**1.3 Repeated violent relationships**

As mentioned, intimate partner violence (IPV) is traumatising and remains a serious public health concern that affects 30% of every partnered women globally. The most prevalent mental health outcome of IPV is PTSD, ranging from 31% to 84.4% among IPV survivors, second is depression with a weighted mean prevalence estimate of 48% [19]. An association has been reported by studies between previous IPV and subsequent violence highlighting the role of PTSD in increasing the risk of future psychological abuse. Krause et al. [20] longitudinal study of IPV survivors found PTSD symptoms significantly associated in the increased likelihood of IPV after 1-year follow-up. Additionally, Bell et al. [21] concluded similar results that the more severe PTSD symptoms in women increased the risk for psychological abuse at an 18-month follow-up. Finally, data from the Chicago Women's Health Study reported the severity of PTSD symptoms is a predictor for future IPV [22]. Therefore, three of the four published studies revealed PTSD symptoms to be a predictive factor for future IPV. Albeit that the prevalence of PTSD and depression are evident mental health risk factors for future interpersonal violence, yet there is limited research that determines the impact specific interventions have upon reducing and preventing mental health outcomes that pose as a risk for future IPV among this vulnerable population.

### **1.4 Psychological impact of migration**

Migration is a process whereby an individual leaves one geographical area for a prolonged or permanent move to another geographical area, due to reasons of economic gain, political upheaval, conflict or other reasoning. Over the last decade, migration has grown at an international level with an estimated 3.1% of the world population having internationally migrated. Migration is a complex process that differs for each individual, yet most often individuals experience stressful events such as violence, war, and persecution. There is often no adequate preparation

nor social support given, difficulties present in the form of barriers, leading to psychological distress and resulting in a negative impact on psychological wellbeing. There are several studies that globally depict the impact on migrant population's mental health, for instance, its impact on incidence of psychosis in African Caribbeans in the UK and Caribeean Islands [23, 24]. Another study by Bhugra [25] conducted in Trinidad and Barbados and on UK African Caribbean population confirmed the impact of migration on the UK migrants in comparison with those in the country of origin. This was further endorsed by Canter-Graae's and Selten [26] meta-analysis which established the significant risk of developing schizophrenia in the migrant populations. In a classic study [27], reported hospital admission rates for schizophrenia were higher among Norwegians who had migrated to the United States compared with Norwegians who stayed in Norway. The result of this increase was based on the migration process these individuals endured. This study is now the benchmark and set the standard for additional studies on comparing the rate of schizophrenia and other psychiatric illnesses in those who migrated to those who did not migrate. Research concludes the exceptional vulnerability migrants have for developing mental health disorder, and yet the local and international efforts to respond are unable to meet the demand. Psychological interventions need to consider the role of migration distress in assessment and formulation stages. It is paramount to understand why individuals might decide to migrate, elicit premigratory stressors and the risk factors associated with this phenomenon. There is an imperative need to develop culturally-sensitive services with trained professionals to implement appropriate interventions that aid in preventing psychological distress and promoting positive mental health and well-being among migrants.

### **1.5 Cognitive behaviour therapy**

Cognitive Behaviour Therapy (CBT) stems from principles of cognitive theory [28] and implements both learning and conditioning in order to treat mental health disorders. Various techniques can be used including cognitive restructuring, exposure and the application of copying skills. CBT is typically delivered in 8 to 12 weekly sessions [29]. The general aim of cognitive therapy is to help individuals identify their unhelpful thoughts and modify beliefs in a way that encourages them to cope and ultimately change negative behaviours [30]. There is an abundance of research that supports the efficacy of cognitive therapy for treating trauma in adults. In addition, there is evidence to support using CBT to treat depression, anxiety, and symptoms of post-traumatic stress disorder (PTSD) resulting from sexual assault, industrial accidents and natural disasters [31].

CBT programs are typically implemented once a week over the course of a number of weeks, however, where this may be a barrier in regards to patient commitment to treatment over long periods of times, and interference with social functioning, researchers have argued for a more intensive delivery of CBT that has been proven to be just as effective as the standard delivery of cognitive therapy [32].

CBT has been consistently proven to be a better treatment of PTSD than relaxation training control groups. Furthermore, it has been shown that CBT is well maintained in follow-ups [33]. Despite the evidence suggesting the efficacy of CBT, many researchers still argue that the results obtained from randomised controlled trials are unlikely to be replicated in clinical settings. Reasons for this could include; inadequate staff training and experience, heavier caseloads, and more comorbidity among patients [33].

Research has found that psychological interventions can significantly reduce PTSD symptoms in adult survivors of childhood trauma. Previous meta-analyses emphasises that trauma-focused CBT (TF-CBT) is the most effective for PTSD. In

#### *Culture Free CBT for Diverse Groups DOI: http://dx.doi.org/10.5772/intechopen.93904*

addition, researchers suggest that TF-CBT should be used as a first-line treatment for PTSD [34]. It has been argued that trauma-focused treatments show significantly larger effects compared to non-trauma interventions such as managing anxiety, problem solving and supportive interventions. A limitation of this research is that adult PTSD survivors from childhood abuse are significantly underrepresented in existing research. Some authors have argued that trauma-focused treatments are not appropriate for individuals with PTSD due to emotion regulation difficulties caused by childhood abuse and that participants would have to re-live traumatic events [34].

Much previous research regarding PTSD has focussed primarily on male veterans. Recent research has tested the efficacy of CBT with a female population. The results found that prolonged exposure (a type of CBT) resulted in a greater reduction of symptoms compared to women who received a supportive intervention [35]. Thus, highlighting that CBT can be effectively generalised to the female population.

In addition to using CBT to treat trauma in adults, research also shows that CBT is an effective treatment for PTSD in children. However, children suffering from trauma have limited access to evidence-based interventions. This is a huge issue as research proves that access to empirically supported PTSD treatment can be vital in treating the effects of trauma exposure [36].
