Examining the Effectiveness, Acceptability, and Feasibility of Virtually Delivered Trauma-Focused Domestic Violence and Sexual Violence Interventions: A Rapid Evidence Assessment

Abstract

The COVID-19 pandemic has forced a rapid shift to virtual delivery of treatment and care to individuals affected by domestic violence and sexual violence. A rapid evidence assessment (REA) was undertaken to examine the effectiveness, feasibility and acceptability of trauma-focused virtual interventions for persons affected by domestic violence and sexual violence. The findings from this review will provide guidance for service providers and organizational leaders with the implementation of virtual domestic violence and sexual violence-focused interventions. The REA included comprehensive search strategies and systematic screening of and relevant articles. Papers were included into this review (1) if they included trauma-focused interventions; (2) if the intervention was delivered virtually; and (3) if the article was published in the English-language. Twenty-one papers met inclusion criteria and were included for analysis. Findings from the rapid review demonstrate that virtual interventions that incorporate trauma-focused treatment are scarce. Online interventions that incorporate trauma-focused treatment for this at-risk group are limited in scope, and effectiveness data are preliminary in nature. Additionally, there is limited evidence of acceptability, feasibility and effectiveness of virtual interventions for ethnically, culturally, and linguistically diverse populations experiencing domestic violence and sexual violence. Accessing virtual interventions was also highlighted as a barrier to among participants in studies included in the review. Despite the potential of virtual interventions to respond to the needs of individuals affected by domestic violence and/or sexual violence, the acceptability and effectiveness of virtual trauma-focused care for a diverse range of populations at risk of violence are significantly understudied.

Introduction

Factors Affecting the Mental Health of Individuals Experiencing Domestic Violence and Sexual Violence During the COVID-19 Global Pandemic

The current COVID-19 global pandemic has had a profound impact on the psychological and mental well-being of individuals and families due to financial and employment instability, changes in family routine, and social isolation due to physical distancing measures, school/childcare closures, and changes to health and social care access (Gadermann et al., 2021). Furthermore, the pandemic has interrupted the systems and structures that previously operated to both support the mental health and well-being of individuals and mitigate the risks that contribute to negative mental health outcomes (Lei & Klopack, 2020; Montesanti et al., 2020; Videgaard & Benros, 2020).

The economic and social stressors brought on by the pandemic has also contributed to a greater risk for violence and conflict in the home (Arenas-Arroyo et al., 2020; Badawy & Radovic, 2020; Bullinger et al., 2020; Ertan et al., 2020). High levels of stress, financial strain, and limited social support can lead to violence, even in relationships where it previously was not present (Sharma & Borah, 2020).

Past studies have shown that natural disasters, crises, epidemics, and pandemics often lead to increased rates of Domestic Violence (DV) and Sexual Violence (SV) (Ertan et al., 2020). For example, the HIV/AIDS epidemic increased rates of DV (Decker et al., 2013; Pellowski et al., 2013; Sharma & Borah, 2020), and natural disasters often lead to an increase in violence against women (Enarson, 1999; Gearhart et al., 2018; Parkinson, 2019; Rahman, 2013; Sharma & Borah, 2020; Wilson et al., 1998).

In Canada, rates of DV and SV has increased by up to 30% since the start of pandemic (Dubinski & Margison, 2020). In a report published by the Ending Violence Association of Canada, it stated 82% of frontline service providers within the anti-violence sector reported increases in the prevalence and severity of violence experienced by their clients (Trudell & Whitmore, 2020). In the early months of the pandemic, reports showed a dramatic surge in calls documented by Kids Help Phone, a national helpline for young people, with a 48% increase in calls about social isolation, a 42% increase in calls about anxiety and stress and a 28% increase in calls about physical abuse (Carr & Kutcher, 2021). Individuals who experience intersecting forms of inequality are particularly at risk of DV and SV including Indigenous, racialized, immigrant, refugee and newcomer, LGBTQ2S+ people and individuals with physical and cognitive disabilities (Barrett et al., 2020). All these groups are especially vulnerable because of the social and economic impacts of the pandemic (Mental Health Commission of Canada, 2019).

DV and SV are forms of trauma that can result in significant mental health distress for individuals. The presence of violence and abuse has significant long-term psychological consequences that range from stress, frustration, post-traumatic stress disorder (PTSD), and anger to severe depression (Gelder et al., 2020). The association between violence against women, mental health and substance use has been studied showing that women who have experienced violence have significantly higher rates of substance use and mental health concerns compared to women who have not (Dutton et al., 2005; Ledermir et al., 2006). For children, DV related trauma can be cumulative, and is associated with social, behavioral, emotional, and cognitive problems, many persisting into adulthood (Rossman, 2001). Similarly, experiencing sexual abuse is associated with significantly increased risk of mental health problems, including PTSD (Ullman et al., 2013). Survivors and individuals experiencing, or at-risk of, DV and SV during the COVID-19 pandemic are struggling with compounded or complex trauma as a result of the violence and COVID-19-related mental distress (Collin-Vézina et al., 2020). For some survivors of DV who have left the abusive relationship, the stay-at-home orders have triggered past traumatic experiences and heightened anxiety (Trudell & Whitmore, 2020).

During the COVID-19 pandemic, the additional factor of social isolation has been a contributing factor to increased rates of DV and SV (Bright et al., 2020; Capaldi et al., 2012; Farris & Fenaughty, 2002; Lanier & Maume, 2009; Myhill & Hohl, 2019). Social isolation as a means of coercive control is frequently used by perpetrators, and when physical distancing and isolation are mandated by governments, rates or coercive control are known to increase (Bright et al., 2020; Myhill & Hohl, 2019; Raghavan et al., 2019; Sharma & Borah, 2020). Moreover, the correlation between families spending more time together and increased level of violence is well documented (Booth, 2017; Nofziger & Kurtz, 2005; Sharma & Borah, 2020). It is likely that the combination of increased interpersonal time spent with abusers, isolation from friends, families, and social networks, and pandemic-related stressors including financial and psychological distress underlies the more frequent incidence and/or severity of DV and SV (Arenas-Arroyo et al., 2020; Badawy & Radovic, 2020; Bullinger et al., 2020; Ertan et al., 2020), which, in some cases, can be lethal (Myhill & Hohl, 2019).

Access to Trauma-Focused Services and Supports for Individuals Exposed to DV and SV During the COVID-19 Pandemic

The serious effects of trauma resulting from violence and abuse have led to a call for trauma-focused interventions and supports which prioritizes safe and accessible care for people who are impacted by trauma and violence (Badawy & Radovic, 2020). Trauma-focused interventions are specific approaches to therapy that recognize and emphasize “how the traumatic experience impacts an individual’s mental, behavioral, emotional, physical, and spiritual well-being” (The Center for Child Trauma Assessment, 2021). Cognitive-processing therapy (CPT) and cognitive-behavioral therapy (CBT) are the most common forms of trauma-focused interventions offered to survivors of DV and SV (Warshaw et al., 2013). The public health measures introduced to limit the transmission of the COVID-19 virus have meant that most services (including mental health and trauma-focused interventions) abruptly pivoted to virtual and remote-based delivery (Montesanti et al., 2020). Widespread adoption of remote delivery of DV and SV services and interventions during the pandemic was a major development, yet it proceeded within little research guidance. Research on virtual and remote-based service delivery for individuals experiencing, at-risk of, or survivors of DV and SV is scarce, and little is known about their effectiveness.

Virtual delivery of interventions incorporates the use of technology to provide communication, education, intervention, or service between a provider and a client (Chen et al., 2020; Hensel et al., 2019; Jack et al., 2020). Virtually delivered interventions include telehealth, telemedicine, eHealth, mHealth, tele-mental health, and telepsychotherapy (Anderson et al., 2019; de Lusignan, 2015; Stewart et al., 2020). The definitions of these intervention types are included in Supplementary Appendix A. These types of interventions can be delivered through videoconferencing, phone calls, mobile applications (“apps”), and web-based portals, to name a few (Chen et al., 2020; Hensel et al., 2019; Jack et al., 2020).

The application of virtual and remote service delivery within the healthcare system, and especially for mental health, was slowly emerging before the COVID-19 pandemic. The few studies previously carried out in users of virtual interventions within the healthcare system, prior to the pandemic, reported positive outcomes for clients and good feedback from providers (Chen et al., 2020). However, virtual or remote delivery of interventions for DV and SV was not widely adopted or considered appropriate by service providers in this field prior to COVID-19, and when used was restricted to remote geographic areas with limited access to in-person care and treatment (Chen et al., 2020). Bayles (2012) questioned whether video calls were acceptable for providing therapeutic support, given the loss of physical connection and difficulties observing and interpreting clients’ non-verbal and physical cues without physical proximity. Other scholars identified challenges with remote counseling, raising concerns about exchanging confidential information via these means, given the potential for misinformation (Byrne & Kirwan, 2019). Additionally, safety risks with virtual delivery of exposure therapy, facing memories or situations associated with the experience of trauma, are understudied (Spence et al., 2014; Valentine et al., 2019).

Although virtual or remote service delivery has been increasingly employed across healthcare settings, few studies have focused specifically on the benefits, challenges, or barriers of virtual or remote delivery of trauma-focused DV and SV interventions (Westwood et al., 2020). Chen et al. (2020) highlight benefits of increased volumes of clients served, reduced logistical barriers, decreased no-shows, easier scheduling, protection for people with disabilities or health conditions, and increased access to support for those unable to leave home. However, scholars have also pointed to some disadvantages of virtual or remote-based interventions including, difficulty reading non-verbal communication, loss of intimacy and privacy and increased disparities affecting people unable to use technology (Chen et al., 2020).

Technology use during COVID-19 has also raised some ethical challenges related to protecting clients’ safety and the coercive control tactics used by perpetrators. For instance, it has been reported that the risks to a women’s safety increases when she uses app-based interventions that can easily be accessed by her perpetrator (El Morr & Layal, 2020). Moreover, some individuals may be struggling with unstable or unavailable internet connections, or they may not be able to afford the required devices, such as a smart phone or tablet, to receive treatment or support virtually (Fiolet et al., 2020; Rossi et al., 2020; Trudell & Whitmore, 2020). Additional barriers to uptake of virtually delivered interventions can include issues concerning confidentiality and privacy and not being comfortable with receiving care or treatment commonly delivered face-to-face over phone or video (Trudell & Whitmore, 2020).

Furthermore, underserved people have faced multiple barriers to accessing virtual or remote-based interventions throughout the pandemic (Trudell & Whitmore, 2020). This has been coined the “digital divide,” which is characterized by inequitable access to technology and the internet (Badawy & Radovic, 2020). For instance, there is ample evidence demonstrating digital exclusion among rural communities where broadband access is limited (Chen et al., 2020; Heyworth et al., 2020). Some individuals affected by DV and/or SV also face barriers to accessing virtual interventions due to a lack of culturally acceptable and appropriate virtual tools (Trudell & Whitmore, 2020).

Although the pandemic has necessitated the leveraging of virtual and remote interventions to increase accessibility and provision of care and treatment for individuals and families experiencing and/or at-risk of DV and SV throughout the crisis (Badawy & Radovic, 2020), evidence of their effectiveness, feasibility, and acceptability across a range of diverse individuals and population groups affected by violence, including interventions that incorporate gender-transformative approaches to trauma (e.g., cultural, historical, and immigration-related trauma), has been limited (Bright et al., 2020). Therefore, we conducted a rapid evidence assessment (REA) of existing trauma-focused virtually delivered DV and SV interventions, and their acceptability, feasibility and effectiveness for diverse individuals and families.

Study Objectives

Given the limited knowledge regarding the delivery of effective and culturally safe virtual and remote-based interventions across a range of diverse DV and SV affected individuals, our REA reviewed published evidence on virtually delivered trauma-focused interventions to support decision-making on the delivery of such interventions for individuals experiencing, at risk of, and survivors of DV and SV during the current public health crisis and beyond. This knowledge synthesis specifically aimed to examine the acceptability, feasibility and effectiveness of these virtual interventions across a range of population groups affected by DV and/or SV. This REA was funded by the Canadian Institute of Health Research COVID-19 Rapid Research in Mental Health and Substance Use initiative (Montesanti et al., 2020).

Method

A REA was undertaken within a 5-month timeframe. Rapid evidence assessment provides a timely, valid and balanced assessment of available empirical evidence related to a particular policy or practice issue (Fiolet et al., 2020). Rapid evidence assessment is a rigorous and explicit method that utilizes a wide range of evidence required for policy and practice recommendations in a short timeframe. The process is characterized by developing a focused research question, a less developed search strategy, literature searches, and then more simplified data extraction and quality appraisal of the identified literature when compared to traditional systematic reviews (Watt et al., 2008).

Search Strategy

Three comprehensive search strategies were executed by an expert searcher/health librarian (SC) on the following databases (Supplementary Appendix B): OVID Medline, OVID EMBASE, OVID PsycInfo, OVID Global Health, Cochrane Library (CDSR and Central), EBSCO CINAHL, Proquest Dissertations and Theses Global, PROSPERO and SCOPUS using controlled vocabulary (e.g., MeSH, Emtree, etc.) and key words representing the following concepts Search 1: “remote care delivery” and “people experiencing DV” and “COVID-19”; Search 2: “remote care delivery” and “people experiencing DV”; Search 3: “remote care delivery” and “trauma informed care.” Results of all three searches (2133) were exported to Covidence systematic review software, where duplicates (703) were removed. No limits were applied. Search strategies are available in Supplementary Appendix A. Additional search was also conducted using Google and Google Scholar to identify studies not published in indexed journals and gray literature sources. A monthly search alert was created using our search terms to allow for notifications of new published literature on the topic and this review was updated accordingly between May 2020 and November 2020. A call was also sent out to contacts and experts in the field to share their knowledge and/or resources in relation to our objectives. However, no data was received through this strategy.

Study Screening and Selection

Two reviewers (WG and KT) independently screened all potential articles. In the case of disagreement, both reviewers read the paper and discussed until consensus was reached. Full texts of eligible articles were independently screened by these two reviewers (WG and KT), and papers were included into this review only if they satisfied all of the following three inclusion criteria: (1) if it included trauma-focused intervention to individuals and families affected by DV, SV and/or related childhood trauma; (2) if the intervention was delivered virtually; and (3) if the article was published in the English-language.

The first search strategy (virtual care interventions + experience of violence + COVID-19) identified 138 potentially relevant articles. The second search strategy (virtual care interventions + experience of violence) resulted in 1058 potentially relevant articles. The third search strategy (trauma-informed interventions + experience of violence) identified 236 potentially relevant articles. A review of the titles and abstracts resulted in the selection of n = 52, n = 206 and n = 44 articles, respectively, for full-text assessment. The full text was retrieved for all articles, and, 21 studies met the inclusion criteria. The PRISMA Flow Diagrams (Moher et al., 2009) for the literature search for each search strategy are included in Supplementary Appendix C; and the PRISMA-S Checklist is included in Supplementary Appendix D.

Quality Assessment

The quality of studies was assessed using the Critical Appraisal Skills Program (CASP) quality assessment tools, namely, the CASP Systematic Review Checklist, CASP Qualitative Checklist, and CASP Randomized Controlled Trial Checklist (Critical Appraisal Skills Programme, 2018). The developers do not recommend using a scoring system when applying this tool. Thus, included studies were assessed based on the clarity of research objectives, the appropriateness of data collection strategy for the study design, quality of the methodology, whether findings clearly correspond to objectives and if the research is valuable and/or applicable to local settings (Critical Appraisal Skills Programme, 2018).

Data Extraction and Analysis Process

Two reviewers (WG and KT) independently extracted the following information from included studies into a standard extraction form (Supplementary Appendix E): author(s), publication date, publication type, population studied, country, study setting, type of virtual care intervention, if the virtual care solution was implemented in the context of an epidemic or pandemic, outcome measures and results, equity considerations and challenges or barriers to implementing the virtual care intervention. Independent extraction by two reviewers ensured the accuracy of included data and that any relevant information was not missed. An inductive, summative content analysis approach was used to analyze the findings (Finfgeld-Connett, 2013).

Results

Study Characteristics

A total of 1432 de-duplicated documents (i.e., academic articles, abstracts, and dissertations) were screened, 175 full-text documents were reviewed, and 21 documents were included for analysis. The included articles were published between 2004 and 2019, with majority of articles (n = 19) published after 2011. Study types included systematic reviews (n = 2), scoping review (n = 1), narrative reviews (n = 3), RCTs (n = 5), and quantitative descriptive (n = 5); and three studies came from gray literature sources (i.e., doctoral dissertations and evaluations). Most of the included evidence is from studies conducted in high-income countries (USA, New Zealand, Canada, and Australia), and only one systematic review included a study conducted in a lower middle-income country (Cambodia). Qualifying studies focused on DV related trauma (n = 9), SV related trauma (n = 2) and both DV and SV related trauma (n = 3). The studies included the following populations: adult female survivors only (n = 8), children and youth survivors only (n = 2), and a range of participant groups (i.e., same-sex couples, pregnant and postnatal mothers, perpetrators, and survivors; n = 10). Most of these studies (n = 17) were targeted to English-speaking participants. Only two studies tailored their interventions for Spanish-speaking participants (McFarlane et al., 2004; Stewart et al., 2020).

Characteristics of Virtual DV and SV Interventions

Our review identified two types of trauma-focused virtual DV and SV-focused interventions: (1) digital safety planning tools that are intended to support individuals currently experiencing DV and/or SV and (2) interventions focused on psychological therapies and treatments for survivors of DV and/or SV. Our review did not identify psychological therapies and treatments specific for individuals experiencing DV and/or SV in the moment.

Digital safety planning tools

Safety planning is defined as a dialogic process that informs and supports an individual exposed to violence or abuse by identifying behaviors they can adopt to increase safety and decrease exposure to violence for themselves and their family at risk (Bloom et al., 2014). Findings from three RCT studies of internet-based safety planning tools highlighted several important online support tools such as online programs and apps for delivering needed safety services to individuals experiencing DV and/or SV (Constantino et al., 2015; Ford-Gilboe et al., 2017; Hegarty et al., 2015). These safety planning tools included HELPP (Health, Education on Safety and Legal Support and Resources in IPV Participant Preferred)—an online program (Constantino et al., 2015), I-DECIDE—an interactive online tool (Hegarty et al., 2019) and iCAN Plan 4 Safety—an online tool (Ford-Gilboe et al., 2020). These digital support tools predominantly focused on supporting female individuals affected by DV to make informed decisions about their safety and well-being (Table 1). HELPP and I-DECIDE are not yet available to the public, while iCAN Plan 4 Safety can be accessed using a weblink for free. These are intended to allow both privacy and real-time access to resources for those at risk and may be particularly appropriate for hard-to-reach populations (e.g., individuals with limited access to technology or individuals residing in remote and rural communities).

Table 1.

Summary of Safety Decision Aid Tools.

Name of program	Target population	Delivery method	Description	Opportunities	Concerns/challenges	Effectiveness
HELPP (Constantino et al., 2015)	Female survivors of domestic violence (who are not living with perpetrator)	Online program	Focus on education on safety, self-reflection and self-evaluation of risk for mental health distress	Intervention showed improvements in all outcome measures (i.e., anger, anxiety, depression, personal and social support)	Long-term sustainability of outcomes is unknown	Significant improvements were shown in all outcome measures (i.e., anger, anxiety, depression, personal and social support) in a random sample of female survivors
I-DECIDE (Hegarty et al., 2019)	Female experiencing domestic violence	Online interactive tool	Help female self-inform, self-reflect, and self-manage, and focuses more on healthy relationships, rather than only safety decisions	Available wherever individuals can find safe access to computer/internet	Not tested among other genders and individuals from different ethnic, cultural or socioeconomic groups	Findings from this intervention indicated positive outcomes on reduced depression, fear and anxiety, as well as increased self-efficacy
iCAN plan 4 safety (Ford-Gilboe et al., 2020)	Female who have experienced domestic violence in the previous 6 months	Mobile app	Helps female assess their particular situation in terms of setting priorities and safety risks	Allow both privacy and real-time access to resources	Not available to individuals without access to smart phones	The effectiveness of this tool are not yet measured

In one systematic review, 11 online interventions that focused on personal safety planning to enable female safety while in an abusive relationship were studied (Rempel et al., 2019). Of the eleven interventions, six focused on personal safety planning that would enable female safety while remaining engaged within the abusive relationship; seven interventions focused on safety planning to support females to physically leave an abusive relationship; and four interventions focused on the provision of services and resources to support females in the immediate aftermath of leaving an abusive situation (Rempel et al., 2019). Similarly, a more recent systematic review also described self-efficacy and safety decision aids for females in abusive relationships (El Morr & Layal, 2020). However, none of the interventions identified in this review focused on supporting women to move on from an abusive relationship and none of the interventions appeared to consider the broader social implications related to DV and SV.

Virtual psychological therapies and treatments

There is strong evidence in support of virtual delivery of trauma-focused treatments such as CPT, CBT and psychotherapy to a range of survivor participant groups; for example, survivors of SV, children and adolescents, and female survivors of DV (Stewart et al., 2020). These treatments and therapies (Table 2) were delivered through mobile health (mHealth) and videoconferencing technologies to wide range of participant groups who have been removed from their traumatic situation (Anderson et al., 2019; Burton et al., 2002; El Morr & Layal, 2020; Gray et al., 2015; Hassija & Gray, 2011; Mattson et al., 2002; Moring et al., 2020; Steinmetz & Gray, 2017; Stewart et al., 2017, 2020; Valentine et al., 2019). For instance, a smartphone-based mobile application called THRIVE was developed to address unmet health needs for mothers who have experienced DV and to improve their mental well-being (Ragavan et al., 2020). Vidyo, a videoconferencing software, was also used to remotely deliver CBT to 15 underserved trauma-exposed youth (Stewart et al., 2017).

Table 2.

Summary of Online Psychological Therapies for Individuals with More Severe Needs.

Name of program	Population	Delivery method	Description	Opportunities	Challenges	Effectiveness
THRIVE app (Ragavan et al., 2020)	Mothers who have experienced domestic violence	Mobile health (mHealth) technologies	Program includes three sections: Myself (maternal self-care, stress coping skills), My child (stress signs in children, talking to children about IPV, mother–child dyadic communication), and My Life (hospital and community-based resources)	Convenience, lower dropout rates, increased access to isolated individuals	Requires access to digital technology	Not measured
The Wyoming trauma telehealth treatment clinic (WTTTC) trauma-focused treatments (Gray et al., 2015)	Rural survivors of domestic violence and sexual violence	Videoconferencing and tele-mental health	Trauma-focused psychological services	Reduce mental health care disparities for those living in rural and remote communities	Access to digital technology access to stable Wi-Fi; privacy and confidentiality concerns	Clinically significant reduction in PTSD symptoms
Telepsychotherapy for treating childhood post-traumatic stress (Stewart et al., 2020)	Children and youth with experience of trauma related to domestic or sexual violence	Telehealth	Trauma-focused Cognitive-Behavioral therapy	Outcome measures indicate reduction in PTSD symptoms	Highly dependent on caregiver involvement	Clinically significant reduction in trauma-related disorder at post-treatment

Note. PTSD = post-traumatic stress disorder.

Effectiveness, Feasibility, and Acceptability of Virtual DV and SV Interventions

Effectiveness and acceptability of safety planning interventions

Evidence from methodologically robust studies that primarily reported on the effectiveness and acceptability of digital safety planning tools, demonstrate positive outcomes on participants’ increased safety-promoting behaviors and improved decision-making and self-efficacy skills (El Morr & Layal, 2020; McFarlane et al., 2004). In a recent systematic review, three high-quality studies of safety decision aids were examined that provided empowerment and support for women (El Morr & Layal, 2020). In one of the included studies, 90% of the female participants left the abusive relationship within a year of receiving the intervention, and in the other two studies more than 70% of the female participants reported gaining important decision-making and self-efficacy skills (El Morr & Layal, 2020). Similarly, an RCT study examined the effectiveness of a safety-promoting behavior intervention which was administered over the course of six phone calls, and post-intervention follow-up at 3,6, and 12 months (McFarlane et al., 2004). The authors concluded that the intervention was efficacious in that the number of safety-promoting behaviors in the treatment group was greater than in the control group, an effect which was consistent throughout the 18-month duration of the study. The participants in the treatment group also increased the number of safety-promoting behaviors that were observed, and the behaviors remained stable throughout the study timeframe.

Effectiveness, feasibility, and acceptability of virtual psychological treatments

There is evidence from varied methodological study designs demonstrating the effectiveness, feasibility, and acceptability of virtual psychological treatments and care for PTSD and other forms of trauma for some DV and SV survivors. Effective online psychological therapies in these circumstances included CPT, CBT, and telepsychotherapy which were delivered through real-time (synchronous) technologies, such as telehealth, mHealth, and videoconferencing (Anderson et al., 2019; Burton et al., 2002; El Morr & Layal, 2020; Gray et al., 2015; Hassija & Gray, 2011; Mattson et al., 2002; Moring et al., 2020; Steinmetz & Gray, 2017; Stewart et al., 2017, 2020).

One study reported on positive outcomes of virtually delivered trauma-focused counseling for survivors in rural and remote settings. The Wyoming Trauma Telehealth Treatment Clinic is cited as a successful evidence-based program that delivers trauma-focused psychotherapy using remote videoconferencing to rural survivors of DV and SV (El Morr & Layal, 2020; Hassija & Gray, 2011). In an effectiveness and feasibility study with 15 clients (Gray et al., 2015), the authors reported large treatment gains among these clients on measures of PTSD and depression symptom severity after receiving psychological services via videoconferencing (Gray et al., 2015). In this study, the presence and severity of PTSD was measured using the Post-traumatic Stress Disorder Checklist (PCL) and symptoms of depression were measured using the Center for Epidemiological Studies Depression Scale (CESD). The study showed that the mean score from the PCL questionnaires completed by clients decreased from 54.43 pre-treatment to 34.10 post-treatment, showing an improvement in PTSD symptoms (Gray et al., 2015). Clients also completed a self-report measuring depression symptoms (CESD). The mean score from this report decreased from 29.33 pre-treatment to 15.24 post-treatment, showing an improvement in depression symptoms (Grey et al., 2015). Additionally, rural survivors of DV and SV who participated in the intervention reported a high degree of satisfaction with videoconferencing administered services. Thus, the findings from this intervention suggest that remote videoconferencing can be an effective means to deliver services to underserved rural DV and SV clients.

Cognitive-processing therapy has also been successfully delivered via clinical video technology and tele-health (Steinmetz & Gray, 2017; Stewart et al., 2017, 2020; Valentine et al., 2019). Two of these studies (Steinmetz & Gray, 2017; Valentine et al., 2019) applied prolonged exposure (PE) therapy—a cognitive-behavioral treatment which incorporates “the gradual confrontation of typically-avoided memories, images, objects, and situations associated with the traumatic experience through exposure exercises.” (Steinmetz & Gray, 2017, p. 145). Valentine et al. (2019) used virtually delivered PE-based treatments with veteran survivors of military sexual trauma (MST). The survivors were given the choice to enroll in remote delivery (i.e., clinical video technology) or in-person therapy. In this study full treatment completion rate was similar between in-person delivery and video delivery. However, the researchers report higher attrition rates early in the treatment phase in the participants who received treatments virtually, which coincided with interventions such as early imaginal exposure and written trauma accounts (Valentine et al., 2019). On the other hand, Steinmetz and Gray, 2017 did not discuss challenges with attrition in virtual delivery of PE to rural survivors DV (80%) and SV (20%). In this study, the mean number of sessions attended was 13.33 (SD = 13.89), and meaningful reduction in depressive symptoms (d = 1.24) and PTSD symptoms (d = 1.17) were reported. One study demonstrated effectiveness (i.e., a therapeutic effect) for the treatment of PTSD among MST survivors with CPT interventions delivered via clinical video technology (Valentine et al., 2019). At the same time, in a systematic review of mHealth interventions (Anderson et al., 2019), the findings showed that dropout rates in mHealth interventions were lower compared to in-person interventions. The authors attributed this to participants feeling more comfortable to disclose their circumstances in the virtual environment than during in-person sessions (Anderson et al., 2019).

In one pilot study that examined the effectiveness of trauma-focused CBT (TF-CBT) via telehealth (Stewart et al., 2017), the authors reported that participants showed a clinically significant reduction in PTSD symptoms with a zero dropout rate. This study specifically assessed technical performance of the telehealth equipment, safety, number of sessions attended, treatment completion rates, and pre-to post-treatment clinical outcomes of PTSD, depression, and anxiety symptoms. All study participants no longer met criteria for PTSD or adjustment disorder at the completion of treatment, demonstrating the effectiveness of this virtual CBT interventions to address PTSD and other forms of trauma. The authors of this study also noted they were able to deliver all treatment components successfully such as, digitally presenting worksheets and written materials using screen sharing function. In a recent follow-up study by the same authors (Stewart et al., 2020), they examined the effectiveness of a telepsychotherapy intervention that enrolled 70 children and adolescents struggling with PTSD as a result of physical abuse, sexual abuse, and witnessing domestic or community violence (Stewart et al., 2020). The authors indicate participants showed clinically meaningful symptom change post-treatment and 96.8% of the participants who competed the treatment no longer met diagnostic criteria for a trauma-focused disorder at post-treatment. The authors conclude these results are indicative of potential effectiveness of the virtual treatment delivery format (Stewart et al., 2020).

Equity Considerations in the Design and Delivery of Virtual DV and SV Interventions

There was limited evidence examining the delivery of virtual DV and SV interventions for underserved and at-risk population groups, including Indigenous, LGBTQS2+, newcomers, individuals with disabilities, and other population groups who are at a greater risk of DV and SV. Only two primary studies (a pilot study and an evaluation study) and three reviews (a narrative review and two systematic reviews) discussed the virtual delivery of trauma-focused interventions for individuals from underserved populations. The pilot study reported on the effectiveness of TF-CBT delivered via telepsychotherapy on children and youth exposed to violence or abuse from a range of ethnic and racial minority groups (Stewart et al., 2020). Telepsychotherapy treatment was delivered to 70 trauma-exposed youth in several underserved communities, and in community-based locations of either schools or patient homes. Results from this study demonstrated clinically meaningful reductions in PTSD symptoms among children and youth. Additionally, an evaluation study of a new trauma-focused smartphone-based mobile application called THRIVE reported mothers who survived DV were engaged in the user design of the application (Ragavan et al., 2020). This was the only study that reported on the engagement of survivors, as the users of the digital tool, in the mobile application’s content, design, safety features, and applicability, thus emphasizing the incorporation of user or client-centered care principles in the design and delivery of the virtual intervention.

Furthermore, a narrative review highlights the importance of inclusive virtual delivery approaches where evidence-based trauma treatments are culturally adopted and delivered by bilingual clinicians (Jones et al., 2014). The authors studied the utility, use, and set-up of a tele-mental health program through the Community Outreach Program-Esperanza (COPE)—an existing community outreach program. COPE is a community agency based in South Carolina that provides virtual care services to underserved populations (ethnic minorities, individuals residing in rural/remote areas, and economically disadvantaged populations). The research team also developed guidelines for the delivery of evidence-based, trauma-focused tele-mental health to a range of diverse population groups (Jones et al., 2014). The authors also recommend that “clinicians be aware of the families’ views of trauma and potential cultural constructs, such as acculturation and ethnic identity, which may impact the treatment process” (Jones et al., 2014, p. 4).

In one systematic review (El Morr & Layal, 2020) the authors noted a gap in research examining the effects of virtually delivered trauma-focused interventions for women with disabilities, immigrant women, and Indigenous women (El Morr & Layal, 2020). Similarly, in their systematic review Anderson et al. (2019) reported the majority of interventions (77%) they reviewed were exclusively delivered in English and did not take language barriers into consideration.

Barriers to Virtual Delivery of DV and SV-Focused Interventions

Challenges and barriers with the implementation of virtual or remote-based interventions were reported. Among the studies that identified barriers and challenges to delivering and implementing virtual interventions, several accessibility barriers were noted (Anderson et al., 2019; Bloom et al., 2014; Brignone & Edleson, 2019; Moring et al., 2020; Paul et al., 2012; Stewart et al., 2017). Barriers to delivering online or web-based applications to some individuals exposed to DV and/or SV, particularly in rural communities, included lack of access to reliable internet or devices such as smart phones, tablets and computers which were necessary to use the online/digital application (Bloom et al., 2014; Brignone & Edleson, 2019; Moring et al., 2020; Paul et al., 2012; Stewart et al., 2017); unacceptable platforms, especially if participants have to download software or learn how to use new hardware (Anderson et al., 2019); and challenges with the telehealth equipment such as login challenges (Stewart et al., 2017).

User attrition was also identified as a potential challenge to implementing virtual DV and/or SV interventions (Brignone & Edleson, 2019; Paul et al., 2012; Valentine et al., 2019). For example, in one study participant attrition was higher at the intervention stage when participants were asked to recount their traumatic experiences (Valentine et al., 2019). The authors of this study highlight, “this is an unfortunate time for clients to dropout, as they may be experiencing temporary symptom exacerbation, which may reduce their likelihood of reengaging in treatment in the future and may negatively impact treatment expectancy” (Valentine et al., 2019).

Ethical concerns and safety of use by those still at risk of DV and/or SV was also identified as a potential barrier (Brignone & Edleson, 2019; El Morr & Layal, 2020; Hassija & Gray, 2011; Paul et al., 2012). Most apps and online resources may not have sufficient safety and security provisions, and this increases the risk of violence for individuals who are still living with their abusers, especially if they share a mobile phone with their abuser (Brignone & Edleson, 2019; El Morr & Layal, 2020). In addition, trauma-focused virtual treatment may not be safe for suicidal survivors because of the inability to manage such crisis distally (Hassija & Gray, 2011). Other studies in our review highlight challenges with the loss of “therapeutic alliance” in virtual delivery of interventions (Paul et al., 2012); and the potential to miss non-verbal cues in virtual settings (Moring et al., 2020).

Discussion

The findings from this REA suggests that there is limited evidence demonstrating the effectiveness, feasibility, and acceptability of a range of virtual DV and SV interventions. Despite these knowledge gaps, there is methodologically sound evidence on virtual delivery of trauma-focused interventions and psychological therapies for survivors of DV and/or SV. In addition, the evidence examined in this review highlighted several important digital tools for delivering safety planning services to individuals who are impacted by DV. However, to our knowledge safety decision aid tools specific for individuals affected by SV have not been tested. These online safety decision aids focused on women creating a safety and/or action plan in the event of a future partner domestic abuse incident, which, in part, involves clarifying the choices individuals have for leaving an abusive relationship. Furthermore, of the evidence-based safety decision aid tools that were included in the studies reviewed they were predominately focused on females. Thus, there remains a knowledge gap on the effectiveness and acceptability of these online support tools across other gender identities, and for individuals affected by SV. Moreover, individuals affected by DV were not engaged in the design, development of safety features, and applicability of the tools.

There is limited evidence on the effectiveness of psychological therapies and treatments specific for individuals currently experiencing DV and/or SV. However, there is methodologically robust evidence that supports the provision of virtual psychological therapies for reducing psychological symptoms such as depression, anxiety and PTSD for survivors of DV and/or SV who are removed from the abusive situations (Brignone & Edleson, 2019; El Morr & Layal, 2020; Emezue, 2020; Hegarty et al., 2019; Hill et al., 2019; McFarlane et al., 2002; Valentine et al., 2019). The effectiveness of virtual psychological therapies was particularly demonstrated for individuals with complex, severe or delayed forms of trauma (i.e., exhibiting symptoms of complex PTSD, have experienced multiple or ongoing traumas, and/or in individuals who have experienced childhood sexual abuse). Effective virtual psychological therapies in these circumstances include CPT, CBT, and telepsychotherapy (El Morr & Layal, 2020; Jackson et al., 2018; Moring et al., 2020; Stewart et al., 2017, 2020). Studies that examined the effectiveness and feasibility of videoconferencing as a means of delivering trauma-focused treatment have also shown comparable gains that accrue during traditional in-person services (Hassija & Gray, 2011; Jones et al., 2014; Paul et al., 2012). However, many of these studies involved a small sample size of which can influence research outcomes and the results cannot be generalizable to a larger population. Thus, RCTs with larger sample sizes comparing videoconferencing and in-person treatment are needed to strengthen the evidence-base.

Furthermore, higher dropout rates, the loss of therapeutic alliance, and the potential to miss non-verbal cues in virtual settings were identified as barriers to implementing and measuring the effectiveness of virtual interventions in our REA. Recent studies have also reported similar results (Montesanti et al., 2020; Trudell & Whitmore, 2020). At the same time, challenges related to the virtual delivery of trauma-focused interventions with exposure component (e.g., PE) for DV or SV survivors is not well documented. Our REA identified only two studies that included exposure component (PE) with contradicting findings (Steinmetz & Gray, 2017; Valentine et al., 2019). However, the participant groups included in these studies were different and faced unique factors associated with their experiences of violence—rural survivors of DV versus veteran survivors of MST (Steinmetz & Gray, 2017; Valentine et al., 2019). Thus, neither of these findings are generalizable. As a result, our understanding of virtually delivered exposure therapy and the associated safety risks remain to be unknown and calls for further exploration.

Some scholars have suggested that internet-based applications and e-mental health programs are likely to be most effective when used to supplement or facilitate (rather than replace) professional care and provider-client engagement (Brignone & Edleson, 2019). For example, Brignone and Edleson (2019) referred to this as “supportive accountability”—where there is an interface between providers and clients, and the online tools or programs are not solely approached as a self-help tool. However, existing evidence of virtually delivered trauma-focused interventions (including mobile applications and safety decision aid tools) for individuals and families affected by DV and SV provided little evidence of how these virtual interventions can best be promoted or offered by providers in a range of health and community settings.

In addition to the already heightened risks for DV and SV faced by individuals and families during COVID-19 (Bogart, 2020), others who experience intersecting forms of inequality are particularly at risk including Indigenous, racialized, non-status, immigrant, refugee and newcomer, LGBTQ2S+ and individuals with disabilities. All these underserved populations are especially vulnerable because of the social and economic impacts of the pandemic (Bright et al., 2020; Ramsetty & Adams, 2020; Trudell & Whitmore, 2020). The use of virtual interventions for these individuals and families affected by DV and SV has the potential to reduce mental health care disparities by increasing access to culturally and linguistically competent clinicians (Jones et al., 2014). However, underserved populations face multiple barriers with the “digital divide” (Badawy & Radovic, 2020). While access to the internet or technology was highlighted as a barrier for participants in several studies included in our REA (Anderson et al., 2019; El Morr & Layal, 2020; Jones et al., 2014; Ragavan et al., 2020; Stewart et al., 2020) limited consideration was given to the issues of equity and access in the virtual delivery of these interventions.

Guidance from available evidence for how to deliver virtual interventions for different individuals affected by DV and SV, including interventions that incorporate gender-responsive approaches to trauma (e.g., cultural, historical, and immigration-related trauma), is not readily available. Thus, further research is needed to examine the delivery of virtual DV and SV-focused interventions from an intersectional lens, as well as attending to inequities in digital access to virtual treatment or care. Furthermore, most of the studies examined in our review demonstrate intervention effectiveness using traditional scientific methods such as RCTs, which obscures the myriad of factors occurring between an intervention and possible reduction in trauma and mental health disorders. Qualitative research on the experience of clients accessing virtual interventions can improve our understanding of effectiveness and acceptability of such interventions for different individuals.

The articles and systematic reviews examined in our REA also describe the ethical challenges with protecting clients’ privacy, confidentiality and safety when accessing and using virtual or remote-based interventions (El Morr & Layal, 2020; Paul et al., 2012). Practice guidelines for professionals delivering virtual interventions and conducting comprehensive intake procedures to assure appropriateness of treatment for clients have been promoted (El Morr & Layal, 2020; Paul et al., 2012). Our findings also highlighted the ethical challenges with protecting clients’ safety. The coercive control tactics used by perpetrators is a major barrier for some individuals accessing treatment services and supports virtually. As previously indicated, a women’s safety concerns increase when she uses app-based interventions that can easily be accessed by her perpetrator (El Morr & Layal, 2020). Therefore, more research into enhancing safety features, privacy, and confidentiality in the delivery of virtual interventions for people experiencing DV and SV is needed.

Given the scarcity of evidence in effective virtual or remote-based interventions, this provides limited guidance for anti-violence sectors to adequately prepare for the sudden influx of the need for virtual interventions for individuals affected by DV and/or SV during the COVID-19 pandemic. As previously indicated, unprecedented challenges and barriers that have arisen include limited digital communication infrastructure such as access to smart devices, broadband access, and compounded by lack of comfort with virtual care technologies by clients and providers (Ragavan et al., 2020). That being the case, as the pandemic continues, virtual interventions are increasingly becoming the “new normal.” Therefore, there is a growing need for government investment, and stakeholder involvement in the development, implementation and evaluation of resources and educational materials that are specifically tailored for the delivery of equitable trauma-focused DV and SV interventions.

Implications and Recommendations for Research Policy and Practice

While this REA highlights the paucity of virtual or remote-based interventions, there is promising evidence supporting the effectiveness and acceptability of virtually delivered interventions that can readily be adopted and utilized by organizations and providers serving individuals and families affected by DV and/or SV during the current COVID-19 pandemic and future pandemics. However, virtually delivering equitable and accessible interventions to a wide range of individuals and families affected by DV and/or SV will require an intersectional and systemic approach to ensure uptake by individuals and families most at-risk of violence and abuse. This will require collective effort from researchers, providers and policy makers (Table 3). Further research is needed to (1) examine the effectiveness and acceptability of online support tools across sex and gender identity, and for individuals affected by SV; (2) undertake mixed method studies examining the effectiveness of psychological treatments delivered via videoconferencing compared to in-person treatment across a diverse range of population groups; (3) apply an intersectional lens and qualitatively assess the acceptability, feasibility and perceived effectiveness of virtual or remote-based interventions for diverse population groups at a greater risk of DV and SV; (4) examine the safety concerns of virtual delivery of interventions within the context of a pandemic; and (5) develop and evaluate virtually delivered psychological treatments for individuals experiencing DV and/or SV during a pandemic or similar public health crisis when access to services and supports are disrupted.

Table 3.

List of Implications and Recommendations for Practice, Policy, and Research.

Recommendations for future research	Further research is needed to examine the following
	1. The effectiveness and acceptability of online support tools across all gender identities, and for individuals affected by sexual violence
	2. RCTs comparing videoconferencing and in-person treatment, and inclusion of larger samples and structured clinical interviews
	3. Virtual interventions applying an intersectional lens, and there is an urgent need to tackle inequities in digital access to care and treatment
	4. The safety concerns of virtually delivered trauma-focused treatments with exposure component
	5. The effectiveness and feasibility of virtually delivered interventions for individuals experiencing DV and/or SV during a pandemic or similar public health crisis
Implications for policy and practice	Recommendations for policy and practice include the following
	1. Practice guidelines for delivering virtual interventions
	2. Engage survivors and other stakeholders in the design, safety features, content and applicability of virtual support tools
	3. Policy measures to ensure sustainable funding resources for the aniti-violence sector to accommodate diverse clients and their unique needs in accessing virtual or remote-based services
	4. Providing access to support resources and treatment during the pandemic, and provincial and national strategies should address potential barriers to accessing services and support preparations for increased intake when public health measures are lifted or when services resume
	5. Developing policy measures to narrow the “digital divide” including funding broadband infrastructure and increasing digital health literacy for vulnerable clients; and increasing global access to digital technologies

The existing evidence is not sufficient to make specific recommendations for practice; however, providers working with individuals and families affected by DV and SV will need practice guidelines for delivering virtual interventions, which include safety assessment and ensuring appropriateness of virtual treatment for clients. In addition, online tool developers need to be mindful of inequities in digital access and improve their design of virtual tools to be more inclusive, secure, and safe for individuals at risk of DV and/or SV. One of the knowledge gaps noted from the REA is the engagement of clients in the development and design of virtually delivered services and supports. Considering what has already been said about understanding the acceptability of these interventions for different population groups, their perspective and voices in the design, safety features, content and applicability of the virtual support tools is important. In addition, the following policy recommendations can guide the implementation and uptake of equitable and accessible virtual or remote-based interventions during the COVID-19 pandemic and beyond. (1) As previously indicated, the anti-violence sector has already been overstretched and was not prepared for the pandemic-related higher volumes of demand for support. Ensuring sustainable funding resources for organizations which provides an avenue to accommodate diverse clients and their unique needs in accessing virtual or remote-based services during the pandemic and beyond is key (Bright et al., 2020). (2) Health systems should continue to ensure that individuals experiencing DV and/or SV and survivors have access to support resources and treatment during the pandemic and future public health crises. Provincial and national strategies should address potential barriers to accessing services (including lack of information about the services and supports available) and support preparations for increased intake when public health measures are lifted or when services resume. Finally, (3) developing policy measures to narrow the “digital divide” including funding broadband infrastructure and increasing digital health literacy for vulnerable clients; and increasing global access to digital technologies would provide an avenue to improve the acceptability and feasibility of implementing virtual or remote-based interventions for individuals and families affected by DV and SV. These include culturally appropriate, and affordable virtually delivered services and interventions (Anderson et al., 2019).

Limitations

Although this REA followed a systematic approach to reviewing and analyzing the evidence, there are still limitations which reflect primarily the relative dearth of studies in this area. More specifically, limitations include the following: (1) that it was conducted within a limited timeframe which may have affected the quality and level of analysis; (2) with the aim of scoping all potentially relevant evidence, we included heterogenous sources of data. Thus, it was difficult to compare and rate qualities of the included studies; (3) the heterogeneity of the included evidence also resulted in the lack of consistency of outcome measures for the quantitative studies; (4) we only included articles published in English, and thus, we may have missed important information published in a different language; and (5) in this review we were only able to identify virtually delivered psychological treatments and therapies for survivors, not individuals currently experiencing DV and/or SV.

Conclusions

Virtually delivered trauma-focused interventions for DV and SV are scarce, and effectiveness data for these approaches are preliminary in nature. In addition, the acceptability and effectiveness of virtual trauma-focused interventions for a range of population groups at risk of DV and SV are understudied. However, there is some evidence indicating virtual delivery of DV and SV interventions have the potential to respond to the needs of individuals and families affected by DV and/or SV, especially during COVID-19.

Further robust, large scale research is required to evaluate a range of virtual or remote-based interventions across diverse population groups to ascertain their effectiveness and acceptability. A stronger evidence-base will allow for the development and implementation of virtual interventions that benefit these at-risk individuals and families. Further, this study shows that inequities in digital access are a barrier to the effectiveness of virtual care. This barrier must be addressed in order for many people experiencing DV and SV violence to take advantage of virtual or remote-based interventions and services.

Authors Biographies

Winta Ghidei is a PhD candidate in the School of Public Health at the University of Alberta. Her research focuses on examining and addressing service inequities experienced by underserved populations affected by domestic violence.

Stephanie Montesanti, PhD, is an Associate Professor in the School of Public Health at the University of Alberta, Canada. She is a health policy and health systems researcher within the field of population and public health. Her research program examines the determinants of policy and systems change in addressing the health of populations. She has extensive research experience in community engagement, domestic and family violence, and mental health and trauma interventions.

Karlee Tomkow is a Master’s of Science student in Health Promotion and Socio-behavioral Sciences at the University of Alberta School of Public Health. Her research focuses on the impact of intersectoral collaboration and community-based interventions to address domestic violence. She is particularly interested in how collective impact networks facilitate integrated responses to domestic violence.

Lana Wells is an Associate Professor and the Brenda Strafford Chair in the Prevention of Domestic Violence at the Faculty of Social Work, University of Calgary where she is leading a primary prevention initiative called Shift: The Project to End Domestic Violence. She is nationally and internationally known for her research on the prevention of gender-based violence and engaging men and boys in violence prevention.

Peter H. Silverstone, PhD, is a Professor in the Department of Psychiatry at the University of Alberta. He is also a psychiatrist who has extensive expertise in addressing mental health issues following trauma, and of designing and implementing a wide variety of rigorously tested e-mental health solutions for over 25 years.

Sandy Campbell is a Health Sciences Librarian at the University of Alberta in Edmonton Canada. Sandy has professional interests in all forms of user-centered delivery of library services. She has research interests in polar literature and health. Sandy has co-authored on more than 50 systematic and scoping reviews.

ORCID iDs

Winta Ghidei https://orcid.org/0000-0002-6778-5303

Karlee Tomkow https://orcid.org/0000-0003-0942-1760