Office for Disparities Research and Workforce Diversity Webinar Series: Addressing the Risk for Persistent Effects of Trauma in the Mental Health of Women Across the Lifecourse

Transcript

TAMARA LEWIS JOHNSON:Thank you. Good afternoon, everyone, and welcome to the 2023 National Institute of Mental Health, Women's Mental Health Research Webinar. My name is Tamara Lewis Johnson, and I'm thedirector of the Women's Mental Health Research Program at the Office of Disparities Research and Workforce Diversity at the National Institute of Mental Health.

The purpose of the webinar series that we offer is to spotlight research on mental health disparities, women's mental health, minority mental health and rural  mental health. So, I'm going to talk a little bit about the topic this afternoon. But first, I want to say that we're spotlighting the research of Drs. Jennifer Stevens and Bernadine Waller. And that this research was funded by the Institute's Division of Translational Research and the Division of Services and Implementation Research.

So, when we think about trauma-related psychiatric disorders such as PTSD and depression, we understand that they affect more than twice as many women than men. And that women are also more likely to experience chronic illness that persists for more than a year. Despite the evidence of sex differences in the epidemiology of trauma-related disorders, little research has outlined clear risk pathways in women. Recent findings are setting the stage for more detailed investigations of sex dependent neurobiological risk factors of trauma-related psychiatric disorders and how to prevent, screen, and treat them. Equally important, structural systems such as health care, carceral system, foster care system can generate trauma-related experiences for women.

This webinar spotlights recent scientific advances in translational, social, behavioral, and intervention research to better understand the sex and gender influences underlying the neurobiology of and advancing improved mental health outcomes for PTSD, depression, and suicidal thoughts and behaviors in women.

And now allow me to introduce our speakers for the webinar. Dr. Jennifer Stevens is an Assistant Professor in Psychiatry at Emory University, where she serves as co-director of the Grady Trauma Project, a longstanding NIH-funded study of civilian trauma and PTSD. She completed her master's degree and Ph.D. in cognitive and developmental psychology at Emory University and her bachelor's degree in psychology at the University of Georgia.

She's the director of the neural imaging core at the Center for Visual and Neurocognitive Rehabilitation at the Atlanta VA Health Care System. Her expertise is in translational neuroscience, using neuroimaging approaches to probe brain function in healthy individuals and neurobiological pathways promoting stress, vulnerability, or resilience. She has investigated individual differences in these circuits in normative and trauma-exposed populations of adults and children.

A major theme of her research has been to understand sex differences in emotion-related brain function and the brain basis of women's increased risk for trauma-related psychopathology. She addresses these questions using cognitive tasks to probe behavioral and subjective aspects of emotion and memory and neurobiological measures such as functional magnetic resonance imaging, scalp electrophysiology, autonomic physiology, and blood-based biomarkers. She is the investigator of several studies investigating brain circuit-based models of trauma-related stress responses.

After Dr. Stevens does her presentation, Dr. Waller will do hers. So, Dr. Bernadine Waller is a clinical researcher and a National Institute of Mental Health Postdoctoral Research Fellow in the Division of Translational Epidemiology and Mental Health Equity in the Department of Psychiatry at the New York State Psychiatric Institute, Columbia University, Irving Medical Center. She completed her bachelor's degree in journalism at Temple University, her master's degree in mental health counseling, and her Ph.D. in social work at Adelphi University.

Her program of research focuses on improving the mental health and overall well-being of African American women victims of intimate partner violence. She is an expert in implementing and evaluating a range of evidence-based interventions that improve the psychological well-being of understudied and underserved intimate partner victims in trusted community settings. And now, Dr. Stevens.

JENNIFER STEVENS: Thank you so much for the opportunity to speak with everyone today. I don't have any conflicts to disclose. And today I'm going to be talking about my work on the effects of trauma on mental health and focusing on women.

So, a lot of times we hear about posttraumatic stress disorder in the context of military traumas. But PTSD is, of course, not only a veteran's issue and there are many traumas that particularly influence women. So, a third of women experience childhood sexual abuse. A quarter of women experience adult sexual assault. And we know that these types of interpersonal traumas and sexual traumas in particular can be particularly impactful on mental health.

So, here's just a really wonderful illustration of some of the data behind that from a review by Yehuda and colleagues showing the different types of traumas that have been endorsed across U.S. populations, with the most common traumas at the top shown in the red bars and the less common traumas at the bottom. But with the traumas occurring in childhood and sexual trauma showing the greatest risk for the development of PTSD, which you can see in the green bars.

And not only are the types of traumas that women experience important, but we have to think about really this entire unique context in which women can experience trauma as potentially influencing a woman's mental health following a traumatic or majorly stressful event. And this can include a whole host of factors at the level of the individual, the environment, and bigger societal systems.

This headline really stood out to me, "All women live in fear. And men just don't get it." So, there are aspects of my life that I think that my male colleagues and family members just really can't relate to, honestly. For example, leaving work, I go out to the parking lot, I'm scanning the area around my car. When I'm walking to a coffee shop or a restaurant, I look around, identify a safe place to sit, where I can have some space and where employees can see me if I'm going to be by myself.

And these things are so automatic that I don't really even think about it at this point very often. But when I try to explain this situation to, for example, my husband, it's something that just doesn't really connect with his experiences at all.

So, I'm really going to be focusing in particular on women's risk for posttraumatic stress disorder and other stress related symptoms following traumatic events. But for the purposes of my presentation, I'm not going to be distinguishing between female sex versus gender. Clearly, both play a role. But I do want to highlight that gender-marginalized groups face heightened violence exposure and greater risk for PTSD and depression.

So, just to highlight some of these numbers, the prevalence of PTSD is up to 48 percent among transgender individuals. And I think that this is a really important priority area for research and the development of effective interventions.

And then I also just want to note, what is the picture for minoritized women and girls. So, here I'm showing an art installation from Red Dress Day, which occurs every year on May 5th, which was created in recognition of missing and murdered indigenous women with the rates of missingness and murder being very high among this population. And this was a way to visualize the losses of those women. But this is not only the case for indigenous groups, but also for many different minoritized groups with greater rates of trauma and posttraumatic stress disorder across many minoritized groups.

And I want to take a second to also give a bit of a definition for what I'm talking about when I talk about trauma. I'll be talking about that throughout the presentation. So, in the Diagnostic and Statistical Manual put out by the American Psychiatric Association, this is what we use to diagnose posttraumatic stress disorder. And the definition is exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence via direct exposure, witnessing, indirectly learning about, or repeated or extreme indirect exposure to aversive details.

Now, this is a very, very technical definition that really sets some hard boundaries on what is considered trauma and what's not. But I really like the SAMHSA definition as an alternative definition that sits well with me in terms of the way that I often think about trauma in my work. And so, their definition is an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and has lasting adverse events on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. And I really like this definition because of its important focus on outcomes.

Posttraumatic stress disorder is really unique relative to many other psychiatric conditions in that it begins with this index event, the trauma exposure, and followed by the unfolding timeline of symptoms. And what you can see here is a large longitudinal study that followed people shortly after trauma. This is an emergency department trauma study conducted in Tel Aviv, Israel, and followed them past the next year.

And what they find - and this has been replicated over and over - is that most people will naturally recover from PTSD symptoms over the first few months following trauma, with some being slower in terms of their natural remission. But there is this highly symptomatic group whose symptoms just do not decrease on their own and can persist over months to years without intervention. And this is the group that we're really interested in focusing on when we're thinking about treating and intervening with posttraumatic stress disorder.

Now, to receive a diagnosis of PTSD, the symptoms have to last for more than a month. Before this, a person can be diagnosed with acute stress disorder, but as you can see from the data, many individuals, almost everybody, experiences some level of heightened symptoms in those first 30 days. And then a PTSD diagnosis can be made after a month, but the presentation can also be delayed with a fair number of people showing later emergence of symptoms several months after the trauma exposure.

In PTSD, symptoms include re-experiencing symptoms; so, nightmares, flashbacks, hyper arousal, having sweaty palms, or racing. Alterations in thought or mood so negative affect, feeling guilt or blame for yourself, or that the world is a harmful place and avoiding symptoms or avoiding things that remind you of the trauma. And you can see that many of these are highly distressing and impairing symptoms.

And I'm a neuroscientist, so a lot of my work really focused on trying to understand what happens to the brain after trauma exposure and what are some of the causal factors in terms of the neuroscience behind why some people develop chronic PTSD symptoms, whereas others recover? But I really like to highlight firstly, that we do have current effective treatments for posttraumatic stress disorder.

So, our first line treatment is trauma-focused therapy. This includes prolonged exposure therapy, cognitive processing therapy, and written exposure therapy as just some of the evidence-supported options in terms of cognitive behavioral therapy following trauma exposure. These therapies all involve a component of thinking about the trauma and discussing it in a therapeutic context until the emotions invoked by the trauma become more bearable or less distressing.

And then another effective option, which is our second line treatment because cognitive behavioral therapy has fewer side effects, but are equally effective, are pharmacological therapies. So, these primarily include selective serotonin reuptake inhibitors, sertraline and paroxetine are FDA approved for PTSD. And there is also an indication for prazosin, another drug which is specifically targeted to posttraumatic nightmares.

Okay, so really thinking about sex differences in trauma-related symptoms, I want to highlight when you look across a variety of different psychiatric disorders in terms of the lifetime incidence ratio in women versus men, here you can see a list of the disorders with those at the top being more prevalent in women, those at the bottom being more prevalent at men. And you can see that PTSD is right at the top of the list. So, trauma-related psychiatric symptoms are some of the most obvious cases in which there is a disparity that more strongly affects women.

And as I highlighted before, we know that some of this comes from the fact that women are more likely to experience more impactful forms of traumatic events such as childhood sexual abuse or adult sexual assault. Of course, men experience these things too, but the rates of exposure are over twice as high for childhood abuse in women and six times as high as for adult assaults.

However, there is some hint from the developmental literature that women's increased risk for PTSD and depression following trauma is not only related to the types of traumas that women tend to experience. So, we know that one thing that is unique in women is that we have this long, protracted, developmental timeline of hormonal changes over the life cycle.

And if you look at the epidemiological literature, this comes from a recent, very large, global epidemiological study that was released in 2021 where they looked across many different psychiatric diagnoses. But you can see PTSD is the red line. And whereas a lot of other diagnoses have the highest incidence around age 20, PTSD has this more extended timeline beginning more around age 15 years, which to me, along with anxiety disorders, looks concurrent with a boost around the time of puberty, suggesting potentially a role for hormones, although this is also an important social time where many things are changing in a child's life.

And then PTSD is really unique relative to the other disorders in that it also shows this marked peak at around 50 years. And we know that this is a time when women in particular are entering into perimenopause and menopause and that this hormonal change may also play a role in a new later incidence of PTSD.

So, a lot of my work has addressed women's risk for posttraumatic stress disorder through the Grady Trauma Project. And this is a longstanding NIMH-funded study of trauma and posttraumatic stress disorder in the civilian population. Grady Memorial Hospital is our large public health care system, so many families who are lower income who lack health insurance and who have fewer economic resources come to Grady for their health care.

And in Grady Trauma Project, we tried to take an epidemiological approach across the hospital. So, we're not working with people who are seeking treatment for mental health care, but we're really going to all of the broad waiting rooms that we can to approach people, to ask them about their experiences of trauma and stress-related symptoms. So, we primarily have worked out of, for example, OB, primary care, the emergency department, diabetes clinic, the pharmacy. We try to go everywhere to get a good cross-section of people who are receiving their health care at Grady.

And what we've seen over time is that trauma exposure, multiple trauma exposures over the life span are really the rule rather than the exception. So, in a sample of 8,000 people who we spoke with in these waiting rooms, people endorsed a median number of four different types of traumatic events that they've experienced in their lifetime. But if you ask them about individual trauma, so not different types of events, but specific incidences, the median number people endorsed are 28 different traumas over the life span. So, this is really repeated chronic trauma.

And what we've seen in this same sample is that both among men and women, the rates of lifetime PTSD and symptoms that we're asking them about are at around 46 percent of people who would meet criteria for PTSD diagnosis. This is really high relative to the US population prevalence of 6 percent and is even very high relative to rates of PTSD among combat veterans.

I also want to finally note that we've observed major gaps in treatment. So, this is data from 633 pregnant patients at Grady, who we interacted with in the OB clinics. And what we found, again, was that around 30 percent of the pregnant women or pregnant patients that we talked with would meet for a probable diagnosis of PTSD or depression, but only around 6 percent of them had ever received past treatment for posttraumatic stress disorder, and fewer than 20 percent had received past treatment for depression. So, despite the fact that we have good depression screening in the OB clinic, there are still some gaps in treatment of these important time related symptoms that are really exerting a major effect on our patients.

So, now we really understand the problem and we're looking towards new treatments and interventions and thinking about what we can do to bridge some of these barriers? What can we do to make mental health care more accessible to women in these lower income families in Atlanta, who are receiving public health care? And then also think about more effective ways to intervene and prevent and treat PTSD and depression.

So, I'll just give one example. This is kind of a typical history that we will gather that's representative of participants we often speak with of the Grady Trauma Project. So, we spoke with a 40-year-old black American female. She was single, had never been married, had no children, unemployed for two years due to medical reasons. She applied for disability, but she was denied and had previously been employed as a truck driver for five years. She was a high school graduate and had a technical college degree. And then I think what's really important to note is her medical history. She had Type II diabetes, high blood pressure, hypothyroidism, chronic arthritis, and obesity. These are all things that we know that chronic stress can promote through its effects on the immune and stress axis as well as metabolic functioning.

She had been prescribed a SSRI, sertraline, in primary care for two years, but she doesn't take it consistently. This is often what we see. So, when a primary care physician finds out about mental health issues, there is often a prescription, but little follow up and very little access to psychotherapy services, which are more of what we'd like to see our individuals being able to access after trauma exposure.

The participant had a significant trauma history across her life span, including childhood abuse, domestic violence in adulthood, which was really the index trauma for her posttraumatic stress disorder symptoms. And I just want to highlight a couple of the things that she noted as far as how the trauma affected her life. She said, well, for one, this event made me more aware of my surroundings and the people around me for my safety. It's also changed the way I have trust for people. I just don't trust that easily anymore.

We find that the impacts of trauma on people's social functioning is really important and that social networks can be some of the most resilience-boosting aspects of people's lives. But trauma can also negatively impact social relationships.

Now, some of our early work established that a brain region called the amygdala, which is involved in detecting and regulating emotional responses to both threats and rewarding stimuli in the environment, this region is hyperactive in response to threat cues in women with PTSD, but not in resilient women who experienced comparable levels of trauma but who didn't meet for a diagnosis of posttraumatic stress disorder. And this is accompanied by reduced functional connectivity with a region of the prefrontal cortex that is involved in adaptively regulating amygdala responses to respond to current contextual demands, the ventromedial prefrontal cortex.

So, this is a central feature of posttraumatic stress disorder that's been replicated across many labs, but which we found was also the profile we observed in women who had experienced these civilian and primarily interpersonal traumas, who participated in the Grady Trauma Project.

And we also, again, found some evidence suggesting that hormones may be playing a role. So, this is work led by Ebony Glover and Tanja Jovanovic, in which they found that women in the Grady Trauma Project who did not meet criteria for PTSD, showed an adaptive ability to extinguish a fear response when something that was previously threatening was no longer associated with an actual threat. But women with PTSD, when they had low levels of estradiol during the fear extinction, they showed high fear responses, suggesting an inability to extinguish a fear response appropriately. But women with PTSD who had higher levels of estradiol showed appropriate reduction of the fear responses to a level that was comparable with resilient control participants.

And complementary work coming from Mohammed Milad's lab showed in an experimental manner that if they supplemented estradiol that this also enhanced participants' ability to extinguish fear response in healthy participants. And this gives us some suggestion that estradiol may really be important for adapting to trauma and natural recovery processes.

So, estradiol is the major female sex hormone or ovarian hormone and estradiol and progesterone, and other ovarian hormones adapt and change in a major way over the lifespan. We know that from the written literature estradiol facilitates memory consolidation. So, in ovariectomized rats who received estradiol replacement, they showed have better objective condition behavior. And this was mediated by an increase in synaptic density, so postsynaptic spine density within important brain regions for memory, including the dentate gyrus of the hippocampus as well as subregion CA3.

Then we really wanted to look and see, what aspects of PTSD symptoms might this influence? And we find that in our cross-sectional studies where we're just in the waiting room asking people, what are your PTSD symptoms, are experiencing any of these symptoms, and when was your last menstrual period? We had some evidence to suggest that in the early luteal phase, right after ovulation, when estradiol levels are sharply declining, that PTSD symptoms may be greater during that cycle phase.

And so, we wanted to follow up on this with a new NIMH-funded study. This is an experimental medicine trial where we are randomly assigning women with PTSD and trauma exposed controls and healthy controls to either estradiol or placebo. And then we have a washout period, and they cross over to the other condition, and we are looking at their brain function during fear conditioning and extinction tasks to understand how it is causally impacted by estradiol.

What we expected to see potentially was that it might increase the signal of the ventromedial prefrontal cortex during fear extinction. And we know that people with PTSD have difficulty engaging this region during extinction. And in one pilot participant that we've looked at so far, it does look like estradiol is increasing the VMPC response during extinction. But we are about to unblind this study and we hope to present and publish the results very soon.

And then just going back to this lifespan plot, we think that there may be importance of hormones in cycling women, younger women, but there may also be an impact of hormonal fluctuations in the menopausal years and perimenopause as well. So, we know that estradiol levels are declining in the years around the final menstrual period and that this decline can impact mental health.

There is very little data on posttraumatic stress disorder, but high-quality longitudinal data from depression suggests that there is a bump in depressive symptoms around natural perimenopause, in particular late perimenopause approaching the last menstrual period.

So, we looked in our participants and found that we replicated - just looking at different age windows here with the cross-sectional data that we had available - we replicated a bump in depressive symptoms in our highly trauma-exposed participants in ages 40 to 55, which is consistent with a potential perimenopausal time window. But we also saw a similar effect for PTSD hyperarousal symptoms, which is important because these symptoms are part of the PTSD profile that does not overlap with depressive symptoms. So, we think there may be an additional effect on PTSD risk.

And what do we know about brain health in menopause? Again, there have been no studies in women with posttraumatic stress disorder or chronic trauma exposure, but there are some classic findings in healthy menopausal women showing that after hormone replacement therapy, important memory-related brain regions such as the hippocampus experience greater blood flow which could contribute to better memory.

What do we still do not know? There have been no studies focusing on the structure or function of the amygdala. No studies of sympathetic nervous system reactivity. No research on how fear responses or fear learning change in the perimenopause. And the preponderance of work has been done in New England, where there has been low diversity in race or socioeconomic status.

I just want to briefly highlight that we are starting a new study to really dig into this. A longitudinal NIMH-funded study where we are recruiting women early in perimenopause and following them for 18 months with sequential visits to assess hormonal changes, emotional state using electronic mobile surveys and neuroimaging to look at the function of the amygdala and its connections with memory and inhibitory brain regions.

I just want to wrap up by highlighting what we can do right now for women with a history of trauma and chronic stress. Of course, I highlighted trauma-focused cognitive behavioral therapy. This is appropriate for women at any age. SSRI is maybe less effective in older women. I didn't have a chance to show that data, but I can come back to this in the Q&A period if you are interested. And we do need a big prospective randomized trial to verify whether hormone therapy boosts efficacy of SSRIs or different pharmacological treatments that we have available for depression and PTSD.

And then I just want to end by saying that most women in the adult and perimenopausal and menopausal years are getting their health care primarily not in primary care context, but with satellite clinics like the local CVS, MinuteClinic, or with their OB/GYN care provider. So, we may not have access in those settings to major mental health care resources. But this connection with the health care system offers opportunities to provide some resilience-boosting strategies to patients.

So, I just want to highlight that boosting patient awareness that symptoms can increase or start during these phases of lifespan could be helpful. Social support is the most important resilience factor. And then also care providers can highlight that exercise and healthy sleep habits, healthy balanced diet, and writing or artistic outlets or religious connection can all be important ways to heal and increase resilience in women who have experienced trauma.

And with that, I will thank the Grady Trauma Project team and turn it over to Dr. Waller.

BERNADINE WALLER: Thank you so much, Dr. Stevens, and thank you all so much for joining us. I will begin by sharing my slides. So, today I'll be sharing with you my research on the DIVA Project. And DIVA is an acronym for Divinely Interrupting Victimization and Abuse.

I have no disclosures. There are no conflicts of interest to disclose. And I first want to begin by providing a real sincere thank you to my funders, my partners, and my mentors, because without them there would not be this body of work. I also would like to foreground the fact that I will be talking with you today specifically about intimate partner violence victimization. And intimate partner violence really is any physical, sexual, psychological, financial abuse, as well as stalking and controlling behaviors.

This information is challenging, and it could be triggering. So, I want you to know that self-care is very important. That means that if you need to take a break at any point during this presentation, I want to encourage you to do so because self-care is so very important. But know that as you have the opportunity to take a break, there are so many people who are experiencing intimate partner violence victimization, who do not have that opportunity to take a break.

The old adage goes, the personal is professional. And so, my work really is informed and really inspired by so many women I know whose lives have been adversely impacted by intimate partner violence victimization. And then also, it's informed by my clinical work. I worked as a clinician for several years with black women who were survivors of intimate partner violence, and realizing that as a clinician, I just did not have culturally salient or culturally responsive interventions that I needed to bring this population to a place of wholeness. And so, there really were gaps in the kinds of services and the types and the nature of services and supports that I could provide to them.

And so, we see that 45 percent of black women are abused by their intimate partner but know that intimate partner violence victimization is not specific to this population of women. It happens across all races, all ethnicities as well as across SES.

The challenge is, is that black women are killed at a rate on average that of white women, three times more. And unfortunately, 91 percent of women are killed by people who they knew. And so, that had me ask the question, what's going on, what's happening with this population of women? And so, today I'll be sharing with you my NIMH-funding journey that began with my dissertation research through to my current T32 postdoctoral fellowship as well as my L30 loan repayment award.

And so, what I do know as a clinician is that this population of women really are precluded by what we might consider to be normative pathways of support. And so, they're oftentimes left asking, where could I, as a black woman, get the services and supports that I need?

And so, my journey began with really conducting a systematic review of the literature to understand what's happening when black women are looking for help. So, we conducted a systematic review to understand the barriers to black women's IPV-help-seeking process. And this was inclusive of both the domestic violence service provision system as well as the black church.

And we found that this population of women are oftentimes marginalized. And when they do engage the police, they find the police very unhelpful. This population of women is also socially stigmatized. And when they are relegated to and referred to shelters, the shelters that they're relegated to are oftentimes dilapidated. And so, it makes sense to me that they also forgo treatment at emergency rooms. Unfortunately, they're, by and large, very untrusting of the mental health providers, and they largely rely on people who are not trained to fully assist them. And when I say that, I'm talking specifically about their family and friends as well as providers within the black church.

And so, this really did lead me to my R36 dissertation award from the NIMH. And this award allowed me to develop a model that identifies US black women's IPV-help-seeking process, because to date, there had been no theories, no models to explain what was going on with this population of women.

And so, the aim of this was to really explain how this population of women cognitively evaluate the available services and supports during their help-seeking process, and secondarily to really understand how they utilize their contextualized exercise of agency to navigate any of these barriers that I've already identified in the systematic review.

So, I had an N of 30. The women were largely African American, the average age was 40 years old, who had been in a relationship for just over nine years. The women were largely uneducated and also largely unemployed. And so, in order to develop my own theories, I utilized theoretical sampling methods really to understand what's going on in each of the very specific pathways of support. So, I sampled, according to the criminal legal system, the shelter system, the health care system, as well as the mental health care system.

I also wanted to know what was happening in the black church and really wanted to find out, this population of women are really known for having very private means of help seeking. And so, in order to capture that, I also included family and friends and women who were help seeking in that pathway of support.

And so, how I developed my theories, I utilized constructivist grounded theory methodology that was developed by Kathy Charmaz, and I used sensitizing concepts from the trained theoretical model of change because I really wanted to understand what women were thinking during their help seeking and how were their beliefs informing how they were responding to the barriers. I also wanted to make sure that I captured their race, class, and gender intersectionality. And so, I used intersectionality theory developed by Kimberly Crenshaw.

And then I wanted to do something different. Oftentimes, theories that were developed for this population of women really were not informed from a strengths-based perspective. And so, in order to make sure that I was incorporating the ways that they employed their power, I utilized agency framework, which was developed by Mahmood. And the women largely said that there is no help.

And so, I want to begin by sharing with you a little bit about Sharon before I share with you what she said during the interviews. Sharon shared with me that she lived about two blocks away from the precinct at the time. She barricaded herself behind closed doors. Her husband had gone into a very violent tirade, and she literally feared for her life. And so, she barricaded herself behind the bedroom door. Glass is crashing in the background. In the meantime, she's on the phone with emergency dispatch for over an hour, calling them, he's going to kill me. The man I know is going to kill me.

And Sharon says to me, "We end up staying in the situation until we probably lose our lives because there is no help. Like for me, I don't know what to do anymore. I really don't know what to do. So, I guess I'm probably just going to have to stay until he kills me."

Karen also had difficulty. This was a woman who shared with me, you know "Bernadine, I told them that I'm going to need a relocation. I'm going to need someone to change my identity so that I can escape my abusive partner. This man I know is going to kill me. He's already put word out on the street that when he gets out from prison in another month, that he's going to kill me." Unfortunately, providers ignored her cries for help. And so, when he did get out and he literally made good on his promise, attempted to try and kill her, she called the center and says, what's going on? And unfortunately, because providers did not listen to her, she no longer trusted them.

And instead of following what they told her to do, their directives, she waited an entire week until I came back, the researcher, and asked me what to do. And I then told her the very same thing the provider shared. And Karen says, " Well, if there is help out there, I haven't found it just as of yet. I felt like when I revealed things, it just falls on deaf ears."

Another finding is that survivors said, "You have to help yourself." To that, Tamika stated, "It felt like hell. It felt like hell because I realized that there were times I couldn't call the police." And then Tammy similarly stated, "It's like you just have to keep going over mad hurdles. I have to fight to get out."

Another finding was that women stated that they really had to pray for help. And Evette stated, "I go straight up the pipeline. They didn't help me the way they should have, so I prayed about it. Prayer really does change things." Likewise, Terri stated, "I pray all the time for any and everything. I do because it's the only thing that's keeping me alive, is allowing me to get through."

So, I was able, as a result of these interviews with the women, to develop three theories that identify US black women's IPV-help-seeking process. I developed the theory of Help-Seeking Behavior, Constructed Agency, as well as Sarah Waller's Help-Seeking Model.

First, I'll share with you a little bit about the Theory of Help-Seeking Behavior. The first construct is that of social context, and social context basically states that women will indeed engage in their help-seeking efforts depending on their positionality and their social context and whether or not they feel like they have the power to do so within that social context.

The second construct is that of beliefs. And so, what we know in the literature is that women's experiences and understandings of what's happening among the different pathways of former supports really do affect whether or not they're going to engage providers.

The third construct is that of individual agency, specifically women's sense of self-efficacy and inner strength, and how they're able to employ that during their help-seeking efforts will really inform whether or not this population of women are actually going to engage in various pathways of support.

The second theory is that of Constructed Agency. Constructed Agency, is you will see that it is a phase-oriented theory that includes four different phases. The first phase is that of resistance. And when women who are in the resistance phase, these women are saying, you know what, they are starting to do things like triangulate and connect with other people in order to resist the barriers that they're experiencing during their help seeking to get the assistance that they need.

The second phase is that of persistence. And in this phase, there were women who were inspired oftentimes by their children, to you know what, I got to keep it moving. I'm experiencing barriers, but I've got to get what it is I need to get out of the systems of support that are available to me.

The third phase is that of rejection. And in this phase, we start to see survivors say, you know what, I can't do this anymore. And in this phase, they start to reject formal systems of support. And so, this is when you will see survivors who may say, you know what, I don't want these anti-depressants. I'd rather more homeopathic methods to help my depression or my anxiety or PTSD. They're doing things like exacting or relying upon street justice because providers within the criminal legal system really have not exacted the justice that these women believe that they needed.

And then what we also found in this last stage is that of resignation. And so, survivors are saying, you know what, the forms, the pathways of support that are being offered, to me, it's just not worth it. I would rather stay with the enemy that I know rather than engage with different formal providers as well as the shelter system, as well as different formal places of support. And so, this is when we see that these women typically will terminate their help-seeking efforts.

The third theory is called Sarah Waller's Help-Seeking model. This theory is near and dear to my heart because it was named in memory of my maternal grandmother, who was the consummate caregiver in her small little rural town in Elizabeth City, North Carolina.

The first three phases of Sarah Waller's Help-Seeking Model, these women are dealing with things like they're aware of what's going on, they begin to acknowledge the abuse that they are experiencing, and they start to assess, why I am here? How did I get here? What resources are available to me?

In the third or three phases we see that women move to a place of, you know what, enough is enough. And they begin to create boundaries and then they start to escalate and say, you know what, I know the cultural scripts within my community are saying it's better that what goes on in this house stays in this house, but it's time for me to enlist assistance because I need to get help. And in Phase 6, we see that women begin to engage formal providers.

In these next three phases, we see that women begin to reject formal systems of support and secure alternative interventions. They then resolve that they're going to persist and do what they need to do in order to get the help that they need. And this last phase is that of restoration. And in this phase, survivors are saying, you know what, it is time for me to get to a place of restoration and reclaim my sense of self.

This theory, this phase, has implications for intervention as well as implementation science. And I'll share with you a little bit about that in just a smidge. Now the strengths and limitations of the theories include you know these theories identify the mental health and social supports needs that are specific to this population of women. Please note that although there is great utility in these theories, this data is limited because it was developed using qualitative data. However, these are the first theories to explain US black women's nuanced health seeking efforts.

I also want to note that these theories are currently being used in the UK to inform service delivery, and again, this has implications to intervention and implementation science.

Now, if you recall back with Sarah Waller's Help-Seeking Model, the first phase was that of a health crisis. And in that first phase of the health crisis, we see that there were internalizing disorders that women experience, specifically depression and PTSD. And so, I really wanted to extend my research and to find out ways to not only develop interventions and to tailor interventions for this population, but I also know that if we are not currently or properly implementing the intervention, we're also going to get failure.

And so, I obtained a T32 postdoctoral research fellowship for training in implementation science at Columbia University with my mentors, Dr. Milton Wainberg, Dr. Myrna Weissman, Dr. Sidney Hankerson. And so, what we know is that one in eight women are depressed in their lifetime. We also know that unfortunately, women are depressed at a rate that is twice that of men. We also know that IPV survivors are depressed at twice the rate of women who have never been abused. And so, we have a problem.

We know that depression is very disabling for IPV survivors. And those women who have experienced a trauma, if you have trauma exposure, it increases the likelihood that they will indeed experience depression. Depression delays help-seeking efforts, and they have greater difficulty securing safety as a result of experiencing depression. And so, that led to my first T32 project to really examine what is the state of the literature on evidence-based interventions for black women survivors.

We conducted a pre-registered systematic review to understand the current evidence-based interventions for black women survivors, and then to provide a field, the field, with a nuanced understanding of what black women need when it comes to developing and delivering culturally responsive, evidence-based interventions.

And so, there are four main conclusions for our systematic review on depression and PTSD evidence-based interventions. Black women prefer brief. When I say brief, I mean fewer than six sessions interventions. Anything longer than that, they're going to be more likely to drop out of treatment. They also - because black women, according to the Pew Research Center, are the most religious population in the country - they really do want their faith and spirituality infused into the intervention.

Also, black women prefer that other black women be the facilitators in community-based settings. And we know that from the literature that when we do this, it's going to increase uptake. So, that means that more black women are going to get engaged in treatment.

And when we're building and developing intervention, we need to account for women's social determinants of health, specifically making sure we're including or providing childcare, transportation, or housing. Because when we are accounting for women's social determinants of health, it really does reduce attrition and or dropout from treatment.

And so, it seems to me that all roads seem to be leading back to the black church. And so, my next step was securing an L30, a loan repayment award to begin to explore what's going on. And so, my L30 project, my first L30 project, was to understand what factors in the black church influence the implementation of a sustainable evidence-based intervention.

I had a sample size of 30 participants. We used both purposive and snowball sampling methods and I employed the Integrated Sustainability Framework, which was developed by one of my mentors, Dr. Rachel Shelton, at Columbia. In order to understand both the inner and outer contextual factors, as well as what are the attributes or what are the characteristics of an intervention, and an interventionist that this population of women need.

And so, there are five contextual factors that influence sustainability. The first is privacy. If there are any folks out there who know the black community, you know that privacy really is the hallmark. What goes on in this house, stays in this house. That is the old adage in the black community. So, privacy is very, very, very important, as well as making sure that we're accounting for confidentiality, stigma, and shame that this population of women experience.

We also found that there is a dearth of education and awareness, as well as an understanding of intimate partner violence victimization within our houses of worship. We also know that pastoral support for intimate partner violence services and supports within the black church, it is critical. If the pastor doesn't provide his or her stamp of approval, whatever intervention you're looking to deliver in the black church is not happening.

We also found that this really is an opportunity for the black church to expand their impact in their touch in the community. And post-pandemic, since we're in the endemic phase of COVID-19, a lot of pastors are really looking to make sure they are touching the community and touching people who've not necessarily been touched before. And we know that community connections are so critical to this being impactful, because what we do know is that if we're connecting with lay health providers in the church, they are not necessarily experienced, nor do they have the expertise for higher levels of care. And so, it is so important that we're bridging and making the connection between clinicians that are culturally responsive and our black churches.

And so, throughout this work, what was really important throughout this particular project and salient for many of the survivors is that we oftentimes say that we're centering survivors' voices. The black women who I've been working with, said “Dr. B, they're centering survivors voices, but our voices are not centered in this work.” And so, I've made a concerted effort to make sure that I'm centering black women survivors' voices.

And so, what one participant said was, "Representation. We need people of color that's working for people of color." And they also noted “that survivors, we are the experts. We need to be included in things that impact us.”

Now, I want you to know just how important centering black women survivors' voices has been in intervention development. The first phase of my L30 award that I just shared with you that included 30 women, data collection for 30 women was completed in a record three and a half weeks. And for those of you who are in the audience who are clinicians, you know that that just doesn't happen. And I also want you to note that most of the sample were snowball. So, this was one black woman survivor saying, "Hey, talk to Dr. B. She's got a study that's centering our voices." And the women were, by and large, very excited about this.

And so, my next step in my NIMH-funding journey is to really obtain a K23 to conduct a clinical trial in black churches. And I just want to say thank you. If you'd like to contact me or reach out to me, you can do so via Twitter or my website. And that is all. I'd like to hand this now over to Tamara.

Q&A

TAMARA LEWIS JOHNSON: Thank you, Dr. Waller and Dr. Stevens for an outstanding webinar this afternoon. We're now in the Q&A section, so I am going to ask one question of each of you and then I'll get questions from the audience. So, those of you who are in the audience, put your questions in the Q&A box, and we will get to you.

So, Dr. Stevens, what are your recommendations for making the standard cognitive behavioral therapy less lengthy and more adaptive to cultural variations among racial and ethnic minoritized women?

JENNIFER STEVENS: Okay. So, it's a great question. I'm a neuroscientist, so I can't speak with a clinician's perspective on cognitive behavioral therapy, but I would like to highlight the work of a few people who are making major advances in this space, who are in particular working in my city in Atlanta. So, Dr. Sierra Carter at Georgia State University has been conducting focus groups and experimental studies to understand racism as a trauma that could be considered a Criterion A trauma for diagnosing PTSD and has identified really interesting effects such that participants endorse new PTSD symptoms when discussing experiences of racism that they didn't endorse when they were discussing prototypical events that we would consider a trauma.

Also, Dr. Isha Metzger at Georgia State, has developed several forms of culturally enhanced trauma treatment and resilience-building interventions, focusing on strengths that come from family relationships, as well as working on creating a standardized cultural add-on for existing evidence-based cognitive behavioral trauma treatments.

And finally, Dr. Abigail Powers Lott is working with me at the Grady Trauma Project. She's the co-director of GTP, working to reduce barriers and engaging with mental health care, adapting manualized treatments to the primary care setting and telehealth formats.

TAMARA LEWIS JOHNSON: Thank you for that response. And Dr. Waller, thank you so much for your presentation. My first question to you is, is the sample primarily women in an urban or rural setting? How might the results of your work differ by place?

BERNADINE WALLER: Thank you so much, Tamara, for that great question. The setting for my work has primarily been in an urban setting, primarily urban and some suburban. However, it does have implications to women in rural settings because women in rural settings have - they prefer privacy. And rural settings are very close knit. And so, it is so important that what's going on in a rural setting, it is, the women understand that privacy is important, and confidentiality is important, and anonymity is important.

Oftentimes rural settings are very close knit and very family oriented. And everyone's telling someone who's telling someone who's telling someone. And so, with this population of women, that is something that you want to make sure that really is not happening and that you really are making sure that privacy is something that is foregrounded with this population of women.

TAMARA LEWIS JOHNSON: So, true. So, true. So, here are some questions from the audience. Bear with me. How might we understand the higher rates of PTSD among minoritized populations who experience trauma? Either of you?

JENNIFER STEVENS: I think that Dr. Waller spoke to this somewhat in her presentation as well. But I think that minoritized groups are at higher risk for experiencing trauma. Much of this is due to the social context and bigger picture systems that we have in place as well as lower access to a lot of the economic resources that make communities and families safe.

So, really, the higher rates of PTSD and depression are really coming from higher rates of trauma, in my experience.

BERNADINE WALLER: I'm sorry, Tamara, could you repeat that question for me, please?

TAMARA LEWIS JOHNSON: How might we understand the higher rates of PTSD among minoritized populations who experience trauma?

BERNADINE WALLER: Wow. So, I can't speak to the rate, but here's what I do know. When it comes to this population of women, when we're looking at minoritized women, they typically don't have access to care that non-minoritized women have. And so, I know with depression, which is what I know really well, depression in black women, in black people, in populations of color don’t have the highest prevalence rates when it comes to depression. And I could assume that it’s probably similar when it comes to PTSD. However, they have a protracted course of this disease because they do not have access to culturally responsive care. And oftentimes they’re underdiagnosed. And because they’re underdiagnosed, they’re also undertreated.

And then when they are diagnosed, I want you to also keep in mind that our medical model for treating minoritized populations have very much been grounded in structural and systemic racism. There is a great paper by Bailey and her colleagues that really do speak to this, and Bailey shared this work back in, I want to say 2017, was a real seminal piece in the medical field that looks at structural racism and how structural racism really does preclude this population from getting the help, the services that they need, that’s more immediate.

TAMARA LEWIS JOHNSON: Thank you, Dr. Stevens and Dr. Waller. Dr. Stevens, here’s a question for you. Can you speak to the potential impact of trauma exposure on introspective processes related to perceptions of physical symptoms, such as pain and fatigue?

JENNIFER STEVENS: Okay. Yes. So, absolutely, trauma can have a major impact on your perception of your body. And I’ll highlight just one example. So, rates of PTSD are very highly comorbid with pain, chronic pain, including fibromyalgia. And we think that PTSD is potentiating a lot of chronic activity of the sympathetic nervous system, which can really change the perception of pain, the way that your body processes pain and as well as other internal signals.

TAMARA LEWIS JOHNSON: And here’s another question for you. I can ask the question is why eye movement desensitization and reprocessing - is that a first line of therapeutic treatment?

JENNIFER STEVENS: Yes. So, I was only able to mention a few of the effective forms of trauma-focused cognitive behavioral therapies. But eye movement and desensitization reprocessing, EMDR, is another established treatment that has no high efficacy comparable to other forms of cognitive behavioral therapies for PTSD.

TAMARA LEWIS JOHNSON: Thank you. Thank you both. Here's another question. Considering how lifespans have increased during human history and high hormonal levels in youth in childbearing years was a survival adaptation, longer lives would suggest the changes in mood, from change in age, would be important to respect as part of biology. Caution from aging changes and strength and mobility for people who have lived longer being more cautious makes sense. How much would such adaptation be part of natural aging and caution to protect younger women and offspring being adaptation and not a problem, and that that can be a protective factor for families in the past and may do so in the present? I think this is getting at the intergenerational impacts of trauma.

JENNIFER STEVENS: And I think I also hear that they're asking could some of these symptoms actually be adaptive. So, would it be protective in a way to be extra cautious about your surroundings in paying attention to potential threats in the environment, especially as you get older? And that's a great point. We don't want to overly pathologize the ways that people process trauma and think about trauma and their emotional responses to trauma. But it's really when these reactions to trauma start to become maladaptive and are impairing people's ability to go about their everyday lives, engage with family members, go to their jobs. That's when we want to start thinking about treatment and intervention.

TAMARA LEWIS JOHNSON: And Dr. Waller, what do you think? Thank you, Dr. Stevens.

BERNADINE WALLER: I am so sorry, Tamara. I was answering questions in the Q&A, so if you could repeat the question again.

TAMARA LEWIS JOHNSON: This is a question about considering human lifespans have increased and our longer lives suggested changes in mood and changes in age are important with respect to biology. Can aging changes in strength and mobility for people who live longer be an adaptation to a part of natural aging and caution to protect younger women and offspring, be an adaptation and not a problem? So, this is getting at can trauma, if you're healed from it, can it help inform future generations and be a protective factor in families in the past and present?

BERNADINE WALLER: That is an awesome question. I have not yet explored the transgenerational effects of trauma. That is a body of work that I have not. So, I don't feel comfortable necessarily speaking to that, but is an awesome question and definitely something for me to look into and get back to whoever just asked that question.

TAMARA LEWIS JOHNSON:  Great. Here's another question for Dr. Waller. Do you see your invention as a healing evolution when a person is recovering from trauma starts to move away from therapy and meds and deals with it more on their own?

BERNADINE WALLER: So, the way I am envisioning this intervention is it could be as an adjunctive to someone who is currently securing services and supports from their clinician, as well as someone who has decided that they are not going to engage and get any medication from their provider. So, it could be either. It's not a one or the other, it can be both and.

TAMARA LEWIS JOHNSON: Right. Here's another one for you, Dr. Waller. Have you considered or are you planning on including peer specialists in your research, given their voice and the need for both representation and survivor-centered approach?

BERNADINE WALLER: That is an awesome question. I have included peers, advocates, and mental health clinicians who treat this population of women as well as members of clergy, folks who are running domestic violence ministries within their churches right now, as well as survivors in this work. We just about three weeks ago wrapped up an intervention work group where we converged at Columbia Psychiatry and centered all of those voices to make sure that what we are developing is what it is that they need, what it is they want, and what it is that is going to help them. Because if they buy into this intervention that we're developing, my guess is, is that we won't have any problem with recruitment or engagement because they will be the folks who are doing this work.

And it is my desire to make sure that I'm engaging lay health providers in the delivery of this work. So, I'm looking to follow a similar model that my mentor, Dr. Sidney Hankerson, is actually employing with the TRIUMPH study.

TAMARA LEWIS JOHNSON: Great. Thank you so much. Has there been any research focused on rates of PTSD in youth and in congregated care settings versus those placed with families and traditional foster care? Either of you, around young women? No. Okay. Are there different therapy or treatment recommendations for PTSD versus CPTSD?

JENNIIFER STEVENS: So, complex PTSD is often observed in the case of childhood trauma and chronic trauma exposure and has some symptoms that can differ from PTSD. I think that treatments that are really effective in addressing these might be potentially pairing things such as mindfulness-based approaches which facilitate getting in touch with an awareness of your physical sensations and how symptoms might present themselves within the body can help in cases of complex PTSD. And there is ongoing research conducted by a number of really great labs that are exploring some treatment options along these lines.

TAMARA LEWIS JOHNSON: And Dr. Stevens, have you seen a link between hormonal changes in pregnancy and PTSD? I think you spoke to this in your slides somewhat.

JENNIFER STEVENS: So, in the Grady Trauma Project, we have done some work among pregnant women and the initial findings suggested that hyperarousal symptoms increase in pregnant women. And this is accompanied by physiological changes. So, greater activity of the sympathetic nervous system in response to threats. And Dr. Vasiliki Markopoulos(ph.) is now leading a longitudinal study to dive into those findings more deeply and look at interactions with hormonal changes over pregnancy, as well as changes in inflammation.

TAMARA LEWIS JOHNSON: Great. Thank you so much. Dr. Waller, regarding your research, how do you plan to tackle stigma surrounding IPV when working with the faith community?

BERNADINE WALLER: That is an awesome question, something that I'm currently grappling with right now and having conversations with many faith leaders. But the wonderful thing about the black church is that the black church really is the hallmark of the black community. The Bible has been used to both be a support and to build resiliency. And it's also been weaponized to keep women in abusive relationships. And so, I really do think there needs to be training, a suite of training for religious leaders to give them an understanding just about the depth and breadth of intimate partner violence victimization, as well as the dangerousness of it.

I think, honestly, when I've had one-on-one conversations with religious leaders, they just don't understand just how dangerous or how lethal it can be and them encouraging women to remain with their abusive partner till death do us part. That does not mean that I need to suffer premature death because my partner is abusive. And so, that is something another study that I have in my mind to kind of work on and work through. But definitely something that needs to be addressed in our faith communities.

TAMARA LEWIS JOHNSON: Yes. And I think this is a related question. So, will prevention be included as a component of your intervention model? And if so, what are your thoughts about preventing intimate partner violence?

BERNADINE WALLER: Prevention, that's another great question. So, thank you for that. Prevention is along the continuum of intervention, and prevention really is before it starts. And so, again, that's something else that I've been kind of toying around in my head and my brain, and what my thoughts are going much quicker than then my research agenda is. So, yes, this is definitely something that is top of mind for me.

And when it comes to prevention, I think that efforts really need to start with adolescents, and with middle school children. And so, there is a wonderful prevention intervention that's been developed that's currently available on the CDC's website. It's called Safe Dates. And what it does is it talks about relationships and how to have healthy relationships. And I think when children understand how to do that, it will decrease the likelihood that they will have unhealthy relationships in adulthood.

At the same token, I think there is also some responsibility on the parents because people model what they see before them. And so, if I don't know what a healthy relationship looks like, it's going to decrease the likelihood that I'm actually going to engage in one. And what we know from the literature is, is that young girls who witness intimate partner violence victimization are four times more likely to then be abused in adulthood. And children, young boys, who witnessed their mother being abused are three times more likely to be abusive. So, we can remit that with the parents and then provide prevention efforts for the children. I think that's the key to success in that part. But again, I'm just toying with the ideas in my mind.

TAMARA LEWIS JOHNSON: Thank you for those responses. Dr. Stevens, please share information on the SSRIs and menopausal women. When you showed that slide when there was a peak of PTSD during the menopause period, can you share a little bit more information on SSRIs in menopausal women?

JENNIFER STEVENS:  Yes so, there is some really interesting research to suggest that SSRIs are less effective in older women, so after the age of 50. But in women who happen to be taking hormone replacement therapy, you didn't see this age-related decline in efficacy. But there hasn't been a randomized trial to actually address this. It was a naturalistic observation that this was the case. So, there really needs to be further work done in this space. And I think a lot of providers have moved away from hormone therapies for menopause, but I think it's important to figure this issue out because we may not want to prescribe SSRIs directly, but there could be other pharmacological approaches to dealing with symptoms of depression and PTSD in women as they get a little bit older.

TAMARA LEWIS JOHNSON: Absolutely. Thank you so much. This is a question for either of you. Will your studies be expanded to include LGBTQIA plus individuals that experienced similar trauma related to domestic violence and minors who experience similar traumas?

BERNADINE WALLER: Dr. Stevens, I can take this first if you'd like. So, the study that I have that's under review currently is really proposing that I include the diaspora of black women and not excluding the LGBTQ community. So, I'm looking across the diaspora of black women. I can say that in the intervention workgroup that I just held three weeks ago, that there were voices in that room who spoke to that population of women. There were voices in that room that spoke to military women who are experiencing victimization, as well as women who were suffering from a physical disability. And so, I really am being very thoughtful and intentional about how we're building this intervention because I want to make sure it is as inclusive as possible.

Unfortunately, the one gap is that there were no rural women who were included in that intervention development. However, I do have a young woman in my lab who that's her area of expertise is working with rural black women. However, there is  a women in my lab who has experience working witeh rural women. And so, this is something that I'm looking to do.

TAMARA LEWIS JOHNSON: Thank you so much. And I think this will be our last question for both of you. Going forward, can you identify what you think is the most critical next step regarding advancing this research and moving this field forward? We'll start with you, Dr. Stevens.

JENNIFER STEVENS: I think in my presentation you saw that there are a ton of huge gap areas for understanding how trauma-related symptoms change over the lifespan in women. So, really just addressing those gaps and starting to understand whether there is a link between trauma-related symptoms and, for example, changes in hormones over the menstrual cycle, during pregnancy, during the perimenopause. None of that has really - we haven't scratched the surface yet, so there is just a lot of work to be done. So, that's where I would start.

TAMARA LEWIS JOHNSON: Thank you. And Dr. Waller.

BERNADINE WALLER: I think in my area, a critical next step is really making sure that we're exhausting what we need to know from an implementation science perspective. Implementation science is really designed to understand the context. We can develop interventions all day, every day, right? You can have an intervention for every day. But if you don't understand the context in which you are looking to implement the intervention and have sustainability, making sure you're accounting for sustainability in the development and the delivery of these interventions, then whatever we're looking to do is going to fail.

And so, I would say a critical next step is making sure that we are fully understanding as comprehensively as possible, the factors that really could really derail an awesome, evidence-based intervention for this population of women. So, I would like to say that I'm really excited about what it is that we're looking to do, what it is I'm looking to do, and ready to make it happen.

TAMARA LEWIS JOHNSON: Thank you. Dr. Waller. Thank you, Dr. Stevens. This was an outstanding presentation. I want people to hold on. We have one more slide for you about the upcoming webinar of our series, which is Creating Equitable and Inclusive Graduate Programs from Recruitment to Admissions to Retention. That's going to be held on Thursday, July 20th. And I hope you will be registering for all of the webinars that are in our series that are spanning out until October 2023.

Thank you so much, Dr. Waller and Dr. Stevens, for this amazing, outstanding presentation. And thank you everyone for attending and providing outstanding questions to the speakers. Thank you so much. Thank you for attending.