Implementing a Targeted Teen Dating Abuse Prevention Program: Challenges and Successes Experienced by Expect Respect Facilitators

Abstract

Purpose

Expect Respect Support Groups (ERSGs) are a targeted 24-week dating abuse prevention program tailored to middle and high school students who have been exposed to violence. As part of a controlled evaluation, this qualitative study was designed to examine facilitators’ experiences with program implementation and generate a deeper understanding of factors that enhance or challenge implementation and program outcomes.

Methods

Semistructured interviews with Expect Respect Support Group facilitators (three males and four females) were conducted at the midpoint and endpoint of the school year. Interview topics included working within the school system, strategies for establishing a productive group process, and individual and group-level responses to the program.

Results

Facilitators indicated that school counselors’ awareness of students’ exposure to violence increased their ability to refer eligible students. Within a supportive school environment, successful groups harnessed the protective qualities of a positive peer group, supported members in questioning the normalcy of abuse, and provided opportunities for building healthy relationship skills. Challenges resulted from impediments to group cohesion including insufficient referrals, inconsistent attendance, and low levels of school support. Students who were frequently absent and disengaged from school were particularly challenging to engage in a school-based program.

Conclusions

This research demonstrates that successful implementation of a targeted school-based dating violence prevention program relies on building school support and awareness of teen dating violence, especially for appropriate identification and referral of at-risk students. High levels of school support enhance the development of a supportive group process and attitudinal and behavioral changes among participants.

Adolescent dating abuse is a serious public health concern that is associated with adolescent risk behaviors, such as alcohol and substance use, sexual risk taking, and poor academic performance [1]. Prevention of dating abuse is critical given its long lasting and serious consequences for adolescents’ mental, physical, and reproductive health [2–4]; educational outcomes [5,6]; and the potential persistence of teen dating abuse across multiple relationships and into adulthood [7].

Research on risk factors for dating abuse suggests that there is a need for targeted prevention programs that engage youth who have experienced maltreatment and other adverse childhood events, demonstrate aggressive behaviors and attitudes, or who are already involved in unhealthy dating relationships [8,9]. However, very few targeted dating abuse prevention programs have been evaluated and, in contrast to universal prevention programs, even fewer are offered within the school system [10,11]. Efforts to bring targeted prevention programming directly into schools where services can be accessed with fewer barriers and stigma mirror the national movement toward school-based delivery models for mental health and substance abuse services [12]. The nature of the school system in which the program is embedded [13,14] offers unique opportunities and challenges that impact program implementation and outcomes [15,16] and require further exploration, especially if a program addresses sensitive issues such as dating abuse.

Expect Respect is a 24-week support group program provided during the school days [17,18] for youth who have been exposed to violence in relationships with their family, peers, and/or dating partners. As part of a larger controlled outcome evaluation of Expect Respect Support Groups (ERSGs), we conducted a qualitative study to examine facilitators’ experiences providing support groups in the school setting and generate a deeper understanding of factors that enhance or challenge program implementation and outcomes. Through interviews, we explored how facilitators (1) work with schools; (2) establish a supportive group process that fosters healthy relationship development; and (3) describe program outcomes for participants.

Expect Respect Support Group Model

ERSGs employ a curriculum-based support group model that strives to create a positive peer environment, increase relationships skills, and promote norms for equal and respectful relationships [19]. Middle and high school students are eligible for participation if they report domestic violence, child abuse, peer or dating abuse, and/or exposure to violence in the community. At intake, 75% of participants disclosed experiencing violence in more than one context and 15% of participants experienced pervasive violence and abuse across all contexts. Participants were among the highest risk students in their respective schools as indicated by significantly lower attendance and higher levels of aggressive behavior offenses.

Youth who grow up in abusive environments learn that relationships are unreliable and may come to expect abandonment, disrespect, and violence in all relationships [20,21]. However, experiencing supportive relationships with other peers and adults has the potential to alter ingrained expectations and help youth develop healthy relationship skills and norms [22]. Positive peer support may also protect youth from entering or staying in relationships with abusive partners [23,24], as peers help to define acceptable behaviors and function as “guardians” over dating relationships.

Boys and girls report being involved in dating violence as both perpetrators and victims [25–27]. ERSGs offer separate groups for boys and girls led by same-sex facilitators that are intended to increase participants’ sense of emotional safety and comfort, allowing them to bond quickly and more freely explore gender-based relationship norms. The 24-session ERSG curriculum [17] includes five units: (1) developing group skills; (2) choosing equality and respect; (3) recognizing and healing from abusive relationships; (4) learning skills for healthy relationships including empathy, communication, boundaries, consent, and handling rejection; and (5) promoting nonviolent relationships in the community. Support group facilitators are encouraged to work creatively with the curriculum, adapt activities and discussion topics to meet the specific needs of their group, and allow time for handling individual concerns and group dynamics.

ERSGs are implemented at middle and high schools through an agreement between SafePlace (the program developer and service provider) and a large urban school district in the Southwestern United States. Facilitators obtain each principal’s agreement for providing ERSGs during the school days and work closely with a designated school contact person—a school counselor or social worker—who coordinates program referrals and provides logistical support (e.g., space, schedules, passes releasing students from class). Facilitators provide information to schools about teen dating abuse, distribute program information and referral criteria, and conduct individual intakes and weekly 55-minute support group sessions.

Methods

This study was guided by a grounded theory approach that explores individuals’ experiences and the perceived causal conditions and consequences of a phenomenon [28,29]. ERSG facilitators were intentionally chosen to participate in in-depth interviews (theoretical sampling) to develop an understanding of the factors that enhance and challenge the implementation and outcomes of the program [13,30].

Participants

All seven ERSG facilitators (three males and four females; 100% participation rate) consented to participate in interviews at the midpoint and endpoint of the school year (December 2012; June 2013). ERSG facilitators were employed by SafePlace and included licensed social workers, counselors, and paraprofessionals with extensive experience in working with youth and training regarding teen dating violence and ERSG implementation. In the 2012–2013 school year, they provided 40 support groups for 306 students at 24 middle and high schools. The facilitators had an average of four years (range, 2–7 years) of experience conducting ERSGs.

Interview protocol

Interviews were conducted through telephone, lasted approximately 60 minutes, and, to minimize bias, were conducted by the Centers for Disease Control and Prevention (CDC) evaluation staff rather than SafePlace staff. Interviews were recorded using WavePad iPad software (Apple Inc., Cupertino, CA), transcribed verbatim, and deidentified to protect the privacy of facilitators. Pseudonyms were assigned to identify facilitators and are used throughout this publication.

Interviews followed a semistructured format with open-ended questions developed a priori by CDC staff. Midyear interview questions focused on general information about groups, school context and referral process, facilitation strategies, and perceptions of individual- and group-level changes. End-of-year interview questions explored perceptions of group- and individual-level changes in greater detail. At both time points, facilitators were asked to think about one group and individual student that functioned well and one group and student that presented challenges. Finally, facilitators were asked to identify factors that contributed to implementation challenges and successes.

Data analysis

Using a combination of grounded theory techniques, including open and axial coding [28], topic codes were developed by the research team (three CDC and three SafePlace staff). Team members independently coded one transcript and met to discuss and further refine the coding system. Coders were subsequently assigned one primary transcript to code and additional transcripts to review (i.e., secondary coding). Primary and secondary coders discussed discrepancies and revised or added codes as needed. Once consensus was reached, coded interview segments were compiled by topic code, summarized using a condensed description, and examined for underlying meanings and connections with other codes. Using the constant comparative method, common patterns and overarching themes were identified through the comparison of similarly coded segments of data [28,31,32]. The team constantly linked interpretation with excerpts from the raw data to maintain transparency, trustworthiness, and to connect micro- and macro-level interpretation [30,33]. The interview guide and research protocol were approved by the CDC Institutional Review Board, and data collection was approved by the Office of Management and Budget.

Results

Findings from facilitator interviews illustrated that program implementation can be successful and challenging at three interrelated and intersecting levels: working within the school system, establishing a productive group process, and engaging individual group members and promoting change (Tables 1–3). Overall, there was a high level of consistency in observations across all facilitator responses regardless of gender. Major themes were corroborated by multiple responses and are presented below with supportive quotes from the interviews.

Table 1.

Working within the school system

	Implementation successes	Implementation challenges
School culture	There’s just an overall feeling of respect in this school. They don’t tolerate … low-grade violence … you don’t see that happening at this school. I think that [positive] school norm really sets the stage for allowing an intimidated student to take risks and step out of those, personal confines and talk about what’s going on. (John)	The whole culture of the school is about denying that there are any problems … They didn’t want to name it, they talked about maybe they would be more comfortable if we were looking for referrals for “guys with anger problems.” They were trying to protect their reputation and so because of that we got very few referrals. (Jack)
	And there are “No bullying” signs on the hall, and everybody is pretty aware of what’s happening [in students’ relationships] over there. (Brendon)	The school that is not going so well – they’re not doing well academically. There is a lot of pressure, that makes it hard for [the teachers] to allow students to come to group. The kids need to be in class because [the teachers’] jobs sort of depend on that. (Melissa)
Referral process	Teachers tend to know what’s going on with their students so [they] are glad to know that a student they know is having these issues is getting help somewhere. (Jessica)	They may make a ton of referrals but most of them will not be good referrals because the student rarely comes to school or skips a lot or is having academic problems to the point where they won’t be allowed to come to group. (Jack)
	The referrals that were given were, for the most part, appropriate referrals. They were students that needed our services, but were also behaviorally able to work in a group setting. (John)	I just can’t get kids to come to group – whether it’s the teachers won’t release them or the kids have attendance issues. If you’re never able to establish a core group, you really just can’t get started. (John)

Table 3.

Engaging individual group members and promoting change

	Implementation successes	Implementation challenges
Planting seeds for healthy relationships	Things changed when they began to understand which people in their lives were being aggressive and controlling and which people in their lives were being assertive and supportive and you could hear in the way they talked that they were looking at things in a little bit different way. (Jack)	Some kids are just so stuck in what they believe. We’re talking about kids who are 15 and 16 years old who have received these messages all their life, who probably have some type of trauma, who see negative relationships. I think it just takes time and consistency instigating change for some of these kids. (Brendon)
Observing behavioral changes	I had a couple of girls who were actually the perpetrators in the relationship. I think I’ve seen the most improvement with them. (Candace)	Her self-esteem was pretty torn, so even at the end of the year she was engaging in a lot of really harmful behaviors sexually. Still not really taking the responsibility for her part in it, blaming it on the other person, and saying it’s the other person’s responsibility, engaging in a lot of risky and unhealthy relationship behaviors. (Melissa)
	And she disclosed how she realizes now that she doesn’t have to solve all her problems through fighting. (Candace)
	And even in her relationships, she realizes that the person she was dating was not good for her. And it took the whole year for her to break up with him, but she finally did. And we all supported her, and she decided that she was just going to take some time for herself, and stay out of relationship for a little bit. (Candace)	I would have wanted her to say that she was no longer in that relationship, but I don’t think that she was ready for that yet. I think she was still attempting to change some dynamics in the relationship, at least on her part. (Kelly)

Working within the school system

ERSGs depend on school support to “build the foundation” for a successful program. Facilitators identified multiple strategies to strengthen support for the program by networking with staff, providing awareness education, and framing the program in a way that demonstrated its relevance to schools.

What makes groups really successful is that piece of support … from the school because if we don’t have that, it’s really tough to even form a foundation for a good group. How that manifests is that the girls are able to really connect with one another, they know how to support each other, they know … they can talk and get some new skills and tools … to build healthier relationships in the future. (Melissa)

The school’s culture was perceived as impacting identification and referral of at-risk students (Table 1). In some schools, ongoing efforts to increase awareness about dating abuse, bullying, and other forms of violence encouraged students to reach out for help and access services. Other schools, however, did not appear to acknowledge the extent of abuse in students’ lives leaving staff reluctant to identify and refer students. In these schools, facilitators stated they were “casting for referrals” and working “in the shadows.” Some low performing schools in neighborhoods with elevated levels of violence experienced so much pressure to improve academic performance that teachers felt as if they had to choose between releasing students from class to access much needed services and focusing on classroom learning.

Additionally, facilitators described the critical role of a supportive school contact person who embraced the need to promote healthy teen relationships, understood risk factors and warning signs of teen dating abuse, was aware of students’ relationships, and typically provided good referrals and support for the program. Facilitators identified “good referrals” as students who not only met ERSGs’ eligibility criteria for exposure to violence but also attended school regularly and were able to work in a group setting. In contrast, some of the most troubled students were frequently absent or suspended for aggressive behaviors, which meant facilitators could “not find” these students despite their best efforts to engage them. Facilitators’ responses revealed that challenges in the referral process impeded timely program commencement and consistent attendance, the formation of a cohesive core group, and ultimately a productive group process.

Establishing a supportive group process

Taking ownership of the group

ERSG facilitators described intentionally creating a group space that modeled key characteristics of healthy relationships including mutual respect, emotional and physical safety, and shared experience and power. Within this group space, facilitators defined their role as non-authoritative group leaders who empowered group members to support each other and take ownership of the group.

I like to sit in a circle and tell them, “We’re sitting in a circle because everybody’s equal here. We’re all sharing, we’re all trying to grow from this experience”. (Brendon)

I tell them that the difference between a facilitator and a teacher is that my job is to make sure the group goes in the way they want it to. (John)

Facilitators unanimously considered groups that took ownership of the process as more successful (Table 2). As condition for this process, positive group norms and a sense of safety had to be established. In more challenging groups, excessive aggressive and disruptive behaviors required constant direction and redirection by the facilitator and deterred participants from taking the initiative to share personal experiences, voice their opinions, or articulate their needs.

Table 2.

Establishing a supportive group process

	Implementation successes	Implementation challenges
Taking ownership of the group	They were really taking the initiative and taking the lead on [the group], they supported each other, learned how to listen to each other, and also to express what they were needing and feeling. (Melissa)	I’m leading everything, and instigating conversation and prompting. It almost feels more like a class. It just has a really different feel because they don’t know each other very well, and it’s always different girls showing up. (Melissa)
Bonding and sharing	Someone will open up about an experience regarding family violence or dating violence, and then someone else will say they’ve been through the same thing, and they’ll share their experiences with the rest of the group members. So then they slowly start trusting each other, kind of seeing that they do have things in common. (Kelly)	There was, a lot of conflict in the group, they weren’t able to build the same level of cohesion. (Kelly)
		She didn’t come to group a lot ’cause her teacher wouldn’t let her out. And then when she did come, she was very quiet, because she had missed so much. I think she just didn’t feel like she fit in, because the group was already bonding and she had missed that bond. (Candace)
Introducing the possibility of change	Instead of it just being that’s normal, or not even really questioning it, or not talking about ’cause they’re embarrassed or ashamed of what’s happening, that they would be able to come and talk really openly about it, and to get support, and then to be open to feedback and then the possibility of change, you know, of choosing somebody who’s healthier, that they deserve something different and that is probably really new for a lot of them. (Melissa)	This was a girl who rarely spoke up and shared her own experiences. I think she still is really struggling with staying in unhealthy relationships, and also quite a bit of violence in her past at home, and pretty unhappy at home and so I’m not sure if it’s just maybe a little bit less maturity, or more fears about what other group members would think, but certainly she was much less likely to share her story and her experiences. (Melissa)

Bonding and sharing

Bonding was identified as another dimension that differentiated a successful group from a challenging one. Facilitators initially observed group members testing the responsiveness and security of the group. They noted that members with previous group experience often catalyzed the process as they modeled how to “open up,” express vulnerabilities, and support others. Bonding facilitated sharing and reflection, which in turn, promoted both individual and group growth (Table 2).

The group norm was about abusive relationships, dominance over women, misogynistic attitudes, slurs and remarks. [There was] change to the point of them really being able to open up and talk about their own personal experiences of domestic violence and [being] able to use those experiences to develop a feeling of empathy and change those attitudes and the way that they spoke about women and the way that they spoke about relationships. (John)

Introducing the possibility of change

In the eyes of the facilitators, the opportunity to process relationship experiences with peers and the facilitator opened up the “possibility of change” and created the potential for interrupting the cycle of violence in participants’ lives. Facilitators observed that this process occurred when students fully engaged in group, opened up, asked questions, received feedback, and experienced support (Table 2).

[He asked] what other guys did and what worked for them. He was pushing me hard on how to handle stuff and what he could possibly do. At first he was like, “There’s no way that would work, there’s no way.” [He] came back and said, “I tried it, and it worked.” (Jack)

One of the factors that seemingly hindered the group process was inconsistent attendance, often due to students not attending school or not being released from class. In these situations, a cohesive core group could not be established thus impeding the unfolding of the group process. Other identified threats to a supportive group process included high levels of conflict and aggression among group members, as well as high levels of trauma and distrust (Table 2).

Engaging individual group members and promoting change

Facilitators formulated their expectations for change in the context of the students’ “lived reality.” They noted that the meaning of key concepts such as “safety” and “respect” may differ for students growing up in a culture of violence where “staying safe means being aggressive” (Jack). Some participants presented with challenging needs and multiple threats to their safety and well-being. Facilitators described handling immediate crises, addressing the continuum of relationships from abusive family relationships to peer and dating relationships, mitigating other risk behaviors, and providing additional referrals.

They’re so used to being treated wrong that they don’t even know what it’s like. So when I bring up healthy relationships or being assertive, they’re looking at me like, “Miss, what world are you living in? ’Cause that’s not our reality.” So I have to change up the way I talk to them. (Candace)

Planting seeds for healthy relationships

Given the abusive environment surrounding many group participants, facilitators viewed themselves as “planting seeds” for healthy relationships: identifying unhealthy relationships, knowing options for ending abusive relationships and getting help, increasing communication and coping skills, and increasing expectations for maintaining healthy relationships (Table 3). Shifting the normalcy of unhealthy relationship behaviors required gentle questioning by facilitators and other group members to introduce the idea that “healthy relationships really exist.” Facilitators stated that, by the end of the program, group members expressed expectations for healthier relationships and identified and took responsibility for unhealthy behaviors, especially more covert forms of abuse.

I definitely see huge changes in them being able to identify what is an unhealthy relationship, what’s controlling. In the beginning there always seems to be this thought of, “Well, if she was okay with it, then it’s not controlling or it’s not abuse.” It does seem like they’re able to take that element out of it [now] and really identify what is abuse and what is controlling in relationships. (John)

Facilitators perceived challenges to planting seeds for healthy relationships when a supportive group process was not established or when students did not consistently attend and engage in the process. They concluded that for students who live in overwhelmingly abusive environments, the program may not provide sufficient support to promote change within one school year (Table 3).

Observing behavioral changes

By the end of the program, facilitators reported observing less aggressive controlling and jealous behaviors (Table 3) and more healthy skills across group, family, peer, and dating relationships. Students tried new skills for communicating assertively rather than aggressively but also understood that they could not control responses, especially those from an abusive partner or parent.

I think that the whole group … started understanding the need to be able to communicate with the people around you in ways that are effective and how important it is to be able to tell people what’s going on with you. And that even though it is difficult to be assertive, it’s really worth trying. And it might work, it might not work. (Jack)

Ending unhealthy or abusive relationships surfaced as a specific concern for girls but was not mentioned by boys’ group facilitators. Facilitators described how several girls struggled with ending unhealthy dating relationships over the course of the school year and that with group support, some of them were ready or willing to take the step (Table 3).

Discussion

This study describes factors that enhance and impede the implementation of ERSGs on three levels: (1) the support of schools where the program is embedded; (2) the development of a productive and supportive group process; and (3) participant responsiveness based on their readiness to benefit from group and make changes in their lives. Interviews with facilitators demonstrated very clearly that the three levels are interrelated and intersect and may impact participant outcomes.

A positive school culture, school counselors’ awareness of the impact of violence and abuse on students’ lives, and their ability to identify at-risk students form the “foundation” for a successful implementation of ERSGs. This finding resonates with other research indicating that successful implementation requires recognition at multiple levels (among teachers, principals, and superintendents) of the impact of the problem behavior and the potential benefits of intervention [13,16]. However, nationwide 71% of high school counselors report that they have not received formal training on dating abuse and 80% do not have school protocols for responding to incidents [34]. Efforts to increase training, screening, and identification of students in unhealthy relationships are critical for supporting targeted programs such as ERSGs. In some schools, especially those failing academically and serving high-risk populations, school-based services like ERSGs get caught in the perceived tension between raising students’ academic performance and meeting their social–emotional needs. New research indicates that dating abuse victimization impedes educational attainment [5,6], but future studies are needed to explore whether targeted prevention programs also improve students’ academic success.

“Introducing the possibility of change” and interrupting the cycle of violence hinge, in the experience of ERSG facilitators, on establishing a cohesive and trusting group in which members are open to sharing and questioning the normalcy of abuse in their lives. Challenges occur when group members do not bond due to high levels of conflict or trauma and/or when a cohesive group is not established as a result of inconsistent attendance or low levels of school support, all of which may impede the development of a supportive group process and program outcomes. The study also clearly demonstrates the limitations of a school-based targeted prevention program in reaching those troubled youth who may be less engaged in school, transitioning to and from alternative and/or disciplinary settings, or involved with the juvenile justice system [35]. It is important for future research to explore the potential to impact multiple risk factors by integrating dating abuse prevention in dropout prevention strategies and alternative school settings.

Program outcomes for individual students must be considered within the context of their “lived reality” and environment. Many at-risk students who have been exposed to violence also participate in other risk behaviors [1] and grow up within a culture of violence. Facilitators view themselves as planting seeds and, over time, observe small steps toward changing expectations and behaviors for healthy relationships. Although some participants demonstrate behavioral changes, others may need support over a longer duration and more comprehensive services to realize behavioral changes. As such, the effect of environmental context on students’ rate of behavioral change may have implications for how interventions such as ERSGs are evaluated and deemed effective, particularly for those students at highest risk levels.

Limitations and strengths

Limitations of the qualitative methodology used in this study include an inability to generalize findings and draw conclusions about program implementation in other school districts or by other service providers. However, a strength of this qualitative approach is its exploratory nature, which highlights specific conditions that facilitators associate with successes and challenges in implementation. It also emphasizes how implementation conditions may affect program outcomes. Most importantly, insights of this study are valuable in identifying areas for program improvement.

Overall, this study demonstrates that successful implementation of a school-based targeted dating abuse prevention program largely depends on a positive school culture and ongoing school support, specifically a thoughtful process for identifying and referring at-risk students who have been exposed to violence. The support group model hinges on establishing a group environment where students who have grown up in violent environments can process past and present experiences and learn new skills to break the cycle of abuse.