= p;LIMIT TO ( EXACTKEYWORD ,  "Psychotherapy, Group" )  OR  LIMIT TO ( EXACTKEYWORD ,  "Women" ) = ;)  AND  ( LIMIT-TO ( LANGUAGE ,&nb= sp; "English" ) )

·&nb= sp;            =        Web of Science (10 results): Domestic Violence AND Therapy (All Fields) AND 2022 OR 2021 OR 2020 = OR 2019 OR 2018 (Publication Years) AND Articles (Document Types) AND English = OR Spanish (Language) AND Psychology OR Family Studies (Research areas)

The title and abstract of = the articles were reviewed based on the inclusion/exclusion criteria; thus, tho= se studies that met the proposed eligibility standards were selected: year and type of publication, age of participants included in the sample, study desi= gn, procedure, durability, and treatment outcomes.

Assessment of study quality

The Consolidated Standards= for Reporting Trials (CONSORT-2010) guidelines will be used to determine study quality.

Results

Figure 1

Flow diagram of article selection for the systematic review

Scoopus:= 1.282

Pubmed:<= span lang=3DEN-US style=3D'font-size:10.0pt;mso-bidi-font-size:9.0pt;font= -family: "Times New Roman",serif;mso-fareast-font-family:"Times New Roman"; mso-ansi-language:EN-US;mso-fareast-language:ES'> 17.719<= /span>

Web of Science: 860

<= o:p>

<= o:p>

<= o:p>

<= o:p>

<= o:p>

<= o:p>

<= o:p>

<= o:p>

<= o:p>

<= o:p>

<= o:p>

<= o:p>

=

Literature review (n=3D6)

Duplicates

Another target

(n=3D5)<= span lang=3DEN-US style=3D'font-size:10.0pt;mso-bidi-font-size:9.0pt;font= -family: "Times New Roman",serif;mso-fareast-font-family:"Times New Roman"; mso-ansi-language:EN-US;mso-fareast-language:ES'><= /p>

IDENTIFICATI= ON

SELECTION

ELIGIBILITY<= o:p>

INCLUSION

Records identified through database searching (n=3D19.861)

Exclusion of articles that do not address the topic (n=3D 19.520)

Exclusion of articles that do not correspond to the study by reading the tit= les and abstracts (n=3D319= )

Selected studies for complete reading (n=3D22)

Excluded studies (n=3D11)

Complete studies evaluated for eligibili= ty (n=3D11)

Complete studies excluded (n=3D3)

Studies included in the final sample (n=3D8)

To the investigation, 19,8= 61 articles were identified in the following databases: Scopus (1,282), PubMed (17,719) and Web of Science (860). A total of 19,520 articles were excluded because they did not meet the objectives of the study. Then, for article se= lection, 319 articles were excluded based on reading titles and abstracts, subtracti= ng twenty-two articles for full reading. Subsequently, for eligibility, eleven articles w= ere excluded because they were literature reviews, duplicate studies (6) or had another objective (5). Finally, eight articles were included in the sample because they met both the main objective and the specific objectives propos= ed. Therefore, three articles (37.5%) correspond to 2018; one article (12.5%) to 2019; two articles (25.0%) to 2020; one article (12.5%) to 2021 and 1 artic= le (12.5%) to 2022.

In Figure 2, it can be visualized that in 2022, there was a higher prevalence of domestic violence (50%), followed by 2018 with 44%.

Figure 2

Prevalence of domestic violence=

Source: Own elaboration

Table 1

Results of the analysis of selected studies

Author

Sample

Intervention details

Therapeutic objectives

Techniques used

TIS (Task intersession)

Habigzang= et al. (2018)

S=3D 11

&nbs= p;

MA=3D42,73 (9,5=3DSD)

<= /o:p>

Symptoms = of anxiety, depression, PTSD, and stress.

P=3D Individu= al

N^0: 13

ST: 1 H=

F: Weekly

PD: 13 s

Country: Brazil

Psychoedu= cation.

-CR<= /o:p>

-Gradual exposure to traumatic memories and Relaxation

-Problem solving

-Relapse prevention

- Collage (patient's self-perception, timeline of her history of violence)

- Psychoeducation on DV and its consequences, ABC Model

- Role play (narrative exposition of feelings and thoughts about the aggressor).

- Image substitution technique.

- Coping technique (Emergency button).

- Relaxation techniques.

- Problem solving training.
- Protection strategies (safety nets).

- Self-protection skills training.

- Construction of a project for the future.=

- Relapse prevention techniques.

-=

Table 1

Results of the analysis of selected studies (continued)

Author

Sample

Intervention details

Therapeutic objectives

Techniques used

TIS (Task intersession)

Johnson et al. (2020)=

S=3D 83

&nbs= p;

MA=3D35,13 (9,12=3DSD)

<= /o:p>

PTSD

HOPE

P=3D Individu= al

N^0: 16

ST: 1 H=

F: Weekly and biweekly

PD: 22 s

&nbs= p;

Country: Middle East countries

- Establish safety, provide information and skil= ls that enhance empowerment.

- Facilitate CBT skills

- Improve relationships, assertiveness, and anger management

- Address concerns after shelter

- Psychoeducation

Empowerment skills

- CR (realistic threat assessment)

- Trigger management

- Sleep hygiene.

- Relaxation and self-control techniques

-Assertiveness (improving relationships) and ang= er management techniques

-List of objectives for future project and safety plan technique

-=

Latif et = al. (2021)

S=3D 25

&nbs= p;

MA=3D27,4 (4,6=3DSD)

&nbs= p;

PTSD

<= /o:p>

CatCBT GSH

P=3D Group

N^0: 9

ST: 15-20 mi= n.

PD: 12 s

&nbs= p;

Country: Pakistan

- Orient the patient to CBT.
- Ident= ify negative thoughts, challenge them, and generate alternative thoughts.

- Expla= in the concept of exposure

- Manage conflicts

- Provide communication skills=

- Psychoeducation

- Symptom management

- Graded exposure technique

-CR

- Behav= ioral activation

- Probl= em solving techniques

-Assertiveness techniques (improvement= of relationship and communication skills)

Thought log diary (CR supplement)

Table 1

Results of the analysis of selected studies (continued)

Author

Sample

Intervention details

Therapeutic objectives

Techniques used

TIS (Task intersession)

Graham-Be= rmann et al. (2019)

S=3D 53

&nbs= p;

MA=3D31,9 (7,19=3DSD)

&nbs= p;

Symptoms of Traumatic Stress

PTSD

MEP

P=3D Group
N^0: 10

ST: 2 H=

F: Weekly

PD: 10 s

&nbs= p;

Country: EEUU/ Canada<= /b>

-Strength= en protective aspects (social support, community resources and parenting skills).

-Treat present symptomatology and address safety issues.

- Psychoeducation (DV and mental health, cycle of violence)

- Techniq= ues of disclosure and exposure to traumatic experiences

-Problem solving techniques

-Safety planning technique (community resources, legal, self-defense ballot, etc.= ).

-

Orang et = al. (2018)

M=3D 24

&nbs= p;

MA=3D38,04 (9,69=3DSD)

&nbs= p;

PTSD

NET

P=3D Individual

N^0: 11

ST: 2 H=

PD: 3-6 m

&nbs= p;

Country: Iran

- Linking traumatic memories to the context

- Elaborate a detailed chronological narrative of the traumatic events.

- Psychoeducation (normalizing, recognizing, explaining) on trauma-related reactions.

-Safety plan= ning techniques

- Lifeline t= echnique (description of autobiography, including past and present traumatic experience)

- Imaginal exposure techniques and narratives of traumatic events,=

- CR

-

Greene et= al. (2019)

S=3D 60

&nbs= p;

MA=3D28,6 (10,4=3DDE)

&nbs= p;

Psychological distress, functional impairment

NGUVU

P=3D Individu= al (1) and Group (7)

N^0: 8

ST: 2 H=

F: Weekly

PD: 8 s=

&nbs= p;

Country: Tanzania

- Establish a defense and security plan

- Guidance on TPC at NGU= VU -Implementation of the ABC model

- Addressing bottlenecks= and reflection questions

- Increase autonomy, empowerment and strengthen linkages with community supports               -Review safety and secur= ity plan

-Review safety plan

- DV psychoeducation, psychological distress and establishing safety and defense plans

- ABC Techniques

-Group relaxation techni= ques

-CR

- Techniques of self-control, self-esteem, and self-care

- Future planning techni= que

- Safety plan review, co= ping and support strategies<= /span>

- Safety = plan

- Identify and explore DV-related thoughts and distress.

- ABC dai= ly practice

Self-care tasks

-Relaxati= on tasks

Table 1

Results of the analysis of selected studies (continued)

Author

Sample

Intervention details

Therapeutic objectives

Techniques used

TIS (Task intersession)

Andersson et al.(2021= )

S=3D 31

&nbs= p;

MA=3D43,03 (9,13=3DSD)<= o:p>

&nbs= p;

PTSD (20) and Depression (11)

ICBT

P=3D Individu= al

N^0: 8

ST: 2 H=

F: Weekly

PD: 8 s=

&nbs= p;

Country: Sweden

-Counsel on intimate partner violence, mental health problems and ICBT.

- Addressing negative cognitions and their role in the etiology and maintenance of mental health problems

-Report on PTSD or Depression on a case-by-case basis

-Exposing the patient= or behavioral activation -Addressing distorted cognitions<= /p>
-Develop a maintenance plan

PTSD

DEPRESSION

PTSD AND Depression: List of treatment objectives, Determine negative thoughts and their influence on depression and anxiety. Write a personal recollection of a traumatic event associated with DV.

PTSD: Exposure hierarchy list and read personal narrative; in vivo exposure according to hierarchy list; detail personal narrative.

Depression: Activity dia= ry (activity planning and development); list of reward behaviors; list of co= mmon negative thoughts and functional alternative thoughts.<= /p>
PTSD AND Depression: Treatment synthesis, formulation of maintenance plan.

-Psychoeducation on DV, CBT, mental health problems and treatment goal setting.=

-Psychoeducation on negative cognitions and their role in maintaining anxiety and depressi= on.

-Psychoeducation on emotional regulation.

-Relaxation and breathing techniques.

-Psychoeducation on trauma, its consequences, development, and maintenance of PTSD

-Psychoeducation on in vivo exposure

-Narrative and in vivo exposure technique

Psychoeducation on depression, its consequences, development, and maintenance.

-Psychoeducation on the association between behavioral activation a= nd mood state.

-Behavioral activation technique

-CR

-Problem solving techniques

Relapse prevention techniques (plan for the future)

<= o:p>

<= o:p>

Table 1

Results of the analysis of selected studies (continued)

Author

Sample

Intervention details

Therapeutic objectives

Techniques used

TIS (Task intersession)

Osma et a= l. (2022)

S=3D 11

&nbs= p;

MA=3D49,64 (5,52=3DSD)

&nbs= p;

Emotional disorders and subclinical affective symptomatology.

UP

P=3DGroup

N^0: 11

ST: 2 H=

F: Weekly

PD: 11 s

&nbs= p;

Country: Spain

Provide alternative emotional regulation strategies for adaptive coping with inte= nse emotions.

<= /o:p>

-Psychoeduca= tion

- Emotion understanding technique

- Emotional awareness technique

- Cognitive ﬂexibility technique.

-Technique of opposition of emotional factors.

-Emotional exposure technique

-=

S=3D Sample; MA=3D Mean Age; P=3D Protocol; N0 =3D session number; ST=3D = Session Time; F=3D Frequency; PD: Prog= ram Duration; CR: Cognitive restructuring

Resultados y discussion

A systematic review was conducted in which eight articles were selected to assess the current empir= ical evidence of CBT for the treatment of psychological harm in domestically abu= sed women. To begin with, based on the articles selected according to the inclu= sion and exclusion criteria, the majority of publications have been conducted at= the international level (87.5%) (Andersson et al., 2021; Graham-Bermann et al., 2019; Greene et al., 2019; Johnson et al., 2020; Latif et al., 2021; Orang = et al., 2018; Osma et al., 2022), compared to the regional (12.5%) (Habigzang = et al., 2018); however, at the national level, no studies addressing the propo= sed topic were found in the databases consulted up to the date of review. Possi= bly the absence of research in Ecuador on CBT in DV may be attributable to mult= iple factors such as the lack of funding (governmental or private) for intervent= ion projects, the inexistence of a governing body that regulates the practice of psychotherapists (Guano & Costales, 2021), and in turn ensures evidence-based process research, scarce research skills on the part of psychotherapists, as well as deficient training in mental disorders derived from exposure to violence, conflict between accumulation of experience vers= us education and continuous updating, absence of consensus among researchers a= nd clinicians, among others. Undoubtedly, the above generalizations demonstrate the existing rupture between clinical practice and research (Fernández-Álva= rez et al., 2020), resulting in a low level of research at the national level a= nd possible psychological treatments of dubious effectiveness. However, it sho= uld also be said that the lack of a psychotherapeutic culture in the Ecuadorian population may predominate in research processes since it intervenes in the decision to initiate, continue, complete, or pay for a treatment, which wil= l make it difficult to establish processes for research purposes. In fact, in addi= tion to the aforementioned idiosyncrasy, it is known that women victims of DV may have difficulties to participate in a therapeutic process given that most victims present shame, insecurity to start treatment, social stigma, econom= ic crisis, lack of communication with sources or support services (Beeble et a= l., 2009), crossing of therapy schedules with work activities or childcare, and beliefs of not requiring treatment as well as the usefulness of treatment (Kantor et al., 2017).

Regarding psychotherapy, t= he selected research is based on CBT; in addition, each one presents particularities that differentiate them from each other. For example, the w= ork conducted by Orang et al. (2018) relies on narrative therapy and previous traumatic memories. The intervention developed by Habigzang et al. (2018) posits the classic CBT model while Greene et al. (2019) propose a multi-sec= tor intervention based on Cognitive Processing Therapy (CPT) and advocacy counseling. Graham-Bermann et al. (2019) developed a manualized program for mothers focused on empowerment and social and emotional adjustment. Likewis= e, Johnson et al. (2020) designed a manualized first-phase program with an emphasis on empowerment, safety, and self-care rather than trauma processin= g. Andersson et al. (2021) and Latif et al. (2021) also designed manualized but guided self-help programs for PTSD symptomatology or depression and PTSD, respectively. Finally, Osma et al. (2022) proposed a transdiagnostic protocolized intervention based on emotion regulation.

Indeed, all studies (Ander= sson et al., 2021; Graham-Bermann et al., 2019; Greene et al., 2019; Habigzang et al., 2018; Johnson et al., 2020; Latif et al., 2021; Orang et al., 2018), h= ave focused on addressing PTSD, anxiety, or depression. This finding is similar with a recent systematic review in which all eleven selected studies identi= fied and treated the mentioned pathologies using CBT (Petersen et al., 2019). The psychological harms cited have the most evidence for association with DV (Aupperle et al., 2016); however, comorbidities, unspecified mood disorders, and subclinical symptoms are ruled out, which represents an important limitation in clinical practice. One study (Osma et al., 2022), has been identified in this review that considers excluded specifiers.

In short, the interventions were aimed at recovering the victim's sense of power and control over her l= ife, as well as reducing and/or eliminating the symptomatology associated with violence. To this end, through an integrated vision of the objectives of th= e programs, it is of utmost importance to psychoeducation the patient about DV, its functioning (cycle of violence) and health implications; in addition to informing her about her rights, available protection networks (community resources) and the development of therapy. Likewise, the programs suggest incorporating a safety plan, reinforcing the protection aspects of women's = lives, and facilitating autonomy and empowerment skills. On the other hand, both in group and individual format, it is proposed to identify distorted cognition= s to discuss and generate functional alternative thoughts (Andersson et al., 202= 1; Greene et al., 2019; Habigzang et al., 2018; Latif et al., 2021). Similarly= , to treat the symptomatology of the associated pictures, one seeks to gradually expose traumatic memories for meaning reprocessing (Andersson et al., 2021; Habigzang et al., 2018; Latif et al., 2021; Orang et al., 2018); in additio= n, the aim is to train patients on cognitive-behavioral strategies for emotion regulation (Osma et al., 2022), conflict management and communication skill= s; finally, relapse prevention is sought through a maintenance plan or future project (reinforcement with community support services). The therapeutic techniques associated with the described objectives have been mentioned in greater detail in Table 1; however, it seems that the techniques of psychoeducation, cognitive restructuring, exposure (imaginary, narrative and invivo) and problem solving reinforce the existing evidence on their effectiveness in addressing the symptomatology associated with DV (Petersen= et al., 2019). Regarding techniques, we want to make it clear that the outcome= of psychotherapy (therapeutic change) is not reduced to the application of a certain number of strategies. Lambert (1986) even pointed out that they represent only 15% of the entire therapeutic process, which allows us to reflect on the excessive importance currently attributed to them both in training programs and by mental health professionals.

Finally, it is worth noting about selected research findings; for example, the intervention developed by Habigzang et al. (2018) reduced anxious, depressive symptomatology and stre= ss; however, no significant changes in PTSD symptomatology were evidenced even after the intervention; this result is possibly attributed to the reduced number of sessions focused on exposure as well as the re-victimization to w= hich women are exposed both in their homes and in the government entities that advocate their case.

Orang et al. (2018) (NET) significantly reduced PTSD symptoms, depression, and stress at 3- and 6-mon= th follow-ups, and at follow-ups there was an improvement in daily functioning= and a reduction in DV experiences and borderline symptoms in both the intervent= ion and control groups (usual treatment). The NET was given to women who were living with their abuser (spouse), which may have caused 22% of the participants to drop out of treatment. In addition to unsafe living conditi= ons, this study found a link between education level and dropout rates as participants with middle and higher education (college or university) compl= eted the program while participants with low education dropped out. Those women = who completed the NET were able to reduce avoidance symptomatology; this result= empowers the victim because it allows her to overcome her fears and stop the differe= nt forms of abuse.

Likewise, Graham-Bermann et al. (2019) reduced the symptoms of traumatic stress, especially re-experiencing, but there was no change in the symptomatology of avoidance= and physiological agitation; moreover, the reduction in symptomatology was link= ed to both the age of participants (especially older mothers) and the number of sessions (>7); such improvement was more evident during the follow-up (in the next 8 months) than immediately after the intervention. In view of this, the authors point out that the sessions of the protocol are linked to each other, so that it is not surprising that those participants who completed a certain number of sessions achieved an improvement in their health status compared to those who attended fewer sessions. They also highlight the likelihood that the beneficial aspects of the MEP may take time to occur, as many women experienced elevated levels of distress and stressors during the intervention, so that the expected results may be evident even months later until the problems mentioned have been resolved.

Greene et al. (2019) propo= sed an experimental study for the implementation of a multisectoral self-help program. However, it is striking that the study included non-professional, = trained, and experienced DV facilitators to deliver the intervention; it is concluded that based on training and supervision it is possible to incorporate facilitators in low-income humanitarian contexts since it allows achieving treatment objectives with available resources. This result should be interpreted with caution because the program was manualized to be delivered= by trained staff and creates a dilemma regarding the ability of the lay therap= ist to manage the unexpected demands that often occur during the development of= the session. However, according to the results obtained in the study, it is possible to implement Nguvu in shelters for the treatment of psychological distress and DV.

On the other hand, Johnson et al. (2020) delivered the HOPE during the shelter stay and after that, the participants achieved significant changes in PTSD symptomatology and degree of DV during= the 12-month follow-up. Likewise, the treatment generated changes (small to med= ium) in depression, post-traumatic thoughts, level of empowerment and quality of life. Comparable results were obtained in the control group treated with Present-Centered Therapy (PCT). However, during follow-up some participants= did not achieve significant changes in empowerment and post-traumatic cognitions since after the shelter stay, they were still victims of abuse in their hom= es. This study determined that both HOPE and CCT are effective for the treatmen= t of DV victims, with no significant differences between the two protocols.

Similarly, Latif et al. (2= 021) conducted their study in a shelter home, it is evident the presence of a bi= as regarding the recruitment of the sample since at the beginning the particip= ants were identified by the shelter staff before the research team. Nevertheless, the intervention improved PTSD symptomatology, depression, anxiety, and deg= ree of daily functioning. It should be noted that the self-help material was adapted to the sociocultural demands of the participants which made the treatment understandable and applicable for this population. In non-Western cultures CBT concepts may conflict due to sociocultural factors (values, population-specific belief systems, etc.), so culturally adapted CBT makes = it possible for subjects from diverse cultures to benefit from a scientifically evidenced treatment (Rathod et al., 2019).

Andersson et al. (2021) proposed an individually tailored intervention to be delivered via the Internet. The results of the study showed a significant reduction in PTSD a= nd depression symptomatology. The ICBT despite being delivered via the Internet showed a low attrition rate (9.4%); however, based on compliance with the proposed modules, adherence to treatment was determined to be moderate. The results of the study promise that the treatment is feasible for women victi= ms of DV, and the efficiency of the program facilitated the reduction of opera= ting costs, expanded accessibility to women from diverse geographic regions and reduced limitations (stigma, shame, etc.) that prevent many women from seek= ing help through face-to-face therapy. According to Gros et al. (2013) online psychotherapy is as effective as face-to-face therapy; however, with this population and with this methodology (self-help via the Internet) there is still a lack of scientific evidence to support this claim.

On the other hand, Osma et= al. (2022) achieved significant results after the intervention and during follo= w-up (3, 6 and 12 months) in terms of decreased affective symptomatology (depression, panic, anxiety, somatization), in addition the participants improved in self-esteem, emotional regulation, quality of life (including family coexistence) and changes in certain personality dimensions (improvem= ents in neuroticism, negative affect and extraversion). However, there were participants (3) who did not show a significant change due to medical and family problems, so that the presence of stressors may be a limiting factor= in obtaining the expected results.

Conclusions

·         Based on the results of the present systematic review, it is concluded that the number of international publications is greater than the regional or nation= al ones, confirming the absence of studies at the national level on this topic= . In general, CBT is effective for the treatment of psychological harm in women = who have suffered domestic violence; however, the results of the studies cannot= be generalized due to the size of their samples and the requirements of each intervention (for example, certain pathologies). Nevertheless, the empowerm= ent of the victim, the restitution of control over her life and the reduction and/or elimination of the symptomatology associated with DV seem to be comm= on objectives that integrate the selected studies. Finally, the results of the experimental and pilot studies are promising, which justifies carrying them= out through an RCT to assess their true effects. Based on this systematic revie= w, it is essential to develop quantitative empirical studies related to the to= pic proposed at the national level. Likewise, future studies should focus their efforts on detailing the process of the sessions, especially the developmen= t of the techniques according to the proposed objectives, since it constitutes a significant limitation before the possibility of replicating the interventi= on in practice; attention to this limitation may possibly contribute to reduce= the existing gap between research and practice described at the beginning of th= is discussion. Furthermore, apart from the evaluation of pre- and post-test as= a specifier of the effectiveness of the therapy, it would be interesting to incorporate instruments for monitoring the results during the intervention,= as this would make it possible to verify whether the treatment is being effect= ive or not with the patients. Similarly, it is necessary to continue working on intervention protocols, especially for disorders other than the representat= ive disorders and comorbidities, so that clinicians have tools for the variety = of cases and for those that require greater complexity. Finally, it would be i= nteresting to incorporate in future research elements on the therapeutic process (therapeutic alliance, motivation for change of the patients, personal styl= e of the therapist, etc.) to further specify the requirements for a given intervention.

Acknowledgment: Smart University

Abbreviations

CatCBT GS= H: Culturally Adapted Trauma-Focused CBT-Based Guided Self-Help

CBT: Cognitive Behavioral Therapy

CONSORT: Consolidated Standards for Reporting Trials

CPT =3D Cognitive Processing Therapy

CPT: Present-Centered Therapy

CTT-BW: Cognitive Therapy of Trauma

DV: Domes= tic Violence

HOPE: Hel= ping to Overcome PTSD through Empowerment

ICBT: Internet Cognitive-Behavioral Therapy

MEP: The Moms’ Empowerment Program

NET: Narrative Exposure Therapy

Nguvu: Strength

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis

PTSD: Post Traumatic Stress Disorder

RCT: Randomized Clinical Trial

UP=3D Unified Protocol

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= ¹=	Juan Andrés Guillermo-Anasicha	https://orcid.org/0000-0002-878= 9-243X=
<= /span>	Universidad Católica de Cuenca, Unidad Académica de Posgrado. Maestría en Psicología = Clínica mención en Psicoterapia, Cuenca - Ecuador. juan.guillermo.55@est.ucacue.edu.ec
= ²=	Andrés Alexis R= amírez-Coronel=	https://orcid.org/0000-0002-699= 6-0443=
<= /span>	Universidad Católica de Cuenca, Laboratorio de Psicometría, Psicología Comparada y Etología (LABPPCE), Cuenca, Ecuador. andres.ramirez@ucacue.edu.ec<= o:p>
= ³=	Pedro Carlos Ma= rtínez-Suárez=	https://orci= d.org/0000-0002-1441-3821=
<= /span>	Universidad Católica de Cuenca, Laboratorio de Psicometría, Psicología Comparada y Etología (LABPPCE), Cuenca, Ecuador. pmartinezs@ucacue.edu.ec=

	Artículo de Investigación Científica y Tecnológica Enviado: 28/03/2022 Revisado: 01/04/2022 Aceptado: 07/04/2022 Publicado:05/07/2022 DOI: = https://doi.org/10.33262/cienciadigital.v6i3.216= 7

&n= bsp; Cítese:=	&n= bsp;	Guillermo Anasicha, J. A., Ram= írez Coronel, A. A., & Martínez Suárez, P. C. (2022). Cognitive-behavioral therapy for psychological h= arm in domestically abused women: systematic review and meta-analysis. Ciencia Digital, 6(3), 61-83. https://doi.org/10.33262/cienciadigital.v6i3.2167 =
	&n= bsp;	CIENCIA DIGITAL, es una revista multidisciplinaria, trimestral, que se publicará = en soporte electrónico tiene como misión contribuir a la formación de profesionales competent= es con visión humanística y crítica que sean capaces de exponer sus resultad= os investigativos y científicos en la misma medida que se promueva mediante = su intervención cambios positivos en la sociedad. https://cienciadigital.o= rg La revista es editada po= r la Editorial Ciencia Digital (Editorial de prestigio registrada en la Cámara Ecuatoriana de Libro con No de Afiliación 663) www.celibro.org.ec = =
	&n= bsp;	Esta revista está prote= gida bajo una licencia Creative Commons Attribution Non Commercial No Derivati= ves 4.0 International. Copia de la licencia: http://creativecommons.o= rg/licenses/by-nc-nd/4.0/.
Palabras claves: Terapia Cognitivo-Conductual, violencia doméstic= a, mujer, abuso, intervenciones	&n= bsp;	Resumen Introducción= . La violencia doméstica vulnera la salud física y mental de la víctima y de su entorno familiar; habitualmente las mujeres son las más afectadas, por razones culturales y sociales la violencia ha sido normalizada dentro del contexto familiar. Los perjuicios, sobre todo el dańo psicológico, es una de las consecuencias que perduran en el tiempo a menos que la víctima reciba una atención integral enfocada en sus principales necesidades. Objetivo. <= span style=3D'mso-spacerun:yes'> El objetivo fue valorar la evidenc= ia empírica actual de la Terapia Cognitivo-Conductual (TCC) para el tratamie= nto del dańo psicológico en mujeres violentadas domésticamente por su pareja.= Metodología. La revisión se realizó en la base de datos Scopus, PubMed y Web of Science, se utilizaron los lineamientos de la declaración Prisma y Consort para obtener la muestra final de los artículos seleccionados en base a los criterios de inclusión y exclusión propuestos= . Resultados. La mayor parte de intervenciones cognitivo-conductuales se han centrado e= n el abordaje de la sintomatología del TEPT, depresión o ansiedad, logr= ando resultados favorables para este tipo de población. Conclusión. La = TCC es eficaz para el tratamiento del dańo psicológico en mujeres violentadas domésticamente por su pareja. Sin embargo, la ausencia de especificidad de las intervenciones constituye una limitante importante al momento de repl= icar en la práctica clínica. = <= /o:p>
Keywords: Cognitive-behavioral therapy, domestic violenc= e, woman, abuse, interventions.		Ab= stract Introduction. Domestic violence violates the physical and mental health of the vi= ctim and her family environment; usually women are the most affected, for cult= ural and social reasons violence has been normalized within the family context. The damage, especially the psychological damage, is one of the consequenc= es that lasts over time unless the victim receives comprehensive care focuse= d on her main needs. Obj= ective. The objective was to assess= the current empirical evidence of Cognitive-Behavioral Therapy (CBT) for the treatment of psychological harm in women who have been domestically abuse= d by their partners. Methodology. The review was conducted in the Scopus, PubMed, and Web of Science databases, using the guidelines of the Prisma and Consort statements to obtain the final sample of articles selected based on the proposed inclus= ion and exclusion criteria. Results. Most cognitive-behavioral interventions have focused on addressing = the symptomatology of PTSD, depression, or anxiety, achieving favorable resul= ts for this type of population. Conclusion. In conclusion, CBT is effective for t= he treatment of psychological harm in women who have been domestically abuse= d by their partners. However, the lack of specificity of the interventions constitutes an important limitation at the time of replication in clinical practice.

Author	Sample	Intervention details	Therapeutic objectives	Techniques used	TIS (Task intersession)
Andersson et al.(2021= )	S=3D 31 &nbs= p; MA=3D43,03 (9,13=3DSD)<= o:p> &nbs= p; PTSD (20) and Depression (11)	ICBT P=3D Individu= al N^0: 8 ST: 2 H= F: Weekly PD: 8 s= &nbs= p; Country: Sweden	-Counsel on intimate partner violence, mental health problems and ICBT. - Addressing negative cognitions and their role in the etiology and maintenance of mental health problems -Report on PTSD or Depression on a case-by-case basis -Exposing the patient= or behavioral activation -Addressing distorted cognitions<= /p> -Develop a maintenance plan	PTSD	DEPRESSION	PTSD AND Depression: List of treatment objectives, Determine negative thoughts and their influence on depression and anxiety. Write a personal recollection of a traumatic event associated with DV. PTSD: Exposure hierarchy list and read personal narrative; in vivo exposure according to hierarchy list; detail personal narrative. Depression: Activity dia= ry (activity planning and development); list of reward behaviors; list of co= mmon negative thoughts and functional alternative thoughts.<= /p> PTSD AND Depression: Treatment synthesis, formulation of maintenance plan.
-Psychoeducation on DV, CBT, mental health problems and treatment goal setting.= -Psychoeducation on negative cognitions and their role in maintaining anxiety and depressi= on. -Psychoeducation on emotional regulation. -Relaxation and breathing techniques.
-Psychoeducation on trauma, its consequences, development, and maintenance of PTSD -Psychoeducation on in vivo exposure -Narrative and in vivo exposure technique	Psychoeducation on depression, its consequences, development, and maintenance. -Psychoeducation on the association between behavioral activation a= nd mood state. -Behavioral activation technique
-CR -Problem solving techniques Relapse prevention techniques (plan for the future)