Using Brief Interventions to Prevent Teen Dating Violence
Articles,  Blog

Using Brief Interventions to Prevent Teen Dating Violence

MARY JO GIOVACCHINI: Good afternoon, everyone,
and welcome to today’s webinar, “Using Brief Interventions to Prevent Teen Dating Violence,” hosted by the National Institute of Justice. At this time, I would like to introduce you to Dr. Carrie Mulford of the National Institute of Justice. DR. CARRIE MULFORD: Thank you, Mary Jo. So, we have a fantastic lineup of
researchers and interventionists to talk about a variety of brief interventions to prevent
teen dating violence today. I want to start off by thanking all of you
for your interest in this topic and by thanking the Federal Interagency
Workgroup on Teen Dating Violence, particularly Mao Yang and Becky Odor at the
Administration for Children and Families, for hosting this webinar series with us. For the past – for the past several years,
to commemorate Teen Dating Violence Awareness Month in February, we have done
research webinars similar to this one. This year, we’re changing the format up a bit to better highlight the practitioner experience in delivering interventions that have been evaluated
through research at the National Institute of Justice. The first half of the webinar will be more
of a traditional presentation format. You’ll hear from our panelists about the interventions that they’ve developed, delivered, and evaluated. Then I’m going to lead a moderated discussion
with all the panelists, followed by a participant Q&A which Mary Jo described to
you – how to submit your questions for … and we’ll try to get to as many questions
as we can in the final segment of the webinar. And if we don’t get to your questions, we
will try to respond to most of those individually if we – if we can do that. Let me start off by introducing
myself and our panelists. My name is Carrie Mulford. I’m a social science analyst at NIJ and I’ve
been here for 14 years. I’ve been doing teen dating
violence work since 2005, so most of the time I’ve been here,
I’ve been doing this work. I’m a psychologist by training. And the National Institute of
Justice is a research funding agency and we’ve spent – since 2008, we’ve spent $18
million on teen dating violence research, primarily in two areas, intervention research
and longitudinal research, although we’ve done
a number of other types of studies as well. So, this webinar highlights some of our intervention work, obviously. The first speaker we’re
going to hear from is Emily – Dr. Emily Rothman, who’s an associate professor at the
Boston University School of Public Health. Her area of research expertise is adolescent
dating abuse and sexual assault. Before becoming a researcher, she worked at a domestic violence shelter and for two different
types of batterer intervention programs. Those experiences on the frontlines inspired
her to think about creating more effective approaches to prevention –
to preventing perpetration in particular. Emily’s going to be
followed by Sarah DeCosta. Sarah was a research assistant and an interventionist
with Boston University School of Public Health, working on the Real Talk project
that Emily’s going to talk about. She worked in the domestic violence field for 13 years in both intervention and
prevention capacities. Eight of those years were
spent working with youth specifically, and she’s currently the program director of after-school
and camp programming for a local school district. Then we’re going to hear from Dr. Elizabeth
Miller, who is a professor in Pediatrics, Public Health, and Clinical and Translational Science at the University of Pittsburgh School of
Medicine and director of the Division of Adolescent and Young Adult Medicine, Children-
Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center. Well, Liz,
that’s a long title! Trained in internal medicine and pediatrics
and medical anthropology, she has over 15 years of practice and research
experience in addressing interpersonal violence prevention and adolescent health
promotion in clinical and community settings. Liz is going to be followed by Lisa James. Lisa is the Director of Health at Futures
Without Violence, a 30-year-old health and social justice organization working to
end violence against women and children. With her team, she implements
the National Conference on Health and Domestic Violence, the National
Health Resource on Domestic Violence, as well as a number of multistate initiatives
working to bring domestic violence and health care professionals together to improve the
health and safety of survivors and promote violence prevention. The last of our panelists will be Janice Goldsborough,
who has a – has been a medical advocate at the Women’s Center and Shelter
of Greater Pittsburgh since 2007. The Women’s Center and Shelter has been
operational in the community for over 40 years, serving women and children who are
victims of domestic violence. As a medical advocate, Janice acts as the
liaison between Women’s Center and Shelter clients and the medical
community in the city of Pittsburgh in terms of one-on-one crisis intervention for victims as well as providing outreach and education
for medical professionals. Our participant question-and-answer session’s
going to be led by my colleague, Mao Yang, who’s a senior program specialist at the Family Violence Prevention and Services Act Program in the Administration for Children
and Families. She manages federal grants and programs related to children, youth, and abused parents. She also co-leads the Federal Agency Workgroup on Teen Dating Violence with NIJ. Okay. So, we’re going to start the discussion today
with Emily Rothman. Emily, I’m going
to ask you a couple of questions that I think you’re queued up to provide answers to. First, can you talk about the Real Talk program, tell us about the intervention and what made
you think this intervention might work, who are you delivering the intervention to, and what has the research shown so far about
how well the intervention is working? DR. EMILY ROTHMAN: Great. Absolutely. Thank you so much for having me. I’m really excited to talk to you about this intervention. And, as I get started, I’d like to thank my
coauthors who are listed on this … on the first slide. I would also like to thank Carrie
Mulford of the National Institute of Justice for the funding for this project, and mention as well that there was a precursor intervention
developed through a K01 grant that I had from the National Institute of Health, and Robert
Freeman, my project officer, who was also extremely helpful and supportive as that was going on. So, I’ll start by saying that why did we decide
to do this one-on-one intervention with youth who’d perpetrated dating violence in a hospital setting? When I started thinking about this,
which was probably in about 2004, there had been some randomized control trials,
evidence for what I would call primary prevention programs – Safe Dates, Shifting
Boundaries, Fourth R, now we have Coaching Boys Into Men – many programs that are
implemented in school settings. And there was a meta-analysis, done in 2017, of 23 different studies of dating abuse prevention
programs by Lisa De La Rue and Dorothy Espelage, and they found out that while these
programs that are offered, you know, someone’s trained, they go into a school classroom
maybe, and they deliver education to everyone sitting in front of them that they
can influence dating violence knowledge and attitudes. But they said, however, to date, the results
for dating violence perpetration and victimization behavior indicate the programs are not affecting these behaviors to a significant extent. So, the question in front of me was, “Is there
something that we can do, maybe in another setting and that isn’t primary
prevention that might get us a little bit further?” So, people may have heard of SBIRT, that stands
for Screening, Brief Intervention, and Referral to Treatment. What that is, it – it’s a type of counseling
that people can train lay people, nonpsychological counselors, to provide. You, more or less, are following a script
and you’re sitting down one-on-one with somebody in order to help them walk through
pros and cons of behavior change and how they might … decisional balance – how they
might choose to make a change, why or why not. This was developed for use with substance
use problems, and when I arrived at Boston Medical Center, my first mentors, Drs. Judith
and Edward Bernstein, were experts in SBIRT and had done many different trials looking
at both adult and adolescent substance use using this model in our setting. And so, I thought, “Well, that’s great. We’ve got this
model, SBIRT. It actually is, you know, now accepted by
SAMHSA as a model program, and clinicians everywhere are being encouraged
to use SBIRT to screen – at least adults age 18 and older for alcohol misuse – using this. Is there a way that we could scoop out
the content of, you know, the – just the alcohol or marijuana piece – and, back from my
days doing batterer intervention work, can… Is there something that I can pull in and put in there that would maybe be effective for that issue? So, that meant that I had to think
about, you know … Back when I worked in a batterer intervention
program, the goal was to hold people accountable, and we would often try to get them to change,
maybe their entire worldview, about their privilege and gender roles,
and how – sort of big topics, large-scale things in their relationship. That wasn’t going to work in a
30-minute SBIRT-type intervention, but I did think that there were some things that
probably could be addressed. So, things like self-regulation problems,
or conflict resolution strategies, coping. So, I started to think a little bit about those things, and how they might be pulled into the SBIRT content. Basically, the main thing that I’ll sort of
mention about what we did that might be interesting or surprising to you is,
we followed all the same usual steps as SBIRT but we didn’t focus on trying to
increase empathy in anyone. So, when we designed this
intervention, it’s very gentle – we don’t ever use the words “dating violence.” We don’t tell people,
“You’re a dating violence perpetrator and you need to stop” or “Don’t you feel bad
for the people you’re hurting?” It’s really not like that. So, it’s different than what I had done
in batterer intervention. Partly, drawing on behavioral economics and
the idea that it was a really short period of time, kind of focus
on, “Look, why might perpetration be bad for you? If you’re trying to make your decision about
whether you want to change the way that you interact with your partner, you know, you
told me your goals for your future and getting involved with the police, or injuring yourself
or your partner could get in the way of all that.” And we really develop a pretty friendly rapport
with them, not in order to support their behavior and their harmful behavior but also,
I think importantly – and many people probably know this about adolescent dating
abuse – in our sample that I’m about to tell you about, 55 percent of those who screened
positive for perpetration also screened positive for victimization. So, the idea of a sort of, you know …
“you’ve used unhealthy behavior, but we’re not trying to skewer you, we’re
trying to just think about behavior change” – was actually a really important
part of how this worked, I think. So, who’s our
target population? What we did is, we decided to do this randomized
control trial in an emergency and adolescent outpatient setting in a hospital –
it was with healthy kids. They just happened
to come to the hospital for a sprained ankle or a urinary tract infection, and so it was
a convenient place to recruit them. They were 15 to 19 years old, English-speaking. They couldn’t be too dangerous, they couldn’t be in a batterer intervention program or above a certain threshold on a dangerousness assessment,
but that was just an IR that was – that was between me and the IRB
[institutional review board]. They were worried about me having,
like, two severely dangerous people in my intervention that they
were responsible for. It wasn’t a conceptual or ideological decision,
really, from the get-go. And to get into the intervention, they had to
report that they had done an act of physical or sexual dating abuse, so there’s a checklist. And they had to check off at least one of those, that they had done them in the past three months. So, we assessed 984 people, and this may surprise
you or not, but 28 percent were eligible, meaning 28 percent of the people
we just walked up to an ED who were in that age group or outpatient said, “Yup, I’ve done physical or sexual dating abuse in the past three months.” Of those who were eligible, were they interested in participating in this intervention? Yeah, 81 percent actually said, “Sure, I’ll
enroll in your study, this sounds fine.” We had pretty good follow-up rates in this
study, so what we did is we, of course – we randomized people to either get our Real
Talk intervention or not. And then we
followed them up at three months, and we followed them up again at six months to see
had – what had changed. Our follow-up at three months was 65 percent,
and it was 73 percent at six months. (I’m going to skip that slide and I’m going
to jump right into results.) So, here’s the thing, here’s what you’re looking at. You’re looking at my results slide, that’s
now talking about any dating abuse perpetration. That rolls together – physical, sexual,
psychological – looking at all of those forms of dating abuse perpetration. If you stare at
the blue line, that’s our intervention group. And, of course, at baseline, everyone was at 100 percent because you couldn’t get into this study unless you said you did dating abuse at baseline. But, then, we followed them forward, and let’s
look at that three-month mark. If you’re in the intervention group, you experienced
a 62 percentage point decrease in any dating abuse perpetration, while if
you’re in the orange control group, it was a 51 percentage point decrease. Now, I know that might
seem funny because, while both groups experienced a decrease and – I don’t
know what to tell you – you know, that actually happens in many SBIRT randomized
control trial studies. People aren’t totally
sure why it is. There are some guesses but it is true that
people do tend to, maybe, naturally decline in some things over time. But nevertheless, you know, if you look at our effect size here and confidence interval,
you know, we – there was – there was a difference, there was something that we saw
here that was of interest. So, then we took it a little further and decided to break down dating abuse into its different forms, and so we looked at psychological dating
abuse perpetration. (I’m just going to show you two forms because
I’m so limited on time right now.) But one of them was this –
you can see that 28 percent at baseline in our intervention group reported that they
perpetrated psychological dating abuse, and that decreased it to the
three-month mark 23 percentage points. Orange group, control group, not so much. You know, this also – like,
so slightly strong – less strong effect size. And in both of these, the changes
didn’t persist to the six-month mark. We generalized this doing the
equations so, you know … looking across the different time points and saw this
change up to the three-month but maybe not the six-month mark. The last one I’ll show you is really interesting. It was cyber dating abuse perpetration. And there was some natural random, coincidental difference at baseline between the two
groups a little bit. But that – so, you see the blue
line or the intervention group – they really dropped quite a bit. And the orange, only 14 percentage
points up to that three-month mark. So, for those of you who have been looking
at my .06 p values and feeling like sticklers like, here – here’s one for
you that’s .004, you know, so, not – .004 the effect size – it’s, like, decent. And we have some potentially real change here, so … oh, this is to just say that this did not
persist to the six-month mark because the p value went up, over .11. So, we may have some work to do in terms of,
like, doing more booster phone calls with them after they leave the
hospital, really – or figure out some way to get it to persist past the three-month mark
would be something worth working on. So I’ve grayed out my results because my article is still under review and I didn’t know if the [NIJ] Journal was going to get mad if I had already
displayed all my results somewhere. So, I wanted to point out,
we had very few males in this trial. You’re looking at the three-month
results right now. We had 10 – we had 10 males but, you know, the p value for them was .014, even though it was a small sample. There was enough of a difference that we managed to get good effect for any kind of dating abuse. And so, that was also true
at six months. Yeah. So you can see it’s, like … but the males,
even though we only had 11 that we were able to follow up with at six months,
you know – not so bad for physical dating abuse, even for this incredibly small group. The other things didn’t persist to
six months, as I have mentioned. So, where does that leave me,
or what am I thinking? I think the – that Real Talk had
some effect and that the strongest effects appear to be in psychological and cyber dating
abuse perpetration, which may make sense. Maybe those are the easier grab after a
30-minute conversation. Maybe …it’s also maybe less
common to perpetrate, right? -physical and sexual dating violence – so harder to pick up differences on those things. The other thing is that, you know, the effect
did persist to six months for males and that any abuse category (and maybe physical abuse)
didn’t persist for females past three months, so that gives us a little something to think about. I am incredibly indebted to my research assistants,
who were amazing, who learned how to do the SBIRT and then went
into the settings in order to do it. And we’re actually going
to hear from one of them right now – Sarah, who’s going to tell you a little bit about her real-life experience during the intervention. DR. CARRIE MULFORD: Yes, Sarah, so I’m going to
turn it over to you, so … to talk about what your role was in the intervention
and as an interventionist delivering the services, what do you feel like worked well and what were some of the challenges in delivering the intervention? So, if you could just talk a little about
that – that would be great. SARAH DECOSTA: Absolutely, thanks. So, my role in the intervention
was to sit in the pediatric emergency department of Boston Medical
Center – that’s where I was particularly stationed on my shift – and to screen for anyone who would come in who fit our criteria. For the age category, and also a few other
things, you know, they couldn’t be coming in for something like … for a grievous wound or with any kind of altered mental state, obviously. We were looking for folks,
as Emily said, that, you know, had sprained ankles and things like that. So, when someone would come in and fit that criteria, I would approach them and
I would, you know, tell them about Real Talk and ask if they were interested. And if they agreed to do the one page –
it was, like, front and back of one piece of paper, a screening form – then I
would review the screening form to see if they were eligible to be in the study. And if they were, then I would ask them if
they wanted to continue. And if they were interested, we review all
of the paperwork we needed to do, you know, consent forms and everything. And then I would randomize them; we had our
own system for how that would happen. And if they were randomized into the intervention
group, I would then conduct the intervention in the emergency department. So, the – I think one of the things that I
– that went really well that I enjoyed was – I was able to build a rapport with the
participants really easily. And I think that part of that is that –
that the SBIRT script actually sets you up to … to, sort of, succeed in that area. I also have a lot of experience working with youth, so I usually am in rooms talking to
people on the page routine anyway, but it was really nice to have, sort of,
the script be the skeleton of it. And then we could ad lib, like the, you know –
the relationship-building pieces of it – as long as we hit all of the
main intervention points and some of the specific lines that we needed to say. And one of the things that I found challenging
– some of the other interventionists were stationed in the outpatient medical center, so they would have a more
regular flow of potential participants. For me, in the emergency department,
it was there … I mean, there were some nights that I was there that nobody
came in, that I couldn’t even screen. And then there were other nights
that I would have so many people at a time that I couldn’t do it for all of them. So, the variability in, sort of, the – your
pool of potential participants is a little bit challenging when you’re in something
as uncontrolled as an emergency room. But I do think that having it in a medical setting was helpful in that we, sort of, just became
part of – “Oh, this is a medical thing and you’re just going to talk to us and it’s okay.” And we didn’t present ourselves as doctors or medical professionals, but
something about the setting, I think, made people more
willing to be involved. DR. CARRIE MULFORD: Thank you. Can I say one quick – I’m going to ask you one quick follow-up question to that. So, when you were recruiting,
were there a lot more female, like, potential participants, or was
it that they were more likely to be willing to talk to you, or why would you think there was
such a big difference in the – in the split? SARAH DECOSTA: In the emergency department, we saw a lot more teenage girls than we did boys. And when the boys came in, it was often for
a broken leg or something severe enough that we couldn’t approach them. A lot of young women end up at the emergency room for things like urinary tract infections and, you know, needing a pregnancy test, and that area … there’s not necessarily folks that
have a primary care provider, so they come to the emergency room
for things that you may normally think of as, like, an emergency as not an emergency. So, we did see a lot more females in the
emergency room for any reason, generally speaking. DR. CARRIE MULFORD: Great, thank you very much. Okay. The next person we’ll hear
from is Dr. Liz Miller. And she’s going to talk about the SHARP intervention. And, Liz, I’m going to ask you
the same questions that I asked Emily – to tell us about the intervention
that you’re doing, the intervention and how it works, and what made you think it might
work, who you’re delivering it to, and what has the research shown so far
about how well it’s working. DR. ELIZABETH MILLER: Well, thank you all so much
for the privilege of sharing this with you and I certainly want to begin by thanking
the National Institute of Justice for the support to actually – to do this
work in the health care setting. And actually, my presentation, which will be followed by Lisa James and then Janice Goldsborough
as an advocate who’s been working very closely with me in Pittsburgh …
are somewhat synergistic. And what I’m going to be sharing with you
is the SHARP intervention and some of that history. And then, when Lisa James will be sharing,
sort of, the broader kind of framework as we’ve been expanding this kind of implementation framework in other health care settings. And the focus here is just a reminder about
why we’re focusing on the health care sector as a point for intervention
and, just as Emily was underscoring the emergency department as a really important
place for prevention work, I’m going to be talking about school-based health centers
as another site, and it has to do with the fact that adolescent relationship abuse (ARA) has really significant health and social
consequences for young people. And that we know that young people who are in unhealthy and abusive relationships actually seek care more for the range of health
problems that’s listed here. The challenge that I’m going to talk about,
which is really an implementation challenge, is that getting health care providers to change their behavior can be a little bit challenging. But we always start by, kind of, reframing
the role of the health care provider and reminding health professionals that they can
actually help to reduce the survivor’s sense of isolation and shame, and encourage them
to believe a better future is possible and that, as health professionals,
we have a really important role to play. We also know, from research
primarily focused in adult women, that those who talked to their health care
provider are significantly more likely to use an intervention. An intervention can be
everything from calling a hotline, reaching out to a victim service advocate, to talking to a counselor, joining a support group, and so forth. So, work that has been done, actually,
here in Pittsburgh with one of my colleagues, Judy Chang, is an interview study with survivors about what they want in the clinical encounter. And, you know … these bullet points should not come as a surprise to any of us, right?) … around being nonjudgmental, around listening,
offering information and support, but most importantly, not to push for disclosure. And so, from my colleagues at Futures
Without Violence, they have really succinctly summarized what we hope could be
success, that perhaps success is measured in our efforts to reduce isolation
and to improve options for safety. So, the work around the SHARP intervention
is really situated in this framework – which is a much more trauma-informed framework – that recognizes that screening alone may not be effective in addressing relationship
abuse in the clinical setting. And what we are seeing across
multiple studies are very, very low disclosure rates when
we focus on screening alone. It is not survivor-centered in the sense that
we are relying on patients to disclose to us on a screening question in
order to connect them to resources, and so that resources are then offered
only based on a patient’s disclosure. And what we thought –
and which is really the foundation for the SHARP intervention – was that this was a
missed opportunity for prevention education. So, in the work that we did in school-based
health centers, this is from our baseline data across eight school health
centers in high schools in California. These are all comprehensive
clinics located in schools. And of the youth who were seeking
care in these clinics, 41 percent reported recent cyber dating
abuse victimization experiences, and 13 percent reported recent physical or sexual
relationship abuse experiences, with an overall prevalence of victimization of 45 percent in the past three months – really underscoring
why we think the health centers and school health centers are a really critical place
to do this work. And so, what we were testing with the SHARP
intervention was a universal education approach and was designed with the support
of – through multiple funders -to create an adolescent relationship abuse educational card. It’s a palm size, kind of, business card-
size informational card that includes some information about healthy and unhealthy
relationships as well as how to help a friend. In our research, we found that the – in a
cluster-randomized trial (oops, I’m not sure why –
I keep clicking back. Sorry about that.) The intervention components were to distribute
the healthy relationships card with every clinic visit and then to do a direct assessment
for sexual health-related visits. And then there was also a youth-led, kind of, relationship abuse awareness across the school. What we found in that randomized trial was,
the young people who were in clinics where they received the information, with increased
recognition of what constitutes abusive behavior and sexual coercion, increased awareness of the ARA resources. Among youth with recent
relationship abuse victimization, they actually reported less victimization
at three-month follow-up. And then, while this was a
nondisclosure-based intervention – it was really intended to not focus on disclosure – actually increased the likelihood of disclosure to the provider
during the clinic visit threefold. In addition, we have continued to
test the – in addition to the, sort of … the SHARP intervention – to test direct
assessment for reproductive coercion with sexually active young women. And in a – and it has to do
with the fact that intimate partner violence really increases young women’s risk
for unintended pregnancies. And what we designed,
very similar to the SHARP intervention, was a reproductive health card
for, again, sharing information about healthy and unhealthy relationships, but with very
specific information about reproductive coercion, which is a … the likelihood of
a … the reproduction coercion being a male partner’s, sort of, active attempts to impregnate
a female partner against her wishes. And the findings from our randomized control
trial showed increases in knowledge of resources and increases in self-efficacy to
use harm reduction strategies, which were really our overall goals for the intervention. But we also found that, for women who were
experiencing high levels of reproductive coercion at baseline, that there was a very significant reduction in reproductive coercion one year later. And, among the feedback
that we received from patients was, “Getting the card makes me actually feel like
I have a lot of power to help somebody.” And Lisa will be going into more of the sort
of theoretical background and, sort of, the research informing this kind of approach. But what we have learned is that patients really, really greatly appreciate receiving this information
during their clinical encounters. So, what I want to conclude with is where we have taken this research, which is with what we
call our “trauma-informed personalized scripts” and … where we randomly – so what we
have done is ask patients to actually complete a brief questionnaire on their tablet
(on a computer tablet) about partner violence and
reproductive coercion, and randomly assigning them to provider scripts only, or
to where the – where young people will complete the questions, but the responses
themselves do not go to the provider. What the provider receives is a prompt with specific language on what to say to their
patient during the clinical encounter. We also tested whether adding
additional patient messages in addition to the provider script would increase
provider discussion about partner violence and reproductive coercion as well
as provision of resources. And what we found, and this
is, again, is a preliminarily … in that the discussion of healthy
relationships in clinics that had already been trained in reproductive coercion
and partner violence went up a little bit, from 68 percent to 78 percent. The receipt of the card increased
from 73 percent to 79 percent, but, most importantly, because this
was focused on reproductive coercion, went from 10 percent per discussion to 61 percent,
simply by giving providers the script on what to say. And, while disclosure is not the goal –
very similar to what we found in the SHARP study disclosure – increased, this time
from 12 percent to 22 percent. And so, I share this – the implementation
piece – with you because working in the health care setting, training health care
providers is not enough. We have to be paying attention to the
clinical systems to support providers to really implement
these kinds of brief interventions. And, in reframing the role of the clinician
in violence prevention, we are really aiming to help health
systems recognize that trauma is prevalent, encouraging providers to offer support in harm reduction (regardless of disclosure) to help youth increase their safety and build resilience. And, in a piece that Lisa James will be talking
about more, is emphasizing the role that young people can play in helping others and
strengthen their connectedness. So, I will conclude there and just
want to acknowledge the many people on the SHARP
research team, our community partners – including Women’s Center and Shelter and my research
team as well as the funding from multiple sources, including the National Institute
of Justice – to allow this work to happen. Thank you. DR. CARRIE MULFORD: Thank you very much. And, with that, I am going to ask Lisa to talk about the extensions to the SHARP intervention project, called CUES – the program
called CUES. Can you talk about, Lisa, the intervention
that you are doing, again, who it’s delivered to and what we know about how well
it’s working so far? (Stay tuned. We’re
trying to find Lisa.) LISA JAMES: Can you hear me now? DR. CARRIE MULFORD: Now we can hear you.
There we go. LISA JAMES: Yeah. Sorry about that. DR.CARRIE MULFORD: Okay. Yeah. No problem. LISA JAMES: So, yeah, I was just mentioning
that the CUES intervention is really a broader framework, as Dr. Miller talked about,
that we have implemented in adolescent health settings but also in family planning
and primary care settings, that walks through this evidence-based and
trauma-informed approach to violence. And we’re seeing great
promise around improving both health and safety of young people and for others who
receive the intervention. So, I’m going to talk a little bit more about
the steps of the CUES intervention, and I want to just start off by saying that I’m representing Futures Without Violence and we’re – we are funded by the
Department of Health and Human Services to operate the National Health Resource Center
on Domestic Violence. And I want to thank
Mao Yang and Becky Odor and the whole team at the FVPSA Office for their support. And it’s because of their support that all of you have access to free resources that we’re going to talk about through the course of this webinar. So, the training and technical assistance
materials and recommendations are available to you, free of charge, through the Health
Resource Center on Domestic Violence. So, the CUES intervention … Let me talk
a little bit more in depth about the different steps of the CUES intervention that has been developed in multiple settings with feedback from survivors, from advocates, and from health care providers. And it goes through these
steps: The first is C, confidentiality and disclosing limits of confidentiality, and
making sure that each setting has a policy, ideally, where
they see a patient or client alone for some portion of the visit so that they can have
that opportunity to talk about violence privately. The U is for universal education, again, about
healthy and unhealthy relationships and the impact that it has on health and health outcomes. The E is empowerment, and Dr. Miller
talked a little bit about that. We’ll talk some more about how critical the
empowerment and how healing, really, it can be for clients
to be able to receive this information about their health and also be able to share it with others. And the S is for support. And there is a
number of different steps to support – around promoting harm reduction strategies and
health promotion strategies, connecting up the client or patient with community-based
programs, and following up at the next visit. So, I had talked a little bit about disclosing
limits of confidentiality, and we know that it’s absolutely critical to build trust – particularly with young people – by sharing what is
reportable and what isn’t. And, so, this is just a script that we use
for training health care providers – around how to address, right upfront,
any limits of confidentiality that … that they may have, so that the young
person knows what might be shared. And it depends, in terms of
each setting and state in which they’re working in and in terms of what’s reportable. But importantly, again, after we had been
doing work for a number of years, we learned more and more about the limits
of disclosure-driven practice, as Dr. Miller talked about. And we know that so many patients are not
ready to disclose for a variety of reasons. And so, we also provide this script around
disclosing limits, confidentiality that’s not disclosure-driven, and saying something
to the effect of “We know a lot of patients aren’t ready or maybe afraid to share certain things about their health or their relationships. But we want you to know that you can use these resources for yourself or for a friend, regardless of what you choose
to share with me today.” And again, that’s just
underscoring that the information is there, regardless of whether or not the young person
decides to share anything with the … the provider about their relationship. And I talked a little bit about making that
connection between violence and health. And Dr. Miller showed you some of the
resources that are used – the two palm-sized cards. And when we began doing the work,
we started with just one card. But, again, we learned over time that, by
giving two cards, we can let patients know that they can share
those resources for them – for themselves, they can keep it, or share with a friend or
a family member. And that’s been particularly
critical in young – with young people because we find that they are very eager to share
the resources with their peers, and so that’s been a very powerful finding. And, on the card, as Dr. Miller discussed, it has information about safe and healthy relationships and what looks – what an unhealthy relationship looks like, and what one … and a healthy relationship looks like. So, you have an opportunity, again, for all
patients to talk about relationships and their impact on health. (And it also has resources on the back.) So, if somebody is experiencing violence, they will be able to leave, with resources to access
ongoing care, if needed. (This just keeps popping ahead a little bit. All right.) And then we talked a bit about
the empowerment piece. And what we have found, from
the qualitative research that we’ve done with Dr. Miller, is how important it is to offer the resources – again, regardless of disclosure. And it’s really a choice for the provider
to share power with the patients. So, you’re not just approaching this
issueas a checklist and screening and then, sort of, treating
a problem that’s identified. Instead, it’s just taking
time to talk about the issue and then offer resources for that patient to
decide what to do with. So, again, we really heard from clients who’ve
received the intervention – that they find that it’s very empowering to have both
the cards and an opportunity to share that with their friends and family members and make a difference in the world. And that act of sharing the resources,
it can be healing in and of itself. And, while disclosure isn’t
necessarily the goal, it definitely happens, as Dr. Miller shared with her research in
the SHARP study. And so, when we do the intervention, we are
sure to acknowledge that disclosures do happen and to – when somebody
does disclose, to make sure to make the connection between their health … so,
not just immediately refer to a community- based expert but take the time to address
the health issue at hand as well. And we heard about a number of different health
consequences of abuse and we’re really seeing – particularly with young people – eating
disorders, increased unintended pregnancies, or STDs. So, really addressing those health issues
with the understanding of the abuse that they might be experiencing, and how their partner might be interfering
with their care. And offering a care plan that can support
them in a trauma-informed way. And I just want to lift up that these harm reduction strategies can really look different in different settings. So, we have a recommendation around visit-specific
harm reduction strategies. And you see there, on the slide, that in primary
care settings, you might be addressing more chronic health issues. In adolescent health, we have a big emphasis
on anticipatory guidance for health and unhealthy relationships. In behavioral health or mental health, you
might assess whether or not someone’s partner is trying to undermine their sobriety or
sanity and make a plan to lessen that interference. And Dr. Miller already talked about the offering
of alternate birth control in reproductive health settings with sexually active young people to, again, decrease the risk for unplanned pregnancy. So, depending on the reason for a visit and
on the setting, those harm reduction strategies can look different,
but they’re really critical. And then, finally,
warm referral. And it’s so critical to partner with community-based
programs who provide services to survivors of domestic violence. And being able to offer that warm referral, right there in the clinic, is important because
sometimes we know perpetrators monitor the use of their partner’s cell phone. And so, being able to offer a phone,
right there in clinic, and say, “If you’re comfortable, I’d like to call
my colleague, and she’s helped many others who’ve been in similar situations,” and make that connection, right upfront, if somebody does disclose. So, that is an overview of the CUES intervention
that has been implemented in adolescent health settings
and primary care settings, and reproductive health settings across the country. And we’ve seen a real – I think –
exciting impact in terms of both increases in health and safety
as a result of the intervention. DR. CARRIE MULFORD: Thank you, Lisa. Okay. So, Janice, I’m going to ask you to talk
about your role in the intervention as an interventionist, and to talk about what worked well and what you thought were some of the challenges
in delivering the intervention – the CUES intervention. JANICE GOLDSBOROUGH: Okay. I was on the study of … with Liz Miller
and her group. And Liz, if you’re still here and I leave
something out, please jump in. But my role as to follow-up of the study is to give a face to the warm referral. So, I was there with Liz when
they did the education portion. And then – as a matter of fact, up until this
point I continue to do site visits at least once a month. And I make sure I don’t take enough cards. I don’t want to take a thousand because I want them to – I want to continue to have an excuse to come back. So I take the cards, and we’ve developed – at the Planned Parenthood downtown, for instance – we have signage in the elevator. We have posters. I’ve given
them posters for the restrooms as well. So, them seeing me coming back and forth also will make me look like a member, sort of, of the team. So, it will not only keep domestic
violence at the forefront of their thinking but also it’ll click with them, “Oh, right,
that’s Janice. I can call this number or I can do this.” I’ve given them my cell phone number that
they’re free to use. No one uses this. And if it’s on the – on the very few times
I’ve actually seen patients, I was able to meet them at their visit
because I knew ahead of time. Sometimes, I talk to a person on the phone,
and the rest of the time they know that they can utilize the hotline as well. So, another thing that I do is try to develop
a positive relationship with the practice manager or, you know, that counterpart because
office culture tends to come from the top down. So, if it’s going to be a culture of awareness
about partner violence, and if that is something that when they ask a question that
they want to hear the person’s answer, they’re not just trying to check
something off their box. So that’s, sort of, of a culture – a
cultural thing, and it’s created from the top down. So, of course, I want to develop positive
relationships with those folks. One of the challenges, I guess the main challenge
is that every site is very different. And if there’s turnover, if one of those people
that left or moved around was one of your champions, you have to keep on continuously recultivating those relationships. And that … that’s something that other medical
advocates run into at other settings. So, the one advantage is that these places
are smaller than hospitals so, unlike with UPMC, people aren’t going to move around,
you know, as often as they do in bigger places. But, still, you would have turnover. So, you have to continually, sort of,
sell your product over and over, and maintain awareness
because, for me, domestic violence is all I’m concerned about, whereas domestic violence
is competing with many other issues that staff are working with, as far as the patients go. DR. CARRIE MULFORD: Janice, thank you very much. JANICE GOLDSBOROUGH: Sure. DR. CARRIE MULFORD: Okay, so that concludes our
first portion of the webinar. Now, we’re going to move to a moderated discussion where I have some questions queued up
for the participants. So, first, we’re going to turn to Sarah. Sarah, for the – when you were
delivering the Real Talk intervention, how receptive are adolescents to talking about
these kinds of things? To talking about unhealthy relationships and,
potentially, abuse in the relationships? And some people might be skeptical that they’d
be willing to talk to adults about these kinds of things. SARAH DECOSTA: I actually found that they
were surprisingly willing to talk to me, and especially about the nonphysical forms of
abuse and unhealthy behavior. And one thing that struck
me over time, you know, doing this intervention repeatedly, was that the
reason for that seemed to be that they don’t recognize this as something that is a problem
or that is not normal. For many of them, this is just
how relationships function. Their peers, maybe, are in the
same types of relationships. In some cases, they and their partners are
both, you know, doing some of these behaviors. As Emily mentioned, a high number of
these participants also score as, you know, on the victimization scale. So they – they’re – they were in relationships
that were just kind of toxic. And they seemed to think it was
completely normal. So, they were totally
willing to tell me all about it. And I also think that
a lot of teens – and I found this in my work, you know, in other programs – a lot of teens
just want somebody to talk to them who’s not going to give them a lecture. And I think the relaxed way that
you approach someone when doing this intervention and the way that
you build that rapport makes them comfortable. And I think a lot of teens, given an
opportunity, would want to get some advice from maybe somebody who knows about this
kind of thing because they don’t often get talked about, you know, talked to about this stuff. They may be told about, you know – you know,
STDs in health class but, in a lot of places, they’re not necessarily “getting”
educational relationships and what they’re supposed to look like. And the other thing that I – that I was really
struck by is, as I was talking to them, how much many of them
struggled with having coping skills. They didn’t – they weren’t doing the things they were doing because they wanted to, often. It wasn’t, like, a “Well, I have planned this and I did this because I wanted x, y, z from my partner.” It was usually because they
would describe how they just got so frustrated that they didn’t know what else to do. And so I think that there’s sort of … the
lesson for me as my takeaway was that letting, you know, providing more education,
generally speaking, to young people about relationship dynamics and also, you know,
working with maybe schools and other … other, you know, settings to provide that
social-emotional development and coping skills stuff I think would be useful. Because the dynamic was very interesting to
me, especially coming from a adult domestic
violence field background. DR. CARRIE MULFORD: Great.
Thank you, thank you so much. And Liz, I’m going to ask
you to – a similar question. So, Sarah was talking about her experience
with Real Talk and is – do you have a similar experience
from the SHARP intervention in terms of willingness of adolescents to open up? DR. ELIZABETH MILLER: Yes. Yes. No, indeed. And actually when it’s – when it’s
phrased, you know, the clinicians working in school-based health centers who, for the
most part, are clinical nurse practitioners. The feedback from young people was how
much they just appreciated that anybody was talking to them about these issues – that
they actually cared deeply about but really have not had a space for really honest conversation about healthy and unhealthy relationships. And one of the extensions of the
SHARP work has been to actually try training school nurses here in the state of Pennsylvania. And in a pilot study we did with five schools
where we worked with school nurses – and, again, talk about, you know,
super light touch – as young people were coming through for headaches and, you know,
and other, you know, sort of belly aches and so forth, that the school nurse actually
spoke with all of the young people about healthy relationships and asked them to distribute
the cards and so forth. And the feedback that we received from young people on that study was phenomenal. Like the, you know, young people are sort of writing in on their comment card, like, “My school
nurse is absolutely the best. Nobody else treats us as – treat us with this
much respect,” which is so striking. The idea of, like, sharing this information
was really appreciated by young people as being respected and being valued. DR. CARRIE MULFORD: It’s so nice to hear. Okay. I’m going to move on to our next
question, which … Lisa? LISA JAMES: Might I – excuse me for just a moment. DR. CARRIE MULFORD: Okay. Please. LISA JAMES: This is Lisa. Might I just add – make one additional comment, which is the other finding with the SHARP Study, is that
the students … because I think they had such a positive experience (that Liz just described) also reported that they would be much more
likely – those who received the intervention – would be much more likely to bring a
friend to the health center or to refer a friend to the health center to talk about
healthy and unhealthy relationships. So, for those working in the school-based
health settings, that is just exactly what you want to hear, that those
referrals will be coming in as well. Thank you. DR. CARRIE MULFORD: Thank you. And Lisa just reminded me of something. So, for any of the presenters, as I move – if I’m moving to the next question and you have
something you want to add, please jump in, that’s, you know, it would be nice if we were
all sitting around a – at a table or something, and you – we could see each other and
then I would know, but then please jump in. So, for the next one, if somebody wanted to
try to implement your intervention in their own community, what would it take, what resources are available to them, and what, you know,
what cost might they incur. I’m going to start with Emily for – to talk
about Real Talk. DR. EMILY ROTHMAN: Yeah, sure. So, I’m actually in the middle of writing
up a cost- benefit analysis-type paper that gets down
into the details of all of this right now, but I can give you some rough sketch answers. So, this is a really inexpensive intervention. And it does matter if you’re doing it in a hospital where you already have, let’s say, a social
worker who does lots of things and could fold this in. So, when someone screens positive
for dating abuse perpetration, they are trained in SBIRT and they can do this or, if you
would have to hire someone, that would be – you would need a really large hospital with a high volume of patients to have to hire a whole other person. I have been talking in Massachusetts to the school nurses and school-based health centers, which are separate
things about … just like Liz and … was talking about – about “Can we train school health personnel to do this as part of their regular job?” So, where this is going is, if you’re … this
is – it’s cheap and easy to train somebody how to do this, and we’re starting to get a couple of requests, here and there now, to just – “Can you come give us a training, like a one-day training?” They now know how to do it,
and they can – and they can start, you know, just start implementing it. If you had nothing
in place and wanted to start from scratch, our estimate right now is that it will cost about $62 to $72 per patient for this intervention
to happen, or about $17,000 per year in order to pull this off – and that’s if you had dedicated
staff and a hospital. So, obviously it’s
going to be less expensive if it – if it’s a school nurse, you’re just folding it in
to their work. DR. CARRIE MULFORD: Thank you, Emily. DR. EMILY ROTHMAN: Should – I mention, too, that
– oh, yeah? DR. CARRIE MULFORD: Oh, go ahead. DR. EMILY ROTHMAN: Okay. I was going to mention that if
there are people who are listening and they like the idea of Real Talk,
we actually recorded a video, it’s not 30 minutes long. We made a seven-minute abbreviated version
of Real Talk so that you could see it on your computer and decide if
it looks interesting to you. And so, if anyone
emails me, I’ll just send them the link and then you get to, kind of, see what it looks
like in real life, a little bit. DR. CARRIE MULFORD: And at the very end, during
the Q&A, we’ll have email addresses up for the presenters, so you can
jot that down or you can come back and look at the presentation later to get Emily’s email
address but … That’s terrific! Thank you so
much. DR. EMILY ROTHMAN: Yeah. DR. CARRIE MULFORD: And I’m going to then turn
the same question to …to Lisa to talk about what resources are available for CUES,
and where folks might go to get those, if they wanted to try to implement it in their
own communities. LISA JAMES: Sure. So, as I mentioned in the beginning, through
the health – National Health Resource Center on Domestic Violence,
we can provide resources, free of charge. You can order them online – and it’s just
a shipping fee, but that includes … (you’ll see here on the slide) … that includes posters that you can hang in exam rooms that talk
about healthy and unhealthy relationships and the impact on health, a training resource
that really walks through how to train your colleagues on this intervention. It’s called “Hanging Out or Hooking Up,” and that really walks through the CUES intervention – and
also a set of consensus guidelines that were developed by a number of health
professionals in the field. So, those are two pieces that really are ready
for you to take and implement and then, of course, the actual
safety card that we talked about that’s so core to the intervention. So, all of those resources are available to
anybody who would like to implement this intervention, free of charge
at The National Health Resource Center and, you know, our website and our email will be
at the last slide, so please do feel free to contact me if you have any questions about what to order and how to implement this work. But I would just say that it is also – like
Emily’s, it’s an inexpensive intervention. You can take these resources in
and use them in your own setting. And when you’re in a very large
setting or if you’re an administrator who’s listening, of course, you want to think about how to scale up the intervention and how to support
the individual providers that are doing it. So, we have a number of different resources
on these websites that you see here, ipvhealth [.org] and,
which is specifically for community health centers that talk through the steps of how
to create a sustainable and systemwide response to intimate partner violence or adolescent
relationship abuse. So, the cost is expens … inexpensive on
an individual level and then, when you scale up, you just have to think about how to – how to train all of your providers, how to support
them through the kind of system support that will make sure that it’s sustainable, and then what are your steps for providing quality
improvement, and making sure that the intervention is being implemented in a way
that’s promoting health and safety? So, we have resources to help
you with all of those steps. DR. CARRIE MULFORD: Excellent. Thank you. And we put a couple of those up on the
screen as you were talking, so people can see that. Does anyone else have anything to
add on this issue of implementing the programs in peoples’ community and expanding out – before I move to the next question? DR. ELIZABETH MILLER: I’ll just jump in. This is Liz Miller. Around working within health
care systems, because what is – I want to underscore what Lisa was sharing on the
online toolkit, which includes guidance around… of the clinic policies and protocols that
really need to be in place to support health care center intervention. And it’s basic things,
like having very clear privacy and confidentiality policies within a clinical setting; having
a partnership, a formal partnership with the
Victim Service Agency Domestic Violence and/or sexual assault, like we do with Women’s
Center and Shelter, and the fabulous Janice Goldsborough – those kinds of things
need to be really formalized. It is not sufficient to simply train providers
and say “go to it,” and so I think that systems- level piece – which is, you know, really at
no cost to the system to make these kinds of straightforward
policy and protocol changes – where there is some cost is that the
training for health care providers is best done in a concentrated period of time. Usually, three and a half to four hours of health care provider training in a trauma-informed
approach, understanding the impact of secondary trauma on clinic staff, and
understanding how to implement the CUES approach and the rationale for that. And that
does take some time. I think that there are attempts to look at
what online training might look like and so forth, but just in terms
of the existing cost piece, that is one for health centers to be mindful about. JANICE GOLDSBOROUGH: Hello, this is Janice. Can everyone hear me? DR. CARRIE MULFORD: Yes, go ahead. JANICE GOLDSBOROUGH: Okay. I just wanted to reiterate:
All of our services are free of charge – whether that’s lecturing to colleges,
a crisis intervention – everything is free, so my portion of the follow-up … and I’m sure I could speak to the – those of my
counterparts in Pennsylvania that fall under the PCADD [Pasadena Council on Alcoholism
and Drug Dependence] provide services free of charge. Anytime an advocate comes out, does education or crisis intervention, always free of charge. DR. CARRIE MULFORD: That’s great. Thank you. Okay. We’re going to move
on to the next question. Which is – what you all plan on doing moving
forward, what are the, sort of, next steps, which would typically be embedded
in a research presentation. But I wanted to broaden the question – it could be research or practice – what are, sort of, the next steps for each of the programs? We’ll go ahead and start with Emily about
Real Talk. DR. EMILY ROTHMAN: Yeah. I have lots of ideas. So, I guess, thinking with my researcher hat on, I’d really like to try this in a new setting. So, I am trying to get school
health centers, school-based health centers onboard for a cluster-randomized controlled trial. We obviously need to redo with more boys and men, so 11 is too few, we got to do a little bit more than that. It would be … and so, it’d be great to get
those off the ground. And I think other types of next steps would be, you know, figuring out how we can go – pick
out the parts of the content that were, like, the pieces that were really working and make
those even stronger and see if we can get those effects lasting even longer, or if we can build in a better system of, you know, double
checking, another booster that will keep it going for people, once they’ve got the hang of this. DR. CARRIE MULFORD: Excellent. Liz, you want to go next? DR. ELIZABETH MILLER: Sure. So, in terms of – for SHARP and the – these trauma- informed kind of brief interventions to support
survivors … For SHARP, one of the things that we’re looking at from a research perspective
is, while we were able to show with the NIJ-supported trial that we were – that we reduced relationship abuse victimization three months later. We – it was really focused on violence as
the outcome and not health outcomes. And among the things that we have been asked
by health centers and health care systems is, is there any evidence that this kind of brief intervention could have an impact on health outcomes? And so that is one area that
we’re looking at, including whether or not this kind of focus on healthy
relationship education might in fact – impact sexual and – sexual and reproductive health
behaviors as well as mental health outcomes. A secondary piece that we’re – that is more
a technology development piece – is based on the implementation data that I shared with
you, where using a prompt to give providers the kind of reminder of what to say to their
patients, and how effective that appears to be in reminding providers to actually implement this intervention – that one of the things that our partners have asked for is embedding the
scripts into the electronic health record. So, to have the tablet-based questions and the providers’ scripts actually
embedded in their clinic flow. So that is also something that we’re working on. DR. CARRIE MULFORD: Okay. I see that we’re getting – I don’t mean to
be doing Mao’s job for her, but our next question that we
have – it seems to be answering a bunch of the questions that are coming in on the chat – which is how these interventions can be used
in other settings. Folks are asking about that. So I’m going to – just in the interests of
time, move us along to that question. Lisa, you want to go first on this one? LISA JAMES: Sure. So, I put up here, on the screen … (Whoops. Now it’s going a little too fast for us.) … a number of different settings in which
we have resources to help you use these types of approaches and to implement
the CUES intervention. So, we talked about
the school-based health settings and we want to further expand and spread that
opportunity to implement the CUES intervention in school-based health settings, and Liz
talked about the school nurses, so there’s definitely opportunity to do more work there. Additionally, in reproductive health settings
– in the same way that we have resources for adolescent health – we have training materials,
a train-the-trainer toolkit, consensus guidelines, and patient safety cards for reproductive health settings that really look at reproductive health issues specifically in
harm reduction strategies there and specific to reproductive health visits. Additionally, we have resources for primary care and that includes consensus guidelines and training
materials and safety cards. And we’re currently involved in
a project in collaboration with the Health Resources and Services Administration and ACF (Administration for Children and Families) to work in four states in partnership with the primary care associations,
the domestic violence programs, and the Departments of Health to implement this intervention
and to … 50 percent – at least 50 percent of the community health centers. So, we’re in the midst of doing that work but there’s resources available for primary care. And, also, we’ve developed some new resources
for pregnant and parenting teens, and you see a picture there for … of a Young
Mom, Strong Kids card. That’s just an …
adapted resources for pregnant and parenting teens to promote, again, safety and
improve health and parenting strategies. And we also have resources for campus health
settings, and Dr. Miller is involved in a study there to, again, lift up
that important role of campus health settings for preventing and
responding to sexual assault and domestic violence. And then we also have community-specific resources
that can be used in community health settings or youth organizations. And you see pictures there, of our
LGBT resources that are being used, again, in community-based settings as well as in
health settings. So, there’s lots of opportunities for student
activism and awareness and then also other organizations that are outside
of the health settings as well. DR. CARRIE MULFORD: Excellent. So I’d like to ask that question
also, of Emily. And I was about to ask – and that I see that one of our assistants also was wondering – what
about … is there – is there any possibility of doing any of these kinds of programs in a justice setting – youth correctional facilities,
probation, detention centers? DR. EMILY ROTHMAN: Yeah, absolutely. DR. CARRIE MULFORD: And you
can answer more broadly than that. Don’t feel confined
to that question. DR. EMILY ROTHMAN: Well, I … you know, it’s
funny you asked. I’ve been talking with a
colleague in Cambridge who runs a very innovative program affiliated with
the high school. It’s, like, a diversion program for teenagers. And, we’ve been talking about how
could we, it’s like – school research officers, diversion officer, people probation, juvenile
probation – how could we train them? But they sound really interested. It’s, like, right up
their alley, so that’s encouraging and exciting. And then, you know, I’ve actually – I’ve
been trying to think quite far outside the box recently, too, so like …
even thinking about… There are a lot of specialists who work,
for example, teaching social skills groups to kids with autism spectrum disorder, or there’s some ADHD, like, you know,
lots of communities. There are these community-based specialists
who do certain kinds of social skills groups. And I’ve been wanting to think too about, you know, “Are these people who we can bring into the fold” because they’re not normally trained to think about dating violence so much. But as kids get older, in addition to the
social-emotional learning and bullying stuff they do as little kids, it’s
appropriate to get in on some of this stuff. So, those are – yeah, definitely justice – and then these other areas or directions that
I’m thinking about, too. So, I’m mainly just really excited to talk
to other people who are excited about wanting to try it because I see lots of possibilities,
and just that we need further … you know, further work, further testing. DR. CARRIE MULFORD: This has been so fabulous. So, I had one more question but I’m going to turn the floor over to the participants in the interests of time. I’m sure – I see a lot
of good questions coming in. So, Mao, I’m going to turn the phone over to you and let you ask the questions that are coming on the Q&A. MAO YANG: Sure. Thanks, Carrie. I just want to thank the presenters for sharing all the information on their
Teen Dating Violence intervention. And I want to thank the
participants for joining today’s webinar and for posting several questions already. A question that had come up for Emily. Actually, there were several
questions that came up for Emily and Sarah about SBIRT. What types of teen dating violence were involved, and was there a difference between male and female
perpetration of teen dating violence? Is SBIRT similar to motivational interviewing? Is the interview protocol or script available,
and what incentives are provided to participants who were in your study? DR. EMILY ROTHMAN: Okay. So that’s a lot of questions, though. Let’s see how I can do. MAO YANG: I know. DR. EMILY ROTHMAN: Yes, motivational interviewing
is the heart of SBIRT, so that was an easy one. Males and females, I think they are, in general
conceptually, often differences in terms of … we know males tend to perpetrate more sexual dating abuse than females. Sometimes, you know, the injury after the
fact and implications and context can be different – just from a raw “looking
at the numbers” type of thing – with this intervention. We didn’t see a ton of difference in terms
of the types of behaviors that – that people are reporting. And I think Sarah was right on when she said,
“You know, look, these are kids whose – their relationships
just are toxic.” There’s bidirectional violence –
you know, to them – unfortunately, just sort of … sometimes what happens. And it’s not that the implications aren’t –
can’t be different, certainly, for males and females, but that
it’s just not all one way. You know, it’s not all male violence towards
females, and that – and that the females are actually … can
put themselves, as they grow older, at risk for being victimized. You know, but – because males, ultimately,
maybe become stronger and larger than when they’re teenagers. And so, we think that it’s worth helping them
figure out how to stop using unhealthy relationship behaviors – no matter, you know,
male, female, nonbinary gender, everybody. So, that’s one thought about that. Incentives, you know, that’s
only connected to the research part of it, but I think they got $20 for doing
baseline, and something like $25 and $30 for doing the third … three-month survey and
six-months survey), so not a ton of money but to reimburse them for their time. (Shoot, what were the other questions? I’m trying to remember. Were there other ones?) MAO YANG: I think you – no, I think you’ve
got to them all. DR. EMILY ROTHMAN: Okay. Well good. Okay. MAO YANG: How about … oh, is the script- the interview protocol or script available? DR. EMILY ROTHMAN: Oh, that’s great. Yeah, so … like Liz said, I feel a little nervous about just tossing this out there to the entire world and just having people run with it without any training. So, technically, yes. I mean, I have a Word document and I can –
I can send it to you. And, in fact, if you are one of those people
who are going to see the video, you wind up seeing pretty much all
of my materials flashed on the screen. So, if you really wanted it, too, you could probably copy them down and just start doing them. I kind of wish that people wouldn’t. I wish that they would talk to us and get –
and get training because it’s, you know … talking to a teenage perpetrator of dating violence is not just automatically easy. And I think, for me, having worked in batterer intervention for a number of years and really thought about perpetration, and then being able to distill some of the messages down into training, it still
takes me, you know, a good six hours – for sure – to train even a research assistant
who had some background in dating abuse, on how to do it and do it safely, and do it right. So, the short answer is: I like to share, and I also like it when people like to get training. MAO YANG: Great. Thank you, this is a good question for everyone. Do your studies include
transgender people and, as a follow-up to that, are your handouts available and/or
are they accessible? And the question was specifically related
to … on handouts being available in other languages. DR. EMILY ROTHMAN: Yeah, so this is Emily, and
I can say that ours is not gender dependent and we actually only – so, this
isn’t the same issue as gender – it’s sexual orientation. However, I can say that only 80 percent of
the people in our trial identified as heterosexual, and so their … I didn’t run
the numbers on the – on the number of people who identified as nonbinary gender in the
RCT, but I can tell you, there definitely were some. And it didn’t pop up in the intervention in
a – in a way that would, you know, at all make it different or work differently, or
anything like that. So, that went pretty smoothly and, in terms of languages, we wandered into starting – to try to think about Spanish a
little bit, which was, sort of, the biggest other language, next language, taught –
I mean, used at our hospital. But we haven’t gone – we didn’t want to spend
money and go down the road of translating until we knew if this
intervention had any effect or not. So … DR. ELIZABETH MILLER: And this is Liz, on the
SHARP work. In our – the school-based
help center study … actually, similar to what Emily found, there was a disproportionate – it was, like, a much, much higher number of
girls seeking care than boys. Which is what we see, really – you know, across the health care system, is that girls tend to seek health services more, and so it’s about 75 percent/25 percent by sex category. We did ask broad questions around
same-sex attraction and same-sex sexual contact. So, there was a substantial
number of sexual minority girls in our sample, and we have certainly published
on that and highlighted the extent to which sexual minority young people are at increased
or elevated risk for relationship abuse victimization (which is a whole ‘nother, sort of,
webinar and conversation). We did not, in our school-based health center
study, have a sufficient number of young people who identified as not on the gender
binary, gender queer, or transgender. In our college health center study
(which is forthcoming), we do have more college students who
are identifying as transgender and/or gender queer, and in … We hope that we will have
– and, you know, certainly want to continue to grow our research in this area. Recognizing that gender and sexual minority
youth and young adults carry, sort of, additional vulnerabilities because of bias-based
harassment, gay-related victimization, transphobia, and so forth, that are really
something we have to be able to address in our prevention programming. LISA JAMES: And, this is Lisa. I’ll just add that I mentioned the resources
that are available. We do have some specific
resources for transgender and gender- nonconforming folks and – so, those who are
available through the National Health Resource Center, and additionally, we also
have a number of our patient education cards translated into a variety of different languages. It sort of depends on the card, how many
languages are available. So, all of that’s available on our website
and if you have any follow-up questions, you see my email and
we can try to get resources that you need out to you. MAO YANG: Thanks for your responses. Another question that came in is –
Is there any specialized training provided for a medical
staff to identify reproductive coercion, and how to build agency and condom negotiations. DR. ELIZABETH MILLER: So, this is Liz Miller. I’ll take that one because it’s a question
that brings joy to my heart, which is yes, there is specialized training. And that the resources and
the training materials are available through the website that
Lisa shared but, again, the in-person training and, in particular, practicing saying the
words around how to talk about reproductive and coercion, how to do universal education
around reproductive coercion, and to actually learn to ask questions in a way that really
signal to a young person that you understand- that things like condom negotiation,
talking to your partner about the need for treatment of a sexually transmitted infection… that these are complicated and difficult conversations
to have, even in nonabusive relationships. And add the power dynamics of an unhealthy
or abusive relationship and it gets really difficult. So, the role of the health care provider – in
just saying, “we understand that these things can be complicated and that “there are people
here who can help you with navigating- that I think it is really really important, and it does include building agency around condom negotiation. Uh-hmm MAO YANG: There were a number of questions
that came in about the interventions, applying in a non-health care setting. So I’m going to, kind of, clump them all together. One question had to do with … would you
recommend it in a mental health setting, and another had to do with whether or not this could be implemented in an after-school setting or a program. DR. ELIZABETH MILLER: Was that for me,
or who’s that for? MAO YANG: That’s for anyone – that’s for all of you. DR. CARRIE MULFORD: And this is
gonna be our last question. No pressure! DR. ELIZABETH MILLER: So, for me, I would say
yes – mental health setting after school. I mean, I don’t have any reason to believe,
right now, that it wouldn’t work and I can’t think of specific barriers to, you know,
trying it and figuring out how to make it work. So, I’ll give that a “thumbs up.” LISA JAMES: And this is Lisa –
oh, go ahead, Liz. DR. ELIZABETH MILLER: Oh, no, no …
go ahead, Lisa. LISA JAMES: I was just going to say yes to
a mental health setting, and we have resources that are specific for mental health
and behavioral health. So, as I talked about, there might
be some different discussion questions that look more at how a partner might
be interfering with efforts to be … with sobriety and insanity … so, we know a lot about substance abuse and mental health coercion
as a component of an abusive relationship. So, yes, you can have – apply this approach
in mental health settings … and that you might want to tailor it a little bit – and
we have resources to help. And similarly, with after-
school settings, absolutely. We think this peer-to-peer education
and, sort of, empowerment approach is applicable for a variety
of different settings. And some of our
resources do have some specifics around health care or clinical care that you might –
that would be less appropriate for an after-school setting, but generally the approach –
around educating young people about healthy and unhealthy relationships and their
impact on health, and how they can share that information with one another – is
absolutely applicable in a number of different settings. SARAH DECOSTA: This is Sarah DeCosta. I’m in, sort of, a unique position in that my career has taken a turn into the school department
and after-school world. And so I have a perspective now of …
as someone who actually runs after-school and out-of-school time
programming. And I definitely think that something like
Real Talk could be adapted for youth in that setting. And I think that if you had the staff – that
already are working with these youth and already know them and have
a rapport in the after-school program – be the ones who were trained to deliver it, I
think it would probably actually be more effective and have probably a longer lasting impact
because it wouldn’t be trying to build a relationship and doing the intervention within it. It would be a relationship that was built
within the structure of this other program and then that’s already a trusted person. So, when they’re the ones saying, “Hey, have you thought about how this behavior is going to affect your future,” your other options?” I think it would have more weight. DR. CARRIE MULFORD: I don’t know who is speaking. This is Carrie. LISA JAMES: Carrie, can I – can I just conclude
with one quick thought? DR. CARRIE MULFORD: Yeah, you want to jump into
the last word, okay. I was – I was
… thinking that was gonna be the last one. LISA JAMES: Yeah, well, just one … one quick
thought and I – and I think I just want us to frame this whole, sort of, webinar by reminding
all of us that we’re not talking about – these are brief interventions in health center
settings – as, kind of, the be-all around prevention. Absolutely, all of the kinds of settings that
we’re talking about are critically important. I think that what we need to hold onto is
that health center settings are really unique – mental health included – in that
people who have experienced violence and trauma are going to be significantly more
likely to seek those health services. So, what we’re able to do in many ways is secondary prevention work in the health setting. And I just wanted to underscore that that while, you know, we’re thinking about all of the
different dimensions of prevention work, that the health setting is one that does have this
very unique quality. DR. CARRIE MULFORD: Well, with that final word,
I want to thank all of our presenters and all of the participants who stayed with
us for so long. I’m very impressed at how long
everyone stayed, which makes me very happy. And, like we said, we will – all the
participants will get an email with a link to the slides and the audio recording of this, within the next couple of weeks, so stay tuned for that. And I just want – I’m just so delighted,
like, to spend the afternoon with some of my most favorite people in teen dating violence work. So, thank you all so much. It’s been a pleasure. SARAH DECOSTA: Thank you. LISA JAMES: Likewise, thank you. DR. ELIZABETH MILLER: Thank you very much. EMILY ROTHMAN: Thank you.

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