Issues in Mental Health Nursing, 35:906–913, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.931496

Community-based PTSD Treatment for Ethnically Diverse Women Who Experienced Intimate Partner Violence: A Feasibility Study Ursula A. Kelly, PhD, ANP-BC, PMHNP-BC Atlanta VAMC, Nursing and Patient Care Services, Decatur, Georgia, USA and Emory University, Nell Hodgson Woodruff School of Nursing, Atlanta, Georgia, USA

Kourou Pich HarborCOV, Inc., P.O. Box 505754, Chelsea, Massachusetts, 02150 USA

The objectives of this study were to: (1) Determine the feasibility of a community-based intervention for Latinas with PTSD who experienced IPV; (2) Explore the intervention effectiveness in reducing PTSD and improving quality of life, social support and self-efficacy. This was a feasibility study, using intervention pretest/post-test qualitative and quantitative data. The experience of living through and surviving IPV was far more important than ethnicity in cultural identity. Significant reductions in PTSD and MDD and increased self-efficacy were sustained 6-months postintervention. Culturally relevant mental health IPV interventions can be feasible and appropriate across ethnic groups.

INTRODUCTION Intimate partner violence (IPV) is reported by Latina women at rates equal to or greater than non-Latinas; lifetime prevalence estimates are as high as 44.6% (Bonomi, Anderson, Cannon, Slesnick, & Rodriguez, 2009). Post-traumatic stress disorder (PTSD) and depression are well-documented as the most common psychological sequelae of IPV for women, regardless of ethnicity (Basile, Arias, Desai, & Thompson, 2004; Campbell, 2002; Ellsberg et al., 2008; Golding, 1999; Pico-Alfonso, 2005). The prevalence of PTSD among battered women ranges from 31% to 84% (Golding, 1999). Women who are experiencing IPV are nearly three times more likely (RR 2.70; 95% CI) to have major depression than those who are not (Beydoun, Beydoun, Kaufman, Lo, & Zonderman, 2012). Rates of PTSD and major depressive disorder (MDD) are significantly higher among general Latina populations and Latinas who experienced IPV, than their Anglo-American counterparts (Caetano, Field, RamisettyMikler, & McGrath, 2005; Fedovskiy, Higgins, & Paranjape, Address correspondence to Ursula Kelly, Emory University School of Nursing, 1520 Clifton Rd. NE, Atlanta, GA 30322, USA. E-mail: [email protected]

2008; McFarlane et al., 2005). In a preliminary study conducted in 2005 at the site for the study reported here, we found that of the immigrant Latinas in the sample (n = 33), 69.7% met the diagnostic criteria for PTSD; 57.6% for MDD; and 54.5% had comorbid PTSD and MDD (Kelly, 2010a, 2010b). This pilot study evaluated the feasibility and preliminary effectiveness of a community-based group psychotherapy intervention for PTSD in immigrant Latina women who experienced IPV. Specific aims were to: (1) Determine the feasibility of the study, including recruitment, acceptability of the intervention and implementation logistics; (2) Determine the extent to which the group psychotherapy intervention (a) reduces the quantity, severity and duration of symptoms of PTSD and major depressive disorder (MDD), (b) improves health-related quality of life (HRQoL) and (c) increases perceived social support and selfefficacy. This study was conducted using a community-based participatory research (CBPR) approach (Minkler & Wallerstein, 2003). This was the fourth study conducted during a 9-year collaboration with a domestic violence services agency in an urban area in the US northeast. This research collaboration developed in the context of an established working relationship between a nurse practitioner in a neighborhood health center and this community-based social services agency. The need for this study, specifically a community-based mental health intervention for PTSD, was identified by and advocated for by the community partner (Kelly, 2009b), based on barriers to health care encountered by this population. Previous studies were focused on describing the healthcare experiences and current mental and physical health of the Latinas who participated in the domestic violence services agency (Kelly, 2006, 2009a, 2010a,b). CBPR is a collaborative process in which community partners and researchers mutually participate in research, draw on the strengths of each partner, and address topics of concern to the community, including health disparities. It is a joint

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process with equal contribution by partners. Key features of CBPR are that it builds on strengths and resources within the community, promotes co-learning and capacity building among all partners, integrates and achieves a balance between research and action for the mutual benefit of all partners, involves community systems development and involves a long-term process and commitment (Minkler & Wallerstein, 2003). IPV, HEALTH CONSEQUENCES AND ACCESS TO HEALTH CARE FOR IMMIGRANT LATINAS PTSD appears to be the most significant mediator in the relationship between exposure to violence and negative health outcomes and functioning (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006; Green & Kimerling, 2004). Trauma and consequent PTSD are linked with risky behaviors, such as substance abuse and lack of health promoting behaviors, e.g., exercise, safer sex, and receiving health care (Rheingold, Acierno, & Resnick, 2004). Abused women have significantly lower HRQoL and self-assessed health than non-abused women (Alsaker, Moen, & Kristoffersen, 2008; Denham et al., 2007; Lown & Vega, 2001). Data suggest that physical and mental health symptoms are magnified and long-lasting among immigrant Latinas, who face additional stressors, including high levels of social isolation and entrapment (Kelly, 2006, 2009a; Ramos & Carlson, 2004); exacerbating cultural factors (Watson, 2010); overall health disparities (Smedley, Stith, & Nelson, 2003; Vega, Rodriguez, & Gruskin, 2009); barriers to healthcare access (Garc´es, Scarinci, & Harrison, 2006); and limited English proficiency (LEP) (Bauer, Rodr´ıguez, Quiroga, & Flores-Ortiz, 2000; Flores, 2006). Social support and material resources have been found to mediate the relationship between IPV and symptoms of PTSD (Coker et al., 2002; Glass, Perrin, Campbell, & Soeken, 2007). However, for abused immigrant Latina women, social isolation, undocumented immigration status, loss of family support network due to immigration, LEP, and lack of material resources increase vulnerabilities to the effects of trauma (Nurius et al., 2003), and serve as barriers to help-seeking (Bauer et al., 2000; Raj & Silverman, 2002). The group format of the intervention in this study was used with the hope of increasing social support, thus moderating the relationship between IPV and symptoms of PTSD. Also, group psychotherapy is more financially feasible than individual therapy. METHODS Initial Study Design The initial study design consisted of two phases. First, preintervention qualitative interviews with staff members (n = 4) and immigrant Latina participants (n = 10) in a domestic violence services agency were conducted to explore the participants’ experiences and manifestations of PTSD symptoms and access to culturally appropriate mental health care. The second

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phase, the findings of which are reported here, was planned as a one-group pre-test/post-test design to evaluate the feasibility and preliminary effectiveness of the intervention. The target sample was 12 Spanish-speaking immigrant Latinas, with limited or no English proficiency and clinically significant symptoms of PTSD. Data collection was planned at three time-points, including pre-intervention and 2 weeks and 3 months postintervention, including both qualitative and quantitative data. Study design modifications to address recruitment feasibility and the needs of the community partner Over the course of the study, consistent with CBPR, the study design was adapted in response to the shifting priorities and needs of the community partner, recruitment challenges, and demand for the intervention by a broader group. The significant changes to the design were incremental and included expanding the target population demographically (ethnicity, immigration status, non-Spanish speaking), adding intervention groups, and extending the follow-up data collection period. These specific changes also addressed feasibility challenges in recruitment and retention. Despite the initial perception of the study site staff that they had an ample pool of immigrant Latinas with LEP who had significant symptoms of PTSD and who were not receiving mental health treatment, the initial rate and pace of referrals to the study was lower than expected and delayed the initial implementation of the intervention. Agency staff frequently referred women who did not fit the initial inclusion criteria (immigrant, self-described Latino/Hispanic, separated from abuser for >30 days, fluent in Spanish, and clinically significant symptoms of PTSD). After the first intervention group (n = 10), at the request of the community partner and responding to their participants’ need for mental health treatment, we conducted a second intervention group, including both immigrant and non-immigrant Latinas with Spanish and/or English proficiency (n = 6). Both of these groups were conducted using bicultural, bilingual interpreters. Finally, also at the request of our community partner, we conducted a third intervention group (n = 6) in English that included women representing a variety of ethnic and cultural backgrounds, including three US-born women (two white, one African-American), one woman born in Puerto Rico, and two immigrants, born in Guatemala and Cambodia, respectively. The original target sample size for the intervention was 12, with the goal of retaining 8–10 women through final data collection at 3 months post-intervention. The final sample size for the intervention was 22, with 16 women completing data collection through final follow-up data collection, which was extended to 6 months post-intervention. These expansions of the study in terms of sample size and the timeframe for follow-up were enabled by lower study expenses than anticipated. The study site provided childcare during the data collection and intervention sessions at no cost to the study to improve retention; graduate nursing students assisted with data collection.

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Initial Intervention Content and Implementation The initial intervention consisted of 6–10-session weekly psychotherapy groups, using a synthesis of supportive psychotherapy, including psycho-education and self-care strategies. Specific topics included PTSD 101; relationships with self, children, and others; sleep hygiene, mindful eating, the relaxation response, and exercise; faith and family. The 90-minute group sessions were structured using a facilitator manual and a participant workbook developed for this study. Workbooks were produced in Spanish and in English, using a process of translation and back-translation, conducted by bicultural, bilingual Latina translators. Each session addressed a specific topic and included experiential exercises when appropriate. The intervention was conducted by two advanced practice psychiatric nurses (PMHCNS and PMHNP), with experience in treating survivors of IPV with PTSD. The first group was conducted in Spanish using an interpreter, as the interventionists did not speak Spanish. Establishing physical safety both within and outside of the group sessions was a priority and included the use of a Safety Protocol (Campbell, Webster, & Glass, 2009). The study was approved by appropriate Institutional Review Boards and by the co-directors of the study site. Revised Intervention Content The initial intervention was revised for the third group (see Results, Aim 1), with the addition of Acceptance and Commitment Therapy (ACT). Mindfulness, a central skill in ACT, is used to address avoidance by assisting clients to be aware of ongoing experience in the present moment. In contrast to traditional cognitive behavioral therapy (CBT), which seeks to modify and control problematic thoughts in order to affect emotion, i.e. to feel better, and therefore to behave better, ACT is explicitly contextualistic and focuses on the functions of thoughts, emotions, and physiologic reactions (Walser & Westrup, 2007). The client is helped to recognize thoughts, emotions, and physiologic reactions as distinct phenomena, separate from themselves, and to understand that these phenomena do not have to be controlled in order to make life-affirming decisions. These thoughts, emotions and physiologic reactions associated with PTSD do not have the deterministic power that clients often perceive them to have. The core components of ACT include: Creative Hopelessness; Control as the Problem; Willingness; Self-as-Context; Valued Living; and Committed Action (Walser & Westrup, 2007). ACT addresses experiential avoidance, a central feature of PTSD. A central tenet of ACT is that attempts to prevent, modify or avoid painful internal experiences are the cause of suffering, and paradoxically, generally exacerbate the very experiences one is trying to avoid (Hayes, Strosahl, & Wilson, 1999). Variables and Measurement Demographic variables included age, level of education, and information about English-proficiency, immigration status, IPV types and severity, and aspects of the abusive relationship. The Index of Spouse Abuse (ISA) was used to measure physical

abuse (ISA-P) and non-physical abuse (ISA-NP) (Hudson & McIntosh, 1981). The clinical cut-off scores for the ISA-P and ISA-NP are 10 and 25, respectively. The ISA was used as an inclusion criterion. Lifetime trauma was assessed using the Trauma History Questionnaire (Green, 1996). The Danger Assessment (Campbell, 1995) was used to assess the risk of homicide by an intimate partner. Several outcome variables were included. The PTSD Checklist–Civilian Version (PCL-C) was used to measure symptoms of PTSD (Weathers, Litz, Herman, Huska, & Keane, 2003). The suggested clinical cut-off score in civilian populations is 30–35 (National Center for PTSD, 2013). The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure depressive symptoms (Radloff, 1977). A score of ≥24 is indicative of severe MDD, with a possible range of 0–60. Pertinent items were used from the CDC Behavioral Risk Factor Surveillance System (CDC BRFSS) to assess HRQoL, specifically, self-rated health on a Likert scale, and days in the past month physical health and days in past month mental health was ‘not good’ (Centers for Disease Control, 2013). Additional measures included the General Self-Efficacy Scale (GSE) (Schwarzer & Born, 1997) and the Tilden Interpersonal Relationship Inventory (IPRI) Support sub-scale, to assess social support (Tilden, Hirsch, & Nelson, 1994). All measures were selected based on established psychometric reliability in both English- and Spanish-speaking populations and Spanish and English versions, as well as common usage in research. Additional questions were added at follow-up time-points assessing self-management of symptoms, specifically the number of days per week participants used strategies they had learned in the intervention, and which strategies were most helpful. Data Collection Aim 1 In addition to the pre-intervention interviews with staff and participants at the study site, focus groups were conducted separately with participants (n = 15) after each of the three intervention groups and with study staff after the first intervention group (n = 2). Focus groups and ongoing discussions were held with individual study site staff members, interventionists, and interpreters, the content of which were recorded via field notes and were used for formative evaluation. Focus groups were conducted in the language of the participants’ choice, either Spanish or English. Post-intervention individual qualitative interviews were conducted to explore participants’ views on the need for culturally-tailored interventions and ethnically homogenous groups. Aim 2 Quantitative data were collected at four points: baseline (T1); within 2 weeks of the end of the intervention (T2); 3 months post-intervention (T3) and 6 months post-intervention (T4). Quantitative measures were administered in the language of the participant’s choice, either Spanish or English.

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Data Analysis Aim 1 Data obtained for formative evaluation via focus groups, individual interviews, and individual discussions with staff and leadership from the study site and research team members were used throughout the course of the study to adapt the intervention and revise the study design, consistent with CBPR. Data from the focus groups about the acceptability of the intervention were analyzed at each data collection point, using nominal group process. This process is used to gather group members’ input into exploring a problem or planning efforts; as such, it is a well-suited approach to evaluating the intervention with stakeholders. The advantages of nominal group process is that it ensures equal input from all members and produces a set of prioritized recommendations that represent the group’s preferences and opinions. Interpretive description (Thorne, Kirkham, & MacDonaldEmes, 1997) was used to analyze data from individual interviews. In this method, individuals’ experiences are understood as contextual and constructed. Interpretive description is particularly useful in this study, in which we are seeking individuals’ observations about the context of the study intervention. All focus groups and individual interviews were transcribed in English. Transcripts were coded line by line, then considered as a whole. Individual codes were organized into themes. Aim 2 Quantitative data were analyzed using descriptive statistics to characterize the sample demographics, trauma histories, and outcome variables. Paired sample t-tests were used to explore the effectiveness of the intervention, comparing mean scores at each post-intervention follow-up time-point to mean baseline scores. Within-subject mean substitution was used to accommodate for missing individual items in multi-item instruments, e.g. CES-D. Each t-test analysis used all available data, therefore the sample size varied in some cases for pairwise comparisons related to individual outcome variables. ANOVA analysis, appropriate for this study design, was not used, given the limited sample size. SPSS© Version 21 was used for analysis. RESULTS Description of the Sample Total enrollment for three intervention groups was 27 women. Retention for the intervention was 100%, 67% and 80%, respectively for the three groups, yielding a final sample size of 22. For groups 2 and 3, women who attended the first session completed the intervention; women who did not attend the first session attended 0–4 sessions. A total of 16 of the 22 women who completed the intervention completed data collection through 6-months post-intervention, a 73% retention rate. The 22 women who completed the intervention groups ranged in age from 19–58 (mean = 36.7); had been in the USA for an average of 17.9 years; had been with the abuser for 6.15 years on

TABLE 1 Demographics of intervention sample (n = 22) n Age Education (years) Years in USA Time with abuser (years) Separated from abuser (months) Immigration status Group 1: Spanish-speaking immigrants Legal resident Undocumented Groups 2–3: English proficiency: Spanish-speaking group US citizen None to minimal Moderate to fluent

Mean

Range

36.7 10.7 17.9 6.2 9.3

19–58 0–14 7–40 1–17 2–24

3 7

12 6 4

average, and separated from the abuser for 2–24 years (mean = 9.3 months) (Table 1). These women reported very high rates of exposure to various forms of trauma. The mean scores on the ISA-P and ISA-NP abuse sub-scales were 49.79 and 70.78, respectively, the mean number of types of significant lifetime trauma reported by this population was 9.14, with a range of 2–17 out of a possible 23. The most common traumas reported were forced intercourse (72.7%); being attacked without a weapon and seriously injured (63.6%); being in a serious accident (59.1%); seeing someone seriously injured or killed (59.1%); and seeing or handling dead bodies, excluding in a funeral home (54.5%). The sample also exhibited clinically significant levels of PTSD and MDD at baseline. The mean score on the PCL was 60.25 with a range of 28–83, with a possible range of 17–85. The mean score on the CES-D was 39.40, with a range of 12–60. Of the 20 women in the sample for whom CES-D data were available, only two did not meet the criterion for MDD (mean total score > 24). Relative to the women with MDD, these two women were younger (mean age = 31.5), had been in the USA for an average of 14.5 vs 17.9 years, had been with the abuser longer (mean = 8.5 years), and separated from the abuser for 6.1 months vs 9.3 months. Aim 1: Determine the Feasibility of the Study, Including Recruitment, Acceptability of the Intervention, and Implementation Logistics Recruitment The recruitment challenges and our response to them are described above. Over-worked staff members were unable to appropriately screen and refer potential participants.

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Additionally, they over-estimated the sample pool size (immigrant Latinas with LEP and PTSD), possibly because of this population’s multiple needs and barriers to care. The Intervention: What Worked, What Didn’t, and What We Changed The intervention content and implementation were modified based on early results. The intervention content was modified after the first and second groups in response to participant feedback and post-intervention data, which indicated that they found the mindfulness-related components the most helpful and most sustainable strategies for self-management of symptoms of PTSD and MDD. Thus, ACT modules replaced some of the initial self-care content (e.g. physical exercise) in the third group, for example ‘Noticing and managing your emotions, thoughts, and memories.’ Meditation, relaxation breathing, and positive affirmations were ranked by the participants as the most appealing and effective strategies they learned in the group sessions. Language and interpretation: ‘We all understood each other anyway’. Participants in the group conducted with an interpreter reported that their sense that the therapists cared about them as individuals was more important than congruent language and culture. They described feeling understood, despite the lag time and potential errors in interpretation, as the therapists were attentive to their body language and tone of voice. The therapists described the groups conducted in English as more spontaneous and interactive. The role of ethnicity and culture: ‘We’re all the same. We all went through the same thing’. For the women in the ethnically diverse third intervention group, the experience of living through and surviving IPV was far more important than ethnicity in cultural identity. Knowing that they were understood by others in the group because ‘they know what it’s like’ was important and highly valued by the participants. Many described the group format as essential for social support and understanding. Those women who had previous experience of one session or more of individual therapy strongly preferred the group format. Logistics. Attendance at intervention sessions was challenging for many participants due to scheduling constraints related to work and parenting responsibilities. The number of sessions per intervention cohort was decreased from 10 to 8 then to 6, based on feedback from participants and on intervention session attendance patterns. Aim 2 While symptoms of PTSD decreased at each time point, statistically significant decreases in PCL scores from baseline were observed at 6 months post-intervention only, from 59.00 to 44.13, respectively (n = 15; p = 0.003). Symptoms of MDD decreased significantly at all post-intervention time-points (Figure 1). The only statistically significant difference in selfrating of general health was from baseline (3.06) to 6-month follow-up (2.63; p = 0.048). Self-reported mental health-related

FIGURE 1 Major depression symptoms (Center for Epidemiologic Studies Depression Scale, CES-D).

QoL also improved significantly at all time-points, with a nearly 50% (p = 0.013) and 66% improvement (p = 0.003) at 3- and 6-month follow-up, respectively (Figure 2). Self-efficacy scores improved at all time-points, reaching statistical significance (p = 0.020) at 6-month follow-up. Physical health-related QoL and perceived social support scores showed improvements at each time-point compared with baseline that were not statistically significant. The 3-month and 6-month follow-up data show that a majority of the participants rated mindfulness strategies as the most helpful component of the intervention. At 3-month followup, of the 14 out of 16 women who reported using strategies that they learned in the group, nine used mindfulness an average of 5.22 days per week. At 6-months post-intervention, of the 15 out of 16 women using strategies they learned, 11 were using mindfulness an average of 4.87 days per week. DISCUSSION The collaborative process of CBPR-guided the strategies and decisions involved in this study, from conceptualization through implementation and follow-up data collection. The study would

FIGURE 2 Mental health-related quality of life. Number of days in the past month that mental health was ‘not good.’

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not have been feasible without the modifications and adaptations that were made throughout the course of the study. The use of CBPR in the field of mental health is relatively new (Stacciarini, Shattell, Coady, & Wiens, 2011); this study adds to the body of knowledge in this arena. Only one other CBPR researcher has reported an intervention to address mental health in the Latino community (Michael, Farquhar, Wiggins, & Green, 2008). The biggest methodological challenge in conducting a CBPR-driven study is being flexible enough to respond to the community partner’s needs while attending to research methods that are necessary to verify the study findings (Stacciarini et al., 2011). The importance of feasibility studies in this context cannot be over emphasized. In this study, scientific rigor that would ensure generalizability of the findings was sacrificed in the interest of maintaining the integrity of the CBPR process. The initial study design was the product of the community partner’s identified need and the researcher’s scientific input. However, the design became unacceptable to the community partner and methodologically challenging to the researcher early in the intervention recruitment and enrollment phase of the study. The sequential modifications made in the study were necessary to re-establish the acceptability of the study to the community partner and to study participants and yielded interesting research findings. These changes in the sample population beyond Latinas responded to demand for the intervention, yet introduced a limitation in the conclusions that can be drawn specifically to the applicability of the intervention to Latinas. Our relatively high retention rates likely reflect our joint efforts to overcome barriers to treatment engagement, for example childcare, language barriers, and financial and logistical access to mental health services (Dixon et al., 2011). Specifically, we provided childcare for all sessions. In the rare instance when transportation was a barrier, we provided a taxi voucher for the participant to attend sessions. The results suggest that the intervention may be effective in reducing symptoms of MDD and improving mental health related QoL and self-efficacy. The intervention also shows promise for reducing symptoms of PTSD. The introduction of mindfulness strategies was a novel intervention in this setting. The findings suggest that ACT may be the most effective component of the intervention. ACT seeks to free the individual to live intentionally rather than reactively by fostering acceptance of client’s internal experiences. This may be particularly useful for women who encounter continued stressors even when they are no longer experiencing IPV. Mindfulness-based treatments are being used more and more to treat mental health problems, including depression, anxiety, and substance abuse (Toneatto & Nguyen, 2007). ACT is being used with increased frequency to treat PTSD in survivors of trauma, including intimate partner violence (Orsillo & Batten, 2005; Walser & Westrup, 2007). Mindfulness-based treatment has been shown to be effective in treating a variety of mental and physical health disorders in culturally diverse populations

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(Fuchs, Lee, Roemer, & Orsillo, 2013). The findings of this study are consistent with this growing body of literature. Limitations This study, while helpful in establishing the feasibility of conducting the intervention and indicating trends towards effectiveness in several domains, has limitations. The limitation in the applicability of the conclusions beyond a Latina population was discussed above. The lack of a control group makes it difficult to isolate the effect of the intervention versus the passage of time or the effect of social interaction as part of the intervention on participants’ mental health. Finally, participants received inconsistent doses of the intervention based on varying attendance at group sessions. Given the sample size, the quantitative findings do not have the statistical power to make inferences about the effectiveness of the intervention. Further, it was impractical to control for dose effect in the data analyses. CONCLUSIONS AND IMPLICATIONS The successful implementation and completion of this pilot study suggest that it is feasible to provide a group psychotherapy intervention and to study its effectiveness in a domestic violence services agency with a CBPR-driven approach. Flexibility and creativity on the part of the researcher and community partner are necessary to ensure acceptability of the research process, to respond to demand for the intervention, and to establish practicality in implementation. Each of these are important areas to address in feasibility studies (Bowen et al., 2009). The results of this feasibility study set the stage for additional programming to address PTSD in this agency. In conjunction with the academic partner, the study site was successful in obtaining private funding to provide on-site psychiatric/mental health advanced practice nursing care. The growing knowledge and understanding of the pervasiveness of PTSD among their clientele spurred additional collaborations. For example, the agency obtained funding in collaboration with a large local healthcare institution to provide therapy to children who are receiving services in their program and education for parents about how to respond to their children in times of crisis, i.e. when both the parent and children have been traumatized. We expect these collaborations and programs to continue to grow. We used a non-traditional approach to PTSD treatment (ACT vs CBT). ACT warrants further investigation as a single modality in treating PTSD and MDD in women who have experienced IPV. Mindfulness strategies were acceptable to women of several ethnic groups and are not necessarily culture-bound. For agencies serving individuals from multiple ethnic groups, interventions provided across ethnic populations are most feasible and may be most culturally relevant, depending upon the individuals’ basis for cultural identity. Provision of mental health treatment in a domestic violence services agency overcomes barriers to receiving these services faced by women who have

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experienced IPV and lack access to or trust in traditional healthcare settings. The finding that being an IPV survivor was the basis for cultural group identity rather than ethnicity has significant implications for the design of ‘culturally appropriate’ mental health interventions for those who experienced IPV. The women’s sense of commonality was derived from their experiences of IPV. This shared experience fostered their sense of being understood in the way that culture based on ethnicity is presumed to. It decreased their sense of isolation and increased their sense of social support. This finding challenges the traditional concept of culture, as it pertains to interventions that are considered culturally relevant and appropriate. Clinicians, educators, researchers, and health policy-makers need an expanded definition of culture beyond ethnicity to include group identity – whatever that group may be. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Alsaker, K., Moen, B. E., & Kristoffersen, K. (2008). Health-related quality of life among abused women one year after leaving a violent partner. Social Indicators Research, 86(3), 497–509. Basile, K. C., Arias, I., Desai, S., & Thompson, M. P. (2004). The differential association of intimate partner physical, sexual, psychological, and stalking violence and posttraumatic stress symptoms in a nationally representative sample of women. Journal of Traumatic Stress, 17(5), 413– 421. Bauer, H. M., Rodr´ıguez, M. A., Quiroga, S. S., & Flores-Ortiz, Y. G. (2000). Barriers to health care for abused Latina and Asian immigrant women. Journal of Health Care for the Poor and Underserved, 11(1), 33–44. Beydoun, H. A., Beydoun, M. A., Kaufman, J. S., Lo, B., & Zonderman, A. B. (2012). Intimate partner violence against adult women and its association with major depressive disorder, depressive symptoms and postpartum depression: a systematic review and meta-analysis. Social Science & Medicine, 75(6), 959–975. Bonomi, A. E., Anderson, M. L., Cannon, E. A., Slesnick, N., & Rodriguez, M. A. (2009). Intimate partner violence in Latina and non-Latina Women. American Journal of Preventive Medicine, 36(1), 43–48.e41. Bowen, D. J., Kreuter, M., Spring, B., Cofta-Woerpel, L., Linnan, L., Weiner, D., et al. (2009). How we design feasibility studies. American Journal of Preventive Medicine, 36(5), 452–457. Caetano, R., Field, C. A., Ramisetty-Mikler, S., & McGrath, C. (2005). The 5-year course of intimate partner violence among White, Black, and Hispanic couples in the United States. Journal of Interpersonal Violence, 20(9), 1039–1057. Campbell, J. C. (1995). Assessing dangerousness: Violence by sexual offenders, batterers, and child abusers. Thousand Oaks, CA: Sage. Campbell, J. C. (2002). Health consequences of intimate partner violence. Lancet, 359(9314), 1331–1336. Campbell, J. C., Webster, D. W., & Glass, N. (2009). The danger assessment: validation of a lethality risk assessment instrument for intimate partner femicide. Journal of Interpersonal Violence, 24(4), 653–674. Centers for Disease Control. (2013). Public Health Surveillance and Informatics Program Office (PHSIPO), March 19. Behavioral Risk Factor Surveillance System. Retrieved from http://www.cdc.gov/brfss/about/index.htm (Accessed April 8, 2013).

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