Dr. Rose Eva Constantino

Attorney Rose Constantino, Ph.D., F.A.A.N., is a psychiatric nurse. Since 1980, she has done research with bereaved widows who survived the suicide of their spouse. Since 1990, she has worked with women who experienced abuse by their male intimate partner. Her research and scholarly interests dovetail with her pro bono law practice representing women in family court seeking a Protection from Abuse (PFA) court order. In her work with suicide survivors, Dr. Constantino serendipitously found that approximately 65% of the women who survived the suicide of their spouse admitted to suffering some type of abuse from the victim prior to the suicide. This finding along with her volunteer work as an attorney representing abused women led to her current studies with women who experienced abuse by their male intimate partner. Below is a description of each of the preliminary studies. Dr. Constantino is currently focusing her research on caring for survivors of SARA (sexual assault, rape, and abuse) by testing an Internet-based intervention program known as eSSN (Electronic Social Support Network).

In honor of Dr. Constantino, the Beta Nu Delta Nursing Society established the Dr. Rose Eva Bana Constantino Nursing Research Partnership. The partnership includes the Dr. Rose Constantino Nursing Research Grant, the Dr. Rose Constantino Visiting Nurse Scholar Project, and the R.E. Constantino Nurse Fellowship. Additional information regarding the Dr. Rose Eva Bana Constantino Nursing Research Partnership is on the Internet at http://betanudelta.com/research.php.

Study #1: Constantino, R. (PI: Principal Investigator). Nursing Postvention for Widows and Widowers. Grant 1RO1 NR02108. Constantino, R., and Bricker, P. (1996). Nursing Postvention for Spousal Survivors of Suicide. Issues in Mental Health Nursing, 17, 131-152. Constantino, R.; Sekula, L.K.; and Rubinstein, E.N. (2001). Group Intervention for Widowed Survivors of Suicide. Suicide and Life-Threatening Behavior, 31(4), 428-441.

Purpose: The purpose of this study was to compare a Bereavement Group Postvention (BGP) with a Social Group Postvention (SGP) in order to determine whether one form of intervention was more effective in reducing depression, psychological distress, and grief and in enhancing social adjustment in widows and widowers whose spouse committed suicide. The investigators used community outreach programs to recruit subjects through newspaper, radio, and television public service announcements; speaking at community centers; and visiting community activity centers.

Methods: The sample was composed of 47 bereaved spouses of suicide victims; 10 males and 37 females. The length of widowhood ranged from 1 to 27 months (mean=10.91 months, SD=8.65 months).

Dependent variables included depression measured using the Beck Depression Inventory (BDI; Beck, 1970); psychological stress measured using the Brief Symptom Inventory (BSI; Derogatis & Spencer, 1982); social adjustment measured using the Social Adjustment Scale (SAS; Weissman, 1975; Weissman & Bothwell, 1976); and grief measured using the Grief Experience Inventory (GEI; Sanders et al., 1979). The independent variable used in this study was the Postvention, composed of two kinds of therapeutic group modalities: (1) the Bereavement Group Postvention (BGP) as a planned and phase specific intervention program and (2) the Social Group Postvention (SGP) as the minimum contact social program. Because the investigators were uncertain of the emotional well being of the study participants, they refrained from using a no treatment control group and instead used a minimum contact group as a control group. Therefore, the investigators used the SGP as their minimum contact control group.

Results: No significant differences existed between the BGP and the SGP on pretest, posttest, and 6- and 12- month time period assessments of the BDI, BSI, GEI, and SAS. Therefore, the two groups were combined for hypotheses testing. To test whether changes in the dependent measures (BDI and BSI) occurred across the four testing intervals (pretest, posttest, 6 months and 12 months), the investigators used a one-way repeated measure analysis of variance. They appled the Bonferroni correction to control for compounding of type I error rate; a p-value <.001 was considered significant. The investigators conducted post hoc analyses to examine the patterns of change over time.

The results related to hypothesis #1: In the combined group (BGP and SGP) at set time points after completion of the group interventions, levels of depression showed a marked and statistically significant (p<.0001) decrease as measured by the BDI. Post hoc analysis revealed that the sharp decrease between Time 1 and Time 2 means (18.66 and 7.62 respectively) was statistically significant (p<.0001). Internal consistency of the BDI, calculated with Cronbach's alpha, was .80.

In regard to hypothesis #2, the results showed a statistically significant decrease in the levels of psychological distress as measured by the BSI in both the BGP and SGP groups. Significant decreases over time were found on the total BSI (p<.0001) and on six of the nine subscales: obsessive-compulsive (p<.0001), depression (p<.0001), anxiety (p<.0001), phobic anxiety (p<.0001), paranoid ideation (p<.0001), and psychoticism (p<.0002). Post hoc analyses revealed a significant decrease between Time 1 (pretest) and Time 2 (posttest) means on the obsessive-compulsive (1.53 and 1.08, respectively), depression (1.39 and 1.00, respectively), and anxiety (1.11 and 0.81, respectively) subscales only. The reliability for the total BSI was .86, while coefficients for all nine subscales ranged from a low of .78 (paranoid subscale) to a high of .96 (depression subscale).

Implications: These findings are important to this proposed study because as reported in study #2, the majority of the widows in study #1 experienced abuse from the suicide victim prior to the suicide. The lessons learned throughout the implementation of study #1 led the investigators to assess experiences of abuse in their female study sample. This study gave the PI, Dr. Constantino, experience in conducting a randomized trial and in implementing an intervention study for women experiencing the suicide of their intimate partner. In addition, the investigators gained experience in recruiting study subjects through community outreach programs including speaking, guest lecturing, and visiting community centers. Furthermore, this study demonstrated the reliability and validity of the instruments used. The lack of a no treatment control group and the use of two similar treatment modalities (BGP and SGP) were major weaknesses of the study. A wait-list control group would have been beneficial and would be ethical in providing treatment later when, at the time informed consent was obtained, participants would have been informed of the possibility that they would be assigned to a condition that would require them to wait three to four weeks before receiving treatment.

Study #2: Constantino, R.E.; Sutton, L.B.; and Rohay, J. (1997). Assessing Abuse in Female Suicide Survivors. Holistic Nursing Practice, 11(2), 60-68. Grant IRO1 NR02108.

In 1992, during intake interviews for NIH study #1, the investigators received reports that abuse was one of the behaviors shown by the suicide victim prior to the suicide. The suicide survivors verbalized their remorse that they did not see the abusive behavior as a sign that something more violent and final was going to happen. At group meetings, members disclosed being abused prior to the suicide of their spouse. All of the subjects reporting abuse were females. Based on this input from the early subjects in the suicide survivors study, the investigators added three questions to the intake questionnaire: 1. Did your spouse verbally abuse you? 2. Did your spouse physically abuse you? 3. Did your spouse sexually abuse you?

Purposes: The purposes of this study were (1) to examine the incidence of abuse in widows who survive the suicide of their spouse and (2) to assess the relationship between verbal, physical, and sexual abuse scores with selected items of the Victim Rejection Scale (VRS; Kreisman et al., 1979).

Methods: The subjects were 49 females who completed the intake portion of study #1. Some of the subjects did not complete the suicide survivor intervention study.

Results: The majority of the respondents (65.3%) indicated that they had experienced some form of abuse, especially verbal abuse. In order to further examine the relationship between abuse and the marital relationship, the investigators examined the associations between the individual responses to the abuse questions and seven other questions on the VRS questionnaire. Significant inverse relationships between abuse and other items on the VRS were found. The strongest inverse relationship (p < .001) between each type of abuse was with the response, "My spouse cared for me." Significant inverse relationships (p < .001) existed between verbal and sexual abuse and satisfaction with the spouse before the suicide. While the relationship between physical abuse and satisfaction was also negative, it was not significant. Interestingly, only verbal abuse was significantly related to the responses, "I enjoyed being with my spouse" and "My spouse was an important part of my life." Verbal abuse apparently had a greater negative association with the marital relationship than either physical or sexual abuse.

Implications: This study (Constantino, Sutton, and Rohay, 1997) is the first identified study of the relationship between pre-suicide abuse by the suicide victim upon female survivors and showed a widespread occurrence of all types of pre-suicide abuse, particularly verbal abuse. The percentages reflecting some form of abuse (verbal abuse, 65.3%; physical, 42.9%; sexual, 32.7%) in suicide survivors were noteworthy. The findings of the study suggested that survivors continue to have feelings of love toward the suicide victim, even when abuse occurred. This study provided the basis for the PI, Dr. Constantino, to develop multifocal holistic nursing interventions to help enhance psychological, physiological, and sociobehavioral health and well being in women. Recognizing the need for social support by abused women in her nursing practice and seeing their need for such help in her pro bono legal work, the PI undertook a descriptive study of abused women outside the confounding situation of suicide.

Study #3: Constantino, R.E., and Bricker, P.L. (1997). Social Support, Stress and Depression Among Battered Women in the Judicial Setting. Journal of the American Psychiatric Nurses Association, 3(3), 81-88.

Purposes: The purposes of this study were (1) to measure the levels of social support, stress, and depression in abused women seeking a final PFA and (2) to examine the relationship among these variables in this group of women.

Methods: The sample for this descriptive study consisted of 42 abused women ranging in age from 20 to 69 years (mean=38 years). Seventy-four percent of the women were White, not Hispanic, and 26% were African-American. The investigators used the Perceived Stress Scale (PSS) by Cohen, Kamarck, and Mermelstein (1983) to measure stress. In addition, the investigators used the Interpersonal Self Evaluation List (ISEL) by Cohen and Hoberman (1988) to measure perceived availability of social support. The investigators used the Beck Depression Inventory (BDI; Beck, 1970) to measure depression.

Results: 83% of the women (n=35) perceived their stress levels to be high. The majority of the women experienced moderate to severe levels of depression. Although these women were probably in the Open Window Phase of the cycle of violence since they were actively seeking legal help, their levels of depression remained moderately high. The BDI showed that 62% (n=26) of the women experienced suicide ideations. Along with high levels of stress and depression, many of the subjects (64%; n=27) perceived the availability of social support to be low. In order to compare levels of stress with social support, the investigators used four subscales: appraisal support, belonging support, self-esteem support, and tangible support of the social support total (ISEL). The scores on the subscales of belonging and tangible support were significantly higher than those of appraisal and self-esteem (F (1,48) -9.14, p .0004). In addition, all social support subscales were negatively correlated with stress, but not with depression.

Implications: The data suggests that the mental and the physical health of these abused women were being compromised. Items on the BDI indicated that they were experiencing sleep and gastrointestinal disturbances in addition to depression. This helped the PI, Dr. Constantino, to understand the profound effects of abuse. Results of this study led the PI to (1) ask whether a relationship exists between social support and physiological processes and (2) the next study to determine the feasibility of adding a physiological marker (T-Cell function) to this group of women.

Study #4: Constantino, R.E.; Sekula, L.K.; Rabin, B.; and Stone, C. (2000). Negative Life Experiences, Depression and Immune Function in Abused and Nonabused Women. Biological Research for Nursing, 1(3), 190-198.

Prior to the initiation of study #4, Dr. Constantino decided to add a physiological marker for immune functioning for these highly stressed abused women. She enlisted Dr. Bruce Rabin, Director of the Brain, Behavior and Immunity Center at the University of Pittsburgh School of Medicine. Dr. Rabin is an expert in the field of psychoneuroimmunology, and he has researched both human and animal subjects. The goal of his research was to determine the central neuronal pathways of stressor-induced immune alterations in rodents. His expertise in stress and immune response was a major strength of the research team. He has collaborated with Dr. Constantino on another study involving the use of T-cell mitogenesis to phytohemaglutinin (PHA) as a measure of immune function.

Purpose: The purpose of this study was to test the feasibility of obtaining an adequate sample size of abused women seeking their final PFA who would be willing to complete self-report questionnaires and allow a nurse phlebotomist to draw 1 1/2 tablespoons of their blood. The hypotheses tested in this study were (1) abused women will have lower T-cell mitogenesis to PHA than nonabused women; (2) abused women will have higher stress compared with nonabused women; (3) abused women will have higher levels of depression than nonabused women; (4) abused women will have lower levels of perceived availability of social support than nonabused women; and (5) abused women will have more negative life events than nonabused women.

Admitted to practice law in Pennsylvania and the United States Supreme Court
Fellow of the American Academy of Nursing
Fellow of the American College of Forensic Examiners
President of the Nursing Foundation of Pennsylvania, 2007-2009
President of the Board of Directors of Pittsburgh Action Against Rape, 2007-2008
Vice-president of the Board of Directors of the Sexual Assault Response Team of Allegheny County, 2006-present
Vice-president of the American Nurses Foundation, 2004-2006
Vice-president of the Nursing Foundation of Pennsylvania, 2005-2007
Member of the American Nurses Foundation Board of Trustees, 2001-present
Member of the Board of Directors of Nursing Knowledge International, 2008-present
Certified in Homeland Security, Level III, by the American College of Forensic Examiners Institute
Member of the Mass Care, Housing and Human Services divisions of the American College of Forensic Examiners Institute, 2006-present
Co-chair of the Pennsylvania Bar Association Report Card Committee, 2005
Vice-chair of the Pennsylvania Bar Association Health Law Committee, 2000-2008
Member of the Pennsylvania Bar Association Women in the Profession Committee, 2004-present
Member of the Executive Board of the American Board of Forensic Nurse Examiners, 1998-present
Member of the board of the Filipino-American Association of the Tri-State, 2006-2008

I. Title: Harnessing the Internet to Reduce Fear Among Survivors of SARA

To survivors of sexual assault, rape or abuse (SARA), fear is the paramount overwhelming feeling that occupies all of their waking hours. Fear is a complex, distracting, and an unpleasant emotion caused by anticipation or awareness of danger affecting mind and body. The body responds to fear by rapid or irregular heartbeat, shallow and rapid respiration, difficulty falling asleep or waking up, and hypervigilance. The mind responds to fear by evoking signs of anxiety, stress, inability to concentrate and irritability. In long-term fear such as experiencing SARA during childhood, adults may show depression, post-traumatic stress disorder (PTSD), and loss of perceived availability of social support. Research has shown that the body is affected by the mind's perception of fear and, in return, the body's response to fear affects the mind. However, a gap exists between what is known about mind/body relationship in the research community and what mind/body fear-reducing interventions are provided in clinical practice settings (Mind/Body Medical Institute 2005).

The purpose of this study is to assess mind and body relationships in adult survivors of SARA during childhood and within the preceding 24 months (n=60) prior to and after an electronic-based intervention called electronic Tailored Interpersonal Psychoeducation (eTIP). The eTIP is a 15-20 minute five days/week individualized computer-based intervention including: Emails, story-telling, remembering, and feedback for a period of 12 weeks with a nurse expert in psychoeducation through the Internet. The specific aims of this pilot study are as follows:

A. Examine differences in manifestations of the mind's responses to fear (anxiety, stress, depression, post-traumatic stress disorder [PTSD], and loss of perceived availability of social support) in adult survivors of SARA. For this specific aim, it will be hypothesized that: Hypothesis #1: There will be differences in the mind's responses to fear as measured by self report of anxiety, stress, depression, PTSD, and perceived availability of social support among survivors of SARA.

B. Examine differences in manifestations of the body's responses to fear (rapid or irregular heartbeat, difficulty falling asleep or waking up, hypervigilance, and high blood pressure in survivors of SARA. For this specific aim, it will be hypothesized that: Hypothesis #2: There will be differences in the body's responses to fear as shown in rapid or irregular heartbeat, difficulty falling asleep or waking up, hypervigilance, and higher blood pressure among survivors of SARA.

C. Explore the effects of electronic Tailored Interpersonal Psychoeducation (eTIP) on the mind's and body's responses to fear between survivors of SARA receiving eTIP intervention and the wait list controls (WLC) post eTIP. For this specific aim, it will be hypothesized that: Hypothesis #3: The treatment group will show significant decrease in mind and body responses to fear compared with the control group post treatment.

Significance. Of the estimated 1 million survivors of SARA in the US annually, an estimated 500,000 survivors do not seek formal healthcare for fear of being re-traumatized. Although basic research on the body/mind response to fear and trauma indicates that there is dysregulation of primary processes in the brain leading to functional and structural changes, there is still insufficient evidence of how the trauma of SARA is encoded in memory and how perceptions of events, and intervening experience post incident such as recalling, retelling or writing her story affect the development and treatment of SARA sequelae.

The Promise and Challenge of the Internet. McBride (2005) enumerated the competing promise and challenge of the Internet as safety, effectiveness, client-centeredness, timeliness, efficiency, equity, and global connectedness described the capacity of the Internet to transform healthcare delivery from just-in-case to "just in time" interventions. Tailored intervention co-developed by consumer and healthcare provider is empowering and energizing and might even be cathartic to participants. But promises will not come true if researchers hesitate to test and translate innovations in information and technology into clinical practice.


II. Title: The Development of an eSocial Support Intervention for Survivors of SARA

Sexual assault, rape, and abuse (SARA) is part of a complex cluster of violent interpersonal crimes against women in the U.S. and a major public health concern (Healthy People 2010, Objective 15-37; Krug, Dahlberg et al. 2002); WHO 2002). The National Violence Against Women Survey found that one in six U.S. women has experienced an attempted or completed SARA as a child and/or adult (Tjaden & Thoennes, 1998). Although more than two-thirds of survivors of SARA are believed to not report the crime, 1.5 women are estimated to survive SARA annually.

The impact of SARA is unique and life-long; often the survivor's body appears whole, but her mind or spirit are broken. Victims often suffer anxiety, depression, post-traumatic stress disorder (PTSD), loss of perceived availability of social support, and decreased ability to function as active members of society. However, there is little empirical evidence to guide the treatment of these effects. An estimated 500,000 survivors of SARA do not seek formal healthcare for fear of being re-traumatized. Some victims are too ashamed or fearful to report sexual assault, rape or abuse to a health provider or law enforcement, and others live far from any such sources of help. These individuals likely suffer the physical, psychological, and social effects of SARA without social support or health care. Research has shown that SARA affects the victim's entire ecological system, that is, individual, intrapersonal, interpersonal, family, and community domains, and that each of these domains, or social networks can mediate or moderate the survivor's outcome.

The ecological model is an appropriate conceptual framework in addressing socially enmeshed public health problems of surviving SARA and in the development of appropriate strategies that may increase the expected outcomes (e.g., the abatement of anxiety, depression, and PTSD) at the intrapersonal level and the abatement of stress, and improvement of perceived availability of social support and health status at the interpersonal level of the survivor's ecological domain. SARA, as the most underreported crime. For the few who report the crime, they become recipients of disparate and/or incomplete care.

We propose to develop and pilot test a confidential, inexpensive, efficient means of communication and support intervention for SARA survivors, to be organized and monitored by practitioners experienced in the treatment and counseling of survivors of SARA. The intervention will be a Web-based electronic Social Support Network (eSSN), designed with the input of survivors of SARA. We will also evaluate its feasibility, acceptability, safety, and effect on mental health and perceived availability of social support. This study will provide preliminary data needed to conduct a larger study comparing this approach with more conventional interventions for SARA survivors.

Specific Aims:

A. To pilot test the eSSN by comparing it with a No Treatment Control (NTC). We will examine answers to the following research questions:

1. Is there a relationship between the individual domain (age; race; education; income) and the intrapersonal domain (anxiety; depression; posttraumatic stress disorder) in survivors of SARA?

2. Is there a relationship between the individual domain and the interpersonal domain (perceived stress;perceived availability of social support; health status) in survivors of SARA?

3. Is there a relationship between the individual domain and family domain (SARA at childhood, abuse at home; tobacco, alcohol, and substance use/abuse at home) in survivors of SARA?

4. Is there a relationship between the individual domain and community domain (participation in social and religious activities; work; healthcare utilization; law enforcement utilization) in survivors of SARA?

5. Is there evidence of change in anxiety, depression, posttraumatic stress, perceived availability of social support, stress or medical outcomes between the intervention groups over time?

B. To evaluate the eSSN intervention both qualitatively and quantitatively. We will interface quantitative and qualitative findings using matrix construction and conceptual triangulation to answer the following questions:

1. Does triangulation of qualitative and quantitative data support a positive or negative impact of the web-based social support system on the mental health and well being of survivors of SARA?

2. Does triangulation of qualitative and quantitative data validate or refute the value of the eSSN intervention as an effective way to improve health outcomes?

C. To develop an eSSN intervention based on current treatment evidence and focus groups through the following activities:

1. Develop a systematic explication of concepts and themes important and personally helpful to survivors of SARA using focus group discussion techniques and content analysis of focus group interactions.

2. Develop a manual or tool kit for use by survivors of SARA that includes guidance about physical, psychological and social well being following SARA.

3. Develop a confidential web site and communication network for survivors of SARA (including a manual providing information about access and use).

4. Develop a manual for facilitators of the eSSN that includes information about privacy/confidentiality and measures of provider competency and fidelity in the implementation of the eSSN.


III. Title: A Practice-Research Partnership to Improve Prosecution of Offenders and the Mental Health Outcome for Survivors of SARA

We plan to respond to the NIMH Program Announcement (PA) on "Interventions and Practice Research Infrastructure Program" (IP-RISP) (R24) PAR-06-441. The proposed project will focus on research partnerships between community-based clinical services settings (SARTAC [Sexual Assault Response Team of Allegheny County] and PAAR [Pittsburgh Action Against Rape]); the DA's Office (for prosecution of SARA cases); law enforcement; and research institutions (UP SON, UP GSPH, and UP WPIC-UPMC) to enhance the capacity to conduct research that will inform mental health services research science, service delivery, program dissemination and implementation, and mental health policy related to reducing sexual assault, rape, and abuse (SARA) in Allegheny County. It further seeks to foster an active, synergistic partnership between researchers and community-based clinical services.
Specifically, we aim to build an ecological systems collaborative research and practice infrastructure aimed at improving the treatment and outcomes of care of survivors of SARA (sexual assault, rape, and abuse) with SARTAC, PAAR, and the DA's Office. The application plans to request funding for conceptual, methodological, and site development of intervention in caring for survivors of SARA in a seamless, competent and compassionate way.

Despite availability of training programs in sexual assault response team and efficacious treatments in EDs, a great majority of survivors of SARA receive no treatment at all for their mental health needs and/or receive only partial treatment of their physical injury in the ED because SARA is the most underreported crime, and for those who report the crime (50%) feels revictimized by healthcare providers and/or law enforcement. Survivors of SARA are at increased risk of injury, death, and somatic and mental health symptoms that impair full participation and contribution to society. A survivor of SARA who reported the crime after 20 years described the post SARA life as "having been placed in a global positioning ankle bracelet; everyone knows where I am but nobody cares what happens to me." We plan to implement RISP initiatives in partnership with three responders to sexual assault, rape and abuse incidents: SARTAC (ED exam and evidence collection), the Allegheny County Office of the District Attorney (prosecution), and PAAR (advocacy and follow-up). Through SARTAC, the City of Pittsburgh Bureau of Police, Allegheny County Police, County of Allegheny Department of Emergency Services, and Allegheny Crime Laboratory will be among the community services included in the practice/academic/research partnership.

The overall aim will be pursued through specific initiatives to facilitate and accelerate conceptual, methodological, and website development of a training program and intervention in caring for survivors of SARA. We plan to use the Ecological Systems Collaborative Model as our conceptual framework. We are in the process of (1) gathering background information on the community setting needs for research infrastructure; (2) gathering evidence of the fit and strengths of partner practice settings and institutions; (3) writing a description of the activities that have been and will be undertaken to develop and strengthen the unique community - academic partnership; and (4) developing at least two pilot or exploratory studies intended to provide the data and foundation for subsequent research applications from the partnership in mental health interventions and services research.