Impact of the COVID-19 pandemic on workplace violence at an academic emergency department.

STUDY OBJECTIVES: COVID-19 brought unique challenges; however, it remains unclear what effect the pandemic had on violence in healthcare. The objective of this study was to identify the impact of the pandemic on workplace violence at an academic emergency department (ED). METHODS: This mixed-methods study involved a prospective descriptive survey study and electronic medical record review. Within our hospital referral region (HRR), the first COVID-19 case was documented on 3/11/2020 and cases peaked in mid-November 2020. We compared the monthly HRR COVID-19 case rate per 100,000 people to the rate of violent incidents per 1000 ED visits. Multidisciplinary ED staff were surveyed both pre/early-pandemic (April 2020) and mid/late-pandemic (December 2020) regarding workplace violence experienced over the prior 6-months. The study was deemed exempt by the Mayo Clinic Institutional Review Board. RESULTS: There was a positive association between the monthly HRR COVID-19 case rate and rate of violent ED incidents (r = 0.24). Violent incidents increased overall during the pandemic (2.53 incidents per 1000 visits) compared to the 3 months prior (1.13 incidents per 1000 visits, p < .001), as well as compared to the previous year (1.24 incidents per 1000 patient visits, p < .001). Survey respondents indicated a higher incidence of assault during the pandemic, compared to before (p = .019). DISCUSSION: Incidents of workplace violence at our ED increased during the pandemic and there was a positive association of these incidents with the COVID-19 case rate. Our findings indicate health systems should prioritize employee safety during future pandemics.

The Pursuit of Research-supported Treatment in Batterer Intervention: The Role of Professional Licensure and Theoretical Orientation for Duluth and CBT Programs.

PURPOSE: The purpose of this study was to understand the importance of research-supported practice for batterer intervention programs. METHODS: This study applied descriptive statistics and chi-square analyses to a novel dataset from the Domestic Violence Perpetrator Treatment Survey (N = 411). This was a 69-item survey developed by domestic violence providers and researchers to understand the role of research-supported practice in the treatment of intimate partner violence (IPV). RESULTS: This study found statistically significant differences between Duluth oriented programs and Cognitive Behavioral Therapy (CBT) oriented programs with respect to the importance of research-supported practices and motivational interviewing, a strategy found effective in treatment of IPV by extant research. DISCUSSION: There appears to have been an evolution among practitioners toward more eclecticism, and an acknowledgment that programs should be research-supported. CONCLUSION: Implications of this study for education and treatment are discussed.

Occupational Well-Being in Sexual Assault Victims and Survivors.

Purpose: While researchers have established that sexual assault may adversely affect successful employment and academic achievement, little is known about the barriers and facilitators of occupational well-being from the perspective of sexual assault survivors. This study assessed the barriers and facilitators of occupational well-being. Design: Constructivist grounded theory. Method: Digitally recorded, semistructured interviews were used to collect data. Data were collected from 22 adult female sexual assault survivors. Analysis consisted of coding, creation of data matrices, and within and across case analysis. Findings: Theoretical saturation was achieved after interviews with 22 participants. Barriers to occupational well-being were mental health symptoms and diagnoses, substance abuse, inflexible attendance policies, and workplace bullying. Facilitators to occupational well-being were personal coping strategies, and organizational and social support. Conclusions: Sexual assault has significant effects on the occupational well-being of women. The work or academic environment can exacerbate the harms of sexual assault or facilitate healing in sexual assault survivors. To facilitate the occupational well-being of sexual assault survivors, workplaces and academic institutions can adopt a trauma-informed approach, create policies that allow for time off to deal with sequela of sexual assault, implement anti-bullying programs, and make resources for gendered violence available.

Informing Human Trafficking Clinical Care Through Two Systematic Reviews on Sexual Assault and Intimate Partner Violence.

BACKGROUND: There is a lack of evidence on the clinical management of patients who have suffered human trafficking. Synthesizing the evidence from similar patient populations may provide valuable insight. This review summarizes findings on therapeutic interventions for survivors of sexual assault and intimate partner violence (IPV). METHOD: We conducted two systematic reviews using the MEDLINE database. We included only randomized controlled trials of therapies with primary outcomes related to health for survivors of sexual assault and IPV. For the sexual assault review, there were 78 abstracts identified, 16 full-text articles reviewed, and 10 studies included. For the IPV review, there were 261 abstracts identified, 24 full-text articles reviewed, and 17 studies included. Analysis compared study size, intervention type, patient population, primary health outcomes, and treatment effect. RESULTS: Although our search included physical and mental health outcomes, almost all the studies meeting inclusion and exclusion criteria focused on mental health. The interventions for sexual assault included spiritually focused group therapy, interference control training, image rehearsal therapy, sexual revictimization prevention, educational videos, cognitive behavioral therapy, and exposure therapy. The interventions in the IPV review included group social support therapy, exposure therapy, empowerment sessions, physician counseling, stress management programs, forgiveness therapy, motivational interviewing, and interpersonal psychotherapy. CONCLUSIONS: Insights from these reviews included the importance of culturally specific group therapy, the central role of survivor empowerment, and the overwhelming focus on mental health. These key features provide guidance for the development of interventions to improve the health of human trafficking survivors.

Healing is not linear: Using photography to describe the day-to-day healing journeys of undergraduate women survivors of sexual violence.

The purpose of this study was to describe the day-to-day healing processes of women who experienced undergraduate sexual violence. We engaged 19 women in a photo-elicitation experience with follow-up individual interviews to identify themes of both healing and darker moments in survivors' everyday lives. Healing was found to function on a continuum influenced by darker moments (i.e., moments that elicited fear, anxiety, loneliness, guilt, anger, and worthlessness) and healing moments (i.e., rebuilding moments of self-care, self-love, connection, hope, peace, and freedom). Responses to darker moments included feeling overwhelmed, disconnected, and intentional vulnerability. Healing moments were influenced by self-reflection, authentic interactions, and resource utilization. The photographs taken in this study shed light on the impact of sexual violence in women's daily lives long after these traumatic and unjust experiences. This knowledge can be used to foster a sense of universality in survivors who are currently struggling and growing after their experiences as well as give service providers greater insight into what survivors' day-to-day needs may be.

Supporting survivors of sexual violence: protocol for a mixed-methods, co-research study of the role, funding and commissioning of specialist services provided by the voluntary sector in England.

INTRODUCTION: The voluntary sector provides a range of specialist services to survivors of sexual violence, many of which have evolved from grass roots organisations responding to unmet local needs. However, the evidence base is poor in terms of what services are provided to which groups of survivors, how voluntary sector specialist (VSS) services are organised and delivered and how they are commissioned. This will be the first national study on the role of the voluntary sector in supporting survivors in England. METHODS AND ANALYSIS: This study uses an explanatory sequential naturalistic mixed-methods design with two stages. For stage 1, two national surveys of providers' and commissioners' views on designing and delivering VSS services will facilitate detailed mapping of service provision and commissioning in order to create a taxonomy of VSS services. Variations in the national picture will then be explored in stage 2 through four in-depth, qualitative case studies using the critical incident technique to explain the observed variations and understand the key contextual factors which influence service provision. Drawing on theory about the distinctive service contribution of the voluntary sector, survivors will be involved as co-researchers and will play a central role in data collection and interpretation. ETHICS AND DISSEMINATION: Ethical approval has been granted by the University of Birmingham research ethics committee for stage 1 of the project. In line with the sequential and co-produced study design, further applications for ethical review will be made in due course. Dissemination activities will include case study and end-of-project workshops; good practice guides; a policy briefing; project report; bitesize findings; webinars; academic articles and conference presentations. The project will generate evidence about what survivors want from and value about services and new understanding about how VSS services should be commissioned and provided to support survivors to thrive in the long term.

Effects of Topper Training on psychosocial problems, self-esteem, and peer victimisation in Dutch children: A randomised trial.

Most interventions aimed at improving social interactions either target internalising or externalising problem behaviour in children. However, a recent review shows that a transdiagnostic approach might fit better to the diversity of problems within a group and within an individual (comorbidity). We examined the effectiveness of a transdiagnostic intervention, called Topper Training: a cognitive behavioural intervention in the peer group with parents included, that targets both internalising and externalising behaviour problems. A randomised trial with a waiting list control group was conducted, using 132 children with mild to severe psychosocial problems. Children were randomised into 77 intervention and 55 waiting list children (50% boys; age = 8-11 years). GLM repeated measures analyses yielded significant intervention effects directly after the training on parent-reported (but not teacher-reported) emotional symptoms (Cohen's d = .70), peer relationship problems (d = .41), and impact of these problems (d = .59). Significant effects were also found for child-perceived peer victimisation (d = .62), self-esteem (d = .45) and teacher-reported conduct problems (d = .42). Parent-reported effects on emotional, conduct problems and impact of the problems and child-reported effects on self-esteem were clinically relevant. No significant effects of Topper Training were found for prosocial behaviour and bullying. Within-participant t-tests in the intervention group between post-intervention and follow-up indicated that effects extended over a six-month follow-up period. Depression decreased significantly from post-test to follow-up. In conclusion, children with mild to severe internalising and/or externalising problems can benefit from the transdiagnostic Topper Training intervention.

Effects of an incremental theory of personality intervention on the reciprocity between bullying and cyberbullying victimization and perpetration in adolescents.

The incremental theory of personality interventions (ITPI) teaches adolescents that people can change. Researchers have found that these interventions can reduce the perpetration of bullying and cyberbullying. Moreover, there is reciprocity between perpetrating bullying behaviors and being a victim of them. The objective of this study was to examine whether the ITPI reduces the reciprocity between victimization and perpetration of bullying and cyberbullying. A sample of 858 high school students (52% boys) aged 12 to 17 at pretest (M = 14.56, SD = 0.97) participated in a double-blind randomized controlled trial (452 participants were assigned to the experimental condition and 406 to the control condition). Measures of bullying and cyberbullying were taken at baseline, six-month, and 12-month follow-ups. The results indicated that victimization was a strong predictor of perpetration for bullying and cyberbullying over time. Perpetration was not a predictor of victimization. Consistently, for both forms of aggressive behavior, the intervention reduced the intensity of the association between victimization and perpetration. This effect was not moderated by the age or sex of the participants. Finally, the effectiveness of the ITPI was moderated by age. Specifically, among the youngest (< 14.48 years), those who received the ITPI showed a slight tendency to reduce aggressive behavior that contrasted with the growing trend in the control group. Among the oldest participants (> 14.48), the trajectories were similar in the two groups. Our findings show that influencing adolescents' reactions to peer aggression victimization is one of the mechanisms that could explain the beneficial effects of the ITPI and other preventive interventions.

Protocol for the first large-scale emergency care-based longitudinal cohort study of recovery after sexual assault: the Women's Health Study.

INTRODUCTION: Worldwide, an estimated 10%-27% of women are sexually assaulted during their lifetime. Despite the enormity of sexual assault as a public health problem, to our knowledge, no large-scale prospective studies of experiences and recovery over time among women presenting for emergency care after sexual assault have been performed. METHODS AND ANALYSIS: Women ≥18 years of age who present for emergency care within 72 hours of sexual assault to a network of treatment centres across the USA are approached for study participation. Blood DNA and RNA samples and brief questionnaire and medical record data are obtained from women providing initial consent. Full consent is obtained at initial 1 week follow-up to analyse blood sample data and to perform assessments at 1 week, 6 weeks, 6 months and 1 year. These assessments include evaluation of survivor life history, current health and recovery and experiences with treatment providers, law enforcement and the legal system. ETHICS AND DISSEMINATION: This study is approved by the University of North Carolina at Chapel Hill's Institutional Review Board (IRB) and the IRB of each participating study site. We hope to present the results of this study to the scientific community at conferences and in peer-reviewed journals.

Current care for victims of sexual violence and future sexual assault care centres in Belgium: the perspective of victims.

BACKGROUND: Sexual violence is a global health problem. After ratifying the Convention of Istanbul in 2016, this Belgian study was set up to map the perspective of victims of rape on the current sexual violence care provision in Belgium and to inquire on their need for more specialised and holistic care in future Sexual Assault Care Centres. METHODS: Sixteen rape victims participated in this sub-study. A mixed-method design (questionnaire, in-depth interview or small focus group) was applied depending on the time elapsed between rape and participation. Descriptive Thematic Framework Analysis was performed in duo. RESULTS: The participants thought it of utmost importance that every victim should receive all medical, psychological and forensic care without necessarily having to involve the police first. They stated that the current Belgian sexual violence care provision could be much more patient-centred, specifically the forensic examination and psychological care. Alongside medical and psychological consequences, victims emphasised the high personal financial and relational burden of sexual violence. The holistic care offered in Sexual Assault Care Centres was perceived to enhance the recovery process of victims of sexual violence. Their doors should be open to all victims and their relatives. They should not only provide acute care for the victim, but also improve victims' reintegration into society while reducing their personal costs significantly. CONCLUSION: All care for victims of sexual violence, especially forensic and psychological care, needs drastic improvement in Belgium. All participants agreed that having specialised, multidisciplinary and longitudinal care in a Sexual Assault Care Centre that would be open 24/7 for everyone, victims and their significant others, would be an improvement to the currently available care all over Belgium. TRIAL REGISTRATION: This research was registered on April 1st 2016. Registration number B670201628242.

Prescription Opioid Misuse After a Recent Sexual Assault: A Randomized Clinical Trial of a Video Intervention.

BACKGROUND AND OBJECTIVES: Prescription opioid (PO) misuse is increasing and is associated with overdose. Individuals who experienced a recent sexual assault are at risk for increased substance use, yet limited interventions target PO misuse after sexual assault. The current study examined the efficacy of video interventions on PO misuse after sexual assault. METHODS: Adolescent girls and women (n = 154) were recruited in the context of a sexual assault medical forensic exam in the emergency department. Effects of a prevention of post-rape stress (PPRS) video and a pleasant imagery and relaxation instruction (PIRI) video were compared with treatment as usual (TAU) during a sexual assault medical forensic exam on PO misuse. Participants reported if they had used POs for non-medical purposes since the sexual assault at 1.5 month follow-up. RESULTS: Results from a logistic regression analysis indicated that participants with a prior sexual assault were less likely to misuse prescription opioids 1.5 months after the assault in the PIRI condition compared with TAU. There were no main effects for video condition and no interactions for the PPRS condition on PO misuse. DISCUSSION AND CONCLUSIONS: Providing the PIRI video, or teaching other types of mindfulness or relaxation exercises, may be warranted as a secondary prevention for individuals during the sexual assault medical forensic exam for those with a prior sexual assault history. SCIENTIFIC SIGNIFICANCE: This research provides an initial examination of the impact of mindfulness skills recently after traumatic event exposure on PO misuse. (Am J Addict 2019;28:376-381).

ACOG Committee Opinion No. 777: Sexual Assault.

Sexual violence continues to be a major public health problem affecting millions of adults and children in the United States. Medical consequences of sexual assault include sexually transmitted infections; mental health conditions, including posttraumatic stress disorder; and risk of unintended pregnancy in reproductive-aged survivors of sexual assault. Obstetrician-gynecologists and other women's health care providers play a key role in the evaluation and management of sexual assault survivors and should screen routinely for a history of sexual assault. When sexual violence is identified, individuals should receive appropriate and timely care. A clinician who examines sexual assault survivors in the acute-care setting has a responsibility to comply with state and local statutory or policy requirements for the use of evidence-gathering kits. This document has been updated to include model screening protocols and questions, relevant guidelines from other medical associations, trauma-informed care, and additional guidance regarding acute evaluation of survivors and evidence-gathering kits.

Introduction to Volume 29, Issue 3.

We close Volume 29 with an issue of Torture Journal focused on measuring processes and results, a subject that has always been considered a priority for the sector. There is a dearth of studies on long-term follow-up to assess rehabilitation success. The paper by Martin Hill and Mary Lynn Everson, "Indicators likely to contribute to clinical and functional improvement among survivors of politically-sanctioned torture" is unique in the length of post-treatment follow-up, and provides an innovative approach in the measurement of rehabilitation outcomes through a structured measure of functional aspects with an instrument designed at the Kovler Center in Chicago. In addition, in the framework of the interminable debate over whether clinical categories of psychiatric classifications respond effectively to the experience of torture victims, Marie Louison Vang and colleagues present in their paper "Testing the validity of ICD-11 PTSD and CPTSD among refugees in treatment using latent class analysis; a validation study through multivariate models to distinguish between the classic Post-Traumatic Stress Disorder (PTSD) diagnosis and the new Complex Post Traumatic Stress Disorder in refugee and torture survivor populations. The results show that this new diagnosis not only complements the previous one but both approaches represent an improved nosological classification and definition of the experiences of torture survivors. Kim Baranowski and collaborators, in their paper, "Experiences of gender-violence in women asylum seekers from Honduras, El Salvador, and Guatemala" propose, supported by the evidence gathered, that types of violence experienced by these women are multi-intersectional, and that restricted categorisation of the concept of torture can ignore the experiences of asylum-seeking women, whose lives, both in their countries of origin, in transit and in the host country, are persistently affected by structural, psychological and physical violence perpetrated by state and nonstate actors alike. Finally, Kristi Rendahl and Pamela Kriege Santoso offer in their contribution Organizational development with torture rehabilitation programs: An applied perspective, a personal, non-data-driven text representing their experience in supporting the creation of torture victim centres in different countries within the framework of the CVT's Partners in Trauma Healing (PATH) Project. In this last issue of the journal we would like to thank all the authors that have chosen Torture Journal as the platform to share their research. In particular, we extend our thanks to those anonymous reviewers who have devoted hours and effort to the indispensable task of giving us their critical and constructive view of the journal's articles. Without them the publication would not be possible. We believe that this issue of the Torture Journal will undoubtedly provide many elements of reflection for our readers. We hope you enjoy reading it as much as we enjoyed preparing it.

Indicators likely to contribute to clinical and functional improvement among survivors of politically-sanctioned torture.

INTRODUCTION: Heartland Alliance Marjorie Kovler Center (Kovler Center) is a torture treatment program located in Chicago, Illinois. Established in 1987, Kovler Center provides medical, mental health, and social services, as well as coordination with legal services, to a diverse population of survivors. Historically, Kovler Center used clinical measurement instruments to assess depression, anxiety and posttraumatic stress, but staff was challenged with finding the best way to assess and ultimately measure changes in functional domains. The purpose of this paper is to describe (1) the Kovler Center framework, philosophical pillars, and model of treatment; (2) the comprehensive outcome evaluation program, including the Marjorie Kovler Center Well-Being Questionnaire (MKC WBQ); and (3) the results and implications to date. METHODS: Kovler Center measured outcome data utilizing three instruments including a well-being tool and supplemented the data with a satisfaction survey. These instruments were administered at intake and re-administered at six-month intervals up to 24 months. RESULTS/DISCUSSION: With nine years of data, Kovler Center can now provide valid and reliable findings in diagnostic and functional changes, with 86.6% of its clients reporting fewer symptoms of anxiety and depression, 83.1% reporting fewer symptoms of trauma, and significant improvement in employment status, housing status, and physical health after receiving services for 24 months. Indicators significantly correlated with clinical improvement at 24 months include stable housing, stable employment, region from where survivors came, number of days between initial assessment and program admittance, number of services (medical, psychological, social) received while in the program, number of medical problems diagnosed with while in the program, and number of psychological problems diagnosed with while in the program. From the Generalized Linear Mixed Models (GLMM) analysis, the total number of psychological problems and whether or not the participant had a secure legal status while in the program were demonstrated to explain the variance in anxiety, depression, and PTSD. Females were more likely to experience depression while in the program compared to males, and participants from the Middle East were more likely to experience symptoms of depression and PTSD compared to participants from Africa. CONCLUSIONS: Since, medical, psychological, and social indicators are demonstrated to correlate with or predict clinical outcomes, this highlights the need for comprehensive and holistic treatment programs for survivors of torture.

Organizational development with torture rehabilitation programs.

Torture rehabilitation has emerged as a field over the past several decades and much of the literature has focused on clinical interventions, related evaluation, and documentation of torture. Less discussed are organizational development initiatives that seek to strengthen organizational effectiveness in order to improve mental health outcomes for torture survivors. Based on applied experience in organizational development with torture rehabilitation programs in post-conflict contexts, the authors explore key organizational development needs in the field of torture rehabilitation, areas of future consideration for international agency donors, and additional future considerations for torture rehabilitation programs themselves. A case is made fo organizational development efforts that prioritize time for strategic thinking that includes participation from stakeholders across the organization's functions; staff care policies that prevent secondary trauma and promote wellbeing and retention; clarity surrounding organizational structure and roles; financial management systems that position the organization for growth and fund diversification strategies beyond the project-based international agency funding model. The work requires longterm commitment in terms of technical and subgrant assistance, including an ongoing process of assessing and adjusting approaches. The case examples included are representative of certain key challenges that may be addressed to some degree within the parameters of a similar project. While the work of torture rehabilitation is urgent by nature, the authors emphasize the need for practical approaches for the important (but not urgent) work of organizational development.

Pilot evaluation of a targeted intervention for peer-victimized youth.

OBJECTIVE: Due to the limited effectiveness of extant prevention and intervention strategies, the current study is an initial evaluation of a cognitive behavioral group intervention, originally designed to treat symptoms of depression and anxiety, for youth who experienced peer victimization. METHODS: Twelve third- through fifth-grade youth participated in the intervention, and their data were compared with 12 youth who were a part of a naturalistic control group. Additionally, school-wide data are reported to provide overall school trends. RESULTS: Whereas the intervention group participants exhibited decreases in relational victimization, depressive symptoms, and passive coping, the control group participants exhibited nonsignificant increases in relational victimization, depressive symptoms, and passive coping. School-wide data also indicated overall increases in relational victimization and depressive symptoms, but no changes in passive coping. CONCLUSION: Findings suggest that cognitive behavioral group interventions may provide a promising avenue for addressing the mental health needs of victimized elementary school-age youth.

"Suddenly Everyone's an Expert in Our Field": Campus Victim Advocates and the Promise and Perils of Professionalization.

Changes in how campuses respond to sexual assault under Title IX may dramatically alter the experiences of survivors and the roles of responders. This exploratory study examines how the roles of campus-based sexual assault victim advocates are changing and the effects on advocacy and survivors. Although most advocates agree that Title IX has increased awareness and reporting of sexual assault, they are concerned about the loss of confidential outlets for reporting, conflicts with other responders, and devaluation of their role. Some advocates see professionalization as a solution, whereas others worry that professionalization might negatively affect their ability to serve survivors.