Posttraumatic Growth among Latina Victims of Interpersonal Violence in Psychological Treatment

Transcription

1 University of Miami Scholarly Repository Open Access Dissertations Electronic Theses and Dissertations Posttraumatic Growth among Latina Victims of Interpersonal Violence in Psychological Treatment Amelia C. Swanson University of Miami, Follow this and additional works at: Recommended Citation Swanson, Amelia C., "Posttraumatic Growth among Latina Victims of Interpersonal Violence in Psychological Treatment" (2015). Open Access Dissertations This Open access is brought to you for free and open access by the Electronic Theses and Dissertations at Scholarly Repository. It has been accepted for inclusion in Open Access Dissertations by an authorized administrator of Scholarly Repository. For more information, please contact

2 UNIVERSITY OF MIAMI POSTTRAUMATIC GROWTH AMONG LATINA VICTIMS OF INTERPERSONAL VIOLENCE IN PSYCHOLOGICAL TREATMENT By Amelia Swanson A DISSERTATION Submitted to the Faculty of the University of Miami in partial fulfillment of the requirements for the degree of Doctor of Philosophy Coral Gables, Florida August 2015

3 2015 Amelia Swanson All Rights Reserved

4 UNIVERSITY OF MIAMI A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy POSTTRAUMATIC GROWTH AMONG LATINA VICTIMS OF INTERPERSONAL VIOLENCE IN PSYCHOLOGICAL TREATMENT Amelia Swanson Approved: Etiony Aldarondo, Ph.D. Associate Dean for Research, School of Education and Human Development Soyeon Ahn, Ph.D. Associate Professor of School of Education and Human Development Debbiesiu Lee, Ph.D. Associate Professor of School of Education and Human Development John Paul Russo, Ph.D. Professor and Chair, Department of Classics Carlos Perez Benitez, Ph.D. Professor of Psychology Carlos Albizu University Dean of the Graduate School

5 SWANSON, AMELIA (Ph.D., Counseling Psychology) Posttraumatic Growth among Latina Victims of (August 2015) Interpersonal Violence in Psychological Treatment Abstract of a dissertation at the University of Miami Dissertation supervised by Professor Etiony Aldarondo No. of pages in text. (150) Posttraumatic growth (PTG) is an area of research that describes the positive psychological changes that often occur after a traumatic event (Tedeschi & Calhoun, 2004). To date, PTG has been documented in many countries for individuals that have experienced a range of traumatic experiences (Tedeschi & Calhoun, 2004; Weiss & Berger, 2010a). However, there is no research on PTG changes as a result of participation in psychological treatment with Latinas in the US. This study used data obtained at a local community mental health clinic to assess PTG levels before and after a trauma treatment among 77 Latinas victims of interpersonal violence. It was hypothesized that: 1. There would be a significant increase in PTG from pre to post treatment, 2. religious affiliations and attending religious services would be positively associated with PTG at post intervention, 3. minutes and duration of treatment would be positive predictors of PTG, 4. post-treatment PTG would be positively associated with post-treatment PTSD symptoms. It was concluded that pre-treatment PTG was a positive predictor while posttreatment PTSD symptoms were negatively associated with post-treatment PTG. Measures of religion were not significant predictors of post-treatment PTG. Clinical implications of this study are discussed and recommendations are made for further research on PTG change during treatment.

6 Dedication I would first like to dedicate this dissertation to the Latina survivors of trauma that I have had the opportunity to work with in clinical and research settings. I am consistently impressed with your strength, grace and ability for growth despite extreme adversity. It has been an honor to witness your courage, healing and growth. I would also like to dedicate this dissertation to the individuals that I have worked with that have dedicated their energy and spirit to helping Latina survivors of trauma. Your ability to witness the pain of trauma survivors, while also having enduring faith and hope in their ability to heal and grow, is a constant source of encouragement to your clients and to me. Thank you for the many ways you have taught me how to hear, respect, and guide my clients on paths of growth. Lastly, I would like to dedicate this dissertation to my husband, my family and my friends, for your encouragement and strength. Without your love and support, this dissertation and my work with trauma survivors would not be possible. iii

7 Acknowledgements This dissertation would not have been possible without the assistance of many individuals and organizations. I would first like to acknowledge the support of Teresa Descilo and the staff at the Trauma Resolution Center for their flexibility and dedication to the community-university partnership that led to this dissertation. I would also like to acknowledge my dissertation committee for your input, advice and recommendations throughout the process. Thank you to Dr. Aldarondo for your ongoing guidance, support and faith in my ability to conduct this study. Thank you to Dr. Ahn for your dedication to helping guide me through methodological and statistical issues. Thank you to Drs. Lee and Perez Benitez for your assistance with methodological issues and your expertise on trauma, outcome studies and culture. Thank you to Dr. Russo for your support and encouragement. I would also like to acknowledge the financial contributions of the Melissa Institute through their dissertation grant, which helped expedite the research process and the completion of this dissertation. The Mitchell Fellowship, through the University of Miami, also allowed me to dedicate myself full time to my dissertation work and was invaluable to my progress on this dissertation. Finally, I would like to acknowledge my husband, mother, father, stepfather, brother, and friends whose support, encouragement and unending patience allowed me to complete this dissertation. iv

8 TABLE OF CONTENTS Page LIST OF FIGURES... LIST OF TABLES... LIST OF APPENDICES... vii viii ix Chapter 1 Introduction... 1 Posttraumatic Growth and Latinos... 2 Posttraumatic Growth during Psychological Treatment... 4 Traumatic Incident Reduction... 5 Present Study Literature Review... 8 Posttraumatic Growth: An Overview... 8 Sociocultural Posttraumatic Growth... 9 Posttraumatic Growth and Type of Trauma Posttraumatic Growth and Latinos Posttraumatic Growth and Posttraumatic Stress Disorder Symptoms Posttraumatic Growth and Psychological Treatment Psychological Treatment: Traumatic Incident Reduction Posttraumatic Growth, TIR and TRC Summary of Literature Hypotheses Methods Community-based Open Trial Methodology Research Design Sample Instruments Procedure Variables Investigated Results Handling of Missing Data Descriptive Statistics Preliminary Analyses Assumptions v

9 Results from Hierarchical Linear Regression Discussion Clinical Implications Limitation Future Research Recommendations A Call for Community-Based Research References Figures Tables Appendices vi

10 LIST OF FIGURES Figure 1: The sociocultural model of posttraumatic growth vii

11 LIST OF TABLES Table1: Means, Standard Deviations, Correlations of Variables Table 2: Hierarchical Linear Regression for post-treatment PTG viii

12 LIST OF APPENDICES Appendix A: In-depth Demographic Intake Form.- English Appendix B: In-depth Demographic Intake Form.- Spanish Appendix C: Measure Packet English Appendix D: Measure Packet - Spanish Appendix E: Qualification Forms - English Appendix F: Qualification Forms - Spanish Appendix G: Administrative Forms ix

13 Chapter 1: Introduction The phenomenon of growth or positive change after extreme suffering is a long standing concept that appears in many religious doctrines, and more recently in existential and humanist theory (Tedeschi & Calhoun, 1995). The renowned psychiatrist and Holocaust survivor Victor Frankl elegantly summarizes the concept of growth after experiencing trauma: We must never forget that we may also find meaning in life even when confronted with a hopeless situation, when facing a fate that cannot be changed. For what then matters is to bear witness to the uniquely human potential at its best, which is to transform a personal tragedy into a triumph, to turn one s predicament into a human achievement. When we are no longer able to change a situation just think of an incurable disease such as inoperable cancer we are challenged to change ourselves. (Frankl, 1985, p.135) This idea that as a result of tragedy and suffering people are able to rebuild their lives, find meaning, and find increased strength is prevalent in many cultures (Weiss & Berger, 2010b) and is a common component of many religions, including Buddhism, Christianity, and Judaism (Tedeschi & Calhoun, 1995). While suffering is not believed to be necessary in order for individuals to grow and find meaning in life, a number of researchers have noted that experiencing suffering offers a unique opportunity for individuals to change their worldview and make positive changes in their lives (Calhoun & Tedeschi, 2006b). Despite the history of interest in growth after trauma, research has focused primarily on the study of negative effects of trauma and stressful events on individuals (Tedeschi & Calhoun, 1995). While some scholars have focused on theory and clinical techniques relating to healing after trauma or loss (Frankl, 1985; Yalom, 1980), only in the past 15 years have researchers actively investigated the concept of posttraumatic growth (PTG). 1

14 2 Posttraumatic growth (PTG) refers to positive psychological change resulting from an individual s struggle with a highly challenging, stressful, or traumatic event (Tedeschi & Calhoun, 2004). PTG is part of a larger movement in psychology focused not only on reducing negative symptoms but also on helping individuals improve the quality of their lives by increasing positive aspects (Tedeschi & Calhoun, 2004). In the field of PTG, traumatic events are broadly defined to include any life event that is stressful, overwhelming, or negative (Calhoun & Tedeschi, 2006b). Thus, research on PTG includes negative events such as cancer, motor vehicle accidents, illness, interpersonal violence, death of a loved one, relationship dissolution or general immigration experiences (Abraído-Lanza, Guier, & Colón, 1998; Berger & Weiss, 2006; Brunet, McDonough, Hadd, Crocker, & Sabiston, 2010; Cobb, Tedeschi, Calhoun, & Cann, 2006; Nishi, Matsuoka, & Kim, 2010; Wagner, Knaevelsrud, & Maercker, 2007). The construct of posttraumatic growth does not minimize or deny the negative impact of trauma; instead, it describes the positive changes that may occur as a result of the struggle to cope and heal from that trauma (Tedeschi & Calhoun, 2004). Following the death of a child, a mother may realize that she is stronger than she previously believed, has become emotionally closer to her husband and other children, and appreciates life to a greater degree than she did prior to her child s death. Simultaneously, she may experience significant grief and sadness over the loss of her son. Posttraumatic Growth and Latinos While the majority of PTG research has been done with samples of White American participants, there is a growing body of researching investigating PTG in different ethnic groups and countries (Weiss & Berger, 2010a). Despite this focus on

15 3 PTG in diverse cultures, research is still limited about PTG and Latinos living in the U.S. (Berger & Weiss, 2010). According to the 2010 census data there are more than 50 million Latinos in the U.S., making up 16% of the population (Ennis, 2011). Thus, understanding PTG among Latinos in the US has potentially important implications for a significant segment of the U.S. population. Latinos in the U.S. are a heterogeneous group made up of many cultures, although many Latino cultures are characterized by similar values (Lopez & Carrillo, 2001). Some of these values may be religiosity, which is religion as a source of support, marianismo, which is the virtue of female sacrifice and suffering in order to care for family, personalismo, which is the importance of interpersonal relationships, and familialismo, which is the importance of family connections (Lopez & Carrillo, 2001). These cultural values may cause differences in how posttraumatic growth is experienced and promoted. Proximal cultural influences, such as how distal cultural norms are represented in the individual s close friend group, personal examples of PTG within the individual s cultural group and quantity and quality of social support also influence the development of PTG for Latinas in the U.S. (Calhoun, Cann, & Tedeschi, 2010). In the area of religiosity Smith, Dalen, Bernard & Baumgartner (2008) found that Latina women had higher rates of PTG than White women and that religiosity moderated the relationship between race and PTG. A dissertation by Cordero (2011) focused on PTG and cultural values of personalism, spiritualism, and familialism, and found that spiritualism and familialism were significant predictors of PTG in Latino men. Researchers have noted high levels of PTG among Latinas (Berger & Weiss, 2006). Moreover, studies with cancer survivors (Smith, Dalen, Bernard, & Baumgartner,

16 4 2008) and arthritis patients (Urcuyo, Boyers, Carver, & Antoni, 2005) have found higher levels of PTG among Latinas than among White women. In terms of predictors of PTG, Berger and Weiss (2006) found participation in counseling to be associated with higher levels of PTG, indicating that participation in psychological treatment may be related to increased PTG for Latinas in the U.S. Religiosity may another important predictor of PTG for U.S. Latinas (Calhoun, Cann, & Tedeschi, 2010). Posttraumatic Growth during Psychological Treatment Researchers and clinicians are still in the early stages of understanding how posttraumatic growth changes during psychological treatment. Researchers have theorized that PTG occurs through deliberate cognitive processing of the traumatic event in order to make sense and find meaning in life (Calhoun & Tedeschi, 2006b). Most trauma-focused treatments focus on cognitive processing and discussion of the traumatic event; therefore, many researchers hypothesize that psychological treatments could promote PTG (Calhoun & Tedeschi, 2006a; Wagner et al., 2007; Zoellner & Maercker, 2006). Despite this clear link between the hypothesized process of PTG and psychological treatment, there are few studies on PTG during psychological treatment. Of the seven published studies that investigate growth change during psychological treatment, only one found no improvement in growth after the psychological treatment (Zang, Hunt, & Cox, 2013). Three studies that used a randomized control design found that those participants that completed psychological treatment compared to no treatment had a greater increase in PTG than those that did not receive treatment (Hagenaars & van Minnen, 2010; Knaevelsrud, Liedl, & Maercker, 2010; Wagner et al., 2007). Some

17 5 studies have used internet based CBT (Knaevelsrud et al., 2010; Wagner et al., 2007), others used exposure based therapies (Gray et al., 2012; Hagenaars & van Minnen, 2010; Zang et al., 2013) while another study used treatment as usual provided at community mental health clinics (Glad, Jensen, Holt, & Ormhaug, 2013). This initial research examining psychological treatment and posttraumatic growth indicates that therapists can support and promote posttraumatic growth through psychological treatment, even with individuals with clinically significant levels of PTSD. Traumatic Incident Reduction Traumatic Incident Reduction (TIR) is a structured, person-centered, memory based procedure used to reduce or eliminate the negative psychological effects of past traumas and to promote insight and personal growth (Gerbode & Moore, 2004; Valentine, 1997, 2002). In TIR, counselors follow the clients lead in terms of pace, trauma discussed and length of session, but follow a structured protocol of processing the trauma (Gerbode & Moore, 2004). Clients are asked to imagine the identified trauma, and then verbally describe the traumatic event. This process repeats until the client feels a sense of relief or calmness (Gerbode & Moore, 2004). TIR is similar to guided exposure, in that clients are asked to repeat the trauma they experienced in order to tolerate emotions that they experience while discussing the memory, and continue this until they begin to feel a reduction of negative emotion (Dulen, 2011). TIR also aims to help clients create a narrative memory of the traumatic event (Gerbode & Moore, 2004). The three main focuses of TIR, increasing tolerance of negative emotions related to trauma, increasing deliberate cognitive processing of the trauma, and creating narrative memory of the trauma, may specifically target PTG. TIR could help move clients from

18 6 intrusive and negative rumination about traumatic events towards thoughtful cognitive processing that would promote PTG. Research on how TIR impacts PTG could help mental health counselors not only learn how to decrease negative symptoms, but also provide a path for how to help clients heal and grow in the face of trauma. Present Study The present research study aims to understand posttraumatic growth in a community-based, Latina, clinical sample. The specific research aims are to: 1) Evaluate posttraumatic growth change during psychological treatment for Latina clients. 2) Determine how the amount of treatment and time elapsed from beginning to end of treatment predict posttraumatic growth post-treatment. 3) Determine the personal, clinical and cultural variables related to posttraumatic growth change during therapy. 4) Evaluate a possible partial mediation and moderation of the relationship of amount of treatment on posttraumatic growth change. Data was collected from closed clinical files at a community mental health center. Hierarchical linear regression was used to answer the research questions. The results of this study may have important theoretical and clinical implications regarding the understanding of posttraumatic growth in Latina clinical populations, as well as understanding how posttraumatic growth changes during psychological treatment. This increase in knowledge can be practically applied at the Trauma Resolution Center (TRC), the agency where the data will be collected, to improve services and optimize the amount of psychological treatment available to promote posttraumatic growth in a cost-effective manner. This knowledge could inform the practice of local community organizations, as well as other community mental health clinics nationally, better target treatment to promote growth in Latina populations.

19 7 In the following sections, Chapter 2 presents a review of PTG sociocultural model, PTG in Latinas in the US, and PTG change during psychological treatment, as well as TIR and the Trauma Resolution service model. Chapter 3 describes the design and methodology of the present study. Chapter 4 presents the results of preliminary analyses and hierarchical linear regression findings. Finally, Chapter 6 discusses the clinical and research implications of this study.

20 Chapter 2: Literature Review Posttraumatic Growth: An Overview Tedeschi and Calhoun (2004) define posttraumatic growth (PTG) as positive psychological change experienced as a result of the struggle with highly challenging life circumstances (p. 1). This idea that stressful events can prompt individuals to make positive changes, find meaning, and appreciate life is a common narrative in many religions and philosophies (Tedeschi & Calhoun, 1995). A central tenant of Buddhism is learning from suffering; in Christianity many central figures are redeemed through suffering and sacrifice; in Judaism the Book of Job describes how after suffering traumatic loss, Job experiences growth, wisdom, and a deepening of his spirituality (Calhoun & Tedeschi, 2006b). Central ideas related to meaning of life, suffering, and healing were incorporated into psychiatric treatment through existential philosophy by Frankl and Yalom (Frankl, 1985; Yalom, 1980). Both Frankl and Yalom focused on the psychological process of how individuals could find meaning in their life after experiencing loss and trauma (Frankl, 1985; Yalom, 1980). This line of theory is in contrast to psychology s traditional perspective on trauma as a solely negative event (Tedeschi & Calhoun, 2004). While it is clear that the central feature of trauma and loss is negative, PTG focuses on how some individuals experience growth in some areas of their life, despite the clearly negative effects of the trauma and its aftermath (Tedeschi & Calhoun, 1995). Traditional research on trauma provides significant information on reduction of symptoms and helping individuals function in their lives after experiencing a traumatic event, which is clearly an important and necessary role of psychology (Tedeschi & Calhoun, 2004). PTG research focuses on how to supplement this focus, by also considering how psychology can promote healing, 8

21 9 growth, and increase positive benefits even when a person is experiencing suffering and loss (Calhoun & Tedeschi, 2006a, 2006b). Many different labels are used to describe potentially traumatic events that lead to PTG. In this manuscript, stressful event, negative life event, seismic event, and traumatic event will all be used to identify potentially traumatic events that may lead to PTG. The terms used in PTG vary widely based on the type of event studied, but all of these terms represent a type of event that is negative, causes distress, and can precipitate PTG. This inclusive use of terminology is consistent with other researchers in the field of PTG (Tedeschi & Calhoun, 2004). Posttraumatic Growth Sociocultural Model Calhoun et al. (2010) created a sociocultural PTG model, which specifically includes sociocultural factors. As seen in figure 1, cultural influences are incorporated into the conceptualization of the person pre-trauma and at different points of the process of PTG after the traumatic event. Cultural influences of PTG are conceptualized as distal or proximal influences (Calhoun & Tedeschi, 2006b). Distal cultural influences are general cultural beliefs or schemas, societal norms, or national or international policies that may impact the individual. Proximal cultural influences are the ways that culture influences the individual through interactions with people in their immediate environment. Examples of proximal cultural influences are knowing someone from the same culture that has experienced PTG, the willingness and ability of friends and family to discuss the trauma and engage in co-rumination, or family beliefs about religion. Although the PTG sociocultural model is complex, the main key aspects are summarized in this paragraph to highlight particularly relevant information to the

22 10 proposed study (For full model, see Figure 1) (Calhoun et al., 2010). The individual pretrauma has a culturally influenced worldview and assumptions about the world and other people. At some point, a potentially disruptive event occurs, which is likely influenced by sociopolitical context. The individual s perception of the event is key, which is influenced by their world view and cultural values. This person s beliefs, assumptions and life narrative are disrupted due to the negative life event, causing emotional distress. The individual may has intrusive and automatic rumination, which typically focuses on negative aspects and may increase emotional distress. The individual begins to manage her emotional distress and redirect her rumination in a more purposeful and deliberate manner. This process of moving towards more deliberate rumination is influenced by cultural beliefs about emotions, trauma and healing (distal cultural influences), as well as by social support, family beliefs, religion and influence of others who may have experienced PTG (proximal cultural influences). The individual focuses on deliberate and constructive rumination regarding the traumatic event. Researchers believe that this is where the main reconstruction of the trauma narrative occurs, and is necessary in order for PTG. Cultural influences such as cultural narratives about trauma and healing, as well as culturally specific ways of cognitively processing trauma may influence this stage. As a result of deliberate rumination, PTG occurs and there is recognition of strengths, interpersonal relationships and new possibilities. It is important to note that emotional distress is connected to all stages of this model, indicating that PTG can occur while the individual also experiences emotional distress. Although these key points of the model are presented in a linear format, it is important to note that the model is a dynamic process that does not necessarily occur in a linear fashion. Rather, individuals move to

23 11 different points in the model over time. This model provides a framework for synthesizing research regarding PTG and type of trauma, PTG in Latinos and PTG during psychological treatment. Posttraumatic Growth and Type of Trauma In the field of PTG, the concept of trauma or a negative life event are more inclusive and broad than the clinical definition of trauma as indicated by the DSM-V (Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.), 2013; Tedeschi & Calhoun, 2004). The DSM-V defines a trauma as: exposure to actual or threatened death, serious injury, or sexual violence by either directly experiencing the traumatic event, witnessing, in person, the event(s) as it occurs to others, learning that the traumatic event(s) occurred to a close family member or close friend... [and] experiencing repeated or extreme exposure to aversive details of the traumatic events. (Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.), 2013, p. 271). In contrast, the field of PTG includes negative life events that are distressing and prompts a person to re-evaluate their worldview and beliefs, but do not necessarily qualify as a traumatic event under the DSM-V (Calhoun & Tedeschi, 2006b). Moreover, the important aspect of a negative event for PTG is the subjective perception that the event is seismic and challenges their worldview (Tedeschi & Calhoun, 2004). This is consistent with research that found the subjective severity of trauma and distress is a better predictor of PTSD than the objective severity of the event (Morris et al., 2005). A recent studying using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) found that 83.66% of White, non-hispanic participants and 68.17% of Hispanic participants reported a potential traumatic event (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). Although the rate was lower for Hispanic than White participants, Hispanic participants were more likely to experience childhood

24 12 maltreatment than White participants. Hispanic women were also more likely to experience war-related events than White women (Roberts et al., 2011). Due to the high rates of exposure to potentially traumatic events, in addition to the common experiences of typically stressful life events, PTG is applicable to a broad range of people who experience a vast diversity of negative events. Although experiencing stressful and traumatic events may be relatively frequent occurrences, researchers often investigate how PTG develops among survivors of distinct types of traumatic experiences. Much of the literature on PTG is focused on cancer and physical illness (Stanton, Bower, & Low, 2006). PTG has been documented in cancer patients, chronic disease patients, and victims of motor vehicle accidents (Abraído-Lanza et al., 1998; Brunet et al., 2010; Nishi et al., 2010). For people who have experienced interpersonal violence, including intimate partner violence, sexual assault and childhood abuse, the experience of the traumatic event is likely different in some key ways from a physical illness or injury (Shakespeare- Finch & Armstrong, 2010). As discussed previously, interpersonal relationship growth is a key domain in PTG and positive social support may increase PTG (Calhoun & Tedeschi, 2006b). Interpersonal trauma may be more likely to interfere with interpersonal relationships than physical illness because worldviews about interpersonal relationships may be differentially impacted (Shakespeare-Finch & Armstrong, 2010). The duration and timeline of events may be another factor that separates interpersonal trauma from illness. For victims of childhood abuse or intimate partner violence, there is likely not one discreet event with a clear timeline; rather, there are likely many negative events over a longer period of time (Goodman, Corcoran, Turner, Yuan, & Green, 1998).

25 13 Due to the ways that distinct types of traumas may influence the PTG process, type of trauma may play a key role in the development and process of PTG. Due to differences between medical trauma and interpersonal violence trauma, growing areas of investigation in PTG are intimate partner violence, sexual assault and childhood abuse (Cobb, Tedeschi, Calhoun, & Cann, 2006; Lev-Wiesel, Amir, & Besser, 2005). Researchers have found that individuals that experience interpersonal violence may also experience PTG and that on average interpersonal violence survivors report a moderate level of PTG (Grubaugh & Resick, 2007). In a study comparing individuals who experienced sexual assault, motor vehicle accident and bereavement, researchers found that those experiencing bereavement reported higher levels of growth than those that experienced sexual assault or a motor vehicle accident (Shakespeare-Finch & Armstrong, 2010). Despite this difference, those participants that experienced sexual assault still reported a moderate level of PTG (Shakespeare-Finch & Armstrong, 2010). In a study that focused specifically on treatment seeking survivors of sexual abuse, survivors also reported a moderate level of PTG (Lev-Wiesel, Amir, & Besser, 2005). Grubaugh and Resick (2007) found that women seeking treatment for physical and sexual assault reported moderate to high levels of PTG, similar to what has been found in other populations. One issue specific to intimate partner violence is the ongoing and unpredictable nature of potential traumatic events. This uncertainty regarding ongoing trauma has lead researchers to question if women currently in abusive relationships can experience PTG (Cobb et al., 2006). In a sample of women who had experienced intimate partner violence, Cob et al (2006) found that 67% reported higher than moderate levels of PTG.

26 14 Those that were not currently in an abusive relationship reported higher levels of PTG than those currently in abusive relationship, but even those currently experiencing abuse reported PTG (Cobb et al., 2006). This is particularly important for the present study because many of the clients at the agency have been referred there due to intimate partner violence, which may be an ongoing threat while they receive treatment. Regarding the issue of PTG development over time, research by Frazier, Conlon & Glaser (2001) indicates that many women report PTG shortly after an experience of interpersonal violence and continue to report an increase in PTG over time. Frazier et al. (2001) found that sexual abuse survivors reported growth as soon as two weeks after the assault, and that PTG generally increased over 12 months after the assault. The best predictor of 12 month PTG was higher levels of PTG at 2 weeks after the assault (Frazier et al., 2001). This indicates that the PTG process may begin shortly after a traumatic event, and increase over time (Frazier et al., 2001). A similar study by Frazier, Tashiro, Berman, Steger & Long (2004) found that the relationship between social support and positive life changes over time was partially mediated by sense of control over recovery and approach coping (cognitive processing and emotion expression). Based on this research, PTG may be supported and promoted by giving interpersonal trauma survivors choice and control over their recovery treatment and encouraging approach coping through psychological treatment. Posttraumatic Growth and Latinos Very little research has been done investigating posttraumatic growth in Latino populations. Although the importance of distal and proximal cultural influences on the development of posttraumatic growth is recognized by many researchers (Calhoun et al.,

27 ; Calhoun & Tedeschi, 2006b; Weiss & Berger, 2010a), there still remains a large gap in knowledge regarding PTG in Latinos. This section will discuss the current knowledge of PTG in Latinos, focusing on Latinos living in the United States. In the discussion of ethnicity in PTG some researchers cite articles with such small sample sizes of non-white participants that they have little power and ability to detect any significant differences. For example, in a review of literature of PTG and cancer patients, Stanton et al. (2006) cites the literature on PTG and ethnicity in cancer patients and reports that there are ten relevant articles. Of those ten articles, many have very small samples of non-white participants, which makes their findings regarding ethnicity to be unreliable and unfounded (Sears, Stanton, & Danoff-Burg, 2003; Tomich & Helgeson, 2004; Widows, Jacobsen, Booth-Jones, & Fields, 2005). One study was not published, therefore cannot be evaluated (Thornton, Perez, & Meyerowitz, 2005). This type of review of PTG and ethnicity highlights the need for research that is focused on ethnic minority populations, such as Latinos, that can accurately investigate PTG in those populations. When this does not happen, very small, likely unrepresentative samples of ethnic minorities can be used to make large generalizations that are not justified and may not be accurate. Two studies that compared Latino participants to other ethnic groups found that Latinos tend to have higher rates of PTG than non-hispanic Whites and that religion partially mediates the relationship between ethnicity and PTG (Smith et al., 2008; Urcuyo et al., 2005). One study investigated PTG in non-hispanic White and English- speaking Hispanic women after cervical cancer and found that Hispanic women had higher rates of PTG than White women (Smith et al., 2008). In their study, religion moderated the

28 16 relationship between ethnicity and PTG, with Hispanic women reporting higher levels of religiosity than White women which lead to increased levels of PTG (Smith et al., 2008). Another study investigating PTG after cancer compared non-hispanic White, Hispanic and Black women. They utilized the Benefit Finding Scale and found that Hispanic women had higher levels of reported benefit following cancer than White women (Urcuyo et al., 2005). Urcuyo et al. (2005) also found that when they included religion as a moderator of the effect of ethnicity on reported benefit finding, religion moderated the relationship between ethnicity and PTG. Other research on PTG has focused on Spanish-speaking and Latino populations exclusively. Researchers in Spain created a Spain-Spanish version of the PTGI and investigated how PTG changes over time for breast cancer patients (Costa & Gil, 2008). They found that participants initially reported moderate levels of PTG and that PTG varied from moderate to high for one year after the cancer diagnosis (Costa & Gil, 2008). A few studies have focused on the experience of Latino populations in the U.S. and PTG. Abraído-Lanza et al. (1998) conducted a mixed-methods design investigating thriving and PTG in Latino arthritis patients. Abraído-Lanza et al. (1998) created a thriving scale based on qualitative data they collected from participants. They chose items from the PTGI, the Benefit Finding Scale, and created items to incorporate all themes from the qualitative data. They found that 83% of participants reported some level of growth and that positive psychological well-being, but not negative psychological functioning, did predict PTG (Abraído-Lanza et al., 1998). This study documented that PTG and thriving after trauma do occur in Latinos in the U.S., and that PTG was related to their overall psychological well-being.

29 17 PTG has also been found in adolescent Latinos in the U.S. (Milam, Ritt-Olson, & Unger, 2004). Milam et al. (2004) created a one-dimensional PTG scale and found that 30% of the Latino adolescents reported some growth after a traumatic event in the past year. The measure they created used a scale that captured both positive and negative outcomes on the same Likert scale (they rated change from very negative to very positive). Because of this, the results should be interpreted with caution because other research has shown that people can experience both positive and negative outcomes simultaneously after a traumatic event (Morris et al., 2005). When positive and negative outcomes are rated on the same scale, it could minimize or mask potential positive and negative outcomes because it combines them instead of looking at them as two separate dimensions (Tedeschi & Calhoun, 1996). Berger and Weiss (2006) investigated PTG related to immigration experiences for Latinas in the New York metropolitan area. This study, along with the validation study (Weiss & Berger, 2006), are the only published studies that utilize the PTGI-S. The sample experienced a variety of traumas, including immigration related traumas. Berger and Weiss (2006) found that participants had experienced a moderate level of stress and reported high levels of PTG. There was no association between stress and reported growth, indicating that for this group higher levels of stress did not cause increased PTG. Higher levels of stress were positively related to participants seeking counseling. Participation in counseling also predicted higher levels of PTG, and those that participated in counseling also reported talking about the traumatic event more often than those not in counseling. This last finding is particularly interesting and suggests that counseling may be a mechanism for increased posttraumatic growth for Latinas by

30 18 increasing the cognitive and emotional processing of the trauma in an interpersonal setting (Berger & Weiss, 2006). Two dissertations have also focused on Latino populations in the U.S. and PTG and have utilized the PTGI-S (Cordero, 2011; Rodgers, 2009). Rodgers (2009) investigated PTG in 62 Latina immigrants and found moderate levels of PTG in her sample. She also found that satisfaction with social support was predictive of PTG. Contrary to the findings by Berger and Weiss (2006) Rodgers (2006) found that participants who spoke less about the traumatic event had higher levels of PTG. While this is contrary to previous research, it does not specifically target psychotherapy or counseling and may be more reflective of speaking with peers or the responses of family and friends. Cordero (2011) focused on PTG in Latino men and found that spirituality and importance of family were predictors of PTG, indicating that those may be factors of particular importance for Latinos U.S. when developing PTG. Research on PTG in Latinos in the U.S. is in the early stages of development. Researchers have used a variety of methods to investigate PTG, including qualitative interviews, as well as a range of measures, some with limited information about specific content, validity and reliability (Abraído-Lanza et al., 1998; Milam et al., 2004). The results of these studies are difficult to compare with other research due to variety of measures used. The PTGI-S has been found to be reliable and valid as a quantitative measure for PTG in Latinos in the U.S. but has not been used with a clinical population (Berger & Weiss, 2006). Many U.S. Latinos have experienced trauma and seek psychological treatment, but there is only very limited information on how psychological treatment might impact PTG for Latinos in the U.S.. Despite these limits in the research,

31 19 some trends appear consistent. Latinos appear to experience moderate to high levels of posttraumatic growth (Berger & Weiss, 2006; Milam et al., 2004; Urcuyo et al., 2005) and appear to experience higher levels of PTG than non-hispanic Whites (Smith et al., 2008; Urcuyo et al., 2005). Religion and spirituality appear to play an important role in PTG development for some Latinos, and they may mediate the relationship between ethnicity and PTG (Smith et al., 2008; Urcuyo et al., 2005). Participation in counseling and discussion of the traumatic event may also be a successful way of promoting PTG in Latinas (Berger & Weiss, 2006). Posttraumatic Growth and Posttraumatic Stress Disorder Symptoms Posttraumatic stress disorder symptoms have frequently been studied with PTG in order to better understand the relationship between growth and distress after trauma (Zoellner & Maercker, 2006). For the current study, the sample consists of Latinas who are seeking psychological treatment due to distress related to a traumatic event. Many report symptoms of PTSD before beginning treatment; therefore, for the current study it is important to understand the relationship between PTSD symptoms and PTG in order to understand how PTG changes during psychological treatment when PTSD symptoms also likely change. The majority of the research on PTG and PTSD does not involve psychological treatment. Therefore, most of the studies are investigating PTG and PTSD without the influence of psychological treatment (Powell, Rosner, Butollo, Tedeschi, & Calhoun, 2003; Schuettler & Boals, 2011; Shakespeare-Finch & Armstrong, 2010). Some studies have investigated PTG and PTSD, but most does not directly evaluate the relationship between PTG and PTSD before, during or after treatment (Gray et al., 2012; Heinrichs et

32 20 al., 2012). Therefore, there is relatively little known about how post-treatment PTG and PTSD are associated. The research that does exist on PTG and PTSD symptoms for participants not in psychological treatment has mixed results, with studies that find that they are not associated (Baker, Kelly, Calhoun, Cann, & Tedeschi, 2008), positively associated (Chopko, 2010; Holgersen, Boe, & Holen, 2010; Shakespeare-Finch & Armstrong, 2010), negatively associated (Johnson et al., 2007; Zoellner & Maercker, 2006) or have a quadratic relationship, such that moderate levels of PTSD are associated with increased PTG (Levine, Laufer, Hamama-Raz, Stein, & Solomon, 2008; Powell et al., 2003; Schuettler & Boals, 2011). Some research supports that PTG and PTSD symptoms are not associated and suggests that they are separate constructs that occur independent from each other. Baker, Kelly, Calhoun, Cann, & Tedeschi (2008) created a scale in which they combined items from the PTGI and items about depreciation since a traumatic event, and found that participants rated positive and negative effects concurrently about the same trauma. This indicated that participants were reporting both negative and positive effects of the same trauma (Baker et al., 2008). Other research indicates that there is a positive relationship between PTG and PTSD symptoms, such that high levels of PTSD symptoms are predictive of PTG. This has been found in cross section research with police officers (Chopko, 2010), in a Norwegian sample of trauma survivors 27 years after an accident (Holgersen, Boe, & Holen, 2010) and with motor vehicle accident victims in Japan (Nishi et al., 2010). A study by Shakespeare-Finch & Armstrong (2010) found that intrusive PTSD symptoms in

33 21 particular were associated with higher levels of PTG, suggesting that intrusive symptoms could increase cognitive processing that leads to PTG. Some researchers hypothesize that there is a negative relationship between PTG and PTSD symptoms, arguing that PTSD by definition means that the individual could not experience growth (Johnson et al., 2007; Zoellner & Maercker, 2006). In a review article, Zoellner & Maercker (2006) argued that longitudinal studies indicated that there was a negative relationship between PTG and PTSD symptoms. The studies reviewed by Zoellner and Maercker (2006) used different measures that were difficult to compare with each other and to other cross sectional research, weakening the strength of their conclusions. A prevailing view is that there is a quadratic relationship between PTG and PTSD symptoms, such that moderate levels of PTSD symptoms lead to higher PTG (Powell et al., 2003). A study of 2,375 Israeli adolescents found a curvilinear relationship between PTG and PTSD symptoms, such that adolescents with moderate levels of PTSD symptoms had the highest levels of PTG (Levine, Laufer, Hamama-Raz, Stein, & Solomon, 2008). A study of trauma survivors in Bosnia showed a similar curvilinear relationship between PTG and PTSD symptoms (Powell et al., 2003). Schuettler and Boals (2011) investigated the predictors of PTG and PTSD symptoms in undergraduates and found a common predictor between PTG and PTSD symptoms: event centrality. High levels of event centrality, or the extent to which an event impacts an individual s identity and sense of self, was related to high levels of both PTG and PTG. This research by Schuettler and Boals (2011) is consistent with the sociocultural PTG model, in that the

34 22 event that precipitates the PTG must be sufficiently stressful and distressing to shake the assumptions and world view held by the individual. While the literature on the relationship between PTG and PTGI is not consistent, it does indicate that there is likely a relationship between PTG and PTSD symptoms. Due to the lack of research, it is unclear how post-treatment PTSD symptoms and PTG are related. It may be possible that if treatment is effective in addressing PTSD symptoms, it may also impact PTG. In the current study, PTSD symptoms before and after treatment must be measured and accounted for in the data analysis and interpretation of results. Posttraumatic Growth and Psychological Treatment The sociocultural PTG model identifies managing negative emotions, positive social feedback, the creation of narratives, the process of rumination, specifically focused and deliberate rumination about the traumatic event, and meaning making as central to the development of PTG (Calhoun et al., 2010). Deliberate rumination can occur individually, through co-rumination or discussions with friends and family, or through psychological treatment (Calhoun et al., 2010). A number of scholars have identified ways that psychological treatment can be adapted to promote these processes and therefore promote PTG. Calhoun & Tedeschi (2006a) identify a process that they call reflective rumination as a particularly useful psychological technique that can help promote PTG. In the process of reflective rumination, a counselor encourages the client to reflect on the traumatic event and how it has changed the person s life, including any positive benefits the person reports. Janoff-Bulman (2006) have written about the ways that cognitive processing during counseling can help clients adapt schemas about the world that they may have held prior to the traumatic event in a realistic but positive way.

35 23 Neimeyer (2006) describes the power of narratives to integrate negative life events by drawing on cultural narratives of strength and hope. Neimeyer (2006) also identifies the use of narrative therapy as a particularly appropriate psychological treatment to promote PTG. The use of psychological treatment to increase PTG may be particularly relevant to Latinas in the U.S. who may be isolated. While many people may be able to ruminate individually or have friends and family that are willing and able to discuss the trauma with them, this is not true of all people. This might be particularly difficult for Latina immigrants that are separated from friends and family (Berger & Weiss, 2010). Latina women in the U.S. who are survivors of intimate partner violence and have recently left their partner may be particularly isolated and would benefit from a psychological treatment that could promote PTG. There is preliminary evidence that a variety of psychological treatments may promote PTG. As with many other areas of PTG, this area of study is continuing to be developed. Based on the research available, psychological treatments appear to increase PTG for many patients in varied cultures, including patients that experience negative symptoms such as PTSD (Glad et al., 2013; Knaevelsrud et al., 2010; Wagner et al., 2007). Two recent studies have been conducted investigating PTG change during psychological treatment that used methods other than the PTGI to assess PTG. In a randomized clinical trial of TF-CBT and TAU for 138 adolescents in Norway, researchers found that both treatment groups experienced an increase in PTG from pre to post therapy. PTG in this study was measured using qualitative analysis of an open-ended

36 24 question (Glad et al., 2013). In a randomized clinical trial of narrative exposure therapy and waitlist control for 22 participants in China, researchers did not find an increase in PTG after the two week treatment (Zang et al., 2013). They did find an increase in PTG at two months post treatment for both narrative exposure therapy and waitlist group (both groups had received treatment at that time) (Zang et al., 2013). Zang et al. (2013) utilized a short version of the changes in outlook questionnaire to measure both positive and negative changes, and used positive changes reported on the scale to measure PTG. One open trial study has been conducted to examine the effect of adaptive disclosure (AD) on PTG in active-duty service members (Gray et al., 2012). AD is a sixweek, manualized, hybrid of exposure therapy that incorporates cognitive techniques (Gray et al., 2012). Gray et al. (2012) found that there was a significant increase in PTG, as measured by the PTGI, and significant decrease in PTSD symptoms. Three clinical trials evaluating PTG change during a psychological treatment utilized the PTGI to assess PTG. A study in the Netherlands investigated PTG change during a clinical randomized trial of an exposure therapy (Hagenaars & van Minnen, 2010). They found that the treatment group has a significant increase in the PTG subscales of relating to others, new possibilities and personal strength, while the control group did not show an increase in PTG. Two studies investigated PTG change during clinical trials of a similar internet based cognitive behavioral therapy treatment in Switzerland and Germany (Knaevelsrud et al., 2010; Wagner et al., 2007). Wagner et al. (2007) found a significant increase in PTG for those in the treatment condition compared to no increase in PTG in controls post-treatment. Knaevelsrud et al. (2010) found similar results in their study; participants

37 25 that received the treatment had a significantly greater increase in PTG than those in the control group. Although the number of studies of PTG during psychological treatment is limited, six of seven published studies indicate that psychological treatment does promote PTG. This research does not include a sample of Latinas in the U.S., but previous research indicate that Latinas in the U.S. that participated in counseling had higher rates of PTG than those that did not participate in counseling (Weiss & Berger, 2006). Further study into PTG for Latinas during psychological treatment is needed to better understand how to promote PTG in this population. Psychological Treatment: Traumatic Incident Reduction Traumatic Incident Reduction (TIR) was first created by Frank Gerbode to reduce trauma symptoms in survivors of traumatic events (Gerbode, 1989). TIR is an individual psychological treatment that is structured, person-centered, brief and memory based that is used to treat symptoms of PTSD, depression and anxiety (Descilo, Greenwald, Schmitt, & Reslan, 2010; Dulen, 2011; Valentine, 1997). One of the assumptions of TIR is that avoidance of traumatic memories and reminders maintains the distress and negative emotion surrounding those memories and reminders (Gerbode, 1989). Based on this assumption, the primary goal of TIR is to process the traumatic information until the individual has explored all aspects of the event and feels a sense of relief or calmness, which is called an endpoint (Gerbode & Moore, 2004). The client is asked to imagine the traumatic event as if the client was watching the event like a movie (Descilo et al., 2010). The client then describes it in detail and the counselor, following a manual of prompts, asks the client to view the event

38 26 again at her own pace, and repeats this processing of the traumatic event (Gerbode & Moore, 2004). The counselor attends to the emotional experience of the client, and when the counselor or client notice that the client has an improved emotional state, they determine that the client has reached the endpoint for the trauma (Gerbode & Moore, 2004). Because this process is client lead and based on the emotional experience and cognitive process of the client, session times vary and can take from one to four hours (Valentine & Smith, 2001). Typically one traumatic event or theme is the focus for each session until an endpoint is reached (Gerbode & Moore, 2004). TIR is most similar to emotional flooding, in which a client is asked to remember an event a number of times in order to re-experience emotions associated with the event (Levis & Hare, 1977). In emotional flooding, the individual is re-experiencing the emotions in order to learn tolerance of the distressing emotions, extinguish the learned response of avoidance, and increase tolerance for the memories so that they are not avoided (Levis & Hare, 1977). In TIR, the repetition of the traumatic memory has a different purpose. One purpose is to re-experience the emotions within the context of a safe therapeutic environment (Gerbode, 1989). This allows the patient to tolerate the negative emotions and focus on processing the event when they would likely avoid a similar situation outside of TIR or other treatment. Another purpose of the repetition is to cognitively process the trauma memory in order to view the event in a new light (Gerbode & Moore, 2004). During the traumatic event, individuals may make assumptions or judgments that lead them to misinterpret or hold onto beliefs that are not helpful to them (Gerbode, 1989). When individuals repeat the event, they examine it

39 27 from a new perspective and may gain insight into the event as well as their own behavior (Gerbode, 1989). Research on TIR is still in the early stages of development but there are studies that have provided empirical support for the effectiveness of TIR in treating PTSD, depression and anxiety in trauma survivors (Bisbey, 1995; Valentine & Smith, 2001). Two dissertations have studied the effectiveness of TIR for reducing negative symptoms of trauma survivors (Bisbey, 1995; Dulen, 2011). One dissertation (Bisbey, 1995) examined the effectiveness of TIR, direct therapeutic exposure (a type of exposure treatment) and waitlist control for their effect on reducing symptoms of PTSD. Bisbey (1995) found those that received TIR had significantly lower symptoms of PTSD compared to both the direct therapeutic exposure and waitlist control groups at posttreatment. A dissertation by Dulen (2011) used open trial methodology and investigated the effectiveness of TIR for reducing symptoms of PTSD, depression and anxiety in a sample of Latina and African American crime victims. Dulen (2011) found that the women in the study experienced a significant reduction in symptoms of PTSD, depression and anxiety from pre to post treatment. Descilo et al. (2010) investigated TIR for reducing symptoms of PTSD with open trial methodology with 33 urban at-risk youth and 31 unaccompanied immigrant youth. With each population, Descilo et al. (2010) found that the youth had a significant decrease in PTSD symptoms from pre to post test. One peer-review article investigated the effectiveness of TIR using a randomized control trial (Valentine & Smith, 2001). Valentine and Smith (2001) investigated the effectiveness of TIR at reducing symptoms of PTSD, depression and anxiety compared to

40 28 a control group with 123 female inmates in a federal prison. The participants were tested pre-treatment, post-treatment and at a three month follow-up. They found that those participants that received TIR had significantly lower rates of PTSD at post-test and 3 month follow up when compared to the control group. Although the research on the effectiveness of TIR is still growing, preliminary research indicates that it is a promising treatment for reducing negative symptoms for Latinas in the U.S. due to trauma, including symptoms of PTSD, depression and anxiety (Dulen, 2011). Posttraumatic Growth, Traumatic Incident Reduction and Trauma Resolution Center Central processes in TIR are managing emotional distress, cognitive processing or deliberate rumination of a traumatic event and creating a narrative of the trauma, which are all consistent with the sociocultural PTG model that outlines how the development and promotion of PTG occurs (Gerbode & Moore, 2004; Tedeschi & Calhoun, 1996). TIR facilitates the managing of difficult emotions by providing a safe, therapeutic environment for individuals to cognitively process and ruminate on negative emotions (Gerbode, 1989). In the sociocultural PTG model, this is an important step in order to be able to deliberatively ruminate on the traumatic event (Calhoun et al., 2010). TIR facilitates the deliberate and thoughtful cognitive processing of a traumatic event. In TIR, clients are asked to view an event, observe it, and then describe it to the counselor (Descilo et al., 2010). This process is to promote deliberate cognitive processing of the event and to create opportunities for insight during which the client may begin to understand the traumatic event from a new perspective (Gerbode & Moore,

41 ). This is similar to the process of deliberate rumination in the PTG sociocultural model during which individuals begin to examine the traumatic event and make meaning from it. In the PTG sociocultural model, as in TIR, this is the stage where the majority of the change occurs (Calhoun et al., 2010; Gerbode & Moore, 2004). The repeated viewing, observing and description of the event in TIR helps clients create a narrative memory of the traumatic event, when it previously may have been fragmented or based on images (Gerbode, 1989). The idea of using narratives to understand and grow from trauma is proposed as a method of creating PTG (Neimeyer, 2006). Due to the similarities between TIR treatment and the PTG sociocultural model, TIR may be particularly effective and promoting PTG for Latinas in the U.S. that are experiencing symptoms of PTSD, depression and anxiety. The Trauma Resolution Center offers a range of additional services to promote healing from trauma, including psychoeducational groups, meditation, massage, acupuncture, yoga, reiki, sound bowl meditation and breath work. This focus on additional service to promote healing may also promote PTG through helping participants manage negative affect, helping them manage physiological symptoms of PTSD, depression and anxiety as well as by teaching relaxation skills that allow them to more thoroughly process traumatic events and engage in purposeful ruminative thought. The model of this agency that promotes healing and growth may also prompt participants to begin thinking that healing is a possibility for them and therefore re-evaluate their hopes and goals for their recovery.

42 30 Summary of Literature Posttraumatic growth is positive psychological growth after experiencing a stressful life event (Tedeschi & Calhoun, 2004). The sociocultural model of posttraumatic growth indicates that sociocultural factors influence the development of PTG at many stages of development, including influencing the individual s pre-trauma world view and beliefs, the management of distress, engagement in cognitive process and meaning making, and development of a new, positive and realistic worldview (Calhoun et al., 2010). In the field of PTG, a negative life event is broadly defined and is largely based on the subjective experience of the individual that experiences the event (Shakespeare-Finch & Armstrong, 2010). Some research has shown that individuals who experience interpersonal violence experience moderate rates of PTG, similar to individual that experience other types of trauma (Grubaugh & Resick, 2007). Survivors of interpersonal violence may experience PTG as soon as two week after the event and PTG tends to increase over time (Frazier et al., 2001). Even women that are still experiencing interpersonal violence may experience PTG (Cobb et al., 2006). Some research indicates that Latinas in the U.S. experience moderate to high levels of growth after traumatic events (Berger & Weiss, 2006), and they also may experience higher levels of PTG than White women (Abraído-Lanza et al., 1998; Urcuyo et al., 2005). In some studies high levels of religion or spirituality predict higher PTG levels for Latinas in the U.S. (Smith et al., 2008; Urcuyo et al., 2005). One study also identified participation in counseling as a predictor of high levels of PTG in Latinas (Berger & Weiss, 2006). Despite the growing research on Latinas, the Spanish

43 31 posttraumatic growth inventory has only been used in an empirical study and validation study with a Latina immigrant population in the U.S. (Berger & Weiss, 2006). It has not yet been used with a clinical population. Several studies indicate that psychological treatment promotes PTG, with three randomized control studies indicating that those receiving psychological treatment had higher levels of PTG than participants in control groups (Hagenaars & van Minnen, 2010; Wagner et al., 2007). Traumatic Incident Reduction (TIR) is a psychological treatment that is brief, client centered, structured and memory based (Gerbode, 1989). Studies have indicated that TIR is effective at reducing symptoms of PTSD, depression and anxiety in Latinas in the U.S. (Dulen, 2011; Valentine & Smith, 2001). TIR promotes clients expression and management of emotional distress, cognitive processing of the trauma and creation of a narrative (Gerbode & Moore, 2004). Moreover, the TRC model of complementary services may promote PTG through management of emotional distress, addressing physiological symptoms of PTSD, depression and anxiety and introducing the idea of healing and growth as a possibility. These areas of treatment are consistent with the sociocultural PTG model of how PTG develops (Calhoun et al., 2010). The present study will investigate PTG in Latinas in the U.S. and how PTG change is impacted by psychological treatment for this population. Therefore, the following hypotheses are offered: Hypotheses: 1. There will be a positive relationship between pre and post PTG scores. 2. There will be a significant increase in PTG from Pre to Post treatment.

44 32 3. Clients that report current religious affiliation and regularly attending religious services will report higher levels of PTG at post treatment. 4. Greater number of hours of treatment and more time elapsed from the beginning to the end of the treatment will predict higher levels of post-treatment PTG after controlling for pre-treatment PTG levels. 5. Lower levels of post-treatment PTSD symptoms will be associated with higher levels of post-treatment PTG.

45 Chapter 3: Methods Community-based Open Trial Methodology This research project was completed through an ongoing partnership that began in 2008 between the Community and Educational Well-Being (CEW) Research Center and the Trauma Resolution Center (TRC). This type of community university research partnership allows researchers to investigate current psychological treatments as they occur in a real-world setting. Partnerships such as the CEW-TRC partnership improve the connection between research and practice, and allow for direct communication between researchers and practitioners. Community-based open trial methodology indicates that the research is based on community-identified needs and interests and community agencies gather data based on their current practices. This type of approach has a number of benefits in terms of research process as well as outcomes. Many have noted the difficulties of translating researcher developed psychological treatments into clinical practice (Drake et al., 2001). Practitioners frequently cite the lack of utility of interventions that do not provide sufficient flexibility to address the many and varied needs and presentations of individuals seeking mental health treatment (Kazdin, 2008). Community-based open trial methodology allows researchers to approach research and clinical innovations from the community, instead of researcher, perspective. This methodology first investigates the effectiveness of current interventions, and builds on the expertise of practitioners already knowledgeable of the community challenges to find realistic and flexible approaches to improving treatment. 33

46 34 This methodology is an open trial because participants are informed of the nature of the psychological treatment and the community organization is provided the same treatment to all of their clients, as they would typically do. This methodology has many practical and functional benefits as well. This approach is cost effective and sustainable in that both the community agency and research partner focus on their area of expertise and their current practice. Because this type of partnership is sustainable and relies on available, current resources, it can provide valuable information for program improvement and validation to local community agencies. Those local community agencies can in turn provide innovate strategies for reaching underserved populations and implementing programs in complex settings to researchers and practitioners. Additionally, this type of community based methodology increases the ability for the researcher to gather information from traditionally under-researched populations. In the case of the present study, the TRC works with a large Latino, Spanish-speaking population of clients. This population may have difficulty participating in traditional psychological research on college campuses for logistical, cultural and linguistic reasons. By engaging in a research partnership with a community organization, this research methodology is adapting to the various needs of underserved participants. A community-based open trial is particularly relevant in the field of posttraumatic growth, which is a growing field that is still in the exploratory phase of theory development and empirical studies. Other researchers, such as the previously discussed open trial studies by Glad et al. (2013) and Gray et al. (2012), have recently used similar open trial methodology based out of pre-existing psychological treatment centers. Most research on PTG during psychological treatment has occurred within the last few years,

47 35 and has just begun to unravel the complex connection of PTG change during psychological treatment. These types of open-trial, community based studies can provide further evidence for what types of psychological treatments may increase PTG, as well as provide insights into the predictors of PTG change during psychological treatments. Based on this research investigators will have more information when tailoring or creating psychological treatments to promote PTG. Research Design This study utilized demographic, cultural, treatment and clinical variables, as well as pre and post-treatment scores on measures of posttraumatic growth, posttraumatic stress disorder, anxiety and depression, to investigate the relationship between psychological treatment and posttraumatic growth change. Sample Participants for this study were identified from clinical files from the time period of May 2013 through December All clinical files reviewed were for participants who had ended treatment. To identify participants that met inclusion criteria for this study, approximately 300 treatment files were reviewed and participant s clinical files were identified for data entry based on inclusion criteria. Inclusion criteria for data entry was being age 18 or older, identifying as Hispanic or Latina, identifying as a woman, completing at least a pre and mid-treatment assessment and having updated forms (including the updated intake assessment form and posttraumatic growth inventory). Two participants were excluded because they did not report any type of interpersonal traumatic event. Based on these criteria, 77 female, adult clients that completed treatment

48 36 at the TRC, with at least a minimum of pre-treatment and mid-treatment assessments were included in this dissertation study. The mean age of participants was (SD = 11.41). The majority of participants preferred to speak Spanish (n = 52, 67.5%), while a smaller percentage preferred English (n = 17, 22.1%). A much smaller percentage preferred a combination of languages, such as bilingual English-Spanish (n = 8, 10.4%). The participants were both Latinas born in the United States (n = 11, 14.3%), as well as immigrants from the Caribbean, Central and South America. The largest groups were from Colombia (n = 12, 15.6%), Argentina (n = 7, 9.1%), Nicaragua (n = 7, 9.1%) and Venezuela (n = 7, 9.1%). For the participants born outside of the United States (n = 65), they lived in the United States for an average of years (SD = 9.80), and had moved to the United States at an average age of (SD = 10.59). The majority of participants were single, divorced or separated (n = 41, 53.3%), while a smaller group was married or cohabitating (n = 32, 41.6%). Participants had a wide variation in education attainment. Twenty three percent (n = 18) had less than a high school education, 23.4% (n = 18) had completed high school or had completed a GED, 26% (n = 20) of the participants completed some college or an associate s degree, while 29.9% (n = 20) had completed a 4-year college degree or more. Most of the participants were currently employed (n = 47, 61%). Instruments Demographic and clinical information. Counselors conduct a structured interview with clients using the in-depth intake form (Appendices A and B). They gathered information regarding gender, ethnicity, language preferred, education, occupation, sexual orientation, country of origin, length of time in the United States,

49 37 previous counseling, current religious affiliation, regular attendance of religious services, current relationship status, medical history information and current medications, suicide assessment, substance use and psychiatric history. This form was translated into Spanish by an IRB certified translator. Trauma Screening. The Stressful Life Events Screening Questionnaire Revised (SLESQ-R) is a measure that was administered verbally during the structured in-depth intake interview (See appendices A and B). It is a trauma history screening questionnaire developed to assess for trauma over the course of a person s lifetime instead of primarily discrete traumatic events. It assesses for life threating illness, accident, physical force used during a robbery, death of a close friend or family member, sexual assault that is forced or occurred while the individual could not give consent, other sexual assault, childhood physical abuse, adult physical abuse, emotional abuse from a family member or romantic partner, being threatened with a weapon, witnessing a traumatic event and any other event that was extremely frightening, horrifying or in which the individual felt hopeless. For each type of trauma, there are follow up questions specifying the age when the individual experienced the event, how many times it occurred, relationship to the perpetrator, as well as other questions specific to the different types of events. It showed good test-retest reliability (mean kappa of.73) and good discriminate validity between DSM-IV criteria A and non-criteria A events (Goodman et al., 1998). There is no Spanish SLESQ that has been used in a published article; therefore, this measure was translated into Spanish by an IRB certified translator. Adaptation of the SLESQ-R. Due to concerns of the partner community agency, the SLESQ-R and Spanish SLESQ was modified to be appropriate for the approach of the

50 38 agency. The SLESQ-R has primary questions about different categories of traumas, with many follow-up questions asking for very specific details. Due to concerns that the level of detail requested would be overwhelming to clients, some follow up questions were removed. All main questions remain, as well as questions about age, frequency and relationship to perpetrator. One question was added: Have you ever sold sex for money, drugs, or anything else? The clinical staff reported that a number of clients were forced into prostitution and the staff did not believe it was sufficiently captured by the other types of traumas included in the measure. Because the main categories are the primary sourced for information used in data analysis, this is not anticipated to alter the validity or reliability of the measure. Posttraumatic Growth. Posttraumatic growth was assessed using the Posttraumatic Growth Inventory (PTGI) (Tedeschi & Calhoun, 1996) (Appendices C and D). It is a 21-item self-report PTG scale that uses a Likert scale from 0 no change to 5 very great change. It has been found to have one overarching factor (Lee, Luxton, Reger, & Gahm, 2010; Palmer, Graca, & Occhietti, 2012; Taku, Cann, Calhoun, & Tedeschi, 2008). The Spanish PTGI is also used and was modified very slightly utilizing input from clinicians at the TRC. The Spanish PTGI (PTGI-S) is a previously translated and validated version (Weiss & Berger, 2006). The PTGI-S was also found to have one overarching factor (Weiss & Berger, 2006). Due to the sample size and the number of items on the PTGI, a factor analysis was not conducted. A previous factor analysis conducted with immigrant Latinas in the US found that 13 of the original 21 items loaded onto an overarching factor for the PTGI-S and explained 66.7% of the common variance as well as being highly correlated with the 21 item version (spearman s rho =.98, p <

51 39.001, n = 100) (Weiss & Berger, 2006). For the present study, the score was calculated from the 21 item version for the participants that completed the PTGI in English and the score was calculated from the 13 selected items for the participants that completed the PTGI in Spanish. There were no mean differences on PTG between the groups for pretest (t(76) = 1.50, p =.14) or post-test (t(76) =.04, p =.97) using dependent t-tests. Clinical variables. Posttraumatic stress symptoms, depression symptoms and general anxiety symptoms were also assessed (See appendices C and D for measures). Posttraumatic stress symptoms were assessed with the Posttraumatic Stress Disorder Checklist Civilian (PCL-C) (Miles, Marshall, & Schell, 2008). The PCL-C is a 17-item self-report scale that uses a five point Likert scale from 1 (not at all) to 5 (extremely) for each item. The scale provides a continuous scored based on the number and severity of PTSD symptoms according to DSM-IV criteria. In addition to the total score, it provides three subscales: re-experiencing, avoidance/numbing and hyper arousal. Although there is a suggested cutoff score for a likely diagnosis of PTSD, it will be used as a continuous severity variable in this study. The PCL-C has good reliability (Cronbach s α =.90), as well as construct validity and convergent validity (Costa-Requena & Gil, 2010). The Spanish PCL-C has been found to have a similar factor structure and to be equivalent to the English version (Miles et al., 2008; Orlando & Marshall, 2002). Depression symptoms were assessed with the Center for Disease Control- Depression scale (CES-D) (Radloff, 1977). It is a 20-item self-report scale that uses a four point liker scale from 0 (rarely or none of the time) to 3 (most or all of the time) to assess depression symptoms during the past week. It was found to have good internal reliability (α = ), and validity (Radloff, 1977). The Spanish CES-D has been

52 40 found to have a similar factor structure and to have content equivalency to the English version (Roberts, Rhoades, & Vernon, 1990; Soler et al., 1997). General anxiety symptoms were assessed with the Clinical Anxiety Scale (CAS) (Westhuis & Thyer, 1989). It is a 25-item self-report scale that uses a five-point Likert scale from 1 (rarely or none of the time) to 5 (most or all of the time) to assess feeling of anxiety currently. It was found to have good internal reliability (α =.94) and discriminate validity (Westhuis & Thyer, 1989). The CAS was translated into Spanish by the bilingual staff at the TRC and has been used in their clinical practice for approximately six years. This was done due to lack of low-cost anxiety measures in Spanish. Although there has not been a reliability or validation study completed on the translation, it has been used in a previous dissertation (Dulen, 2011). Administrative forms. Additional information about treatment was collected from administrative forms, such as total minutes of TIR, psychoeducational groups, holistic services, total psychological treatment, dates of services provided, minutes of TIR per session and time of each session. These forms are the session summary form, measurement summary form, and client qualification form (See appendices E, F and G). Procedure Clients at the TRC followed standard intake and assessment procedures. After clients were referred to the TRC, either through community partners or self-referral, they were scheduled for a preliminary session during which time informed consent, confidentiality and clinical procedures are explained to them. They signed informed consent forms, which included an agreement that their clinical information be used for research purposes (see appendices E and F). After completing this paperwork, they then

53 41 completed pre-treatment assessments, which include the PTGI, PCL, CES-D and CAS. All clients then attended up to 4 psychoeducational groups depending on the types of trauma they experienced. The group topics were psychobiology of trauma, trauma bonding, cycle of violence (for intimate partner violence), and the effects of domestic violence on children. Based on availability, clients may have begun individual treatment two weeks to two months after completing the initial assessment. Two weeks allows the participants to participate in some of the psychoeducational groups before beginning individual counseling. Resources are limited at the TRC, as in many community mental health agencies; therefore, at times there are wait-lists to begin counseling and some clients may wait up to two months to begin therapy. Clients completed a structured indepth intake interview during the first individual treatment session. As part of the intake interview, the participants completed the SLESQ-R. The psychoeducational groups, measures and intake interview were provided in the language that is preferred by the client, either in English or Spanish. Clients also complete the four measures (PCL, CES- D, CAS and PTGI) after approximately 10 hours of the treatment (mid-test) and after approximately 20 hours (post-test). After treatment was completed, data was entered from clinical files into a research database on-site at the TRC. Variables Investigated Demographic, cultural, clinical and treatment variables were investigated. The following is a list of the specific variables utilized: pre-treatment PTG, post-treatment PTG, employment status (employed or not employed), current psychiatric medication usage (yes or no), history of psychiatric diagnosis (yes or no), history of suicide attempt (yes or no), history of psychiatric hospitalizations (yes or no), age, country of origin, born

54 42 in US (born in U.S./Canada or other country), years lived in U.S., age when moved to U.S., language preference (Spanish or other), number of types of trauma (sum of items from SLESQ-R that participant responded yes), type of traumas experienced, current religion (Catholic/Christian or other), belonging to a religious group (yes or no), attending religious group regularly (yes or no), pre-treatment anxiety, depression and PTSD symptoms, post-treatment PTSD symptoms, minutes of all intervention received, minutes of TIR, duration of treatment (in days from admission appointment to last session date).

55 Chapter 4: Results IBM SPSS Statistics (version 22) was used for data cleaning and all statistical analyses. First, descriptive statistics for each variable were examined to identify any outliers and potential errors in data entry. Second, the percentage and pattern of missingness in the data were examined. Third, composite scores were created by taking the average of individual responses on items for PTGI, PCL, CAS and CESD, for all participants that answered more than 80% of items. Fourth, descriptive statistics were examined to better understand the distribution of participants responses. Fifth, a number of preliminary analyses were performed in order to determine whether posttest scores of PTG differed by participants language and treatment endpoints. Sixth, each variable of interest s relationship with the dependent variable, post-treatment PTG, was examined. Results from these analyses guided the choice of independent variables in the hierarchical regression analysis due to exploratory nature of the current study that primarily stems from a lack of research in PTG changes during treatment for Latinas. The preliminary analyses included: (1) Paired t-test for pre and post treatment PTG and (2) Analysis of Covariance (ANCOVA) were utilized to find any group differences on language (grouped as Spanish or other) as well as treatment endpoint (grouped as mid-test or posttest) by language, employment status, currently using psychiatric medications, history of psychiatric diagnosis, history of suicide attempt, history of psychiatric hospitalization, current religion, belonging to a religious group, attending religious group regularly and born in US (3) correlation among pre-treatment PTG, PTSD, depression and anxiety; post-treatment PTG, PTSD; age, years lived in US, age when moved to US, total number 43

56 44 of types of trauma, total number of types of interpersonal trauma, minutes of total treatment, minutes of TIR and duration of treatment. Seventh, the assumptions of hierarchical linear regression were tested. Lastly, a post-hoc power analysis was conducted to assure the observed power for the hierarchical linear regression analysis with seven predictors. Handling of Missing Data It was found that the patterns of missing data were not systematically related to any variables in the data. In addition, less than 5 percent of the data was missing, which can be considered negligible (Enders, 2010). For some variables, missing values were assumed to be zero, none or other. This was the case for: current religion, attend religious groups, belong to a religious group, and individual trauma items on the SLESQ-R. For other types of missing data, the missing value was replaced with the value of another matched participant. This method was utilized for pre-treatment PCL, CAS, CESD that were missing more than 20% of items as well as the variables currently taking psychiatric medication, history of psychiatric medication, history of psychiatric diagnosis, history of suicide attempt, time in US, age moved to US, country of origin, total minutes of TIR. Matched participants were chosen by matching categorical variables and matching within 1.5SD on most of the continuous variables. The variables chosen as a basis for matching responses were as follows: Pre-treatment PTGI, post-treatment PTGI, pre-treatment PCL, post-treatment PCL, number of types of traumas, total minutes of treatment, total minutes of TIR, duration of treatment, language, country of origin (US or other), time in US and attend religious group. For participants that were missing only some of the session

57 45 minutes of TIR, but had others intact, mean substitution was utilized based on the mean minutes of TIR for that session number. Descriptive Statistics Data was gathered from clinical files after treatment had ended and was identified for analysis through the following inclusion criteria: self-identifying as Latina or Hispanic, female, age over 18 years old, experiencing at least one interpersonal trauma and completing at least a pre and mid treatment assessments. Based on this process, 77 participants were gathered for preliminary analysis. After identifying and managing missing data, all 77 women were included in the main analyses. Most of the participants identified with a current religious belief of Catholic or Christian (n = 49, 63.6%), and a smaller percentage reported belonging to a religious organization (n = 33, 42.9%). A smaller group of participants attended religious services on a regular basis (n = 31, 40.3%). Participants in this sample reported a high number of different types of traumas, with a mean of 5.66 different types of traumas experienced (SD = 2.54). Participants reported emotional abuse (n = 68, 88.3%), physical abuse as an adult (n = 60, 77.9%), coerced sexual contact (n = 39, 50.6%) and physical abuse as a child (n = 39, 50.6%), as the most common types of traumas experienced. Participants started treatment with a range of levels of PTSD, depression and anxiety symptoms. They reported mean PTSD symptoms level of 3.41 (SD = 1.0), which corresponds to moderately to quite a bit bothered by symptoms of PTSD. They reported mean level of depression symptoms of 1.59 (SD =.72), which corresponds to moderate or mostly feeling symptoms of depression, and mean anxiety symptoms level of 2.71 (SD =

58 46.80), which corresponds to a little to some of the time experiencing anxiety symptoms. Prior to treatment, participants reported mean PTG of 2.72 (SD = 1.17), which corresponds to a small to moderate degree of change. After treatment, participants reported lower levels of PTSD, depression and anxiety symptoms, and higher levels of growth, compared to pre-treatment scores. They reported mean PTSD symptoms of 1.8 (SD =.82), which corresponds to none to a little amount of PTSD symptoms. They reported a mean level of depression symptoms of.64 (SD =.63), which corresponds to rarely or some of the time experiencing symptoms of depression. They reported mean levels of anxiety of 1.78 (SD =.61), which corresponds to rarely to a little of the time experiencing anxiety symptoms. They reported a mean level of PTG of 3.84 (SD = 1.12), which corresponds to a moderate to great degree of change. Preliminary Analyses This study is exploratory in nature and is based on a small body of literature on PTG in Latinas in the United States as well as PTG change during treatment. Variables were chosen for preliminary analysis based on previous literature and theory. To further guide the choice of predictors, measures of association between the dependent variable, post-treatment PTG, and variables of interest were conducted to guide the decisions of variables to be included in the analysis. Please see table 1 for correlations between continuous variables included in preliminary analyses. Relationship between pretest and posttest PTG. A paired sample t-test was conducted to determine if pre-treatment PTG was significantly different from post-

59 47 treatment PTG. The means were found to be significantly different (t (76) = -6.84, p =.00). Control variables. ANCOVAs were conducted to determine if mean differences between groups varied for post-treatment PTG after controlling for pre-treatment PTG for dichotomous variables intended to control for severity of psychopathology in participants. ANCOVAs were conducted for employment status (F (2, 74) =.78, p =.38), currently taking psychiatric medications (F (2, 74) =.59, p =.46), history of psychiatric diagnosis (F (2, 74) = 1.79, p =.19), history of attempted suicide (F (2, 74) =.07, p =.79), and history of psychiatric hospitalization (F (2, 74) =.004, p =.95). These results indicate that there were not significant mean differences on post-treatment PTG after controlling for pre-treatment PTG for these variables. Personal and cultural variables. ANCOVAs were conducted to determine if mean differences between groups varied for post-treatment PTG after controlling for pretreatment PTG for variables related to dichotomous personal and cultural variables. ANCOVAs were conducted for current religion (F (2, 74) <.01, p =.98), belonging to a religious organization (F (2, 74) = 1.19, p =.16), attending a religious group (F (2, 74) = 2.33, p =.13), language preference (F (2, 74) =.28, p =.60) and US born (F (2, 74) =.39, p =.54). Correlations with a sample size of 77 were conducted to determine if there were significant relationships between post-treatment PTG and continuous personal and cultural continuous variables. Age (r = -.01, p =.97), years lived in the US (r = -.13, p =.27) and age when moved to the US (r =.13, p =.27) were not significantly correlated with post-treatment PTG.

60 48 Clinical variables. Correlations with a sample size of 77 were conducted to determine if there were significant relationships between post-treatment PTG and continuous pre-treatment clinical variables. Number of types of traumas experienced (r =.10, p =.38), number of types of interpersonal traumas experienced (r =.07, p =.57), pretreatment depression symptoms (r = -.06, p =.62), pre-treatment anxiety symptoms (r =.03, p =.81), and pre-treatment PTSD symptoms (r =.09, p =.45) were not significantly correlated with post-treatment PTG. Treatment amount variables. Correlations with a sample size of 77 were conducted to determine if there were significant relationships between post-treatment PTG and treatment amount variables. Total minutes of intervention (r = -.001, p =.99), total minutes of TIR (r =.08, p =.48), and duration of treatment (r = -.13, p =.26) were not significantly correlated with post-treatment PTG. Post-treatment variable. A correlation was conducted to determine if there was a significant relationship between post-treatment PTG and post-treatment PTSD symptoms. Post-treatment PTSD symptoms was significantly correlated with post-treatment PTG (r (77) = -.33, p <.01). Differences between groups on language and treatment endpoint. ANOVAs and Chi-square analyses were used to explore mean differences between groups for language and treatment endpoint with all variables included in the hierarchical multiple regression analysis. For attending religious organization, there was no mean difference between groups based on language (Spanish and other) utilizing Chi-square analysis (χ2 (1) =.31, p =.33). For pre-treatment PTG (F (1, 75) =.75, p =.39), number of types of trauma (F (1, 75) = 1.03, p =.31), minutes of intervention (F (1, 75) = 1.18, p =.28),

61 49 minutes of TIR (F (1, 75) =.33, p =.57), duration of treatment (F (1, 75) = 2.21, p =.14), post-treatment PTG (F (1, 75) = 1.19, p =.28), and post-treatment PTSD symptoms (F (1, 75) =.66, p =.42), there were no mean differences between groups for language based on ANOVAs. Eight participants were included in the analysis that completed treatment, but only had pre-treatment and mid-treatment assessments. ANOVAs and Chi-Squared analyses were conducted to determine if there were mean differences for the mid-test only versus post-test groups on any of the variables included in the analyses. There were mean differences for minutes of intervention (F (1, 75) = 13.12, p =.001), minutes of TIR (F (1, 75) = 5.61, p =. 02), and duration of treatment (F (1, 75) = 9.16, p =. 003) based on ANOVAs. These results indicated that participants with mid-treatment assessments received lower amounts of treatment than participants with post-treatment assessments. Mid-treatment only participants also had higher end treatment scores for PTSD symptoms than post-treatment participants (F (1, 75) = 16.76, p <.001). There were no other mean differences on demographic variables, clinical variables or variables included in the hierarchical linear regression. For employment status (χ2 (1) =.31, p =.47), attending religious group (χ2 (1) =.35, p =.4), language preference (χ2 (1) =.20, p =.26), and born in US (χ2 (1) =.80, p = 1.00) there were no significant differences between groups based on Chi-square analyses. For age (F (1, 75) = 2.57, p =.11), age moved to US (F (1, 75) =.06, p =.81), time in US (F (1, 75) = 1.21, p =.27), number of types of trauma (F (1, 75) =.04, p=.85), pre-treatment PTSD symptoms (F (1, 75) =.00, p =.99), pre-treatment depression symptoms (F (1, 75) =.38, p =.54) pre-treatment anxiety symptoms (F (1, 75) =.06, p =.81), pre-treatment PTG (F (1, 75) =.41, p =.53)

62 50 and post-treatment PTG (F (1, 75) =.36, p =.55) there were no significant mean differences between mid-treatment only and post-treatment participants using ANOVAs. Due to only minor differences between groups, these 8 participants were included in the analysis, and their mid-treatment assessments were considered post-treatment assessments. Assumptions The following assumptions were investigated to assure that the hierarchical linear regression model was properly specified: the dependent variable is a linear function of the independent variables (linearity), each participant is drawn independently from the population (independence of errors), all variables are identified appropriately for the model (model properly specified), errors are normally distributed (normality of errors), and errors have equal variance at all values of the independent variables (homoscedasticity of errors). Linearity. Scatterplots of all the pairs of the independent and the dependent variables were visually examined. None of the scatterplots show any deviation from the linear relationship between variables. Normality of errors. The normality of errors was evaluated by examining the distribution of the residuals. The histogram and P-P plots of residuals suggested that normality of errors can be assumed. Independence of errors. Although it is possible that there could be concerns regarding independence (i.e., individuals that know each other participating in the study), independence of errors is unlikely as it is not typical for more than one adult family member to receive treatment at the agency where data was collected. Due to the nature of

63 51 a de-identified data set as required by HIPAA waiver and IRB approval, this assumption could not be investigated more closely. The participants were not recruited through their own connections or relationships, therefore this assumption is assumed. Homoscedasticity of errors. A scatterplot of standardized residuals and standardized predicted values was analyzed to check the homoscedasticity of errors. A relatively equal range of residuals across the predicted values showed that the homoscedasticity of errors can be assumed. Model properly specified. All variables were chosen for analysis based on previous literature and theory, as well as a number of preliminary analyses using correlations, ANCOVA and paired t-tests, as described previously. Multicollinearity. Tolerance was greater than.1 and the variance inflation factor was less than 10 for all independent variables, suggesting that multicollinearity was not an issue. Reliability of measures. Cronbach s alpha was obtained for the pre-treatment and post-treatment measures PTGI English version, PTGI Spanish version and PCL. Internal reliability analyses were also conducted for pre-treatment measures CAS and CESD. The Posttraumatic Growth Inventory English version consisted of 21 items and the analyses was conducted for the participants that completed the measure in English. The Cronbach s alpha was.95 at pre-treatment, and.96 at post-treatment. The Posttraumatic Growth Inventory Spanish version consisted of 13 items as recommended by Weiss and Berger (2006) and Cronbach s alpha was calculated for participants that completed the measure in Spanish (pre-treatment α =.90; post-treatment α =.96). The Posttraumatic Stress Disorder Checklist Civilian version is a 17 item measure (pre-

64 52 treatment α =.93; post-treatment α =.96). The Clinical Anxiety Scale is a 25 item measure (pre-treatment α =.91). The Center for Disease Control Depression Scale is a 20 item measure (pre-treatment α =.92). All variables have a Cronbach s alpha value above.80, which is considered to be reasonable in social science (George & Mallery, 2003). Power analysis. A post hoc test of power was conducted via G*Power, to determine the power achieved in this study for the hierarchical linear regression. Effect size (f 2 =.02 to.1), alpha error probability (.05), total sample size (77) and number of predictors (7). Assuming a small effect size ranging from f 2 =.02 to.1 this study achieved an estimated power of.1 to.4. This is a low level of power for the hierarchical linear regression analysis. A power level of.95 is typically aimed for as to have an appropriate level of power to accurately identify relationships between variables. A low level of power decreases the likelihood of identifying a statistically significant effect. Results from Hierarchical Linear Regression Analysis Choice of predictors. Theory, previous empirical studies and preliminary analyses were utilized to determine the variables included in the hierarchical regression model. All variables were carefully considered for inclusion while also balancing the importance of parsimony and limited power for the hierarchical regression analysis. Variables were investigated for inclusion in the analysis to control for the level of functioning and psychopathology of participants. All variables investigated as control variables, including employment status, currently taking psychiatric medications, history of psychiatric diagnosis, history of suicide attempt, history of psychiatric hospitalizations, did not have any mean group differences for post-treatment PTG. Because no variables

65 53 had mean differences for post-treatment PTG, they were not included in the hierarchical multiple regression. Next, cultural and religious variables were investigated to determine if they predicted post-treatment PTG. All variables investigated as cultural variables, including language, country of origin, time in US, age when moved to US, identifying as Catholic or Christian, belonging to a religious organization and attending religious services were not associated with post-treatment PTG. There was no previous research that cultural variables of language or country of origin within Latino populations were associated with PTG, so those variables were not included. Although measures of religion were not found to be significantly related to post-treatment PTG in preliminary analyses, previous literature found that religiosity was a significant predictor of PTG (Berger & Weiss, 2006). For this reason, attending religious services was included as a measure of religiosity. This variable was chosen as a measure religious social support and discussion of religious issues that may occur during religious services. Next, measures of trauma were investigated for inclusion in the analysis. All measures of trauma, including number of types of trauma and number of types of interpersonal trauma, were not significantly correlated with post-treatment PTG. Although not found to be statistically correlated, number of types of trauma was included in the analysis due to a theoretical connection between amount of traumas experienced, level of emotional distress and levels of PTG (Calhoun, Cann, & Tedeschi, 2010; Hetzel-Riggin & Roby, 2013). Pre-treatment levels of clinical symptoms (PTSD, depression and anxiety) were evaluated for inclusion in the regression to account for pre-treatment levels of clinical distress. They were not included in the regression, as they were not significantly correlated with post-treatment PTG and there is no specific previous research or theory indicating their relationship with PTG.

66 54 Variables measuring the amount of treatment were evaluated for their relationship to pretreatment PTG, including minutes of total services received, minutes of TIR and duration of treatment. Although none of these variables were found to be significantly associated with post-treatment PTG, all three measures of amount of treatment were includes as they were a key focus of this study. Finally, post-treatment PTSD symptoms was investigated due to previous literature indicating that PTSD symptoms and PTG may be associated (Knaevelsrud, Liedl, & Maercker, 2010). Post-treatment PTSD symptoms were found to be significantly negatively correlated to post-treatment PTSD and was included in the analysis. A hierarchical linear regression was conducted to determine if post-treatment posttraumatic growth could be predicted from pre-treatment posttraumatic growth, attending religious services, number of types of trauma, amount of treatment received, and post-treatment posttraumatic stress disorder symptoms. The null hypotheses tested were that the multiple R 2 coefficients were equal to 0 and that the regression coefficients were equal to 0. Block 1 was comprised of pre-treatment PTG score. Block 2 included the variable from block 1, pre-treatment PTG, and added attending religious services (dummy variable). Block 3 included variables from block 3 and added number of types of trauma. Block 4 included variables from block 3 and added total minutes of services, minutes of TIR and duration of treatment. Block 5 included variables from block 4 and added posttreatment PTSD symptoms. No interaction terms were included based on preliminary analyses.

67 55 As shown in table 2, the summaries for each model predicting post-treatment posttraumatic growth are as follows. For block 1 with one independent variable, the overall model was not significant, F (1, 75) = 3.7, p =.058, R 2 =.05. For block 2 with two independent variables, the overall model was not significant, F (2, 74) = 3.05, p =.053, R 2 =.08. It was found that the variables added to block 2 did not significantly explain the additional variance in the outcome variable, ΔF (1, 74) = 2.33, p =.13, ΔR 2 =.03. For block 3 with three independent variables, the overall model was not significant F (3, 73) = 2.65, p =.055, R 2 =.10 and the variable added to block 3 did not significantly explain the additional variance in the outcome variable, ΔF (1, 73) = 1.8, p =.18, ΔR 2 =.02. For block 4 with six independent variables, the overall model was not significant F (6, 70) = 1.91, p =.09, R 2 =.14. The three variables added to block 4 did not significantly explain the additional variance in the outcome variable, ΔF (3, 70) = 1.14, p =.34, ΔR 2 =.04. For block 5 with seven independent variables, the overall model was significant F (7, 69) = 3.78, p =.002, R 2 =.28. The overall results suggest that a significant proportion (28%) of the total variance in post-treatment PTG was predicted by pre-treatment PTG, attending religious services, number of types of traumas experienced, total minutes of services, minutes of TIR, duration of treatment and post-treatment PTSD symptoms. The variable added in block 5 significantly explained the additional variance in outcome, ΔF (1, 69) = 13.02, p =.001, ΔR 2 =.14. Therefore, block 5 was retained as a final model and discussed below. As shown in Table 2, for pre-treatment PTG, the slope (b =.25, SE =.10, β =.26) is statistically significant (t (69) = 2.42, p =.018); with each standard deviation increase in pre-treatment PTG, post-treatment PTG, on average, will increase by.26 of a standard

68 56 deviation, after controlling for all other variables in the model. For post-treatment PTSD symptoms, the slope (b = -.54, SE =.15, β=-.39) is statistically significant (t (69) = -3.61, p =.001); with each standard deviation decrease in post-treatment PTSD symptoms, posttreatment PTG, on average, will increase by.39 of a standard deviation, after controlling for all other variables in the model. Number of types of traumas was found to be a significant predictor, with a statistically significant slope (b =.13, SE =.05, β =.30, t (69) = 2.5, p =.02). This variable functions as a classical suppressor variable in this analysis (Pandey & Elliott, 2010; Pedhazur, 1982). A classic suppressor variable does not have a significant correlation with the outcome variable but increases the prediction of the overall model as well as the prediction of other independent variables by accounting for irrelevant predictive variance. In this analysis, number of types of trauma does not have a significant correlation with post-treatment PTG (r =.10, p =.38). Despite this nonsignificant correlation, the inclusion of the variable number of types of trauma increase the overall prediction of the model, as well as the predictive weight of pre-treatment PTG, total minutes of service, total TIR minutes, duration of treatment and post-treatment PTSD symptom. When number of types of trauma is removed from the analysis, the overall model prediction ability is decreased, F (6, 70) = 3.25, p =.007, R 2 =.22. Many of the independent variables also show a decrease in the coefficients when number of types of trauma is removed, including pre-treatment PTG (b =.21, SE =.10, β =.22, t (70) = 2.01, p =.048), total minutes of service (b =.000, SE =.000, β = -.10, t (70) = -.57, p =.57), total TIR minutes (b =.001, SE =.001, β =.17, t (70) = 1.00, p =.32), duration of treatment (b = -.003, SE =.002, β = -.15, t (70) = -1.34, p =.19) and post-treatment PTSD

69 57 symptom (b = -.43, SE =.15, β = -.31, t (70) = -2.91, p =.005). These results indicate that number of types of trauma acts as a classical suppressor variable in this analysis and therefore increases the predictive weight of the model and other independent variables. Because it is a suppressor variable, it is defined by its effects on other variables and not on its own weight in the analysis (Pandey & Elliott, 2010). Because of this, the regression coefficient should be interpreted as accounting for variance associated with the independent variables, not the outcome variable. All other predictors in model 5 were not statistically significant, as indicated in Table 2.

70 Chapter 5: Discussion The purpose of this study was to further examine PTG change during psychological treatment for Latinas in the U.S.. It examined potential predictors of PTG for Latinas in the U.S., including personal, cultural, clinical and treatment variables. To date, there has not been a study focusing on this topic and population. Additionally, there has been relatively little research on Latinas in the U.S. and PTG, as well as how PTG changes during treatment for various populations. Further investigation in PTG change during treatment for Latinas in the U.S. would bridge the limited research on PTG change during treatment as well as how cultural issues may impact PTG for Latinas in the US. More information could help clinicians provide optimal treatment and shape policy regarding mental health to promote growth and healing in Latinas in the United States. This results of this study provided valuable information about the sample, as well as predictors of PTG change for Latinas in psychological treatment. This sample was found to have high numbers of different types of trauma and began treatment with clinically significant levels of PTSD symptoms, and moderate levels of depression and anxiety. The results indicated that post-treatment PTSD symptoms and pre-treatment PTG were important predictors of post-treatment PTG. Low levels of post-treatment PTSD symptoms were associated with higher levels of post-treatment PTG, while high levels of pre-treatment PTG was predictive of high levels of post-treatment PTG. Number of types of trauma was found to be an important suppressor variable and strengthened the model by accounting for variance associated with other predictor variables. Some variables investigated were not significantly associated with post-treatment PTG, such as pre-treatment clinical symptoms, measure of religiosity and treatment amount variables. 58

71 59 This study provided a more complex understanding of Latinas in the U.S. that sought treatment in this mental health center. They reported a relatively high level of different types of traumas experienced, including physical abuse and sexual assault. They began treatment with moderate to high levels of PTSD symptoms, and moderate levels of anxiety and depression. Latinas in this sample reported moderate levels of PTG before beginning any psychological treatment, which is consistent with previous findings in a non-clinical Latina population (Berger & Weiss, 2006). It is important to note that many participants experienced clinically significant improvements in their PTSD symptoms from pre to post-treatment. The Reliable Change Index (RCI) was utilized to evaluate PTSD symptoms improvement as PTSD symptoms are the primary target for the psychological treatment provided (Jacobson & Truax, 1991). Sixty three (82%) participants had a clinically significant decrease in PTSD symptoms from pre to post treatment. Of the 14 (18%) that did not have a clinically significant decrease in PTSD symptoms, 6 started treatment with low levels of PTSD symptoms. It is also important to note that 6 of the 8 participants that only had a midtreatment assessment (and no end-treatment assessment) did not have clinically significant improvement in PTSD symptoms. Based on these results, the psychological treatment provided was effective in providing a clinically significant reduction in PTSD symptoms for Latina victims of interpersonal violence. Pre-treatment level of PTG was found to be a significant positive predictor of post-treatment PTG, after controlling for all other variables in the model. This is consistent with a previous study that found similar results (Knaevelsrud et al., 2010). It is also consistent with theoretical and empirical findings that the PTG process may begin

72 60 before psychological treatment begins (Frazier, Tashiro, Berman, Steger, & Long, 2004), and continue to increase during psychological treatment (Knaevelsrud et al., 2010). Post-treatment PTSD symptom was found to be a significant negative predictor of post-treatment PTG in all analyses. These results suggest that low levels of PTSD symptoms at the end of treatment may be important in order to have high levels of PTG at the end of treatment. This is consistent with earlier research that found that psychological treatment was effective in reducing PTSD symptoms as well as increasing PTG (Hagenaars & van Minnen, 2010; Knaevelsrud et al., 2010). Previous treatment research did not separately examine how post-treatment levels of PTSD related to posttreatment PTG and instead focused on PTSD and PTG change scores (Hagenaars & van Minnen, 2010; Knaevelsrud et al., 2010). Additionally, only one study looked at pretreatment and post-treatment PTSD and PTG as separate variables instead of relying on a change score (Knaevelsrud et al., 2010). By focusing on change scores instead of pre and post-treatment scores, previous research was unable to identify different effects of PTSD symptoms based on point in treatment. Due to separating pre and post-treatment scores on PTSD symptoms and PTG, the present study was able to identify different impacts of pre post-treatment PTSD symptoms. It was found that pre-treatment levels of PTSD are not predictive of post-treatment PTG, while low levels of post-treatment PTSD is associated with higher levels of post-treatment PTG. This way of analyzing the data provides more direct evidence that post-treatment PTSD symptoms may be critical negative predictor of post-treatment PTG, while pre-treatment PTSD symptoms may be less important.

73 61 Number of types of trauma was found to be a significant classical suppressor variable (Pandey & Elliott, 2010). Number of types of trauma did not have a significant correlation with post-treatment PTG, but its inclusion in the analysis was important as it accounted for extraneous variance related to other predictors and therefore strengthened the overall modal. Number of types of trauma may be an important variable to consider not for its direct effect on post-treatment PTG, but how it may influence other variables such as treatment amount, PTSD symptoms and pre-treatment PTG. It is also important to note that some variables were not significant predictors of post-treatment PTG, such as clinical, religiosity and treatment amount variables. Results from this study found that pre-treatment levels of PTSD, anxiety and depression symptoms did not predict post-treatment levels of PTG for this sample of participants. These results suggest that pre-treatment levels of symptoms may not dictate the level of healing that an individual experiences after completing treatment and even individuals with high levels of symptoms may experience high levels of PTG after psychological treatment. Religiosity was found to be a positive predictor of PTG in a prior study of Latinas in the U.S., but this was not the case with the current study (Berger & Weiss, 2006). In a previous study by Berger and Weiss (2006), religiosity was measured by affinity to religious beliefs, while in this study religiosity was measured as attending religious services regularly. It is possible that religious beliefs and world views regarding PTG are an important positive predictor of PTG for Latinas in the U.S., while social support found in attending religious services and increased exposure to religious ideas by attending religious services on a regular basis are not related to PTG. Further research that can

74 62 directly investigate how religiosity may be a predictor of PTG for Latinos in the U.S. will be important to understanding how cultural, religious and social issues may promote PTG. The amount of treatment a client received, measured by total minutes of all interventions, minutes of TIR, or duration of treatment, were not predictors of posttreatment PTG. It is possible that there were confounding variables that accounted for the null findings. Logistic complications that impacted clients ability to attend treatment, clinician variance and individual differences on time needed for processing trauma may have confounded the relationship between PTG and amount of treatment. Further research that incorporates measures of mechanism of change of PTG, such as rumination, may further elucidate the mechanisms PTG change during treatment. When understanding the results of this study in context of the current body of literature, it is important to understand that most previous research focuses on pretreatment PTG with Latinas (Berger & Weiss, 2006, 2010). All previous research on PTG in Latinas in the U.S. was only looking at general PTG, which was typically PTG prior to psychological treatment (Berger & Weiss, 2006, 2010; Roger, 2007). Predictors of general PTG may not be the same as predictors of PTG that develops after psychological treatment; therefore, more research on PTG during treatment specifically for Latinas will be critical to understanding cultural and social influences on PTG development. These results can help elucidate the development of PTG when applied to the sociocultural model of PTG (Please refer back to Figure 1). The findings of this study suggest that number of types of traumas experienced by Latinas in the U.S. may influence other factors related to PTG development, such as PTSD symptoms, amount of treatment

75 63 they receive and pre-treatment PRG. Latina victims of interpersonal violence may have already begun the process of PTG by the time they begin treatment, reflected by their moderate levels of PTG when they begin psychological treatment. Lower PTSD symptoms at the end of treatment may help the individual shift to from intrusive rumination to deliberate and purposeful rumination around the trauma. This purposeful rumination may lead to the flourishing of posttraumatic growth at the end of psychological treatment. Clinical Implications These findings have important implications for Latinas in the U.S. that are seeking psychological treatment for issues related to trauma. As is consistent with previous research and clinical knowledge of Latinas in the U.S., many show a great degree of growth prior to seeking treatment (Berger & Weiss, 2010; Cardoso & Thompson, 2010). Despite experiencing many traumatic events and significant psychological distressing symptoms, participants in this study also experienced moderate levels of growth. Clinicians can benefit from continuing to capitalize on the strengths of their Latina clients to engage in treatment and increase their growth. Pre-treatment levels of PTSD, depression and anxiety symptoms did not predict post-treatment PTG in the present study. This is heartening news for clients and providers alike, that clients with a range of severity of symptoms can benefit from TIR and other treatments to reduce clinical symptoms and increase PTG. This study suggests that an important piece of any treatment focusing on increasing PTG may be to first decrease symptoms of PTSD. Some researchers have focused on narrative therapies as the ideal treatment to increase PTG (Calhoun &

76 64 Tedeschi, 2006). This study suggest that a combination of exposure and narrative approaches, such as that found in the holistic treatment used in this study, may be a particularly effective method to promote PTG. This approach would first focus on reducing intrusive rumination, managing negative affect and then promote deliberate and reflective rumination. Limitations As with any study, the results and conclusions were limited by a number of factors. The sample size was a limitation of this study and caused the regression analyses to be under-powered. Associations between variables that had a small to medium effect size may not have been detected due to the low power in the regression analysis. Data collection is currently underway to increase the sample size for publication of this and other studies. Other limitations of this study are related to the ability to generalize these findings to other Latina trauma survivors. Although the Latina sample in this study was quite homogenous, there may be importance cultural differences between groups and based on current sociocultural context. It will be important for research in other areas of the United States to further understand the relationship between PTG and culturally diverse Latinas in the US. The results of this study may not generalize to other types of psychological treatment. The model utilized at the TRC is unique in terms of the holistic approach, method of trauma treatment (TIR) and client centered approach. Other psychological treatment approaches may have different outcomes in terms of PTG for Latina trauma survivors. The data was collected from clinical files from a community agency; therefore, certain variables were not explored in detail such as religiosity, social support and

77 65 mechanisms of change. Additional research with more nuanced measures of religion, social support and cultural values would be important to help understand how culture impacts the process of PTG for Latinas in the U.S.. This study did not have any direct measures of mechanisms of change which would help elucidate how PTG change occurs during psychological treatment. Finally, this study found only a small set of significant predictors for posttreatment PTG, which limited the hierarchical linear regression results and interpretation. A future analysis, with a larger sample, could utilize path modeling to better understand the relationships among variables instead of focusing solely on post-treatment PTG. This may provide more comprehensive information regarding the relationship between trauma, treatment, PTSD symptoms and PTG. Future Research Recommendations This study points to various areas of research that would allow for better understanding of PTG for Latina trauma survivors psychological treatment. Based on this exploratory study, some areas of PTG for Latina trauma survivors in psychological treatment remain to be well understood. Firstly, further investigation into the mechanism of change for PTG for Latina trauma survivors in treatment would be helpful to better understand this process. Future studies utilizing self-report and performance based measures of rumination and attention given during psychological treatment may elucidate the underlying mechanisms of PTG development. Secondly, further research into the complexities of how various cultural factors impact PTG development for Latinas is needed in order to understand this multi-faceted and nuanced process. In-depth qualitative research focusing on Latinas that have experienced PTG and have received

78 66 treatment may also be a meaningful approach to help understand the nuanced relationship between trauma, culture and growth. A Call for Community-Based Research The approach utilized in this dissertation is one example of how innovative community-university partnerships can promote community-based research. This dissertation is only one product of this community-university partnership, which included many processes and products during its development. As part of the process, researchers and community agency providers collaborated to streamline the assessment process for clients and include new measures to better address clinical needs and areas of research interest. Community partners were able to provide valuable insight and direction for areas of research that would help guide and improve the clinical services that they provide. The data collection from this partnership will be able to provide important information regarding healing, growth and trauma that highlights the complexity and nuance of the clinical and personal characteristics of the people receiving treatment at this community agency. Ongoing research collaboration is based on outcomes specific to the communities involved and is responsive to their unique challenges and strengths. This way of engaging in research requires a long-term perspective but serves the function of allowing the expertise of community partners to guide the research process, incorporates opportunity for community members and research participants to learn from and benefit from the results of the research, and anchors the research in current practices and sociocultural contexts. While many types of community-based research exist, this study services as an example of benefits and challenges of community-university partnerships for research and social change.

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86 74 Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), doi: /s pli1501_01 Thornton, A. A., Perez, M. A., & Meyerowitz, B. E. (2005). Posttraumatic growth in prostate cancer patients and their partners. Unpublished Data. Tomich, P. L., & Helgeson, V. S. (2004). Is finding something good in the bad always good? Benefit finding among women with breast cancer. Health Psychology, 23(1), doi: / Urcuyo, K. R., Boyers, A. E., Carver, C. S., & Antoni, M. H. (2005). Finding benefit in breast cancer: Relations with personality, coping, and concurrent well-being. Psychology & Health, 20(2), doi: / Valentine, P. V. (1997). Traumatic Incident Reduction: Brief treatment of trauma-related symptoms in incarcerated females. (Doctoral Dissertation), Retrieved from Proquest Information & Learning. Valentine, P. V. (2002). Traumatic Incident Reduction: Moving beyond the wreckage of lives. In C. R. Figley (Ed.), Brief treatments for the traumatized: A project of the Green Cross Foundation (pp ). Westport, CT US: Greenwood Press/Greenwood Publishing Group. Valentine, P. V., & Smith, T. E. (2001). Evaluating Traumatic Incident Reduction therapy with female inmates: A randomized controlled clinical trial. Research on Social Work Practice, 11(1), doi: / Wagner, B., Knaevelsrud, C., & Maercker, A. (2007). Post-traumatic growth and optimism as outcomes of an internet-based intervention for complicated grief. Cognitive Behaviour Therapy, 36(3), doi: / Weiss, T., & Berger, R. (2006). Reliability and validity of a Spanish version of the Posttraumatic Growth Inventory. Research on Social Work Practice, 16(2), doi: / Weiss, T., & Berger, R. (2010a). Posttraumatic growth and culturally competent practice: Lessons learned from around the globe. Hoboken, NJ US: John Wiley & Sons Inc. Weiss, T., & Berger, R. (2010b). Posttraumatic growth around the globe: Research findings and practice implications. In T. Weiss & R. Berger (Eds.), Posttraumatic growth and culturally competent practice: Lessons learned from around the globe. (pp ). Hoboken, NJ US: John Wiley & Sons Inc.

87 75 Widows, M. R., Jacobsen, P. B., Booth-Jones, M., & Fields, K. K. (2005). Predictors of posttraumatic growth following bone marrow transplantation for cancer. Health Psychology, 24(3), doi: / Yalom, I. D. (1980). Existential psychotherapy. New York, NY US: Basic Books. Zang, Y., Hunt, N., & Cox, T. (2013). A randomised controlled pilot study: The effectiveness of narrative exposure therapy with adult survivors of the Sichuan earthquake. BMC Psychiatry, 13. doi: / X Zoellner, T., & Maercker, A. (2006). Posttraumatic growth and psychotherapy. In L. G. Calhoun & R. G. Tedeschi (Eds.), Handbook of posttraumatic growth: Research & practice. (pp ). Mahwah, NJ US: Lawrence Erlbaum Associates Publishers.

88 FIGURES Figure 1 The sociocultural model of posttraumatic growth.. From The posttraumatic growth model: Sociocultural considerations, by L.G. Calhoun, A. Cann and R.G. Tedeschi, 2010, in T. Weiss and R. Berger (Eds), Posttraumatic growth and culturally competence practice: Lessons learned from around the globe, p.6. Copyright 2010 by John Wiley & Sons, Inc. 76

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90 78 Table 2 Regression Coefficients and Model Summary of Predictors of Posttraumatic Growth after Treatment Block Variable ββ b (SE) R 2 ΔR 2 ΔF Block 1 Pre PTGI (.11) Block 2 Pre PTGI (.11) Attend Religious (.26) Organization Block 3 Pre PTGI (.11) Attend Religious (.26) Organization Number types of traumas (.05) reported Block 4 Pre PTGI.24*.23 (.11) Attend Religious (.26) Organization Number types of traumas (.06) reported Total minutes of services (.00) Total minutes of TIR (.00) Total duration of treatment (.00) Block 5 Pre PTGI.26*.25 (.10)*.28*.14* Attend Religious (.24) Organization Total types of traumas.30*.13 (.05)* reported Total minutes of services (.00) Total minutes of TIR (.00) Total duration of treatment (.00) Post PTSD -.39** -.53 (.15)** Pre-PTGI: Pre-treatment Posttraumatic Growth Inventory score; Total of minutes of services: sum of all minutes of individual, group and complementary services; Post PTSD: Post-treatment score on the PCL. * significant at p <.01, ** significant at p <.001

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133 APPENDIX C. MEASURE PACKET ENGLISH TRAUMA RESOLUTION CENTER Measurement Summary Form 2013 Client name: 1st Test (Pre) 2nd Test (Control) 3rd Test (Mid) 4th Test (Post) Date of Testing: PTSD Self Assessment Scale PTGI CAS CES-D Please fill out when client completes Type of Crime: Total Clinical Hours: Total TIR Hours: Counselor: Date: 121

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138 126 CAS Bruce A. Thyer This questionnaire is designed to measure how much anxiety you are currently feeling. It is not a test so there are no right or wrong answers. Answer each item and carefully and as accurately as you can by placing a number beside each one as follows: 1 = Rarely or none of the time 2 = A little of the time 3 = Some of the time 4 = A good part of the time 5 = Most of all of the time 1. I feel calm. 2. I feel tense. 3. I feel suddenly scared for no reason. 4. I feel nervous. 5. I use tranquilizers or antidepressants to cope with my anxiety. 6. I feel confident about the future. 7. I am free from senseless or unpleasant thoughts. 8. I feel afraid to go out alone. 9. I feel relaxed and in control of myself. 10. I have spells of terror or panic. 11. I feel afraid in open spaces. 12. I feel afraid I will faint in public. 13. I am comfortable traveling on public transportation. 14. I feel nervousness or shakiness inside. 15. I feel comfortable in crowds. 16. I feel comfortable when I am left alone. 17. I feel afraid without good reason. 18. Due to my fears, I unreasonably avoid certain animals, objects, of situations. 19. I get upset easily or feel panicky unexpectedly. 20. My hands, arms, or legs shake or tremble. 21. Due to my fears, I avoid social situations, whenever possible. 22. I experience sudden attacks of panic which catch me by surprise. 23. I feel generally anxious. 24. I am bothered by dizzy spells. 25. Due to my fears, I avoid being alone, whenever possible.

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140 APPENDIX D. MEASURE PACKET SPANISH TRAUMA RESOLUTION CENTER Measurement Summary Form 2013 Client name: 1st Test (Pre) 2nd Test (Control) 3rd Test (Mid) 4th Test (Post) Date of Testing: PTSD Self Assessment Scale PTGI CAS CES-D Please fill out when client completes Type of Crime: Total Clinical Hours: Total TIR Hours: Counselor: Date: 128

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145 133 CAS Este questionario está designado para medir que cantidad de anxiedad usted tiene ahora. No es prueba; no hay malas respuestas. Conteste cada uno con cuidado y lo más correcto que pueda. Ponga el numero al lado de cada uno uzando la siguiente clave: 1. Me siento en calma. 2. Me siento tenso(a). 1 = Raro o poco del tiempo 2 = Poco del tiempo 3 = Parte del tiempo 4 = Mucho del tiempo 5 = Todo el tiempo 3. De repente (por ninguna razon) me siento asustado(a). 4. Me siento nervioso(a). 5. Uso tranquilizantes o antideprimientes para hacerle frente a la ansiedad. 6. Me siento confidente sobre el futuro. 7. Me siento libre de malos pensamientos (o pensamientos inconsientes). 8. Me siento temoroso(a) salir de mi casa solo(a). 9. Me siento relajado(a) y que tengo control de mi vida. 10. Tengo ratos de terror o pánico. 11. Me siento temoroso(a) de los espacios abiertos o de estar en las calles. 12. Me siento temoroso(a) de que me voy a desmayar en público. 13. Estoy cómodo(a) viajando por autobus, tren subterraeno, o en tren regular. 14. Me siento nervioso(a) o tembloroso(a) por dentro. 15. Me siento cómodo(a) en muchendumbres, como yendo de compras o en el cine. 16. Me siento cómodo(a) cuando estoy solo(a). 17. Pocas veces me siento temoroso(a) sin razón. 18. Por mis temores, sin razón evito algunos animales, objetos o situaciones. 19. Me pongo aterrorizado(a) inesperadamente. 20. Mis manos, brazos o piernas tiemblan. 21. Por mis miedos, evito situaciones sociales cuando sea possible. 22. De repente experimento ataques de pánico que me sorprenden. 23. Me siento ansioso(a) generalmente. 24. Me molestan mareos. 25. Por mis miedos, evito estar solo(a) cuando es possible.

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147 APPENDIX E. QUALIFICATION FORMS - ENGLISH TRAUMA RESOLUTION Trauma Resolution Center Client Funding Qualification Form The information on this form is used to assign the appropriate funding source for your case. Clients Name: Date: If client is a child please include legal guardians name. Name Relationship Is the client a crime victim? Yes\ No Was there a police report? Yes\ No When did the incident occur? If yes, when was it filed? / / Does the client have the police report? Yes\ No Does the report indicate an injury? Yes/ No Does the client live in the City of Miami Beach? Yes/ No Was the client referred by Legal Aid? Yes/ No Was the client referred by Americans for Immigrant Justice (AIJ)? Yes/ No Including yourself, how many people reside in your household? (If you live in a residential program what was the number of people living with you before the program? What is the combined annual income for household? What form of transportation will you be using to get to TRC? Automobile Public transportation Other How many children under the age of 18 do you have? Do you currently have sole or joint custody of your children? Yes/ No Are you currently pregnant? Yes/ No Are you currently receiving Disability or Social Security Benefits? Yes/ No Is the client a victim of a sexually related crime? Yes\ No If yes, please circle. Sexual Assault Sexual Battery Rape Childhood Molestation Other Funding Source: VWF VC AIJ-VAWA VAWA-State SFBHN AIJ-CT AIJ-H CVAC Medicaid Self Pay 135

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154 APPENDIX F. QUALIFICATION FORMS SPANISH TRAUMA RESOLUCION EDUCACION EMPOWERMENT Trauma Resolution Center Client Funding Qualification Form La información en este formato es utilizada para asignar los recursos monetarios apropiados para su caso. Nombre del Cliente: Fecha: Si el cliente es un niño incluya el nombre de su representante legal: Nombre: Relación: Es el cliente víctima de crímen? Si\ No Hubo un Reporte Policial? Si\ No Cuándo ocurrió el incidente? Si es si, cuándo fue archivado? / / Tiene el cliente el Reporte Policial? Si\ No Indica el Reporte alguna herida? Si/ No Vive el cliente en la ciudad de Miami Beach? Si/ No Fue referido el cliente por Legal Aid? Si/ No Fue referido el cliente por Americans for Immigrant Justice (AIJ)? Si/ No Incluyéndose usted, cuántas personas viven en su casa? (Si usted vive en un Programa Residencial, cuántas personas vivieron con usted antes del programa? Cuánta es la entrada económica total (combinada) en su casa? Cuál es el tipo de transporte para llegar a TRC? Carro Autobus Otro Cuántos niños menores de 18 años tiene usted? Tiene usted actualmente guardia y custodia individual o en conjunto de sus niños? Si/ No Está usted actualmente embarazada? Si/ No Está usted actualmente recibiendo alguna ayuda por incapacidad o algún beneficio de incapacidad por el Seguro Social (SSI/SSA)? Si/ No Es usted víctima de un crimen relacionado con sexo? Si\ No Si es si por favor circule:. Asalto Sexual Herida Sexual Violación Molestias Sexuales en la Infancia Otros Recursos Monetarios: VWF VC AIJ-VAWA VAWA-STATE SFBHN AIJ-CT AIJ-H Medicaid CVAC Self Pay 142

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157 145 Trauma Resolution Center 3000 Biscayne Blvd. Suite 210 Miami, FL Tel Fax DECLARACION DE DERECHOS DE NUESTROS CLIENTES Yo,, como cliente del Centro de Servicios para Victimas entiendo mis derechos. Mis preguntas e inquietudes sobre estos derechos han sido explicadas a mi entera satisfacción. Mi derecho a que los servicios sean suministrados por un representante que ha sido entrenado para entender mis necesidades. Mi derecho a la confidencialidad, excepto en aquellos casos en que mi vida o la de otros esté en peligro, o se conozca que un niño o un anciano estén siendo abusados. Mi derecho a ser tratado en forma educada y amistosa. Mi derecho a ser referido a otras agencias, si mis requerimientos y/o necesidades son diferentes a las que pueda suministrar el centro de servicios para víctimas. Mi derecho a sentirme seguro. Mi derecho a expresar desacuerdos o reclamos por escrito, personalmente o por teléfono a la Directora Ejecutiva o a la Directora Clínica sobre el comportamiento de alguno de los representantes del centro. Firma del Cliente Fecha Padre o Representante Fecha Testigo Fecha

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159 147 Informacion General Investigación: Yo estoy de acuerdo en participar en la investigación que está siendo conducida por el Centro y Servicio de Victimas. (también llamada VSC). Este tratamiento consiste en la Reduccion de Incidentes Traumáticos (TIR) para reducir los efectos del trauma. Yo entiendo que los resultados de mi examen pueden ser parte de un estudio conducido por investigadores capacitados. Beneficios y Riesgos: Este tratamiento me ha sido explicado en detalle por una persona calificada del VSC. Haciendo el tratamiento posiblemente puede reducirse o eliminarse los síntomas que han sido asociados con el trauma. Un riesgo del tratamiento es que no sea efectivo al reducir o eliminar los síntomas asociados con el trauma. Los tratamientos en sesiones se dan semanalmente y la duración de cada sesión es de una hora o más. Yo entiendo que mi participacion en este servicio es estrictamente voluntaria y puede terminar cuando yo quiera. Confidencialidad: Toda la información que yo haya dado a VSC es confidencial, al menos que yo le diga a un consejero que me quiero hacer daño o le quiero hacer daño a otra persona, o que estoy abusando de una persona que es menor de edad. La ley de la Florida requiere que una persona que sepa, o tenga motivos para sospechar, que una persona menor de edad está siendo abusada, debe reportarlo al registro central de abuso del estado (FS ). Acuerdo: Para obtener los beneficios de el tratamiento, estoy de acuerdo en venir a las sesiones en buenas condiciones, estando reposado y que voy a estar disponible al menos una vez por semana durante dos horas, y voy a llamar si me es imposible venir. No voy a beber alcohol 24 horas antes de mi sesión ni usar drogas que no me hayan sido recetadas por un doctor. Yo entiendo que los grupos informativos forman una parte integral en el programa. También entiendo que todos los clientes requieren asistir el grupo sobre la psicobiología del trauma, que se presenta mensualmente. Los clientes de Violencia Doméstica tienen que asistir a la series de cuatro grupos que se ofrecen cubriendo todos los aspectos de Violencia Doméstica y la psicobiologia. Todos los clientes deben asistir a estos grupos antes de comenzar con sus sesiones individuales. Responsabilidad Financiera: Yo autorizo al VSC a dar cualquier información necesaria durante el proceso de la reclamación de pagos. Los honorarios por los servicios prestados de VSC serán presentados al estado de la Florida, Crimes Compensation Bureau para su pago correspondiente. Yo entiendo que el estado de la Florida, Crimes Compensation Bureau es un provedor que será el ultimo recurso. Si por cualquier razón mi aplicación al Crimes Compensation Bureau es rechazada, yo soy completamente responsable en pagar los honorarios a VSC. Fecha Fecha Cliente Nombre del cliente Testigo

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161 APPENDIX G. ADMINISTRATIVE FORMS 149

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