Advocacy Opportunities from Academic- to Include Abenefit to the Communities in the Research Plan

association for behavioral and ISSN 0278-8403 ABCT cognitive therapies

s VOLUME 43,NO. 7•OCTOBER 2020 the Behavior Therapist

Contents

President’s Message PRESIDENT’SMESSAGE Martin M. Antony Planning for ABCT’s Future • 229 Planning for ABCT’s At ABCT Mary Jane Eimer Future From Your Executive Director • 232 Martin M. Antony, Ryerson University special issue PSYCHOLOGISTS’ nExT MOnTH,ABCT willhold its 54th Annual Convention, ROLE in ADVOCACY which, for the first time, will to SUPPORT the HEALTH occur virtually. The novem- berconvention willmark the of MARGINALIZED endofmytermasABCT president and the beginning of POPULATIONS David Tolin’s term. So, this will be my last column as ABCT president. I want to take amoment to thank everyone who Guest Editors: Brian A. Feinstein helped to move ABCT’swork forward over the JaeA.Puckett past year, including the numerous volunteers whoserve the association (e.g.,board members, coordinators, committee members, committee Message From the Editors chairs, editors, reviewers, and SIG leaders), BrianA.Feinsteinand Jae A. Puckett thosewho contribute contentfor our conven- Introduction to the Special Issue: Psychologists’ Role in Advocacy to tion (i.e., presenters) and publications, ourded- Support theHealth of Marginalized Populations • 234 icatedstaff, and all of our members who work hard every day to advance the alleviation of Science Forum human suffering. Iamproud and honored to Claire Burgessand Abigail Batchelder have had the opportunity to serve ABCT as ImprovingClinical Research to Inform AdvocacyInitiatives With president. This column focuses on ABCT’s new strate- UnderservedIndividuals • 235 gic direction. Every 3years, ABCT’s Board of Melissa A. Cyperski, Mary E. Romano, Cassandra C. Brady Directors, coordinators, and senior staff meet SupportingTransgender/Gender DiverseYouth Across Settings for astrategic retreat. This year’s retreat andSystems of Care:ExperiencesFromaPediatric Interdisciplinary occurred virtually over 2days in June. The Clinic • 242 meeting was facilitated by Jeff De Cagna of Foresight First LLC.Initially, some of us won- Debra A. Hope, Nathan Woodruff,RichardMocarski dered whether turbulent 2020 was the right Advocacy OpportunitiesFrom Academic-Community Partnerships: time to begin astrategic planning process. Three Examples From TransCollaborations • 247 However,itquickly became clear that this was exactlythe right time to consider where we are at, where we want to be in thecomingyears,and

[Contents continued on p. 230] [continued on p. 231]

October • 2020 229 [Contents continued] the Behavior Therapist Published by the Association for Behavioral and Cognitive Therapies Original Research 305 Seventh Avenue -16th Floor Corinna Klein, ErikaLuis Sanchez, Juan Carlos Gonzales, Iliana Flores, new York, nY 10001 |www.abct.org (212) 647-1890 |Fax: (212) 647-1865 Yessica Green Rosas, Miya Barnett The RoleofAdvocacy in Community-PartneredResearch With Lay Health Workers in Latinx Communities(Promotoras de Salud) • 250 Editor: Richard LeBeau Science Forum Editorial Assistant: Resham Gellatly Anu Asnaani,Su-AnneR.CharleryWhite,Tammi-Marie Phillip Mobilizing Mental Health Training Efforts to Align With Advocacy for Associate Editors Disenfranchised Groups in GlobalContexts: Trauma-Related Training RaeAnn Anderson in the Caribbean as an Example • 254 Trey Andrews Original Research Shannon Blakey Monique C. Aguirre,Heather Brown, Dana Gershenoff,Kristie L. Hinton, Olivia M. Lily Brown Huntzinger, Natalie Klein, Carmen Ramos, O. FahinaTavake-Pasi,Brieanne Witte, Amanda Chue Marc Wolfsfeld, Tamara Sher, Debra L. Simmons, Timothy W. Smith,LaurenClark, najwa Culver KatherineJ.W. Baucom The RoleofAdvocacy in Adapting theDiabetesPreventionProgram for Brian Feinstein Couple-Based Delivery ThatReaches MarginalizedGroups • 261 David Hansen Angela Moreland Science Forum Lorraine U. Alire, Kaitlyn R. Gorman, Anna M. Ying, Karen L. Suyemoto Samantha Moshier RefillYour Well:AnOnline Acceptance-Based Behavioral BurnoutManagement Amy Murrell Guide forActivitsofColor Resisting Racism • 266 Alayna Park Jae Puckett Discussion Jennifer Regan KevinL.Nadal From RevelationstoRevolutions: Integrating Social Justice Principles Into Amy Sewart Behavioral and Cognitive Science • 271 Tony Wells Monnica Williams Katherine Young

ABCT President: MartinM.Antony INSTRUCTIONS Ñçê AUTHORS Executive Director: Mary JaneEimer TheAssociation for Behavioral and Cog- Submissions must be accompanied by a DirectorofCommunications: nitive Therapies publishes the Behavior CopyrightTransferForm (which can be David Teisler Therapist as aservicetoits membership. downloadedonour website: http://www. ConventionManager: StephenCrane Eight issues are published annually.The abct.org/Journals/?m=mJournal&fa=TB Managing Editor: Stephanie Schwartz purpose is to provide avehicle for the T): submissions will not be reviewedwith- Membership ServicesManager: rapid dissemination of news, recent out acopyright transfer form.Prior to DakotaMcPherson advances, and innovative applications in publication authors will be asked to submit afinal electronic version of their Copyright ©2020 by the Association for Behavioral behavior therapy. and Cognitive Therapies. All rights reserved. no part Feature articles that are approxi- manuscript. 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Send both old and new should be accompanied by a75- to phrase tBT submission and the author’s addresses to the ABCT office. 100-wordabstract. last name (e.g., tBT Submission -Smith et ABCT is committed to apolicy of equal opportunity in all of its activities, including employment. Letters to the Editormay be used to al.)inthe subject line of your e-mail. ABCT does not discriminate on the basis of race, respond to articles published in the Include the corresponding author’s e- color, creed, religion, national or ethnic origin, sex, BehaviorTherapist or to voice aprofes- mail address on the cover page of the sexual orientation, gender identity or expression, age, disability, or veteran status. sional opinion. Letters should be lim- manuscript attachment. Please also All items published in the Behavior Therapist, itedtoapproximately3double-spaced include, as an attachment, the completed including advertisements, are for the information of copyright transfer document. our readers, and publication does not imply endorse- manuscript pages. ment by the Association. 230 president’ smessage how we can get there, given this uncertain We are now in the process of learning vention will occur virtually. Months of environment in which we findourselves. from the information collectedsowecan deliberation went into our decision to Our process began with an “environ- prepare ABCTfor the future. We are cancel our in-person meeting, taking into mental scan” in which agroup of stake- exploring and challenging our orthodox account the impact on our members, as holders (e.g., ABCT leaders, staff, mem- beliefs andfine tuningour strategic direc- wellasthe impactonthe association. More bers, external contributors) answered tion. We are still working out the details, than 2,000 of you completed our online questions about both ABCT and environ- but Iexpect our new directiontobe survey regarding your plansfor november, mental trends and shifts. Through this grounded in amoreaccessible and inclusive and the message was clear—traveling to process, we identified arange of orthodox approachtocreating value for bothcurrent Philadelphia was simply not an option for beliefs held about ABCT. An orthodox and emerging stakeholderswho share our most of us. belief is similar to what many of us might passion for using behavioral science to Although we’ll miss connecting with refer to as a“core belief” or “underlying understand and treat awide range of friends and colleaguesinperson,the virtual assumption.” These are beliefs that we typ- human problems. ABCT’s future will be format will provide opportunities to do ically assumetobetrue, and that may hold guided by anumber of core principles, things differently thisyear. Many presenta- us back from making meaningfulchange. whichare likelytotouch on themes such as: tions willberecorded, with ongoing access Like any type of belief, orthodox beliefs for aperiod after the convention. So, may be true, untrue, or partially true. •Building diversity, equity, inclusion, anyone registered for the convention will be able to attend some events that are Examples of the more than 30 orthodox accessibility, and an antiracist stance scheduled at the same time—something beliefs that were identified through our in our association, and in the field of that usually isn’t possible. The online scan include: behavioral health,moregenerally; •Fostering innovation to create and format willalso allow for more flexibilityin “CBTissuperior to other treatments” enhance evidence-based approaches when you attend presentations(your par- ticipationwon’t need tobelimited to the 4 to behavioral health; “ABCT is primarily the ABCT days of the convention). Also, without the convention” •Promoting disseminationand imple- need fortravel, we hope thatwe’ll be able to “ABCT values diversity of perspectives” mentation of evidence-based behav- reach abroader audience than might be the ioral health, in part through promoting “ABCT represents andvaluesresearchers case for our more traditional convention stakeholder engagement. over clinicians” format. Finally, Iwant to highlight that this “ABCT focuses too muchonanxiety Importantly, we are carefully consider- issue of the Behavior Therapist is aspecial disorders” ing our purpose, who we see as key stake- issue, entitled “Advocacy in Action: Psy- holders, how to carry out our work, and chologists’ Role in Advocacy to Improve Another important purpose of our how to measure whether our goals have the Health of Marginalized Populations.” environmental scan was to identify antici- been met. ABCT’s ongoing strategic Thank youtoBrian Feinsteinand JaePuck- pated external shifts that might impact us, process will continue through the end of ett for helping ABCT to address this both over the short term (2020 through my term and well into the future.Creating importanttopicthrough their role as guest 2022) and longer term (2023 through strategy is adynamic process,necessary to editors. 2029), including general societal shifts (e.g., meet the demands of an ever-changing Ilookforwardtojoining youatour vir- antiracism, antiscience,agingpopulation), world. We will have more to share in the tual conventionnext month! shiftsinhealth, technology,and well-being coming months, and of course, stakeholder (e.g., focus on global mental health, shift input (including from members) will be ... towardtelehealth, precision and personal- invited and encouraged before any impor- ized medicine), and shifts in behavioral tant decisions are made. no conflicts of interestoffunding to disclose. health (e.g., mobile applications, expansion Before Isign off, there are acouple of Correspondence to MartinM.Antony, of BA- and MA-level providers, increased otherthings Iwant to mention. First, a Ph.D., Department of Psychology, Ryerson emphasis on social determinants of health, word about the convention.Bynow,you University, 350 Victoria Street, Toronto, On, movementtoward tiered care). probably know that ABCT’s Annual Con- M5B 2K3,Canada;[email protected]

ABCTPIONEERS SERIES

www.abct.org ABCT > FORMEMBERS > CBTPIONEERS Russell Barkley Alan Kazdin David Barlow Art Nezu Explore David Burns Christine Maguth Nezu Andrew Christensen Patricia Resick ABCT’s growing CBTPioneers series: Phil Kendall Tom Ollendick Interviews with CBT’sinfluential thinkers, Judith Beck Steven Safren researchers, and practitioners— Esther Deblinger Gail Steketee Steven C. Hayes Greg Siegle Steve Hollon

October • 2020 231 AT ABCT Award nominations and nominate acol- league or yourself! Don’t overlook the opportunity to nominate colleagues out- From Your Executive Director: sideofABCT for our Champions Award. As President Antony mentionedinhis What Your Leadership and Staff column, the leadership of ABCTisactively engaged in addressing our stakeholders Are Working on to Serve You Better and considering shifting from strategic planning to strategic intent. Iwould like to Mary Jane Eimer, Executive Director thank Dr. Antony for his commitment to ABCT over the past year. We all had no idea of all the “extra” time and attention that would be required due to the pan- Once the decision was platform.Then we will tackle betteralter- demic, social injustice, and switching to a made to hold our nativesfor the listserve. virtual convention. Thank you, Marty, for november convention We movedthe annual election process your openness to new ideas, inclusion of virtually, your staff to november, thinking more members many perspectives,and generosity of spirit. focused its attention on would vote if we held it the same month as Members, please continue to be active all the details that need our Annual Convention. The election has in ABCT by renewing your membership to be addressed to been held onlinefor over adecade and we and registering for the convention. Partici- ensure asuccessful con- hopeyou will participate. We have astrong pate in our list serve or in one of Special vention. Iwould like to formally acknowl- lineup of candidates for your considera- Interest Groups. This is your organization edge and thank the Philadelphia Marriott tion. Their bios and position statements and your opinion and participation mat- Downtown Hotel for their partnership in will be available on our website in mid- ters. The Board listens, as does the staff. We working with us to resolve an amicable October. The 2021 candidates are: are counting on you. cancellation of the space we reserved for You are always welcometocontact me our november convention. They under- President-Elect directly at [email protected] Thank you. stoodour need to cancelbased on the feed- •Jill Ehrenreich-May, Ph.D. Stay safeand positive, everyone. backfrom our conventionsurvey. We have •Alec Miller,Psy.D. Until nexttime! along history with the MarriottCorpora- tion and thePhiladelphiaDowntown Mar- Representative-at-Large and Liaison ... riottHotel in particular. If your travels take to Convention and Education Issues you to Philadelphia, perhaps you would •Katherine J.W. Baucom,Ph.D. Correspondence to MaryJane Eimer,CAE, consider staying at this hotel. FYI, we will •Ana J. Bridges, Ph.D. Executive Director, ABCT, 305 Seventh be holding our 2024 convention at the Ave., Suite 1601, new York, nY 10001; Philadelphia Marriott. Secretary Treasurer [email protected] As Iwrite this column,weare working •Barbara W. Kamholz, Ph.D. with the Finance Committee and the Board •Erin Ward-Ciesielski, Ph.D. regarding conventionregistration fees. We are very much aware that COVID-19 has It is my sincerepleasuretoinform you impacted your funding. Staff is working to the ABCT Board of Directors approved a offer the lowest rates possible for the con- new award, the Francis C. Sumner Excel- ventionregistration fees while beingmind- lence Award. The award is named in honor ful of our overhead expenses. We will be of Dr. Sumner, the first African American able to continue to offer reduced rates for to receive aPh.D. in psychology, in 1920. our2021 webinars and archivedwebinars Commonly referred to as the “Father of to help memberscontinuetoearn continu- Black Psychology,” he is recognized as an ing education credits. Please continue to American leader in education reform. The support ABCT by renewing your dues and award is intended to acknowledge and pro- remaining active in the services and bene- mote the excellence in research, clinical fits we provide. We continue to produce8 work, teaching, or service by an ABCT Congratulations issues of tBT and offer6issues of Behavior member who is adoctoral studentorearly Therapy and 4issues of Cognitive and career professional within 10 years of earn- to David Antonuccio, Ph.D., Behavioral Practice.ABCT has 41 Special ing aPhD/PsyD/EdD/ScD/MD and who InterestGroups that are active; you need to identifies as Black or Indigenous. The who was recently presented be amember of ABCT to be amember of award is given to recognize Black and one of ourSIGs. We are updating our web- with the National Register’s Indigenous practitioners and scholars site constantly with resources for all stages making important contributions to our Alfred M. Wellner Lifetime of your professional development and field. The Francis C. Sumner Excellence interests. In 2021 we will migratetoamore Achievement Award Award is meant to reflect the overarching user-friendly database and anew website goal of ABCT supporting its members of in Research Excellence color. Please take alookatthe 2021 Call for

232 the Behavior Therapist Become an author with the Advances in Psychotherapy bookseries

About Advances in Psychotherapy − Evidence-based Practice Developed and edited with the supportofthe Society of Each bookisa“how-to”reference on aparticular disorder. Clinical Psychology(APADivision 12),the Advances in Psy- Thebooks allhaveasimilarstructure,and each titleisa chotherapy series provides therapists andstudents with compactand easy-to-follow guidecoveringall aspectsof practical,evidence-basedguidanceonthe diagnosisand practicethatare relevant in real life.Tables, boxedclinical treatment of themost common disordersseeninclinical “pearls,”and marginalnotes assist orientation, while practice–and does so in auniquelyreader-friendly manner. checklistsfor copyingand summaryboxesprovide tools for Anew strand is dealing with methods and approaches rather useindaily practice. than speciﬁc disorders.

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We look forwardtoseeingyourbookproposal! Find outmoreabout thebookseries at https://hogrefe.com/us/apt or visitour servicesites at https://hogrefe.com/us to getinformationfor authors! Drop EditorinChief DannyWeddinganemail to discussyourideas [email protected].

Forthcoming volumes Bullying and Peer Victimization Time-Out forChildBehavior Management Substance Use Problems in Older Adults Domestic Violence Psychological Approaches to Cancer Care Group Therapyfor DepressiveDisorders HarmReduction Approaches AfﬁrmativeCounselingfor Transgender and Gender Diverse Panic Disorder and Agoraphobia Clients Body Dysmorphic Disorder Collaboration With Schools Occupational Stress CulturallySensitivePsychotherapy Dating Violence Supporting Children AfterMassDisaster

www.hogrefe.com MESSAGE FROM THE EDITORS examples of how researchers, clinicians, educators, and trainees can use their knowledgeand skills to incorporate advo- Introduction to the Special Issue: cacy into their own professional work. We believe that psychologists need to do more Psychologists’ Role in Advocacy to Support than just repair the damage of our unjust world. Instead, psychologists must the Health of Marginalized Populations embrace advocacy as aprofessional responsibility and work to create true Brian A. Feinstein, Institute for Sexual and Gender Minority Health change by dismantling the power struc- and Wellbeing, Northwestern University tures that give rise to health inequities to begin with. We hope the examplesofpsy- Jae A. Puckett, Michigan State University chologists engaging in advocacy included in this specialissue will sparkcreative ideas for your own vision of your responsibilities as apsychologist. In 2019, ALOnG WITH SEVERAL of ourcol- the topicofadvocacy.Fast forward to min- leagues, we organized apanel for ABCT’s utesbeforethe beginning of the panel and Annual Convention focused on psycholo- we weresitting in front of apackedroom References gists’ role in advocacy to support the health with 88 attendees, many of whom had to Glassgold,J.M.(2007).“In dreams begin of marginalized populations. We knew that stand for the duration of the session responsibilities” Psychology, agency, and advocacy could be apowerfultool for col- because there were not enough seats to activism. Journal of Gay&Lesbian Psy- laborating with marginalized communities accommodate such alarge audience. chotherapy, 11,37-57. to reduce health disparities, and that it During the panel, as we shared our experi- Hargons, C., Mosley,D., Falconer, J., could play an important role in science ences engaging in advocacy and responded Faloughi,R., Singh,A., Stevens-Watkins, (e.g., by generating hypotheses based on to attendees’ questions, it became even D.,&Cokley, K. (2017). Black lives matter:Acall to action forcounseling the experiences of community members). more apparent to us that psychologists psychology leaders. TheCounseling Psy- However, we also knewthat psychologists were eager to learn how to incorporate chologist, 45,873-901. were rarely trained to engageinadvocacy, advocacy into theirown professionalwork. King, M. L., Jr. (1968). The role of the and that there was adivide in the field This specialissue of the Behavior Therapist behavioralscientist in the civil rights wherein some viewed advocacy as part of is thenext step in our efforts to raise aware- movement. AmericanPsychologist, 23, their professional responsibilities and ness of the importance of engaging in 180-186. others did not. The potential for psycholo- advocacy as psychologists. We have Kozan, S., &Blustein, D. L. (2018). Imple- giststoengage in advocacy has longbeen curated acollectionofarticles that address menting social change: Aqualitative acknowledged (e.g., King, 1968; Pettigrew, arange of topicsrelated to advocacy, such analysis of coun- 2018), andthere has been excellent schol- as responding to the needs of community selingpsycholo- arship on the topic of integrating asocial partners, adapting evidence-based inter- gists’ engagement in advocacy. The Counseling Psychologist, 46,154-189. justice perspective into psychology (e.g., ventions, teaching self-advocacy skills, and Hargons et al.; nadal,2017). Still, advocacy preventing burnout (a common conse- nadal, K. L. (2017). “Let’sget in formation”:Onbecomingapsychologist- continues to be treatedasaniche topic in quence of engaging in advocacy, especially activistinthe 21st century. American psychology (particularly in clinical psy- for people who are members of marginal- Psychologist, 72,935-946. chology) rather than as acore value of the izedcommunities themselves). The collec- Pettigrew, T. F. (2018).Summingup: Did field. We believethat advocacy is critical to tionofarticles addresses the experiences of social psychology answerDr. King’s call? the workofpsychologists—even an ethical various marginalized populations (e.g., JournalofSocial Issues,74,377-385. imperative (Vasquez, 2012)—and that a people of color, sexual and gender minori- Prilleltensky, I. (2001).Value-based praxis commitment to advocacy and social justice ties, people living with HIV) and describes in community psychology: Moving should be embedded in clinical practice work being conducted in anumber of towardsocial justiceand socialaction. (e.g.,Glassgold, 2007; Puckett,2019; Rus- unique settings (e.g., community-based AmericanJournalofCommunity Psychol- sell &Bohan, 2007), research (e.g., Prillel- organizations, clinics, camps, national and ogy,29,747-778. tensky, 2001, 2003),teaching, and all of the international contexts). The special issue Prilleltensky, I. (2003). Understanding, other responsibilities of psychologists(e.g., concludes with acommentarywritten by resisting, andovercoming oppression: Hargons et al., 2017; Kozan &Blustein, Dr. Kevin nadal, aleader inthe movement Towardapsychopolitical validity. Ameri- 2018). As such, we organized the afore- for psychologists to combat systemic can Journal of Community Psychology, 31,195-201. mentioned panel to shareexamples of how oppression through activism. Puckett, J. A. (2019). An ecological psychologists could use advocacy as atool In closing,weare extremely grateful to approach to therapywith gender minori- for disseminating scientific knowledge, for the Editor of the Behavior Therapist,Dr. ties. Cognitiveand BehavioralPractice, increasingthe impact of psychological sci- Richard LeBeau, for supporting this special 26,647-655. ence, and ultimately for supporting the issue, and to all of the contributing authors Russell,G.M., &Bohan, J. S. (2007). Liber- health of marginalized populations. for sharing their expertise, research find- ating psychotherapy: Liberationpsychol- As we organized the panel, we were ings, and personal experiences. We hope ogy andpsychotherapywith LGBT hopeful and cautiously optimistic that con- that the articles included in this special clients. JournalofGay &Lesbian Psy- vention attendees would be interested in issue will inspire readers and serveasuseful chotherapy, 11,59-75.

234 the Behavior Therapist advocacy initiatives with underserved individuals

Vasquez, M. J. T. (2012).Psychologyand socialjustice:Why we do whatwedo. American Psychologist, 67,337-346. ABCT Apps &PsyberGuide ... no conflicts of interest or funding to disclose. ABCTisdelighted to announce apartnership with PsyberGuide,anonprofit website reviewing smartphone applications and other digital mental health tools. This partner- Correspondence to Brian A. Feinstein, ship was established with the aim of disseminating reviews of digital mental health tools Ph.D., Institute forSexualand Gender to abroad audience of researchers, psychologists, psychiatrists, and other mental-health MinorityHealth and Wellbeing, northwest- practitioners. App reviews from both PsyberGuide and Cognitive and Behavioral Practice ern University, 625 n. Michigan Ave.#14- are integrated on both sites. Forfull listings, visit: 047, Chicago, IL 60611 http://www.abct.org/Resources/?m=mResources&fa=ABCT_APPS [email protected]

marginalized in health care and research SCIENCE FORUM settings, and discuss how these settings can implement collaborative, inclusive practices aimed at alleviating chronic and sys- Improving Clinical Research to Inform temic stressors of underserved populations Advocacy Initiatives With Underserved through advocacy. Individuals Addressing Health Inequities: Underserved Populations’ ExperiencesinHealth Careand Claire Burgess, VA Boston Healthcare System and Harvard Research Settings Medical School Marginalized and underserved people Abigail Batchelder, Harvard Medical School, Massachusetts have consistently faced structural or sys- General Hospital, and The Fenway Institute, Fenway Health temic inequity and discrimination, which may be particularly felt by those with inter- secting stigmatized identities (Robinson &

ADVOCACYISDEFInED by Webster’s Dic- rately identify critical problems facing their Ross, 2013). For example, African Ameri- tionary as “the act or process of supporting communities, identify effective strategies to canorBlack sexual minority men are sub- acause or proposal” (Merriam Webster, address those problems, and accurately stantially more likely to acquire HIV and 2020). Health advocacy has been defined as interpret the results of the clinical assess- face barriersinaccessing or initiatingpre- “activities related to ensuring access to ments used in research. Problematically, exposure prophylaxis (PrEP medication) care, navigating the system, mobilizing the collaborative aspect of advocacy has not compared to White sexual minority men resources, addressing health inequities, always been followed in clinical research. (Batchelder et al., 2017).These disparities influencing health policy and creating Health care settings have unknowingly are related to layers of socioecological system change”(Hubinette et al., 2017, p. contributed to minority stress for members inequalities rooted in systemic racism 128). Asubstantial amount of clinical of marginalized communities due to (Hanks et al., 2018), homonegativity (neg- research has focused on addressing stigma and discriminationinboth clinical ative attitudestowardsexual minorityindi- inequities to reduce disparities and and research contexts (Gessner et al., 2019; viduals), and stigmarelatedtoHIV/AIDS. improve quality of health care among Gomez, 2013; Lambda Legal, 2014; For some clinical researchers and underserved individuals, consistent with national Coalition of Anti-Violence Pro- providers, understanding the history both definitions of advocacy.Therefore, in grams, 2017). The historical legacy of behind underserved populations’ interac- many cases, particularly when research is minority health care consumers being mis- tions in health care and research settings aimed at improving the health and well- treated and underserved in medical and may require additional effort and educa- beingofunderserved people, it can be con- research settings has exacerbated existing tion. Without an understanding of minor- sidered aform of advocacy, or at least be structural barriers to health care access, ity stress (King et al., 2008; Meyer, 2003), thought of as informing and contributing resulting in poor engagement in care for health disparities outcomes and minority to advocacy efforts. many that must be addressed to improve However, to effectively advocate for the health and well-being of underserved health engagement and adherencemay not underserved individuals, researchers and communities and to foster advocacy make sense. An understanding of the cur- providers—including clinical psychologist (Marmot, 2005; Rivenbark &Ichou, 2020). rent and historicalstressors and inequities researchers—must involve membersofthe In the present paper we briefly describe experienced in healthcare andresearchset- populationswith whom they work to accu- ways underserved individuals have been tingsisneeded for researchers to appreci- ate what is needed to develop, refine, and

October • 2020 235 burgess & batchelder implement effective interventions for dents endorsed mistreatment and discrim- Relatedly, the concept of cultural mis- underserved people. ination in health care settings. Specifically, trust, the adaptive attitudinal stance in Relatedly,quality of provider education one-thirdofTGDindividualssurveyedin which aperson of color is suspicious or on minority health topics directly impacts USTS reported having anegative experi- guardedtoward aWhiteperson (Terrell et the availability of competent, culturally ence in ahealth care setting, including al., 1981),may influence the acceptanceof sensitive care. This education has been experiences of verbal harassment, physical, medical and psychiatricdiagnoses and psy- notably lacking in many medical educa- or sexual assault in the pastyear. Of those chological interventions (Whaley, 2001). tional settings (Denboba et al., 2013; sampled, individuals who identified as For example, the messages patients tell Gamble Blakey &Treharne, 2019; Like, racial minorities or as disabled reported themselvesabout potential sideeffects and 2011), despite its absence having deleteri- higher rates of negative health care experi- medical treatments, informed by the his- ous consequences for quality of care as well ences compared to those without these torical context of exploitative experiments as health engagement outcomes (Awo- interlockingidentities,evidencing the need and procedures, can reduce treatment sogba et al., 2013; McGuire &Miranda, to be aware of interlocking stigmatized engagement and adherence. Myers et al. 2014). Additionally, providers’ perceptions identities when considering chance of (2018) examinedurban African American of their competence related to one compo- experiencing discrimination. Underserved women and found that age, uncertainty nent of an underserved individual’s iden- individuals who experience discrimina- (measured via the need for Closure Scale), tity may not be sufficient for effectively tion, including gender minority individu- and conspiracy beliefs predicted medical treating aperson with interlocking under- als, may avoid health care settings alto- mistrust towards HIV treatment. The served and stigmatized identities. For gether due to fear of mistreatment study authors acknowledge that conspiracy example, White et al. (2015) found that (national Transgender Discrimination beliefs have been astrong historical predic- while providers may feel competent dis- Survey, 2010; USTS, 2015), perpetuating tor of medical mistrust, and also have a cussing HIV prevention with their patients, continued expectations of stigma and protective and social role, permitting the they may not feel prepared or comfortable invalidation within care settings (Sloan et passage of information as it pertains to pro- with topics related to gender identity, al., 2017). This population exemplifies a tecting aminority group. Thus, clinical interventionists are challenged to develop which is problematic given increased risk starklook at direct experiences of violence and implement effective strategies to for HIV in patients who identify as trans- that may lead to anegative association with gender or gender diverse. While topics address the impact of limitedinclusion of health care settings,which can be extrapo- related to minority health have not been underserved individuals who may not be lated to other marginalized and under- routinely included in medical or mental trusting of medical systems. In pivoting to served populations, as many underserved health curricula (Beach et al., 2004; van acollaborative model (discussed in the fol- patientscarry mistrust of the very medical Ryn, 2004), recent efforts seek to address lowing paragraphs), informed by an under- system intended to serve them.Inorder to this gap (e.g., Boroughs et al., 2015; Truong standing of minority stress and the histori- reduce medical and research mistrust, et al., 2014).Despite these efforts, inconsis- cal context of exploitation, insufficient efforts are needed to prevent discrimina- tencies in trainings focused on effectively training related to working with under- tion in healthcare and clinical research set- addressing underserved population health served individuals,and continued discrim- tings and implement trauma-informed raisesconcern about sufficient assessment ination, providers have the opportunity to competency, as some providers may feel care practices. strategically improve the quality of care uncomfortable inquiring about minority- Medical and research mistrust are and health and mental health outcomes health topics (Moll et al., 2014; White et al., common barriers to producing research through collaborations with community 2015). Further, the lack of comfort and that informsand supports advocacy efforts. members. training addressing these topics can result Marginalized underserved communities, in important topics not being brought up particularly people of color, have long Discussion/SpecificPractice or inquired about awkwardly or unfamil- faced exploitation and discrimination in Recommendations: Improving the context of medical treatment and iarly, leaving patients feeling stigmatized. Access to Care andNavigating Systematic efforts are neededtoimplement research (e.g., Tuskegee; Darcell et al., training to ensure competence and comfort 2010). Evidence indicates that many the Health careSystem among providers and clinical researchers African American health care consumers While there are challenges related to working with underserved individuals, remain aware of pastviolations of rights in merging advocacy and psychological including those with interlocking stigma- the Tuskegee Syphilis Study, yielding a research, including potentially competing tized identities. demonstrable negative effect on attitudes goals and outcomes as well as differing In addition to incompetent care and toward medical care (Freimuth et al., conceptualizationsofhow to achieve psy- care settings marked by systemic 2001). Further, lackoftrust in research is chological well-being, there are several inequities, underserved individuals may an influential barrier to participation in strategies that may be useful. Community- also experience discrimination or violence research (Brown et al., 2014; George et al., based participatory research (CBPR), as during treatment. For example, one under- 2014; Limkakeng et al., 2014; Schmotzer, described by Israel(2010) and others(e.g., served population disproportionately 2012). In addition to the historicalcontext, Collins et al., 2018; Unertl et al., 2016), impacted by mistreatment in health care insufficient provider training resulting in emphasizes amethodology based on alat- settingsare transgender and gender diverse culturally incompetent or even discrimina- eral, partnered approach in which both (TGD) individuals. Guiding our knowl- tory behaviors continue to perpetuate partners are egalitarian. Its methodology edge of these outcomes, the 2015 United medical and research mistrust and, focusesonequitablycounting all partners’ States Transgender Survey (USTS; 2015) thereby, perpetuate inequities in health expertise (community members, academic revealed that ahigh rate of TGD respon- care morebroadly. researchers, and other stakeholder team

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Learn moreabout evidence-based continuing education and training with praxiscet.com burgess & batchelder members) into decisionmaking, resulting into more traditional research methods, ventioncontent and materials in culturally in shared ownership of the project. CBPR including interventiondesign and testing. relevant ways. The results from this work hasbeen described as away to increase the One example of using community- were then presented to local community odds an intervention is effective by ensur- informed strategies is exemplified through advisory boards and community-based ing underserved community partners are Batchelder et al. (2015) and Batchelder et organizations that serve people living with empowered to voice their perspectivesand al.’s (2013)studies.Batchelderdeveloped a HIV to obtain additional feedback. This contribute throughout the research process psychological intervention strategy to later iterative refinement involved adding (Wallerstein &Duran, 2010).Byinvolving reduce internalized stigma and shame some newcontent identified in the inter- members of an underservedcommunity in among people living with HIV and sub- views, including examples related to inter- everystage of the research, including iden- stance use disorders based on previously locking stigmatized identities described in tification of critical questions, the develop- conducted qualitative and quantitative the interviews (e.g., femmephobia) as well ment of intervention strategies to be tested, analyses which solicited open-ended feed- as additionalcontentrelated to the role of as well as interpretation of results, research backfrom individuals living with HIV and stigmatizing language (using the “Addic- can best identify areas in need of advocacy substance use disorders about the root tionary”; Kelly, 2004). This trajectory of and, ultimately, identify effective interven- causes of suboptimal engagement in HIV work exemplifieshow clinical psychology tion strategies. As many challenges faced self-care behaviors. Through this work, researchers can involveempowered mem- by underserved individualsare influenced community members identified internal- bers of underserved groups at varying and exacerbated by socio-political histori- ized stigma and shame as psychological stages of clinical research to iteratively cal contexts, systemicinequity,and socio- barriers to engagement in HIV self-care. identify the problem or area of focus, ecological layers of bias and discrimina- Batchelder then iteratively developed an inform the development and refinementof tion, the research questions identified by intervention to improve HIV self-care interventions, and to interpretthe results, members of underserved communities behaviors (Batchelder et al., 2020) based on even when full CBPRmethods are not fea- often indicate areas of needed advocacy additional qualitative interviews with indi- sible. that are often underappreciated by “the viduals living with HIV and substance use In addition to working collaboratively ivorytower” (e.g., Chung et al., 2008; Will- disorders and providers who work with with members of underserved communi- yard et al., 2018). Further, by equitably fos- this population, such as infectiousdisease ties to identify areas in need of focus,spe- teringlateral collaborations betweenmem- and addiction medicine physicians, psy- cific research questions, and the develop- bers of an underserved community and chologists with expertise in HIV and sub- ment and iterative refinement of researchers, as well as other key stakehold- stance use, and case managers who work interventions, collaborations are impera- ers, questionsthat may isolate the underly- with this population to identify key com- tive for accurately interpreting the results ing challenges,orroot causes, of problems ponents. These interviews started with Dr. of research projects and ways that research as well as effective solutions can be identi- Batchelder presenting evidence-based con- results can inform advocacy initiatives. fied, tested, and accurately interpreted. For tent to the individuals living with HIV and Involving community members and key problems that are rooted in historical dis- substance use disorder, and next their stakeholders, via community advisory crimination, economic inequity, and sys- providers, iteratively refining the content boards or peer advisors, in the interpreta- tematic oppression, these collaborations and presenting the updated content in sub- tion of resultsoften facilitates accurateand can resultinthe identification of commu- sequent interviews. Through this process, meaningful interpretationofresearch find- nity and research-based advocacy strate- Batchelder updated language, including ingsand the identification of areas in need gies. The end goal may be ensuring access reading level and word choice; examples of clarification. Further, as those who have to care, navigating research or medical set- used in exercises; figures in worksheets lived experiences relevant to the questions tings, mobilizingresources, which are ulti- (e.g., changing cartoons,perceived by indi- being asked frequently have critical matelyneeded to improve the psychologi- viduals living with HIV and substance use insights regarding the interpretation of cal and physical health of underserved disorders as child-oriented and conde- research results and ways in which research individuals, consistent with Hubinette’s scending, to emojis, which were perceived findings can meaningfully inform advo- definition of health advocacy (Hubinette et as more adult-oriented); the number of ses- cacy strategies in the very communities al., 2017). sions; and added atext platform to meet they are geared to aid. For example, in a However, effectively implementing the needs of the marginally housed individ- qualitative study of people with substance CBPR is difficult, time-consuming, and uals who had government subsidized cell- use disorders enrolled in group-based often expensive, which precludes its use in phones without smartphone capabilities Hepatitis Ctreatment in the Bronx,partic- many contexts. Therefore,when conduct- (Batchelder et al., 2020). She then tested the ipants identified ways in which their group ing full CBPR is not possible, we propose refined intervention content in aproof-of- treatment impacted their views of them- that clinical researchers consider using concept study, after which she conducted selves, suchasthrough reducing internal- components of thisstrategy, often referred exit interviewswith participants to obtain ized stigma (Batchelder et al., 2015). Fur- to as community-informed strategies. additional insightfor interpretation of the ther, group members noted that the These practices can be thoughtfully and results.Tothen adapt the intervention for camaraderie they fostered in group treat- systematically implemented in arange of men who have sex with men living with ment generated advocacy initiatives, research methodologies, with the goal of HIV and substance use disorders who were includinglobbying for increased access to involving empowered community mem- suboptimallyengaged in HIV care in adif- Hepatitis Ctreatment for others. bers at various stages across the research ferent city, Batchelder et al. (2020) then When working withunderserved indi- process. While the strategies we describe conducted another set of qualitative and viduals, it is imperative to foster trust do not strictly adhere to CBPR methodolo- quantitative interviewstoconfirm the need through empowerment and gratitude for gies, we suggest infusing these strategies for the intervention and refine the inter- their contribution. In research contexts,

238 the Behavior Therapist advocacy initiatives with underserved individuals advocacy includes ensuring research par- reluctant to disclose literacy challenges will the quality of clinical research, the effec- ticipants have aclear understanding of engageininformed consent.Food insecu- tiveness of interventions, and the utility of what is involved in the research in which ritycan also be abarrier to informed con- research in advocacy endeavors, even if the they are being asked to consider participat- sent; Batchelder and colleagues routinely feedback comes from asmall corps of coming. In both clinical and clinical research offer impoverished, marginally housed munitymembers. contexts, practices of informed consent at individuals with substance use disorders a For clinical research to effectivelycon- appropriate reading levels at the outsetof snackand beverage prior to completing the tribute to advocacy efforts,wepropose that treatment can be useful to guide treatment, informed consent process to ensure indi- research questions, methods, and clinical confirm participants understand the pro- viduals are comfortable prior to the interventions should be developed with the cedures taking place, and illustrate how informed consent process and subsequent perspective of the target population in their contribution will be used. Informed study visits. Working to foster trust and mind. When possible, clinical research consent optimally allows patients to weigh empowerment when working with under- should strivetoequitably involve members the risks against perceived benefits and served individuals requires facilitating of the target population and stakeholders at make an unbiased choice towards partici- active participation in informed consent, each phase. Efforts should be made to pating (or withdrawing) in any treatment which often includes being cognizant of ensure all perspectives influencethe forma- or outcomes research. Working to ensure potential barriers, including literacy level tion of research questions, intervention potential research participants feel com- and unmet immediate needs, whenneces- fortable and empowered to ask questions sary (e.g., providingfood). development and refinement, and final and voice disagreement is imperative in One issuethat may occur within hidden interpretation. When it is not possible to medical and research contexts. or lowbase rate populations is the issue of involvemembersofthe target population Being aware of any barriers to informed scarcity, which may require plansinplace at each stage, involving individuals at consent is helpfulfor ensuring underserved for thoughtfully addressing insufficient selected stagescan increase the likelihood individuals feelempowered in clinical and representation of apopulation’s feedback that clinical research can inform advocacy. clinical research contexts. For example, on aprotocol. Either by using aformal For example, involving target population when working with individuals with vari- method, such as CBPR, or by thoughtfully members in the pilotingofstudies, giving able reading levels, consistently offering to incorporatingmembers of the population feedback on the instruments being used, as read the consent form to participants, and with whom clinical researchers are focused, well as the mode of deliveryhave been suc- normalizing this practice, can increase the lateral opportunities for offering insights, cessfully implemented in Batchelder’s likelihood that individuals who may be guidance,and interpretations will improve recentwork.

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October • 2020 239 burgess & batchelder

Conclusion Batchelder, A.W., Brisbane,M., Litwin, Tower, Intothe Real World: Examples of A.H.,nahvi,S., Berg, K.M., &Arnsten, Street-Smart Community Health In the presentpaperwedefined health J.H. (2013) "Damaging whatwasn't dam- Research. RAnD Corporation. advocacy using Hubinette et al.’s (2017) aged already": Psychological tensionand https://www.rand.org/pubs/research_bri definition: that which helps to ensure antiretroviraladherence among HIV- efs/RB9394.html access, proper navigation, resources, policy infected methadone-maintaineddrug Collins,S.E.,Clifasefi, S.L., Stanton,J., The andsystems in place resulting in adecrease users. AIDS Care, 25(11),1370-1374. Leap Advisory Board,Straits,K.J.E., Gil- of health inequities. Based on this defini- Batchelder, A.W., Foley, J., Wirtz,M.R., Kashiwabara,E.…Wallerstein, n. tion, we propose that clinical psychology Mayer,K.M., &O’Cleirigh, C. (2020). (2018). Community-based participatory research aimedatidentifying and address- Substance use stigma, avoidancecoping, research (CBPR): Towards equitable andmissed HIV appointmentsamong ing the health and well-being of under- involvement of community in psychol- MSMwho use substances.[Manuscript ogy research. AmericanPsychologist, served individualshas the potential to serve submittedfor publication.] 73(7), 884-898. doi: as atool in informing advocacy as well as Batchelder,A.W., Gonzalez,J.S.,Palma, 10.1037/amp0000167. be aform of advocacy in itself. Further, we A., Schoenbaum, E.,&Lounsbury, D.W. Darcell,P.S., Mathews, K.J., Jackson, P., examined how clinicians and clinical (2015).Asocialecological model of syn- Hoffsuemmer,J., &Martin, E. (2010). researchers can achieve research that demic risk affecting women with and at- More than Tuskegee: Understanding informs and contributes to advocacy, by risk for HIVinimpoverishedurban mistrust about researchparticipation. involving tenets and strategies of CBPR communities. American Journal of Com- Journal of HealthCare for the Poorand even when full CBPR is not feasible,with a munity Psychology, 56(3-4),229-240. Underserved, 21(3), 879-897. focus on the barriersoften faced by under- Batchedler, A.W., Moskowitz, J.T., Jain, J., Denboba,D.L.,Bragdon, J.L., Epstein, served individuals accessing and navigat- Cohn, M., Earle, M.A., &Carrico,A.W. L.G., Garthright, K., &McCann Gold- (2020). Anovel technology-enhanced ing health care systems. man, T. (2013) Reducing health dispari- internalized stigmaand shame interven- ties through cultural competence. Jour- There is alonghistory of underserved tion forHIV-positivepersons with sub- health care consumers receiving subopti- nal of HealthEducation,29(1),S47-S53. stanceuse disorders. Cognitive and doi: 10.1080/10556699.1998.10603386 mal treatment in medical, clinical psychol- Behavioral Practice, 27(1), 55-69. ogy, andclinical research settings. This dis- Freimuth, V.S., Quinn, S.C., Thomas,S.B., Batchelder, A.W., Peyser, D.,nahvi, S., Cole, G., Zook,E., &Duncan,T.(2001). criminatory historical context hasdirectly Arnsten,J.H.,&Litwin, A.H.(2015). African American's views on research “Hepatitis Ctreatment turnedme contributed to pooraccess, undue barriers, andthe Tuskegee syphilisstudy. Social around:” Psychological and behavioral and poor engagement in care—hurdles Science &Medicine, 52(5), 797–808. transformation related to hepatitis C that must be addressed in order to improve https://doi.org/10.1016/S0277- treatment. Drugand AlcoholDependence, the quality of care and its effectiveness. In 9536(00)00178-7 53,66-71. the present paperwereviewedseveral ways GambleBlakey, A., &Treharne, G.J. Batchelder, A.W., Safren, S., Mitchell, that underserved individuals have been (2019) Overcomingbarriers to transgen- A.D.,Ivardic,I., &O'Cleirigh, C. (2017). derhealth careeducation in Aotearoa marginalized in health care and research Mentalhealth in 2020 formen who have settings, and discussed how the implemen- sex withmen in theUnitedStates. Sexual newZealand. New ZealandJournalof tation of collaborative, inclusive practices Health,14(1), 59-71. Educational Studies, 54, 357-366. mightinform strategies for alleviating the https://doi.org/10.1007/s40841-019- Beach,M.C.,Cooper, L.A., Robinson, 00143-2 chronic and systemic barriers to effective K.A., Price,E.G., Gary, T. L., Jenckes, and accessible care for these historically M. 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October • 2020 241 SCIENCE FORUM through the application of therapeutic interventions that enhance self-esteem, promote effective interpersonal communi- Supporting Transgender/Gender Diverse cation, or facilitate skill development. For example,imagine you are working Youth Across Settings and Systems of Care: with astudent who identifies as nonbinary and is repeatedly misgendered with consis- Experiences From aPediatric Interdisciplinary tent incorrect pronoun usage by one of Clinic their teachers. As the provider, you offer to reach out to their teacher to express your concerns and request they change their Melissa A. Cyperski, Mary E. Romano, and Cassandra C. Brady, classroom behavior to become more Vanderbilt University Medical Center affirming, but the patient declines and indicates they would like to talk with their OnEOFTHE GUIDInG PRInCIPLES of work- Therefore, the purpose of this paper is teacher independently first. To help the ing as amental health provider is to recog- to outline several possible opportunities for youth prepare for the conversation effec- nize and respond to various psychosocial mental health providers or other health tively,the provider can practice role-play- needsinordertopromote health and well- care professionals to advocate for TGD ing various scenarios and possible out- being. Supporting and advocating for the patients in order to address theirpsychoso- comes with the youth. You may wish to needsofour clients/patients is particularly cial needs, enhance health outcomes, and practice what it might be like to receive a important when working with diverse or promote resiliency across settings. We variety of responses from affirming to dis- marginalized populations such as sexual hope to highlight various strategies or missive and develop aplan for how the and gender minorities (SGM; e.g., lesbian, actions providers can take as needed to youth will cope in the moment accord- gay, bisexual, transgender individuals) who support patients and their families on an ingly. During follow-up sessions, providers may experience greater physical and individual, community, or systemic scale. can review the consequences of the conver- mental health needs subsequent to experi- Additionally, although health care sation withthe teacherand assess forongo- ences of minority stress and frequent providers can be of service and benefit by ing needs. If the youthencountered resis- harassment or discrimination (e.g., acting on behalf of their TGD patients, pro- tance or did not experience the intended Wagner et al., 2019). Transgender and fessionals are ultimately encouraged to outcome, collaborate with the patient on gender diverse individuals (TGD) are at work alongside their patients and empower the development of aplan to escalate con- particular risk. Arecent study found that them to advocate for themselves. We have cerns such as involving the provider in a 40% of TGD adults in the United States provided case examples from our own follow-up discussion or sharing concerns with the school principal and guidance reported attempting suicide in their life- work throughout this manuscript to counselor for additional support. time, which is approximately nine times expand upon how to implement advocacy higher than the national average (James et efforts. Community Level al., 2016). TGD children and adolescents •School.TGD youth may require con- exhibit similar mental health outcomes, Advocacy Examples and sistent supportasthey navigate avariety of with 44% of TGD youth endorsing that Recommendations challenges at school or in the community. they have considered suicideascompared Adversity may be pervasive in the educa- to 11% of their cisgender peers (Johns et al., Individual Level tional setting as acts of discriminationare 2019). Unfortunately,many TGD children At an individual level, TGD youth may perpetrated by peers or adults alike and adolescents often experience violence, feel disempowered after experiencing (Kosciw et al., 2018). Domínguez-Martínez rejection, and other adverse experiences rejection, bullying, discrimination, mar- and Robles (2019) reportedthat 9out of 10 within thevarious contextsinwhichthey ginalization, and/or disenfranchisement. TGD students experienced actsofphysical live and interact, including, but not limited Mental health providers or allied health abuse, verbal abuse, and cyber-bullying. As to, experiences in their families, intimate professionalshave the opportunity to col- adirect result of their experiences, many relationships,and schools (e.g., Kann et al., laborate with TGD youth to regulate emo- TGDadolescents feel unsafe at school;sub- 2018; Kosciw et al., 2018; Ryan, 2009). tions and thenco-construct an action plan sequently, theyhave higher rates of school Health care professionals and mental that honors the patient’s wishes or needs. absences, truancy, and prematuredropout, health counselors, in particular, are in a The provider might offer to intervene on which places them at greater risk for unique position to recognize, respond to, the patient’s behalf or work to support the adverse outcomes in the future (Wagner et and advocatefor themultifarious and com- youth as theyadvocate forthemselves. Sup- al., 2019). For this reason, it is important plex needs of TGD youth. However, pro- porting and empoweringthe individual to that health care providers frequently screen fessionalsmay hesitate to step into the role advocate for themselves may be partially for academic and school safety concerns in of patient advocate for avariety of reasons, accomplished through the provision of their TGD patients. including alack of awareness aboutappro- nonspecifictherapeutic factors (e.g., active Multiple national and international priate resources for SGM patients and fear listening, validation, willingness to collabo- organizations have called for increased of overstepping their boundaries as a rate) that offer acorrective emotional expe- research productivity to evaluate best prac- provider or operating outside the bounds rience for the TGD youth and help them tices, curriculum, and programs that sup- of their competence—even if they feel believe that change is possible. Addition- portSGM students. GLSEn (2019a) is one strongly about the cause. ally, empowerment may be achieved suchorganization that works to create safe

242 the Behavior Therapist supporting transgender/ gender diverse youth and inclusive schools. They offeravariety and research findings about gender dys- team members agree and offer astatement of materials that studentsand families can phoria, described risks associated with of support. However, such an action bears use to advocate for SGM youth, as well as noninclusive practices, and offered evi- its own set of ethical considerations and resources educators and administrators dence-based recommendations for more must be made in careful partnership with may utilizetoimplement inclusive curricu- affirming practices or policies. Materials the youth in order to representtheirvoice, lumorprogramming like gender and sexu- provided by GLSEn, such as On the Team: wishes, and needs effectively. The impor- alityalliances (GSAs) in theirschools. Equal Opportunity for Transgender Stu- tance of collaborating with and involving For example, consider the case of a dent Athletes (Griffin &Carroll, 2010) and TGD youth in decision making that transgender adolescent male who was for- the Transgender Inclusion in HighSchool impacts them cannot be overstated. bidden by his high school to participate in Athletics: Policy Brief (GLSEn, 2019b), Providers who advocate for TGD youth at extracurricular activities in his affirmed were also attached to the letter to provide school or another public forum may play gender. Historically, this youth exhibited precedence and support for the argument. an importantrole in promotingaccess and increased gender dysphoria and suicidal As is to be expected, sociopolitical fac- equal opportunity for TGD youth, but it is ideation after experiencing such an injus- tors often dictate the extent to which the not without risk. For instance, apublicdis- tice, but even with increased suffering he school system may be able to accommodate play of support requires that astudent has felt hopeless about changing his circum- requests and adapt their policies; however, come out about their identity, whichmay stances and believed speaking up or speak- it has been our experience that educational place them at risk for discrimination or ing out would only make the situation staff members will hear and respond to violence. It may also increase feelings of worse. Therefore, uponobtaining consent individual requests to the extent possible. gender dysphoria, even if temporarily, by from the patient, his health care provider Providers may wish to be prepared to offer highlighting differences and disparities advocated directly on his behalf by express- compromises and solutions that are agree- between TGD youth and their cisgender ing concern to school administrators in a able to the patients they serve. For instance, peers. letter of support. Primary goals when draft- even if amending the school’s athletic In addition to collaborative problem ing the letter included raising awareness policy is still awork in progress, the school solving, health care professionals are also about the patient’s needs and making a district may agree that an individual youth advised to be proactive in engaging TGD request for achange in the district’spolicies can be offered the opportunity to partici- patients about their needs and offering to allow this student to participate. Specifi- pate in extracurricular activities in their their support. Although some patients may cally,the letter presented psychoeducation affirmed gender if the parents of other make specific requests of their providers,

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October • 2020 243 cyperski et al. othersmay not be aware of the waystheir using therapeutic skills and interventions stance use, and health concerns such as health care teamcan be utilized to advocate common in mental health practice. Skills sexually transmitted infections (Wagneret or addressconcern outside themedicalset- such as managing competing demands, al., 2019). ting. For example, providers may offer to assessing underlying motivations, moni- Although family members of TGD ado- document the medicalnecessity and their toring interpersonaldynamics,using effec- lescents can serve as perpetrators of vio- support of studentsgainingaccess to bath- tive written or verbal communication, and lence and emotional abuse,caregivers can rooms or locker rooms consistent with engaging in collaborative problem solving also enhance resilience. For instance, by their affirmed gender. In our experience, are particularlyimportant. using the name their child has chosen in letters of support are best received when Similarly, therapeutic skills can be used affirmation of their gender identity, care- they include aspecific request forchange, to help direct parents on how to best givers can significantly decrease their an evidence-based rationale for the request, approach the school system regardingsitu- child’s suicidal ideation and self-harming and when the provideroffers to be available ations where their child feels unsafe or behavior (Russell et al., 2018).TGD adoles- for additionalconsultationordialogue. An unsupported. We have witnessed how cents who report receiving parental sup- invitation for ongoing communication fos- some parents are hesitant to become portand acceptance also experience fewer ters astrong working alliance with the involved, uncertain of their role or prefer- symptoms of depression or anxiety and schoolsystem and leavesthe door open for ring to empower their teen to take matters greaterlife satisfactionoverall when com- future collaboration should the patient’s into their own hands. However, adult pared to TGD adolescents who encounter needs evolve or change over time. voicesare also important and may have a parental rejection or those whodonot feel Consider the case of aTGD adolescent greater capacity for influence in some set- comfortable coming out to their caregivers who experienced bullying when using the tings. Parents may need to be coached by (Ryan, 2009; Wagneretal., 2019). restroom associated with their affirmed their child’s healthcare provider on how to Data are lacking, but anecdotally gender at school. Experiences resulted in manage their emotions effectively in meet- parental responses to their SGM youth are fear, bathroom avoidance, and subsequent ing with school staff and how to use lan- oftenaffected by factors such as culture, medical concernsvia frequent urinarytract guageorstructure their argument to be the socioeconomic status, and religious beliefs. infections. In time, the patient was able to most successful. Similar to working with Therefore,toassess and addressthe needs successfully advocate for themselves and individual TGD youth, caregivers may of TGD youth effectively, health care asked for an alternative solution at school. benefit from intentional practice,planning, providers are encouraged to do acompre- Initially they feltsupportedbytheiradmin- and/or role-play activities. Parents may hensive assessment of various values, istrators who permitted use of the facilities also needassistance identifying key stake- strengths, and needs within the child/ in the faculty lounge and nursing station. holders and determining what level of amily system and advocate for change as However, after trying the school’s pro- intervention is most appropriate or who indicated. By identifying sources of both posed solution for several weeks, the stu- would be the best person to help them strength and strain in relationships dent realized the faculty lounge was too far achieve ameaningful, timely change for between TGD youth and their parents, from their classes and they did not have theirchild. That is to say, not all concerns providers can use apositive framework enough time to use the restroom without need to be presented to the state board of that capitalizes on parents’ identified receiving sanctions for being late to class. education or escalated to the governor’s strengths (e.g., protective spirit, willingness However, they were nervousabout raising office (as an extreme example) and, to try, interest in learning more)while also the issue again as they were worried they instead, can be addressed ethically and intervening and addressing specific con- might appear ungrateful and because they effectively one-on-one. cerns such as parents’ sense of stigma or did not believe another solution was possi- fears of danger befalling theirchild (Ryan, ble. Upon hearing the concern, the •Family context. It is important to eval- 2009). provider was able to reach out to educa- uate and enhance experiences of TGD Although there may be asignificant tional personnel directly and collaborate youth in educational settings whenever overlap with family therapy in the identi- on the generation of another solution in possible since many SGM youth receive fied goals of improving the health and which the student was permitted to be late critical support at school, particularly when functioning of the family system, assessing to select classes. their home life is challenging or unstable. and addressing the family contextisalso an The school system was initially frus- Although manycaregiversare highly sup- important form of advocacy in which trated and resistant to making such accom- portive of their TGD youth, there is awide health care providers can align with and modations as they believed they had spectrum of caregiving behaviors present intervene on behalf of the patient. For already provided areasonable accommo- in this population, ranging from fierce example, imagine anonbinary adolescent dation; however, they were ultimately advocacy to disengaged and even harmful. is seeking affirmative surgical intervention swayed by persistent advocacy and articu- Asurvey of SGM youth found higher rates andtheircaregivers are ambivalentabout lation of the patient’s need in asensitive of abuseperpetrated by caregivers as well as the need for the procedure given their manner.Although the provider was singu- lower levels of parental closeness and child’s nonbinary identity. In traditional larly focused in advocating for the youth’s decreased sense of parental attachment family therapy,the mental health provider right and need to feel comfortable and safe when compared with reports from their may strive to enhance communicationand using the restroom of their choosing, the cisgender peers (Katz-Wise et al., 2016). facilitate aprocess by which each party presentation of this information was bal- Subsequently, familial rejection con- contributes to the sharedvisionand solu- anced with validating the school’s concerns tributestohigh rates of homelessness and tion within the family context; whereas in (e.g., missing too much class) and effortsto involvement in the child welfare system an advocacy-focused intervention, the compromise. Therefore, in this case and among SGM youth, which further provider will first collaborate with the manyothers,providers are well-served by increases risk for trauma exposure, sub- youth around their hopes and intentions,

244 the Behavior Therapist supporting transgender/ gender diverse youth then steer the family through psychoeduca- competent best practices and strategies for their traditional patient care roles to pro- tion and processing toward the particular enhancing the patient experience so all vide education about affirmative best prac- solution that is consistent with the youth’s may feel welcome and supported in their tices to their administrative staff, care goal (e.g., surgery). health-related needs. teams, medical students or other adult Systemic Level Particular consideration should be learners to increase access to quality ser- given to patients who have had previous vices. Outside the office environment, •Health care.Inaddition to unsafe or adverse experiences in health care as each health care professionals have also con- uncomfortable conditions at home or interaction with the system—from sched- ductedtrainings and provided consultation school, TGD youth may experience chal- uling an appointment to meeting anew with managed care organizations or other lenges in other settings as well, including the health care system. Diverse patients provider and revealing personal informa- systems of care (e.g., child welfare) in the haveencountered alongstanding history of tion—can be anxiety provoking.Given the past in which professionals played acritical implicit bias, discrimination, and dispari- negative personal or collectivist experi- role in increasing awareness about impor- ties in medical and mental health care set- ences TGD patients have encountered in tant TGD health concerns and used the tings (e.g., Boroughs et al., 2017; FitzGerald the health care setting in the past, it is available evidence base to informbest prac- &Hurst, 2017; Harless et al., 2019). As a important for providers and their staff to tice recommendations. field, health care researchersand providers be fully committed to offering culturally One additional health care resource should strive to advance theirunderstand- competent care by demonstrating inclusive worth highlighting is the Trans Buddy pro- ing and approach to factors such as race, and affirmative practices at every point of gram (Reilly, 2020). As part of the Program ethnicity, gender, sexuality, socioeconomic contact,including on the telephone and in for Lesbian, Gay, Bisexual, Transgender, status, and intersectional identities (Har- the waiting room. To facilitate the provi- and Queer (LGBTQ) Health at Vanderbilt less et al.). We must continue to consider sion of comprehensive affirmative care, University Medical Center (VUMC), a ways to promote evidence-based, culturally professionals may need to step outside Trans Buddy is atrained volunteer patient

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October • 2020 245 cyperski et al. advocate who is available upon request to care professionals may also be asked to mendations to legislators and those who help TGD patients navigate the complexi- serveinarenas outside the health care set- aremaking TGD-relatedpolicy decisions. ties of the health caresystem.Asrequested ting. In particular, we wouldberemiss if we However, there are many other opportuni- by the patient, aTrans Buddy can visit with did not acknowledgethat TGD youth and ties for providers to engage on asmaller or accompany TGD individuals to their their families are influenced by the scale and in day-to-day operations that can medical appointments and serve as aliai- sociopolitical landscape. Therefore, also support and address the psychosocial son to improve access to affirmative care providers can play an important role in needs of TGD patients and families.Inthe and enhance clinical outcomes. The advo- advocating at the state and federal level for community and settings where youth cate will collaborate with the patient legislation thathonors, protects,and serves interact frequently, health care profession- around their unique needs and tailor their the SGM community. als can work with educationalpersonnel to service accordingly. This may include For instance, health care professionals establish affirmative schools and spaces being afriendly, supportive presence may be called to increase publicawareness that provideasafe place for TGD patients. during procedures; advocating for pre- about importantTGD health issues such as At the individual level, providers can offer ferred name and pronouns to be used when anumber of discriminatory policies to be of support to youth as needs arise in throughout the visit as well as in the med- were proposed by the Tennessee state legis- treatment and continue to engage in icalrecord;speaking up if patient’s needs, lature in 2020. Several bills wereintroduced patient-centered practices that communi- concerns, or requests are overlooked by the that proposed to restrict access to affirma- cate genuine care and concern for the well- provider;ormaking referrals to affirmative tive care for TGD children and adolescents. being of their TGD patients. providers. Mental health and affiliated care Health careprofessionals collaboratedwith For mental health care workers and professionals can serve as volunteers, community agencies, legal experts, and other allied health professionals who work ensure patients are aware of the service, lobbyists to draft expert testimony to be with TGD youth,wehope that this paper and collaborate with apatient advocate presented to legislators. In particular, has provided examples of ways in which when available. providers engaged in advocacy efforts by professionals can get involved and advo- Additionally, in an effort to work and using their expertiseand social privilege for cate effectively within the scope of their learn alongside patient advocates, aTrans good to present case examples and synthe- current practices. Ultimately, however, Buddy attends visits in our interdiscipli- size the evidencebase in away that could professionals are advised to balance their nary clinic for TGD pediatric patients to be easilyunderstood by alay audiencewith own call to action and desire to help with offer an introduction to the service and the goal of influencing informed decision empowering their TGD patients to serve as assist with any needs as requested by the making. In addition to providing expert their own advocates and agents of change. patient or family. As with other aspects of testimony to policymakers, health care In our practice, we believe this is feasible medicine, patients are expected to have professionals also wrote to their local con- andthatchildren, adolescents, and families betteroutcomeswhen the care is provided gress members, signed petitions, penned are best served by acollaborative relation- in an interdisciplinary setting (e.g., Epstein, op-edpiecesinlocal news sources, and ship with their teamofhealth care profes- 2014) and ateam of health care profession- posted commentaries on social media. sionals who provide ongoing assessment als can communicateorcollaborate seam- However, social activism and public dis- and support for their biopsychosocial lesslyunder one roof.However, establish- plays of social justice may not be for every- needs. ing and maintaining an interdisciplinary one; therefore, health care providers can clinic requires asignificant amount of also engage the discourse and advocate References advocacy and personal investment. Specif- effectively by sharing their concerns Boroughs, M. S.,Feinstein, B. A., Mitchell, ically, health care providers may need to among listservs, colleagues, and friends to A. D.,Shipherd, J. C.,&O’Cleirigh,C. communicate to organizational leadership raise awareness and generateapublic pres- (2017). Establishingprioritiesfor lesbian, aclear need for the interdisciplinary service ence regarding the issue of affirmative gay,bisexual, and transgender health dis- and develop aplan for reallocation of health care and equal rights for TGD parities: Implications for intervention resources as significant effort may be people. development,implementation,research, required to designate space, establish andpractice. the Behavior Therapist, provider schedules, or create new billing Conclusion 40(3), 119-127. structures. As with all advocacy efforts, Domínguez-Martínez,T.&Robles,R. providers are encouraged to have aclear In conclusion,ithas become clear while (2019). Preventingtransphobic bullying “why” and mission statement around the working with TGD youth that psycholo- andpromoting inclusiveeducational identified cause. gists and other allied health professionals environments: Literature review and have an important role to play in advocat- implementing recommendations. Sociopolitical and Policy Implications ing for their patients’ rights and needs. Archives of MedicalResearch, 50(8), 543- Providers who are interested in offering Each provider will need to decide what 555. https://doi.org/10.1016/j.arcmed. 2019.10.009 high-quality care to TGD youth are level of intervention is right for them per- encouraged to be aware that they will be sonally and for their patient(s). Upon dis- Epstein, n. E. (2014).Multidisciplinary in- hospital teams improve patient out- called to go above and beyond for their cussion and assessment of the patient’s comes: Areview. SurgicalNeurology patients by promoting wellness and sup- unique needs, the provider may determine International,5(7), S295-S303. porting collaboration, coordination, or action is required to promote change https://doi.org/10.4103/2152-7806. continuity of care outside the standard across various systems and settings. At a 139612 appointmenttime. Although this process is systemic level, providers can serve as advo- FitzGerald, C., &Hurst, S. (2017).Implicit facilitated by working in an interdiscipli- cates and community leaders by presenting biasinhealthcare professionals: Asys- nary team as previously identified, health testimony regarding best practice recom- tematic review. BMC MedicalEthics,

246 the Behavior Therapist conflicts in client- clinicianbeliefs

18(19). https://doi.org/10.1186/s12910- wood, M. (2019).Transgender identity https://www.vumc.org/lgbtq/ 017-0179-8 and experiencesofviolence victimiza- trans-buddy-program GLSEn. (2019a). About us. tion, substance use,suicide risk, and Russell, S.T.,Pollitt, A., M., Li, G.,& https://www.glsen.org/about-us sexual risk behaviorsamonghigh school Grossman,A.H.(2018). Chosenname GLSEn.(2019b). Transgender inclusion in students –19states and large urban useislinked to reduced depressive symp- high schoolathletics:Policybrief. school districts, 2017. (2019). Morbidity toms, suicidal ideation, and suicidal https://www.glsen.org/sites/default/files/ and Mortality WeeklyReport,68(3),67– behavioramong transgender youth. Jour- 2019-10/GLSEn-Transgender-Inclu- 71. https://doi.org/10.15585/ nal of AdolescentHealth, 63(4), 503-505. sion-High-School-Athletics.pdf mmwr.mm6803a3 https://doi.org/10.1016/ Griffin, P., &Carroll,H.J.(2010). On the Kann, L., McManus, T., Harris,W.A., j.jadohealth.2018.02.003 team: Equal opportunity fortransgender Shanklin, S. L.,Flint,K.H., Queen, B., Ryan,C.(2009). Supportive families, student athletes.national Center forLes- Lowry,R., Chyen, D., Whittle,L., Thorn- healthy children: Helping families with bianRights, Women’s Sports Founda- ton, J.,Lim,C., Bradford, D.,Yamakawa, lesbian, gay,bisexual &transgenderchil- tion, and It Takes aTeam! Y., Leon, M., Brener, n., &Ethier, K. A. dren.Family Acceptance Project, Marian https://www.glsen.org/sites/default/files/ (2018).Youth risk behavior surveil- Edelman Institute, San Francisco State 2019-10/GLSEn-Changing-the-Game- lance—UnitedStates,2017. Morbidity University. https://familyproject.sfsu. On-the-Team-Equal-Opportunity-for- andMortality Weekly Report Surveillance edu/publications Transgender-Student-Athletes.pdf Summaries,67(8). https://doi.org/10. Wagner, J., Sackett-TaylorA.C., Hodax,J. Harless,C., nanney, M., Johnson, A. H., 15585/mmwr.ss6708a1 K., Forcie, M., &Rafferty, J. (2019). Psy- Polaski, A., &Beach-Ferrara, J. (2019). Katz-Wise, S. L.,Rosario, M., &Tsappis, chosocial overview of gender-affirmative Thereport of the2019 southernLGBTQ M. (2016) Lesbian, gay,bisexual, and care. Journal of Pediatric and Adolescent healthsurvey. Campaign forSouthern transgender youthand familyaccep- Gynecology, 32(6), 567-574. Equality.https://southernequality.org/ tance. PediatricClinics of North America, https://doi.org/10.1016/j.jpag.2019.05.004 wp-content/uploads/2019/11/South- 63(6), 1011-1025. https://doi.org/10. ernLGBTQHealthSurvey%E2%80%93Fu 1016/j.pcl.2016.07.005 ... llReport.pdf Kosciw,J.G., Greytak, E. A., Zongrone,A. James, S. E., Herman, J. L., Rankin,S., D., Clark, C. M.,&Truong,n.L.(2018). Melissa A. Cyperski: Keisling, M.,Mottet,L., &Anafi, M. The2017 national schoolclimate survey: https://orcid.org/0000-0001-9524-3344 (2016). The report of the2015U.S. trans- The experiences of lesbian, gay, bisexual, MaryE.Romano: gender survey. Washington, DC: national transgender,and queer youth in our https://orcid.org/0000-0002-4932-0043 Center forTransgender Equality. nation’sschools. new York: GLSEn. https://www.transequality.org/ https://www.glsen.org/sites/default/files/ We have no conflicts of interest to disclose. sites/default/files/docs/USTS-Full- 2019-10/GLSEn-2017-national-School- Correspondence to MelissaCyperski, 3841 Report-FInAL.PDF Climate-Survey-nSCS-Full-Report.pdf Green Hills Village Drive, Room#3000-C, Johns, M. M., Lowry, R., Andrzejewski, J., Reilly,S.(2020). Transbuddyprogram. nashville Tn 37215;melissa.cyperski@ Barrios, L. C., Demissie, Z.,McManus, Program for LGBTQHealth, Vanderbilt vumc.org T.,Rasberry, C. n.,Robin, L.,&Under- University Medical Center.

SCIENCE FORUM becoming more suspicious of researchers (e.g., Christopher et al., 2008). Recognizing the problem, sometimes researchers tried Advocacy Opportunities From Academic- to include abenefit to the communities in the research plan. Community Partnerships: Three Examples Community-based participatory From Trans Collaborations research (CBPR) takes adifferent approach, partnering with marginalized communities in the research process. As Debra A. Hope, University of Nebraska-Lincoln described by Wallerstein and colleagues Nathan Woodruff, Trans Collaborations Local Community Board (2018), “CBPR embraces collaborative efforts among community, academic,and Richard Mocarski, University of Nebraska at Kearney otherstakeholderswho gather and use research and data to build on the strengths and priorities of the community for multi- ,much of what 2016). In part, this occurred because very FORAnUMBER OF YEARS level strategiestoimprove health and social we know aboutmarginalized communities few researchers are themselves membersof equity” (p. 3). The essential aspect of CBPR from psychological research, even most these communities. In addition, research- is the partnership across the research social science work, came from the per- ers would come into acommunity, collect process at all stages, including which ques- spective of “research on” aparticular mar- their data, and leave, with little ongoing tionstoask, selectionofresearchmethods, ginalized group, with the majority group as benefit to the community itself. Over time, and interpretation and dissemination of the “healthy” reference sample (Awad et al., this exploitation led to communities results.

October • 2020 247 hope et al.

Trans Collaborations adults and an entirely new line of research eringdata aboutthe workshop experience for the academic team. and outcomes, the academic researchers set Foundedinlate 2014, Trans Collabora- Once the local community board had the stage to seek federal funding and even- tions is aCBPR collaboration between identified the need, the academic team,led tually enlargethe impact of the workshops, transgender and gender diverse (TGD) by Mocarski, gathered expertise andfund- magnifying the impactofthe local commu- communities in nebraska and academic ing to develop self-advocacy workshops. nity board. researchers at two of the University of Sim Butler, anationally recognized foren- nebraska system campuses, Lincoln and sics specialist, came on board and Camp BOLD Kearney. From the very beginning, the aca- Woodruff, Mocarski, and Butler developed The second project that illustrates our demic researchers, Debra Hope and thefirst workshop plan and piloted it with community-academic collaboration is Richard Mocarski (first and third authors) one smallgroup of six participants. Based Camp BOLD, our campfor TGD children and local community leader nathan on feedback from the pilot group, the self- aged 5–15 and their families. Camp BOLD Woodruff (second author), were fully advocacy workshop grew from a4-to6- is aproject of the local community board, involved in building the organization. A hour format, built around narrativemedi- not aresearchorclinical endeavor. Camp local community board of six TGD adults, cine, behavioral rehearsal of common BOLD addresses the needs of TGD chil- representing arange of ages and gender health care interactions,and development dren who cannot safely participate in most identities, guides Trans Collaborations. A of advocacy skills. Our national advisory overnightcamp experienceswithout fear of national advisory board of academic schol- board, especially medical providers, con- marginalization. Camp BOLD is aweek- ars and three additional sites at University tributed to the selection of key interactions end-longcamp at aretreat center with all of Alabama, Michigan State University, in the health care process—for example, thetraditional camp activities, including and Louisiana State University round out making an appointment—a challenge for bonfires, swimming, arts and crafts, paddle the organizational structure. All research TGD people who have avoided seeking boating, etc. Five families were enrolled the projects are developed in collaboration health care. Local foundationfunding sup- first year, growing to 7families the second with the local community board, including ported delivery of the workshopto36TGD year and 10 families planned for 2020. project aims, recruitment strategies, and adults. Butler and Woodruff ran the self- Given the growing evidence that strong methodology. The local community board advocacy workshops. Led by Mocarski,the family support, affirming spaces, and posi- gives feedback on all questionnaire and restofthe academic team collected efficacy, tive peer interactions are associated with interview itemsbefore deployment, recom- acceptability, and satisfaction data. Full positive mental health and well-being of mends participant payment amounts, and pilot data are being published elsewhere TGD youth (e.g., Austin et al., 2020), the helps recruit participants for research. For but workshop participants were positive goal is to create asafe space where the chil- example,the local board recentlyserved as about their experience. For example, on a dren and theirfamilies can be themselves modified version of the Borkovec and nau and meet other families like their own. an informalfocus group to developcontent (1972) credibility measure, mean ratings Many of the parents have never met aTGD for anew online study of the psychosocial were above 8onthe 0–9 scales (9 being the adult, so interacting with the local board assessment process for obtaining gender- most positive) for whether the workshop membersisvery helpfultothem. The pri- affirming medicalprocedures. The acade- would preparethem to share their gender mary contributions of the academic mem- micteam took the board’s information and journey with their provider and whether bers of Trans Collaborations are help with developed specific surveyitems,withongo- they would recommend the workshops to logistics, fundraising,and collecting partic- ing consultation.The board will help inter- afriend in the TGD community. We are ipants’ feedback. The local community pret the meaning of the results.Woodruff currently seeking federal funding to board has determined that all costs for represents the entire board as aco-author develop the model further, including Camp BOLD should be covered for the on all papers,reviewing them before sub- online modules that would aid dissemina- families. In the past 2years, funds have mission. Although this is our process over- tion. come from national foundations, local all, three Trans Collaborations projects How do the self-advocacy workshops churches, and individual donations, with have moved beyond the typical CBPR reflect our community-academic partner- the feedback data helpingsupport funding research collaboration. We would like to ship? First, the initial idea of the work- applications. Feedback from families has describe these examples of advocacy in shops came from amember of the local been positive, describing the transforma- more detail. community board. Second, the community tive experience of being in an affirming Self-Advocacy Workshops board, and especially the board chair, were space that celebrates their children, fully involved in every phaseofworkshop decreases their sense of isolationand fear, Duringalocal community board meet- development, refinement, and delivery. and starts asupport network that has con- ing, board members noted that our efforts Third, the workshop participants them- tinued among the families after camp is to help providers be more TGD-affirming selves helped guide development of the over. would be along-term project. In the mean- workshops by conveying their desire to time, TGD people would stillneed to seek take more ownershipoftheir interactions COVID 19 Virtual Support Groups medical and mental health treatment, with health care providers and sharing Most recently,the Trans Collaborations negotiating the oftentreacherousterrainof their lived experience in small groups. Community Board has started athird interactions with providers andhealthcare Fourth, the academic researchers gathered advocacy initiative, online support groups staff with the likelihood of being marginal- the needed expertise to develop ahigh- for TGD adults in nebraska during the ized in the process (James et al., 2016). Out quality, evidence-based product, in collab- COVID-19 pandemic. Social support can of this conversation was born the idea to orationwiththe community to ensure it help buffer the effects of marginalization develop aself-advocacy workshop for TGD was also culturally sensitive. Fifth, by gath- stress (e.g., Hendricks &Testa, 2012; Pflum

248 the Behavior Therapist trans collaborations et al., 2015) and the local board sensed that opportunities to engage in camp activities important advocacy work. Ashared sense many community members would be espe- and be together. At the parents’request, the of socialjustice, acommitment that TGD cially isolated during the stay-at-home second yearwehad amedical provider who communities deserve the best evidence- orders. For these groups, the onlyrole for works with the TGD community join via based, culturally sensitive health and the academic researchershas been to help teleconference, so parentscould ask ques- mental healthcare, and asense of trust with publicize the support groups. However, the tions from an appropriate source rather each other have been essential to our suc- overallstructure and organizationofTrans than the TGD board members. Camp cess. Although there have been challenges Collaborations was important in several counselors are amix of individuals who along the way, the shared community and ways. The local community board met identify as cisgender and TGD, many of academic leadership keeps everyone online to discuss the need and format for whom are graduate students on the focusedonthe mission. The advocacy pro- the groups with the project manager pro- research team. jects described above were not in anyone’s viding some logistical support.The Trans Mutual Respect and Good mind when we started, but have been an Collaborations brand is wellknowninour important and valued outgrowth of the Communication community and many mental health research. providers and local organizations were Trans Collaborationsincludes the local willing to share information about the sup- community board as well as academic References port groups because we have built trust members from various disciplines (psy- over time. chology, health communications, marriage Austin, A.,Craig, S. L.,D’Souza,S.D., & and family, forensics, etc.), ranging from McInroy,L.B.(2020). Suicidalityamong Lessons Learned graduate students to fully promoted pro- transgender youth: Elucidatingthe role fessors. Good communication has been of interpersonal risk factors, Journal of Interpersonal Violence.First online. Despite the success of these three illus- essential to develop trust and mutual trations of our community-academic col- https://doi.org/10.1177/08862605209155 respect. The academic members have 54 laboration for advocacy, the development learned to monitor their use of acronyms Awad, G. H.,Patall, E. A., Rackley, K., & of Trans Collaborations has not been with- and technical language, balancing commu- out its challenges. Below we will describe Reilly, E. D. (2016).Recommendations nicatingwhat is neededwith the board and forculturallysensitive research methods. some of the lessons we have learned along avoiding bogging them down in details the way. Journal of Educational and Psychological better discussed laterinthe research team Consultation, 26,283-303. Process and Development of the Local meeting. The local board members speak https://doi.org/10.1080/10474412.2015.1 Community Board from their own lived experience as well as 046600 their senseofthe broader TGD communi- It tookabout 2years for the Local Com- Borkovec,T.D., &nau, S. D. (1972). munity Board to develop into acohesive ties. Credibilityofanalogue therapy ratio- nales. JournalofBehavior Therapyand working group. Manymembers had been Extra Time and Effort Needed Experimental Psychiatry,3,257-260. on advisory boards in which they func- for Research https://doi.org/10.1016/0005- tioned as arubber stamp or for whom it The CBPR approach means it takes 7916(72)90045-6 was moreanopportunity to socialize.Over longer to get research done but the part- Christopher, S.,Watts, V., KnowsHis Gun time,board members haveengaged more nership has made the science stronger. We McCormick, A., &Young,S.(2008). fully in Trans Collaborations, excited by ask better questions in away that is amore Building andmaintaining trust in acom- the positiveimpact theycan have on TGD accurate assessment of constructs of inter- munity0based participatory research communities.Having an experienced chair est. The advocacy work benefits from the partnership. AmericanJournal of Public for the local board has been important as academic partnership in terms of accessing Health, 98,1398-1406. https://doi.org/10.2105/AJPH.2007.1257 he conductsthe meetings, not theacademic resources (e.g., afinancial structure to seek 57 researchers. In fact, there is very little hier- andreceive community foundation grants) archy on display in the meetings—every- but can be slowed down by thelimited time Hendricks, M. L., &Testa,R.J.(2012). A conceptual frameworkfor clinical work one has their roles and takes turns speaking available from the academic partners as and listening. The local boardtook the lead withtransgenderand gendernoncon- well as university bureaucracy. Managing on development of the Trans Collabora- formingclients: An adaptation of the this requires patience and organization to tions mission statement and developed a Minority StressModel. Professional Psy- keepactivities moving ahead.Shared pro- policy that every research project had to chology: Research and Practice,43, 460– jectlists reviewed at weekly team meetings 467. https://doi.org/10.1037/a0029597 have adirect “product” for the TGD com- attended by the local board chairperson munity. As the local community boardhas James, S. E.,Herman, J. L.,Rankin,S., and academic research teammembers and developed, they have initiated the three Keisling, M.,Mottet,L., &Anafi, M. the addition of apaid project manager have (2016). TheReport of the 2015 U.S. advocacy projects described above. been helpfultoproductivity. Transgender Survey.Washington,DC: Camp BOLD requires fullengagement nationalCenter forTransgender Equal- from the local community board. The Conclusion ity. board membersatcamp embody the diver- Pflum,S.R., Testa,R.J., Balsam, K. F., sity of TGD people for the youth, siblings, In the 5years since its founding,Trans Goldblum,P.B., &Bongar, B. (2015). andparents. Theyare present and available Collaborationshas grown from two infor- Social support, trans community con- as needed but camp counselors lead many mal conversations to aproductive and nectedness, and mental healthsymptoms of the activities. Board members avoid impactful community-basedparticipatory among transgender and gender noncon- giving advice, seeingtheirroleasproviding research partnership that has spawned formingadults. PsychologyofSexual ori-

October • 2020 249 entation and Gender Diversity,2,281- 286. https://doi.org/10.1037/sgd0000122 ABCT Leadership and Elections, 2021 Wallerstein, n., Duran, B.,Oetzel, J., Min- kler,M.(Eds).(2018). Community-based participatory research for health:Advanc- The Leadership and Elections Committee is pleased to announce ingsocialand healthequity.Jossey-Bass. the slateofcandidates forthe 2021ABCT election: President Elect ... Jill Ehrenreich-May, Ph.D. Alec Miller,Psy.D. Thisworkwas supported in part by a SystemScience TeamBuilding Award from Representative-at-Large &Liaison to Convention and Education Issues the University of nebraskaand aBiomed- Katherine J.W.Baucom, Ph.D. ical Seed Grant from University of Ana J. Bridges, Ph.D. nebraska-Lincoln. Secretary-Treasurer Correspondence to Debra A. Hope, Ph.D., Barbara W. Kamholz, Ph.D. DepartmentofPsychology, University of Vote Erin Ward-Ciesielski, Ph.D. nebraska-Lincoln, Lincoln, nE 68588-0308 in [email protected] November!

ORIGINAL RESEARCH members navigate services, providing education, bridging gaps in access to services, and disseminatinginformation about ser- The Role of Advocacy in Community-Partnered vice availability to their communities (Sharma et al., 2019). LHWs use their social Research With Lay Health Workers in Latinx proximity, or membership in and familiar- ity with the diverse communities they Communities (Promotoras de Salud) serve,inorder to engage clients and build trust (Gustafson et al., 2018). Although the Corinna Klein, Erika Luis Sanchez, Juan Carlos Gonzalez, social proximity and shared cultural and Iliana Flores, Yessica Green Rosas, and Miya Barnett, linguistic attributesofLHWs, suchaspro- motoras, are critical for their effectiveness University of California, Santa Barbara in supporting service delivery, engaging families, building trust, and providing interventions, their shared attributes also LAYHEALTH WORKERS (LHWs) have been programs, in avariety of roles from con- mean that promotoras face many of the recommended as apotential workforce ducting outreach to serving as the primary same challenges as the communities they solution to decrease disparities in access to treatment providers (Barnett,Gonzalez, et serve. Promotoras may face similar dis- both medical and mental health care global., 2018). Though LHWs have successfully crimination, poverty, linguistic barriers, ally and within the United States (Barnett delivered EBPs in studies conducted in and immigration concerns as the individu- et al., 2018; Lehmann et al., 2009; Sharma low- and middle-income countries,licen- als theyworkwith. Whilepromotorasmay et al.,2019). LHWs include manydifferent sureand certification requirementsinthe contributetohealth equity for Latinx com- types of paraprofessionals, including com- United States frequentlyrestrict EBP deliv- munities, theyalso run the risk of exploita- munity health workers, patient navigators, ery to professionals in mental health set- tion by health care services and research parent partners, peer support specialists, tings. Therefore, LHW roles may need to institutions. and promotoras de salud.Promotoras de be distinct in regards to addressing service The risk of exploitation of LHWs is a salud are aspecific type of LHW that has disparities domestically (Barnett, Lau, et pressing issue, particularly as health care helped improve equitable access to services al., 2018). For example, in this project the systems increasingly rely on LHWs to 1 for Latinx communities (Ayala et al., role of LHWs was to provide auxiliary sup- decrease inequities. Task shifting, in which 2010). LHWs are often members of the port to professional providers to increase certain tasks that require minimalqualifi- communitiesthey serve or share some sig- engagement in the EBP, Parent-Child cations are shifted from highly trained nificant characteristicwith the clients they Interaction Therapy (PCIT; Barnett et al., workers, who are in shorter supply, to help support. Research has demonstrated 2019). LHWs, has been recommended as apoten- that LHWs can increase access to evidence- LHWs address disparities in services by tial remedy for inequities in health care based practices (EBPs), such as cognitive- supporting linguistically and culturally access (Orkin et al., 2019). Interventions behavioral therapy and parent training competent services, helping community focused on task shifting demand increased reliance on LHWs, whose positionsare not governed by licensing boards, training 1 The terms promotor/promotores and promotora/promotoras reflect the genderofLHW(s)based requirements, or established systems of on grammatical rules in Spanish. In thispaper,wepredominantly use promotora/s as all partic- remuneration. Without established poli- ipantswerefemaleidentified, which is common in thisworkforce. cies and regulatory frameworks, LHWs are

250 the Behavior Therapist promotoras de salud exposed to the arbitrary decisions of indi- network providestraining in being apro- aboutthe work promotoras had done,their vidual projects and agencies. It has been motor and coordinates projects with other role as promotoras, and culminated in a recommendedthat taskshiftingbeaccom- service sectors. With approximately 200 question abouthow LEEP might best sup- panied by significant policy and infrastruc- members, promotores,who are apredom- port the work promotoras were already ture developments in order to ensurethat inantly volunteer workforce, can provide doing with families. All interviews were LHWs are receiving adequate support, services in English,Spanish, and some also then transcribed and codedinSpanish by a training, and funding (Lehman et al., speak Mixteco and nahuatl (thelatter two coding teamofbilingual, bicultural gradu- 2009). Currently, although promotoras are nativelanguages within Mexico). Pro- ate students. Initial codingtook place using have developed robust organizations and motores serve families in the communityto apriori codes based on interview questions systems within their communities and provide education and connection to (e.g., engagement strategies) and also have successfully partnered with health resources in avarietyofmental health (i.e., allowed for the development of emergent care systems nationally, the infrastructure alcoholism, drug abuse) and physical codes (e.g., advocacy). An iterative consen- to support their work is often lacking health topics (i.e., diabetes, cancer, and sus process was utilized in which coding (Schneider &Lehmann, 2016). family violence prevention, emergency team members met regularly to establish a This paper will discuss how commu- preparedness, low-cost health insurance). final code book, discuss emergent codes, nity-partnered research and advocacy can Through hands-on experience, this net- and resolve any coding discrepancies be leveraged to mitigate the potential work’s mission is to “empower families and through dialogue untilconsensus had been exploitation of promotoras, avital but individuals with respect, dignity, and com- reached. Uponcompletion of coding,the- undersupported workforce within health passion by enhancing the quality of all matic analysis of co-occurring codes was care systemswho are increasingly playing a aspects of their livesthrough education and conducted using nVivo software. The- critical role in promoting health equity in the promotion of healthybehaviors” (Santa matic analysis involved aprocess of analyz- Latinx communities. Acommunity-acade- Barbara County Promotores network, ingthe quotes that emerged within specific mic partnered research project with uni- n.d., para. 1). Given the rangeofhealthand co-occurrences of codes (e.g., Advocacy + versity researchers and apromotora net- social issues addressed, promotores Community) to produce themes. Textual work will serve as an example to becomeinvolved in specific projects based analysis provided further insight into demonstratesteps researchers can take to on their interests. For the current project, themes such as advocacy. Advocacy learn about advocacy from promotoras, promotoras with ahistory and interest in emergedasamultifaceted theme, referring serve as advocates for promotoras, and to working with parents were approached by either to promotoras advocating for their ensure that their advocacy is directly the region’s lead promotora to participate. community or as arequest that the responsive to the promotoras’ expressed The Quality Implementation Frame- research team advocate for promotoras in needs. work (QIF) informed the study aims and order to supporttheir work. design (Meyers et al., 2012). The QIF out- The LEEP Project lines four phases for implementing new •Promotoras advocating for their com- interventions and programs, the first of munity.Promotoras discussed serving as Lay Health Workers Enhancing which is conducting athorough assessment advocates for their community, by hearing Engagement for Parents (LEEP) is an of needs, fit,and readiness for anew inter- the concerns of the individuals they serve nIMH-funded research study to develop, vention (Meyers et al., 2012). The frame- and either helping individuals voice their implement, and evaluate aLHW-delivered work recommends assessing the needsand needs or serving as an advocate for the intervention aimed at increasing Latinx resources of the organization and commu- individual. They discussed how helping parent engagement in PCIT (Barnett et al., nity in which anew intervention will be members of their community find their 2019).Inthis intervention, LHWs conduct implemented, as well as evaluating whether voiceswas agratifying part of their role as home visits to promote entry into and the intervention fitsthese needs and aligns promotoras: engagement in PCIT, whichisdelivered by with the organization and community’s professional providers in community preferences and values (Meyers et al.). This This was asuccessfor me because she could mental health agencies. LEEPisacommu- paper outlines the steps the LEEP team not raise hervoiceonher own. So Ihelped nity-partnered study with university took to understand the promotoras’ needs her, Iadvisedher abit, and this boostedher researchers, community mental health and preferences, beginning withqualitative confidence in herself and gave her the agencies, and alocal promotora network. interviews,and to provide advocacy shaped courage to report[domestic violence]. The LEEP intervention was developedcol- and informed by and directly responsive to laboratively with promotoras and agency their expressed requests. They also narrated stories about fami- leaders. The intervention was informed by lies who were unable to navigate educa- promotora knowledge of their community Qualitative Interviews tional and other systems independently needs and strategies they use to enhance As part of the first phase of the QIF, due to the many barriers they face, includ- engagement into services,aswell as agency qualitative interviews wereconductedwith ing language, time constraints, and work- awareness of mental health service provi- LHWs to understand the local contextand ing multiple jobs. Promotoras described sion within the community, and existing their training needs. Semistructured quali- how they were able to support familiesin intervention materials from apilot trial tative interviews were conducted by two navigating thesesystems, often serving as a (Barnett et al., 2016). bilingual, bicultural graduate students in voice in order to pave the way so that the The SantaBarbara County Promotores Spanishwith 15 Latina, Spanish-speaking familiesthey served wouldthen have aplat- network is acounty-wideorganization promotoras, who eachhad 1to20years of form on which to speak and be heard. A providing services to the community since experience serving in their promotora role promotora described helping asingle 2002 (SBC Promotoresnetwork; n.d.).The (M =4.29, SD =4.78). Questions inquired mother who was unable to attend parent-

October • 2020 251 klein et al. teacher meetings at school because of her presented in this paper and additional work schedule, and her inability to com- In addition to their frequent mention of themes related to engaging parents, and the municate with the teachers about her need the need for funding and public recogni- promotoras’ training needs, in order to for adifferent meeting time due to lan- tion and legitimacy, promotoras stressed ensure that their voices were being accu- guage barriers and uncertainty about their desire for additional training. Promo- rately represented in each theme. Their approaching aschool authority. The pro- toras described dedicating their personal feedback was incorporated into the results motora accompanied the mother to meet time to obtaining training in the commu- and additional thoughts and concerns with the principal and help advocate for nity on avariety of topics that may be per- emerged in dialogue between the promo- modified scheduling: tinent to their communities, including dia- tora network and the research team. betes education, Alzheimer’s education, During this meeting, the importance of Iwas only atranslator for [the mother], parenting,and more. However, due to their advocacy was further highlighted as the [she] wouldn’t speak and tell them her status as paraprofessionals, they reflected promotora network requested that univer- needs, [she] was afraid because they had on limited educational opportunities avail- sity researchersuse their privileged acade- told [her] this principal is very strict and able to them, particularly at no cost.They mic positions to advocate for increased that you can’t speak with her….but now repeatedly articulated the need for more integration of promotoras within health yousee what we achieved. trainings as demonstrated by the two equity projects and to support promotoras quotes below: in receiving the funding, training, sup- All of the advocacy activities the pro- ports, and recognition that they need in motoras described were based in the [You can support us by] giving us alittle order to continue their work. They specifi- expressedneeds of the families they served. more training to know how to give the cally requested that LEEP’s lead researcher The promotoras frequently mentioned the people what theywant. present the study findings to system lead- trust that they were able to establish, and ers (e.g., health caredirectors)onintegrat- the communication they were privy to as a Another promotora described the need ing promotoras into new projects and ini- result. Because community members trust for more training in the following way: tiatives in an equitable way. the promotoras, due, in part, to their Advocacy with the promotoras shared lived experiences, promotoras were You, as aschool [could help us] havemore included fully integrating them into the granted further insight into the advocacy access to your projects,… like how parents research project to make sure their voices needs of these community members. and children enrich each other, you and and expertise shaped the LEEP interven- [thepromotoras] can enrich each other…. tion and their roles. Promotoras who •Promotoras requesting advocacy.Pro- There are many things that we can learn, expressed interest in participating at a motoras identified several areas of their and there are many professional peoplein higher level in the project were invited into own need during the qualitativeinterviews. many fields who we can learnfrom,and do an Advisory Group, whichmet quarterly to They spoke at length about the personal many programs together. Because Ithink collaboratively discuss the needs that had benefits they derive in their role as promo- that you have themeans to do it, and this been identified through the qualitative toras,emphasizing their work as acompo- wouldbenefitboth the promotorasand the interviews and to develop the promotora- nent of their identity and the primary com- community, no? delivered intervention. In accordance with pensation being gratification at serving the promotoras’ expressedwishes for addi- their community. However, promotoras Thepromotoras expressedeagerness to tional training, atraining sequence was also voiced financial need, emphasizing develop and maintain partnerships that developed by the research team using a their desire to receive monetary compensa- will ultimately benefit their communities previous model for training LHWs and tion for their labor: and the families they serve.This quote also incorporating promotoras’ requests (Bar- highlightsthe multiple levels of supportive nett et al., 2016).Promotoras weretrained Ithinkwehavetovalidate allthe workthe collaborationand advocacy that permeate in providing LEEP care extensionservices promotora does, and also, we have to pay the work of promotoras. Promotoras for PCIT, as well as in conducting the promotora who does that job. Why? enable parents to support children and informed consent for parents. Training Because the fact of being apromotora does emphasized the expertise they have in was aimedatenhancing promotora knowl- not mean we don’thave needs. reaching families, while simultaneously edge of PCIT, addressing practical barriers expressing adesire to benefit from the to engagement, motivating parents for In addition to highlighting the impor- resources and training available from the treatment,modeling parenting skills taught tance of receiving financial compensation university researchers to enable them to in the program, and promoting homework for their work, promotoras discussed the support these parents. adherence. Advisory Group meetings need for legitimacy as aprofessional iden- ensured that promotoras’ knowledge of tity and recognition: Community-Partnered Activities their community’s needs, their own capac- Following the qualitative interview and ities, and their aspirations for the project Ibelieve they should prepare us better as thematic analysis, the LEEP research team were being regularly considered and incor- promotoras because as promotoraswehave presented its preliminary results to the porated into LEEP. Furthermore, the pro- alot of reach in the communityand many interview participants in acommunity motorasand research teamco-presented at times the promotora is not recognized and I meeting. The meeting was held at the pro- an annualconference for promotoras, led believe thepromotora should alsoget recog- motoras’ primarymeetingsite in order to by Vision yCompromiso, astatewide nized because now that Iamapromotora, I ensure accessibility, and feedback was agency providing training and support to seethat we havealot of reachinthe com- elicited from the promotoras on the quali- promotoras. At the conference, university munity. tative analyses, which included the themes research team members presented along-

252 the Behavior Therapist promotoras de salud side promotoras, who are members of they share. Disparities in access to services The promotoras’ descriptions of their LEEP’s advisory group,allowing bothpro- have led to increased focus on task sharing advocacy efforts and their direct requests motoras and researchers to present and to and collaborating with promotoras and shaped advocacy efforts that emerged from bolster one another’s voices. Promotoras otherLHWs who can addressthesedispar- LEEP. Promotoras described their role to gave direct input on theirexperiencescol- ities. Because infrastructure and systemsof the research team as abridge (“mi rol es un laborating with researchers and participat- support for the work of LHWs are fre- Puente”) between their communityand the ing in the LEEP project. quently limited, especially within formal services they need. Just as the promotoras described actingasabridgebetweentheir Advocacy With Health Care Leaders systems of care, it is pertinent that researchers, agencies, and academic insti- communities and medical and mental In response to the promotoras’request tutionswho work with LHWs work to health services, they requested that the that qualitative results be shared with other develop such supports by both providing research team serve as abridge between system leaders, research team members them and advocating for policies to their network and the larger legislativesys- presentedatalocal eventthatwas intended enhance theirwork. This advocacy has the tems that impact the policy landscape. to helpresearchers and other system lead- potential to improve training, supervision, ers (e.g., hospital administration) learn recognition,and compensationfor promo- References about how to integrate promotoras into toras, which may help address the potential research and service projects with alens on Ayala,G.x., Vaz,L., Earp, J. A., Elder,J. for exploitation and burnout within their equity. The need fortraining, supervision, P., &Cherrington, A. (2010). Outcome efforts to address mental health needs in effectiveness of the layhealth advisor and compensation were all discussed in a theircommunities. modelamong Latinosinthe United panel that included researchers, promo- States: An examination by role. Health toras, and other system leaders, who had Advocacy efforts must be informed by theexpressed desires of promotoras and Education Research, 25(5),815–840. successfully worked with promotoras. https://doi.org/10.1093/her/cyq035 should be directly responsive to their Advocacy to State Legislators requests, particularly since university Barnett,M.L., Davis,E.M., Callejas, L. M., White,J.V., Acevedo-Polakovich, I. D., In order to continue responding to the researchers may not be members of the niec, L. n., &Jent, J. F. (2016). The needs voiced by the promotoras and to group they are advocating on behalf of. development and evaluation of anatural their requests for advocacy by their univer- Within their interviews, promotoras high- helpers’training program to increase the sity partners, LEEP’s lead researcher pre- lighted the core components of the advo- engagement of urban, Latina/o families sented at The California Initiative for cacy they partake in on behalf of theircom- in parent-child interaction therapy. Chil- Health Equity and Action (Cal-IHEA)’s munity, with an emphasis on establishing dren andYouth Services Review, 65,17– Workforce Innovation Briefing, an evi- trust, listening to the voices of the families 25. dence-briefing for legislative staff and they serve, and either supporting their Barnett,M.L., Gonzalez,A., Miranda,J., advocacyorganizations focusedoninform- community in voicing their own needsor Chavira, D. A., &Lau, A. S. (2018). ing policy to strengthen health care in Cal- serving as avoice only when the individuals Mobilizing community health workers to ifornia by supporting front-line workers address mentalhealthdisparities for they serve were unable to do so on their underserved populations: Asystematic such as LHWs. Communicating research own. LEEP attempted to follow these review. Administration andPolicy in to policymakers is acritical component of guidelines, developing partnerships with MentalHealthand MentalHealth Ser- the advocacy workpsychologists canpar- promotoras,ensuring that their needs were vices Research,45(2), 195–211. ticipate in (Emmons &Gandelman., 2019; being understood through ongoing dia- https://doi.org/10.1007/s10488-017- Purtle et al., 2017).LEEP’s lead researcher logue and feedback, presenting at their 0815-0 communicated the study’s findingstopol- request, and presenting alongsidethem so Barnett,M.L., Lau, A. S., &Miranda, J. icymakers after discussing themwith pro- that bothsides of the academic-promotora (2018). Layhealth worker involvement in motoras in ordertoensureaccuracy of rep- partnership were being voiced and heard in evidence-basedtreatment delivery: A resentation. The findings focused on the tandem. conceptual modeltoaddressdisparities need for financing, certification, and train- in care. AnnualReview of Clinical Psy- Many of the requests for advocacy that chology, 14,185-208. ing in order to support the promotoras’ the promotoras voiced in their qualitative ongoingservice to their community.Policy Barnett, M., Miranda, J., Kia-Keating,M., interviews align with recommended steps Saldana,L., Landsverk,J., &Lau, A. S. recommendations in the presentation in the QIF,includingadesire for additional includedestablishing infrastructure to sup- (2019). Developing and evaluating alay training, support, funding, and certifica- health workerdeliveredimplementation port this vital workforce and ensure that tion (Meyers et al., 2012).These concerns interventiontodecrease engagement dis- they can continue to promote health raised by thepromotoras are not only vital parities in behaviouralparenttraining: A equity. to their work and ability to serve their com- mixedmethods study protocol. BMJ munity, but are critical within multiple Open, 9(7). https://doi.org/10.1136/ Conclusion phases of the QIF, which emphasizes build- bmjopen-2019-028988 Promotoras are uniquely situated to ing capacity for the implemented interven- Emmons, K. M., &Gandelman,E.(2019). tion by maintaining and training staff,fos- Translating behavioralmedicine evi- facilitate engagement and access to health, dence to publicpolicy. Journal of Behav- mental health,educational,and parenting tering asupportive climate, providing ioral Medicine, 42(1),84–94. services for Latinx families, in part due to assistance and supervision, and ensuring https://doi.org/10.1007/s10865-018- the trust they engenderintheir communi- ongoing support. In order to make LEEP 9979-7 ties.The factorsthat enable them to build responsive to the communityand sustain- Gustafson, E. L., Atkins, M.,&Rusch, D. trust and effectively support Latinx com- able over time, advocacy efforts emergedas (2018). Community health workers and munities are frequently vulnerabilities that acritical component of the project. social proximity: Implementation of a

October • 2020 253 parentingprogram in urban poverty. SCIENCE FORUM American JournalofCommunity Psy- chology,62(3–4),449–463. https://doi.org/10.1002/ajcp.12274 Mobilizing Mental Health Training Efforts to Lehmann,U., VanDamme, W., Barten, F., &Sanders, D. (2009). Task shifting: Align With Advocacy for Disenfranchised The answertothe human resources crisis in Africa? Human Resourcesfor Groups in Global Contexts: Trauma-Related Health, 7(1), 49. https://doi.org/10.1186/1478-4491-7-49 Training in the Caribbean as an Example Meyers, D. C.,Durlak, J. A., &Wanders- man,A.(2012).The Quality Implemen- tationFramework: Asynthesis of critical Anu Asnaani, University of Utah steps in the implementation process. American Journal of CommunityPsy- Su-Anne R. Charlery White, HERStoire Collective, Castries, chology, 50(3–4), 462–480. https://doi. Saint Lucia org/10.1007/s10464-012-9522-x Orkin, A. M., McArthur, A.,Venugopal, Tammi-Marie Phillip, Butler Hospital, Providence, RI J., Kithulegoda,n., Martiniuk, A., Buch- man,D.Z., …Upshur, R. (2019).Defin- ingand measuring health equity in research on taskshifting in high-income THECARIBBEAn,aregion comprised of 13 agement to these overburdened providers countries: Asystematic review. SSM - sovereignstates, 17 dependentterritories, (Caldas de Almeida &Horvitz-Lennon, Population Health.https://doi.org/10. and approximately43million persons, rep- 2010; Jareroetal., 2014). Another barrier to 1016/j.ssmph.2019.100366 resentsanarea rich in diversityofall forms. more widespread dissemination of evi- Purtle, J., Brownson, R. C., &Proctor, E. While this region has made significant dence-based practices (EBPs) in particular K. (2017). Infusing science into politics strides in anumber of health care sectors, has been aglaring lack of resources related andpolicy: The importanceoflegislators mental health progress has fallen behind. to conductinghigh-quality research on fac- as an audience in mentalhealth policy Historically, theCaribbean region followed tors impacting EBP utilization or imple- disseminationresearch. Administration the British model of mentalhealth delivery, mentation in this region (Razzouk et al., andPolicyinMental Health andMental HealthServices Research, 44(2), 160–163. initially focusing on institutionalization 2008; Sharan et al., 2009), which further https://doi.org/10.1007/s10488-016-0752-3 and then later de-institutionalizationonce impedessystematic roll-outsofEBPs in the Santa Barbara County Promotores net- more effective psychotherapeutic and psy- region. This, coupled with the low num- work(n.d.). Aboutus.https://sbcpromo- chopharmacologic interventions became bers of providers (psychiatrists/psycholo- toresnetwork.weebly.com/about.html available (Hickling&Gibson, 2005). This gists, psychiatric nurses, and social work- Schneider, H.,&Lehmann, U. (2016). model, however, remained highly central- ers), has led to limited access to effective Fromcommunity health workers to ized to mental health hospitals and major treatments in the area (Caldas de Almeida community health systems:Time to cities within the region, with limited out- &Horvitz-Lennon,2010). widenthe horizon? Health Systems & reach andcommunity-based mental health The current lack of legislation and Reform, 2(2), 112–118. resources, apattern that continues to exist national oversighttoprovide services and https://doi.org/10.1080/23288604.2016. today. Areport published by the World to protect the rights of those with mental 1166307 Health Organization (WHO) found that health disorders in the Caribbean further Sharma, n., Harris,E., Lloyd, J., Mistry, S. although roughly one quarter of the total compounds these issues. For instance, K., &Harris,M.(2019, December 17). disease burden in Latin America and the SaintLucia, an independentisland nation Community health workersinvolvement in preventativecare in primary health Caribbean is due to mental or neurological in this region(and one of the main coun- care:Asystematicscoping review. BMJ disorders, countries within these regions, triesoffocus in this article), has none of the Open.https://doi.org/10.1136/bmjopen- on average, only spendabout 4.3% of their following:mental health policies outlining 2019-031666 health budget on mental health (World triage of services, strategic plansthatout- Health Organization, 2011). More recent line national mental health education or ... studies have actually put this number awareness campaigns, legislation that pro- closer to 2%, onlythe minority of which is tects the rights and safety of individuals no conflicts of interest to disclose. allocated to outpatient, community mental seeking mental health treatment, or an Thisstudy was supportedbyK01MH110608 health centers (Phillip, 2017). overarching national mental health awarded to MLB. Additionally,the prepara- As aresult of this limited budgetary authority/council. These deficits exist even tion of thisarticlewas supported in partby allocation for mental health care systems, thoughseveral documents to address some the Implementation Research Institute(IRI) the treatment infrastructure across the of thesedeficiencies have been drafted (but at theBrown School, Washington Univer- Caribbean remains deficient. Specifically, not enacted)inthe past decade (Francis et sityinSt. Louis, through an award from the there is alack of governmental funding to al., 2018). Current governmental budgets national Institute of Mental Health (R25 support agreater network of providers for mental health cater primarily to emer- MH080916).MLB is afellowofIRI. (who are, as aresult,very overburdened in gency or disaster situations, with little pro- Correspondence to Corinna Klein, these settings; WHO, 2011),and relatedly, visions for thedaily mental healthcare of Gevirtz School,University of California, alack of funding to provide essential train- the citizens (WHO, 2009), similar to the SantaBarbara, CA 93106;[email protected] ing in effective treatments and crisis man- majority of other countries in this region

254 the Behavior Therapist trauma- related training in the caribbean

(WHO, 2011). Of most concern, these the current state of the poor mental health crucial (Desai et al., 2019; Kirmayer &Ped- reports highlight the fact that the vast legislation and treatment infrastructure in ersen, 2014).Several advocacy frameworks majority of the countriesinthe Caribbean this globalsetting, we believedthat it was of have emerged to guide psychologists to last updated their mental health legislation paramount importance to establish apart- conduct suchwork, such as one by Hodges prior to the 1960s, which predatesthe cur- nership between research scientists (who and Ferreira (2013) that identified three rent conventions for human rights. have psychological science expertise on levels of policy work (provider-, system-, This legislative weakness in ensuring implementation of EBPs) and regional and funder-levels) along with five action the protection of humanrights is particu- advocates (who have public health and domains (Intervention Intent, Communi- larly worrisome given that there still exist, policy expertise) to makeimplementation cation, Administrative Leadership, Staff quite prominently, laws that criminalize efforts in the region maximally effective Development and Support, and Evalua- whole subsections of the population— and culturallyresponsive. tion) at which advocacyefforts can be most specifically, those who identify as being successful. partofthe LGBTQ+(lesbian, gay,bisexual, Establishing Advocacy Partnerships As aresult of this call, the first author transgender, queer and related sexual or (A.A.), aclinical researcher working in out- gender minorities) community across the Given anumber of priority areas in patient- and community-based settings, region (Government of Saint Lucia, 2005; mental health, it is important to discuss started to follow the work of public health Human Rights Watch, 2018a; Jackman, here briefly why trauma-related psy- advocates and educators to better under- 2017). This ongoing criminalization of chopathology and training were chosen for stand how their expertise could be inte- LGBTQ+ citizens (specifically, with cur- the partnership we established with advo- grated into such advocacy frameworks to rent legal codes outlining 5- to 10-year cates for mental healthreforminthe region broaden the impact of treatment-oriented imprisonment terms for actual or even (thespecifics of which will be discussed in research studies in mental health. In the intended consensual sexual activity detail below). First, given very hightrauma summer of 2018, the workofaSaintLucian between two members of the same sex) has exposure rates across the Caribbean and public health advocacy group dedicated to led to anotable number of individuals flee- world (Benjet et al.,2016), coupled with a improving the sexual and reproductive ing the region to seek asylum in the United fairly significant proportion of trauma- health (SRH) of women in the region, the Statesand Europe where there are human exposed individuals going on to develop HERStoire Collective (www.herstoirecol- rights in place to protect members of this posttraumaticstress disorder (PTSD)ora lective.com), was very visible on social community (Alessi, 2016; Phillip & number of other mental health problems media. Specifically, the founder and Execu- Williams, 2013). Governing bodies have (e.g., generalized anxiety, specificphobias, tive Director of this organization (second argued that while these laws are technically depression, substance use; Asnaani et al., author S.R.C.W.) was effectively utilizing in place, they are not enforced. However, 2010; Himle et al., 2009; Kessler et al., 2012; social media platforms to provide educa- the fact that no antidiscrimination laws Pilgrim &Blum, 2012; Sabri et al., 2013), tionabout important SRH issues,publiciz- exist to protect these individuals or to this area was regarded by public health ing efforts to change legislation and ser- buffer ongoing stigma towards individuals advocates and providersonthe ground as vices for SRH in the region, and had made identifying as LGBTQ+ means this group an important area for collaboration for the arequest for those interested in various is stillatconstant risk for real threats to Caribbean region. notably, there exists relatedfields to provide more expertiseand their safety by Caribbean societies at large robust evidence for psychological treat- support of these efforts. Thus, the authors (Human Rights Watch, 2018a, 2018b). ments for trauma-related symptoms, with of this paperstarted adialogueaboutcol- needless to say, the lack of legislation pro- significant support for cognitive behavioral laborating on ongoing projects. tecting human rights violations towards treatments (CBT)for PTSD symptoms in At this time, the organization was the LGBTQ+ population (and others, particular(one of the most common psy- engaged in piloting the Sister2Sister(S2S) specifically women and youth; United chological sequelae following trauma expo- Virtual Safe Space Program as adigital nations Development Programme,2012), sure; American Psychiatric Association, platform to address the significant gaps combined with the lack of mental health 2013).Finally, giventhe well-documented existing in SRH resources and service legislation,creates significant concernfor higher rates of trauma and subsequent delivery in Saint Lucia (and the wider those individualswith mental health disor- mental health burden in the youth,women, Caribbean), particularly for marginalized ders in such vulnerable communities in the and LGBTQ+individuals in the Caribbean young women who identified as victims of Caribbean. specifically(Asnaani et al.; Himle et al.; Pil- abuse/violence, LGBTQ+, as engaging in Othercomplicatingfactorsunderlying grim &Blum), this area was deemedtobe transactional sexual activities, or belonging thesedeficient mental healthlawsinclude an important focus of mental health advo- to other vulnerable groups. S2S was jointly ongoing stigma about mental health more cacy and education. funded by the Caribbean Vulnerable Com- broadly (i.e., that expressing mental health It is also important to acknowledge that munities Coalition(CVC) and the Organi- concerns is asign of weakness or other the current partnership described in this sationofEastern Caribbean States(OECS), moral failing) in this region (Dudley- paper came from agrowing call from col- under the Global Fund’s Safe Space and Grant, 2016; Yorkeetal., 2016), low treat- leagues in the public health domain for Service Access Grant for Marginalized ment-seeking rates for mental health (Pan clinical researchers to engage in direct Youth in the OECS. The pilot initiative, American Health Organization & social justice and advocacy activities deliveredoverthe span of 9months, pro- Caribbean Community [CARICOM] Sec- (Horne et al., 2019). In order to more vided an integrated educational program retariat, 2006), and disparate access to appreciably address the inordinate and that consisted of 14 virtual psychosocial mental health care in various parts of this well-documentedmental healthdisparities support group sessions covering arange of island archipelago (Sharpe &Shafe, 2015). in underresourced and underrepresented pertinent SRH and associated mental Thus,given these various factors impacting communities, this type of engagement is health topics. These safe space virtual chats

October • 2020 255 asnaani et al. were moderatedbytrained expertsinthese the knowledge exchange (Campbell et al., ation leadersfrom 6other countries (Saint content areas (such as authors S.R.C.W. 2004). As aresult, HERStoire (specifically, Vincent, Grenada, Antigua, Jamaica, Bar- and A.A.),who would also provide helpful author S.R.C.W., as aseasoned public bados, and Trinidad). The HERStoireCol- external resources during the virtual sup- health educator) and the speakers (authors lective was instrumental in tappinginto its port sessions,archived on HERStoire web- A.A., alicensed psychologist, and T.M.P., professional regional network to broaden site for later reference by attendees. an attendingpsychiatrist)devised a1-day the reach of this second workshop. The program primarilytargeted young workshop program that took in this advise- Funding womenaged 16–24 years old in Saint Lucia, ment to determine the final topics: psy- who possess limited access to SRH and choeducation on types of trauma and typi- It is important here to briefly mention related mental health services. Importantly, cal posttrauma reactions, informational the role of funding, given its relevance to this intervention utilized and bolstered session on evidence-based PTSD treat- establishing and maintaining partnerships existing mental health infrastructure by ments (specifically, Prolonged Exposure, with advocacy groups, particularlyinlow- partnering with existing organizations PE; Foa et al., 2007), hands-on skills train- resourced settings or non-federally-funded such as PROSAF, aregistered support ser- ing for short-term strategies to handle research areas. This first workshop was vice provider for survivors of abuse and immediate trauma crisis (e.g., breathing partially funded by alocal corporate finan- trauma in St. Lucia. Relevant funding agen- retraining, distress tolerance skills), and a cial institution and hotel venue willing to cies, local and regional body stakeholders, final session dedicated to self-carepractices donate space and technical equipment to as well as the beneficiaries of the program with small group break-out discussions on us, and all remaining costs were covered by considered the pilot to be highly successful ways to engage in regular self-care to the firstauthor’s general research funds so in meeting both the SRH and associated reduce burnout. Provision of suchanedu- that there was absolutely no cost to atten- mental health needs of young women, by cationalsession to arange of stakeholders dees of the workshop, alongwith meals for providing those who accessed the virtual wasdeemed consistent with recommended the day free of charge. However,this lim- safe space with credible and sound SRH advocacy workatthe provider level, target- ited funding in the first workshop, given related information,resources and referral ing the intervention intent and staff devel- the no-cost model for attendees, greatly systems, as wellasconfidentialand respon- opmentdomains (Hodges &Ferreira, hindered our ability to accept the majority sive psychosocial support. Consequently, 2013). Such atraining also closely followed of interested providers. the OECS has deemed this pilot program to work highlightingthe significant utility of The HERStoire Collective was vocal in be aBest Practice for the region, and the educational interventions as an advocacy sharing the success of this first workshop HERStoire Collective has since received tool to effect meaningful change in com- and strongly advocated for asecond work- commitments from local and regional munity mental health settings (Ponce et al., shop to be part of aregionally funded pro- partnerships to expand the reach of the 2019). ject provided by the Equality and Justice program to several other Caribbean Alliance (EJA), in order to obtainfinancial nations, via integrated mobile technology Recruitment support to provide this training to those innovation. The first scheduled workshop (held in who had been wait-listed for the firsttrain- March, 2019) was advertised amonth ing, among others. EJA is acoalition pro- Project Implementation before the workshop via an emailed flyer to ject across several human rights organiza- the leadershipofvarious relevant associations based in the United Kingdom that is Content Determination tions/organizations (e.g., medical nurses, dedicated to supportingcivil societies and Given HERStoire’s success with the S2S psychiatric providers, school counselors, legislative reform that ensuremore expan- program and with working with other advocacy groups, and governmental health sive antidiscrimination laws (specifically providers/advocates suchasPROSAF and educatorsinSaint Lucia; for more detailed towards women and LGBTQ+ individuals) governmental bodies in the region(includ- information on methods, see Asnaani et al., in specific Commonwealth countries. To ing the Bureau of HealthEducation at the 2020). Despite some 100 requests to attend this end, this coalition launched afunded Ministry of Health and Wellness in St. within the first 2weeks of recruitment, we initiative across multiple countries in the Lucia), we decided to leverage these con- could only offer 45 participants aspot to Caribbean regioninthe spring of 2019to nections to assess specific mental health attenddue to funding constraints,but we specifically encourage the development of training needsacross arange of stakehold- prioritized attendance from amaximal aunified advocacy strategy across the ers involved in mental health support in the range of stakeholders representing some19 region to support national-level activities region. Leaders of these groups noted the different organizations/associations on the that could inform legislative reform efforts, need for more training around trauma- island. We then offered asecond workshop with mental health reform recognized as related issues, and further highlighted the in February 2020 to those who had not one of the three key areas in need of utility of providing practical tips for sup- been given an opportunity to attend the improvement in this region. Our teampre- porting traumasurvivors in crisis. In addi- first one, and were able to increase our pared ajoint proposal to apply for this seed tion, PROSAF was forthcoming about a capacity to 60 in-person attendees. Fur- funding (another advocacyaction recom- high rate of burnout in those providing thermore, to expand the reach of this train- mendation; Ponce et al., 2019), for which supportfor survivors in variouscapacities, ing and mobilize other partners in the we received the funds to hold the second and thus requested that the team ensure broader region, we were able to offer this workshop. Importantly, to better meet the provision of training in self-care. second workshop as concurrent remote objectives of this seed grantand the fund- An important feature of effectivecollab- training(via the online platform Zoom) to ing body (EJA), we added some pre- and orativepublic health initiatives is the inclu- an additional 12 participants who identi- postworkshop questions to assess change sion of community partners (such as these fied as advocacy group leaders, clinical in stigma towards women and LGBTQ+ advocacy groups) as equal contributors to researchers, therapists,and medical associ- individuals, and incorporated abrief

256 the Behavior Therapist trauma- related training in the caribbean formal presentation with testimonials by holder groups, which our team collated cant (and tangible) improvements in two invitedLGBTQ+ activists from alocal and distributed to all attendees. mental health legislation. advocacy group (United and Strong), who Another major deliverable from these provided education on key terms and trainingswas the provisionofwidely used Challenges to Advocacy- issues surrounding mental health for this (in the U.S., at least) psychometrically PartneredWork community, which proved to be avery sound self-report questionnaires for PTSD powerful addition to the originalcontent. in adults (namely, the Posttraumatic Diag- As theprocess described above for this nostic Scale for DSM-5; Foa et al., 2016) advocacypartnership demonstrates, there Outcomes and children (namely, the Child PTSD is apotential for greater impact of our work All participants completed pre- and Symptom Scale for DSM-5; Foa et al., as clinical trainers and researchers as a postworkshop questionnaires generated by 2018), to equip providers with betterways result of systematicpartnership with advo- our team assessing changes in knowledge to assess for PTSD in those theysupported. cates and engagement in social justice about trauma and effective treatments for In addition, slide copies, handouts for skills activities. That said, this work is certainly PTSD, stigma towards survivors, and self- taught and self-care, and some publicly not without its significant challenges. By care knowledge/practice. Of the 95 individ- available psychoeducation handouts were sharingthesehere,itisour hope that they uals who attended both workshops, 93 of provided to all attendees for use as needed serve as considerations (and not deter- these individuals provided informedcon- with their clients (or for themselves). rents) to colleagues engaging in similar sent for thesedata to be examined, and the Finally, amajor deliverable from the work. second workshop in particular, given its analytic approach andspecificresults of the Limited Funding primary fundingbythe EJA and their man- first workshop have been discussed in As mentioned already, inadequate detail elsewhere (Asnaani et al., 2020). date to advocate for mentalhealth reform in the region, was the presentation of the funding from legislative bodies continues Briefly here, the datarevealedthat partici- to be amajor challenge to doing such work. pants from both workshops found the preliminary results of the second workshop by second author S.R.C.W. within days of it While obtainingresearch funds fromfed- trainings to be overwhelmingly helpful in eral or privatefoundations is itself no easy adding to their knowledge on effective and occurringtoaregional body plenary session heldinthe first week of March, 2020. undertaking, looking for financial support evidence-based treatments for trauma. In During this session, it was made clear that for mental health efforts related to policy or addition, participants reported signifi- to address existing intersectionality in vul- legislation change can feel like an even cantly improved understanding around nerablepopulations such as women,girls, taller order. It was because our team could definitions of trauma, and lower stigma and members of the LGBTQ+community, fund the first workshop with some combi- towards trauma survivors, all of which it would be beneficial to capitalize on the nation of corporate sponsorship andgen- were promisingindicators of the utility of involvementand organic creation of work- eral research funds (greatly limiting the such atraining endeavor in this global con- ing groups in the mental health realm with number of attendees as aresult) that we text. Participants also found the self-care members representing the diverse mental had enough data to justify inclusion in the module particularly helpful in addressing health needs of key populations. It was funding initiative offered by the EJA, burnout. strongly suggested by the regional public allowing us to hold asecond workshop. health advocates and legal representatives Indeed, with each passing success and Advocacy-RelatedDeliverables attending this plenary session that intra- impact on policy/legislation, the likelihood An importantaspect of broadening the and inter-country working groups be of additional funding increases. However, impact of training and research public established in order to yield significant to initially build this momentum, it health efforts in such global settings is to improvements in mental health legislation. requires monetary infusion from some- have concrete and well-defined deliver- Specifically,this would entail having advo- where outside of traditional outlets. Even cates in these workgroups use the results in the second workshop, additional corpo- ables to provide to the community, fromthisproject,and othersthatwere con- rate sponsorship and engagement with providers, and legislators/policymakers currently occurring across the region over local vendors to increase awareness and looking to make achange in their ser- the course of the 1-year EJA initiative, to on-the-ground support were key, but this vice/approach(e.g., Valdez et al., 2019). As inform strategies that advance mental endeavor can feel foreign to those of us aresult, there were severalkey deliverables, health legislation at local and regional based in the U.S., where such corporate some previously defined and some that levels. These strategies include identifica- sponsorship is not always the norm for our emerged as potentially useful. For instance, tion of key mental health training targets, work as psychologists. during the first workshop with so many stakeholder groupstopartner with in each different stakeholders in the room, it was country, availability and accessibility of Credibility and Media Exposure clear from group discussions that there currently offeredservices,and ongoing sit- Anotherobstacle faced during this pro- were many more resources available to uations where the rights of those seeking ject was creating buy-in from leaders of trauma survivors and their providers than mental health services are threatened. various health care systems in the region, each individual group/organization was These workgroups’ efforts in synthesizing several of whom were reticent to engage aware of. Thus, one deliverable that was these data and engaging in ongoing dia- with aresearcher who actually originates not initially conceived in the first work- logue on mental health are intended to from the region (as firstauthor A.A. does). shop, but came about organically, was the result in the ability to provide stronger, That is, we surprisingly learned thatthere creation of agroup-think resourceguide of documented, and evidence-supported is actuallymore inherent trust and belief of local mental health treatment and support arguments for these teams to present to credibility in foreigners wishing to provide services provided by each of the stake- governing bodies to advocate for signifi- support to the region. In addition, this

October • 2020 257 asnaani et al. spilled over into the media exposure for as an example of how such apartnership tions in need?” It should come as no sur- this event (another featurewedonot typi- can work well. However, this project is still prise that the answer is aresounding “Yes!” cally prioritize when doing community- ongoing, andasitcontinues to grow,itis For too long, our field has relegated such based work stateside, but that is important important to continually assessthe impact efforts to those few who are “the ones who in such settings: building awareness of such apartnership. Thus, future direc- like to get involved in social justice issues in through TV and print media about such tions are framedmore readily as questions the community” and “are known for doing trainings to support advocacy efforts). around how to effectively continueengag- minority population work” while the rest Specifically, the trainers were purposely ing in this fairly unchartered territory. of us get to sit on the mainstream side of presented as “International doctors” by First, giventhe significantcurrent con- things, testing, innovating and, to put it some media outlets and then proudly troversy in our own training programs as bluntly—having our work miss the mark of hailed as “Saint Lucians returning home” psychologists and clinical researchers on actually making an impact where it counts by others, creating interesting, sometimes how (and whether) to integrate advocacy and where it is needed. opposing, optics around the expertise of and social justice issues into our profession Every singleone of us dedicated to evi- the speakers. (Ali &Sichel,2019), what are some of the dence-based practices should be thinking changes we need to systematically make about maximizing our impact in the Technical Limitations and Resources across our traditional training models to mental health realm by mobilizing our While the second workshop expanded encourage our current trainees to more efforts with thesebroader societalissues in the reach of the material to providers in the widely engage in such efforts? Surveys of mind (Chu et al., 2012).Otherwise, to use a region via the Zoom remote platform, clinical psychology doctoral candidates popular CBT metaphor, we are simply there were certainly associated challenges increasingly highlight adesire for greater puttingaband-aid over agushingwound with this addition. For instance, there was integration of diversity-focused issues of mental health disparities, considerably no ethernet wiredconnection in the hotel across the clinical and research training unequal human rights, and alimited venuewhere the workshop was beingheld, curriculum (Gregus et al., 2019), with bottom-upapproach to dissemination that and internet connectivity was quite incon- growing guidancethat we should explicitly has already been failing and will continue sistent as aresult, with frequent disconnec- include direct instruction on working with to do so. Some of our greatest strengths as tions and loss of sound/video feeds. In advocates and other stakeholders to build mental healthresearchersand practitioners addition, while the utilization of webinar- such competencies (Chu et al., 2012). have beenthe ability to be flexible, thought- style trainings is quite commonplace and Second, many global researchers and ful, and effective in our improvement of growing in popularity elsewhere in the implementation experts have recognized psychological science. Making the commit- world (Cummings, 2011; Matza et al., that simply rolling out mass training in ment to integrate this dimension of advo- 2015), this is amodalitythat individuals are EBPs in low-resource settings is not going cacy-partnered work wouldbewonderfully still learning to adopt more readily in the to suffice in terms of appreciably reducing in line with theseideals and has the poten- Caribbean region. That said, the partici- health disparities globally. That is, if the tial to appreciably broaden the impact of pants who did join on remotely werevery overall legislation, policy, and services what we do. actively engaged in discussions about the infrastructure do not support such training topics with the online moderator for the efforts,they are more likelytofail (Yorke et References entire duration of the workshop. al., 2016). As aresult,the onus is both on those of us who assess efficacy and effec- Alessi, E. (2016). Resilience in sexual and Other Cultural Nuances and Lessons genderminority forced migrants: Aqual- tiveness of EBPs, and for those of us who Finally, several other cultural nuances itative exploration. Traumatology, 22(3), push for the dissemination and implemen- to doing such work in thisspecific region 203–213. https://doi.org/10.1037/ tation of EBPs, to make the engagement included conforming to the preferred trm0000077 with local or national legislative or policy- mode of communication (i.e., use of the Ali, A.,&Sichel, C. E. (2019).Radicalizing making bodies amajor objective of what mobile application WhatsApp, and not advocacy in service settings: Using struc- we aim to do (Hodges &Ferreira, 2013; email,asaprimary modeofcommunica- tural competency to address tensions Horne et al., 2019). Working with advo- tion with most contacts on the ground), between social action and psychological cates to reach those top-down decision practice. PsychologicalServices. only providing informationthat is relevant makers is an effective and sometimes less https://doi.org/10.1037/ser0000382 to each sponsoring or partnering body intimidating way to reach such agoal. American Psychiatric Association.(2013). (versus giving the whole pictureofthe pro- Indeed,this project closelypartnered with Diagnosticand Statistical Manualof ject), and understanding the value of the MinistryofHealth and Wellness in St. MentalDisorders (5thed.). Arlington, important elements such as free training Lucia, with the hope that continued part- VA: American PsychiatricAssociation. and free provision of fully catered meals nershipwith such leadership (whooversee Asnaani, A., Charlery White, S. R., (another feature taken for granted in coun- the larger health care system in the coun- Majeed,I., &Phillip, T. M. (2020). tries such as the U.S., where providers often try) could be an effective way to take such a Trauma educationand stigmareduction self-pay). in globalsettings: An evaluation of the top-down approach. impactofaone-daytraumapsychoedu- FutureDirections This point is clearly related to the ulti- cation workshopwith communitystake- mate consideration as we move forward, holders in theCaribbeannation of Saint This paper presented adetailed account which is to ask ourselves, “Is it even our Lucia. International JournalofEnviron- of the logistics, implementation, chal- responsibility as psychologists and as clini- mentalResearch and Public Health, lenges, and benefits of engaging in a cal researchers to engage in such social jus- 17(7), 2255. research-advocacy partnership, with tice activities and advocacy efforts to Asnaani, A., Richey, J. A.,Dimaite, R., trauma-related training in aglobal context broadenthe impactofour worktopopula- Hinton, D. E.,&Hofmann, S. G. (2010).

258 the Behavior Therapist trauma- related training in the caribbean

Across-ethnic comparison of lifetime ChildPTSD Symptom Scalefor DSM-5 me/discriminatory-laws-against-lgbt- prevalence ratesofanxietydisorders. for trauma-exposed children andadoles- people-eastern-caribbean JournalofNervous and Mental Disease, cents. Journal of Clinical Child and Ado- Human Rights Watch. (2018b). Eastern 198(8), 551–555. https://doi.org/10.1097/ lescentPsychology, 47(1), 38–46. Caribbean: LGBT peoplefacebias, vio- nMD.0b013e3181ea169f https://doi.org/10.1080/15374416.2017.1 lence.https://www.hrw.org/news/ Benjet, C., Bromet, E.,Karam,E.G., 350962 2018/03/21/eastern-caribbean-lgbt- Kessler, R. C., McLaughlin,K.A., Ruscio, Foa, E. B., Hembree,E., &Rothbaum, B. people-face-bias-violence A. M., Shahly, V., Stein, D. J., Petukhova, (2007). Prolonged ExposureTherapy for Jackman, M. (2017).Protectingthe fabric M.,Hill,E., Alonso,J., Atwoli, L., PTSD: TherapistGuide.Oxford Univer- of society? Heterosexual views on the Bunting,B., Bruffaerts, R., Caldas-de- sity Press. usefulness of the anti-gay laws in Barba- Almeida, J. M.,deGirolamo,G., Flo- Foa,E.B., McLean, C. P., Zang, Y., Zhong, dos, Guyana and Trinidad andTobago. rescu, S., Gureje, O., Huang,Y., … J.,Powers,M.B., Kauffman, B. Y.,Rauch, Culture,Healthand Sexuality,19(1),91– Koenen, K. C. (2016).The epidemiology S., Porter, K., &Knowles,K.(2016). Psy- 106.https://doi.org/10.1080/ of traumatic eventexposure worldwide: chometricproperties of thePosttrau- 13691058.2016.1207806 resultsfromthe WorldMental Health matic Diagnostic Scale forDSM-5 (PDS- Jarero, I.,Artigas, L., Uribe, S.,&Miranda, Survey Consortium. PsychologicalMedi- 5). Psychological Assessment, 28(10), A. (2014). EMDRtherapyhumanitarian cine, 46(2), 327–343. https://doi.org/10. 1166–1171.https://doi.org/10.1037/ trauma recovery interventions in Latin 1017/S0033291715001981 pas0000258 America andthe Caribbean. Journalof Caldas de Almeida, J. M., &Horvitz- Francis,K., Molodynski, A., &Emmanuel, EMDRPracticeand Research, 8(4),260– Lennon, M. (2010). Mental health care G. (2018).Mentalhealthcare in Saint 268. https://doi.org/10.1891/1933- reforms in Latin America: An overview Lucia. BJPsych International, 15(1), 14– 3196.8.4.260 of mentalhealth care reforms in Latin 16. https://doi.org/10.1192/bji.2017.12 Kessler,R.C., Petukhova, M., Sampson, n. Americaand theCaribbean. Psychiatric Government of Saint Lucia. (2005). Crimi- A.,Zaslavsky,A.M., &Wittchen, H. U. Services, 61(3),218–221. (2012).Twelve-monthand lifetime https://doi.org/10.1176/ps.2010.61.3.218 nal Code. In Laws of SaintLucia (pp. 94– 95). prevalence and lifetime morbidriskof Campbell, C., Cornish, F., &Mclean, C. anxietyand mood disordersinthe (2004).Social capital, participation and Gregus, S. J.,Stevens, K. T., Seivert,n.P., United States. International Journalof the perpetuationofhealth inequalities: Tucker, R. P.,&Callahan, J. L. (2019). Methods in Psychiatric Research, 21(3), ObstaclestoAfrican-Caribbean partici- Student perceptions of multicultural 169–184. https://doi.org/10.1002/ pationin‘partnerships’ to improve training andprogram climate in Clinical mpr.1359 Psychology Doctoral Programs. Training mentalhealth. Ethnicity&Health, 9(3), Kirmayer,L.J., &Pedersen,D.(2014). and Education in Professional Psychology. 305–327. https://doi.org/10.1080/ Toward anew architecture forglobal https://doi.org/10.1037/tep0000289 1355785042000250120 mental health. Transcultural Psychiatry, Chu, J. P.,Emmons,L., Wong, J., Gold- Hickling, F., &Gibson, R. (2005). The his- 51(6), 759–776. toryofCaribbean Psychiatry.InF.W. blum, P., Reiser, R.,Barrera, A. Z., & Matza, A. R., Sloan, C. A., &Kauth, M. R. Hickling&E.Sorel (Eds.), Images of Psy- Byrd-Olmstead, J. (2012). Public psy- (2015).Quality LGBT health education: chiatry: the Caribbean. Kingston, chology:Acompetency model forprofes- Areviewofkey reports and webinars. sional psychologists in community Jamaica: University of theWestIndies. Clinical Psychology:Science and Practice, mental health. Professional Psychology: Himle,J.A., Baser, R.E., Taylor,R.J., 22(2),127–144. https://doi.org/10.1111/ Researchand Practice, 43(1),39–49. Campbell, R. D.,&Jackson, J. S. (2009). cpsp.12096 https://doi.org/10.1037/a0026319 Anxiety disorders amongAfrican Ameri- Pan American Health Organization, & Cummings, J. A. (2011). Technology in the cans, blacks of Caribbean descent, and CARICOMSecretariat. (2006). Report of practiceofSchool Psychology: The future non-Hispanicwhites in the United theCaribbean Commission on Health is past tense. In M. A. Bray&T.J.Kehle States. JournalofAnxiety Disorders, and Development. Caribbean Commis- (Eds.), TheOxford Handbook of School 23(5),578–590. https://doi.org/10.1016/ sion on Healthand Development.Ian Psychology (pp.831–859). The Oxford j.janxdis.2009.01.002 Randel Publishers. University Press. Hodges, S.,&Ferreira,K.(2013). AMulti- Phillip, D. K., &Williams, T. S. (2013). Desai, M. U., Bellamy, C.,Guy, K.,Costa, level Frameworkfor Local Policy Devel- Bullermen andZamis: The LGB West M., O’Connell,M.J., &Davidson,L. opment and Implementation.InA.Culp Indian’sPerspective. Journal ofLGBT (2019). “If you want to know aboutthe (Ed.), Child andfamily advocacy:Bridg- IssuesinCounseling,7(2), 143–153. book, ask the author”: Enhancingcom- ingthe gapsbetween research, practice, https://doi.org/10.1080/15538605.2013.7 munity engagement through participa- andpolicy (pp.205–215).Springer Sci- 85416 toryresearchinclinical mentalhealth ence +Business Media. https://doi.org/ Phillip, T. M. (2017).Telementalhealth in settings. Behavioral Medicine, 45(2), 10.1007/978-1-4614-7456-2_14 Latin Americaand the Caribbean. In 177–187. https://doi.org/10.1080/ Horne, S. G., Maroney, M. 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October • 2020 259 asnaani et al.

Ponce, A. n., Carr, E. R.,Miller, R., factors influencing mentalhealth help- other administrative tasks on the dayofthe Olezeski, C. L., &Silva, M. A. (2019). seeking attitudes amongBlackEnglish- workshopstomakesure they each ran Psychologists as educators:Creating Speaking Caribbean immigrants in the smoothly.Weare also very thankfulfor changeincommunity mental health. UnitedStates andBritain. SocialWork in Ifrah Majeed,the Research Coordinator at Professional Psychology: Research and Mental Health 14(2), 174–194. the TreatmentMechanisms,Community Practice, 50(6), 427–433. https://doi.org/10.1080/15332985.2014.9 Empowerment, andTechnologyInnova- https://doi.org/10.1037/pro0000253 43832 tions (TCT)Lab at theUniversity of Utah Razzouk, D.,Gallo, C.,Olifson,S., (PI: Asnaani)who spearheaded efforts Zorzetto,R., Fiestas, F., Poletti, G., Maz- ... related to administrative,data, andremote zotti, G., Levav,I., &Mari,J.J.(2008). Challenges to reduce the “10/90 gap”: implementation of the project(and prepara- Mental health research in Latin Ameri- tion of subsequent manuscripts fromthis canand Caribbean countries. Acta Psy- First, our deepest appreciation to theEqual- project), andwho oversaw the immense chiatrica Scandinavica,118(6),490–498. ityand JusticeAlliance (EJA; www.equali- efforts of anumberofdedicatedundergrad- https://doi.org/10.1111/j.1600- tyjusticealliance.org) forinvesting their uateresearchassistantsinthe lab, particu- 0447.2008.01242.x financialand technicalsupport resources larly Ally Askew, TraceyTacana, and Rachel Sabri,B., Stockman, J. K.,Bertrand, D. R., into the Caribbean region (and conse- Cole. Last, butcertainly not least, we would Campbell, D. W.,Callwood, G. B., & quently, our second workshop) in orderto liketodeeply thank allofthe stakeholders Campbell, J. C. (2013). Victimization trytoeffectlegislative changeand improve- and workshop attendees who were open to experiences, substance misuse, and ment of the rights of women andLGBTQ sharing their feedback about the workshop, mentalhealth problems in relation to risk community members in this geographical so thatwecan continuetoimproveand for lethality among AfricanAmerican location. In addition,the regional organiza- expandour advocacy efforts to improve the and African Caribbean women. Journal tion EasternCaribbean Alliance forDiver- mental healthofvulnerable populationsin of Interpersonal Violence, 28(16),3223– sity andEquality (ECADE; www.ecequal- 3241.https://doi.org/10.1177/ thisregion. 0886260513496902 ity.org) provided significantfinancial none of the authorsofthisstudy have support in thesecond workshop to cover Sharan,P., Gallo,C., Gureje, O., Lamberte, anyconflictsofinteresttodeclare in this E., Mari,J.J., Mazzotti, G., Patel, V., some of the other costs(such assnacks and study. Swartz, L., Olifson,S., Levav, I., De Fran- sometechnicalequipment), andnegotiated Correspondence to AnuAsnaani, Ph.D., cisco,A., &Saxena,S.(2009). Mental theprice of services with localvendorson DepartmentofPsychology, University of health research prioritiesinlow-and our behalf,for which we are very grateful. In Utah, 380 S. 1530 EBEH S502, SaltLake middle-incomecountries of Africa, Asia, addition,wewereable to providemeals for City, UT 84112; LatinAmericaand the Caribbean. British theday for all attendees inthis second work- [email protected] JournalofPsychiatry, 195(4), 354–363. shop, thanks to thegenerous financial, cater- https://doi.org/10.1192/bjp.bp.108.050187 ing, and staffcontributionsbyacompany Sharpe, J.,&Shafe, S. (2015). Mental based in Saint Lucia called JTCStore healthinthe Caribbean. In J. L. Roopnar- (www.jtcstore.com), which is an onlinedis- ine &D.Chadee (Eds.), Caribbean psy- tributorofethnicfoods servicing several chology:Indigenous contributions to a globaldiscipline (pp. 305–325). American islandsinthe EasternCaribbean. In addi- Psychological Association. tion,the Bank of Saint Lucia providedfinan- https://doi.org/10.1037/14753-013 cial supportfor both workshops, forwhich St.Lucia news Online. (2019). Regional we arethankful. Rights Group UrgeGov’ts to Denounce In termsofindividualsfromthe commu- Violence on the Basis of SexualOrienta- nity who made thispartnershippossible and tion. for whom we are deeply indebted:JessicaSt. UnitednationsDevelopmentProgramme. Roseand Milly Moses, fromthe St. Lucian (2012). Caribbean Human Development advocacygroup Unitedand Strong, who Report2012. were brave enough to present in oursecond Valdez,C.R., Rodgers, C. R. R., Gudiño, workshop to botheducate theproviders on O. G.,Isaac, P., Cort, n. A., Casas, M., & issuespertinent to theLGBTQ community Butler, A. M. (2019).Translating andshare theirown stories;natasha Lloyd- researchtosupportpractitionersin Felix,Director of the BureauofHealth Edu- addressing disparities in child and ado- cation in the Ministry of Health andWell- lescentmentalhealth and services in the ness (Government of Saint Lucia);Joycelyn UnitedStates. Cultural Diversity and Ethnic MinorityPsychology, 25(1),126– Eugene,Coordinatorofthe Guidance and 135.https://doi.org/10.1037/cdp0000257 CounsellingDivision withinthe Ministry of World HealthOrganization.(2009). Education(GovernmentofSaint Lucia), and WHO-AIMS Report on Mental Health Souyenne Dathorne, Founder of thePositive Systems in SaintLucia. Reactions OverSecretsand Fear(PROSAF), World HealthOrganization.(2011). for all of theirsupport and guidance WHO-AIMS Report on Mental Health throughoutthe project so far. Systems in the Caribbean. Further, theauthorswould like to thank Yorke, C. B., Voisin, D. R.,Berringer,K. theHERStoire Collectiveprogram volun- R., &Alexander,L.S.(2016).Cultural teerswho assisted with registration and

260 the Behavior Therapist ORIGINAL RESEARCH numerous studies have explored the relationship between close relationships and physical health. In the context of The Role of Advocacy in Adapting the Diabetes chronic physicalillnesses (e.g., T2D, HIV), involving romantic partners and other Prevention Program for Couple-Based Delivery family members in psychosocial interventions appears to lead to greater improve- That Reaches Marginalized Groups ments in adjustment than interventions delivered individually (Martire &Helge- Monique C. Aguirre, University of Utah son, 2017). Despite this, few programshave utilized close relationships in the preven- Heather Brown, Community Collaboration &Engagement Team, tion of chronic diseases through health Center for Clinical and Translational Science, University of Utah promotion programs (see Arden-Close & McGrath, 2017, forareview). Incorporat- Dana Gershenoff, Park Nicollet International Diabetes Center ing close others into the DPP has the potential to increase its effectiveness and Kristie L. Hinton, Urban Indian Center of Salt Lake extend its reach. Consistent with this, a recent studydemonstrated that those who Olivia M. Huntzinger, University of Utah signed up for the DPP with another member of their household were more Natalie Klein, Lifestyle Coach and Master Trainer Select likely to start, complete, and stay in the program longer than those who signed up Carmen Ramos, Office of Wellness and Integrative Health, individually (Ritchie et al., 2020). As the DPP does not directly focus on relation- University of Utah ships, and relationship functioning is closely linked with health (Kiecolt-Glaser O. Fahina Tavake-Pasi, National Tongan American Society &Wilson, 2017; Robles et al., 2014), an explicitfocusonrelationships is crucial for Brieanne Witte, Community Collaboration &Engagement Team maximizing the impact of the DPP when Center for Clinical and Translational Science, University of Utah delivered to couples. The prevalence rate of T2D is higher Marc Wolfsfeld, Calvary Baptist Church among underrepresented racial and ethnic groups compared with non-Hispanic Tamara Sher, The Family Institute, Northwestern University Whites (Chengetal., 2019). However, non- Hispanic Whites are more likely to attend Debra L. Simmons, University of Utah and Salt Lake City VA four or more sessionsofthe DPP and lose more weight on average than those from Timothy W. Smith, University of Utah other racial and ethnic groups (Ely et al., 2017).These healthdisparitiesreflect social Lauren Clark, School of Nursing, UCLA and economic disadvantage rather than essential differences based on race and eth- Katherine J.W. Baucom, University of Utah nicity (Braveman, 2014). To reduce health disparities among underrepresented racial and ethnic groups, it is importanttocare- 30 MILLIOn people in the stress and coping more broadly (CDC, MORE THAn fullyconsider social determinants of health United States suffer from Type 2diabetes 2018).During the first 4years of its imple- in collaboration with members of disad- (T2D), the seventh leading causeofdeath mentation(2012–2016), more than 35,000 vantagedgroups.Weparticularlywant to nationwide (Centers for Disease Control people at risk for T2D participated in the reach those from underrepresented racial [CDC], 2017). To address this significant DPP (Ely et al., 2017). Despite the strong and ethnic groups who are at higher risk publichealth concern,the CDC has imple- evidence base for the program, completion for T2D (Cheng et al.), yet are less likely to mented the nationalDiabetesPrevention rates remain relatively low in health care remain in—orbenefitfrom—the DPP rela- Program (DPP) Lifestyle Change Program. and community settings, with only 1in10 tive to non-Hispanic Whites (Ely et al.). The DPP aims to facilitateweight loss and participants who began the program com- Diabetes prevention efforts that are applic- reduce the riskfor T2Dthrough increased pletingthe full 22-session intervention (Ely able to awider range of individuals, partic- physical activity and improved nutrition. ularly those from underrepresented racial et al.). Social factors, particularly close The year-long programincludes 22 group and ethnicpopulations at heightened risk family relationships, play akey role in the sessions focused on methods for tracking of developing T2D, are critical to increas- and increasing physical activity, methods health behavior of individuals. The goal of ingthe effectivenessand reach of the DPP. for tracking and improving nutrition, nav- this article is to describe and evaluate the Givenwell-documented health dispari- igating challenges related to physical activ- use of aCommunity Advisory Board to ties in T2D among underrepresented racial ity and nutrition (e.g., maintaining activity adapt the DPP for delivery to awide range and ethnic groups,weare in the process of and healthyeating away from home),and of couples. designing an adaptation of the DPP that

October • 2020 261 aguirre et al. willbeapplicable to awide range of couples grant support from the nationalInstitutes racial and ethnic groups. Four CAB mem- at riskfor T2D. The World Health Organi- of Health (K23DK115820; UL1TR002538). bers are known to have prediabetes or T2D. zationidentifies advocacy as akey strategy The CAB was establishedincollaboration Last, two members of the CAB are acouple for achieving health promotion goals to with the University of Utah Center for coping with one partner’sT2D. The mean reduce health disparities (Carlisle, 2000). Clinical and Translational Science Com- age of the 12 CAB members is 50.3 years The current project utilizes advocacy in munity Collaboration and Engagement old (SD =13.1 years). The ethnic/racial health promotion by ensuring broad par- Team. This team contacted community identities of CAB members include ticipation of stakeholders in planning leaders from five organizationswithin the Latinx/Hispanic (n =4), Hawaiian (Carlisle, 2000). We createdapartnership SaltLake Valley to identify potential CAB native/Pacific Islander (n =3), White (n = between community membersand clinical members: Best of Africa, Calvary Baptist 3), and Black/African American (n =2). researchers usingCommunity-Based Par- Church, the Hispanic Health Care Task The CAB meets on amonthly basis to ticipatory Research (Wallerstein et al., Force, the national Tongan American discuss potential modifications to the 2017) methods. These methods were Society of Utah, and the Urban Indian CDC’s “Prevent T2” DPP curriculum. Pre- designed to reduce health disparities Center of Salt Lake. Relationships between vent T2 is an updatedversion of the origi- related to chronic disease through commu- the Community Collaboration and nal curriculum tested in alarge RCT nity engagement. Community Advisory Engagement Team and these community demonstrating the efficacy of lifestyle Boards (CABs) (newman et al., 2011) are a leadershave existedfor adecade as part of intervention in T2D prevention (Diabetes specific Community-Based Participatory CommunityFaces of Utah, acommunity, Prevention Program Research Group, 2002), and thus is the curriculum we chose Research tool for collaboration between university, and health departmentpartner- to adapt in the current study. Organiza- community members and researchers to ship(Drits-Esser et al., 2019). For the CAB tions recognized by the CDC to deliver the promote processes that are maximally ben- to be maximally effective, we sought to DPP may develop alternative curricula eficial and appropriate for members of the identify additional CAB members with provided they meet CDC standards (of community. Within health promotion, extensive professional expertise in the length,dose, content, focus) and have been CABs allow for the incorporation of acom- DPP. Towards this end, the principal investigatorcontacted colleaguesatorgani- approved by CDC (CDC, 2018). munity’s voice in advocatingfor and shap- Amember of the Community Collabo- ing the development of an intervention zations recognized by the CDC to deliver the DPP. ration and Engagement Team with exten- (Carlisle; newman et al.). In doing so, com- sive group facilitation training facilitates Members of the CAB include lifestyle munitymembers have asignificant role in each meeting, although the principal inves- coaches delivering theDPP, mastertrain- the process of developing amoreappropri- tigator of the project has taken amore ers with extensive lifestyle coach experi- ate and effective intervention for their active role in co-facilitationover time. The ence who train facilitators to deliver the community. In the current paper, we current adaptation of the DPP is based on DPP,and community health workers who describe and evaluate the nIH-funded, Resnicow et al.’s (1999) model of cultural have been professionally involved with Couple-Based DiabetesPrevention CAB. sensitivity in public health. A“surface T2D prevention and management in their structure” approach to cultural sensitivity community. The master trainers and Couple-Based Diabetes refers to the broadanalysisofsurface-level PreventionCAB lifestyle coaches haveexperiencedelivering concerns regarding racial, social, and cul- the DPP in afamily context (e.g., teaching tural differences in order to expand the The Couple-Based Diabetes Prevention classesthat include multiple family mem- structure and delivery of agivenprogram CAB was formed in January 2019 with bers) and to members of underrepresented to awider range of individuals (e.g.,updating pictures, stories, and examples) (Resni- cow et al.). A“deep structure” approach involves amorein-depth consideration of Table 1. CAB Meeting Topics the factors that influence healthbehavior in aspecificpopulation (Resnicow et al.). As Meeting Topics our goal was not to target any one group, 1Overview of CAB: Introductions, CAB Summary we utilize asurface structure approach to 2Prevent T2 Module Review: Program Overview cultural sensitivity in our adaptation of the 3Prevent T2 Module Review: Introduction to the Program Prevent T2 curriculum to couples across 4Prevent T2 Module Review: Get Active to Prevent T2 race, ethnicity, and culture. 5Prevent T2 Module Review: Track Your Activity The goal of each CAB meeting is to col- 6Prevent T2 Module Review: Eat Well to Prevent T2 &Track Your Food lect feedback on changes to the DPP that would extend its reach to awide range of 7ReviewofEdits: Program Overview couples. The week prior to each meeting, 8Prevent T2 Module Review: Get More Active &Burn More Calories Than CAB membersreceivethe meetingagenda You Take In and materials for review, along with the 9ReviewofEdits: Introduction to the Program minutes from the previous meeting. As 10 Prevent T2 Module Review: Manage Stress &Find Time for Fitness Table 1illustrates, meetings alternate 11 Review of Edits: Get Active to Prevent T2 between review of Prevent T2 modulesand 12 Review of Edits: Track Your Activity review of edits madebythe research team 13 Prevent T2 Module Review: Cope with Triggers &Keep Your Heart Healthy based on feedback from previous CAB 14 Review of Edits: Eat Well to Prevent T2 &Track Your Food meetings. CAB members come to each

262 the Behavior Therapist diabetes prevention meeting prepared to provide feedback cen- and facilitator organization (meeting inductive descriptive approach (Saldaña, tered around two overarching questions: length,communication from and prepara- 2016). The coding was reviewed and dis- (1) Are there additions needed to increase tion by facilitation team) as wellasthe per- cussedwith the last author, and finaltopics the relevance/appropriateness for couples sonalvalue of the meeting (e.g., if beneficial and topiclabels were determined through across communities? and (2) Are there connections were made with others,what consensus. The University of Utah IRB potential issuesdiscussing materialwith a made participation worthwhile). reviewed thisproject and determineditdid partner present and/or relationship The four Likert-typeitems examined in not meet the definitionofHumanSubjects processes that need to be addressed? All the current study assessed participation Research. CAB members are compensated for their and collaboration among CAB members time, and dinner is provided at each meet- (“The CAB facilitator allowed everyone’s Results ing. voice to be heard” and “I learned from otherparticipants”), whether members CAB Evaluation CABEvaluation perceive the CAB to meet its overarching Table 2presents average ratings across goal of broadening the applicabilityofthe participants on the fourLikert-type items Regular evaluationisacritical compo- DPP to awide range of couples ("The input at each meeting. Across the eight evalua- nent of CAB maintenance (newmanetal., provided by the CAB is having apositive tions, CAB members generally perceived 2011). As such, we regularly evaluate impact on the research project"), and gen- advocacy to be successful, as indicated by member perspectives on CAB functioning. eral satisfaction with the CAB meetings (“I average ratings between “agree” and For the first 6monthsofthe CAB, informal was satisfied with the CAB meeting”)ona “strongly agree” for the Likert-type items feedback was elicited from many CAB scalefrom 1(strongly agree)to4(strongly focusedonthe inclusion of CAB members members at the end of each meeting and disagree). The two open-ended items in the adaptation process. In addition to between meetings. We formalizedthe eval- examined in the current study assessed these quantitative ratings, many CAB uationprocesswithwritten evaluations at CAB member perspectives on the most members provided additional feedback in the end of the seventh monthly meeting, important contributions to the larger response to open-ended items about how then at the end of eachofthe seven meet- research project ("What do you believe are the CAB helped the larger project andwhat ings thereafter. CAB members were the most important contributions the CAB helped the CAB function well. Responses informed their responses were voluntary has madetothe research project?”) and the regarding the most important contribu- and anonymous, and designedtohelp the most important factors related to CAB tions of the CAB to the larger researchpro- facilitators improve CAB functioning. The functioning (“What has been most impor- ject included four topics: cultural compe- evaluation includes 10 Likert-type items tant in helping the CAB function well?”). tence (“Cultural outlook to make this and 4open-ended items. The focus of this CAB members completed the evalua- program more understandable for this study is on 4Likert-type items we believe tion by hand at the end of each meeting. All community,” “Language and cultural sen- best capture whether advocacy via the CAB data were then entered into aQualtrics sitivity”), applicability to couples (“Finding is thus far successful (i.e., whether CAB survey by members of the research team. necessary changes to make curriculum members are effectively included in the Descriptive statistics for the four Likert- more applicable to couples,” “Giving a adaptation process), as well as 2open- type items were computed in SPSS after the voice to couples”), diverse perspectivesof ended items that capture perspectives on data were exported from Qualtrics. In members (“I think the varying back- contributions to the larger research project ordertocategorizethe topics of responses grounds of the CAB members is super and the CAB process. Other items on the to the open-ended items, the first author helpful and is very impactful for discus- evaluation, excluded from the current manually coded responses to each item sion,” “Multicultural perspectives”), and manuscript, focused on meeting logistics across participants and meetings using an collaboration (“Being able to worktogether

Table 2.CAB Member Evaluations

Meeting Number

Item 7* 8910 11 12 13 14

The CAB facilitator allowed 1.13 (.35) 1.00 (.00) 1.00 (.00) 1.00 (.00) 1.22 (.44) 1.00 (.00) 1.22 (.44) 1.14 (.37) everyone’s voice to be heard. Ilearned from other participants. 1.13 (.35) 1.00 (.00) 1.17 (.41) 1.14 (.38) 1.11 (.33) 1.00 (.00) 1.11 (.33) 1.14 (.37) Iwas satisfied with the CAB 1.13 (.35) 1.00 (.00) 1.00 (.00) 1.00 (.00) 1.11 (.33) 1.00 (.00) 1.22 (.44) 1.43 (.53) meeting. The input provided by the CAB is 1.13 (.35) 1.11 (.33) 1.17 (.41) 1.00 (.00) 1.11 (.33) 1.00 (.00) 1.22 (.44) 1.43 (.53) having apositive impact on the research project.

Note. M (SD). n =number of CAB members completing evaluation. Items were rated on scale from 1(strongly agree)to4(strongly disagree). Data presented are from all members who completed evaluation forms following each meeting. *In the first evaluation, which occurred following meeting 7, CAB members were asked to report on their experiences across meetings 1-7.

October • 2020 263 aguirre et al. to come up with ideas and strategies to together, shared physicalactivity may not group environment centered on respect, improve the curriculum,” “CAB team be feasible or of interesttoother couples. trust, and cohesion. CAB members effort”). Responses regarding the most appeared to feel comfortable providing important factors for CAB functioning Discussion feedback to the research team and other included two topics: facilitator characteris- members on possible adaptions to the DPP This article illustrates thepotential util- tics (“The facilitators are amazing at curriculum, which helped maintain ity of Community Based Participatory makingsure everyone has avoice,” “Great engagement and create positive relation- Research methods, and CABsspecifically, facilitators that are aware of the group ships within the CAB. as ameans for advocacy in the context of It is important to recognize severallim- dynamic”) and member characteristics health promotion. Acentral feature within itations to the current project. First, (“The openness of everyone in hearing CABsisthe collective participation among although evaluations were anonymous, it is others’ comments,” “Group communica- all members (newman et al., 2011), which possible member responses werebiased or tion –everyone’s voice is valued”). demonstrates an active role and voice of community members that facilitatesadvo- that CABmembers who were less satisfied Suggested Adaptations to the DPP chose not to complete the evaluations in The perspectives of CAB members from cacyonbehalf of theirrespective communities based on their experiences and their entirety. On average, one or two CAB avariety of racial and ethnic backgrounds members declined to completethe evalua- facilitated review of the DPP through acul- knowledge (Lating et al., 2009; Shilton, 2006). Consistent with this, CAB members tion at each meeting. Members who did tural and contextual lens that considered complete the evaluations occasionally primary health concernsacross communi- perceived meetings to be collaborative and informative, believedthe input provided by skipped items. Finally, CAB members were ties. Suggestions from members included CAB members was useful to the couple- occasionally absent fromthe meetings. updating the language, pictures, and stories based adaptation of the DPP, and reported These factors may have led to collectionof to include more racial and ethnic diversity general satisfaction with the meetings. data from only the most satisfied and and to focus more explicitly on couples. Consistent with advocacy as ameans to engaged members. Additional assessment For example, basedonmemberfeedback, reduce health disparitiesinhealth promo- of theCAB process by an objective we updated one of the stories by highlight- tion (Carlisle, 2000), CAB members from observer would reduce the likelihood of ing an interracialcouple with one partner communities at high risk of T2D had criti- demand characteristics. with diabetes, culturallydiverse eatingpat- calinsights on how the interestin, and ben- Another limitation is the composition terns, varying preferences in physicalactiv- efits of, an adapted program could be max- of theCAB, which will likely lead to a ities, and differences in fitness and weight imized. Members identified cultural couple-based adaptation that is not inclu- goals. Members also identified ways in competence, applicability to couples, sive,culturally competent, or comprehen- whichexamples in the curriculum could be diverse perspectivesamong members, and sive in addressing T2D-related health con- more broadly applicable. For instance, collaboration as key contributions of the cerns of all possible participants. The memberssuggested that examples of types CAB to the research project. CAB mem- primary goal of the diverseCAB member- of food focus on those consumed across bers raised suggestions in response to the ship is to ensure the concerns of awide cultures. Membersalso noted that some of two overarching questions. Thus, the range of communities are considered in the the examples of ways to be active made common concern that CAB membersmay couple-based adaptation of the DPP.How- assumptions about the participants’ envi- relyonthe researchers to findsolutions or ever, there is substantial variability in T2D ronment (e.g., that they lived in asafe alternativestothe issues at hand (Cramer prevalence among racial and ethnic sub- neighborhood). Importantly, the changes et al., 2018) did not appear to be an issue for groups (Cheng et al., 2019), and the CAB suggested did not alter the content of the this CAB. does not include members from all sub- intervention curriculum,but rather its pre- Several factors likely facilitated the suc- groups at high risk. Further,the approach sentation and delivery. Throughout discus- cess of the CAB. The research team’s col- to recruitment of CAB members included sions, CAB members were highly engaged laboration withthe CommunityCollabora- identification of representatives from a and collaborative. tion and Engagement Team allowed range of communities, but the degree to With regard to afocus on couples, CAB existing partnerships to be leveraged, and which any one person can truly “speak for” members raised key considerations for the researcherstolearn from the extensive agiven community ignores the substantial screening couplesbeforeenrolling them in experience of facilitators. We believe the variabilitywithin communities.Thus, the the program. Therewas consensus among facilitators’ existing relationships with voices of individuals from anumber of CABmembers that both partners in partic- many of the CAB membershelpedcreate a racial and ethnic subgroupsare not repre- ipating couplesneedtobewilling to con- balanced and equal partnership between sented (Ross et al., 2010). The CAB also sider certainlifestyle changes andfeelcom- community members and the research includes only one (heterosexual,married) fortable participating in the program team that ensured all members’ thoughts couple. It would benefit from the perspec- together with their partner. There was and opinions were voiced. Consistent with tives of additional couples including those extensive discussion about differences this, CAB members described facilitator from the LGBTQIA+ community. Includ- between couples, including potential cul- characteristics as akey factor for CAB ing perspectives of LGBTQIA+ CAB mem- tural differences, in how they may functioning. We also followed applicable berswould increase the likelihood that the approach acouple-based lifestyle interven- processes for the formation, operation, and couple-based adaptation of the DPP appro- tion, and the need to facilitate partners’ maintenance of CABs (newman et al., priately addresses potential health con- support of one another regardless of its 2011). Havingclear and open communica- cerns of individuals and couples within the form. For example, whereas some couples tion among CAB members and between LGBTQIA+ community (Cahill et al., may prefer to engage in physical activity members and the research team created a 2016).

264 the Behavior Therapist diabetes prevention

Despite these limitations, this project 2016. JAMA, 322(24),2389–2398. demystified. Ethnicityand Disease, 9(1), highlights the potential for Community https://doi.org/10.1001/jama.2019.19365 10–21. Based Participatory Research to facilitate Cramer, M. E., Lazoritz,S., Shaffer,K., Ritchie, n. D.,Baucom, K. J. W.,&Sauder, advocacy in health promotion by including Palm,D., &Ford, A. L. (2018). Commu- K. A. (2020).Benefitsofparticipating membersofmarginalized communities in nity Advisory Board members’ perspec- with apartner in the national Diabetes the process of developing an intervention tives regarding opportunities andchal- Prevention Program. Diabetes Care, with the goals of increasing its acceptability lenges of research collaboration. Western 43(2), e20–e21.https://doi.org/10.2337/ JournalofNursing Research, 40(7), 1032– dc19-1489 and efficacy. Upon completion of the adap- 1048. https://doi.org/10.1177/ tation, our team will test the feasibility, Robles, T. F., Slatcher, R. 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October • 2020 265 SCIENCE FORUM actions and conversations to eradicate racial injustice related to the marginalization of their identities as People of Color Refill Your Well: An Online Acceptance-Based (Gorski, 2018). Given this nuanced understanding of Behavioral Burnout Management Guide for the unique psychological and physical costs of racism and particularly engaging in Activists of Color Resisting Racism activism against racism among People of Color, therapists can use their skills to sup- Lorraine U. Alire, Kaitlyn R. Gorman, Anna M. Ying, port activists of color, both directly or and Karen L. Suyemoto, University of Massachusetts Boston through the development and dissemination of resources. Agrowing body of research indicates that mindfulness-based MULTIPLE PSYCHOLOGISTS have called on Race and Ethnicity in Psychology). strategiesmay foster more positive mental attention to the inherent relationship More specifically, experiences of racism health and sustainability for People of between psychological well-being and have been associated with lower life-satis- Color addressing racism (Harrell, 2018; socialjustice (e.g., Martín-Baró et al., 1994; faction and well-being, anxiety, depression, Zapolski et al., 2018). These strategies Prilleltensky,2012; Vera &Speight,2003). race-based traumatic stress,cardiovascular could also be effective in supporting Given this relationship, it is important to disease, chronic pain, and various other activists of color, so that they might plan consider how therapists can support the negative health consequences (e.g., for and engage in effective activism promotion of social justice. One way that Bromanetal., 2000; Carter, 2007; Carter et (Gorski, 2015). In order to address this we might do so is through providing psy- al., 2017; Chou et al., 2012; Deitch et al., need, we developed Refill Your Well chological skills and support to activists 2003; Franklin et al., 2012; Harrell et al., (https://sites.google.com/view/refillyour- who are seeking to make positive change 2003;Liu &Suyemoto,2016; nadal et al., well),anonline burnout management web- for social justice. Working to make positive 2014; Scurfield et al., 2014). Some evidence site to promote self-careand burnout pre- change in the world is anoble yet taxing indicatesthat coping strategies enactedby vention for activists of color.This resource endeavor. The cost of activism is greater People of Color, such as social support integratesunderstandings of racism related still when an individual is personally con- seeking and developing racial and ethnic stress and activist burnout and connects nected to the cause they are defending identity pride, can offset the distress associ- these understandings to strategies basedon (Gorski &Erakat, 2019). Although ated with racism (Barnes &Lightsey, 2005; acceptance-based behavioraland mindful- activism exactsacost on individuals,ther- Brondolo et al., 2009; Sanders Thompson, ness principles (Orsillo &Roemer, 2016). apists are uniquely situated to offer skills 2006). These coping strategies have been In this article, we briefly describe the development needed to understand and associated with participating in racial three componentsofRefill Your Well.We ameliorate theburdensome psychological activism (Suyemoto et al., in press); how- present relevant psychologically based costs of engaging in and sustaining ever, there is agrowing need to develop skills from each module from the online activism. Based on our understanding of psychological-based resources that may resource, which may aid activists of color the negative psychological effects of racism empower and protect People of Color, and/or their therapists to identify signs of and discrimination (see APA Guidelines allowing them to sustain resistance against burnout, interrupt burnout, and sustain on Race and Ethnicity for Psychologists; racism. theiraction. We hopethat providing ther- American Psychological Association, 2019; One unique contribution that psycholo- apists and activists of color with such a Pappas, 2019) and of the potential positive gists could make is in the area of empower- website and toolset may encourage both impact of mindfulness (Zapolski et al., ing and supporting the mental health and clinicians and activiststocontinue to fight 2018) and value living (Graham et al., well-being of activists of color, fighting against systemic racial injustice, and to fur- 2015), we developed an online resource to against racial injustice. Activists of color, ther disseminate and sustain their impor- support activists of color working to pro- particularly those who are advocating in tant workwithin their communities. mote racial justice. Our primary goal in the areas in which they are themselves online resource is to speak to and support oppressed, are at risk of activist burnout PositionalityofAuthors activists of color to prevent burnout. Our (Gorski, 2018). Activist burnout is acondi- goal in this article is to familiarize readers tion characterized by feelings of amotiva- We would like to acknowledge our rel- with this resource so that therapists may tion, depletion, and irritability that not evant positionalities to thereaders, recog- use this resource with clients who identify only leads to the deterioration of the well- nizingthat these positionalitiesmay affect as activists of color and with White allies to being of individual activists (Gorski & biases that may have influenced the devel- assess burnout, implement these burnout Chen, 2015), but also undermines the sus- opment and dissemination of Refill Your prevention strategies, and offer this tainability of social justice movements Well. Lorraine U. Alire (first author)iden- resource as asupport for clients. (Gorski, 2015). More specifically, for tifies as amultiracial, Asian American and Abundant research indicates that activists of color who target racial injustice Latinx activist of color, who notices and racism has detrimental effects on both the in theirwork, activist burnout may be espe- feels the emotional and physical costs of psychological and physical health and cially high, given research suggesting that a challenging systemic racism and oppres- overall well-being for racialized ethnic barrier to activism can be unreasonably sion. Kaitlyn R. Gorman(secondauthor) minorities (Gee et al., 2007; Paradies et al., high self-expectations (Bobel, 2007); identifies as aWhite, Jewish cisgender- 2015; Schmitt et al., 2014; Williams et al., activists of color mayfeelparticular pres- woman and White ally. Anna M. Ying 2003; see review in 2019 APA Guidelines sure toconstantly engage in difficult (third author) identifies as abiracial

266 the Behavior Therapist burnout management for activists of color

(Asian/White) activistofcolor,who has felt systems of oppression, power, and privi- racism and systems of oppression that they the personal relevanceofactivist burnout. lege.The “wells” of activists of color con- have faced with their communities KarenL.Suyemoto(fourth author) identi- sist of the energy and time theyare able to throughout their lives. They may feel the fies as amultiracial Asian American queer give. Although these resources are not tan- need to be self-sacrificing, or even to be a psychologist of color who strives to engage gible like water,atany given time, theyare "martyr," in order to be a“real” advocate in racial justice activism. This online guide finite. Activists of color can give of them- for social justice (Bobel, 2007). This sets the was developedasaprojectbythe first three selves and their resources towards multiple bar impossiblyhigh to achieve the “perfect authors who are clinical psychology doc- goals and directions, including activism. standard” of effective activism for social toralstudents in Psychology 897: Psychol- However, like aliteral well, this process of justice for People of Color. The goal for ogy and Social JusticeActivism, offered at sharing cannot be endless. Activists of activism often needs to be astep forward, the University of Massachusetts Boston, color become depleted if they are con- in collaboration with others. Taking on under the mentorship of Dr. Suyemoto stantly giving of themselveswithouttaking personal accountability for major social (syllabus availableatklsuyemoto.net). time to restore. Burnout is the experience change is impossible; recognizing this is Collectively, we acknowledge that we of “the well runningdry.” As apsychologi- central to preventing burnout. In Refill are limited by our own inherent biases, cal experience, it is akin to emotional Your Well,weencourage activists of color both privileged and marginalized, which exhaustion (Maslach et al., 1996) or battle who feelthemselves striving for perfection may have influenced the design and dis- fatigue (Gorski, 2019). Individuals may to challenge these perfectionistic standards semination of this guide. We would like to experience physical symptoms (e.g., fatigue perpetuated by the “perfect standard” by acknowledge that we are writingthis article and gastrointestinal distress), cognitive asking, “Who is really setting the bar that from aU.S. perspective, and speak from symptoms (e.g., difficulty concentrating), I’m trying to reach?”Our goal is to remind our own personal and academic experi- and emotional symptoms (e.g., powerless- activists of color that the ideal activistthey ences, holdingrelative educationand U.S. ness or sadness; Arman et al., 2011). For may be striving for is not obtainable by citizenship privileges. Thisinevitably limits activists of color, burnout often manifests anyone (and often, we are our own worst the generalizability and accessibility of the with feeling hopeless, disengaged, and dis- critics). We also encourage activists of skills we present in our guide, but we hope couraged(Kovan &Dirkx, 2003). color to ask themselves, “Is there away I that the currentcontent of this guide may Moreover, activism may be particularly can find some kindness for myself when provide first steps helpful to some. challenging for activists of color resisting this bar feels especially high in this racism, for whom advocating for racial jus- moment?” One way to go deeper in this RefillYour Well: AGuide to Manag- tice often means encountering discrimina- practice is to ask the activist of color to ingBurnout for ActivistsofColor tion and paying attention to what is think about someone they loveand want to painful,both for the individual and for the take care of (a child, friend,orparent, etc.) Refill Your Well consists of three mod- communities of color they serve. For and ask themselves, “Whatwould you want ules: What Is Burnout, Interrupt Burnout, activists of color, feeling the pain of oppres- for them when they feel like they can’t and Sustaining Activism. WhatIsBurnout reach these standards?” Often activists of provides an introduction to the signs and sivesystems is personal.Itisunderstand- able and natural to experience the physical, color can find kindness for others they symptoms of activist burnout and the cannot muster for themselves. higher risks posed to activists of color emotional, and cognitive symptoms of burnout as that pain buildsupand can be Given the often impossible standards resisting racism. Interrupt Burnout pro- set on the meaning of effective activism and vides acceptance-based behavioral and heavy to carry.Remember, burnout is not a sign of weakness. noticing the signs of action, activists of color are vulnerable to mindfulnessskills specifically adapted for falling into mind traps of self-critical or activists of color resisting racism to chal- burnout, as described here, is the first step towards preventingoraddressing it. self-defeating thoughts, as they may be lenge the cognitive, physical, and emo- prone to criticize themselves for not learn- tional costs of burnout. Sustaining ing or doing enough in their work against Activism focuses on preventing burnout,to Module Two: Interrupting Activist racial injustice andinequality. Self-critical support activists’ well-being and sustain of Color Burnout thoughts may arise,such as, “If Ican't even their activism. The three modules were The second module of RefillYour Well, advocate for justicefor my family,how am developed upon the scholarship founda- called Interrupting Activist of Color Isupposed to engage in this work for the tionpresented above. Here, we present an Burnout,offers acceptance, behavioral, and public and society as awhole?” or “I’m not introduction to the contentofeach module mindfulness-based skills adapted for doing enough since Ican’t get people to see below, generally using amore colloquial activists of color to notice and challenge that we are operating under systems of voice with minimal citations. perfectionism and self-critical thinking, White supremacy.” One tool an activist of Module One: What Is Burnout? find emotional acceptance, and engage in color might practice is thought decenter- The first module of Refill Your Well values-based social support seeking and ing. Thought decentering is one of the first provides an overview of the signs and community building to interrupt the emo- prerequisites underlying both cognitive symptoms activists of color may endorse tional and physical costsofactivist of color and mindfulness-based skills (Sauer & when they experience burnout. burnout. It is our hope that these skills may Baer, 2010). Often activists of color find help activists of color refill their wells and their identity and thoughts deeply fused, •Activists of color resistingracism face a sustain the marathon against racism. for example, an activist of color might have higher risk.Activism involves giving of the thought, “I will never make any differ- yourself in the effort to create change. It is •Challenging perfectionism and the per- ence,” and in the moment, having that an evolvingand continual process of resis- fect standard in activism.Activists of color thoughtfeelslike evidence that the thought tance against the inequities maintained by often experience extra pressures to resist is true. In practice, thought decentering

October • 2020 267 alire et al. allows activists of color to notice the action to combat racism and systemic well-being and fuel activism, as well as pro- thought as justathought.One way to prac- oppression. vide afoundationfor theimportance of the tice thought decentering is to use language prevention strategies that follow. Some to distance oneselffrom one’sthoughts. In •Building acommunity of change. self-care activities include, but are not lim- the same example, when the thought “I will Effective activism for social justice is the ited to, healthy sleep and eating, exercise, never make any difference” comestomind, meeting of the heart and mind (Ruiz Junco, hobbies, and music. activists of color may practice observing 2013). Refill Your Well highlights the the thought. For example: “I notice the importance of finding and building acom- •Noticeearlysigns. Sometimesactivists thought that Iwill never make any differ- munity of activists of colorand allies who of color go into autopilot to advance action ence.” This small change may allow share values and lived experiences—this and forget to notice how they are doing. activists of color to take afigurative step may allow room for growth and greater They may not evenrealizethey are burned back from these impossible standards and meaningful change for social justiceagainst out untilthe impactforces them to notice. see them as thoughts and expectations racism (Polletta &Jasper, 2001).Working Refill Your Well aims to help activists of shaped by systems of power in our socio- across differences is hard and may some- color to notice the early warning signs cultural world. We encourage activists of times seem impossible. nevertheless, find- before they are burnedout. Practicenotic- color to interrupt the inner critic by view- ing allies who are open to communicating ing thoughts, emotions, physical sensa- ing these self-critical thoughts as thoughts, and understanding these differences may tions, and behaviors. “How do they relate, ratherthan definitive truths. foster an even greatercommunity to thrive and do daily activities affect them?” with (Suyemoto et al., 2019). For activists Activists of color are encouraged to notice •Harnessing power through emotional of color, even making small steps to chal- when activities push their limits.Everyone acceptance. It is natural and understand- lenge racism is often very hard work. has different levels of water in their well able for activists of color to experience Proactively seeking social support and based on their personal settings, resources, increased levels of both positive and nega- building acommunity of both activists of responsibilities, andexperiences. tive emotions surrounding their activism color and allies will cultivate bigger waves for racial justice. Positive emotions, like of change. Remember, everyone should do •Prefill your well. In addition to notic- happiness or satisfaction, may arise when their part navigating systems of oppression ing early signs, we suggest that it may be they experience asense of pride or reward andracism.Activistsofcolor do not have helpful to try strategies to preemptively towards their work. On the other hand, to do allthe work.Let others helpactivists “refill your well,” or prefill, to prevent negative emotions, such as anger, guilt, and of colorcarry the burden and heal this pain. burnout. Self-compassionisone strategy to shame, may arise as they experience chal- We encourage activists of color to sur- prefill your well (Gorski, 2015).The act of lenges or obstacles in their work. For exam- round themselves with people who make self-compassion can be thought of as sit- ple, activists of color resisting racismmay them feel safeand communicate their gen- ting with one's own pain—not judging it, especially feel asense of silent rage uine intentions to grow together with not fixing it, but sitting and allowing it (Rodriguez, 2011) as they struggle to them. Safety, honesty, and genuineness space. Given the nature of oppressivesys- manage emotional experiences related to contribute to building trusting, authentic tems, it is natural for activists of color to experiencing oppression (whether implicit relationships. feel pressure for their work to be “every- or explicit racism) as they advocate for thing” or be “perfect.” Refill Your Well racial justice for their own communities. Module Three: Sustaining Activism encourages activistsofcolor to try to notice Refill Your Well encourages activists of The initial modules of RefillYourWell thoughts of perfectionism before they color to practice strategies of emotional focus on identifyingburnout and address- become overwhelming, offer themselves acceptance (Hayes et al., 2009). Through ing the acute experience of burnout, as self-compassion as an act of resistance. emotional acceptance, activists of color described above. The final module focuses Activists of color may consider asking may learn to accept and experience, rather on preventing burnout, to support themselves, “Can the small steps matter?” than criticize and reject both their negative activists’ well-being and sustain their “Can your activist work be good enough?” and positive emotions. For example, activism. activists of color may feel guilt for not “Can you allow yourself to be human?” doing more to resist racism and conse- •Self-care.Activists often feel that they Activists of color may ask themselves these quential anger that internalized oppressive must always be selfless (Bobel, 2007), espe- questions before or during situations that systems contribute to these negative emo- cially activists of color who are resisting mayevoke thoughts, feelings, and behav- tions. Accepting that negative emotionsare racism and systems of oppression (Gorski, iors related to perfectionism or self-criti- natural and part of the process of activist 2015). They may think that “time that I’m cism and intentionally replace these work can mitigate the potential paralyzing using for self-care is time that I’m not responses with more adaptive behaviors effectsoftheseemotions and highlight the resisting theseoppressive systems.” These (e.g., developing amoremanageable taskof importance of sustaining activism to dis- thoughts are valid and natural. However, activisminareasonable time frame). Addi- mantle the systems that produced these self-care is ahelpful strategy to sustain tionally, activists of color may want to con- emotions. Although negative emotions activism (Gorski,2015). It may be helpful sider the importance of community build- may feel pesky and be perceived as getting for activists of colortounderstandself-care ing and allyship in prefilling their wells in the way of the work,emotions are also a as aburnout management skill to use (Vacarro &Mena, 2011). We encourage powerful tool to fuel activism. Finding before their well is “dry,” and consider how activists of color to surround themselves ways to balance and connect their pain and self-caremay fit within their activist values, with peopletheycan trust and who affirm rage with self-love and appreciation may to prevent the negative view of selfless sac- their identity and values,includingpeople help activists of color sustain and empower rifice. Self-care can be away to promote who share their primary oppressed identi-

268 the Behavior Therapist burnout management for activists of color ties and those who do not share thembut EthnicityGuidelinesinPsychology: Pro- https://doi.org/10.1177/00187267035611 work as allies. moting Responsiveness and Equity. 002 Retrieved fromhttp://www.apa.org/ Franklin,A.J., Boyd-Franklin, n., &Kelly, •Intentional and plausible goal setting. about/policy/race-and-ethnicity-in- S. (2012).Racism andinvisibility: Race- Finally, activists of color may try to set psychology.pdf Related stress, emotional abuseand psy- themselves up for sustainable activist work Arman,M., Hammarqvist, A.,&Rehns- chologicaltrauma forpeople of color. by making intentional, plausible, and feldt, A. (2011). Burnoutasanexistential Racism and RacialIdentity: Reflections on actionable goals. Given the limited “water deficiency—Lived experiencesof Urban Practice in MentalHealth and in their wells,” activists of color may ask burnout sufferers. Scandinavian Journal SocialServices, 6(2–3),9–30. themselves, “What is reasonable and sus- of CaringSciences, 25(2), 294–302. https://doi.org/10.1300/J135v06n02_02 https://doi-org.ezproxy.bu.edu/10.1111/ tainable?” They may consider what areas of Gee,G.C., Spencer, M. S.,Chen, J.,& j.1471-6712.2010.00825.x activism energize them, where activism can Takeuchi,D.(2007). Anationwidestudy Barnes, P. W., &Lightsey, O. R. (2005). of discriminationand chronichealth be easily integrated into life, areas that need Perceived racist discrimination, coping, conditions among Asian Americans. boundary-setting, initiatives that could stress, and life satisfaction. Journal of American Journal of PublicHealth, 97(7), wait for alater time, and the resources Multicultural Counseling and Develop- 1275–1282.https://doi.org/10.2105/ available considering their personal set- ment, 33(1), 48–61. https://doi.org/10. AJPH.2006.091827 tings and experiences. Similarly, consider 1002/j.2161-1912.2005.tb00004.x Gorski, P. C. (2018). Fighting racism, bat- specific,attainable goals based on currently Bobel, C. (2007).'I'm not an activist, tlingburnout: Causes of activist burnout available internal and external resources. thoughI've done alot of it': Doing in US racial justice activists. Ethnicand With the sameintentionalitygiven to their Activism, Being Activistand the 'Perfect RacialStudies, 42(5),667-687.doi: work, intentionally give space away from Standard' in aContemporary Movement. 10.1080/01419870.2018.1439981 work for nourishing and meaningful activ- Social Movement Studies, 6(2), 147-159. Gorski,P.C.(2015).Relieving burnout ities. doi:10.1080/14742830701497277 andthe “martyrsyndrome” among social Brondolo, E.,Ver Halen,n.B., Pencille, justiceeducation activists:The implica- Summary andFinalWords M., Beatty,D., &Contrada, R. J. (2009). tions andeffects of mindfulness. The Copingwith racism:Aselective reviewof Urban Review, 47(4),696–716. of Encouragement the literatureand atheoretical and https://doiorg.ezproxy.lib.umb.edu/10.10 In summary, we hope that these skills methodological critique. Journal of 07/s11256-015-0330-0 presented from Refill Your Well will Behavioral Medicine,32(1),64–88. Gorski, P.C. &Chen, C. (2015) ‘Frayed all https://doi.org/10.1007/s10865-008- empower and support activists of color in over’:The causes and consequences of 9193-0 activist burnout among socialjustice their work resisting systemic racism and Broman, C. L., Mavaddat,R., &Hsu, S. Y. education activists. Educational Studies oppression. And we hope that therapists (2000).The Experience and Conse- 51(5), 385–405. https://doi.org/10.1080/ and psychologists will use thisresource to quences of Perceived Racial Discrimina- 00131946.2015.1075989 support themselves(if they are activists of tion: AStudyofAfrican Americans. Jour- Gorski,P.C., &Erakat, n. (2019).Racism, color) andtheirclients, students,peers, and nal of Black Psychology, 26(2), 165–180. whiteness,and burnout in antiracism colleagues who are activists of color. We https://doi.org/10.1177/00957984000260 movements: How whiteracial justice recognizethat the skills discussedmay not 02003 activists elevate burnout in racial justice be entirely accessible and doable for all, Carter, R. T. (2007). Racismand Psycho- activists of colorinthe United States. given the limited nature of resources, logical and Emotional Injury: Recogniz- Ethnicities,19(5), 784–808. https://doi. which may include time, finances, and ing and AssessingRace-Based Traumatic org/10.1177/1468796819833871 emotional and cognitive capacities, Stress. The CounselingPsychologist, Graham, J. R.,West,L., &Roemer, L. activists of color have in their existing 35(1), 13–105. https://doi.org/10.1177/ (2015).Apreliminaryexploration of the wells. Rather, we encourage activists of 0011000006292033 moderating role of valued living in the color to pick and choose one or two of Carter, R. T.,Johnson,V.E., Roberson,K., relationships betweenracist experiences and anxious and depressive symptoms. them to practice and spread the word by Mazzula, S. L., Kirkinis,K., &Sant- Barket, S. (2017).Race-based traumatic JournalofContextual Behavioral Science, modeling to others what it looks like to stress,racial identity statuses,and psy- 4(1), 48-55https://doi.org/10.1016/ “refill your well.”And we encourage thera- chological functioning: An exploratory j.jcbs.2014.11.001 pists and psychologists to emphasize this Investigation. Professional Psychology: Haenfler, R., Johnson, B., &Jones, E. flexible and person-centered approach Research and Practice, 48(1), 30–37. (2012).Lifestyle movements:Exploring whendisseminating thisresource or foster- https://doi.org/10.1037/pro0000116 theintersectionoflifestyle and social ing these skills. When activists of color can Chou,T., Asnaani, A., &Hofmann, S. G. movements. SocialMovement Studies, practice ways to notice and interrupt (2012). Perception of racial discrimina- 11(1), 120. https://doi.org/10.1080/ burnout and sustain theiractivism against tion andpsychopathology across three 14742837.2012.640535 racism with acommunityofactivists of U.S. ethnic minoritygroups. Cultural Harrell, J. P.,Hall, S., &Taliaferro, J. color and allies, we all win! Sustain your Diversityand EthnicMinorityPsychology, (2003). Physiologicalresponses to racism activism. Address burnout. Take good care 18(1), 74–81. anddiscrimination:Anassessment of the of yourself. https://doi.org/10.1037/a0025432 evidence. AmericanJournal of Public Deitch, E. A., Barsky, A., Butz, R. M., Health, 93(2), 243–248. https://doi.org/10.2105/AJPH.93.2.243 References Chan, S., Brief, A. P., &Bradley,J.C. (2003).Subtleyet significant: The exis- Harrell, S. 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October • 2020 269 alire et al.

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new The Artand Science of Ethical Practice in NativeCommunities: ANativePsychologist’s Webinar Perspective —William H. Shunkamolah, Ph.D. This webinar provides clinicians with an introductoryexamination of factorsthat influence ethical decision making in the treatment of www.abct.org/Conventions/?m=mConvention&fa=Webinars American Indian clients utilizing examples and vignettes based on the experiences of aNativepsychologist. An overviewofthe Society of Indian Psychologist commentaryonthe APAEthical Principles of •MODERATOR:Laurie Zandberg, Psy.D. Psychologists will also be utilized to assist clinicians with self-assess- •COSPONSORED BY:ABCT Native American Issues in Behavior ment and considerations when initiating services with an individual Therapyand Research SIG client or in aNativecommunity.

270 the Behavior Therapist DISCUSSION different racial and ethnic groups, trans- genderand gender diverse (TGD) people, and other specific identity groups. Given From Revelations to Revolutions: Integrating that social justiceissuesare often an after- thought, or that many journals tend to only Social Justice Principles Into Behavioral and highlight one or two marginalized groups in an entire issue, it was refreshing to see Cognitive Science the editors’ intentionality in their inclusivity. Being intentional about inclusivity is a Kevin L. Nadal, City University of New York crucial aspect to living as apsychologist- activist; one must be aware of the multiple intersectional dynamicsthat operate across In 2020, THEMURDERS of George Floyd, more visible, with many people publicly various identity groups—accounting for Breonna Taylor, Ahmaud Arbery, Tony advocating against queer and trans injus- which identity groups are included versus McDade,and manyother Black Americans tices in law, government, and the criminal excluded, as well as which groups hold inspired anew revolution for racial justice. justice system (nadal, 2020). Relatedly, powerand which groups do not. While it While unarmed Black people have been while disability rights activists have been would be difficult (or even impossible) to killed for centuries by both law enforce- vocal about systemic ableism for decades represent every single identity group in any ment and White supremacist vigilantes (Dirth &Branscombe, 2019), societal setting (e.g., ajournal issue, aconference (Hargons et al., 2017), in the summer of awareness about ableism had grown expo- panel,acoursesyllabus, etc.), it is impor- 2020, multiple protests, demonstrations, nentially, albeit in still limited ways, in tant to make an overt attempt; when short- and uprisings emerged throughout the recent years. Further, among all of these comings exist, it is necessary to make note entire country, resulting in what has been movements, there have been calls for inter- of theexclusion and to acknowledge why labeled the most populous movement in sectionality, or the ability to examine the the exclusion may exist. As an example, American history (Buchanan et al., 2020). impact of systemic oppression on people when voices of Indigenous Peoples are Perhaps,the advocacy for racial justice was with multiple marginalized identities unheard or unrepresented in certain influencedbythe growing awareness of the (Crenshaw, 2017). For example, women of spaces, one must acknowledge how issues #BlackLivesMatter movement, which color and transgender women have like genocide and systemic racism may began in 2014, after George Zimmerman describedfeeling marginalized from femi- result in the group’s lack of representation was acquitted for murdering 17-year-old nist movements (nadal, 2017a), while in specific fields and situations, while also Trayvon Martin (Garza, 2014). Perhapsthe queer and trans people of color have been committing to more representations in COVID-19pandemicand the shutdownof vocal about exclusion from both main- future programs. Similarly, when LGBTQ the entire nation led to increased reflec- streamLGBTQ movementsand racial jus- people are invisible in specific settings, one tions and revelations about race relations tice movements(nadal, 2020). may question if some environments are in the U.S.Regardless of the impetus, many The purpose of this commentary is safe enoughfor individuals to disclose their institutions, groups, and individuals had twofold: first, Iwill review the articles in sexual orientations or gender identities,as begun to consider the ways that they this special issue of the Behavior Therapist well as identify the factors that impede should advocate for social justice in their (Feinstein &Puckett, 2020), all of which themfrom doing so. work. Psychologists and mental health highlightthe many ways that psychologists nonetheless, the special issue begins practitioners, specifically, created ways to have integrated their advocacy work into with Burgess and Batchelder (2020), who participate in activism; for instance, Dr. practice—namely, through schools, clinical introduce the ways that clinicalresearchers DellaV.Moseley and psychology doctoral work, community-based organizations, can integrate advocacyintotheir practice. student Pearis Bellamy co-founded Acade- and other institutions and collaborations. After listing the many ways that people of mics for Black Lives (www.academics4 Second, Iwill provide recommendations historically marginalized groups have been blacklives.com), acampaign that initiated a that will assist psychologists in integrating unfairly treated by clinical research, they series of online curricula and dialogues social justice principles into all aspects of offer theneedfor community-based partic- promoting Black survival and wellness in behavioral and cognitive science. While I ipatory research (CBPR)and community- academia and everyday life. have advocatedfor the need for psycholo- informed practices. Involving underrepre- Over the years, many other social justice gist-activists in past writings (see nadal, sented communities is indeed essential in movements involving other identity 2017b), the goal of this paper is to offer conductingethical and effective research, groupshad emerged as well. Following the additional tangible and accessible recom- as it allows opportunities for people of such presidential election of 2016, advocacy mendations for practitioners with arange communities to share their own perspec- issues involving women’s rights became of experiences of activismengagement and tives and to contextualize cultural compo- more public and mainstream, with the who workacross avariety of sectors. nents that are often misunderstoodormis- Women’sMarch gathering millions of par- interpreted by researchers who are ticipants in January 2017 (nadal, 2017a) Reviewofthe Special Issue outsiders to those communities. For and the #MeToo and #TimesUp move- instance, when White people conduct ments encouraging people, particularly In this special issue of the Behavioral research or provide psychotherapy with women, to speak out about their experi- Therapist, it is clear that the editors were peopleofcolor andpathologize theirpar- ences with sexual harassment and sexual intentional in representing an array of his- ticipants’ or clients’ valuesand behaviors, assault (Strauss Swanson &Szymanski, torically marginalized groups. In reviewing those diagnoses are influenced by their 2020). LGBTQ rights have also become the titles alone, one will notice articleson own Western biasesand lack of knowledge

October • 2020 271 nadal and awarenessofothergroups (Sue et al., Relatedly, using community-based ment on some of the many waysthat psy- 2007). Similarly, when heterosexual or cis- methods, threearticles focus on advocacy chologists can integrate social justiceprin- gender researchers or clinicians patholo- efforts for myriadgroups—namelyLatinx ciples into thefieldofbehavioral and cog- gize LGBTQ people for behaviors thatare people, Caribbean people, and people at nitive sciences. First, Iacknowledge two considered normalized within LGBTQ risk fordiabetes. First, Kleinand colleagues theories that inform the ways that Ipresent communities, it is more reflective of soci- (2020) discussresearch with promotoras de my perspectives: Queer Theory (see etal heterosexism,aswell individuals’ het- salud (or lay health workers) who are able Ghaziani &Brim, 2019, for areview) and erosexist and transphobic biases (nadal, to utilize culturally appropriate strategies Intersectionality Theory (see Crenshaw, 2013, 2020). While CBPR is especiallycrit- to promote healthy behaviors and health 2017). Queer theorists argue that historical ical for researchers who work with com- care access among underserved, Latinx definitions and conceptualizations of munities they are not members of, re- communities. Second, Asnaani and col- gender and sexuality are based on privi- searchers must also question why there leagues (2020) describe the ways that leged and dominantworldviews; they offer aren’t peoplefromthose communitieswho trauma-related training can be usedeffec- the notion of “queering” the status quo, by are engaged in academic research. In these tivelyamong Caribbeans. Third, Aguierre disrupting and challenging all things that circumstances, it becomes apersonal and colleagues (2020) introduceadiabetes have been socialized as normal and stan- responsibility for researchers to not just preventionprogram that has been used to dard. Meanwhile, as aforementioned, collect data from these communities, but to target people of historically marginalized intersectionality considers the multiple alsocreate or offer programs and services groups. Central to each of thesearticlesis ways that people of historically marginal- for community members, particularly the notion of cultural humility, or the idea ized groups are harmedbymultiple forms those from younger generations, who may that psychologists(a) recognize their own of oppression. In her original conceptual- not have access to such opportunities. limitations in working with diversegroups izations, Kimberlé Crenshaw describes Two articles in thisissue focus on expe- and (b) considerthe worldviews and lived how Black women live at the intersectionof riences of transgender and gender diverse experiences of others,instead of centraliz- racism and sexism; metaphorically, if they (TGD) people, highlightingthe many dis- ing one’s own biases and perspectives ever get into acar accident, they would parities faced by TGD people, particularly (Hook et al., 2017). Cultural humility is experience more damage because of their TGD youth. Cyperski and colleagues essential in serving and interacting with location at that intersection. These two foundational theories providetwo integral (2020) provide recommendationsbased on diversecommunities, because what works argumentsthat will be embedded into all of their experiences with TGD youth in a well with some communities may not be my recommendations: (1) to “queer” or holistic pediatric clinic,and Hope and col- effective with others. Further, making con- disrupt the status quo, and (2) to always leagues(2020) impartaCBPR model called scious efforts to be culturally humble consider multiple marginalized oppres- Trans Collaborations, which demonstrates across various situations keeps psycholo- sions. ways academics can work in conjunction gists and other practitioners vigilantly My first major recommendation is for with alocal communityboard. Both papers focusedonensuring that cultureisconsid- people to questionand reconsider all that examine practical approaches that can be ered in all of their conceptualizations, deci- people have ever learned about psychology. useful on individual, institutional,and sys- sion-making processes, and interventions. For decades, it has been argued that temic levels. For instance, Hope and col- Finally, Alire and colleagues (2020) propose an online guide called “Refill Your modern psychology has been based on leagues describe various projects such as Well” as away to assistactivists of color in White, Western, heteronormative, cisgen- workshops, online support groups, and navigating and copingwith racism in their der male perspectives and it has been even aweekend-long campfor TGD youth everyday lives. Presenting severalmodules, common for cultural considerations to be and children. Cyperski and colleagues including (a) interrupting burnout among dismissed or overlooked (Sueetal., 2019). share advocacy strategies for individuals activists of color and (b) sustaining In this way, psychologists must reflect on (e.g., practicing role-plays with TGD youth activism, the authors propose ways for how their training has been embedded in clients on how to talk to their teachers building community and engaginginself- systemic oppression and the erasure or about being misgendered) and systems care. Given that burnout is acommon and pathologizing of historically marginalized (e.g., starting apetition for aschool or the detrimental reason that prevents and/or groups. Further, psychologists and other statelegislature to changetransphobic poli- deters the development or persistence of practitioners must “unlearn” the ways that cies). Given the many health disparities psychologist-activists (nadal, 2017b),these they have been taught to view or evaluate involving TGD people (e.g., poverty, practical recommendations are helpful in concepts or people. As an example, many homelessness, overrepresentation in the both normalizing the typical psychological psychologists may be hesitant to become criminal justice system, etc.)—whichhave stressors of activists of color, while also social justice advocates because they are been found to be especially detrimentalfor encouraging health and sustainability for afraidofviolating boundaries—a practice TGD people of color (nadal,2013, 2020)— these individuals who often take care of so that is consideredanethical breach in the it is imperative for governmentand com- many other people that they forget to take profession (nadal, 2017b). While there is munity organizations to provide program- care of themselves. certainly autility to setting boundaries in ming and support services for TGD youth. various aspects of one’s life, one must ques- If such programs or services do not exist, Integrating Social Justice Into tionhow such arule cametobe, as wellas psychologists and other practitioners must Behavioraland Cognitive Sciences whose values thisrule was based on. If we jumpstart such initiatives in order to dis- know that collectivism and community rupt the status quo and assistTGD people Consideringthese concreteexamples of involvement is integral for Indigenous (particularly TGD people with other mar- how psychologistshave beenable to inte- people andother people of color, perhaps ginalizedidentities) to thrive. grate activisminto their work, Iwill com- theprofession should focus more on train-

272 the Behavior Therapist discussion ing future psychologists to successfully seem nonsensicaltoteachaDevelopmental any and every injusticetheymay observe in manage and navigate boundaries, instead Psychology course without examining how the workplace—from everyday microag- of punishing or shaming people with less issues like gender and race influence chil- gressions to systemicissues like inequities rigid boundaries. dren’s and adolescents’ development, as it in hiringand promotions. For others, the Relatedly, many people may be hesitant would be odd to teach acourse on Person- revolution may consist of creating new in becoming activists because they fear that ality Theories and ignorethe cultural fac- programs and organizations, advocating they will not appear to be “professional” tors that influence personality develop- for changes in systemic policies, conduct- and therefore will lose credibility or ment. Thus, Irecommend that all pro- ing community-based and culturally esteem. Again, one must question who had grams “decolonize” their curricula by dis- empowering research and scholarship, or set such standards that have now become cussing the history of oppression at the engaging in local or state government. For normalized across the profession; perhaps onsetofeach course and by centering the others,the revolution may involve teaching one can challenge who sets standards of experiences of historically marginalized the next generationwith different language professional dress,professional hairstyles, people. As an example, in teaching aDevel- and values—disrupting all gender role professional language or communication opmental PsychologyoraPersonality The- norms; encouraging children to recognize style, professional behavior, etc. One can oriescourse, Iencourage professors to start and talk about race, sexual orientation,and also hypothesize who willhave amoredif- the course by naming how the subfield in difference; vocalizing disdain about soci- ficulttime maintainingthesestandards, as psychology had been historically oppres- etal standards of beauty;and empowering well as who will be more successful as a sive to Black people, Indigenous people, all children to find their voice and purpose. result of their proximity to these standards. and otherpeople of color—perhaps shar- For some people, the revolution will con- For example,ifBlack women are criticized ing how psychologists have ignored race sistofall or some of these things; and for or questioned for their hairstyles not being altogether or have pathologized people others, the revolution willlook completely professional (Sue et al., 2008) or if queer who did not fit White standards. Ialso different and unique. Considering each and trans people are punished or microag- encourage professors to present models individual’s circumstances and personal gressed for dressing in gender noncon- that center marginalized people’s experi- capacity, it is my hopethat everyone finds forming ways (nadal, 2013), they are ences first, before (or ever) teaching about the revolutionary path that fits best for already at adisadvantage for notabidingto models that are considered standard. For them. White, male, heterosexual, or cisgender instance, instead of presenting Freud’s or Finally, Iamsincerely optimistic that standards. When people hold multiple Erickson’s theories as “normal” stage this current generation of psychologists marginalized identities (e.g., aBlack, les- models of development, present Carol recognizesthat we must go beyonddoing bian, cisgender woman), they will face Gilligan’s models on girls’ development, no harm and instead do everything we pos- more obstacles than their privileged coun- Janet Helms’ models on identity develop- sibly can toensure that the people we serve terparts (e.g., aWhite, heterosexual, cis- ment, or Derald Wing Sue’s models on per- can thrive and live their best lives. Ihope gender man). sonality development. Introducing these that all psychologists realize that the revo- Another major recommendation is to models first changes the waysthat students lution is indeed happening; this is not just a explore all of the current ways that psy- learn aboutnorms and standards; concur- moment,but amovement towards change. chology is taught and to critically analyze rently, educators also provide opportuni- Thus, we all have to decide whether we how social justice is integrated into psy- ties to acknowledge and correct past want to assist in helping the revolution chology training. In scrutinizing curricula wrongdoings of the profession, while progress forward, or if we will choose to in psychologydoctoral programs, training empowering people who have been serve as ahindrance to justice and equity directors and professorsmust review when silenced to feel included in the field. for all. and how social justice is taught and dis- Athird major recommendation for cussed. While many programs offer asole advocating for historically marginalized References multicultural psychology course (which groups is for individualstotake apersonal Aguirre,M.C.,Brown, H.,Gershenoff, D., typically fulfills accreditation require- responsibility and commit to socialjustice Hinton, K. L.,Huntzinger, O. M.,Klein, ments), other classes fail to cover issues of in all aspects of theirlives. WhileIhad pre- n., Ramos, C., Tavake-Pasi, O., Witte, B., race, class, gender, sexual orientation, abil- viously written about psychologist-activists Wolfsfeld, M., Sher, T., Simmons,D., ity, religion, age, or other identities at all. integrating social justice into work and Smith,T.W., Clark, L., &Baucom, K.J.W. Such omissions are not just careless; they even their personal lives (nadal, 2017b), I (2020). The Role of advocacy in adapting are also both unethical and illogical. Ignor- take it astep further by challenging all psy- theDiabetesPrevention Program for ing cultural factors is an ethical concern chologists to take responsibility and partic- couple-based delivery thatreaches mar- because it negates the American Psycho- ipate in this social justice activism every ginalized groups. theBehavior Therapist, logical Association’s (2017) multicultural moment of their lives. no longer is it 43,261-265. guidelines, which have been integrated into acceptable for people to merely have reve- Alire, L. U.,Gorman,K.R., Ying, A. M., & the organization’s Code of Ethics. If the lations about injustice and then ignore Suyemoto,K.L.(2020).Refill Your Well: governing board of the profession deter- such truths when they become inconve- An Online acceptance-based behavioral burnout management guidefor activists mines that culture must be considered in niences; instead, it is imperative for people of color resistingracism. the Behavior all forms of practice, then practitioners to join the revolution. For some, the revo- Therapist, 43,266-270. who refuse or ignore such standardswould lution may be participating in protests or American Psychological Association. be considered in ethical violation. actions that advocate for Black lives, for (2017). Multicultural Guidelines: An Eco- Ignoring cultural factors is also illogical Indigenous People’s rights, or for LGBTQ logical Approach to Context, Identity,and because culture is related to every single equity and justice. For others, the revolu- Intersectionality. Washington, DC: aspect of psychology. For instance, it would tion maybevocalizing concern or angerfor Author.

October • 2020 273 nadal

Find aCBT Therapist Asnaani, A., Charlery White, S., &Phillip, nadal,K.L.(2013). That’ssogay! Microag- T. M. (2020). Mobilizingmental health gressions and the lesbian, gay, bisexual, training effortstoalign with advocacy for and transgender community. Washing- disenfranchisedgroupsinglobal con- tonDC: American Psychological Associ- texts: Trauma-related traininginthe ation. Caribbean as an example. the Behavior nadal,K.L.(2017a). Gender and Society. Therapist,43,254-260. In K. L. nadal (Ed.), Sage Encyclopedia of Buchanan, L., Bui,Q., &Patel,J.K.(2020, Psychology and Gender (pp.772-778). July). BlackLivesMatter may be the Thousand Oaks, CA:Sage. largest movement inU.S.History. New nadal, K. L. (2017b). “Let’sget in forma- YorkTimes.Retrievedfrom: tion”: On becoming apsychologist- https://www.nytimes.com/interac- activist in the21st century. American tive/2020/07/03/us/george-floyd- Psychologist, 72,935-946. protests-crowd-size.html nadal, K. L. (2020). Queering law and Burgess, C.,&Batchelder, A. (2020). order: LGBTQ communities and thecrim- Improving clinical researchtoinform inaljusticesystem. Lanham, MD: ABCT’s Find aCBT Therapist advocacy initiatives with underserved Rowman&Little. individuals. the Behavior Therapist, 43, directory is acompilation of prac‐ Strauss Swanson, C., &Szymanski, D. M. 235-241. (2020).From pain to power:Anexplo- titioners schooled in cognitive and Crewshaw,K.(2017). On Intersectionality: ration of activism,the #MeToo move- Essential Writings.new Press. ment, and healing from sexual assault behavioral techniques. In addition Cyperski,M.A.,Romano, M. E.,&Brady, trauma. JournalofCounselingPsychol- to standard search capabilities C. C. (2020).Supporting transgender/ ogy.Advance online publication. genderdiverse (TGD) youthacross set- https://doi.org/10.1037/cou0000429 (name, location, and area of exper‐ tings and systems of care: Experiences Sue,D.W., Capodilupo, C. M., Torino,G. tise), ABCT’s Find aCBT Therapist from apediatric interdisciplinary clinic. C.,Bucceri,J.M., Holder, A., nadal, K. the Behavior therapist,43,242-247. L., &Esquilin,M.(2007). Racial offers arange of advanced search Dirth,T.P., &Branscombe,n.R.(2019). microaggressions in everyday life:Impli- capabilities, enabling the user to Recognizing ableism:Asocial identity cations forclinical practice. American analysis of disabledpeople perceiving Psychologist, 62,271-286. take aSymptom Checklist, review discrimination as illegitimate. Journalof Sue, D. W., nadal, K. L., Capodilupo, C. Social Issues,75,786-813. specialties, link to self‐help books, M., Lin, A. I., Torino, G. C., &Rivera, D. Feinstein, B. A., &Puckett, J. A. (2020). P. (2008).Racial microaggressions and search for therapists based on Introduction to the special issue: Psy- against Black Americans: Implications chologists’ role in advocacy to support for counseling. Journal of Counseling & insurance accepted. the healthofmarginalized populations. Development,86,330-338. We urge you to sign up for the the Behavior Therapist, 43,234-235. Sue, D. W., Sue, D.,neville,H.A., & Garza,A.(2014). AHerstoryofthe Smith, L. (2019). Counselingthe cultur- Expanded Find aCBT Therapist #BlackLivesMatter movement.InJ. allydiverse (7thed.).John Wiley &Sons. (an extra $50 per year). With this Hobson (Ed.), Are all the women still white? Rethinkingrace,expandingfemi- ... addition, potential clients will see nisms (pp. 23-28). SUnYPress. what insurance you accept, your Hargons,C., Mosley, D., Falconer, J., no conflicts of interestorfunding Faloughi, R.,Singh, A., Stevens-Watkins, to disclose. practice philosophy, your website, D., &Cokley, K. (2017).Black lives Correspondence to Dr. Kevin nadal, and other practice particulars. matter:Acall to actionfor counseling psychology leaders. The Counseling Psy- Ph.D., 524 W. 59th Street, newYork,nY To sign up for the Expanded Find chologist,45,873-901. 10031; [email protected] Hook,J.n., Davis, D.,Owen, J.,& aCBT Therapist, click mEmBEr DeBlaere, C. (2017). Culturalhumility: loGIn on the upper left‐hand of the Engaging diverse identities in therapy. Washington DC: AmericanPsychologi- home page and proceed to the calAssociation. ABCT online store, where you will Hope,D.A., Woodruff,n., &Mocarski, R. (2020).Advocacy Opportunitiesfrom click on “Find CBTTherapist.” Academic-Community Partnerships: Forfurther questions, call the Three Examples fromTransCollabora- tions. the Behavior Therapist, 43,247- ABCTcentral office at 212‐647‐ 250. 1890. Klein, C., Sanchez, E.L., Gonzalez, J.C., Flores, I., Rosas, Y. G., &Barnett,M. (2020).The roleofadvocacyincommu- nity-partnered researchwith lay health workers in Latinx communities (promotoras de salud). the Behavior Therapist, 43, 250-254.

274 the Behavior Therapist ticketed 55th Annual Convention sessions call November 18–21, 2021|New Orleans for Ticketed Sessions

Workshops &Mini Workshops Workshops coverconcerns of the practitioner/ educator/researcher.Workshops are 3hourslong, are generally limited to 60 attendees, and are scheduled for Fridayand Saturday. Please limit to no more than 4presenters. Mini Workshops address direct clinical care or training at abroad introductorylevel. Theyare 90 minutes long and are scheduled throughout the convention. Please limit to no more than 4presenters. When submitting forWorkshops or Mini Workshop, please indicatewhether youwould liketobeconsidered forthe other format as well. Formore information or to answer anyquestions before yousubmit your abstract, email Christina Boisseau, Workshop Committee Chair,[email protected] Institutes Conference Theme: Institutes, designed forclinical practitioners, are 5hoursor7hourslong, are generally limited to 40 attendees, and are scheduled forThursday. Please limit to “Championing CBT: no more than 4presenters. Promoting Cognitive Formore information or to answer anyquestions before yousubmit your abstract, email Samantha G. Farris, Institutes Committee Chair,[email protected] and Behavioral Practice and Science Master Clinician Seminars in the Context of Master Clinician Seminarsare opportunities to hear the most skilled clinicians explain their methods and showtaped demonstrations of client sessions. They Public Health, are 2hourslong, are limited to 40 attendees, and are scheduled Fridaythrough Social Justice, Sunday. Please limit to no more than 2presenters. Formore information or to answer anyquestions before yousubmit your Policy,Research, abstract, email CourtneyBenjamin Wolk,Master Clinician SeminarsCommittee Chair, Practice, and [email protected] Tr aining” Research and Professional Development Presentations focus on “howto” develop one’s owncareer and/or conduct research, rather than on broad-based research issues (e.g., amethodological or design issue, grantsmanship, manuscript review) and/or professional development topics (e.g., evidence-based supervision approaches, establishing aprivate Information about the con- practice, academic productivity,publishing forthe general public). Submissions will be of specific preferred length (60, 90, or 120 minutes) and format (panel dis- vention and how to submit cussion or more hands-on participation by the audience). Please limit to no more abstracts will be on ABCT's than 4presenters, and be sure to indicate preferred presentation length and for- website, www.abct.org, mat. after January1,2021. Formore information or to answer anyquestions before yousubmit your abstract, email Cole Hooley, Research and Professional Development Committee Chair, [email protected]

Submission deadline: February 1, 2021, 3:00 A.M.EST

October • 2020 275 2021 Call for Award Nominations to be presented at the 55th Annual Convention in neworleans

The ABCT Awards and Recognition Committee, chaired by Sara R. Elkins, Ph.D., of University of Houston Clear Lake is pleased to announce the 2021 awards program. Nominations are requested in all categories listed below. Given the number of submissions received for these awards, the committee is unable to consider additional letters of support or supplemental materials beyond those specified in the instructions below. Please note that award nominations may not be submitted by current members of the ABCT Board of Directors.

Career/Lifetime Achievement Eligible candidates for this award should be members of ABCT in good standing who have made significant contributions over a number of years to cognitive and/or behavior therapy. Recent recipients of this award include Thomas H. Ollendick, Lauren B. Alloy, Lyn Abramson, David M. Clark, Marsha Linehan, Dianne L. Chambless, Linda Carter Sobell and Mark B. Sobell, and Philip C. Kendall. Applications should include anominationform (available at www.abct.org/awards), three letters of support, and the nominee’s curriculum vitae. Please e-mail the nomination materials as one pdf document to [email protected]. Include “Career/Lifetime Achievement” in the subject line. Nomination deadline: March 1, 2021.

Outstanding Training Program This award will be given to atraining program that has made asignificant contribution to training behavior therapists and/or promoting behavior therapy. Training programs can include graduate (doctoral or master's), predoctoral internship, postdoctoral programs, institutes, or continuing education initiatives. Recent recipients of this award include the Doctoral Program in Clinical Psychology at SUnY Albany, Massachusetts General Hospital/Harvard Medical School Predoctoral Internship in Clinical Psychology, the University of nebraska-Lincoln Clinical Psychology Training Program, the Charleston Consortium Psychology Internship Training Program, Clinical Science Ph.D. Program at Virginia Polytechnic Institute &State University, and Florida State University’s Clinical Psychology Ph.D. program. Please complete the on-line nomination form at www.abct.org/awards. Then e-mail the completed form and associated materials as one pdf document to [email protected]. Include “Outstanding Training Program” in your subject heading. Nomination deadline: March 1, 2021.

Outstanding Contribution by an Individual for Research Activities Eligible candidates for this award should be members of ABCT in good standing who have provided significant contributions to the literature advancing our knowledge of behavior therapy. Recent recipients of this award include Alan E. Kazdin, David H. Barlow, Terence M. Keane, Thomas Borkovec, Steven D. Hollon, Michelle Craske, and Jennifer P. Read. Applications should include anomi- nation form (available at www.abct.org/awards), three letters of support, and the nominee’s curriculum vitae. Please e-mail the nomination materials as one pdf document to [email protected]. Include “Outstanding Researcher” in the subject line. Nomination deadline: March 1, 2021.

The Francis C. Sumner Excellence Award The Francis Cecil Sumner Excellence Award is named in honor of Dr. Sumner, the first African American to receive aPh.D. in psychology in 1920. Commonly referred to as the “Father of Black Psychology,” he is recognized as an American leader in education reform. This award can be given on an annual basis, awarded in even years to agraduate student and in odd years to an early career professional within the first 10 years of terminal degree. Candidate must be acurrent member of ABCT at the time of the awards cer- emony and priority will be given to students and professional members of ABCT at the time of the nomination. The award is intended to acknowledge and promote the excellence in research, clinical work, teaching, or service by an ABCT member who is adoctoral student or early career professional within 10 years of award of the PhD/PsyD/EdD/ScD/MD who identifies as Black or Indigenous. The award is given to recognize that Black and Indigenous practitioners and scholars are underrepresented in clinical psychology, despite making important contributions to our field. The Francis C. Sumner Excellence Award is meant to reflect the overarching goal of ABCT supporting its members of color. The recipient will receive $1,000 and acertificate. Please complete the online nomination materials at www.abct.org/awards. Then email the nomination materials as one PDF document to [email protected]. Include “Francis C. Sumner Award” in the subject line. Nomination deadline: March 1, 2021.

Anne Marie Albano Early Career Award for Excellence in the Integration of Science and Practice Dr. Anne Marie Albano is recognized as an outstanding clinician, scientist, and teacher dedicated to ABCT’s mission. She is known for her contagious enthusiasm for the advancement of cognitive and behavioral science and practice. The purpose of this award is to recognize early career professionals who share Dr. Albano’s core commitments. This award includes acash prize of $1,000 to support travel to the ABCT Annual Convention and to sponsor participation in aclinical treatment workshop. Eligibility requirements are as

276 the Behavior Therapist awards & recognition follows: (1) Candidates must be active members of ABCT, (2) new/Early Career Professionals within the first 10 years of receiving his or her doctoral degree (PhD, PsyD, EdD). Preference will be given to applicants with ademonstrated interest in and commitment to child and adolescent mental health care. Applicants should submit: nominating cover letter, CV, personal statement up to three pages (statements exceeding 3pages will not be reviewed), and 2to3supporting letters. Application materials should be emailed as one pdf document to [email protected]. Include candidate's last name and “Albano Award” in the subject line. Nomination deadline: March 1, 2021.

Student Dissertation Awards •Virginia A. Roswell Student Dissertation Award ($1,000) •Leonard Krasner Student Dissertation Award ($1,000) •John R. Z. Abela Student Dissertation Award ($500) Each award will be given to one student based on his/her doctoral dissertation proposal. Accompanying this honor will be amonetary award (see above) to be used in support of research (e.g., to pay participants, to purchase testing equipment) and/or to facilitate travel to the ABCT convention. Eligibility requirements for these awards are as follows: 1) Candidates must be student members of ABCT, 2) Topic area of dissertation research must be of direct relevance to cognitive-behavioral therapy, broadly defined, 3) The dissertation must have been successfully proposed, and 4) The dissertation must not have been defended prior to november 2020. Proposals with preliminary results included are preferred. To be considered for the Abela Award, research should be relevant to the development, maintenance, and/or treatment of depression in children and/or adolescents (i.e., under age 18). Self-nominations are accepted, or a student's dissertation mentor may complete the nomination. The nomination must include aletter of recommendation from the dissertation advisor. Please complete the nomination form found online at www.abct.org/awards/. Then e-mail the nomination materials (including letter of recommendation) as one pdf document to [email protected]. Include candidate’s last name and “Student Dissertation Award” in the subject line. Nomination deadline: March 1, 2021

President’s New Researcher Award ABCT's 2020-21 President, David F. Tolin, Ph.D., invites submissions for the 43rd Annual President's new Researcher Award. The winner will receive acertificate and acash prize of $500. The award will be based upon an early program of research that reflects factors such as: consistency with the mission of ABCT; independent work published in high-impact journals; and promise of developing theoretical or practical applications that represent clear advances to the field. Requirements: must have had terminal degree (Ph.D., M.D., etc.) for at least 1year but no longer than 5years (i.e., completed during or after 2015); must submit an article for which they are the first author (in press, or published during or after 2018); 2letters of recommendation must be included; self-nominations are accepted; the author's CV, letters of support, and paper must be submitted in electronic form. Applicants from traditionally underrepresented backgrounds, or whose work advances our understanding of behavioral health disparities, are particularly encouraged to apply. E-mail the nomination materials (including letter of recommendation) as one pdf document to [email protected]. Include candidate's last name and "President's new Researcher" in the subject line. Nomination deadline: March 1, 2021.

Graduate Student Research Grant The ABCT Research Facilitation Committee is sponsoring agrant of up to $1000 to support graduate student research. The grant will be awarded based on acombination of merit and need. Eligible candidates are graduate student members of ABCT seeking funding for an unfunded (including internal sources of funding) thesis or dissertation project that has been approved by either the faculty advisor or the student's full committee. Applications should include all of the materials listed in GSRG Application Guidelines (https://www.abct.org/Resources/index.cfm?m=mResources&fa=GraduateStudentGrant) and one letter of support from afaculty advisor. Please email the application, excluding the advisor letter, in asingle pdf to the chair of the Research Facilitation Committee, Shannon Sauer-Zavala, PhD, at [email protected]. Include "Graduate Student Research Grant" in your subject heading. Please ask your faculty advisor to e-mail aletter of support separately. Application deadline: March 1, 2021

Nominations for the following award are solicited from members of the ABCT governance: Outstanding Service to ABCT Please complete the nomination form found online at www.abct.org/awards/. Then e-mail the completed form and associated materials as one pdf document to [email protected]. Include “Outstanding Service” in the subject line. Nomination deadline: March 1, 2021.

For details on all ABCT Awards, visit our websiteatwww.abct.org

October • 2020 277 ABCT s Renew

...because, in these uncertain times, “membership”iscrucial. ABCT provides a ground. Aground of training, of learning, of collaborating, of rethinking. When you renew,werenew— when youuncover new expertise and awareness at the convention or through awebinar,when youjoin aSIG, when youforge connection with colleagues on the list serve,when youtakeaction and vote,when youabsorb new insights from a journal article, when yougain aclient from Find aCBT Therapist, this vitality carries us all. Our aim is to help sustain, on may levels, your crucial work in this world. In light of these precarious times, at ABCT youcan count on: ◊ the cost of renewing your membership will hold steady for 2021 ◊ virtual convention registration demonstrates significantly reduced rates ◊ webinars, at $20 for members, will maintain this modest ratein2021 ◊ convention CE will be nominal for those demonstrating need ◊ anew category, Community Practitioner,has been added to registration

Visit us at www.abct.org and click

rEnEW •

278 the Behavior Therapist 2020 Award Winners awards&Recognition

Lifetime Achievement Award John R. Z. Abela Student Dissertation Award Richard G. Heimberg, Temple University ChristopherJ.Senior, M.A., Catholic University of America Outstanding Mentor David A. F. Haaga, Ph.D., Professor of Psychology, Student Research Grant American University Kelsey Pritchard, University of Toledo HOnORABLE MEnTIOn:Christina L. Verzijl, B.A., Anne Marie Albano Early Career Award for University of South Florida the Integration of Science and Practice Emily L. Bilek, Ph.D., ABPP, University of Michigan President’s New Researcher Joseph McGuire, Ph.D., Johns Hopkins University Sobell Innovative Addictions Research Award School of Medicine Christopher Correia, Ph.D., Auburn University Student Travel Award Distinguished Friend to Behavior Therapy Katherine Venturo-Conerly, Harvard University Andrea Petersen, Wall Street Journal in-house writer, who consistently takes aCBT approach Elsie Ramos Memorial Student Poster Awards when covering mental health •Danielle Weber, M.A., University of North Carolina at Chapel Hill:“Patterns of Emotional Outstanding Service to ABCT Communication in Same-Sex Female Couples Lata K. McGinn, Ph.D., Yeshiva University Before and After Couple Therapy” and Cognitive Behavioral Consultants •Gemma T. Wallace, B.A., Colorado State University: “Personality and Emotion Dysregulation Virginia A. Roswell Student Dissertation Dimensions Differentially Predict Engagement in a Wide Range of Self-Injurious and Health-Risk Award Behaviors” Alexandra Werntz Czywczynski, M.A., University of •Rachel Weiler, MSc, PGSP-Stanford PsyD Virginia and University of Massachusetts Boston Consortium:“Is Dialectical Behavior Therapy aGood Fit for Transgender and Gender nonbinary Leonard Krasner Student Dissertation Award Patients?” nur Hani Zainal, M.S., Pennsylvania State University

Visit www.abct.org/Awards: •Past winners •Champions program •Comprehensive list of all awards •Call for2021Nominations •Awards &Recognition Committee

October • 2020 279 the Behavior Therapist PRSRTSTD Association for Behavioral U.S. POSTAGE and Cognitive Therapies PAID 305 Seventh Avenue, 16th floor new York, nY 10001-6008 Hanover,PA 212-647-1890 |www.abct.org Permit No. 4

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ABCT VOTING 2020

VOTE for ABCT’s future during the month of November: President, Representative-at-Large, &Secretary-Treasurer. Let your voice be heard!

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