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Exploring Treatments of Childhood Sexual

Abuse
Todd L. Grande, Andrew Lightfoot, Chelsey Davis and Elizabeth Adair
Wilmington University
Author Note:
Todd Grande, Ph.D., LPCMH, LCDP, CAADC, NCC is a Licensed Professional Counselor
of Mental Health (LPCMH), Licensed Chemical Dependency Professional (LCDP),
National Certified Counselor (NCC), and Certified Advanced Alcohol and Drug Counselor
(CAADC) in the State of Delaware. He holds a Master’s of Science in Community Counseling
from Wilmington University and a Ph.D. in Counselor Education and Supervision from
Regent University. He is an assistant professor in Wilmington University’s CACREP-
accredited Clinical Mental Health Counseling program. Andrew W. Lightfoot, M.S.. is
currently working as a therapist at Eagleville Hospital treating individuals with addiction
and co-occurring disorders. Chelsey M Davis, M.S., is a recent graduate from Wilmington
University, with her masters in Mental Health Counseling. Elizabeth Adair, M.S., NCC,
LAC, is a Licensed Associate Counselor (LAC) in the State of New Jersey and a National
Certified Counselor (NCC). She is a graduate of the Clinical Mental Health Program at
Wilmington University where she is also a faculty member. Correspondence concerning
this article should be addressed to Chelsey M. Davis, 16 Pelham Drive, Landenberg, PA
19350. Email: P Cdavis024@my.wilmu.edu

Abstract
The researchers discuss the severity of issues occurring because of childhood sexual abuse.
They describe the importance of encouraging further research to explore childhood sexual
abuse treatment options and introduce the need for exploratory research of a four-phased
treatment modality that combines several current treatment techniques used in many of
today’s treatment facilities. Researchers sought to add to existing childhood sexual abuse
treatment knowledge by collecting outcome assessment data from a local childhood sexual
abuse treatment clinic using this treatment. The participants (n = 74) were administered
the SCL-90-R before and after treatment, and the results were analyzed using a dependent
sample t-test. Clients improved across nearly every symptom scale of the SCL-90-R.
Keywords: Childhood Sexual Abuse, trauma, PTSD, Gestalt Therapy, psychoeducation

Exploring Treatments of Childhood Sexual Abuse


The importance and influence of positive childhood experiences for long term
health and wellness are without debate. Unfortunately, many children are subject to
experiences of a vastly different nature; one of trauma, victimization, abuse of varying
types, and neglect. Childhood sexual abuse is traumatic, difficult to treat, and has long-term
adverse consequences for its victims (Dube et al., 2001; Elkjaer, Kristensen, Mortensen,
Poulsen, & Lau, 2013). Victims of childhood sexual abuse may experience interpersonal
and somatic issues including: (a) sexually based anxieties, (b) increased rates of divorce,
(c) struggle to maintain a monogamous relationship, (d) shame, guilt, feelings of low
self-worth, (e) antisocial behavior, or (f) problems securing healthy relationships moving

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forward (Hunter, 2006; Sigurdardottir, Halldorsdottir, & Bender, 2012).
Individuals who have a history of childhood sexual abuse are ten times more likely
to be diagnosed with mental disorders (Sigurdardottir et al., 2012) such as PTSD, anxiety,
and depression. They are more likely to exhibit behaviors relating to suicidal ideation and
the abuse of alcohol (Gibb, Chelminski, & Zimmerman, 2007; Green et al., 2006; Ozbaran,
Erermis, Bukusoglu, Bildik, & Tamar, 2009). Adverse childhood experiences may more
than double an individual’s risk of suicide; these suicidal feelings are often associated with
a lack of self-esteem and the internalization of negative emotions (Dube et al., 2001).
Several studies identify comorbid diagnoses in clients who have experienced
childhood sexual abuse, such as PTSD (Green et al., 2006), depression (Cort et al., 2012),
and dissociative disorders (Jepson, Langeland, Sexton, & Heir, 2013). These comorbid
diagnoses have a vast impact on further treatment. Green et al. (2006) established that clients
who suffered with PTSD resulted in physical, mental and social deficiencies, including but
not limited to difficulty maintaining relationships and social-emotional regulation. Due
to the three-fold effect physically, mentally, and socially of these comorbid diagnoses,
it is encouraged that further research be conducted in efforts of achieving overall health,
wellness, and healing with clients who have experienced childhood sexual abuse.
Some studies were conducted on integrative techniques with this population
such as: (a) trauma-focused group psychotherapy (TFGT), (b) present focused group
psychotherapy (PFGT), (Classen et al., 2011), (c) systemic group psychotherapy (Elkjaer
et al., 2014), and (d) a combination of individual and group therapies that work through
past trauma and present functioning (Cort et al., 2012; Jepsen, Langeland, Sexton, & Heir,
2013).
TFGT includes the exploration and identification of traumatic memories at a
pace that is both safe and comfortable for the client. The goal of this practice is to further
understand the continued impact of trauma on social relationships, and ones’ view of
self. The intent is to facilitate cognitive restructuring, in efforts of limiting the lasting
impact on the client’s future abilities and functioning. PFGT focuses on the present group
functioning and behaviors that emerge throughout the therapy process that may inhibit
growth, interpersonal interactions, and distorted thinking surrounding others and view of
self (Classen et al., 2011). Systemic group therapy includes a briefer psycho-educational
approach focusing on current guilt, and receiving validation (Lau & Kristensen, 2007).
The results of these studies were mixed. When Classen et. al. (2011) studied
the effectiveness of TFGT and PFGT, the researchers found no difference between the
treatment and control groups. Systemic group psychotherapy resulted in less drastic
initial improvement of psychological health, but these small gains lasted longer than other
previous treatments (Elkjaer et al., 2014). Contrary to these results, Jepsen et. al. discovered
significant and lasting decreases in psychiatric symptoms measured on the SCL-90-R,
when used as a dependent variable in the multivariate analysis of the variance (MANOVA)
with repeated measures (Jepsen et al., 2013). This study set the precedence for the design
described in this discussion.
Research into group psychotherapy showed a reduction in symptoms of clients who
have experienced childhood sexual abuse, including risky behaviors of re-victimization,
drug use, and risky sexual practices (Classen et al., 2011). This therapy also demonstrated
a reduction in PTSD related symptoms on the Impact of Event Scale (IES), depression
on the Beck Depression Inventory-II (BDI-II), and general psychiatric symptoms on the

Spring 2017 55
Symptom Checklist-90-Revised (SCL-90-R; Jepsen et al., 2013). However, Jepsen et al.
(2013) found that group and individual psychotherapy did not impact symptoms on the
Dissociative Experiences Scale-II (DES-II). Due to these mixed results, more research is
required to further explore these options.

Review of the Experimental Treatment


For this study we explored the effectiveness of utilizing a treatment model
consisting of four phases: (a) Safety and Stabilization, (b) Working through Trauma, (c)
Reconnection, and (d) Aftercare. These phases were developed and implemented at a
treatment facility in New Castle, DE, known as SOAR: Survivors of Abuse in Recovery.
SOAR attempted to implement a mixture of several of the main interventions described
in this paper, including psychoeducation, Gestalt group therapy, and interpersonal skill
building. The first phase (Safety and Stabilization) is a 12 week psychoeducational
program focusing on informing the patients on the effects of trauma. The patients then
move into Working through Their Trauma by engaging in a 16 week program of Gestalt
group therapy, and the participants finished the treatment with 12 weeks of Reconnection,
traditional group therapy focusing on intimacy and interpersonal skills. The data was
collected from the results from the admission and completion SCL-90-Rs. Evidence based
strategies such as psychoeducation, Gestalt group therapy, and interpersonal skill building
are incorporated into the treatment model.
Although research shows that psychoeducation is most effective when used
to prepare for a future traumatic event (Wessely et al., 2008), other studies still present
moderate decreases in symptoms from PTSD, learned helplessness, and irrational beliefs
when using psychoeducation after a traumatic event of sexual abuse (Lubin, Loris, Burt,
& Johnson, 1998; Ulusoy & Duy, 2013). Established treatment facilities, such as the Sex
Abuse Treatment Center at Kapi’olani Medical Center, have implemented evidence based
psychoeducational techniques into their standard treatment model (Sex Abuse Treatment
Center, 2014).
The evidence based therapeutic technique used in this study is Gestalt based group
therapy. Gestalt therapy has proven effective when treating clients who have experienced
childhood sexual abuse due to the ability of recreating the traumatic events into challenges
that have been overcome through guided imagery (Denton, 2014; Trask, Walsh, & DiLillo,
2011). Other Gestalt based group therapy practices include bringing the group to present
awareness and reframing questions into statements (Passons, 1972). Other studies have also
shown that group therapy is one of the most effective treatments in decreasing presenting
symptoms of PTSD (Llewelyn, 1997; Martsolf & Draucker, 2005).
Learning to reconnect with others is important to clients who have experienced
childhood sexual abuse and is the last required phase of the study. The theory and work
of Yalom has revealed the strength of group therapy through the instillation of hope and
comradery (Yalom & Leszcz, 2008), especially when utilizing the mentality of group-
fostered self-esteem and well-being by demonstrating the common themes of struggle
and growth. (Marmarosh, Holtz & Schottenbauer, 2005). The growth of interpersonal
relationships and coping strategies helps individuals cope with trauma; clients have
reported better outcomes due to connecting with others of similar traumatization (Anderson
& Hiersteiner, 2008).
The purpose of this research is to determine how effective treatment modalities

56 THE WISCONSIN COUNSELING JOURNAL


used in and by community mental health programs are when working with clients. The
treatment offered in this study addresses the symptoms listed in the SCL-90-R and the
purpose of this research analysis is to explore a current treatment model for clients who
have experienced childhood sexual abuse. The research question for this study is as follows:
“Would a treatment model that encompasses the Gestalt therapy, psychoeducation, and
interpersonal skill building decrease a subject’s negative symptoms on the SCL-90-R?”

Method
The purpose of this research was to explore changes in the SCL-90-R scales after
completing a Gestalt oriented four phase treatment regimens. This study consisted of 74
participants chosen through convenience sampling who were given the SCL-90-R for both
pre- and posttests. The data were analyzed using a dependent-sample t-test (Chard, 2005;
Martsolf & Draucker, 2005; Sultan & Long, 1988).

Analysis
The researchers weighed the benefit of using a Bonferroni correction to control
for the possibility of an inflated type I error rate in the analysis results. However, it was
determined that the SCL-90-R scales represent distinct mental health constructs and not
multiple measures of the same construct. Therefore, a Bonferroni correction, or other
similar correction to control for inflated type I error, would not be consistent with the
original purpose of the analysis. The intent of the analysis was to maintain an alpha of .05
for rejecting or accepting the null hypothesis on each scale individually (Armstrong, 2014).

Participants
The participants for this study were chosen from a treatment center within the
Mid-Atlantic region. The agency’s main purpose is to treat individuals who suffer with
symptoms due to sexual trauma. The sexual trauma may include: (a) molestation, (b) rape,
or (c) inappropriate touching. However, this study did not exclude or differentiate for these
criteria. The agency accepted the participants for treatment based solely on their self-report
of childhood sexual trauma, and entry into treatment for said abuse was voluntary based on
willingness to participate in treatment modality. The sample was made up of adult clients
(n = 74) and ranged in age from 18 to 66 years, with a mean age of thirty-six years and a
standard deviation of thirteen years. In the sample population of seventy-four, four of the
assessed clients were male.

Procedure
Participants approached the facility for services and were given the SCL-90-R
along with the other normal agency documentation such as: (a) demographic surveys,
(b) questionnaires, (c) billing information, (d) identification, and (e) insurance. Informed
consent for the study was included in the preliminary paperwork prior to meeting with
researchers conducting the study. Clients were informed that their information would be
kept confidential but may be used in research to improve overall agency treatment. The
assessments were completed at the testing agency in a 45-60-minute time frame and the
SCL-90-R was administered before and after treatment. To protect the participants’ identity
and confidentiality, the response sheets were coded and kept secure in the treatment facility.
The data then entered a password-secured spreadsheet for collection and analysis

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in SPSS. Data collection was conducted at the agency under supervision of a lead
researcher. All the site procedures were compliant with HIPAA laws and ethical guidelines
set by agency administration. Clients’ participation began with two assessment interviews.
Clients undergoing the program participated in individual psychotherapy in addition to a
four-phase group program with each phase directed towards a specific focus: (a) Safety and
Stabilization, (b) Working Through Trauma, (c) Reconnection, and (d) Aftercare.

Measures
The effectiveness of the treatment program was measured using the Symptom
Checklist-90 Revised (SCL-90-R). The SCL-90-R is a questionnaire used to measure a
client’s self-reported symptoms in nine separate symptom scales (somatization, obsessive-
compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety,
paranoid ideation, and psychoticism) and 3 global indices (global severity, positive
symptom distress, and positive symptom total; Pearson, 2014). The measure is comprised
of 90 testing items ascertaining the client’s self-reported distress over the previous seven
days. The items are ranked on a Likert scale ranging 0-4 in representation of ‘not at all’
to ‘extremely likely’ that a symptom relating to the above scales occurred. It is often used
in measuring outcomes in research focused on psychotherapy, such as the interventions
used in this study (Pederson & Karterud, 2004). Research supports that the SCL-90-R
demonstrates high construct and high concurrent validity when compared to other testing
measures, with a fair to moderate level of accurate and reliable prediction in evaluation
(Grande, Newmeyer, Underwood & Williams, 2014).
Clients completed the SCL-90-R before and after treatment. The subjects (n = 74)
answered 90 questions, rated their responses on a 4-point Likert scale and recorded their
responses on the SCL-90-R sheet. The data were then analyzed in SPSS to explore any
change in self-reported symptoms of the nine symptom scales and three global indices.

Treatment Interventions
In beginning phase one, Safety and Stabilization, the researchers utilized a twelve-
week psychoeducational program intended to help a client develop safety and stability
in his or her everyday lives. The intention of this step was to lay the groundwork for
further intensive psychotherapy through a structured group format. Counselors focused
on stabilizing the clients during this phase by building therapeutic rapport, establishing
the group culture, and grounding the clients. Afterward, the group moved into utilized
workbooks such as Seeking Safety (Najavits, 2002), the Beyond Anxiety & Phobia
Workbook (Bourne, 2001), and The Feeling Good Handbook (Burns, 1999). The first phase
of treatment lasted for 14 weeks before advancing into the second phase.
The second phase, Working Through Trauma, included sixteen weeks of
individual and group counseling. A Gestalt based counselor led the group counseling
sessions in efforts of promoting a safe environment for victims of sexual abuse to share
and express emotional reactions and receive support from one another. The counselors
began the process by first selecting volunteers to participate in an individual session that
was observed by other participants in the group. The session included the summarization
of the clients’ narrative through brief exposure therapeutic tactics. This brought the clients’
emotional reaction into the present, and they focused on changing the present relationship
to the memory of the past. At the completion of individual counseling, the clinicians led a

58 THE WISCONSIN COUNSELING JOURNAL


group discussion focusing on the clients’ experience and explored ways that other members
could relate in a safe therapeutic environment.
Phase Three, Reconnection, was a year-long process utilizing the work of Yalom
and Leszcz (2008) to create a cohesive group which focused on helping the individuals
reconnect with society in a healthy manner. The group members were aided in their
development of life skills including: (a) appropriately reconnecting with authentic versions
of themselves, (b) intimate relationships with others and (c) fighting fear and disassociation
through an experiential process. The group modeled and explored ways that subjects could
practice making contact in the present moment with safe individuals.
The last stage, Aftercare, was offered for the individuals who wished to return to
treatment at a later time on an optional basis. Most clients were guided through the outside
aftercare referral process to other practitioners and additional outside groups. These outside
groups focused on more practical aspects of recovery and rehabilitation including: (a)
community reintegration, (b) intimate relationship skill building, and (c) human sexuality
psychoeducation.

Results
The analyses showed that three global indices moderately improved across the
board. The Global Severity Index showed the greatest development from before (M =
49.43, SD = 10.253) and after treatment (M = 46.26, SD = 9.419), t(73) = 3.956, p < .05, d =
.460. Likewise, the Positive Symptom Distress Index moderately improved after treatment
(M = 45.53, SD = 9.02;), t(73) = 3.345, p < .05, d = .389. The positive symptom total from
before (M = 50.54, SD = 10.19) also showed a moderate improvement (M = 44.27, SD =
10.53), t(73) = 2.64, , p < .05, d = .307.
The samples were compared with the use of a dependent-sample t-test to compare
pre- and posttests of the nine symptom scales of the SCL-90-R. The findings varied slightly
with each symptom (see Tables 1 and 2). All of the scales except the somatic symptoms
scales presented with lower scores of the symptoms. Levels of hostility and phobic anxiety
were higher before treatment than after treatment; obsessive-compulsive, depression,
and anxiety scales all showed a moderate decrease. The most significant and notable
improvements were made in psychoticism and interpersonal sensitivity.
Overall, the four-phased treatment model has shown to decrease scores in the nine
symptom scales and three global indices of the SCL-90-R. Every scale, with the exception
of the somatic symptom scale, showed improvement at a statistically significant level.
Participants showed enhancement in the interpersonal sensitivity scale, which demonstrates
the treatment’s ability to aid individuals in their ability to reconnect with others in a healthy
relational manner. Clients also reported a significant decrease in their scores on the Global
Severity Index, which displays a decrease in overall psychological distress. The somatic
symptom scale was the only measurement of the twelve that did not significantly improve.
The psychoticism scale of the SCL-90-R showed the most improvement. Psychoticism is
defined as metacognitive dysfunction, self-accusation and detachment (Pedersen, Urnes,
Kvarstein, & Karterud, 2014).

Discussion
Issues and symptoms for clients who have experienced childhood sexual abuse can
be both chronic and threatening to emotional and physical well-being (Dube et al., 2014;

Spring 2017 59
Turner, Taillieu, Cheung & Afifi, 2017). Therefore, clinicians are encouraged to continue
to research and explore treatment modalities for the severity of the effects observed on
this population. Based on the findings, the Four-Phased Treatment model has shown to
moderately decrease scores in the nine symptom scales and three global indices of the
SCL-90-R. Each scale, with the only exception of the somatic symptom scale, showed
improvement at a statistically significant level for participants.
Although research shows that psychoeducation is most effective when used to
prepare for a future traumatic event (Wessely et al., 2008), this study, along with Ulusoy
and Duy (2013), demonstrated moderate decreases in symptoms of PTSD, learned
helplessness, and irrational beliefs when psychoeducation practices are implemented
after the event. This study adds to the existing knowledge surrounding psychoeducational
treatment modalities by suggesting that psychoeducation can also help decrease symptoms
of anxiety, depression, hostility, and psychoticism.
Learning to reconnect with others is important in the recovery process for CSA
clients therefore reconnection is the last required phase of the treatment. Developing new
interpersonal relationships and coping strategies helps individuals deal with traumas of
their past. Clients have reported better outcomes due to connecting with other victims
dealing with the similar issues (Anderson & Hiersteiner, 2008). The Reconnection stage
of this model aided the individuals in their ability to relearn how to intimately connect
with friends, family, and partners in the community. The evidence is demonstrated by the
increase in interpersonal sensitivity on the posttest SCL-90-R measurements.
A significant decrease on the Global Severity Inventory (GSI) demonstrates that
clinicians may effectively treat this population by combining techniques and utilizing
them in following the procedural process. Due to the statistically significant nature of
this research and added knowledge for the CSA community, it is encouraged that other
therapeutic approaches be further explored in the hopes of yielding more significant
treatment modalities for the CSA population in the future.

Implications for Counseling


A significant aspect of this four-phased model is its ability to utilize the most useful
aspects of treatments for CSA clients. With this knowledge, counselors can better treat
this population by exploring similar techniques. This claim is defended by the significant
decrease in the Global Severity Inventory (GSI). The GSI is a total of all the symptoms
measured on the SCL-90-R, and the overall decrease of client reported issues should be
considered by counselors when looking to implement new techniques in their practice with
clients of this particular nature.
These discoveries encourage the use of treatment strategies and the need for
further research. Using the four-phased treatment model will enable counselors to address
several issues while working with clients who have symptoms as a result of CSA, and the
issues outlined by the nine symptom scales and three global indices. The treatment has also
shown to assist clients in developing healthy personal relationships by raising levels of
interpersonal sensitivity.
In order to fully explore the treatments of this population, we encourage the
research community to continue using empirically validated measures like the SCL-
90-R with other demographical and clinical information. There are several independent
and dependent factors addressed in this study, and the gathered data would benefit from a

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statistical factor analysis of the presented relationships to possibly specify which segment
of the four-phased treatment model is responsible for specific clinical success.

Future Research
Topics of further consideration for further research may include gender differences
in treatment and how said differences may influence long term outcomes in wellness. It is
also fascinating to see the lack of modern research on Gestalt treatment outcomes as they
were found effective in earlier decades (Edwards, 1990; Joy, 1987; Smucker, Dancu, Foa,
& Niederee, 1995). The socioeconomic status of the participants and if status contributes
to availability of long-term treatment, and the ethnicity and cultural identity of participants
should be collected in future studies to further explore any confounding relationships.
Future researchers would also benefit the insight into CSA treatment by conducting a
factorial analysis and surveys to explore which treatment modality was most effective in
lowering symptom scores.

Limitations
The self-selection processes are a limitation to the research study. Data sets were
drawn from a pool of clients who voluntarily initiated treatment, creating a sample of
individuals who would share the same traits that would lead one to seek treatment at the
facility. This method of convenience sampling suggests outside variables may be present
that could affect the ability to generalize the findings to the entire population of victims of
childhood sexual abuse.
Another limitation of this study is the lack of control for patient characteristics.
The majority of the information was found from a pool of data collected at the treatment
facility. The collection process, unfortunately, featured a lack of differentiation of client
characteristics that would have ultimately increased the exploration of the study. Future
research of this kind should separate subjects by additional traits, such as race, gender,
socioeconomic status, and type of victimization. No control group was implemented due
to symptom severity of CSA. The existence of a control group for this study is not of
an ethical nature as those with severe symptoms should not be declined when seeking
treatment.

Conclusion
Childhood sexual abuse is a detrimental, costly, and pervasive issue in our society
that affects thousands of individuals daily. Clients who have experienced childhood sexual
abuse show serious negative effects in somatic symptoms, mental health, self-esteem, and
interpersonal relationships. Several techniques are used to treat childhood sexual abuse,
including individual and group therapy, psychoeducation, interpersonal training, and
various art therapies. This research explored a four-phased approach of treating clients
who have experienced childhood sexual abuse, and the treatment modality was found to
significantly lower self-reported symptoms outlined in the SCL-90-R. These findings can
help counselors explore new strategies to help CSA clients and discuss which techniques
may be helpful in treating clients in the future.

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Appendix A
Table 1
Measurements of Change in Means Before and After Treatment
SCL-90-R Symptom Scales Mean SD
Pre-treatment Post-treatment Pre-treatment Post-treatment
Somatization 51.32 49.58 10.41 9.80
Obsessive-Compulsive 51.45 49.57 9.94 8.20
Interpersonal Sensitivity 51.08 47.70 10.01 9.64
Depression 47.22 44.50 9.56 9.64
Anxiety 46.73 44.27 10.19 8.41
Hostility 49.58 47.74 9.94 8.55
Phobic Anxiety 49.68 46.97 10.55 9.83
Paranoia 52.34 49.20 8.74 9.26
Psychoticism 49.38 47.23 10.19 10.03
Global Severity Index 49.43 46.26 10.25 9.42
Positive Symptom Distress Index 48.77 45.53 10.84 9.02
Positive Symptom Total 50.45 44.27 10.19 10.53

Measurements of Change in SCL-90-R Scores after Treatment

SCL-90-R Cohen’s d t statistic Sig. p


Symptom Scales Effect Size
Somatization .192 1.65 .103 < .05
Obsessive-Compulsive .254 2.18 .032 < .05
Interpersonal Sensitivity .434 3.73 .000 < .05
Depression .351 3.02 .004 < .05
Anxiety .303 2.61 .011 < .05
Hostility .244 2.10 .039 < .05
Phobic Anxiety .306 2.63 .010 < .05
Paranoia .405 3.49 .001 < .05
Psychoticism .285 2.45 .017 < .05
Global Severity Index .460 3.96 .000 < .05
Positive Symptom Distress Index .389 3.35 .001 < .05
Positive Symptom Total .307 2.64 .010 < .05

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