Training LEADers to Accelerate Global Mental Health Disparities Research (LEAD) Program: A Research Training Program Protocol.

Background: There is a critical need to address mental health needs across the globe, especially in low and middle-income countries where mental health disparities are pervasive, including among children. The global mental health disparities suggest an imperative for culturally and contextually-congruent mental health services models that expand upon the existing services and interventions for these groups. Rigorous research is a key tool in providing the scientific evidence to inform public policy and practice efforts to effectively address these needs. Yet, there is a limited number of researchers, especially those from diverse backgrounds, who study these issues. In this paper, we describe the "TrainingLEADers to Accelerate Global Mental Health Disparities Research" (LEAD) program, a research training program funded by the National Institute on Minority Health and Health Disparities and focused on global mental health disparities research for early career researchers from under-represented minority groups. Methods: The LEAD program is designed as a two-phase training program for advanced pre-doctoral students, postdoctoral fellows, and junior faculty from diverse backgrounds in the U.S., including groups underrepresented in biomedical, behavioral, clinical and social sciences research, interested in global mental health disparities research. Trainees are matched with mentors and participate in an intensive 12-week program. Discussion: The LEAD program seeks to provide a robust platform for the development, implementation and expansion of evidence-based culturally and contextually-congruent interventions and services models addressing global mental health disparities across the life cycle, especially in low-resource communities in the global context. By producing a sustainable network of well-trained investigators from underrepresented backgrounds, LEAD will potentially contribute to the shared lessons and efforts relevant to addressing global mental health disparities and improving care for vulnerable populations in low-resource settings.

Disclosing Sex Trading Histories to Providers: Barriers and Facilitators to Navigation of Social Services Among Women Impacted by Commercial Sexual Exploitation.

Sex trafficking and commercial sexual exploitation (CSE) can lead to devastating health and mental health consequences for women, such as elevated rates of substance use, trauma, posttraumatic stress disorder, depression, sexually transmitted infections (STIs), and HIV. Consequently, engagement with services that address addiction, mental health, and housing, and provide general advocacy is critically important to women's increased safety, stabilization, and quality of life. The purpose of this study is to identify perceived barriers and facilitators to service access and engagement with social services among women involved in CSE. Drawing from a larger grounded theory study that partnered with an anti-trafficking coalition and a substance use treatment center for women, in-depth, semistructured interviews were conducted with 30 adult women who traded sex as adults and 20 service providers who come into contact with this population. Women engaging in services were sampled through maximum variation sampling (n = 24) and women not engaged with services (n = 6) were recruited through snowball sampling. Providers were recruited through purposive sampling through the coalition (n = 10) and nominations sampling (n = 10). Open and focused coding were conducted. Multiple enhancements to methodological and analytic rigor were taken, including collaboration with multiple key stakeholders, use of nonstigmatizing language, self-reflexivity processes, analytic memo-writing, and member checking. Findings suggest that women experienced judgment when disclosing sex trading in social service intakes, and individual and group sessions from providers and other women in the groups. Although some women saw disclosure as helpful in addressing the complex feelings stemming from sex trading, as well as the desire to help or relate to other women in similar situations, they also identified risk of harm and multiple barriers to disclosing during intake meetings and individual sessions with providers as well as group sessions with providers and other clients. Implications for individual and group practice are discussed.

Opening the Black Box: Identifying Common Practice Approaches in Urban and Rural Rape Crisis Centers.

This study sought to open the black box of services at rape crisis centers (RCCs), particularly related to counseling, to better understand what is available to survivors in urban and rural settings. Findings from a survey of directors and counselors in Texas RCCs reveal a number of strengths: supporting services for survivors of sexual assault and insights that can help to further advance the implementation of evidence-based trauma treatments in this sector. Although many areas of congruence were found between urban and rural settings, differences were noted that have implications for implementation of evidence-based trauma treatments.

Understanding School Sabotage Among Survivors of Intimate Partner Violence From Diverse Populations.

Higher education is an important pathway to safety for survivors of intimate partner violence (IPV). Recent work documents tactics of school sabotage (behaviors aimed at sabotaging educational efforts) identified by school staff and IPV advocates. However, the perspectives of current students who are IPV survivors are unexplored. As part of a multiphasic study, 20 semi-structured qualitative interviews with community college students who reported current or recent IPV were conducted. Identified tactics included disrupting child care, emotional abuse tied to school, and using manipulation to limit access to campus or resources. Identified impacts include preventing focus, diminished academic achievement, emotional or mental health challenges, and instilling a desire to overcome.

Exploring Bullying Perpetration and Victimization Among Adolescent Girls in the Child Welfare System: Bully-Only, Victim-Only, Bully-Victim, and Noninvolved Roles.

Childhood abuse is a common experience for youth in the child welfare system, increasing their risk of bullying perpetration and victimization. Little research exists that has examined the rates of bullying perpetration and victimization for child welfare-involved adolescent girls. The study addressed the following aims: (a) to generate frequency estimates of physical, nonphysical, and relational forms of bullying perpetration and victimization; (b) to identify the frequency of bully-only, victim-only, bully-victim, and noninvolved roles; and (c) to identify risk and protective factors that correlate with these bullying role types. Participants were 236 girls (12-19 years) in the child welfare system from a Midwestern urban area. Participants were referred to the study to join a trauma-focused group program. Seventy-five percent of the total sample were youth of color, with the remaining 25% identifying as White, non-Hispanic. Data were collected through baseline surveys that assessed childhood abuse, bullying perpetration and victimization, posttraumatic stress, substance misuse, aggression-related beliefs and self-efficacy, placement type, placement instability, and mental health service use. Child welfare-involved adolescent girls were found to assume all four major role types: bully-only (6.4%, n = 15), victim-only (20.3%, n = 48), bully-victim (44.1%, n = 104), and nonvictims (29.2%, n = 69). The bully-victim rate was approximately 7 times higher than the rate found in a nationally representative sample of non-child welfare-involved youth. The current study identified posttraumatic stress disorder (PTSD) symptoms, anger self-efficacy, and alcohol use as significant correlates of bullying roles. The identification of a substantially higher rate of bully-victims has important practice implications, suggesting child welfare and school systems adopt trauma-informed systems of care. Bully-victims are very likely traumatized children who are in need of effective trauma treatment rather than punitive sanctions.

Treatment Goals, Assessment, and Evaluation Practices in Rape Crisis Centers.

Counselors in Rape Crisis Centers (RCCs) provide crucial services to survivors of sexual violence. However, little is known about RCCs, including the treatment goals and assessment strategies of counselors. Counselors in all Texas RCCs (n = 83) were invited to participate in a web-based survey. Participants were asked to indicate which treatment goals they frequently identified and assessed, as well as their usual assessment techniques. Counselors endorsed treatment goals around self-esteem, empowerment, and relational functioning, along with trauma and mental health. Fewer counselors endorsed goals around drugs/alcohol or school/work/sexual functioning. Few counselors reported use of standardized measures. Counselors in urban settings were more likely to endorse goals related to mental health. There are discrepancies between counselors' goals and how often outcomes are assessed. Increased assessment could promote the provision of effective services and access to funding.

Intimate partner violence, trauma, and mental health need among female community college students.

OBJECTIVE: The impact of interpersonal violence on college students has received considerable attention, yet no studies have been conducted among community college students, who comprise 40% of all American college students, and have unique risk factors and needs. Community College students are more likely to be women, people of color, working, parenting, and first generation college students. PARTICIPANTS: Data were collected from a simple random sample from four community colleges (n=435). METHODS: A cross-sectional quantitative survey was used to assess the extent of intimate partner violence, trauma exposure, sexual violence, and associated mental health consequences among female students. RESULTS: Over 27% of participants reported IPV in the past year, while 25% reported sexual assault and 34% reported other uncomfortable sexual experiences in their lifetime. Nearly 20%of participants were currently reporting PTSD symptoms. CONCLUSIONS: Community Colleges should work with service providers to build their capacity to respond to students' needs.

Mental Health Pathways Linking Childhood Maltreatment to Interpersonal Revictimization During Adolescence for Girls in the Child Welfare System.

This study compares the association of histories of childhood emotional, physical, and sexual abuse, and physical neglect with revictimization among adolescent girls, and investigates the role of posttraumatic stress and symptoms of depression as mediators. Participants were 234 girls aged 12 to 19 years, who have been involved with the child welfare system in a Midwestern urban area. Data were collected from baseline surveys of a trauma-focused group program to which the participants were referred. The majority of participants were youths of color (75%) who were primarily African American (70%), and the remaining participants were White, non-Hispanic (25%). Data were collected through surveys that assessed histories of child abuse and neglect, symptoms of posttraumatic stress and depression, and experiences of physical, verbal, and relational revictimization in the last 3 months. All types of abuse and neglect were significantly associated with higher frequencies of revictimization and higher levels of posttraumatic stress and depressive symptoms. Parallel mediation analyses demonstrated that both posttraumatic stress and depression fully mediated the relationships between emotional abuse and revictimization, and sexual abuse and revictimization. Physical abuse was fully mediated by posttraumatic stress, but not by depression. Results also indicated that neither posttraumatic stress nor depression were mediators for the relationship between neglect and revictimization. There were similar pathways to revictimization in adolescents from emotional and sexual abuse through posttraumatic stress and depression. Evidence is mounting for the deleterious effects of emotional abuse. There is evidence that treatment of both posttraumatic stress and depression in emotionally and sexually abused adolescents involved in child welfare is warranted to prevent future revictimization.

Design strategies from sexual exploitation and sex work studies among women and girls: Methodological considerations in a hidden and vulnerable population.

The study of sex trafficking, prostitution, sex work, and sexual exploitation is associated with many methodological issues and challenges. Researchers' study designs must consider the many safety issues related to this vulnerable and hidden population. Community advisory boards and key stakeholder involvement are essential to study design to increase safety of participants, usefulness of study aims, and meaningfulness of conclusions. Nonrandomized sampling strategies are most often utilized when studying exploited women and girls, which have the capacity to provide rich data and require complex sampling and recruitment methods. This article reviews the current methodological issues when studying this marginalized population as well as strategies to address challenges while working with the community in order to bring about social change. The authors also discuss their own experiences in collaborating with community organizations to conduct research in this field.

Adaptation and implementation of a trauma-focused cognitive behavioral intervention for girls in child welfare.

This study describes the process of adapting and implementing Girls Aspiring toward Independence (GAIN), a trauma-focused, group-based therapy adapted from Cognitive Behavioral Intervention for Trauma in Schools (CBITS) for girls in child welfare. Descriptive data were examined on 3 outcomes: posttraumatic stress disorder (PTSD), depression, and social problem-solving skills among adolescent girls in the child welfare system. Qualitative and quantitative methods were utilized to inform the adaptation of the CBITS intervention, evaluate feasibility, treatment fidelity, and acceptability, and to test the effects of the intervention. Girls ages 12 to 18 (N = 27) were randomly assigned to the experimental and usual care conditions. Participants' symptoms of PTSD and depression and social problem-solving skills were evaluated at pre, post- (3 months), and follow-up (6 months) assessments. Adaptations for GAIN were primarily related to program structure. Data indicated that the program was receptive to girls in child welfare and that it was feasible to recruit, randomize, assess outcomes, and implement with adequate fidelity. Retention was more successful among younger girls. Descriptive initial data showed greater reductions in the percentage of girls with PTSD and depression, and modest increases in social problem-solving skills in the experimental versus usual care condition. Despite the growth of knowledge in dissemination and implementation research, the application of trauma-focused empirically supported treatment to child welfare populations lags behind. A large-scale RCT is needed to determine if GAIN is effective in reducing mental health problems and social problem-solving in the child welfare population. (PsycINFO Database Record

Childhood Abuse and Aggression in Adolescent Girls Involved in Child Welfare: The Role of Depression and Posttraumatic Stress.

This study investigated the relationship between histories of childhood abuse and aggressive behaviors among adolescent girls involved in child welfare, and determined whether symptoms of post-traumatic stress and depression mediated this relationship. Participants were 237 girls ages 12-19 years. Overall, results indicated 89 % of the adolescents endorsed at least one aggressive behavior towards others. Specifically, 72.0 % engaged in physical aggression, 78.5 % engaged in non-physical aggression, and 51.5 % endorsed relational aggression. Greater severity of emotional and physical abuse were significantly associated with a higher frequency of aggressive behaviors. Sexual abuse was not significantly related to aggression. Post-traumatic stress and depression fully mediated the relationship between emotional abuse and aggression, controlling for race, service use, and living situation. The linkages between physical abuse and aggression were not mediated by either post-traumatic stress or depression. Findings suggest that among adolescent girls with histories of emotional abuse, post-traumatic stress and depression represent potential modifiable risk factors to target for reducing aggression.

Mexican immigrant survivors of intimate partner violence: conceptualization and descriptions of abuse.

This phenomenological qualitative study examines intimate partner violence (IPV) experienced by a sample of 29 Mexican immigrant women residing in New York and St. Louis. The findings reveal important insights about culturally specific abuse tactics employed by batterers and the forms of abuse that are experienced as most hurtful to the survivors. Ten different abusive tactics emerged: verbal, economic, physical, sexual, and extended family abuse, social isolation, physical abuse of children, stalking and monitoring, stolen bride, and sex trafficking. Cultural values and expectations appear to be inextricably linked to how the participants characterized the severity of each of the abusive tactics as evidenced by which abusive behaviors the participants found most hurtful. The findings will help service providers have a better understanding of the role cultural context plays in the IPV experiences of Mexican immigrant women.

Evaluation of a spiritually focused intervention with older trauma survivors.

This study evaluated the effectiveness of an 11-session, spiritually focused group intervention with older women survivors (age 55 years and older) of interpersonal trauma (child abuse, sexual assault, or domestic violence) in reducing trauma-related depressive symptoms, posttraumatic stress, and anxiety. Forty-three community-dwelling women survivors of interpersonal trauma were randomized into treatment (n = 21) or control (n = 22) groups. Participants in group psychotherapy discussed spiritual struggles related to abuse and developed spiritual coping resources. The treatment group had significantly lower depressive symptoms, anxiety, and physical symptoms at posttest compared with the control group. In a separate analysis, posttraumatic stress symptoms also dropped significantly in the treatment group. Gains were maintained at three-month follow-up. This study provides strong initial support for the effectiveness of spiritually focused group intervention for older survivors of interpersonal trauma from a Christian background.

Macro practice teaching and curriculum development from an evidence-based perspective.

This article contributes to the discourse around evidence-based practice (EBP) as an organizing principle and guiding framework for macro-practice education as it has developed in the George Warren Brown School of Social Work at Washington University in St. Louis. In examining the first five years of implementing evidence-based education at the macro level, some lessons learned are provided. This learning has opened the door for continuing the dialogue on surmounting the challenges around training macro social workers in evidence-based practices. The overarching challenge in integrating EBP into the curriculum lies in the complexity of the multi-dimensional conceptualization of evidence.

Signs of resilience in sexually abused adolescent girls in the foster care system.

In a sample of 99 sexually abused adolescent girls in the foster care system (64% in congregate living situations and 36% in family/foster care homes), nearly half were psychologically functioning well despite having experienced moderate-to-severe emotional, physical, and sexual abuse. It was hypothesized that these girls with resilient trajectories would differ from the currently symptomatic girls on several protective factors: education, future orientation, family support, peer influence, and religion. The results revealed that the girls with resilient trajectories were significantly more certain of their educational plans and optimistic about their future and had more positive peer influences.

Assessing the long-term effects of EMDR: results from an 18-month follow-up study with adult female survivors of CSA.

This 18-month follow-up study builds on the findings of a randomized experimental evaluation that found qualified support for the short-term effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) in reducing trauma symptoms among adult female survivors of childhood sexual abuse (CSA). The current study provides preliminary evidence that the therapeutic benefits of EMDR for adult female survivors of CSA can be maintained over an 18-month period. Furthermore, there is some support for the suggestion that EMDR did so more efficiently and provided a greater sense of trauma resolution than did routine individual therapy.

Denial in addiction: toward an integrated stage and process model--qualitative findings.

Focus groups were conducted at five chemical dependency treatment facilities assessing residents' (N = 65) conceptualizations of denial and the role it may have played in the pathogenesis and progression of their substance use disorders. Two of the authors read verbatim transcripts of the focus group proceedings and independently developed models of denial based on those data. The first reader identified a core set of interpersonal and attributional processes that appeared to explain why many participants did not perceive their substance abuse and associated problems as clearly aberrant and/or chose not to self-identify as alcohol or other drug dependent until late in the course of their chemical dependency. The second reader identified five stages that clients appeared to pass through as they progressed from no awareness of their substance use disorder to full awareness. A second set of readers then independently developed an integrated stage and process model of denial that incorporated elements of the models identified earlier. Though obviously exploratory in nature, these findings suggest that denial is a far more complex and dynamic set of intra- and interpersonal processes than is generally recognized.

Differences between sexually abused and non-sexually abused adolescent girls in foster care.

This descriptive study examines the differences between sexually abused and non-sexually abused adolescent females in the foster care system who were participating in an independent living program. Fifty-four percent of the 190 girls met the criteria for being categorized as sexually abused. Those who experienced sexual abuse had also experienced significantly more of other types of child maltreatment. In addition, those who had been sexually abused were much more likely to be living in a congregate living setting, such as a group home or residential center, than those who were not sexually abused. The girls who had been sexually abused exhibited significantly more behavioral difficulties, including internalizing and externalizing problems, with 51% of them having clinically significant scores on the Youth Self-Report version of the Child Behavior Checklist. When co-occurrence of substance use and mental health problems were examined, sexually abused girls were significantly more likely than the non-sexually abused girls to meet the established criteria.