Using Brief Interventions to Prevent Teen Dating Violence

MARY JO GIOVACCHINI: Good afternoon, everyone, and welcome to today's webinar, "Using Brief Interventions to Prevent Teen Dating Violence," hosted by the National Institute of Justice. At this time, I would like to introduce you to Dr. Carrie Mulford of the National Institute of Justice.

DR. CARRIE MULFORD: Thank you, Mary Jo. So, we have a fantastic lineup of researchers and interventionists to talk about a variety of brief interventions to prevent teen dating violence today. I want to start off by thanking all of you for your interest in this topic and by thanking the Federal Interagency Workgroup on Teen Dating Violence, particularly Mao Yang and Becky Odor at the Administration for Children and Families, for hosting this webinar series with us.

For the past several years, to commemorate Teen Dating Violence Awareness Month in February, we have done research webinars similar to this one. This year, we're changing the format up a bit to better highlight the practitioner experience in delivering interventions that have been evaluated through research at the National Institute of Justice. The first half of the webinar will be more of a traditional presentation format. You'll hear from our panelists about the interventions that they've developed, delivered, and evaluated.

Then I'm going to lead a moderated discussion with all the panelists, followed by a participant Q&A, which Mary Jo described to you, on how to submit your questions. We'll try to get to as many questions as we can in the final segment of the webinar. If we don't get to your questions, we will try to respond to most of those individually if we can do that. Let me start off by introducing myself and our panelists.

My name is Carrie Mulford. I'm a social science analyst at NIJ and I've been here for 14 years. I've been doing teen dating violence work since 2005, so most of the time I've been here, I've been doing this work. I'm a psychologist by training. The National Institute of Justice is a research funding agency and, since 2008, we've spent $18 million on teen dating violence research, primarily in two areas, intervention research and longitudinal research, although we've done a number of other types of studies as well. So, this webinar highlights some of our intervention work, obviously. The first speaker we're going to hear from is Dr. Emily Rothman, who's an associate professor at the Boston University School of Public Health. Her area of research expertise is adolescent dating abuse and sexual assault. Before becoming a researcher, she worked at a domestic violence shelter and for two different types of batterer intervention programs. Those experiences on the frontlines inspired her to think about creating more effective approaches to preventing perpetration in particular. Emily's going to be followed by Sarah DeCosta.

Sarah was a research assistant and an interventionist with Boston University School of Public Health, working on the Real Talk project that Emily's going to talk about. She worked in the domestic violence field for 13 years in both intervention and prevention capacities. Eight of those years were spent working with youth specifically, and she's currently the program director of after-school and camp programming for a local school district.

Then we're going to hear from Dr. Elizabeth Miller, who is a professor in Pediatrics, Public Health, and Clinical and Translational Science at the University of Pittsburgh School of Medicine and director of the Division of Adolescent and Young Adult Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center. Well, Liz, that's a long title! Trained in internal medicine and pediatrics and medical anthropology, she has over 15 years of practice and research experience in addressing interpersonal violence prevention and adolescent health promotion in clinical and community settings. Liz is going to be followed by Lisa James.

Lisa is the Director of Health at Futures Without Violence, a 30-year-old health and social justice organization working to end violence against women and children. With her team, she implements the National Conference on Health and Domestic Violence, the National Health Resource on Domestic Violence, as well as a number of multistate initiatives working to bring domestic violence and health care professionals together to improve the health and safety of survivors and promote violence prevention.

The last of our panelists will be Janice Goldsborough, who has a — has been a medical advocate at the Women's Center and Shelter of Greater Pittsburgh since 2007. The Women's Center and Shelter has been operational in the community for over 40 years, serving women and children who are victims of domestic violence. As a medical advocate, Janice acts as the liaison between Women's Center and Shelter clients and the medical community in the city of Pittsburgh in terms of one-on-one crisis intervention for victims as well as providing outreach and education for medical professionals.

Our participant Q&A session is going to be led by my colleague, Mao Yang, who's a senior program specialist at the Family Violence Prevention and Services Act Program in the Administration for Children and Families. She manages federal grants and programs related to children, youth, and abused parents. She also co-leads the Federal Agency Workgroup on Teen Dating Violence with NIJ.

So, we're going to start the discussion today with Emily Rothman. Emily, I'm going to ask you a couple of questions that I think you're queued up to provide answers to. First, can you talk about the Real Talk program, tell us about the intervention and what made you think this intervention might work, who are you delivering the intervention to, and what has the research shown so far about how well the intervention is working?

DR. EMILY ROTHMAN: Great. Absolutely. Thank you so much for having me. I'm really excited to talk to you about this intervention. As I get started, I'd like to thank my coauthors who are listed on this … on the first slide. I would also like to thank Carrie Mulford of the National Institute of Justice for the funding for this project, and mention as well that there was a precursor intervention developed through a K01 grant that I had from the National Institute of Health, and Robert Freeman, my project officer, who was also extremely helpful and supportive as that was going on.

So, I'll start by saying that why did we decide to do this one-on-one intervention with youth who'd perpetrated dating violence in a hospital setting? When I started thinking about this, which was probably in about 2004, there had been some randomized control trials, evidence for what I would call primary prevention programs — Safe Dates, Shifting Boundaries, Fourth R, now we have Coaching Boys Into Men — many programs that are implemented in school settings. In 2017, a meta-analysis of 23 different studies of dating abuse prevention programs, conducted by Lisa De La Rue and Dorothy Espelage, found that, while these programs are offered, someone's trained, they go into a school classroom maybe, and they deliver education — to everyone sitting in front of them that they can — to influence dating violence knowledge and attitudes. However, to date, the results for dating violence perpetration and victimization behavior indicate that the programs are not affecting these behaviors to a significant extent. So, the question in front of me was, "Is there something that we can do, maybe in another setting and that isn't primary prevention that might get us a little bit further?"

So, people may have heard of SBIRT, that stands for Screening, Brief Intervention, and Referral to Treatment. It's a type of counseling that people can train lay people, nonpsychological counselors, to provide. You are following a script, more or less, and you're sitting down one-on-one with somebody in order to help them walk through the pros and cons of behavior change and about decisional balance — how they might choose to make a change, why or why not.

This was developed for use with substance use problems. When I arrived at Boston Medical Center, my first mentors, Drs. Judith and Edward Bernstein, were experts in SBIRT and had done many different trials looking at both adult and adolescent substance use using this model in our setting. So, I thought, "Well, that's great. We've got this model, SBIRT." It actually is now accepted by SAMHSA as a model program, and clinicians everywhere are being encouraged to use SBIRT to screen adults age 18 and older for alcohol misuse. Is there a way that we could scoop out the content of the alcohol or marijuana piece? Is there something that I can pull in and put in there that would maybe be effective for that issue?

Back when I worked in a batterer intervention program, the goal was to hold people accountable, and we would often try to get them to change, maybe their entire worldview, about their privilege and gender roles, and how — sort of big topics, large-scale things in their relationship. That wasn't going to work in a 30-minute SBIRT-type intervention, but I did think that there were some things that probably could be addressed. So, things like self-regulation problems, or conflict resolution strategies, coping. So, I started to think a little bit about those things, and how they might be pulled into the SBIRT content.

Basically, the main thing that I'll sort of mention about what we did that might be interesting or surprising to you is, we followed all the same usual steps as SBIRT but we didn't focus on trying to increase empathy in anyone. So, when we designed this intervention, it's very gentle — we don't ever use the words "dating violence." We don't tell people, "You're a dating violence perpetrator and you need to stop" or "Don't you feel bad for the people you're hurting?" It's really not like that. So, it's different than what I had done in batterer intervention. Partly, drawing on behavioral economics and the idea that it was a really short period of time, kind of focus on, "Look, why might perpetration be bad for you? If you're trying to make your decision about whether you want to change the way that you interact with your partner you told me your goals for your future and getting involved with the police, or injuring yourself or your partner could get in the way of all that."

We develop a pretty friendly rapport with them, not in order to support their behavior and their harmful behavior but also to keep in mind that half (55 percent) of those who screened positive for perpetration also screened positive for victimization. Many people probably know this about adolescent dating abuse — in our sample, the idea that "You've used unhealthy behavior, but we're not trying to skewer you, we're just trying to think about behavior change" was an important part of how this worked.

So, who's our target population? We decided to conduct this randomized control trial with healthy kids in an emergency and adolescent outpatient setting in a hospital. They came to the hospital for a sprained ankle or a urinary tract infection, and so it was a convenient place to recruit them. They were 15 to 19 years old and English-speaking. They couldn't be too dangerous, or be in a batterer intervention program, or be above a certain threshold on a dangerousness assessment, but that was between me and the institutional review board. They were worried about me having two severely dangerous people in my intervention that they were responsible for. It wasn't a conceptual or ideological decision from the get-go. To get into the intervention, they had to report that they had done an act of physical or sexual dating abuse. There's a checklist, and they had to check off at least one that they had done in the past three months.

We assessed 984 people — and this may surprise you — 28 percent were eligible, meaning that 28 percent of the people we walked up to in the emergency department who were in that age group or outpatient said, "Yup, I've done physical or sexual dating abuse in the past three months." Of those who were eligible, were they interested in participating in this intervention? Yes, 81 percent actually said, "Sure, I'll enroll in your study. This sounds fine." We had pretty good follow-up rates in this study, so we randomized people to either get our Real Talk intervention or not. We followed them up at three months and again at six months to see what had changed. Our follow-up at three months was 65 percent and was 73 percent at six months.

You're looking at my results slide, about any dating abuse perpetration. We're looking at physical, sexual, and psychological forms of dating abuse perpetration. The blue line is our intervention group. Of course, at baseline, everyone was at 100 percent because you couldn't get into this study unless you said you did dating abuse at baseline. Let's look at that three-month mark. If you were in the intervention group, you experienced a 62 percentage point decrease in dating abuse perpetration, and if you were in the orange control group, it was a 51 percentage point decrease. I know that might seem funny that both groups experienced a decrease, but that happens in many SBIRT randomized control trial studies. People aren't totally sure why that is. There are some guesses. It is true that people do tend to naturally decline in some things over time. Nevertheless, if you look at our effect size and confidence interval, there was a difference — there was something that we saw here that was of interest.

So, then we took it a little further and decided to break down dating abuse into its different forms, so we looked at psychological dating abuse perpetration. You can see that 28 percent at baseline in our intervention group reported that they perpetrated psychological dating abuse and that decreased 23 percentage points to the three-month mark. The orange control group, not so much, with a less strong effect size. In both of these, the changes didn't persist to the six-month mark. We generalized this in doing the equations. Looking across the different time points, we saw this change up to the three-month mark but maybe not the six-month mark.

The last one I'll show you is really interesting. It was cyber dating abuse perpetration. There was some natural random, coincidental difference at baseline between the two groups a little bit. So, you see the blue line, or intervention group, they dropped quite a bit, and the orange group was only 14 percentage points up to that three-month mark. So, for those of you who have been looking at my .06 p values and feeling like sticklers, here's a p value that's .004, the effect size, which is decent, so we potentially have some real change here. This did not persist to the six-month mark because the p value went up, over .11. We may have some work to do in terms of doing more booster phone calls with them after they leave the hospital, or figuring out some way to get it to persist past the three-month mark, would be something worth working on. I've grayed out my results because my article is still under review and I didn't know if the [NIJ] Journal was going to get upset if I had already displayed all my results somewhere. I want to point out, we had very few males in this trial. You're looking at the three-month results right now. We had 10 males, but the p value for them was .014, even though it was a small sample. There was enough of a difference that we managed to get a good effect for any kind of dating abuse, and that was also true at six months. However, even though we only had 11 males, we were able to follow up with at six months — not so bad for physical dating abuse, even for this incredibly small group. The other things didn't persist to six months.

Where does that leave me? I think that Real Talk had some effect and that the strongest effects appear to be in psychological and cyber dating abuse perpetration, which may make sense. Maybe those are the easier grab after a 30-minute conversation. Maybe it's less common to perpetrate physical and sexual dating violence, so it's harder to pick up differences on those things. The other thing is that the effect did persist to six months for males and that any abuse category (and maybe physical abuse) didn't persist for females past three months, so that gives us a little something to think about.

I am incredibly indebted to my research assistants, who were amazing, who learned how to do the SBIRT and then went into the settings in order to do it. We're actually going to hear from one of them right now — Sarah, who's going to tell you a little bit about her real-life experience during the intervention.

DR. CARRIE MULFORD: Yes, Sarah, so I'm going to turn it over to you. Talk about what your role was in the intervention and as an interventionist delivering the services, what do you feel like worked well and what were some of the challenges in delivering the intervention? So, if you could just talk a little about that — that would be great.

SARAH DECOSTA: Absolutely, thanks. So, my role in the intervention was to sit in the pediatric emergency department of Boston Medical Center — that's where I was stationed on my shift — and to screen for anyone who would come in who fit our criteria. For the age category, and also a few other things they couldn't be coming in for a grievous wound or with any kind of altered mental state, obviously. We were looking for folks, as Emily said, that had sprained ankles and things like that. When someone would come in and fit the criteria, I would approach them and I would tell them about Real Talk and ask if they were interested. And if they agreed to do the one page — it was front and back of one piece of paper, a screening form — then I would review the screening form to see if they were eligible to be in the study. If they were, then I would ask them if they wanted to continue. If they were interested, we review all of the paperwork we needed to do, consent forms and everything. I would then randomize them; we had our own system for how that would happen. If they were randomized into the intervention group, I would then conduct the intervention in the emergency department.

I think one of the things that went really well and that I enjoyed was that I was able to build a rapport with the participants really easily. And I think that part of that is that the SBIRT script actually sets you up to succeed in that area. I also have a lot of experience working with youth, so I usually am in rooms talking to people on the page routine anyway, but it was really nice to have the script be the skeleton of it. And then we could ad lib the relationship-building pieces of it as long as we hit all of the main intervention points and some of the specific scripts that we needed to say.

And one of the things that I found challenging was that some of the other interventionists were stationed in the outpatient medical center so they would have a more regular flow of potential participants. For me, in the emergency department, there were some nights that that nobody came in, so I couldn't even screen. But there were other nights that I would have so many people at a time that I couldn't do it for all of them. So, the variability in your pool of potential participants is a little challenging when you're in something as uncontrolled as an emergency room. I do think that having it in a medical setting was helpful in that we became part of the process, "Oh, this is a medical thing and you're just going to talk to us, and it's okay." We didn't present ourselves as doctors or medical professionals, but something about the setting made people more willing to be involved.

DR. CARRIE MULFORD: Thank you. I'm going to ask you one quick follow-up question to that. So, when you were recruiting, were there a lot more female, like, potential participants, or was it that they were more likely to be willing to talk to you, or why would you think there was such a big difference in the split?

SARAH DECOSTA: In the emergency department, we saw a lot more teenage girls than we did boys. When boys came in, it was often for a broken leg or something severe enough that we couldn't approach them. A lot of young women end up at the emergency room for things like urinary tract infections and needing a pregnancy test, and that area … there's not necessarily folks that have a primary care provider, so they come to the emergency room for things that you may normally think of as, like, an emergency as not an emergency. So, we did see a lot more females in the emergency room for any reason, generally speaking.

DR. CARRIE MULFORD: Great, thank you very much. Okay. The next person we'll hear from is Dr. Liz Miller, and she's going to talk about the SHARP intervention. Liz, I'm going to ask you the same questions that I asked Emily. Tell us about the intervention that you're doing, how it works, and what made you think it might work, who you're delivering it to, and what has the research shown so far about how well it's working. DR. ELIZABETH MILLER: Well, thank you all so much for the privilege of sharing this with you and I certainly want to begin by thanking the National Institute of Justice for the support to do this work in the health care setting. My presentation is followed by presentations by Lisa James and Janice Goldsborough. Janice is an advocate who's been working very closely with me in Pittsburgh, so our work is somewhat synergistic. What I'm going to be sharing with you is the SHARP intervention and some of its history. Lisa James will be sharing the broader kind of framework as we've been expanding this kind of implementation framework in other health care settings. It is important to remember about why we're focusing on the health care sector as a point for intervention. Just as Emily was underscoring the emergency department as a really important place for prevention work, I'll be talking about school-based health centers as another site. It has to do with the fact that adolescent relationship abuse (ARA) has really significant health and social consequences for young people. We also know that young persons who are in unhealthy and abusive relationships actually seek care more for the range of health problems that's listed here.

The challenge that I'm going to talk about, which is really an implementation challenge, is that getting health care providers to change their behavior can be a little bit challenging. But we always start by reframing the role of the health care provider and reminding health professionals that they can actually help to reduce the survivor's sense of isolation and shame, and encourage them to believe a better future is possible and that, as health professionals, we have a really important role to play. We also know, from research primarily focused in adult women, that those who talked to their health care provider are significantly more likely to use an intervention. An intervention can be everything from calling a hotline, reaching out to a victim service advocate, talking to a counselor, or joining a support group. Work that has been done here in Pittsburgh with one of my colleagues, Judy Chang, is an interview study with survivors about what they want in the clinical encounter — being nonjudgmental, listening, offering information and support but, most important, not to push for disclosure. From my colleagues at Futures Without Violence, they have really succinctly summarized what we hope could be success, that perhaps success is measured in our efforts to reduce isolation and to improve options for safety.

The work around the SHARP intervention is really situated in this framework — which is a much more trauma-informed framework — that recognizes that screening alone may not be effective in addressing relationship abuse in the clinical setting. And what we are seeing across multiple studies are very, very low disclosure rates when we focus on screening alone. It is not survivor-centered in the sense that we are relying on patients to disclose to us on a screening question in order to connect them to resources, and so that resources are then offered only based on a patient's disclosure. And what we thought — and which is really the foundation for the SHARP intervention — was that this was a missed opportunity for prevention education. So, in the work that we did in school-based health centers, this is from our baseline data across eight school health centers in high schools in California. These are all comprehensive clinics located in schools. And of the youth who were seeking care in these clinics, 41 percent reported recent cyber dating abuse victimization experiences, and 13 percent reported recent physical or sexual relationship abuse experiences, with an overall prevalence of victimization of 45 percent in the past three months — really underscoring why we think the health centers and school health centers are a really critical place to do this work. And so, what we were testing with the SHARP intervention was a universal education approach and was designed, through multiple funders, to create an adolescent relationship abuse educational card. It's a palm size business card-size informational card that includes some information about healthy and unhealthy relationships as well as how to help a friend. In our research, we found that the intervention components were to distribute the healthy relationships card with every clinic visit and then to do a direct assessment for sexual health-related visits. And then there was also a youth-led relationship abuse awareness across the school.

What we found in that randomized trial was, the young people who were in clinics where they received the information, with increased recognition of what constitutes abusive behavior and sexual coercion, increased awareness of the ARA resources. Among youth with recent relationship abuse victimization, they actually reported less victimization at three-month follow-up. And then, while this was a nondisclosure-based intervention intended to not focus on disclosure, it actually increased the likelihood of disclosure to the provider during the clinic visit threefold, in addition to the SHARP intervention — to test direct assessment for reproductive coercion with sexually active young women. It has to do with the fact that intimate partner violence increases young women's risk for unintended pregnancies. So, what we designed, very similar to the SHARP intervention, was a reproductive health card for sharing information about healthy and unhealthy relationships, but with very specific information about reproductive coercion, which is likely to be a male partner's active attempts to impregnate a female partner against her wishes.

The findings from our randomized control trial showed increases in knowledge of resources and increases in self-efficacy to use harm reduction strategies, which were really our overall goals for the intervention. We also found that, for women who were experiencing high levels of reproductive coercion at baseline, there was a very significant reduction in reproductive coercion one year later. And, among the feedback that we received from patients was, "Getting the card makes me actually feel like I have a lot of power to help somebody."

Lisa will be going into more of the sort of theoretical background and the research informing this kind of approach. But what we have learned is that patients really, really greatly appreciate receiving this information during their clinical encounters. So, what I want to conclude with is where we have taken this research, which is with what we call our "trauma-informed personalized scripts. What we have done is ask patients to complete a brief questionnaire on their tablet (on a computer tablet) about partner violence and reproductive coercion and then randomly assigning them to either provider scripts only or to the group who will complete the questions but the responses do not go to the provider. What the provider receives is a prompt with specific language on what to say to their patient during the clinical encounter. We also tested whether adding patient messages in addition to the provider script would increase provider discussion about partner violence and reproductive coercion as well as provision of resources. Preliminary results were that discussion of healthy relationships in clinics that had been trained in reproductive coercion and partner violence went up a bit, from 68 percent to 78 percent. Receiving the card increased it from 73 percent to 79 percent but, most important, because this was focused on reproductive coercion, it went from 10 percent per discussion to 61 percent, simply by giving providers the script on what to say. Although disclosure is not the goal — very similar to what we found in the SHARP study disclosure — it increased, this time from 12 percent to 22 percent.

So, I share this — the implementation piece — with you because working in the health care setting, training health care providers is not enough. We have to be paying attention to the clinical systems to support providers to really implement these kinds of brief interventions. And, in reframing the role of the clinician in violence prevention, we are really aiming to help health systems recognize that trauma is prevalent, encouraging providers to offer support in harm reduction (regardless of disclosure) to help youth increase their safety and build resilience. And, in a piece that Lisa James will be talking about more, is emphasizing the role that young people can play in helping others and strengthen their connectedness. So, I will conclude there and just want to acknowledge the many people on the SHARP research team, our community partners — including the Women's Center and Shelter and my research team — as well as the funding from multiple sources, including the National Institute of Justice, to allow this work to happen.

DR. CARRIE MULFORD: Thank you very much. I am going to ask Lisa to talk about the extensions to the SHARP intervention program, called CUES. Lisa, can you talk about the intervention that you are doing, again, who it's delivered to and what we know about how well it's working so far?

LISA JAMES: Yes, I was just mentioning that the CUES intervention is really a broader framework, as Dr. Miller talked about, that we have implemented in adolescent health settings but also in family planning and primary care settings, that walks through this evidence-based and trauma-informed approach to violence. And we're seeing great promise around improving both health and safety of young people and for others who receive the intervention. So, I'm going to talk a little bit more about the steps of the CUES intervention, and I want to just start off by saying that I'm representing Futures Without Violence and we are funded by the Department of Health and Human Services to operate the National Health Resource Center on Domestic Violence. And I want to thank Mao Yang and Becky Odor and the whole team at the FVPSA Office for their support. And it's because of their support that all of you have access to free resources that we're going to talk about through the course of this webinar. So, the training and technical assistance materials and recommendations are available to you, free of charge, through the Health Resource Center on Domestic Violence.

Let me talk a little bit more in depth about the different steps of the CUES intervention that has been developed in multiple settings with feedback from survivors, from advocates, and from health care providers. And it goes through these steps: The first is C, confidentiality and disclosing limits of confidentiality, and making sure that each setting has a policy, ideally, where they see a patient or client alone for some portion of the visit so that they can have that opportunity to talk about violence privately. The U is for universal education, again, about healthy and unhealthy relationships and the impact that it has on health and health outcomes. The E is empowerment, and Dr. Miller talked a little bit about that. We'll talk some more about how critical the empowerment and how healing, really, it can be for clients to be able to receive this information about their health and also be able to share it with others. And the S is for support. And there is a number of different steps around promoting harm reduction strategies and health promotion strategies, connecting up the client or patient with community-based programs, and following up at the next visit.

So, I had talked a little bit about disclosing limits of confidentiality, and we know that it's absolutely critical to build trust, particularly with young people, by sharing what is reportable and what isn't. And, so, this is just a script that we use for training health care providers — around how to address, right upfront, any limits of confidentiality that they may have, so that the young person knows what might be shared. And it depends, in terms of each setting and state in which they're working in and in terms of what's reportable. But importantly, again, after we had been doing work for a number of years, we learned more and more about the limits of disclosure-driven practice, as Dr. Miller talked about. And we know that so many patients are not ready to disclose for a variety of reasons. And so, we also provide this script around disclosing limits, confidentiality that's not disclosure-driven, and saying something to the effect of "We know a lot of patients aren't ready or maybe afraid to share certain things about their health or their relationships. But we want you to know that you can use these resources for yourself or for a friend, regardless of what you choose to share with me today." And again, that's just underscoring that the information is there, regardless of whether or not the young person decides to share anything with the provider about their relationship.

And then we get to the universal education. And I talked a little bit about making that connection between violence and health. And Dr. Miller showed you some of the resources that are used, for instance, the two palm-sized cards. And when we began doing the work, we started with just one card. But, again, we learned over time that, by giving two cards, we can let patients know that they can share those resources for themselves, they can keep it, or share it with a friend or a family member. That's been particularly critical with young people because we find that they are very eager to share the resources with their peers, so that's been a very powerful finding. On the card, as Dr. Miller discussed, it has information about safe and healthy relationships, and what an unhealthy relationship looks like. The card also has resources on the back. So, you have an opportunity for all patients to talk about relationships and their impact on health. If somebody is experiencing violence, they will be able to leave with resources to access ongoing care, if needed.

And then we talked a bit about the empowerment piece. And what we have found, from the qualitative research that we've done with Dr. Miller, is how important it is to offer the resources, regardless of disclosure. It's really a choice for the provider to share power with the patients. So, you're not just approaching this issue as a checklist and screening and then treating a problem that's identified. Instead, it's just taking time to talk about the issue and then offer resources for that patient to decide what to do with. So, we really heard from clients who've received the intervention. They find that it's very empowering to have both the cards and an opportunity to share them with their friends and family members and make a difference in the world. (The card also has resources on the back.) That act of sharing the resources can be healing, in and of itself. And, while disclosure isn't necessarily the goal, it definitely happens, as Dr. Miller shared with her research in the SHARP study. So, when we do the intervention, we are sure to acknowledge that disclosures do happen. When somebody does disclose, make sure to make the connection between their health and dating abuse. Don't immediately refer them to a community-based expert — take the time to address the health issue at hand.

And we heard about a number of different health consequences of abuse and we're really seeing — particularly with young people — eating disorders, increased unintended pregnancies, or STDs. So, really addressing those health issues with the understanding of the abuse that they might be experiencing, and how their partner might be interfering with their care. And offering a care plan that can support them in a trauma-informed way. And I just want to lift up that these harm reduction strategies can really look different in different settings. So, we have a recommendation around visit-specific harm reduction strategies. And you see there, on the slide, that in primary care settings, you might be addressing more chronic health issues. In adolescent health, we have a big emphasis on anticipatory guidance for health and unhealthy relationships. In behavioral health or mental health, you might assess whether or not someone's partner is trying to undermine their sobriety or sanity and make a plan to lessen that interference.

And Dr. Miller already talked about the offering of alternate birth control in reproductive health settings with sexually active young people to, again, decrease the risk for unplanned pregnancy. So, depending on the reason for a visit and on the setting, those harm reduction strategies can look different, but they're really critical. And then, finally, warm referral. And it's so critical to partner with community-based programs who provide services to survivors of domestic violence. And being able to offer that warm referral, right there in the clinic, is important because sometimes we know perpetrators monitor the use of their partner's cell phone. And so, being able to offer a phone, right there in clinic, and say, "If you're comfortable, I'd like to call my colleague, and she's helped many others who've been in similar situations," and make that connection, right upfront, if somebody does disclose. So, that is an overview of the CUES intervention that has been implemented in adolescent health settings and primary care settings, and reproductive health settings across the country. And we've seen an exciting impact — the increases in health and safety — as a result of the intervention.

DR. CARRIE MULFORD: Thank you, Lisa. Okay. So, Janice, I'm going to ask you to talk about your role in the intervention as an interventionist, and to talk about what worked well and what you thought were some of the challenges in delivering the intervention — the CUES intervention.

JANICE GOLDSBOROUGH: Okay. I was on the study with Liz Miller and her group. And Liz, if you're still here and I leave something out, please jump in. But my role as to follow-up of the study is to give a face to the warm referral. So, I was there with Liz when they did the education portion. As a matter of fact, up until this point I continue to do site visits at least once a month. And I make sure I don't take enough cards. I don't want to take a thousand because I want to continue to have an excuse to come back. So, I take the cards, and we've developed — at the Planned Parenthood downtown, for instance — we have signage in the elevator. We have posters. I've given them posters for the restrooms as well. So, seeing me coming back and forth also makes me look like I'm a member of the team. It will not only keep domestic violence at the forefront of their thinking but also it'll click with them, "Oh, right, that's Janice. I can call this number or I can do this." I've given them my cell phone number that they're free to use, but no one does. On the very few times I've actually seen patients, I was able to meet them at their visit because I knew ahead of time. Sometimes, I talk to a person on the phone and, the rest of the time, they know that they can use the hotline as well.

Another thing that I do is try to develop a positive relationship with the practice manager, or their counterpart, because office culture tends to come from the top down. If it's going to be a culture of awareness about partner violence, when managers ask questions, they should want to hear the person's answers and not just check off that box. That's a cultural thing, and it's created from the top down, so of course I want to develop positive relationships with those folks. One of the challenges, I guess the main challenge, is that every site is very different. And if there's turnover, if one of those people that left or moved around was one of your champions, you have to keep on continuously recultivating those relationships. That's something that other medical advocates run into at other settings. So, the one advantage is that these places are smaller than hospitals, unlike the University of Pittsburgh Medical College, people aren't going to move around as often as they do in bigger places. But, still, you would have turnover. So, you have to continually sell your product and maintain awareness because, for me, domestic violence is all I'm concerned about, whereas domestic violence is competing with many other issues that staff are working with, as far as the patients go.

DR. CARRIE MULFORD: Janice, thank you very much. JANICE GOLDSBOROUGH: Sure.

DR. CARRIE MULFORD: Okay, so that concludes our first portion of the webinar. Now, we're going to move to a moderated discussion where I have some questions queued up for the participants. So, first, we're going to turn to Sarah. Sarah, for the — when you were delivering the Real Talk intervention, how receptive are adolescents to talking about these kinds of things? To talking about unhealthy relationships and, potentially, abuse in the relationships? And some people might be skeptical that they'd be willing to talk to adults about these kinds of things.

SARAH DECOSTA: I actually found that they were surprisingly willing to talk to me, and especially about the nonphysical forms of abuse and unhealthy behavior. And one thing that struck me over time doing this intervention repeatedly, was that the reason for that seemed to be that they don't recognize this as something that is a problem or that is not normal. For many of them, this is just how relationships function. Their peers, maybe, are in the same types of relationships. In some cases, they and their partners are both doing some of these behaviors. As Emily mentioned, a high number of these participants also score high on the victimization scale. They were in relationships that were just toxic. And they seemed to think it was completely normal. So, they were totally willing to tell me all about it. I found that, in my work in other programs, a lot of teens just want somebody to talk to them who's not going to give them a lecture. I think the relaxed way that you approach someone when doing this intervention and the way that you build that rapport makes them comfortable. And I think a lot of teens, given an opportunity, would want to get some advice from maybe somebody who knows about this kind of thing because they don't often get talked about talked to about this stuff. They may be told about STDs in health class but, in a lot of places, they're not necessarily "getting" educational relationships and what they're supposed to look like.

And the other thing I was really struck by is, as I was talking to them, how much many of them struggled with not having coping skills. They weren't doing the things they were doing because they wanted to, often. It wasn't, "Well, I had planned this and I did this because I wanted x, y, z from my partner." It was usually because they would describe how they just got so frustrated that they didn't know what else to do. The lesson for me, my takeaway, was providing more education, generally speaking, to young people about relationship dynamics and also working with schools and other settings to provide that social-emotional development and coping skills stuff I think would be useful. The dynamic was very interesting to me, especially coming from my background in the adult domestic violence field.

DR. CARRIE MULFORD: Great. Thank you, thank you so much. Liz, I'm going to ask you a similar question. So, Sarah was talking about her experience with Real Talk. Do you have a similar experience from the SHARP intervention in terms of willingness of adolescents to open up?

DR. ELIZABETH MILLER: Yes. Yes. No, indeed. And actually when it's phrased the clinicians working in school-based health centers who, for the most part, are clinical nurse practitioners. The feedback from young people was how much they just appreciated that anybody was talking to them about the issues they actually cared deeply about but have not had a space for honest conversation about healthy and unhealthy relationships. And one of the extensions of the SHARP work has been to try training school nurses here in the state of Pennsylvania. And in a pilot study we did with five schools where we worked with school nurses — and, again, super light touch — as young people were coming through for headaches and and other sort of belly aches and so forth, that the school nurse actually spoke with all of the young people about healthy relationships and asked them to distribute the cards and so forth. And the feedback that we received from young people on that study was phenomenal. Like the young people are sort of writing in on their comment card, like, "My school nurse is absolutely the best. Nobody else treat us with this much respect," which is so striking. The idea of, like, sharing this information was really appreciated by young people as being respected and being valued.

LISA JAMES: This is Lisa. Might I make one additional comment, which is the other finding with the SHARP Study. Because they had such a positive experience (that Liz just described), they also reported that those who received the intervention would be much more likely to bring a friend to the health center or to refer a friend to the health center to talk about healthy and unhealthy relationships. So, for those working in the school-based health settings, that is just exactly what you want to hear, that those referrals will be coming in as well. Thank you.

DR. CARRIE MULFORD: So, for the next one, if somebody wanted to try to implement your intervention in their own community, what would it take, what resources are available to them, and what cost might they incur. I'm going to start with Emily to talk about Real Talk.

DR. EMILY ROTHMAN: Yeah, sure. So, I'm actually in the middle of writing up a cost-benefit analysis-type paper that gets down into the details of all of this right now, but I can give you some rough sketch answers. So, this is a really inexpensive intervention. And it does matter if you're doing it in a hospital where you already have, let's say, a social worker who does lots of things and could fold this in. So, when someone screens positive for dating abuse perpetration, they are trained in SBIRT and they can do this or, if you would have to hire someone, you would need a really large hospital with a high volume of patients to have to hire another whole person. I have been talking in Massachusetts to the school nurses and school-based health centers (which are separate things) and asking, "Can we train school health personnel to do this as part of their regular job?"

It's cheap and easy to train somebody how to do this, and we're starting to get a couple of requests, here and there, "Can you come give us a training, like a one-day training?" They now know how to do it, and they can just start implementing it. If you had nothing in place and wanted to start from scratch, our estimate right now is that it will cost about $62 to $72 per patient for this intervention to happen, or about $17,000 per year in order to pull this off — and that's if you had dedicated staff and a hospital. So, obviously it's going to be less expensive for a school nurse, since you're just folding it into their work.

DR. EMILY ROTHMAN: Okay. I was going to mention that if there are people who are listening and they like the idea of Real Talk, we actually recorded a video, it's not 30 minutes long. We made a seven-minute abbreviated version of Real Talk so that you could see it on your computer and decide if it looks interesting to you. And so, if anyone emails me, I'll just send them the link and then you get to see what it looks like in real life, a little bit.

DR. CARRIE MULFORD: And at the very end, during the Q&A, we'll have email addresses up for the presenters, so you can jot that down or you can come back and look at the presentation later to get Emily's email address. That's terrific! Thank you so much.

DR. CARRIE MULFORD: And I'm going to then turn the same question to …to Lisa to talk about what resources are available for CUES, and where folks might go to get those, if they wanted to try to implement it in their own communities.

LISA JAMES: Sure. So, as I mentioned in the beginning, through the National Health Resource Center on Domestic Violence, we can provide resources, free of charge. You can order them online, just a shipping fee, but that includes posters that you can hang in exam rooms that talk about healthy and unhealthy relationships and the impact on health, a training resource that really walks through how to train your colleagues on this intervention. It's called "Hanging Out or Hooking Up," and that really walks through the CUES intervention — and also a set of consensus guidelines that were developed by a number of health professionals in the field. So, those are two pieces that really are ready for you to take and implement and then, of course, the actual safety card that we talked about that's so core to the intervention. So, all of those resources are available to anybody who would like to implement this intervention, free of charge at The National Health Resource Center and our website and our email will be at the last slide, so please do feel free to contact me if you have any questions about what to order and how to implement this work.

Like Emily said, it's not an expensive intervention. You can take these resources in and use them in your own setting. And when you're in a very large setting or if you're an administrator who's listening, of course, you want to think about how to scale up the intervention and how to support the individual providers that are doing it. So, we have a number of different resources on these websites that you see here, ipvhealth.org and ipvhealthpartners.org, which is specifically for community health centers that talk through the steps of how to create a sustainable and systemwide response to intimate partner violence or adolescent relationship abuse.

So, the cost is not expensive on an individual level and then, when you scale up, you have to think about how to train all of your providers, how to support them through the kind of system support that will make sure that it's sustainable. What are your steps for providing quality improvement and making sure that the intervention is being implemented in a way that's promoting health and safety? We have resources to help you with all of those steps.

DR. CARRIE MULFORD: Excellent. Thank you. And we put a couple of those up on the screen as you were talking, so people can see that. Does anyone else have anything to add on this issue of implementing the programs in peoples' community and expanding out — before I move to the next question?

DR. ELIZABETH MILLER: I'll just jump in. This is Liz Miller. Around working within health care systems, because I want to underscore what Lisa was sharing on the online toolkit, which includes guidance on the clinic policies and protocols that really need to be in place to support health care center intervention. And it's basic things, like having very clear privacy and confidentiality policies within a clinical setting; having a partnership, a formal partnership with the Victim Service Agency Domestic Violence and/or sexual assault, like we do with Women's Center and Shelter, and the fabulous Janice Goldsborough — those kinds of things need to be really formalized.

It is not sufficient to simply train providers and say "go to it," and so I think that systems-level piece is at no cost to the system to make these kinds of straightforward policy and protocol changes. Where there is some cost, the training for health care providers is best done in a concentrated period of time. Usually, three and a half to four hours of health care provider training in a trauma-informed approach, understanding the impact of secondary trauma on clinic staff, and understanding how to implement the CUES approach and the rationale for that. And that does take some time. I think that there are attempts to look at what online training might look like and so forth, but just in terms of the existing cost piece, that is one for health centers to be mindful about.

JANICE GOLDSBOROUGH: Hello, this is Janice. Can everyone hear me? DR. CARRIE MULFORD: Yes, go ahead.

JANICE GOLDSBOROUGH: Okay. I just wanted to reiterate: All of our services are free of charge — whether that's lecturing to colleges, a crisis intervention — everything is free. My counterparts in Pennsylvania that fall under the PCADD [Pasadena Council on Alcoholism and Drug Dependence] provide services free of charge. Anytime an advocate comes out, does education or crisis intervention, it's always free of charge.

DR. CARRIE MULFORD: That's great. Thank you. Okay. We're going to move on to the next question. What do you all plan on doing, moving forward, what are the next steps that would typically be embedded in a research presentation? But I wanted to broaden the question — it could be research or practice — what are the next steps for each of the programs? We'll go ahead and start with Emily about Real Talk.

DR. EMILY ROTHMAN: Yeah. I have lots of ideas. So, I guess, thinking with my researcher hat on, I'd really like to try this in a new setting. So, I am trying to get school health centers, school-based health centers onboard for a cluster-randomized controlled trial. We obviously need to redo with more boys and men, so 11 is too few, we got to do a little bit more than that. It would be great to get those off the ground. And I think other types of next steps would be figuring out how we can pick out the parts of the content that were, like, the pieces that were really working and make those even stronger and see if we can get those effects lasting even longer, or if we can build in a better system of double checking, another booster that will keep it going for people, once they've got the hang of this.

DR. CARRIE MULFORD: Excellent. Liz, you want to go next?

DR. ELIZABETH MILLER: Sure. For SHARP, one of the things that we're looking at from a research perspective is, while we were able to show with the NIJ-supported trial that we reduced relationship abuse victimization three months later. It was really focused on violence as the outcome, and not health outcomes. And among the things that we have been asked by health centers and health care systems is, is there any evidence that this kind of brief intervention could have an impact on health outcomes? And so that is one area that we're looking at, including whether or not this kind of focus on healthy relationship education might in fact impact sexual and reproductive health behaviors as well as mental health outcomes.

A secondary piece that is more a technology development piece is based on the implementation data that I shared with you, where using a prompt to give providers the kind of reminder of what to say to their patients, and how effective that appears to be in reminding providers to actually implement this intervention. One of the things that our partners have asked for is embedding the scripts into the electronic health record. So, to have the tablet-based questions and the providers' scripts actually embedded in their clinic flow. So that is also something that we're working on.

DR. CARRIE MULFORD: Okay. Our next question that we have." How can these interventions be used in other settings? Folks are asking about that. Lisa, you want to go first on this one?

LISA JAMES: Sure. I put up here, on the screen, a number of different settings in which we have resources to help you use these types of approaches and to implement the CUES intervention. So, we talked about the school-based health settings and we want to further expand and spread that opportunity to implement the CUES intervention in school-based health settings, and Liz talked about the school nurses, so there's definitely opportunity to do more work there. Additionally, in reproductive health settings — in the same way that we have resources for adolescent health — we have training materials, a train-the-trainer toolkit, consensus guidelines, and patient safety cards for reproductive health settings that really look at reproductive health issues specifically in harm reduction strategies there and specific to reproductive health visits. Additionally, we have resources for primary care and that includes consensus guidelines and training materials and safety cards. And we're currently involved in a project in collaboration with the Health Resources and Services Administration and ACF (Administration for Children and Families) to work in four states in partnership with the primary care associations, the domestic violence programs, and the Departments of Health to implement this intervention and to … 50 percent — at least 50 percent of the community health centers. So, we're in the midst of doing that work but there's resources available for primary care.

And, also, we've developed some new resources for pregnant and parenting teens, and you see a picture of a Young Mom, Strong Kids card. That's an adapted resource for pregnant and parenting teens to promote safety and improve health and parenting strategies. And we also have resources for campus health settings, and Dr. Miller is involved in a study there to, again, lift up that important role of campus health settings for preventing and responding to sexual assault and domestic violence. And then we also have community-specific resources that can be used in community health settings or youth organizations. And you see pictures there, of our LGBT resources that are being used, again, in community-based settings as well as in health settings. So, there's lots of opportunities for student activism and awareness and then also other organizations that are outside of the health settings as well.

DR. CARRIE MULFORD: Excellent. So I'd like to ask that question also, of Emily. Is there any possibility of doing any of these kinds of programs in a justice setting — youth correctional facilities, probation, detention centers?

DR. EMILY ROTHMAN: Yeah, absolutely.

DR. CARRIE MULFORD: And you can answer more broadly than that. Don't feel confined to that question.

DR. EMILY ROTHMAN: Well, it's funny you asked. I've been talking with a colleague in Cambridge who runs a very innovative program affiliated with the high school. It's, like, a diversion program for teenagers. And, we've been talking about how could we — school research officers, diversion officers, people probation, juvenile probation — how could we train them? But they sound really interested. It's, like, right up their alley, so that's encouraging and exciting. And then I've been trying to think quite far outside the box recently, too. There are a lot of specialists who work, for example, teaching social skills groups to kids with autism spectrum disorder, or there's some ADHD, like lots of communities. There are these community-based specialists who do certain kinds of social skills groups. And I've been wanting to think too about "Are these people who we can bring into the fold" because they're not normally trained to think about dating violence so much. But as kids get older, in addition to the social-emotional learning and bullying stuff they do as little kids, it's appropriate to get in on some of this stuff. Those are definitely justice and then these other areas or directions that I'm thinking about, too. So, I'm mainly really excited to talk to other people who are excited about wanting to try it because I see lots of possibilities, and just that we need further work, further testing.

DR. CARRIE MULFORD: This has been so fabulous. So, I had one more question but I'm going to turn the floor over to the participants in the interests of time. I see a lot of good questions coming in. So, Mao, I'm going to turn the phone over to you and let you ask the questions that are coming on the Q&A.

MAO YANG: Sure. Thanks, Carrie. I just want to thank the presenters for sharing all the information on their Teen Dating Violence intervention. And I want to thank the participants for joining today's webinar and for posting several questions already. A question that had come up for Emily. Actually, there were several questions that came up for Emily and Sarah about SBIRT. What types of teen dating violence were involved, and was there a difference between male and female perpetration of teen dating violence? Is SBIRT similar to motivational interviewing? Is the interview protocol or script available, and what incentives are provided to participants who were in your study?

DR. EMILY ROTHMAN: Okay. So that's a lot of questions, though. Let's see how I can do. MAO YANG: I know.

DR. EMILY ROTHMAN: Yes, motivational interviewing is the heart of SBIRT, so that was an easy one. Males and females, I think they are, in general conceptually, often differences in terms of … we know males tend to perpetrate more sexual dating abuse than females. Sometimes the injury after the fact and implications and context can be different — just from a raw "looking at the numbers" type of thing — with this intervention. We didn't see a ton of difference in terms of the types of behaviors that people are reporting. And I think Sarah was right on when she said, "You know, look, these are kids whose — their relationships just are toxic." There's bidirectional violence —to them both — unfortunately, that's sometimes what happens. And it's not that the implications can't be different for males and females, but that it's just not all one way. It's not all male violence towards females, and and that the females can put themselves at risk for being victimized as they grow older. Because males, ultimately, maybe become stronger and larger than when they're teenagers. And so, we think that it's worth helping them figure out how to stop using unhealthy relationship behaviors — no matter, male, female, nonbinary gender, everybody. So, that's one thought about that. Incentives that's only connected to the research part of it, but I think they got $20 for doing baseline, and something like $25 and $30 for doing the third (three-month survey and six-months survey), so not a ton of money but to reimburse them for their time.

MAO YANG: Is the interview protocol or script available?

DR. EMILY ROTHMAN: Like Liz said. I feel a little nervous about just tossing this out there to the entire world and just having people run with it without any training. So, technically, yes. I have a Word document and I can send it to you. In fact, if you are one of those people who are going to see the video, you wind up seeing pretty much all of my materials flashed on the screen. So, if you really wanted it, too, you could probably copy them down and just start doing them. I kind of wish that people wouldn't. I wish that they would talk to us and and get training because it's talking to a teenage perpetrator of dating violence is not just automatically easy. And I think, for me, having worked in batterer intervention for a number of years and really thought about perpetration, and then being able to distill some of the messages down into training, it still takes me a good six hours to train even a research assistant who had some background in dating abuse, on how to do it and do it safely, and do it right. So, the short answer is: I like to share, and I also like it when people like to get training.

MAO YANG: Great. Thank you, this is a good question for everyone. Do your studies include transgender people and, as a follow-up to that, are your handouts available and/or are they accessible? And the question was specifically on handouts being available in other languages.

DR. EMILY ROTHMAN: Yeah, so this is Emily, and I can say that ours is not gender dependent. This isn't the same issue as gender — it's sexual orientation. However, I can say that only 80 percent of the people in our trial identified as heterosexual. I didn't do the stats on the number of people who identified as nonbinary gender in the RCT, but I can tell you, there definitely were some. And it didn't pop up in the intervention in a way that would at all make it different or work differently, or anything like that. So, that went pretty smoothly and, in terms of languages, we try to think about Spanish a little bit, which was the next biggest language used at our hospital. We didn't want to spend money and go down the road of translating until we knew if this intervention had any effect.

DR. ELIZABETH MILLER: his is Liz, on the SHARP work. In the school-based help center study, similar to what Emily found, there was a much higher number of girls seeking care than boys. What we see across the health care system is that girls tend to seek health services more, and so it's about 75 percent / 25 percent by sex category. We did ask broad questions around same-sex attraction and same-sex sexual contact. So, there was a substantial number of sexual minority girls in our sample, and we have certainly published on that and highlighted the extent to which sexual minority young people are at increased or elevated risk for relationship abuse victimization (which is another whole webinar and conversation).

We did not, in our school-based health center study, have a sufficient number of young people who identified as not on the gender binary, gender queer, or transgender. In our college health center study (which is forthcoming), we do have more college students who are identifying as transgender and/or gender queer. We certainly want to continue to grow our research in this area. Recognizing that gender and sexual minority youth and young adults carry additional vulnerabilities because of bias-based harassment, gay-related victimization, transphobia, and so forth, that are really something we have to be able to address in our prevention programming.

LISA JAMES: And, this is Lisa. I'll just add that I mentioned the resources that are available. We do have some specific resources for transgender and gender-nonconforming folks, which are available through the National Health Resource Center, and additionally, we also have a number of our patient education cards translated into a variety of different languages. It sort of depends on the card, how many languages are available. So, all of that's available on our website and if you have any follow-up questions, you see my email and we can try to get resources that you need out to you.

MAO YANG: Thanks for your responses. "Is there any specialized training provided for a medical staff to identify reproductive coercion, and how do you build agency and condom negotiations?"

DR. ELIZABETH MILLER: So, this is Liz Miller. I'll take that one because it's a question that brings joy to my heart, which is yes, there is specialized training. And that the resources and the training materials are available through the ipvhealth.org website that Lisa shared but, again, the in-person training and, in particular, practicing saying the words around how to talk about reproductive coercion, how to do universal education around reproductive coercion, and to actually learn to ask questions in a way that really signal to a young person that you understand — that things like condom negotiation, talking to your partner about the need for treatment of a sexually transmitted infection —these are complicated and difficult conversations to have, even in nonabusive relationships. And add the power dynamics of an unhealthy or abusive relationship and it gets really difficult.

So, the role of the health care provider in just saying, "We understand that these things can be complicated and that "there are people here who can help you with navigating that. I think it is really important, and it does include building agency around condom negotiation.

MAO YANG: There were a number of questions that came in about the interventions, applying in a non-health care setting. So I'm going to clump them all together. One question was, "Would you recommend it in a mental health setting? Could this be implemented in an after-school setting or a program?"

DR. ELIZABETH MILLER: So, for me, I would say yes — mental health setting after school. I mean, I don't have any reason to believe, right now, that it wouldn't work and I can't think of specific barriers to trying it and figuring out how to make it work. So, I'll give that a "thumbs up."

LISA JAMES: I was just going to say yes to a mental health setting, and we have resources that are specific for mental health and behavioral health. So, as I talked about, there might be some different discussion questions that look more at how a partner might be interfering with efforts to be … with sobriety and insanity … so, we know a lot about substance abuse and mental health coercion as a component of an abusive relationship. So, yes, you can apply this approach in mental health settings — you might want to tailor it a little bit — and we have resources to help. And similarly, with after-school settings, absolutely. We think this peer-to-peer education and empowerment approach is applicable for a variety of different settings. And some of our resources do have some specifics around health care or clinical care that would be less appropriate for an after-school setting, but generally the approach — around educating young people about healthy and unhealthy relationships and their impact on health, and how they can share that information with one another — is absolutely applicable in a number of different settings.

SARAH DECOSTA: This is Sarah DeCosta. I'm in a unique position in that my career has taken a turn into the school department and after-school world. And so I have a perspective now as someone who actually runs after-school and out-of-school time programming. And I definitely think that something like Real Talk could be adapted for youth in that setting. And I think that if you had the staff — who already are working with these youth and already know them and have a rapport in the after-school program — be the ones who were trained to deliver it, I think it would probably actually be more effective and have probably a longer lasting impact because it wouldn't be trying to build a relationship and doing the intervention within it. It would be a relationship that was built within the structure of this other program and then that's already a trusted person. So, when they're the ones saying, "Hey, have you thought about how this behavior is going to affect your future," you know, "what are your other options?" I think it would have more weight.

LISA JAMES: Just one quick thought. I just want us to frame this whole webinar by reminding all of us that these are brief interventions in health center settings — not as the be-all around prevention. Absolutely, all of the kinds of settings that we're talking about are critically important. I think that what we need to hold onto is that health center settings are really unique — mental health included — in that people who have experienced violence and trauma are going to be significantly more likely to seek those health services. So, what we're able to do in many ways is secondary prevention work in the health setting. And I just wanted to underscore that that while we're thinking about all of the different dimensions of prevention work, that the health setting is one that does have this very unique quality.

DR. CARRIE MULFORD: Well, with that final word, I want to thank all of our presenters and all of the participants who stayed with us for so long. I'm very impressed at how long everyone stayed, which makes me very happy. And, like we said, we will — all the participants will get an email with a link to the slides and the audio recording of this, within the next couple of weeks, so stay tuned for that. And I just want — I'm just so delighted, like, to spend the afternoon with some of my most favorite people in teen dating violence work. So, thank you all so much. It's been a pleasure.