Trauma-sensitive Care Research Articles

Trauma–Sensitive Residential Care: Perspectives of Portuguese Professionals to Spark Change

ABSTRACT Despite global pressure for deinstitutionalization of children in care, and recent legislative changes, Portugal remains a country with very high prevalence of residential care amongst at-risk children. These children were exposed to multiple traumatic events that can disrupt development. Thus, the expansion toward a truly sensitive approach to trauma is valuable, as it aims to increase awareness of its effects and ensure the best empathic care, providing a safe and healthy environment, with consequences also for the wellbeing of residential care staff. The present study aims to characterize the quality of residential care environments in Portugal through the lens of trauma-sensitive care, and to map professionals understanding of main domains, priorities and obstacles to change in this area. The study adopts a mixed method design, reporting on the perceptions of 85 professionals. Main findings show that professionals demonstrate better perceptions regarding physical environment but consider training and supervision as fragile dimensions. Qualitative data bring detail to these views, reinforcing the call for training to all staff and for continuous support to demanding job roles. This exploratory study highlights major aspects that urge to ensure trauma-sensitive residential care – supportive of professionals, to meet the needs of children and youth. Practice Implications The need to invest in training as the cornerstone to gather staff consensus around the importance of trauma-sensitive care and leverage change. The value of supervision in order to strengthen all residential care community. The importance of a shared theoretical background, common to all staff, to ensure secure and restorative relations with children and youth in line with trauma-sensitive care. The added value of the Trauma-Sensitive Care Evaluation Questionnaire for Welfare System as a tool to guide and monitor organizational change and its multilevel impact.

Veterans with chronic pain: Examining gender differences in pain type, overlap, and the impact of post-traumatic stress disorder.

Women are more likely to experience multiple overlapping pain conditions (MOPCs) relative to men. Post-traumatic stress disorder can negatively impact the severity and trajectory of chronic pain and its treatment. Specific associations between gender, post-traumatic stress disorder (PTSD), and MOPCs require further examination. A cohort of all Veterans in 2021 who met criteria for one or more of 12 chronic pain types was created using national Veterans Health Administration administrative data. MOPCs were defined as the number of pain types for which each patient met criteria. Multivariable logistic regression models estimated gender differences in frequency for each of the 12 pain subtypes, after controlling for demographics and comorbidities. Negative binomial regression was used to estimate gender differences in the count of MOPCs and to explore moderation effects between gender and PTSD. The cohort included 1,936,859 Veterans with chronic pain in 2021, which included 12.5% women. Among those with chronic pain, women Veterans had higher rates of MOPCs (mean = 2.3) relative to men (mean = 1.9): aIRR = 1.31, 95% CI: 1.30-1.32. PTSD also served as an independent risk factor for MOPCs in adjusted analysis (aIRR = 1.23, 95% CI: 1.23-1.24). The interaction term between gender and PTSD was not significant (p = 0.87). Independent of PTSD, depressive disorders also served as a strong risk factor for MOPCs (aIRR = 1.37, 95% CI: 1.36-1.37). Individuals with MOPCs and PTSD may have complex treatment needs. They may benefit from highly coordinated trauma-sensitive care and integrated interventions that simultaneously address pain and PTSD. Women were significantly more likely than men to experience MOPCs. PTSD was also significantly, independently, associated with MOPCs. Patients, particularly women, may benefit from tailored interventions that address both trauma and MOPCs.

Travma Bilgili Bakım Ölçeği: Türkçe Geçerlilik ve Güvenilirlik Çalışması

The aim of this study is to adapt the trauma-informed care scale, a scale developed to measure the level of knowledge, attitude and practice related to trauma-informed care, to Turkish culture by making the appropriate analysis. 161 mental health professionals participated in this survey model study. The data of the study were collected by using the convenience sampling method, the demographic information form and the Trauma Informed Care Scale. The data were generated through the online data collection platform surveey.com. It was determined that most of the mental health professionals (70.2%) in the study had never heard of the trauma-informed care model, and 87% did not use this model in their practice. The EFA analysis showed that a 3-factor structure was emerged, which explained 50.36% of the total variance and in which all items were included in the subscales of the original scale. According to the results of the analyzes, 3 items in the Attitude subscale were removed from the total items of the scale and the final version of 18 items scale that could be used in Turkish culture was created. The correlation analyzes showed that the total mean score was highly and positively correlated with all subscales. The Trauma-Informed Care Scale is a reliable measurement tool with proven structural validity and suitable for use by mental health professionals (physicians, nurses, psychologists, psychological counselors, social workers) working with trauma survivors, and researchers planning studies on trauma-informed care and/or trauma-sensitive care.

Trauma and the perinatal period: A review of the theory and practice of trauma-sensitive interactions for nurses and midwives.

With high rates of trauma in the population, known links between trauma and perinatal distress, and the intimate and close nature of the nursing and midwifery roles, ensuring awareness and understandings of trauma is crucial for guiding practice. This paper aims to explore the relationship of trauma to the perinatal period, based on theory and practice, to consider on how nurses and midwives can deliver trauma-sensitive interactions. This discursive discussion draws on relevant research from the fields of trauma therapy, attachment theory and nursing and midwifery practice to consider elements of trauma-sensitive practice in the perinatal period. Nurses and midwives can foster safety for people who have experienced trauma through noticing and responding to triggers, supporting awareness of attachment and its relationships to trauma, undertaking psychosocial screening with care, supporting linearity and cohesion in narratives and developing collaborative care plans that maximise safety and agency. For nurses and midwives, understandings of the relationship between trauma, pregnancy, birth, early parenting and distress is crucial for effective care delivery. Delivering perinatal nursing or midwifery care of any kind, without universal trauma precautions risks reinforcing, misinterpreting or re-enacting dynamics of trauma. To be trauma-sensitive in this period requires nurses and midwives to have awareness of the dynamics of trauma in relation to pregnancy, birth and attachment. This paper fills a gap in the translation of theory to practice for trauma-sensitive care in the perinatal period, with a focus on the therapeutic relationship formed by nurses and midwives. The findings highlight that nurses and midwives can foster safety for people who have experienced trauma within their practice, when they hold a robust understanding of the relationship between trauma, pregnancy, birth, early parenting and distress. No patient or public contribution.

Art is Patient: A Museum-Based Experience to Teach Trauma-Sensitive Engagement in Health Care.

Psychological trauma is ubiquitous, an often hidden yet influential factor in care across clinical specialties. Interdisciplinary health professions education is mobilizing to address the importance of trauma-sensitive care. Given their attention to complex human realities, the health humanities are well-poised to shape healthcare learners' responses to trauma. Indeed, many such arts and humanities curricula propose narrative exercises to strengthen empathy, self-reflection, and sensitive communication. Trauma, however, is often unwordable, fragmentary, and physically encoded, incompatible with storying methods. This article presents a recent innovation, the Art is Patient seminar series, which focuses on aesthetic exercises to help learners access and share non-verbal, embodied, and relational responses to art. Based in an art museum context, it provides successive experiences of approaching, witnessing, and engaging with visual art as an analogue to developing trauma-sensitive relationships. Reflections on the process locate the seminar vis-à-vis health humanities practices, aesthetics, and trauma-informed approaches.

De-Implementing a Point and Level System in Youth Residential Care without Increased Safety Risk: A Case Study

ABSTRACT Point and level (P&L) systems are commonly used for behavior management and modification in youth residential treatment centers. In 2019, the Association of Children’s Residential Centers (ACRC) released a position paper urging youth residential programs to abolish prescriptive, universally applied point and level systems because they are inconsistent with the principles of trauma-sensitive care and can be counterproductive to treatment. Despite this, few residential agencies have executed this change, possibly due to the complexities of dismantling long-held practices, concerns about youth safety, and lack of knowledge about other trauma-sensitive approaches. In this case study, we describe how one agency de-implemented its universal P&L system across three residential campuses, replacing it with the Neurosequential Model of Therapeutics (NMT) and Collaborative Problem Solving (CPS). An analysis of administrative data before and after the removal of P&L suggests no evidence of increased safety risk for youth or staff. We discuss the agency’s strategies for de-implementation and the determinants that helped and hindered the process and provide recommendations for other residential agencies seeking to make this change.

Care When It Counts: Establishing Trauma-Sensitive Care as a Preventative Approach for 0–3-Year-Old Children Suffering from Trauma and Chronic Stress

Adverse childhood experiences are an important societal concern. Children aged 0–3 are particularly vulnerable to unpredictable chronic stress due to the critical period for brain development and attachment. Trauma-sensitive care is a preventative approach to reduce the burden of stressful experiences by committing to positive relationships. Professional caregivers are ideally placed to offer trauma-sensitive care; however, earlier research reveals that the tools they need to consciously apply trauma-sensitive care principles are missing. The current study organized living labs (co-creative research method) to present trauma-sensitive care as a preventative approach aimed at children aged 0–3. Two living labs were organized in Belgium and Hungary, where professional caregivers collaborated to create a protocol that offers guidelines on how to implement trauma-sensitive care. The resulting protocol included a theoretical foundation on trauma as well as a translation of these guidelines into practical recommendations. The protocol was evaluated by incorporating it into a training intervention delivered to 100 professional caregivers from childcare organizations across four European countries. The protocol received positive feedback from participants, with results indicating a self-reported increase in knowledge, attitude and practice of trauma-sensitive care principles. We conclude that this trauma-sensitive care protocol is a promising answer to the needs of professional caregivers working with children aged 0–3.

The ethical imperative of trauma-sensitive care for electroconvulsive therapy (ECT)

Background The empirical literature on the lived experience of electroconvulsive therapy (ECT) is limited, divergent, and largely focused on the experiences of procedures, (adverse) effects, information provision, or decision-making. Aims This study aimed to investigate aspects related to the lived experience and meaning-making of people who have had ECT. Method In-depth interviews with 21 women (21–65 years old) were analyzed using interpretative phenomenological analysis (IPA). Findings A subgroup of nine participants described more negative experiences with ECT. A common factor for these participants was the experience of trauma that remained under-treated. The superordinate themes identified were a lack of trauma-based and recovery-oriented treatment. The rest of the sample (12) expressed more positive experiences with ECT. Conclusions This study suggests that exploring more broadly the impacts of ECT at the long term offers insights that can help design more person-centered services aligned to the needs of the treatment recipients. Educational modules for mental health care staff should include, besides knowledge on the methods’ effectiveness, additional evidence about treatment recipients’ subjective concerns and the relevance of trauma and recovery-oriented care models.

THE UNPRECEDENTED COVID-19 EFFECT: SECONDARY TRAUMA IN PATIENTS & STRATEGIES FOR CLINICAL PRACTICE

Whether one is a new graduate from nursing school, a skilled veteran of many crises, or well-versed in trauma, the need to understand COVID-19 secondary trauma cannot be overstated. It reflects on our daily lives, with the flow into our workplaces. Dealing with another’s suffering is not something that most (except a noticeable few) have been trained for. When it comes to communication, many rely on spoken language at the expense of the rest of our communication toolbox. People suffering secondary trauma might withdraw or be resigned to bad behavior to avoid physical harm. One way to support people with secondary trauma stress is through mindfulness techniques based on trauma-sensitive care. There are simple ways healthcare workers can help patients become calm, help connect, and communicate more effectively with others. The purpose of this paper is to provide clinical practice strategies for secondary trauma in patients.

Training to Enhance the Knowledge and Comfort Level of Emergency Physicians Providing Care for Survivors of Sexual Assault.

Although sexual assault (SA) is a substantial public health problem, emergency physicians do not universally undergo continuing education on caring for survivors of SA. The goal of this intervention was to develop a training course that improves physician understanding of trauma-sensitive care in the emergency department and equips physicians with knowledge of the specialized care required to treat SA survivors. Thirty-nine attending emergency physicians underwent a 4-hour training on trauma-sensitive care for survivors of SA and completed prequestionnaires and postquestionnaires to assess training efficacy in improving knowledge base and comfort level providing care. The training consisted of didactic portions focused on the neurobiology of trauma, communication skills, and forensic evidence collection techniques and a simulation portion with standardized patients to practice evidence collection and a trauma-sensitive anogenital examination. Physicians demonstrated significantly improved performance (P < .05) on 12 of 18 knowledge-based questions. Physicians also showed significant improvement (P < .001) on 11 of 11 Likert scale questions that assessed comfort level communicating with survivors and using trauma-sensitive techniques during medical and forensic examinations. Physicians who received the training course demonstrated a significantly improved knowledge base and comfort level treating survivors of SA. Considering the prevalence of sexual violence, it is imperative that physicians are appropriately educated on trauma-sensitive care.

A Call to Action for Delaware:: Why Recruiting and Sustaining a Culturally and Linguistically Diverse Behavioral Health Workforce is Integral to Trauma-Sensitive Care.

A Call to Action for Delaware:: Why Recruiting and Sustaining a Culturally and Linguistically Diverse Behavioral Health Workforce is Integral to Trauma-Sensitive Care.

Enhancing Mental Health Outcomes for Adolescent and Older Veterans through Conflict Management and Therapeutic Communication Strategies in Trauma-Informed Care

Objectives: This study investigates the application of Trauma-Informed Care (TIC) for military veterans, particularly those with trauma-related experiences, emphasizing conflict management and therapeutic communication. It focuses on addressing the unique needs of adolescent and older veterans to improve mental health outcomes and facilitate smoother transitions to civilian life. Method: The research examines TIC’s effectiveness in enhancing veterans' emotional regulation, collaborative problem-solving, and interpersonal conflict management skills. It emphasizes therapeutic communication techniques such as active listening and reflective statements to foster trust and support veterans in exploring their emotions safely. Results: TIC helps adolescent veterans, who often struggle with emotional expression, and older veterans, who may have repressed emotions over time, in managing conflicts and understanding their trauma. Therapeutic communication under TIC builds trust between veterans and healthcare providers, facilitating open emotional expression. However, barriers, including limited TIC training for healthcare providers, rigid care structures, and organizational constraints, impede effective implementation. Discussion: While TIC provides a promising framework for supporting veterans, its success relies on overcoming institutional challenges. Expanding training, restructuring healthcare models, and fostering an organizational culture that prioritizes trauma-sensitive care are critical steps to fully integrating TIC. Addressing these challenges could significantly improve mental health outcomes for adolescent and older veterans, promoting resilience and facilitating successful reintegration into civilian life.

The Relationship Between Sexual Assault History and Cervical Cancer Screening Completion Among Women Veterans in the Veterans Health Administration.

Background: Sexual assault affects one in three U.S. women and may have lifelong consequences for women's health, including potential barriers to completing cervical cancer screening and more than twofold higher cervical cancer risk. The objective of this study was to determine whether a history of sexual assault is associated with reduced cervical cancer screening completion among women Veterans. Materials and Methods: We analyzed data from a 2015 survey of women Veterans who use primary care or women's health services at 12 Veterans Health Administration facilities (VA's) in nine states. We linked survey responses with VA electronic health record data and used logistic regression to examine the association of lifetime sexual assault with cervical cancer screening completion within a guideline-concordant interval. Results: The sample included 1049 women, of whom 616 (58.7%) reported lifetime sexual assault. Women with a history of sexual assault were more likely to report a high level of distress related to pelvic examinations, and to report ever delaying a gynecologic examination due to distress. However, in the final adjusted model, lifetime sexual assault was not significantly associated with reduced odds of cervical cancer screening completion (OR 1.35, 95% CI 0.93-1.97). Conclusions: Contrary to our expectations, sexual assault was not significantly associated with gaps in cervical cancer screening completion. Three- to five-year screening intervals may provide sufficient time to complete screening, despite barriers. Trauma-sensitive care practices promoted in the VA may allow women to overcome the distress and discomfort of pelvic examinations to complete needed screening. ClinicalTrials.gov (#NCT02039856).

Implementing a program to reduce restraint and seclusion utilization in a public-sector hospital: Clinical innovations, preliminary findings, and lessons learned.

The Alternative to Restraint and Seclusion State Incentive Grant was a national initiative to reduce restraint and seclusion use in psychiatric hospitals and community based mental health settings sponsored by the National Association of State Mental Health Program Directors. This initiative was implemented in a large public sector psychiatric hospital. It involved the use of a restraint and seclusion prevention project team and a Patient-Staff Steering Committee collaborating on violence prevention. It also entailed systematic data collection and case reviews, staff-training on trauma-sensitive care and other relevant topics, employee recognition, as well as the use of specific restraint prevention tools including sensory modulation, positive behavioral support plans, comfort rooms, Wellness Recovery Action Plans, modified restraint orders, and new debriefing protocols. Compared with a 4-year baseline period, a 4-year implementation phase showed a reduction in annual restraints hours by 89%, annual staff injuries by 18%, and annual Workmen's Compensation medical costs by 24%. The findings illustrate the value of implementing systemic evidence-based practices to reduce restraint use, enhance the quality of care in tertiary care settings, and promote a new, patient-centered and recovery-oriented institutional culture. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Survivors' Input on Health Care-Connected Services for Intimate Partner Violence.

Background: Intimate partner violence (IPV) is increasingly recognized as a social factor impacting health, and health care providers are encouraged to routinely screen and refer patients for needs related to IPV. Health care settings are often challenged, however, in their ability to connect patients with community-based IPV services. Some organizations have invested in on-site programs to facilitate identification and connection. Methods: The goal of this study was to understand IPV survivors' experiences with and perspectives on health care-connected IPV services. Semistructured in-depth interviews were conducted in-person by a trained and experienced interviewer and were audio-recorded and transcribed verbatim. Interview transcripts were analyzed using team-based qualitative thematic content analysis. Participants included 68 individuals who had experienced IPV, recruited through one of two settings: (1) a health care organization with embedded IPV services or (2) a community-based IPV service organization that partners with health care settings. Results: Interviews revealed benefits of having health care-connected IPV services, including that the health care setting can be critical for providing information about IPV programs and that survivors may need assistance with navigation of community services. Survivors further highlighted recommendations for trauma-sensitive care that includes providing clarification about the role and scope of IPV services, following-up with but not forcing intervention, and ensuring privacy, confidentiality, and trust in interactions. Conclusions: Findings support health care settings having in-house or close partnership with IPV advocates to adequately support patients' needs in connecting with and navigating community based IPV-related services.

The "3 Es" of trauma-informed care in a federally qualified health center: Traumatic Event- and Experience-related predictors of physical and mental health Effects among female patients.

Federally Qualified Health Centers (FQHCs) are a fast-growing source of healthcare for women with intersectional identities, or those most frequently exposed to and negatively impacted by interpersonal trauma. According to the "3 E" conceptualization of trauma, certain Event- and Experience-related characteristics of a trauma predict victims' physical and mental health Effects. The "3 Es" have yet to be studied in female FQHC patients. The current study examined the prevalence of interpersonal trauma and interrelationships among traumatic Event-related factors (e.g., cumulative trauma by victim-perpetrator relationship), Experience-related factors (e.g., betrayal, resilience), and Effects (e.g., somatic symptoms, posttraumatic stress (PTS), anxiety/depression, mistrust, reduced sense of safety) among 138 predominantly Black (89.1%) women receiving care at an FQHC in the southeastern U.S. Roughly 65% of participants (n = 86) endorsed exposure to at least one type of interpersonal trauma. More cumulative trauma was significantly correlated with more somatic, PTS, and anxious/depressive symptoms,and a reduced sense of safety. Experiences of betrayal and/or resilience were better predictors of PTS and anxious/depressive symptoms and lack of safety than Event-related factors. Findings support the need for the implementation of trauma-informed care within community-based health centers. Healthcare providers should consider women's subjective experience of trauma when screening for exposure and providing trauma-sensitive care.

Buffering the effects of childhood trauma within the school setting: A systematic review of trauma-informed and trauma-responsive interventions among trauma-affected youth

Exposure to trauma during childhood is highly prevalent. This review seeks to evaluate the current state of the literature in regard to trauma-informed care within the school setting. A number of models have been put forth to describe broad trauma-informed approaches integrated within school systems, which incorporate trauma-sensitive care and practices within the broader structure of an organization. The goal of this paper was to systematically review papers detailing relevant interventions to the provision of trauma-informed and trauma-responsive practices within schools. Using a three-tiered system of service delivery as our organizing framework (where the level of support increases across tiers depending on the student’s individual needs), the research that has evaluated the efficacy of trauma-informed interventions is reviewed. Results indicated that much of this work has been exclusively conducted within one level of a three-tiered system that comprises a trauma-informed approach to the school setting. Although there is a foundation of research on interventions applied within specific tiers, few studies have sought to integrate the tiers to test the effectiveness of a fully trauma-informed model within the educational system and most that have integrated the three tiers do not include statistically rigorous evaluations of program effectiveness, such as randomized control trials. A basic model for trauma-informed schools with considerations for intervening directly with students is provided as well as recommendations for future research, which is necessary to inform clear, specific models for fully integrated trauma-informed schools.

Barriers to the access and utilization of healthcare for trafficked youth: A systematic review

BackgroundHealthcare has been identified as an important target for training on identification of trafficked youth. Survivors of human trafficking experience challenges in accessing healthcare, both during enslavement and in survivorship. ObjectiveTo examine the current evidence in the literature regarding barriers to healthcare faced by trafficked youth. MethodsA systematic review of the literature was conducted using the PRISMA guidelines. Through an electronic database search, articles were screened and included if they primarily addressed victims or survivors of child trafficking and focused on barriers to healthcare or problems accessing healthcare. Articles were assessed for overall quality. Data from the articles selected for review were organized into major themes using a framework analysis. ResultsOf 3,274 articles resulting from the search, 8 were included in the review. Three sub-themes were coded and classified as extrinsic, intrinsic, and systemic barriers. Extrinsic barriers included trafficker control, physical confinement, and influence of peers. Intrinsic barriers included discrimination, confidentiality, trust in healthcare providers, knowledge of the healthcare system, and emotional reluctance. Systemic issues inherent to the healthcare system included healthcare provider knowledge, complex registration process, language barriers, appointment times, and service coordination. ConclusionThe combination of extrinsic, intrinsic, and systemic barriers leads to reduced utilization and access to medical services for trafficked youth. While extrinsic and intrinsic factors are difficult to eliminate given the clandestine nature of human trafficking, systemic barriers can be eliminated through improving effective training for healthcare providers on identification of victims and implementing trauma sensitive care.

Primary Care Providers' Perspectives on Providing Care to Women Veterans with Histories of Sexual Trauma.

One in four women Veterans who use the Veterans Health Administration (VA) screen positive for military sexual trauma and may need trauma-sensitive care and coordination. VA primary care providers (PCPs), women veterans' main source of care, need to be well-versed in trauma-sensitive approaches to care. Women veterans' numerical minority in the VA can make provider exposure to female patients inconsistent, which may impede PCP experience in providing appropriate care. To inform strategies for improving trauma-sensitive primary care, we sought to better understand PCPs' current approaches to providing care to women veterans with sexual trauma histories. We conducted semistructured telephone interviews with PCPs (n=28) practicing in VA primary care clinics. Participants were asked about their experiences delivering trauma-sensitive care as well as best practices. Interviews were recorded, transcribed, and analyzed for major themes regarding barriers to and facilitators of trauma-sensitive care. Participants expressed challenges delivering care to women with sexual trauma histories, including 1) insufficient time, 2) lack of perceived proficiency and/or personal comfort (with general physical examinations as well as gender-specific care such as Pap, breast, and pelvic examinations), and 3) difficulties with fostering positive patient-provider relationships. Access to mental health resources was noted as a key facilitator of providing trauma-sensitive care. Participants also shared existing (and potential) best practices and recommendations, such as paying special attention to patient behavioral cues related to comfort. PCPs delivering care to women in VA facilities may benefit from an increased awareness of best practices to facilitate the delivery of trauma-sensitive care.

A feasibility study of trauma-sensitive obstetric care for low-income, ethno-racial minority pregnant abuse survivors

Purpose: This study evaluated the feasibility and acceptability of an integrated (psychological and obstetric) intervention for pregnant abuse survivors with posttraumatic stress symptoms (PTS) from low-income, ethno-racial minority backgrounds.Methods: Trauma-sensitive obstetrics to promote control, anxiety-reduction and empowerment (TO-CARE) offers cognitive-behavioral therapy (CBT) coping skills delivered over six sessions by therapists, coupled with trauma-sensitive obstetric care from specially-trained obstetric physicians.Results: Participants were 21 women who completed at least three sessions of CBT, totaling 51.2% of eligible participants. Participants received approximately one-third (M = 2.29; SD = 2.15) of their prenatal visits with obstetric residents trained in trauma-sensitive care. Nearly all participants (95%) reported that they benefited from the intervention. Although most participants demonstrated improvement in PTS, only four demonstrated reliable improvement, and two demonstrated reliable improvement in depression symptoms. These improvements appeared to be maintained at postpartum follow-up for two of the participants.Conclusions: Our findings suggest that TO-CARE was acceptable to pregnant abuse survivors and may be a promising intervention to reduce symptoms of distress. Implications of the low retention rate for the CBT (51.2%) are discussed in the context of interventions for low-income minority pregnant women. Limitations regarding feasibility of the integrated intervention are discussed.