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

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Article

Support for At-Risk Girls

A School-Based Mental Health Nursing Initiative Journal of Holistic Nursing
American Holistic Nurses Association
Volume 33 Number 3
September 2015 228237
Pamela Adamshick, PhD, RN, PMHCNS-BC The Author(s) 2014
10.1177/0898010114564683
Moravian College, Bethlehem, PA, USA http://jhn.sagepub.com

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

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

Background and Significance early assessment and identification, fragmented ser-

vices, challenges in accurately diagnosing mental
Mental health needs among children and adoles- health problems, and disparities in access to care
cents are extremely prevalent, with an annual esti- (U.S. Public Health Service, 2000). According to
mate of 14% to 20% of youth manifesting mental, recent data compiled by the USDHHS (2013), these
emotional, or behavioral disorders (Institute of challenges persist, with increased prevalence rates of
Medicine & National Research Council, 2009; U.S. mental disorders reported in children between 2005
Department of Health and Human Services and 2011. Treatment for mental disorders is also
[USDHHS], 2013). These disorders include diag- lacking. In the past year, 60.1% of older adolescents
nosable psychiatric disorders and also problem diagnosed with a major depressive episode did not
behaviors such as aggression, violence, and sub- receive intervention (Substance Abuse and Mental
stance use. The purpose of this article is to describe Health Services Administration, Center for Behavioral
an advanced nursing practice mental health initia- Health Statistics and Quality, 2014). Absence of a
tive for teenage girls at risk for mental health disor- dedicated surveillance system to capture the preva-
ders, based on Hildegard Peplaus nursing theory, lence of all childhood mental disorders continues to
group process, and healing through holistic health impede achievement of outcomes for prevention and
approaches. treatment of mental disorders (USDHHS, 2013).
Seventy-five percent of mental illness begins
before age 25 (Insel, National Council on Behavioral
Health, 2014). Yet only 20% of children with mental Authors Note: Please address correspondence to Pamela
Adamshick, PhD, RN, PMHCNS-BC, Associate Professor of
health problems receive appropriate treatment. Nursing, Moravian College, 1200 Main Street, Bethlehem, PA
Reasons for these deficits include stigma, lack of 18018, USA; e-mail: adamshp@moravian.edu.

Adding to the complexity of addressing mental
health needs is the impact of poverty and ethnic
diversity among youth in the United States. The
Hispanic population is rapidly increasing in the
United States, with Hispanic adolescents the largest
and fastest growing minority in the adolescent age-
group (Kurtzleben, 2010; Rothe, 2004). Hispanic
adolescents are at a heightened risk for emotional
distress due to poor socioeconomic resources, and
also discrimination (Alvarez, 2001; Potochnick &
Perreira, 2010). They are more likely to feel sad and
hopeless compared to adolescents from other ethnic
groups (Centers for Disease Control and Prevention,
2007). Their distress translates into the highest rate
of suicide attempts among any ethnic group of ado-
lescents, with Hispanics at 10.2%, African Americans
at 7.7%, and Whites at 5.6% (Centers for Disease
Control and Prevention, 2007).
Mental, emotional, and behavioral disorders are
costly not only in terms of lives lost, but in youths
functional ability, family stability, and productivity
loss for society. Youth who are burdened by mental
health problems struggle to achieve success in
school, healthy interpersonal relationships, and inte-
gration into the work force. They are also more likely
to experience residential instability and to engage in
delinquent behaviors (Substance Abuse and Mental
Health Services Administration, Center for
Behavioral Health Statistics and Quality, 2014).
Data from 2007 estimate the annual cost of such
disorders in youth at 247 billion dollars (Institute of
Medicine & National Research Council, 2009;
USDHHS, 2013). Considering a fragile economy,
coupled with a fragmented health care program, it is
not surprising that many youth slip through the
cracks and are neither adequately diagnosed nor
treated for existing mental health disorders nor iden-
tified for preventative services that might address
risk factors.
The RICHES Support Group
In tracing the history of the development of a
school-based support group (RICHES) for at-risk
adolescents, the Institute of Medicine (1994) report
Reducing Risks for Mental Disorders: Frontiers for
Preventive Intervention Research provided a salient
framework for addressing mental health problems in
young people. In particular, Institute of Medicine
interventions were designed to target at-risk groups
or individuals, with goals to modify risk factors and
Support for At-Risk Girls / Adamshick 229
promote protective factors. Research on mental
health programs with children and adolescents
found that primary prevention programs were sig-
nificant in reducing problems and promoting com-
petencies in children (Durlak & Wells, 1997).
In an effort to address mental health issues in
at-risk teens, RICHES, a school-based support
group, was formed. Two coincidental circumstances
in 1999 served as inspiration for the RICHES ini-
tiative. A community health partnership had
recently formed between a local hospital and com-
munity agencies representing medical, social, reli-
gious, and educational groups. The partnership
members completed a health needs assessment of
the local community. Findings revealed, among
other priorities, startling mental health concerns
among adolescents in the following areas: anger
and stress management; suicidal thoughts or
attempts; feelings of depression or anxiety; rela-
tionship problems with peers, parents, or guardi-
ans; and concerns for personal safety at school and
at home. The second inspirational circumstance
was a specific plea for help from the local high
school students, who wrote a letter to the editor of
the school newspaper describing high levels of
stress experienced by many students. The opportu-
nity for an advanced practice mental health nursing
initiative was evident.
Based on evidence citing schools as the most
suitable setting for adolescent mental health inter-
ventions (Lamb & Puskar, 1991) and the effective-
ness of group interventions with youth (Eggert,
Thompson, Herting, & Nicholas, 1995; Jacobson,
1991), a support group format was chosen for the
school mental health initiative. The group name,
RICHES, is an acronym for the core components or
focus areas of the group: relationships, identity,
communications, health, esteem, and support. The
belief in the individual riches and talents of each
group member was also a basic philosophy of the
group and rendered the name appropriate. This
advanced practice initiative was offered in a large
suburban high school in the northeastern United
States.
Research over the past decade reinforces group
experiences as a viable approach to address mental
health needs of adolescents (Gerrity & DeLucia-
Waack, 2007; Houck, Darnell, & Lussman, 2002).
Additional literature also highlights advantages of
school-based mental health and skills training
interventions, as they provide immediate opportunity
230 Journal of Holistic Nursing / Vol. 33, No. 3, September 2015
to apply learning to real-life situations in the class-
room and in peer relationships (Evans, Axelrod, &
Sapia, 2000). More recently, Hale, Fitzgerald-Yau,
and Viners (2014) systematic review identified
school-based interventions as effective for reduc-
ing health risk behaviors, including violence, in
adolescents.
To respond to priorities of access to care and
economical health resources, the group facilitators
decided to provide the intervention without charge to
students, and the facilitators volunteered their time.
Written permission from parents or guardians for
child participation in the support groups and other
partnership health activities was obtained. Group
sessions were held weekly for 45-minute intervals for
a series of 10 to 12 meetings during each semester of
the academic year. Membership included 5 to 10
students each semester, with some students continu-
ing into the subsequent semester or the following
year. The first offering of the group was gender-
mixed. Based on participant and facilitator evalua-
tion, the subsequent RICHES groups were
female-only, and the community partnership arranged
for a male-only group for at-risk male students.
The Group Facilitators
Two board certified advanced practice psychiat-
ric/mental health nurses, the author and a colleague,
were the initial cofacilitators for the RICHES group.
This arrangement was in place for a few years, until
the colleague moved away from the area. Since then,
masters or doctoral prepared nurses, with back-
grounds in mental health, pediatrics, or community
health nursing, have cofacilitated with the author,
contributing 2 to 4 year stints. The author provided
basic orientation to the facilitators on principles of
group dynamics. The facilitators engaged in brief
pre- and postgroup discussions about plans for the
group and evaluation of progress. The continuity in
the facilitator role has been important for fostering
group trust and cohesiveness.
The Population Served
Marginalized means to be on the outside or on
the boundaries, to be prevented from having atten-
tion or power, or to place [be placed] in a position of
marginal importance, influence, or power (Random
House Websters unabridged dictionary, 1998, p. 1175).
Based on this definition, there are many who may
be considered marginalized, or to whom the term
might be applied on particular occasions or circum-
stances in ones life. However, the sting of marginali-
zation is likely more intense, more pervasive,
depending on the number and type of areas in which
one feels marginalized. In the case of many high
school students, being marginalized may be an over-
riding factor due to an accumulation of several dis-
tinct ability-based circumstances, along with more
comprehensive identity-based circumstances, such
as ones ethnic or racial background, socioeconomic
status, and gender identity.
Counselors, the school nurse, health van nurse,
and teachers referred girls to the group. From the
inception of the RICHES initiative in 1999 through
May, 2014, over 380 hours of group sessions have
been provided to 220 participants. Clinically, these
numbers translate to lives affected by holistic nursing
care. Interventions with a population of vulnerable
girls modified their mental health risk factors and
promoted healthy coping and resilience through
ongoing support and connection with resources. The
participants, all female, ranged in age from 13 to 17
years, and their ethnic/racial identification was 60%
Hispanic, 30% White, and 10% Black. The students
referred for the RICHES group were typically experi-
encing marginalization, usually in several areas.
Unruly, aggressive behavior was one way that girls
expressed their distress and anxiety; while it margin-
alized them, ironically it also brought attention and a
certain degree of power over others. Although
RICHES was not specifically for anger management,
anger was the symptom that allowed girls (and their
needs) to be visible, and provided an access to inter-
vention. Physical fighting was often the primary rea-
son for referral to the RICHES group. Usually, this
consisted of girl-to-girl fighting. Specific vignettes
provide more insight into fighting events, their mean-
ing, and girls perspectives.
Many girls shared their experiences of academic
difficulties, including failure and repetition of a grade
level, special learning classes, and instances of feeling
shamed or ridiculed related to academic performance
in a class. Participants also identified situations of
racial/ethnic marginalization, which often triggered
their disruptive behavior. Gender identity was another
area in which some girls experienced marginalization.
A few participants, by self-report, were already in treat-
ment or had been in treatment for a mental health
problem or diagnosis. Almost every semester, the facili-
tators identified students in need of additional mental

health counseling and reported these cases through
the appropriate school channels.
Nursing Theory Framework
Hildegard Peplaus nursing theory of interper-
sonal relations applies to the holistic care process of
the RICHES initiative. Phenomenology, based on
observation and interpretation of human behaviors,
is the philosophical underpinning of Peplaus theory.
Peplau described her assumption that patients strug-
gle with everyday interpersonal difficulties or health
problems, and the nurse responds by fostering per-
sonality development in the direction of maturity for
the patient (Peterson, 2009, p. 208). Through the
verbal and nonverbal exchanges in the nursing situa-
tion, the nursepatient interactions can influence
recovery. Peplau also believed that psychobiological
experiences such as conflict, frustration, and anxiety
were sources of energy that had the potential to move
one toward both destructive and constructive actions
(Peplau, 1991). Through the process of the nurse
patient relationship, individuals can gain under-
standing of their experiences and learn productive
outcomes (Peterson, 2009).
The girls in the RICHES program had complex
problems and needs, wrapped around a core network
of vulnerabilities and emotions typical of adoles-
cents. The therapeutic relationship established with
the facilitators and the group members was the vehi-
cle to help girls move toward creative and construc-
tive problem solving. The goal, as applied from
Peplaus theory, was to assist members to convert
tension and anxiety into action for problem solving.
The Group Process
A signed confidentiality agreement was requested
of all group participants. The terms of the agreement
included maintaining group discussion issues as
confidential, with the exception of mandated report-
ing by facilitators of any situations that represented
a danger to self or others. Group development fol-
lowed stages as outlined by Yalom (1995). The stages
of orientation, conflict, and cohesiveness as applied
to the RICHES group are described.
Orientation
The orientation stage of group process was cen-
tered on building trust among members. Imbedded
Support for At-Risk Girls / Adamshick 231
in this process was the issue of respectful interac-
tions among members. Many members had little
exposure to active listening, either as the listener or
the recipient. Learning this basic communication
skill was pivotal for group work and individual
growth of members. Establishment of trust and
respect transpired gradually, building throughout
several sessions. Principles of Peplaus theory on
patient interactions that incorporate humane treat-
ment, dignity and respect, and healing discussion
guided group development over time.
Members particular needs and concerns were
the priority for weekly discussion. Often one of the
members brought a story or problem for which she
needed guidance or feedback. Crisis intervention
was also common. On several occasions, girls came
to the group angry, close to losing control after an
altercation in the hall or in a classroom. In the safety
of the group, they had the opportunity to think,
reframe, problem solve, and consider alternative
responses to their situations. Members comfort and
trust in the group were illustrated in sharing critical
information about rumored fights, including loca-
tions and times. With alerts passed on to school
authorities, student safety was preserved.
Conflict
The conflict stage is characterized by a shift from
acceptance and commitment to the group to a con-
cern over dominance and power of members (Yalom,
1995). In the RICHES group, the addition of new
participants often exerted a negative influence in the
group, as they flaunted an attitude, tested rules, and
often provoked havoc in the group. Tense moments
and altercations among the members were not unu-
sual under these circumstances, illustrating the con-
flict stage of group process (Yalom, 1995). The most
effective interventions were firm limits and constant
redirection, while acknowledging the anger and
encouraging verbal discussion of feelings. Usually
within a few sessions, the group progressed toward
sufficient cohesion to allow basic group respect and
cooperative interaction.
Cohesiveness
In the cohesiveness stage, group sessions focused
on skill development in several areas. Participants
desired help with conflictual relationships and han-
dling emotions. Group process was used to facilitate
232 Journal of Holistic Nursing / Vol. 33, No. 3, September 2015
members thinking, including problem solving and
recognizing consequences. Yalom (1995) describes
increase in morale, trust, and self-disclosure in the
cohesiveness stage. This was evident as members
acted out their conflicts in role-plays and gained
new perspectives on feelings of others and on how to
express themselves without aggression. Specific
exercises related to anger management were offered,
including recognition of triggers and physiological
indicators, types of anger behavior, and calming
strategies. Anger journals were suggested to help
members track their progress in anger incidence and
reduction. Many members attested to high levels of
anxiety and stress in their lives. Interventions tar-
geted root cause analysis and basic strategies to
promote self-care and healthy lifestyles.
Education was also an ongoing focus during
group sessions. Health topics assumed high priority,
the range including sexually transmitted diseases,
awareness of ones sexuality and maintaining per-
sonal sexual boundaries and safety, drug use, nutri-
tion, prescription medication, dating violence, and
mental health concerns.
The curative power of groups is related to several
factors that help promote change in the members
(Yalom, 1995). The predominant curative factors
operating in the RICHES group included the univer-
sality of experience, the instillation of hope, develop-
ment of socializing techniques, information giving,
interpersonal learning, catharsis, and group cohe-
siveness (Yalom, 1995). Shared discussion allowed
common identification of problems and a repertoire
of resources and alternatives for solutions. Holistic
health practices were incorporated throughout the
series of group sessions. The facilitators suggested
and educated members on spirituality and relaxation
strategies, journal writing, music for relaxation, find-
ing and using supportive people and resources, and
exercise outlets.
Challenges
Personal engagement in acknowledging, think-
ing about, and coping with their problems did not
come easily to most RICHES members. Denial was
a predictable barrier, which provided an escape for
several members. After attending only one session, a
common refrain was, I dont have a problem. I dont
know who referred me to this group or why. Others
in denial had no choice but to attend, in conjunction
with juvenile probation requirements.
Achieving and maintaining safety, both physical
and emotional, in the group was an absolute priority.
Girls referred to the group often knew each other,
and, in some cases, had fought one another or had
participated in relationally aggressive behaviors that
contributed to girls experience of feeling marginal-
ized. The facilitators typically did not know this
information until or unless members shared it with
the group. Comments on gender identity or racial/
ethnic background were the cruelest and most hurt-
ful, causing the most derision in the group. Once a
safe environment was assured, the conflicts provided
salient opportunity to discuss the many factors
related to aggression and marginalization, and to
propose appropriate interactions. Any advance
notices of potential fights were critical to student
safety, and rumors were conveyed to school authori-
ties.
Group Themes
The topics of group discussion spanned a gamut
encompassing fights with peers; anxiety and stress;
healing after trauma and loss; causes of anger and
ways to express anger; dealing with rumors, jealousy,
and bullying; cyber or social media incidents; asser-
tive communication; life goals; health and illness;
and relationships, including parental, friendships,
and dating. The selected themes of fighting, trauma,
and toxic relationships are described in vignettes to
allow for enhanced understanding of the health
needs and the healing process as facilitated through
this mental health initiative. These themes represent
the overarching areas of critical impact in girls lives,
under which many of the other topics were sub-
sumed. Pseudonyms are used to protect the identity
of participants.
Vignette on Fighting.Girl-to-girl fights were a fre-
quent discussion topic. Angelette, an Hispanic fresh-
man, described a fight with another girl, which began
with loud rhythmic clapping, a preemptive signal.
There was not a clearly defined reason for the fight,
but Angelette described feeling the other girl had
disrespected her with eye-rolling and giving atti-
tude. This progressed to Angelette punching the girl
in the face and slamming her into the wall. Several
group members chimed in with similar fight stories,
seeming to compete for most dramatic fighting event.
Discussion revealed that fights were often planned,
and friends had to be nearby and had to be able to

provide assistance during a fight. Girls in this session
concurred that one of the criteria for choosing a
friend was that she be able to fight in a physical way.
Group members had been shown how to fight by
mothers, brothers, or other family members. Girls
described being admonished and scolded by mothers
if they did not fight and stand up for themselves. It
was a necessity to be a good fighter, to be able to
preserve ones rank or recognition. Anger was not
always part of the equation in a fight; the priority was
to maintain ones identity as one who fights and is
not a punk. Universality of experience was a group
curative factor at work in these discussions. Fighting
provided a common connection among the members
that overcame the sense of marginalization that oth-
ers had assigned to their behavior. Members, even
those who were nonfighters, accepted one another
and felt less isolated.
Vignette on Trauma. Many participants had experi-
enced devastating types of traumatic life events,
such as rape or other attack, loss of a family member
in a fire, and witnessing the death of a family mem-
ber who had been the victim of a neighborhood
shooting. Mercedes, a junior who was Hispanic,
shared a vivid memory of being raped repeatedly at
age 9 by a man known to her and her family. She
recounted the brutalities she endured, terrifying
uncertainty each day, and lack of safety and support
within her family structure. Yet she was resilient, a
survivor, and remarkably insightful regarding the
contribution of that experience to her school prob-
lems, emotional distress, and persistent anger issues.
Mercedess case illustrates healing factors of the
group process. Her story instilled hope in other
members as they witnessed her strength and empow-
erment over adversity. Mercedes herself experienced
healing through the cathartic telling of her story,
gaining mastery over a horrific event through pur-
poseful review in a safe situation where she felt trust
and acceptance. Perhaps most important, the heal-
ing and curative factor of group cohesiveness enabled
Mercedes to feel connected in a caring situation,
bonded with members, and in a place where she
experienced belonging and acceptance.
Vignette on Toxic Relationships. Relationships of all
kinds were a major group discussion topic each
week. In most cases, the relationships were layered
with troubles or conflicts. Kendra was African
American, a junior, and a mother of twins. She was
Support for At-Risk Girls / Adamshick 233
a labile presence in the group and highly emotional,
alternating between tears and anger on most days.
She frequently contributed an ongoing story about
a relationship with a male who, now incarcerated,
was nonetheless uppermost in her life. Although
she presented evidence of his selfishness, abusive
qualities, and untrustworthiness, she was also
enamored by his attention to her and declarations
of caring for her. She indicated his future plans
included moving in with Kendra after he was
released from prison.
Kendras history included a violent rape by a
known perpetrator, which resulted in the twins
birth; she had moved to the new town in order to
lessen the possibility of meeting up with her rapist.
Kendra lived with her mother, but the relationship
was conflictual with inconsistent support. Group
feedback to Kendra often encouraged her to con-
sider the toxic qualities of her relationship with the
incarcerated male. Over time, she displayed a glim-
mer of insight and uncertainty about the health of
the relationship for herself and her children. One of
the group members, herself a survivor of toxic rela-
tionships, took that opportunity to share an observa-
tion with Kendra:
Youve been looking at that relationship with rose-
colored glasses and that made everything look great.
Now you have the glasses off and you are seeing
everything in black and white and that makes it
bland and not as interesting. You need to realize how
it looks now, and that is how it really is.
This exemplar illustrates the group curative and
healing factor of interpersonal learning (Yalom,
1995).
Kendra was able to gather data about her inter-
personal behaviors as witnessed by others.
Subsequently, she gained greater understanding of
herself, ultimately assuming changes in cognitions
and reactions. Healing occurred for all members as
illustrated by the development of socializing tech-
niques. In particular, members exhibited greater
ability to listen and talk with each other, showing
respect and regard for struggles and growth in one
another. Members were empathetic and understand-
ing of Kendras newfound and thoughtful efforts to
control her unstable affect, outbursts, and crude
remarks. These were social techniques and practices
members could take forward in their daily communi-
cations with others.
234 Journal of Holistic Nursing / Vol. 33, No. 3, September 2015
Discussion
The cases portrayed by the group members reso-
nate with research findings on similar mental health
concerns. Girls who fight physically are often from
situations where fighting is normative. Literature
depicts reasons for girls fighting, suggesting both
protection issues and the desire to be recognized or
esteemed for fighting ability (Adamschick, 2010;
Ness, 2004). Nesss (2004) ethnographic study of
inner-city girls from Philadelphia deciphered the
layered cultural and social issues that influenced
girls violence. Safety as a hierarchal need required
knowing how to stand up for oneself, making street
fighting a necessity. Being able to fight also provided
a valuable enhancement to a girls status (Ness,
2004) and/or was a core aspect of how a girl defined
herself (Adamschick, 2010). Similar to the girls in
the RICHES group, girls from high-risk backgrounds
have been coached and educated on ways of fighting
by mothers or other family members who recognize
the need for self-defense and safety in their social
and cultural environments (Adamschick, 2010;
Ness, 2004).
Strategies to address fighting were two-pronged.
Girls needed assistance with basic anger manage-
ment, which was handled through cognitivebehav-
ioral approaches. In addition, attention was given to
the sense of mastery, esteem, identity, and connec-
tion with other girls operationalized through fight-
ing. Understanding the role of friendship and
connection in girls lives, the facilitators channeled
discussions toward qualities of friendships and
healthy relationships. Self-respect and respect for
others factored into these discussions and provided
opportunity to broach topics about identity and girls
hopes and goals for their future.
The majority of the girls in the RICHES group
described having experienced some type of trauma,
and in many cases, girls were severely traumatized.
According to neurodevelopmental research, the
sequential development of the brain dictates which
areas and related functions are affected by trauma
events as a child ages (Perry, 2009). Repeated adverse
experiences such as neglect, sense of threat, loss, and
injury lead to changes in the stress response net-
works of the brain. Ultimately, molecular structures
and brain systems are disrupted, and the altered
reactivity of the stress response system essentially
produces a constant state of high alert necessitating
a fight or flight reaction (Perry, 2009). Based on this,
it is highly understandable how traumatized individu-
als such as the girls in the RICHES group displayed
emotional instability, were on edge, hypervigilant,
easily annoyed, and inclined to misinterpret normal
environmental cues as threatening. Perry (2009)
advises an elaborate neurosequential model of thera-
peutics with maltreated children to counteract the
disturbed pathways. Cognitivebehavioral techniques
can be helpful in older children once self-regulation
and relational skills have improved (Perry, 2009).
Interventions with members in the RICHES
group included cognitivebehavioral strategies for
hyperarousal, whether linked to trauma or to anger
scenarios. Girls were assisted to identify triggers for
their arousal and the accompanying physiological
responses, such as sweating, flushing, tensing, and
rapid breathing. Emphasis was placed on noting the
very earliest sign of distress, and immediate imple-
mentation of a type of deescalation strategy to avoid
aggressive or heightened anxiety feelings spiraling
out of control. The group members assisted one
another to recognize cognitive distortions, as these
prevented them from seeing situations realistically.
Cognitive restructuring, the pivotal work to change
behavior, required group members to rethink possi-
ble solutions to their anger or arousal responses and
to substitute a more acceptable behavior (Feindler &
Engel, 2011). The combinations of these strategies
were repeated frequently in the group setting for
topics related to anger management.
Varied terms and definitions are used to describe
violent personal relationships, including dating vio-
lence and intimate partner violence. Common com-
ponents, however, are consistent across definitions,
and include physical, sexual, emotional, or psycho-
logical types of abuse. According to data from a
national study, 1 out of 11 adolescents report being
a victim of dating violence, with 9.3% Hispanics and
13.9% African Americans being victims, compared to
7% Whites (Halpern, Oslak, Young, Martin, &
Kupper, 2001). Literature also reveals the higher
risk for posttraumatic stress disorder and other men-
tal health problems among victims of dating violence
as compared to nonvictims (Rizzo, Esposito-
Smythers, Spirito, & Thompson, 2010).
In phenomenological research on teenage lived
experience of abusive partner relationships, girls
described feeling disconnected from family or friend
support, uncertainty in understanding their relationship

experiences and their needs for affection, and a gen-
eral feeling of powerlessness (Reynolds & Shepherd,
2011). The RICHES exemplar vignette of toxic rela-
tionships mirrors these findings, including the mental
health risk for victims and the feeling of being adrift
from family.
Research on school-based interventions suggests
abusive relationships are the elephant in the room in
terms of lack of protocols for addressing the prob-
lem. In a recent national study of high school nurses
(N = 750), about half reported assisting a victim of
dating violence, usually by referring the student to a
counselor. Yet 79.5% of those nurses responding
reported that their schools did not have a specific
protocol for intervention in a dating violence inci-
dent. Also, 70% of the nurses reported a lack of
training on how to assist a victim of dating violence
in particular (Khubchandani, Telljohann, Price,
Dake, & Hendershot, 2013).
Interventions suggested in the literature include
broad school approaches such as awareness and edu-
cation of staff, students, and administrators on dat-
ing violence and a clearly defined policy that addresses
the problem (Khubchandani et al., 2103). Findings
from a qualitative study identify school-based strate-
gies for individualized care, beginning with safe
places for students to discuss violence issues
(Reynolds & Shepherd, 2011). Their findings also
cite the importance of assisting victims to reframe a
relationship as abusive, recognizing behaviors as abu-
sive rather than normative or caring. In addition to
the reframing strategy, the support group approach
offers another dimension for use in school settings.
Using the group process format, RICHES provided
an opportunity for case finding, intervention, and
education on the topic of abusive relationships.
Outcomes
Participants completed pre- and postgroup self-
assessments that measured progress in five areas:
anger management, stress management, relation-
ships, self-esteem, and future orientation.
Respondents were asked to rate their degree of
satisfaction in the designated areas from 1 to 4, with
1 = not at all satisfactory, 2 = somewhat satisfactory,
3 = satisfactory, and 4 = very satisfactory. While
matched pre- and postgroup self-assessments were
not compared, overall pre and post group scores for
selected cohorts showed increase in mean scores, as
shown in Table 1.
Support for At-Risk Girls / Adamshick 235
Table 1. Degree of Satisfaction in Self-Assessment
Areas
Pregroup Postgroup
Anger management 2.19 2.76
Stress management 2.41 2.56
Relationships with impor- 2.94 3.32
tant people
Self-esteem 2.81 3.12
Future orientation 3.09 3.16
In narrative data, typical participant responses
about the most helpful aspects of the group included
helps me control my anger and helps me under-
stand where others are coming from, learned how
to control my anger, helped calm me down, help-
ing my anger and how to deal with certain prob-
lems, being able to communicate with others, and
the group leaders.
Group members often were referred for addi-
tional individual treatment with counselors, or they
were connected with agencies for need-specific
assistance. The facilitators followed reporting pro-
cesses for students who were at risk for personal
harm due to violent relationships.
As for any type of treatment, ongoing client par-
ticipation was essential for safe and effective care. In
the case of the members in the RICHES group, fol-
low-through was related to trust. As the girls gained
trust in the group experience, they continued to
attend and often proclaimed they looked forward to
the group sessions. Healing occurred through several
integrated processes. The nursepatient relationship
as described in Peplaus theory was one of the pillars
that sustained member investment and movement
toward personality growth. Healing took place through
recognizing and understanding meanings of behavior,
always guiding the members toward discovery of
aspects of the self that were previously unknown
(Peterson, 2009). The group experience was the other
pillar that contributed to healing and hope. Layered
on the foundation of group and relationship princi-
ples, other holistic healing processes included cogni-
tivebehavioral strategies, healthy lifestyle education,
discussion of coping skills, relaxation techniques,
self-affirmation, and compassionate regard.
Conclusion and Implications
Healthy People 2020 goals indicate that the
United States needs to continue to advance an
236 Journal of Holistic Nursing / Vol. 33, No. 3, September 2015
agenda for mental health of youth, with attention to
strategies aimed at violence and other issues that
remain risk factors for mental, emotional, and
behavioral disorders in youth (USDHHS & Office
of Disease Prevention and Health Promotion,
2012). An implication for nursing practice is use of
support groups such as the RICHES initiative to
advocate for mental health. It is an avenue for sup-
port and connection, offering a resource and heal-
ing alternative for at-risk girls. In-school support
groups provide an economical and readily available
access to care, perhaps a lifeline for youth who oth-
erwise falter. Teens might remain in school rather
than opting out, if they experience a connection
with at least one person.
Implications for nursing education should be
targeted at school nurses and those seeking nurse
practitioner roles in psychiatric/mental health
nursing or any advanced practice nurse role.
Advanced practice nurses may benefit from expo-
sure to the realities of vulnerable youth in the
school setting, where common problems include
fighting, bullying, dating violence, trauma seque-
lae, and diagnosable mental health disorders. Such
situations will inform their understanding and care
of teens in both primary and acute care settings.
Those nurses seeking advanced psychiatric nursing
roles should be encouraged to seek clinical prac-
tice in school settings where they can influence
mental health promotion and care for at-risk popu-
lations. Outcomes from the RICHES initiative
establish beginning validation of the clinical impact
of advanced practice psychiatric nurses in contrib-
uting to stabilization of vulnerable youth, promo-
tion of positive coping, problem solving, and
resilience, and reduced risk for mental health
exacerbations.
An implication for research is to test the effec-
tiveness of support groups to reduce the many facets
of violent relationships in at-risk girls. It is also
important to consider primary prevention. Further
research should address the efficacy of support
groups to modify risk factors and promote healthy
behaviors and relationships. Research findings
(Khubchandani et al., 2013) suggest that school
nurses might benefit from a standardized compe-
tency to guide interventions related to dating vio-
lence. Additional research should examine
approaches for detection and intervention in teen
dating/relationship violence with goals to develop a
national guideline or protocol for sensitive and
timely intervention.
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Pamela Adamshick, PhD, RN, PMHCNS-BC, holds certifica-
tion as an advanced practice nurse and is engaged in education
and practice in psychiatric/mental health nursing. She has com-
pleted research on girl-to-girl aggression and the experience of
cultural immersion in registered nurses. She currently is an
Associate Professor of nursing, teaching in the Masters,
Baccalaureate, and RN-BS completion programs.