Está en la página 1de 10


JHNXXX10.1177/0898010114564683<italic>Journal of Holistic Nursing</italic>Support for At-Risk Girls / Adamshick



Support for At-Risk Girls

A School-Based Mental Health Nursing Initiative Journal of Holistic Nursing
American Holistic Nurses Association
Volume 33 Number 3
September 2015 228237
Pamela Adamshick, PhD, RN, PMHCNS-BC The Author(s) 2014
Moravian College, Bethlehem, PA, USA

Mental health problems often go undiagnosed or unaddressed until a crisis or extreme event brings the
problem to the forefront. Youth are particularly at risk for lack of identification and treatment in regard
to mental health issues. This article describes an advanced nursing practice mental health initiative for
at-risk teenage girls based on Hildegard Peplaus nursing theory, group process, and healing through
holistic health approaches. A support group, RICHES, was developed with focus on core components
of relationships, identity, communication, health, esteem, and support. The acronym RICHES was
chosen as the name of the support group. Selected themes and issues addressed in this school-based
support group are illustrated in case vignettes. Through a collaborative approach with the community
and school, this practice initiative presents a unique healing process that extends knowledge in the
realm of intervention with at-risk teenage girls. Further research is needed on the efficacy of support
groups to modify risk factors and to address goals for primary prevention in at-risk teenage girls.

Keywords: at-risk; stress and coping; mental health; adolescent girls; support group; nursing practice;
school-based; Peplaus theory

Background and Significance early assessment and identification, fragmented ser-

vices, challenges in accurately diagnosing mental
Mental health needs among children and adoles- health problems, and disparities in access to care
cents are extremely prevalent, with an annual esti- (U.S. Public Health Service, 2000). According to
mate of 14% to 20% of youth manifesting mental, recent data compiled by the USDHHS (2013), these
emotional, or behavioral disorders (Institute of challenges persist, with increased prevalence rates of
Medicine & National Research Council, 2009; U.S. mental disorders reported in children between 2005
Department of Health and Human Services and 2011. Treatment for mental disorders is also
[USDHHS], 2013). These disorders include diag- lacking. In the past year, 60.1% of older adolescents
nosable psychiatric disorders and also problem diagnosed with a major depressive episode did not
behaviors such as aggression, violence, and sub- receive intervention (Substance Abuse and Mental
stance use. The purpose of this article is to describe Health Services Administration, Center for Behavioral
an advanced nursing practice mental health initia- Health Statistics and Quality, 2014). Absence of a
tive for teenage girls at risk for mental health disor- dedicated surveillance system to capture the preva-
ders, based on Hildegard Peplaus nursing theory, lence of all childhood mental disorders continues to
group process, and healing through holistic health impede achievement of outcomes for prevention and
approaches. treatment of mental disorders (USDHHS, 2013).
Seventy-five percent of mental illness begins
before age 25 (Insel, National Council on Behavioral
Health, 2014). Yet only 20% of children with mental Authors Note: Please address correspondence to Pamela
Adamshick, PhD, RN, PMHCNS-BC, Associate Professor of
health problems receive appropriate treatment. Nursing, Moravian College, 1200 Main Street, Bethlehem, PA
Reasons for these deficits include stigma, lack of 18018, USA; e-mail:
Support for At-Risk Girls / Adamshick 229

Adding to the complexity of addressing mental promote protective factors. Research on mental
health needs is the impact of poverty and ethnic health programs with children and adolescents
diversity among youth in the United States. The found that primary prevention programs were sig-
Hispanic population is rapidly increasing in the nificant in reducing problems and promoting com-
United States, with Hispanic adolescents the largest petencies in children (Durlak & Wells, 1997).
and fastest growing minority in the adolescent age- In an effort to address mental health issues in
group (Kurtzleben, 2010; Rothe, 2004). Hispanic at-risk teens, RICHES, a school-based support
adolescents are at a heightened risk for emotional group, was formed. Two coincidental circumstances
distress due to poor socioeconomic resources, and in 1999 served as inspiration for the RICHES ini-
also discrimination (Alvarez, 2001; Potochnick & tiative. A community health partnership had
Perreira, 2010). They are more likely to feel sad and recently formed between a local hospital and com-
hopeless compared to adolescents from other ethnic munity agencies representing medical, social, reli-
groups (Centers for Disease Control and Prevention, gious, and educational groups. The partnership
2007). Their distress translates into the highest rate members completed a health needs assessment of
of suicide attempts among any ethnic group of ado- the local community. Findings revealed, among
lescents, with Hispanics at 10.2%, African Americans other priorities, startling mental health concerns
at 7.7%, and Whites at 5.6% (Centers for Disease among adolescents in the following areas: anger
Control and Prevention, 2007). and stress management; suicidal thoughts or
Mental, emotional, and behavioral disorders are attempts; feelings of depression or anxiety; rela-
costly not only in terms of lives lost, but in youths tionship problems with peers, parents, or guardi-
functional ability, family stability, and productivity ans; and concerns for personal safety at school and
loss for society. Youth who are burdened by mental at home. The second inspirational circumstance
health problems struggle to achieve success in was a specific plea for help from the local high
school, healthy interpersonal relationships, and inte- school students, who wrote a letter to the editor of
gration into the work force. They are also more likely the school newspaper describing high levels of
to experience residential instability and to engage in stress experienced by many students. The opportu-
delinquent behaviors (Substance Abuse and Mental nity for an advanced practice mental health nursing
Health Services Administration, Center for initiative was evident.
Behavioral Health Statistics and Quality, 2014). Based on evidence citing schools as the most
Data from 2007 estimate the annual cost of such suitable setting for adolescent mental health inter-
disorders in youth at 247 billion dollars (Institute of ventions (Lamb & Puskar, 1991) and the effective-
Medicine & National Research Council, 2009; ness of group interventions with youth (Eggert,
USDHHS, 2013). Considering a fragile economy, Thompson, Herting, & Nicholas, 1995; Jacobson,
coupled with a fragmented health care program, it is 1991), a support group format was chosen for the
not surprising that many youth slip through the school mental health initiative. The group name,
cracks and are neither adequately diagnosed nor RICHES, is an acronym for the core components or
treated for existing mental health disorders nor iden- focus areas of the group: relationships, identity,
tified for preventative services that might address communications, health, esteem, and support. The
risk factors. belief in the individual riches and talents of each
group member was also a basic philosophy of the
The RICHES Support Group group and rendered the name appropriate. This
advanced practice initiative was offered in a large
In tracing the history of the development of a suburban high school in the northeastern United
school-based support group (RICHES) for at-risk States.
adolescents, the Institute of Medicine (1994) report Research over the past decade reinforces group
Reducing Risks for Mental Disorders: Frontiers for experiences as a viable approach to address mental
Preventive Intervention Research provided a salient health needs of adolescents (Gerrity & DeLucia-
framework for addressing mental health problems in Waack, 2007; Houck, Darnell, & Lussman, 2002).
young people. In particular, Institute of Medicine Additional literature also highlights advantages of
interventions were designed to target at-risk groups school-based mental health and skills training
or individuals, with goals to modify risk factors and interventions, as they provide immediate opportunity
230 Journal of Holistic Nursing / Vol. 33, No. 3, September 2015

to apply learning to real-life situations in the class- be considered marginalized, or to whom the term
room and in peer relationships (Evans, Axelrod, & might be applied on particular occasions or circum-
Sapia, 2000). More recently, Hale, Fitzgerald-Yau, stances in ones life. However, the sting of marginali-
and Viners (2014) systematic review identified zation is likely more intense, more pervasive,
school-based interventions as effective for reduc- depending on the number and type of areas in which
ing health risk behaviors, including violence, in one feels marginalized. In the case of many high
adolescents. school students, being marginalized may be an over-
To respond to priorities of access to care and riding factor due to an accumulation of several dis-
economical health resources, the group facilitators tinct ability-based circumstances, along with more
decided to provide the intervention without charge to comprehensive identity-based circumstances, such
students, and the facilitators volunteered their time. as ones ethnic or racial background, socioeconomic
Written permission from parents or guardians for status, and gender identity.
child participation in the support groups and other Counselors, the school nurse, health van nurse,
partnership health activities was obtained. Group and teachers referred girls to the group. From the
sessions were held weekly for 45-minute intervals for inception of the RICHES initiative in 1999 through
a series of 10 to 12 meetings during each semester of May, 2014, over 380 hours of group sessions have
the academic year. Membership included 5 to 10 been provided to 220 participants. Clinically, these
students each semester, with some students continu- numbers translate to lives affected by holistic nursing
ing into the subsequent semester or the following care. Interventions with a population of vulnerable
year. The first offering of the group was gender- girls modified their mental health risk factors and
mixed. Based on participant and facilitator evalua- promoted healthy coping and resilience through
tion, the subsequent RICHES groups were ongoing support and connection with resources. The
female-only, and the community partnership arranged participants, all female, ranged in age from 13 to 17
for a male-only group for at-risk male students. years, and their ethnic/racial identification was 60%
Hispanic, 30% White, and 10% Black. The students
referred for the RICHES group were typically experi-
The Group Facilitators
encing marginalization, usually in several areas.
Two board certified advanced practice psychiat- Unruly, aggressive behavior was one way that girls
ric/mental health nurses, the author and a colleague, expressed their distress and anxiety; while it margin-
were the initial cofacilitators for the RICHES group. alized them, ironically it also brought attention and a
This arrangement was in place for a few years, until certain degree of power over others. Although
the colleague moved away from the area. Since then, RICHES was not specifically for anger management,
masters or doctoral prepared nurses, with back- anger was the symptom that allowed girls (and their
grounds in mental health, pediatrics, or community needs) to be visible, and provided an access to inter-
health nursing, have cofacilitated with the author, vention. Physical fighting was often the primary rea-
contributing 2 to 4 year stints. The author provided son for referral to the RICHES group. Usually, this
basic orientation to the facilitators on principles of consisted of girl-to-girl fighting. Specific vignettes
group dynamics. The facilitators engaged in brief provide more insight into fighting events, their mean-
pre- and postgroup discussions about plans for the ing, and girls perspectives.
group and evaluation of progress. The continuity in Many girls shared their experiences of academic
the facilitator role has been important for fostering difficulties, including failure and repetition of a grade
group trust and cohesiveness. level, special learning classes, and instances of feeling
shamed or ridiculed related to academic performance
in a class. Participants also identified situations of
The Population Served
racial/ethnic marginalization, which often triggered
Marginalized means to be on the outside or on their disruptive behavior. Gender identity was another
the boundaries, to be prevented from having atten- area in which some girls experienced marginalization.
tion or power, or to place [be placed] in a position of A few participants, by self-report, were already in treat-
marginal importance, influence, or power (Random ment or had been in treatment for a mental health
House Websters unabridged dictionary, 1998, p. 1175). problem or diagnosis. Almost every semester, the facili-
Based on this definition, there are many who may tators identified students in need of additional mental
Support for At-Risk Girls / Adamshick 231

health counseling and reported these cases through in this process was the issue of respectful interac-
the appropriate school channels. tions among members. Many members had little
exposure to active listening, either as the listener or
the recipient. Learning this basic communication
Nursing Theory Framework
skill was pivotal for group work and individual
Hildegard Peplaus nursing theory of interper- growth of members. Establishment of trust and
sonal relations applies to the holistic care process of respect transpired gradually, building throughout
the RICHES initiative. Phenomenology, based on several sessions. Principles of Peplaus theory on
observation and interpretation of human behaviors, patient interactions that incorporate humane treat-
is the philosophical underpinning of Peplaus theory. ment, dignity and respect, and healing discussion
Peplau described her assumption that patients strug- guided group development over time.
gle with everyday interpersonal difficulties or health Members particular needs and concerns were
problems, and the nurse responds by fostering per- the priority for weekly discussion. Often one of the
sonality development in the direction of maturity for members brought a story or problem for which she
the patient (Peterson, 2009, p. 208). Through the needed guidance or feedback. Crisis intervention
verbal and nonverbal exchanges in the nursing situa- was also common. On several occasions, girls came
tion, the nursepatient interactions can influence to the group angry, close to losing control after an
recovery. Peplau also believed that psychobiological altercation in the hall or in a classroom. In the safety
experiences such as conflict, frustration, and anxiety of the group, they had the opportunity to think,
were sources of energy that had the potential to move reframe, problem solve, and consider alternative
one toward both destructive and constructive actions responses to their situations. Members comfort and
(Peplau, 1991). Through the process of the nurse trust in the group were illustrated in sharing critical
patient relationship, individuals can gain under- information about rumored fights, including loca-
standing of their experiences and learn productive tions and times. With alerts passed on to school
outcomes (Peterson, 2009). authorities, student safety was preserved.
The girls in the RICHES program had complex
problems and needs, wrapped around a core network
of vulnerabilities and emotions typical of adoles- Conflict
cents. The therapeutic relationship established with The conflict stage is characterized by a shift from
the facilitators and the group members was the vehi- acceptance and commitment to the group to a con-
cle to help girls move toward creative and construc- cern over dominance and power of members (Yalom,
tive problem solving. The goal, as applied from 1995). In the RICHES group, the addition of new
Peplaus theory, was to assist members to convert participants often exerted a negative influence in the
tension and anxiety into action for problem solving. group, as they flaunted an attitude, tested rules, and
often provoked havoc in the group. Tense moments
The Group Process and altercations among the members were not unu-
sual under these circumstances, illustrating the con-
A signed confidentiality agreement was requested flict stage of group process (Yalom, 1995). The most
of all group participants. The terms of the agreement effective interventions were firm limits and constant
included maintaining group discussion issues as redirection, while acknowledging the anger and
confidential, with the exception of mandated report- encouraging verbal discussion of feelings. Usually
ing by facilitators of any situations that represented within a few sessions, the group progressed toward
a danger to self or others. Group development fol- sufficient cohesion to allow basic group respect and
lowed stages as outlined by Yalom (1995). The stages cooperative interaction.
of orientation, conflict, and cohesiveness as applied
to the RICHES group are described.
In the cohesiveness stage, group sessions focused
on skill development in several areas. Participants
The orientation stage of group process was cen- desired help with conflictual relationships and han-
tered on building trust among members. Imbedded dling emotions. Group process was used to facilitate
232 Journal of Holistic Nursing / Vol. 33, No. 3, September 2015

members thinking, including problem solving and Achieving and maintaining safety, both physical
recognizing consequences. Yalom (1995) describes and emotional, in the group was an absolute priority.
increase in morale, trust, and self-disclosure in the Girls referred to the group often knew each other,
cohesiveness stage. This was evident as members and, in some cases, had fought one another or had
acted out their conflicts in role-plays and gained participated in relationally aggressive behaviors that
new perspectives on feelings of others and on how to contributed to girls experience of feeling marginal-
express themselves without aggression. Specific ized. The facilitators typically did not know this
exercises related to anger management were offered, information until or unless members shared it with
including recognition of triggers and physiological the group. Comments on gender identity or racial/
indicators, types of anger behavior, and calming ethnic background were the cruelest and most hurt-
strategies. Anger journals were suggested to help ful, causing the most derision in the group. Once a
members track their progress in anger incidence and safe environment was assured, the conflicts provided
reduction. Many members attested to high levels of salient opportunity to discuss the many factors
anxiety and stress in their lives. Interventions tar- related to aggression and marginalization, and to
geted root cause analysis and basic strategies to propose appropriate interactions. Any advance
promote self-care and healthy lifestyles. notices of potential fights were critical to student
Education was also an ongoing focus during safety, and rumors were conveyed to school authori-
group sessions. Health topics assumed high priority, ties.
the range including sexually transmitted diseases,
awareness of ones sexuality and maintaining per-
Group Themes
sonal sexual boundaries and safety, drug use, nutri-
tion, prescription medication, dating violence, and The topics of group discussion spanned a gamut
mental health concerns. encompassing fights with peers; anxiety and stress;
The curative power of groups is related to several healing after trauma and loss; causes of anger and
factors that help promote change in the members ways to express anger; dealing with rumors, jealousy,
(Yalom, 1995). The predominant curative factors and bullying; cyber or social media incidents; asser-
operating in the RICHES group included the univer- tive communication; life goals; health and illness;
sality of experience, the instillation of hope, develop- and relationships, including parental, friendships,
ment of socializing techniques, information giving, and dating. The selected themes of fighting, trauma,
interpersonal learning, catharsis, and group cohe- and toxic relationships are described in vignettes to
siveness (Yalom, 1995). Shared discussion allowed allow for enhanced understanding of the health
common identification of problems and a repertoire needs and the healing process as facilitated through
of resources and alternatives for solutions. Holistic this mental health initiative. These themes represent
health practices were incorporated throughout the the overarching areas of critical impact in girls lives,
series of group sessions. The facilitators suggested under which many of the other topics were sub-
and educated members on spirituality and relaxation sumed. Pseudonyms are used to protect the identity
strategies, journal writing, music for relaxation, find- of participants.
ing and using supportive people and resources, and
exercise outlets. Vignette on Fighting.Girl-to-girl fights were a fre-
quent discussion topic. Angelette, an Hispanic fresh-
man, described a fight with another girl, which began
Challenges with loud rhythmic clapping, a preemptive signal.
Personal engagement in acknowledging, think- There was not a clearly defined reason for the fight,
ing about, and coping with their problems did not but Angelette described feeling the other girl had
come easily to most RICHES members. Denial was disrespected her with eye-rolling and giving atti-
a predictable barrier, which provided an escape for tude. This progressed to Angelette punching the girl
several members. After attending only one session, a in the face and slamming her into the wall. Several
common refrain was, I dont have a problem. I dont group members chimed in with similar fight stories,
know who referred me to this group or why. Others seeming to compete for most dramatic fighting event.
in denial had no choice but to attend, in conjunction Discussion revealed that fights were often planned,
with juvenile probation requirements. and friends had to be nearby and had to be able to
Support for At-Risk Girls / Adamshick 233

provide assistance during a fight. Girls in this session a labile presence in the group and highly emotional,
concurred that one of the criteria for choosing a alternating between tears and anger on most days.
friend was that she be able to fight in a physical way. She frequently contributed an ongoing story about
Group members had been shown how to fight by a relationship with a male who, now incarcerated,
mothers, brothers, or other family members. Girls was nonetheless uppermost in her life. Although
described being admonished and scolded by mothers she presented evidence of his selfishness, abusive
if they did not fight and stand up for themselves. It qualities, and untrustworthiness, she was also
was a necessity to be a good fighter, to be able to enamored by his attention to her and declarations
preserve ones rank or recognition. Anger was not of caring for her. She indicated his future plans
always part of the equation in a fight; the priority was included moving in with Kendra after he was
to maintain ones identity as one who fights and is released from prison.
not a punk. Universality of experience was a group Kendras history included a violent rape by a
curative factor at work in these discussions. Fighting known perpetrator, which resulted in the twins
provided a common connection among the members birth; she had moved to the new town in order to
that overcame the sense of marginalization that oth- lessen the possibility of meeting up with her rapist.
ers had assigned to their behavior. Members, even Kendra lived with her mother, but the relationship
those who were nonfighters, accepted one another was conflictual with inconsistent support. Group
and felt less isolated. feedback to Kendra often encouraged her to con-
sider the toxic qualities of her relationship with the
Vignette on Trauma. Many participants had experi- incarcerated male. Over time, she displayed a glim-
enced devastating types of traumatic life events, mer of insight and uncertainty about the health of
such as rape or other attack, loss of a family member the relationship for herself and her children. One of
in a fire, and witnessing the death of a family mem- the group members, herself a survivor of toxic rela-
ber who had been the victim of a neighborhood tionships, took that opportunity to share an observa-
shooting. Mercedes, a junior who was Hispanic, tion with Kendra:
shared a vivid memory of being raped repeatedly at
age 9 by a man known to her and her family. She Youve been looking at that relationship with rose-
recounted the brutalities she endured, terrifying colored glasses and that made everything look great.
uncertainty each day, and lack of safety and support Now you have the glasses off and you are seeing
within her family structure. Yet she was resilient, a everything in black and white and that makes it
survivor, and remarkably insightful regarding the bland and not as interesting. You need to realize how
contribution of that experience to her school prob- it looks now, and that is how it really is.
lems, emotional distress, and persistent anger issues.
Mercedess case illustrates healing factors of the This exemplar illustrates the group curative and
group process. Her story instilled hope in other healing factor of interpersonal learning (Yalom,
members as they witnessed her strength and empow- 1995).
erment over adversity. Mercedes herself experienced Kendra was able to gather data about her inter-
healing through the cathartic telling of her story, personal behaviors as witnessed by others.
gaining mastery over a horrific event through pur- Subsequently, she gained greater understanding of
poseful review in a safe situation where she felt trust herself, ultimately assuming changes in cognitions
and acceptance. Perhaps most important, the heal- and reactions. Healing occurred for all members as
ing and curative factor of group cohesiveness enabled illustrated by the development of socializing tech-
Mercedes to feel connected in a caring situation, niques. In particular, members exhibited greater
bonded with members, and in a place where she ability to listen and talk with each other, showing
experienced belonging and acceptance. respect and regard for struggles and growth in one
another. Members were empathetic and understand-
Vignette on Toxic Relationships. Relationships of all ing of Kendras newfound and thoughtful efforts to
kinds were a major group discussion topic each control her unstable affect, outbursts, and crude
week. In most cases, the relationships were layered remarks. These were social techniques and practices
with troubles or conflicts. Kendra was African members could take forward in their daily communi-
American, a junior, and a mother of twins. She was cations with others.
234 Journal of Holistic Nursing / Vol. 33, No. 3, September 2015

Discussion a fight or flight reaction (Perry, 2009). Based on this,

it is highly understandable how traumatized individu-
The cases portrayed by the group members reso- als such as the girls in the RICHES group displayed
nate with research findings on similar mental health emotional instability, were on edge, hypervigilant,
concerns. Girls who fight physically are often from easily annoyed, and inclined to misinterpret normal
situations where fighting is normative. Literature environmental cues as threatening. Perry (2009)
depicts reasons for girls fighting, suggesting both advises an elaborate neurosequential model of thera-
protection issues and the desire to be recognized or peutics with maltreated children to counteract the
esteemed for fighting ability (Adamschick, 2010; disturbed pathways. Cognitivebehavioral techniques
Ness, 2004). Nesss (2004) ethnographic study of can be helpful in older children once self-regulation
inner-city girls from Philadelphia deciphered the and relational skills have improved (Perry, 2009).
layered cultural and social issues that influenced Interventions with members in the RICHES
girls violence. Safety as a hierarchal need required group included cognitivebehavioral strategies for
knowing how to stand up for oneself, making street hyperarousal, whether linked to trauma or to anger
fighting a necessity. Being able to fight also provided scenarios. Girls were assisted to identify triggers for
a valuable enhancement to a girls status (Ness, their arousal and the accompanying physiological
2004) and/or was a core aspect of how a girl defined responses, such as sweating, flushing, tensing, and
herself (Adamschick, 2010). Similar to the girls in rapid breathing. Emphasis was placed on noting the
the RICHES group, girls from high-risk backgrounds very earliest sign of distress, and immediate imple-
have been coached and educated on ways of fighting mentation of a type of deescalation strategy to avoid
by mothers or other family members who recognize aggressive or heightened anxiety feelings spiraling
the need for self-defense and safety in their social out of control. The group members assisted one
and cultural environments (Adamschick, 2010; another to recognize cognitive distortions, as these
Ness, 2004). prevented them from seeing situations realistically.
Strategies to address fighting were two-pronged. Cognitive restructuring, the pivotal work to change
Girls needed assistance with basic anger manage- behavior, required group members to rethink possi-
ment, which was handled through cognitivebehav- ble solutions to their anger or arousal responses and
ioral approaches. In addition, attention was given to to substitute a more acceptable behavior (Feindler &
the sense of mastery, esteem, identity, and connec- Engel, 2011). The combinations of these strategies
tion with other girls operationalized through fight- were repeated frequently in the group setting for
ing. Understanding the role of friendship and topics related to anger management.
connection in girls lives, the facilitators channeled Varied terms and definitions are used to describe
discussions toward qualities of friendships and violent personal relationships, including dating vio-
healthy relationships. Self-respect and respect for lence and intimate partner violence. Common com-
others factored into these discussions and provided ponents, however, are consistent across definitions,
opportunity to broach topics about identity and girls and include physical, sexual, emotional, or psycho-
hopes and goals for their future. logical types of abuse. According to data from a
The majority of the girls in the RICHES group national study, 1 out of 11 adolescents report being
described having experienced some type of trauma, a victim of dating violence, with 9.3% Hispanics and
and in many cases, girls were severely traumatized. 13.9% African Americans being victims, compared to
According to neurodevelopmental research, the 7% Whites (Halpern, Oslak, Young, Martin, &
sequential development of the brain dictates which Kupper, 2001). Literature also reveals the higher
areas and related functions are affected by trauma risk for posttraumatic stress disorder and other men-
events as a child ages (Perry, 2009). Repeated adverse tal health problems among victims of dating violence
experiences such as neglect, sense of threat, loss, and as compared to nonvictims (Rizzo, Esposito-
injury lead to changes in the stress response net- Smythers, Spirito, & Thompson, 2010).
works of the brain. Ultimately, molecular structures In phenomenological research on teenage lived
and brain systems are disrupted, and the altered experience of abusive partner relationships, girls
reactivity of the stress response system essentially described feeling disconnected from family or friend
produces a constant state of high alert necessitating support, uncertainty in understanding their relationship
Support for At-Risk Girls / Adamshick 235

experiences and their needs for affection, and a gen- Table 1. Degree of Satisfaction in Self-Assessment
eral feeling of powerlessness (Reynolds & Shepherd, Areas
2011). The RICHES exemplar vignette of toxic rela- Pregroup Postgroup
tionships mirrors these findings, including the mental
health risk for victims and the feeling of being adrift Anger management 2.19 2.76
Stress management 2.41 2.56
from family.
Relationships with impor- 2.94 3.32
Research on school-based interventions suggests tant people
abusive relationships are the elephant in the room in Self-esteem 2.81 3.12
terms of lack of protocols for addressing the prob- Future orientation 3.09 3.16
lem. In a recent national study of high school nurses
(N = 750), about half reported assisting a victim of
dating violence, usually by referring the student to a In narrative data, typical participant responses
counselor. Yet 79.5% of those nurses responding about the most helpful aspects of the group included
reported that their schools did not have a specific helps me control my anger and helps me under-
protocol for intervention in a dating violence inci- stand where others are coming from, learned how
dent. Also, 70% of the nurses reported a lack of to control my anger, helped calm me down, help-
training on how to assist a victim of dating violence ing my anger and how to deal with certain prob-
in particular (Khubchandani, Telljohann, Price, lems, being able to communicate with others, and
Dake, & Hendershot, 2013). the group leaders.
Interventions suggested in the literature include Group members often were referred for addi-
broad school approaches such as awareness and edu- tional individual treatment with counselors, or they
cation of staff, students, and administrators on dat- were connected with agencies for need-specific
ing violence and a clearly defined policy that addresses assistance. The facilitators followed reporting pro-
the problem (Khubchandani et al., 2103). Findings cesses for students who were at risk for personal
from a qualitative study identify school-based strate- harm due to violent relationships.
gies for individualized care, beginning with safe As for any type of treatment, ongoing client par-
places for students to discuss violence issues ticipation was essential for safe and effective care. In
(Reynolds & Shepherd, 2011). Their findings also the case of the members in the RICHES group, fol-
cite the importance of assisting victims to reframe a low-through was related to trust. As the girls gained
relationship as abusive, recognizing behaviors as abu- trust in the group experience, they continued to
sive rather than normative or caring. In addition to attend and often proclaimed they looked forward to
the reframing strategy, the support group approach the group sessions. Healing occurred through several
offers another dimension for use in school settings. integrated processes. The nursepatient relationship
Using the group process format, RICHES provided as described in Peplaus theory was one of the pillars
an opportunity for case finding, intervention, and that sustained member investment and movement
education on the topic of abusive relationships. toward personality growth. Healing took place through
recognizing and understanding meanings of behavior,
Outcomes always guiding the members toward discovery of
aspects of the self that were previously unknown
Participants completed pre- and postgroup self- (Peterson, 2009). The group experience was the other
assessments that measured progress in five areas: pillar that contributed to healing and hope. Layered
anger management, stress management, relation- on the foundation of group and relationship princi-
ships, self-esteem, and future orientation. ples, other holistic healing processes included cogni-
Respondents were asked to rate their degree of tivebehavioral strategies, healthy lifestyle education,
satisfaction in the designated areas from 1 to 4, with discussion of coping skills, relaxation techniques,
1 = not at all satisfactory, 2 = somewhat satisfactory, self-affirmation, and compassionate regard.
3 = satisfactory, and 4 = very satisfactory. While
matched pre- and postgroup self-assessments were Conclusion and Implications
not compared, overall pre and post group scores for
selected cohorts showed increase in mean scores, as Healthy People 2020 goals indicate that the
shown in Table 1. United States needs to continue to advance an
236 Journal of Holistic Nursing / Vol. 33, No. 3, September 2015

agenda for mental health of youth, with attention to References

strategies aimed at violence and other issues that
remain risk factors for mental, emotional, and Adamshick, P. Z. (2010). The lived experience of girl-to-girl
behavioral disorders in youth (USDHHS & Office aggression in marginalized girls. Qualitative Health
of Disease Prevention and Health Promotion, Research, 20(4), 541-555.
2012). An implication for nursing practice is use of Alvarez, L. R. (2001). Substance abuse in the Hispanic
support groups such as the RICHES initiative to population. In A. G. Lopez & E. Carillo (Eds.), The Latino
psychiatric patient: Assessment and treatment (pp. 193-
advocate for mental health. It is an avenue for sup-
218). Washington, DC: American Psychiatric Press.
port and connection, offering a resource and heal- Centers for Disease Control and Prevention. (2007). Youth
ing alternative for at-risk girls. In-school support risk behavior surveillancethe United States. Atlanta, GA:
groups provide an economical and readily available Author.
access to care, perhaps a lifeline for youth who oth- Durlak, J. A., & Wells, A. M. (1997). Primary prevention
erwise falter. Teens might remain in school rather mental health programs for children and adolescents: A
than opting out, if they experience a connection meta-analytic review. American Journal of Community
with at least one person. Psychology, 25, 115-152.
Implications for nursing education should be Eggert, L. L., Thompson, E. A., Herting, J. R., & Nicholas,
L. J. (1995). Reducing suicide potential among high-risk
targeted at school nurses and those seeking nurse youth: Tests of a school-based prevention program.
practitioner roles in psychiatric/mental health Suicide and Life-Threatening Behavior, 25, 276-296.
nursing or any advanced practice nurse role. Evans, S. W., Axelrod, J. L., & Sapia, J. L. (2000). Effective
Advanced practice nurses may benefit from expo- school-based mental health interventions: Advancing the
sure to the realities of vulnerable youth in the social skills training paradigm. Journal of School Health,
school setting, where common problems include 70, 191-194.
Feindler, E. L., & Engel, E. C. (2011). Assessment and inter-
fighting, bullying, dating violence, trauma seque- vention for adolescents with anger and aggression diffi-
lae, and diagnosable mental health disorders. Such culties in school settings. Psychology in the Schools, 48,
situations will inform their understanding and care 243-253.
of teens in both primary and acute care settings. Gerrity, D. A., & DeLucia-Waack, J. L. (2007). Review of
Those nurses seeking advanced psychiatric nursing research on group work in schools. Journal for Specialists
in Group Work, 32, 97-106.
roles should be encouraged to seek clinical prac- Hale, D. R., Fitzgerald-Yau, N., & Viner, R. M. (2014). A
tice in school settings where they can influence systematic review of effective interventions for reducing
mental health promotion and care for at-risk popu- multiple health risk behaviors in adolescence. American
lations. Outcomes from the RICHES initiative Journal of Public Health, 104(5), e19-e41. doi:10.2105/
establish beginning validation of the clinical impact AJPH.2014.301874
Halpern, C. T., Oslak, S. G., Young, M. L., Martin, S. L., &
of advanced practice psychiatric nurses in contrib-
Kupper, L. L. (2001). Partner violence among adolescents
uting to stabilization of vulnerable youth, promo-
in opposite-sex romantic relationships: Findings from the
tion of positive coping, problem solving, and national longitudinal study of adolescent health. American
resilience, and reduced risk for mental health Journal of Public Health, 91, 1679-1685.
exacerbations. Houck, G. M., Darnell, S., & Lussman, S. (2002). A support
An implication for research is to test the effec- group intervention for at-risk female high school stu-
tiveness of support groups to reduce the many facets dents. Journal of School Nursing, 18, 212-218.
of violent relationships in at-risk girls. It is also Insel, T. (2014, May). Quest for the cure: Scientific break-
important to consider primary prevention. Further throughs in treating mental illness. Paper presented at the
research should address the efficacy of support meeting of National Council on Behavioral Health,
groups to modify risk factors and promote healthy Washington, DC.
behaviors and relationships. Research findings Institute of Medicine. (1994). Reducing risks for mental dis-
orders: Frontiers for preventive intervention research.
(Khubchandani et al., 2013) suggest that school
Washington, DC: National Academies Press.
nurses might benefit from a standardized compe-
Institute of Medicine & National Research Council. (2009).
tency to guide interventions related to dating vio- Preventing mental, emotional, and behavioral disorders
lence. Additional research should examine among young people: Progress and possibilities. Washington,
approaches for detection and intervention in teen DC: National Academies Press.
dating/relationship violence with goals to develop a Jacobson, J. M. (1991). The relationship between social sup-
national guideline or protocol for sensitive and port and depression in adolescents. Journal of Child and
timely intervention. Adolescent Psychiatric Nursing, 4, 20-24.
Support for At-Risk Girls / Adamshick 237

Khubchandani, J., Telljohann, S. K., Price, J. H., Dake, J. A., & phenomenological analysis. Psychology and Psychotherapy:
Hendershot, C. (2013). Providing assistance to the victims of Theory, Research, and Practice, 84, 314-334.
adolescent dating violence: A national assessment of school Rizzo, C. J., Esposito-Smythers, C., Spirito, A., & Thompson,
nurses practices. Journal of School Health, 83, 127-136. A. (2010). Psychiatric and cognitive functioning in adoles-
Kurtzleben, D. (2010, December 14). U.S. Hispanic popula- cent inpatients with histories of dating violence victimiza-
tion is booming. U.S. News & World Report. Retrieved tion. Journal of Aggression, Maltreatment & Trauma, 19,
from 565-583.
us-hispanic-population-is-booming Rothe, E. M. (2004). Hispanic adolescents in the United
Lamb, J., & Puskar, K. R. (1991). School-based adolescent States: Psychosocial issues and treatment considerations.
mental health project survey of depression, suicidal idea- Adolescent Psychiatry, 28, 251-278.
tion, and anger. Journal of Child and Adolescent Psychiatric Substance Abuse and Mental Health Services Administration,
Nursing, 4, 101-104. Center for Behavioral Health Statistics and Quality.
Ness, C. D. (2004). Why girls fight: Female youth violence (2014). The CBHSQ report: Serious mental health chal-
in the inner city. Annals of the American Academy of lenges among older adolescents and young adults. Rockville,
Political and Social Science, 595, 32-48. MD: Author.
Peplau, H. E. (1991). Interpersonal relations in nursing: A U.S. Department of Health & Human Services. (2013).
conceptual frame of reference for psychodynamic nursing. Mental health surveillance among children: United States,
New York, NY: Springer. 2005-2011. Centers for Disease Control and Prevention
Perry, B. D. (2009). Examining child maltreatment through Morbidity and Mortality Weekly Report, 62(2), 1-36.
a neurodevelopmental lens: Clinical applications of U.S. Department of Health & Human Services & Office of
the neurosequential model of therapeutics. Journal of Disease Prevention and Health Promotion. (2012).
Loss & Trauma, 14, 240-255. doi:10.1080/1532502090 Healthy people 2020. Washington, DC: Author.
3004350 U.S. Public Health Service. (2000). Report of the surgeon
Peterson, S. J. (2009). Interpersonal relations. In S. J. generals conference on childrens mental health: A national
Peterson & T. S. Bredow (Eds.), Middle range theories action agenda. Washington, DC: U.S. Department of
application to nursing research (pp. 202-230). Philadelphia, Health & Human Services.
PA: Lippincott Williams & Wilkins. Yalom, I. D. (1995). The theory and practice of group psycho-
Potochnick, S. R., & Perreira, K. M. (2010). Depression and therapy. New York, NY: Basic Books.
anxiety among first-generation immigrant Latino youth:
Key correlates and implications for future research.
Pamela Adamshick, PhD, RN, PMHCNS-BC, holds certifica-
Journal of Nervous and Mental Disorders, 198, 470-477.
tion as an advanced practice nurse and is engaged in education
Random House Websters unabridged dictionary (2nd ed.). and practice in psychiatric/mental health nursing. She has com-
(1998). New York, NY: Random House. pleted research on girl-to-girl aggression and the experience of
Reynolds, F., & Shepherd, C. (2011). Young womens cultural immersion in registered nurses. She currently is an
accounts of intimate partner violence during adolescence Associate Professor of nursing, teaching in the Masters,
and subsequent recovery processes: An interpretative Baccalaureate, and RN-BS completion programs.