B Christopher Frueh

University of Hawaiʻi at Hilo, Hilo, Hawaii, United States

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Publications (228)567.73 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background This study compared a dimensional, trait domain approach to characterizing personality pathology with the traditional polythetic approach with respect to their associations with interpersonal functioning and personality traits from the five factor model. Methods Psychiatric inpatients (N = 1,476) were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders. Dimensional representations of trait domains were derived from reorganizing DSM-IV criteria into personality trait domains from DSM-5 Alternative Model. Dimensional scores and personality disorder (PD) total criterion scores served as independent variables in predicting interpersonal profile clusters, as well as extraversion, agreeableness conscientiousness, neuroticism and openness from the five factor model traits. Results Trait domain scores and PD criteria totals were significantly correlated with submissive interpersonal style yet none proved significant in regression analyses. Avoidant and Borderline PD total criteria were negatively associated with a normative interpersonal style. Combined trait domain of detachment and Avoidant PD total criteria predicted a hostile/withdrawn interpersonal style. The trait domain of detachment was negatively associated with five factor traits of extroversion, whereas Borderline PD total criteria was negatively associated with conscientiousness. Avoidant and Borderline PD total criteria were positively associated with neuroticism. Conclusions The cross-cutting dimensional approach provided useful information in predicting a hostile/withdrawn interpersonal style as well as extroversion. Importantly, PD criterion scores and dimensional trait scores combined to predict this interpersonal style providing support to the alternative model of personality diagnosis in DSM-5. Clinicians are encouraged to assess dimensions of personality traits as these are related to interpersonal problems frequently encountered in psychiatric settings. While potentially useful, the dimensional approach articulated here did not yield substantial prediction of behavior.
    Comprehensive Psychiatry 09/2014; · 2.38 Impact Factor
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    ABSTRACT: The purpose of this paper is to cast a vision for the next generation of behavioral health and criminal justice interventions for persons with serious mental illnesses in the criminal justice system. The limitations of first generation interventions, including their primary focus on mental health treatment connection, are discussed. A person–place framework for understanding the complex factors that contribute to criminal justice involvement for this population is presented. We discuss practice and research recommendations for building more effective interventions to address both criminal justice and mental health outcomes.
    International Journal of Law and Psychiatry 09/2014; 37:427-438. · 1.19 Impact Factor
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    ABSTRACT: The authors previously demonstrated an 82.3% reduction in seclusion and restraint use at an inpatient psychiatric facility, largely attributable to changes to the physical environment. This study investigated whether the reduction was sustained over time.
    Psychiatric services (Washington, D.C.) 07/2014; · 2.81 Impact Factor
  • Jeffrey Allen Smith, Kristi L Masuhara, B Christopher Frueh
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    ABSTRACT: We have little understanding of the increased active duty military suicide rates found in the United States, and little understanding of what is historically normative for combatants. Therefore, we examined historical records on suicides among the British Army during the Crimean War for the years 1854-1856. There were 18 documented suicides in the British Army during this period. Calculating an accurate annual suicide rate per 100,000 is impossible because it is unclear how many of the 111,313 military personnel were in country for each of the 2 years of the war. However, the range is conservatively estimated between 8 and 16 per 100,000, with the likely answer somewhere near the middle. This suggests the possibility that increasing suicide rates among active duty military may be a modern U.S. phenomenon.
    Military medicine. 07/2014; 179(7):721-723.
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    ABSTRACT: Patient satisfaction is increasingly used as an indicator of health care quality. Few measures are available to assess characteristics unique to inpatient psychiatric hospitals, especially those that provide longer-term care. Furthermore, there is limited guidance on how to utilize patient satisfaction data to guide quality improvement initiatives. The authors developed the 20-item, Menninger Quality of Care measure at The Menninger Clinic in Houston, Texas. Psychometric analyses were based on responses from 337 adult inpatients. The measure has excellent internal reliability (Cronbach α = 0.92) with adequate concurrent and construct validity. We present a methodology to identify targeted quality improvement efforts by (1) highlighting the perspective of patients who are generally satisfied but had at least some reservations regarding the care they received and (2) highlighting areas of concern that are most associated with overall quality of care. We discuss our findings in light of national health care quality trends.
    Quality management in health care 07/2014; 23(3):178-187.
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    ABSTRACT: Little is known about the psychometric properties and clinical utility of the Beck Depression Inventory-II (BDI-II) among adult clinical inpatients, a group at high risk for major depressive disorder (MDD). Data from 1,904 adult inpatients were analyzed using confirmatory factor analysis (CFA), Cronbach's alpha, and Pearson's correlations. Receiver operating characteristic (ROC) analyses evaluating MDD diagnostic performance were conducted with a subsample (n = 467) using a structured diagnostic interview for reference. CFA of 3 previous 2-factor oblique solutions, observed in adolescent and older adult inpatient clinical samples, and 3 corresponding bifactor solutions indicated that BDI-II common item variance was overwhelmingly accounted for by 1 general factor specified to all items, with minor additional variance contributed by 2 specific factors. Analyses revealed high internal consistency (Cronbach's α = .93) and significant (p < .01) intercorrelations between the BDI-II total scale and Behavior and Symptom Identification Scale-24's Depression/Functioning (r = .79) and Overall (r = .82) subscales. ROC analyses generated low area under the curve (.695; 95% confidence interval [.637, .752]) and cutoff scores with poor sensitivity/specificity balance. BDI-II use as a screening instrument for overall depressive symptomology was supported, but MDD diagnostic performance was suboptimal. Clinicians are advised to use the BDI-II to gauge severity of depression and measure clinical changes to depressive symptomology over time but to be mindful of the limitations of the BDI-II as a diagnostic tool for adult inpatients. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
    Psychological assessment. 06/2014;
  • Nancy Wolff, Jessica Huening, Jing Shi, B Christopher Frueh
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    ABSTRACT: Trauma exposure and trauma-related symptoms are prevalent among incarcerated men, suggesting a need for behavioral health intervention. A random sample of adult males (N = 592) residing in a single high-security prison were screened for trauma exposure and posttraumatic stress disorder (PTSD) symptoms. Trauma was a universal experience among incarcerated men. Rates of current PTSD symptoms and lifetime PTSD were significantly higher (30 to 60 %) than rates found in the general male populations (3 to 6 %). Lifetime rates of trauma and PTSD were associated with psychiatric disorders. This study suggests the need for a gender-sensitive response to trauma among incarcerated men with modification for comorbid mental disorders and type of trauma exposure. Developing gender-sensitive trauma interventions for incarcerated men and testing them is necessary to improve the behavioral health outcomes of incarcerated men who disproportionately return to urban communities.
    Journal of Urban Health 05/2014; · 1.89 Impact Factor
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    ABSTRACT: To compare clinical and process outcomes of cognitive processing therapy-cognitive only version (CPT-C) delivered via videoteleconferencing (VTC) to in-person in a rural, ethnically diverse sample of veterans with posttraumatic stress disorder (PTSD).
    The Journal of clinical psychiatry. 05/2014; 75(5):470-476.
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    ABSTRACT: Objective This study investigated predictors of therapeutic outcomes for veterans who received treatment for dysregulated anger.Method Data are from a randomized controlled trial investigating the effectiveness of video teleconferencing compared to in-person delivery of anger management therapy (AMT) among 125 military veterans. Multilevel modeling was used to assess 2 types of predictors (demographic characteristics and mental health factors) of changes in anger symptoms after treatment.ResultsResults showed that while veterans benefited similarly from treatment across modalities, veterans who received two or more additional mental health services and who had longer commutes to care showed the greatest improvement on a composite measure of self-reported anger symptoms.Conclusion Results highlight that veterans with a range of psychosocial and mental health characteristics benefited from AMT, while those receiving the most additional concurrent mental health services had better outcomes.
    Journal of Clinical Psychology 04/2014; · 2.12 Impact Factor
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    ABSTRACT: Gender differences in prevalence rates of Borderline Personality Disorder (BPD) may reflect true differences between groups or may reflect some form of gender bias in diagnostic criteria. The detection of differential item functioning (DIF) using item response theory methods provides a powerful method of evaluating whether gender differences in prevalence rates of BPD reflect true mean differences or criterion bias. The aim of the current study was to evaluate gender-based DIF in DSM BPD criteria. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Axis II Personality Disorders (SCID-II: First, Spitzer, Gibbon, Williams, & Benjamin, 1994) was administered to 747 adult inpatients. Results indicated DIF for 2 BPD criteria (impulsivity and uncontrolled anger), such that it was easier for these items to be endorsed for men compared with women at the same level of latent trait. At the level of the test, men were expected to be rated slightly higher than women on the SCID-II at the same level of latent BPD liability. Implications of these results for research and clinical assessment are discussed. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
    Journal of Abnormal Psychology 02/2014; 123(1):231-6. · 4.86 Impact Factor
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    ABSTRACT: Purpose: Major depressive disorder (MDD) is a common mental disorder (U.S. lifetime prevalence rate = 16.5%) associated with severe clinical consequences (e.g., functional impairment and suicide). For providers seeking to screen clients for MDD, the well-established Beck Depression Inventory (BDI-I) has been widely utilized due to its demonstrated psychometrics across multiple clinical subpopulations. Yet, the psychometric properties and clinical utility of the revised BDI-II among adult psychiatric inpatients, a group at elevated risk for MDD, is largely unknown; a gap in the literature this paper sought to address. Methods: Psychiatric inpatient participants (N= 1,904) recruited from a non-profit psychiatric hospital in Texas completed the BDI-II and the Behavior and Symptom Identification Scale (BASIS-24) upon admission. BDI-II reliability was examined via Cronbach’s alpha and construct validity via inter-item correlations and BDI-II total score correlations with BASIS-24 subscales. Factor analyses (exploratory and confirmatory) evaluated BDI-II factor structure. Diagnostic utility was explored using receiver operating characteristic (ROC) analyses of a 575 participant subsample assessed for MDD using the Structured Clinical Interview for DSM Disorders (SCID). Results: The BDI-II sample mean was 24.93 (SD=13.20), indicating that on average, participants experienced moderate depression at admission. Analyses of psychometric properties yielded Cronbach’s alpha of .93, and significant (p<0.01) BDI-II correlations with the BASIS-24 Depression (r=.79) and Overall subscales (r=.81). BDI-II factorial structure was explored by splitting the sample into two random halves. Maximum likelihood estimation extraction with direct oblimin rotation conducted on one random half decomposed the items into three factors with eigenvalues greater than one (8.57, 1.51, 1.20) although scree plot and principal components parallel analyses supported a two factor model (i.e., Cognitive and Affective/Anhedonia) that accounted for 48.03% of variance. The pattern and structure matrices indicated all items loaded onto one of the two factors (>.35); inter-factor correlation was -.68. Generalized least squares with bootstrapping confirmatory factor analysis (CFA) was conducted on the second random half due to non-normality of data; factors were correlated, correlated errors were not permitted. Chi-square tests were significant (p<0.001) due to the large sample size (Hoelter’s critical N=285). The RMSEA=.06, SRMR=.06, GFI=.93, and Adjusted GFI=.91 indicated good model fit. As the RMSEA of the null model was lower than .158 (RMSEA=.07), incremental indices of fit such as TLI and CFI were not valid. ROC analyses on the SCID subsample (72% prevalence rate of major depression) revealed low AUC (95% CI) = .65 (.61 - .71) for the BDI-II and produced cutoff scores with poor balance between sensitivity/specificity. Implications: This large-scale psychometric investigation of the BDI-II with psychiatric inpatients revealed good internal consistency and convergent validity but suboptimal MDD diagnostic performance. Factor analyses decomposed the BDI-II into two factors (Cognitive and Affective/Anhedonia), mirroring the Cognitive and Somatic/Affective factors previously reported for psychiatric outpatients by the instrument authors. Study findings support BDI-II utility as an inpatient screening measure of depressive symptomology but call into question its diagnostic capabilities. Social workers within inpatient settings are recommended to use the BDI-II to assess depression severity but to consider alternative screening methods for MDD.
    The Society for Social Work and Research 2014 Annual Conference; 01/2014
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    ABSTRACT: We investigated potential mechanisms of action for anger symptom reductions, specifically, the roles of anger regulation skills and therapeutic alliance on changes in anger symptoms, following group Anger Management Treatment (AMT) among combat veterans with posttraumatic stress disorder (PTSD). Data were drawn from a published randomized controlled trial of AMT conducted with a racially diverse group of 109 veterans with PTSD and anger symptoms residing in Hawaii. Results of latent growth curve models indicated that gains in calming skills predicted significantly larger reductions in anger symptoms at post-treatment, while the development of cognitive coping and behavioral control skills did not predict greater symptom reductions. Therapeutic alliance had indirect effects on all outcomes mostly via arousal calming skills. Results suggest that generalized symptom reduction may be mediated by development of skills in calming physiological arousal. In addition, arousal reduction skills appeared to enhance one's ability to employ other anger regulation skills.
    Journal of Anxiety Disorders. 01/2014;
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    ABSTRACT: Background: Impaired capacity for emotion regulation is associated with a broad spectrum of psychiatric disturbances; however, little is known about treatment response in emotion regulation functioning among patients with severe mental illness. This study examined treatment response and the role that experiential avoidance plays in mediating the relationship between attachment anxiety/avoidance and change in emotion regulation. Methods: Difficulties in emotion regulation were assessed at admission and at discharge, and rates of improvement and deterioration in emotion regulation were calculated. Attachment anxiety and avoidance were assessed in conjunction with experiential avoidance at baseline in a large cohort (N = 493) of adults admitted to a specialized adult psychiatric hospital. Results: Inpatient treatment was associated with clinically significant improvement in emotion-regulation capacities for 49 percent of patients completing at least four weeks of treatment. Fifty-six percent of patients attained a status of recovery. Greater attachment avoidance and anxiety were related to positive change in emotion regulation at discharge. Experiential avoidance fully mediated the relationship between insecure attachment and change in emotion-regulation capacities. Conclusions: Contrary to expectation, greater attachment insecurity (anxiety and avoidance) as well as greater experiential avoidance predicted improvement in emotion regulation. These counterintuitive findings add to a growing evidence base indicating that severity of psychopathology is associated with greater improvement in hospitalized patients. Results of the mediation analysis suggest that targeting experiential avoidance may be an effective augmentation in the treatment of impaired emotion regulation functioning.
    Borderline Personality Disorder and Emotion Regulation. 01/2014; 1(19).
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    ABSTRACT: Objective: Persons admitted for inpatient psychiatric care often present with interpersonal difficulties that disrupt adaptive social relations and complicate the provision of treatment. Whereas domains of psychosocial functioning in this population demonstrate clear growth in response to intervention, the impact of treatment on more complex patterns of interpersonal behavior has been largely overlooked within the existing literature. Interpersonal profiles characteristic of psychiatric inpatients were identified in the current study to determine rates of transition to adaptive functioning following hospitalization. Methods: Personality disturbance was assessed in 513 psychiatric inpatients using the Inventory of Interpersonal Problems. Scores were analyzed within a series of latent profile models to isolate unique interpersonal profiles at admission and at discharge. Longitudinal modeling was then employed to determine rates of transition from dysfunctional to adaptive profiles. Relationships with background characteristics, clinical presentation, and treatment response were explored. Results: Normative, Submissive, and Hostile/Withdrawn profiles emerged at both admission and discharge. Patients in the Normative profile demonstrated relatively moderate symptoms. Submissive and Hostile/Withdrawn profiles were related to known risk factors and elevated psychopathology. Approximately half of the patients who had been identified as Submissive or Hostile/Withdrawn transitioned to the Normative profile by discharge. Transition status evidenced modest associations with background characteristics and clinical presentation. Treatment engagement and reduction of clinical symptoms were strongly associated with adaptive transition. Conclusion: Maladaptive interpersonal profiles characteristic of psychiatric inpatients demonstrated categorical change following inpatient hospitalization. Enhanced therapeutic engagement and overall reductions in psychiatric symptoms appear to increase potential for interpersonal change.
    Psychiatry. 01/2014; 77(3):247-262.
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    ABSTRACT: Adults with serious mental illness (SMI) experience criminal victimization at rates higher than the general population whether they reside in the community or correctional settings. This study examines the past-six month prevalence and correlates of criminal victimization among a large community sample (N = 2,209) of consumers with SMI newly admitted to outpatient mental health services during 2005 through 2008. A cross-sectional design was used with self-report and clinical data collected from administrative records. Victimization was determined by responses to direct questions about experiences in the previous 6 months with respect to victimization of a non-violent and/or violent crime. Socio-demographic, clinical and criminal correlates of victimization were abstracted from a quality of life survey and clinical assessment interview conducted at admission. Overall, 25.4 % of consumers reported being a victim of any crime (violent or non-violent) in the past 6 months, with 20.3 % reporting non-violent and 12.3 % violent victimization. The risk of victimization was elevated for those who were female, White, not taking atypical psychotropic medication, not feeling safe in their living arrangement, and were arrested or homeless in the six-months prior to engaging in mental health outpatient treatment. Policy and practice implications of these findings are discussed.
    Community Mental Health Journal 12/2013; · 1.03 Impact Factor
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    ABSTRACT: The present study sought to gain a better understanding of cyber bullying (i.e., the use of information technologies to inflict harm on another person) by examining its prevalence, its relationship with traditional bullying, and the relationship between bullying, anxiety, and depression in a sample of rural and ethnoracially diverse youth (N = 211; ages 10–13). Thirty-three percent of participants reported being victims of traditional bullying and 9 % reported perpetrating traditional bullying behavior. Seven percent of participants were victims of cyber bullying, 4 % reported that they participated in cyber bully behavior, and 2 % were both of victims and perpetrators of cyber bullying. Bullying victims reported significantly higher levels of anxiety and depression compared with non-victims and bullies endorsed significant anxiety and depression. Results suggest that while cyber bullying does occur in rural communities, it often co-occurs with traditional bullying. Additionally, a novel cyber bullying measure was developed and utilized, and information regarding its reliability and validity is included.
    School Mental Health 12/2013;
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    ABSTRACT: Existing literature indicates significant comorbidity between posttraumatic stress disorder (PTSD) and major depression. We examined whether PTSD's dysphoria and mood/cognitions factors, conceptualized by the empirically supported four-factor DSM-5 PTSD models, account for PTSD's inherent relationship with depression. We hypothesized that depression's somatic and non-somatic factors would be more related to PTSD's dysphoria and mood/cognitions factors than other PTSD model factors. Further, we hypothesized that PTSD's arousal would significantly mediate relations between PTSD's dysphoria and somatic/non-somatic depression. Using 181 trauma-exposed primary care patients, confirmatory factor analyses (CFA) indicated a well-fitting DSM-5 PTSD dysphoria model, DSM-5 numbing model and two-factor depression model. Both somatic and non-somatic depression factors were more related to PTSD's dysphoria and mood/cognitions factors than to re-experiencing and avoidance factors; non-somatic depression was more related to PTSD's dysphoria than PTSD's arousal factor. PTSD's arousal did not mediate the relationship between PTSD's dysphoria and somatic/non-somatic depression. Implications are discussed.
    Psychiatry research. 10/2013;
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    ABSTRACT: A systematic review of trauma treatment outcome literature was conducted to determine the impact of treatment on comorbid panic symptoms. Major databases were searched (from 1989 to 2013) and 64 randomized controlled trials using cognitive behavioral approaches to treat acute stress disorder, subthreshold posttraumatic stress disorder (PTSD), and full PTSD met inclusion criteria for this review. Results showed that 41% of the studies reviewed did not assess for Axis I psychiatric comorbidity at any point during the course of treatment. Only 5% of the studies reviewed reported rates of comorbid panic disorder (PD) at more than one time point during the study. Results indicate that approximately 56% of people no longer meet PD criteria following PTSD treatment.
    Clinical Psychology Science and Practice 09/2013; 20(3). · 2.92 Impact Factor
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    ABSTRACT: The psychiatric sequelae associated with childhood experience(s) of trauma is complex and distinguishable from that of adult trauma exposure. Categories of impairment associated with experiences of early trauma include internalizing and externalizing emotional and behavioral problems, posttraumatic stress symptomatology, and dissociation. The present study assessed the relationship between the type of trauma experience (i.e., non-interpersonal or interpersonal) and the manifestation of a wide range of psychiatric symptomatology using prospective longitudinal data from a community sample of ethnically diverse children and adolescents (N=1676; ages 4-18). The study also examined the relationship between different types of trauma experiences (e.g., direct, vicarious, interpersonal) and levels of various symptom domains (e.g., anxiety, posttraumatic stress, conduct problems). A number of factors relevant to the relationship between early trauma experience and subsequent impairment including temperament, socioeconomic status, sex, and age were included in the analyses. Results indicated that interpersonal traumas involving significant interpersonal proximity were associated with externalizing problems (i.e., oppositional defiant and conduct problems). Direct trauma experiences and emotionality were positively associated with almost all symptom domains. Implications for the relationship between trauma and developmental psychopathology are discussed.
    Journal of anxiety disorders 08/2013; 27(7):652-660. · 2.68 Impact Factor
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    ABSTRACT: Abstract Background: Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, high percentages of Veterans in need of services are unable to access them. One particular challenge to providing cost-effective psychological treatments to Veterans with PTSD involves the difficulty and high cost of delivering in-person, specialized psychotherapy to Veterans residing in geographically remote locations. The delivery of these services via clinical videoteleconferencing (CVT) has been presented as a potential solution to this access to care problem. Materials and Methods: This study is a retrospective cost analysis of a randomized controlled trial investigating telemedicine service delivery of an anger management therapy for Veterans with PTSD. The parent trial found that the CVT condition provided clinical results that were comparable to the in-person condition. Several cost outcomes were calculated in order to investigate the clinical and cost outcomes associated with the CVT delivery modality relative to in-person delivery. Results: The CVT condition was significantly associated with lower total costs compared with the in-person delivery condition. The delivery of mental health services via CVT enables Veterans who would not normally receive these services access to empirically based treatments. Additional studies addressing long-term healthcare system costs, indirect cost factors at the patient and societal levels, and the use of CVT in other geographic regions of the United States are needed. Conclusions: The results of this study provide evidence that CVT is a cost-reducing mode of service delivery to Veterans with PTSD relative to in-person delivery.
    Telemedicine and e-Health 08/2013; · 1.40 Impact Factor

Publication Stats

3k Citations
567.73 Total Impact Points

Institutions

  • 2007–2014
    • University of Hawaiʻi at Hilo
      • Department of Psychology
      Hilo, Hawaii, United States
  • 2013
    • The Menninger Clinic, Inc.
      United States
    • National Center for PTSD
      Washington, Washington, D.C., United States
  • 2012–2013
    • Harvard University
      • Department of Psychology
      Cambridge, MA, United States
    • University of Melbourne
      • Australian Centre for Posttraumatic Mental Health
      Melbourne, Victoria, Australia
  • 2010–2013
    • University of Toledo
      • Department of Psychology
      Toledo, OH, United States
  • 2008–2013
    • Baylor College of Medicine
      Houston, Texas, United States
    • University of Georgia
      • Department of Psychology
      Athens, GA, United States
    • University of Washington Seattle
      Seattle, Washington, United States
  • 2004–2013
    • University of Wyoming
      • Department of Psychology
      Laramie, WY, United States
  • 1994–2013
    • Medical University of South Carolina
      • Department of Psychiatry and Behavioral Sciences
      Charleston, SC, United States
  • 2007–2012
    • University of Hawai'i System
      Honolulu, Hawaii, United States
  • 2011
    • University of New Mexico
      • Department of Psychiatry
      Albuquerque, NM, United States
  • 2008–2011
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States
  • 2003–2011
    • University of South Dakota
      • Department of Psychology
      Vermillion, South Dakota, United States
    • New York State
      New York City, New York, United States
    • Nova Southeastern University
      • Center for Psychological Studies
      Florida, NY, United States
  • 2009–2010
    • UConn Health Center
      • Department of Psychiatry
      Farmington, CT, United States
    • Murdoch University
      Perth City, Western Australia, Australia
  • 2006–2007
    • University of North Carolina at Chapel Hill
      • Cecil G. Sheps Center for Health Services Research
      Chapel Hill, NC, United States
    • George Mason University
      • Department of Psychology
      Fairfax, VA, United States
  • 2005
    • Westat
      Maryland, United States
  • 2001–2005
    • University of Maryland, College Park
      • Department of Psychology
      College Park, MD, United States
  • 2000
    • University of Pennsylvania
      Philadelphia, Pennsylvania, United States
    • South Carolina Department of Mental Health
      Columbia, South Carolina, United States
  • 1997
    • State University of New York
      New York City, New York, United States