Comorbid Disorders Among Women

By: Shabria L. Mayne, MS, LPC, LCMHC, NCC, DBH Candidate at Cummings Graduate Institute for Behavioral Heath Studies, written for the course DBH 9033: Emerging Trends in Integrated Care

Comorbid Disorders Among Women: The Impacts of Trauma on Women’s Health and Applied Treatment Strategies using the Biodyne Model

Abstract

The relationship between physical and mental health is explained by direct and indirect effects of past mental and physical health (Ohrnberger et al., 2017, p.43). The prevalence of traumatic experiences throughout developmental years has a significant impact on the manifestation of future comorbid conditions, particularly among women. Exposure to trauma progresses into biological changes and stress responses. For instance, various studies indicate women to have an increased prevalence of mental health diagnosis such as post-traumatic stress disorder (PTSD) and other internalizing disorders like depression and anxiety. Correspondingly, this correlates to higher rates of diagnosed medical conditions such as high blood pressure/hypertension, thyroid diseases, cardiovascular diseases (CVD), and substance abuse related disorders. A practical therapeutic encounter will be examined for the purpose of exploring this notion. Additionally, examples of effective, ongoing treatment planning employed using the Biodyne Model within integrated healthcare will be provided.

Purpose/Objectives

After reading the research presented along with the applicable case scenario, readers will be able to:

Identify criteria for diagnosing post-traumatic stress disorder (PTSD) among women presenting with considerable symptoms of stress, anxiety, or depression.
Compare the relationship between extensive experiences with childhood trauma and the development of adverse adult functioning.
Recognize the connection between comorbid medical diagnosis and trauma-specific mental health diagnosis.
Evaluate the best treatment plan to address this comorbid concern based on the Biodyne Model within integrated care delivery.

Target Audience:

Applicable to all medical and behavioral health practitioners working in various healthcare settings with advanced (applied theory) level of experience.

Findings:

There is a proven correlation between a person’s medical health and mental health. Further, the prevalence of diagnosed comorbid conditions is high among women (Mayne, 2024). A study by Davis et al. (2022) concluded that the economic burden of treating PTSD is in the billions of dollars and a high percentage of this treatment is with civilian women. The use of integrated healthcare not only treats patients therapeutically and medically, but also addresses the social determinants of health in measuring cost-effective treatment outcomes.

Key words: Trauma; Childhood trauma; Post-traumatic stress disorder; Women’s healthcare; Women’s stress; Women’s mental health; Cardiovascular disease; Integrated healthcare; Comorbid disorders; Biodyne Model

Introduction

Many patients seeking treatment in medical and behavioral health settings have preexisting histories of trauma but are often unaware of the connection between their trauma history and presenting concerns. The American Psychological Association (APA) defines trauma as an emotional response to an extreme or distressing event, usually placing one at risk for serious harm or death, which results in a lasting emotional response (American Psychological Association, 2021). Long-term reactions to traumatic experiences may include unstable emotions, anxiety-provoked flashbacks, strained relationships, sleep disturbances, and physical symptoms. As it relates to gender, women have a 2-3x higher risk of developing post-traumatic stress disorder (PTSD) compared to men (Olff, 2017). There are many research studies aimed to consider the high prevalence of comorbid health-related conditions among women. This linkage assumes that there is a significant association between mental health and physical health. For instance, Ohrnberger et al. (2017) found that present physical and mental health are explained by direct and indirect effects of past mental and physical health (p.43). Therefore, women diagnosed with a pre-existing trauma-related mental health disorder may also suffer from medically related health concerns such as cardiovascular disease (CVD).

Cardiovascular Disease

The American Heart Association (2017) identifies cardiovascular diseases (CVDs) as a group of disorders of the heart and blood vessels. To elaborate, blood flow to different areas of the body may be reduced. This reduction can be caused by a build-up of fatty deposits inside the arteries or due to blood clots. There are diverse types of cardiovascular disease, such as coronary heart disease, valve disease, peripheral artery disease, heart failure, and stroke. “There are various physical symptoms of cardiovascular disease, including chest pain, or noticeable changes in heartbeat, dizziness, or lightheadedness, swelling of the extremities (legs, ankles, or feet), and uncommon skin rashes” (Mayne, 2023). Additionally, the CDC identifies risk factors for cardiovascular disease to include high blood pressure, tobacco use, obesity, stress, diabetes, and genetics related to family history (CDC, 2023). The Centers for Disease Control and Prevention states that heart disease is the leading cause of death for women in the America (2023).

Thyroid Disease

Thyroid disease is a diagnosed medical condition in which the thyroid does not produce the appropriate number of hormones. According to the American Thyroid Association (n.d.), thyroid disease is a common occurrence among Americans, and the disease impacts more women than men with women being 5-8x more likely to have thyroid problems (2016). There are two prominent types of thyroid disease; hyperthyroidism (overactive thyroid) and hypothyroidism (underactive thyroid), both of which may be caused by preexisting conditions or may be genetic in nature. Hyperthyroidism and anxiety are interrelated due to its symptoms, and patients with hyperthyroidism may experience heightened anxiety. For instance, while current research does not support the claim that hyperthyroidism is caused by anxiety, hyperthyroidism can significantly increase stress hormone levels in patients and exacerbate PTSD symptoms such as increased heart rate, hyperactivity, and agitation (Mayne, 2023).

Trauma

Trauma Defined

While trauma is intricately linked to acts of violence, it is unique to the individual experiencing the event. Varying traumatic experiences may account for instances related to abuse (physical, sexual, and emotional), bullying, loss of a loved one or a significant breakup, child neglect, poverty, racism, accidents, and medical interventions. Exposure to traumatic experiences can have immediate and lasting effects on one’s mental health. For instance, exposure to trauma progresses into biological changes and stress responses. This includes a “complex interchange of nervous, endocrine, and immune mechanisms that involves activation of the sympathetic-adreno-medullar (SAM) axis, the hypothalamus-pituitary-adrenal (HPA) axis, and immune system” (Chu et al., 2022). Further, people impacted by trauma may develop maladaptive behaviors, to cope with this stress response, directly contributing to mental health disorders like anxiety and depression, cognitive impairment, and chronic heart disease. Table 1 defines distinct types of traumas experienced and their unique estimated prevalence.

Table 1 Interpersonal Trauma Definitions and Data Points

Trauma Type	Definition	Prevalence	Source
Child neglect & physical abuse	When a parent or caregiver acts, or fails to act, in a way that results in physical injury to a child or adolescent, even if unintentional	>600,000 children were victims of abuse and neglect in 2021. 76% of children are neglected, & 16% are physically abused.	National Children’s Alliance, 2023
Sexual Assault	Sexual violence refers to any sexual activity in which consent is not obtained or freely given	>50% women & 1 in 3 men have experienced sexual violence. > 4 in 5 female rape survivors reported the occurrence before age 25.	Centers for Disease Control and Prevention, 2022
Intimate partner violence	Physical violence, sexual violence, stalking, and psychological aggression by a current or former intimate partner	1 in 4 women & 1 in 9 men experience severe intimate partner physical violence. Women ages18-24 are most abused by an intimate partner.	National Coalition Against Domestic Violence, 2021
Child sexual abuse	An interaction between a child and an adult or child in which the child is used by the perpetrator for sexual stimulation.	10% of children are sexually abused, and 0.2% are sex trafficked.	National Children’s Alliance, 2023
Community Violence	Exposure to intentional acts of interpersonal	1 in 5 high school students reported being bullied on	Federal Data Youth.gov, 2019

Content adopted from Gerber, M. R., & Gerber, E. B. (2019). An Introduction to Trauma and Health. Trauma-Informed Healthcare Approaches, 3–23. https://doi.org/10.1007/978-3-030-04342-1_1

Epidemiology

More than half of all women will be exposed to at least one traumatic event in their lifetime, according to the National Center for PTSD (Novotney, 2023). As stated earlier, the body’s stress response due to exposure to traumatic incidents can have adverse physiological effects. For example, the hypothalamic-pituitary-adrenal (HPA) axis controls the body’s stress response. According to Sheng et al., (2021) critical developmental stages must be attained to warrant proper functionality of the HPA axis and appropriate behavioral and physiological stress-responses in adulthood. A physical or emotional stressor may trigger an HPA axis response and because the thyroid is so associated with the HPA axis, any dysfunction in that axis will impact thyroid functioning. Furthermore, stress may increase inflammation in the body causing an increase in heart rate and blood pressure. The “fight or flight” response is explained by Chu et al., (2022) as “increased blood flow and pressure to active muscles and decreased blood flow to organs not required for rapid motor activity, increased rate of blood coagulation, cellular metabolism, muscle strength, mental activity, blood glucose concentration, and glycolysis in the liver.”

Post-Traumatic Stress Disorder

One of the most known stressor-related mental health disorders is post-traumatic stress disorder (PTSD). PTSD is a mental health disorder that some individuals may develop after experiencing a traumatic event. Symptoms are emotional, cognitive, and behavioral in nature and childhood trauma increases the severity and likelihood of developing the diagnosis. Figure 1 displays a simplistic version of the DSM-5 diagnostic criteria for posttraumatic stress disorder.

Figure 1

Women are at greater risk for developing PTSD and experience symptoms longer than men due to a higher exposure to interpersonal and high-impact trauma like sexual abuse. Further, it takes women 4 years to be diagnosed and obtain appropriate treatment (Companies, 2023). Repeated traumatic experiences during critical developmental years are associated with poorer early childhood brain development.

Galli et al. (2021) sought to research the role of trauma in the development of cardiovascular diseases. The authors considered various studies focusing on childhood adversities, such as family conflict and neglect, and how psychological factors created a 50% higher risk of developing CVD (2021). Overall, the authors confirmed that childhood trauma has a greater impact on adult cardiovascular health, and that the burden is worse in women due to the types of traumas experienced (p.10). Furthermore, women experience more distress than men on almost all symptoms identified on The Traumatic Experience Checklist (TEC). Women are also more likely to experience internalizing disorders like anxiety and depression (Cherry, K. 2021).

Box 1: Case Scenario

Case Study

Janet, 44, is a single mother of two children with an extensive history of complex trauma beginning in childhood. Traumatic experiences include rearing by a parental figure with an alcohol addiction and instances of sexual abuse at the hands of her older sister. Janet reported multiple suicide attempts throughout her adolescence leading to numerous psychiatric hospitalizations. She was diagnosed with bipolar disorder at age 14, has a preexisting diagnosis of PTSD, ADHD, and a comorbid medical diagnosis of hyperthyroidism. Relationally, Janet reported various physically and verbally abusive relationships with men throughout her adulthood. Further, she reported present frequent discord with her mother (abuses alcohol), stress in managing her relationship with her partner (who is in SA recovery), and a healthy dynamic with her sister. Functionally, Janet reports she experiences mood swings ranging from significant bouts of depression to borderline mania. She routinely meets with a psychiatrist for medication management, and is prescribed the following medications: Lamotrigine, Seroquel, Abilify, Prozac, Vyvanse, and Adderall. However, she expressed interest in reducing or eliminating some of her prescribed medications. Janet reported that she smokes marijuana 2-3x weekly to manage stress. She attends Al-ANON meetings regularly to develop a support system and learn about substance abuse. Additionally, Janet engages in healthier stress-management activities such as weekly horseback riding and writing poetry.

Some valuable points of consideration when developing a treatment plan for this patient include the following:

Who is presenting? In other words, can this patient be identified as an Onion or a Garlic?
With the patient’s extensive history, what precipitating incident sparked the need for therapy services?
What is the diagnosis that requires treatment, and is the disorder medication responsive?
What is the most efficient and cost-effective manner to streamline treatment? Organizational investment in developing trauma-informed services may convert to cost effectiveness (Center for Substance Abuse Treatment, 2019).

Trauma-Informed Care and the Biodyne Model

Trauma-Informed treatment is a therapeutic approach which primarily focuses on the belief that trauma can significantly impact an individual’s well-being, including one’s physical and mental health. A trauma-informed approach highlights three primary elements: (1) understanding trauma prevalence (2) understanding how trauma affects all individuals involved and (3) responding by putting such knowledge into practice (SAMHSA, 2012, p.4). The benefits of trauma-informed care are that it employs an integrated healthcare approach during treatment to arrive at specified goals responding to comorbid conditions. Figure 2 highlights the guiding principles of trauma-informed care employed within the integrated healthcare system.

Figure 2: Trauma-Informed Care

Treatments such as cognitive behavioral therapy (CBT) and prolonged exposure therapy are proven effective in treating patients diagnosed with PTSD. Comparable to principles of the Biodyne Model, trauma-informed care allows patients to be fully engaged in their treatment process through interdisciplinary collaboration, treatment is fostered through integrated professional and community support, and the social determinants of health are considered in understanding the patient’s relationship to his/her presenting concerns. The Center for Substance Abuse Treatment (2019) explains that building relationships across the service system, provider networks, and the local community boosts trauma-informed care continuity when patients are involved in multiple services at one time. Table 2 depicts the stages of behavioral health integration.

Table 2: Stages of Behavioral Health Integration

Coordinated	Co-located	Integrated
Behavioral health and other healthcare professionals practice separately within their respective disciplines. Details regarding shared patients are exchanged when necessary and there is limited collaboration.	Behavioral health and medical providers practice in the same office. Co-location depicts where services are provided rather than a particular service. Therefore, patient care is often limited to each provider’s area of expertise.	Behavioral health and medical providers collaborate and create patient treatment/care plans. There exist closely integrated, on-site efforts with a unified care plan. Additional on-site services like social services may also be available.

Content adopted from Agency for Healthcare Research and Quality. (2011). Lexicon for behavioral health and primary care integration. Retrieved on December 1, 2013 from http://integrationacademy.ahrq.gov/lexicon

The goal of the Biodyne Model is to produce life change. In assessing the medical and mental health impacts of trauma throughout one’s developmental years, it is crucial to consider which techniques can be employed to support this goal. For instance, the Biodyne Model uses various treatment strategies such as relaxation, systematic desensitization, reinforcement schedules, homework assignments, cognitive restructuring, and role playing (Cummings et al, 2013). Additionally, preventative, or management efforts can be offered from professional to patient via psychoeducation, linkage to community health referrals, and health equity. Health equity can be achieved when everyone is afforded the same opportunities to be as healthy as possible. This may be accomplished by increasing provider awareness on health disparities, expanding healthcare coverage, improving existing coverage, and creating local efforts to not solely educate, but create opportunities for healthier standards of living (Mayne, 2023).

In addition, creating a clinical pathway which engages notions of the Biodyne Model, applies trauma-informed principles, utilizes a professional referral system, and links community support services considering the social determinants of health may establish an innovative standard of practice. Early psychoeducation efforts can be promoted through community engagement to encourage health and wellness, and further facilitate preventative strategies. Upon entering treatment, warm handoffs between medical doctors and behavioral create a foundational understanding of diagnosis and appropriate treatment considerations. Additionally, culturally sensitive, peer-led community and health care professional education is a necessary step in CVD prevention (Mehta et al., 2023).

Conclusion

There is a proven link between a person’s medical health and mental health, and the prevalence of comorbid conditions is high among women. Understanding the physiology of trauma in conjunction with developing medical conditions is a concern worth continual research. In the meantime, the utilization of integrated healthcare treatment in managing these interconnected issues is significant to reducing cost, prevalence, and morbidity.

References

Administration for Children and Families. (n.d.). Trauma. Administration for Children and Families. https://www.acf.hhs.gov/trauma-toolkit/trauma-concept

Agency for Healthcare Research and Quality. (2011). Lexicon for behavioral health and primary care integration. Retrieved on December 1, 2013 from http://integrationacademy.ahrq.gov/lexicon

American Heart Association. (2017, May 31). What is Cardiovascular Disease? Www.heart.org; American Heart Association. https://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease

American Psychological Association. (2021). Trauma and Shock. American Psychological Association. https://www.apa.org/topics/trauma

American Thyroid Association. (2016). General Information/Press Room | American Thyroid Association. American Thyroid Association. https://www.thyroid.org/media-main/press-room/

CDC. (2023). Heart Disease Risk Factors. Centers for Disease Control and Prevention. https://www.cdc.gov/heartdisease/risk_factors.htm

Centers for Disease Control and Prevention. (2022, June 22). Preventing sexual violence. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/sexualviolence/fastfact.html

Center for Substance Abuse Treatment . (2019). Trauma-Informed Care: A Sociocultural Perspective. Nih.gov; Substance Abuse and Mental Health Services Administration (US). https://www.ncbi.nlm.nih.gov/books/NBK207195/

Cherry, K. (2021). What Are the Signs of PTSD in Women? Verywell Mind. https://www.verywellmind.com/ptsd-in-women-signs-and-symptoms-5198684

Chu, B., Marwaha, K., Ayers, D., & Sanvictores, T. (2022, September 12). Physiology, Stress reaction. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541120/

Companies, S. (2023, May 3). Post-Traumatic Stress Disorder in Women: Signs & Symptoms. Capital Women’s Care. https://www.cwcare.net/post-traumatic-stress-disorder-in-women-signs-symptoms/

Cummings, N. A., & Cummings, J. L. (2013). Refocused psychotherapy as the first line intervention in behavioral health. Routledge.

Davis, L. L., Schein, J., Cloutier, M., Gagnon-Sanschagrin, P., Maitland, J., Urganus, A., Guerin, A., Lefebvre, P., & Houle, C. R. (2022). The Economic Burden of Posttraumatic Stress Disorder in the United States From a Societal Perspective. The Journal of Clinical Psychiatry, 83(3). https://doi.org/10.4088/jcp.21m14116

Federal Data | Youth.gov. (2019). Youth.gov. https://youth.gov/youth-topics/violence-prevention/federal-data

Galli, F., Lai, C., Gregorini, T., Ciacchella, C., & Carugo, S. (2021). Psychological Traumas and Cardiovascular Disease: A Case-Control Study. Healthcare, 9(7), 875. https://doi.org/10.3390/healthcare9070875

Gerber, M. R., & Gerber, E. B. (2019). An Introduction to Trauma and Health. Trauma-Informed Healthcare Approaches, 3–23. https://doi.org/10.1007/978-3-030-04342-1_1

Harper, C. R., Li, J., Sheats, K., Hertz, M. F., Merrill-Francis, M., Friar, N. W., Ashley, C. L., Shanklin, S., Barbero, C., Gaylor, E. M., & Hoots, B. E. (2023). Witnessing Community Violence, Gun Carrying, and Associations with Substance Use and Suicide Risk Among High School Students — Youth Risk Behavior Survey, United States, 2021. MMWR Supplements, 72(1), 22–28. https://doi.org/10.15585/mmwr.su7201a3

Mayne, S. (2023). Population Health Intervention: Thyroid Disease and Mental Health. Cummings Graduate Institute.

Mehta, L. S., Velarde, G. P., Lewey, J., Sharma, G., Bond, R. M., Navas-Acien, A., Fretts, A. M., Magwood, G. S., Yang, E., Blumenthal, R. S., Brown, R.-M., & Mieres, J. H. (2023). Cardiovascular Disease Risk Factors in Women: The Impact of Race and Ethnicity: A Scientific Statement From the American Heart Association. Circulation. https://doi.org/10.1161/cir.0000000000001139

National Children’s Alliance . (2023). National Child Abuse Statistics from NCA. National Children’s Alliance. https://www.nationalchildrensalliance.org/media-room/national-statistics-on-child-abuse/#:~:text=More%20than%20600%2C000%20children%20are

National Coalition Against Domestic Violence. (2021). National Statistics. NCADV. https://ncadv.org/statistics

Novotney, A. (2023). Women who experience trauma are twice as likely as men to develop PTSD. Here’s why. Apa.org. https://www.apa.org/topics/women-girls/women-trauma

Ohrnberger, J., Fichera, E., & Sutton, M. (2017). The relationship between physical and mental health: A mediation analysis. Social Science & Medicine, 195(195), 42–49. https://doi.org/10.1016/j.socscimed.2017.11.008

Olff, M. (2017). Sex and gender differences in post-traumatic stress disorder: an update. European Journal of Psychotraumatology, 8(sup4), 1351204. https://doi.org/10.1080/20008198.2017.1351204

Ramanuj, Parashar & Ferenchik, Erin & Docherty, Mary & Spaeth-Rublee, Brigitta & Pincus, Harold. (2019). Evolving Models of Integrated Behavioral Health and Primary Care. Current Psychiatry Reports. 21. 10.1007/s11920-019-0985-4.

Sheng, J. A., Bales, N. J., Myers, S. A., Bautista, A. I., Roueinfar, M., Hale, T. M., & Handa, R. J. (2021). The Hypothalamic-Pituitary-Adrenal Axis: Development, Programming Actions of Hormones, and Maternal-Fetal Interactions. Frontiers in Behavioral Neuroscience, 14(601939). https://doi.org/10.3389/fnbeh.2020.601939

Substance Abuse and Mental Health Services Administration. SAMHSA’s working definition of trauma and principles and guidance for a trauma-informed approach. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012.

Testimonials

“As a member of the AAPI community, I’m very familiar with the barriers to mental health services and the need to break through the glass wall of cultural stigma that prevents many from receiving potentially life–saving treatment. I was the only Asian American person in my master’s cohort, the only Asian American person in many of my clinical work settings, the only Asian American person to walk into many of the professional settings that I pushed myself to show up to. In my current practice, I’m constantly reminded by my patients of how difficult it is to find an Asian American mental health provider, though this reminder constantly informs me that more needs to be done for my community. Day after day, I read stories of Asian American people who die by suicide as a consequence of our culture’s avoidance of mental health topics. As a DBH, my biggest goal is to use my expertise in whole–person care to amplify the conversation around mental health and help my community understand that mental healthcare is not a privilege that we are not entitled to, it is a crucial part of our healthcare that will manifest differently in us than what many Western psychology or psychiatry textbooks will describe, and that our unique experience of mental health issues are valid, important, and is time to be part of the larger conversation.”
Willam Chum, LMHCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - September 16, 2022

“The DBH represents something that I've always embraced in my professional career. And that's collaboration and working across a lot of different disciplines to make sure you’re delivering the best care for the patient. Everything is about being patient centered about finding innovative ways and creative ways to collaborate with other professionals.”
CDR Sean K. Bennett, LCSW, MSWAC, BCDDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - October 10, 2023

“This program will change how you present to the world, not just as a professional but as an individual. Understand this is work but the work is worth it and the journey is undeniably transformative. If you are seeking a doctorate for the title, this is not the program for you. If you are seeking a doctorate to interrupt and disrupt the course of healthcare, then this is the program for you. You won’t find a more supportive program with professors who are dedicated to your success and your education. This program is not about the regurgitation of information. It is about the appropriate applied application of knowledge and information to push forward and become an advocate for equitable and quality care for all.”
Brandy K. Biglow LMHC, CCTP, QSDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - February 5, 2024

“The Doctor of Behavioral Health (DBH) program has definitely transformed my understanding of behavioral health. Understanding the links between physical and mental health has taught how to make better treatment decisions. The DBH program has also given me insights that otherwise would not be possible and allows me to view individuals through a lens that I was previously ignorant of. This program has helped me grow into a more confident individual, provider, and parent.”
Cory H. Cannady, BCBA, LBADBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - March 13, 2024

“The DBH program has been a pivotal turning point in my understanding and application of behavioral health principles. Recently, the concept of ‘whole person health’ has gained widespread attention in healthcare circles, becoming somewhat of a buzzword. Like many others, I embraced this term, believing in my capacity to deliver comprehensive care.

Prior to my engagement with the program, my approach, albeit well-intentioned, lacked an appreciation for the intricate interplay between physical and mental health. More importantly, the role of unmet social needs as a catalyst for health disparities was a dimension I had not fully integrated into my practice. The DBH program illuminated these connections, offering me a robust framework to understand and address the multifaceted needs of individuals, especially within marginalized communities.

Additionally, the confidence I have gained through the DBH program extends beyond theoretical knowledge. My role as a connector and advocate for these individuals has become more pronounced, driven by a deep-seated commitment to fostering accessibility, equity, and comprehensiveness in care.”
Michelle Stroebel MA, NCC, LCMHC, NADD-CCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - June 12, 2024

“I have worked in behavioral health for the entirety of my professional career starting with college internships up to my current role as Deputy Executive Commissioner of Behavioral Health for the Texas Health and Human Services Commission. While I have years of experience in the field, the DBH program at Cummings has framed my perspective as leveraging therapy as a first line of intervention. As a public servant, much of the work I do is usually in the aftermath of crises or when the system is being forced to respond to a service gap. However, the DBH program takes a much more proactive and integrative approach to health. This perspective/approach has the potential to positively shape policy in Texas in my role as a public servant charged with addressing the safety net needs of the most vulnerable constituents in Texas.”
Trina K. Ita, MA, LPCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - July 10, 2024

“CGI feels like a community of long-lost cousins that finally met as adults and we realized that we share the same goals. The support from the faculty and classmates have been nothing short of amazing. I can reach out to my advisor at any given time to discuss course work, career endeavors, or to just vent about life. There is a feeling of closeness and belongingness at CGI that is just unmatched. I am very happy to be a member of the family and will continue to spread the word of how great this DBH program is.”
Michelle Francis, LCSW/LICSW-QSDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - September 10, 2024

“The DBH program’s mission, purpose, and objective say it all: We strive for intentional care outcome improvement practices that exemplify whole person-centered integrated healthcare advanced competency. The program of study drives insights and awareness of the ever-changing patient population and multidisciplinary practice environments to change how the world experiences healthcare. This is further reinforced by the pillars of medical literacy, integrated behavioral health intervention, and entrepreneurship skills and expertise. Development growth is needed to prepare the aspiring DBH for the future of the shifting healthcare marketplace through international networking in a growing community of disruptive innovators and an evolving movement toward systemic healthcare change. I feel that I will be positioned alongside a fellowship of like-minded professionals trying to improve the quality of healthcare service delivery value and outcome sustainability.”
Jose Mathew, LCSW, LAC, ACS, EMDR-T, CCTP-IIDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - October 8, 2024

“The DBH program has reinforced my vision of viewing behavioral health (BH) as an integrated component of the healthcare system rather than a siloed service. As a practitioner in the focused BH realm of substance use disorder (SUD) treatment, I observe on a regular basis how identifying and serving SUD patients is often missed, ignored and stigmatized in primary healthcare, despite the fact that early intervention at these check-points often has the potential to intervene earlier and lessen the negative SUD outcomes frequently seen by the time a patient reaches specialty SUD services. Reinforcement received in my DBH program has motivated me to promote integration as a leader in my workplace and is a primary factor in considering the long-term trajectory of my individual career path.”
Kenneth L. Roberts, MPS, LPCC, LADCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - November 5, 2024

“By becoming a DBH, I have found that I am able to have different conversations with different people. Before having my doctorate degree, I was able to speak to certain items in behavioral health, but was only seen as a licensed therapist where as a doctor, I am able to speak to the changemakers and policy makers in a more collaborative manner which then allows us as a group to enhance the services we are providing. I also found that as a DBH, my confidence in the treatment room has improved immensely and cases that may have been more difficult for me before are no longer as difficult due to the training I have received in the program.”
Dr. Allison Earl, DBH, LPC-SDBH Alumna, Cummings Graduate Institute for Behavioral Health Studies - November 13, 2024

“I think the DBH is quite groundbreaking, it allows you to study from anywhere in the world. The support is fantastic, and you can make out of the DBH what you want. Unlike standard professional doctorates, the DBH was trying to break new ground, not trying to go over just old ground. It greatly encourages its students to be those people who break new ground.

As a person who actually has a disability, I found CGI staff to be very supportive, very accommodating. If I need extensions, they are always there. In fact the staff will reach out and check on you, if they haven’t heard from you in a very short period of time. Which I have never had from any other university.

I find the community of fellow DBH students absolutely wonderful, we reach out across numerous social media platforms, we email each other. Doesn’t matter where I am in the world or where they are in the world, everyone is supportive. Its support, support and encouragement with the DBH.”
Jason P. Sargent, B Policing, GDip Psych, MSW, JPDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - December 10, 2024

“Graduating from the DBH program has influenced and enhanced my approach to addressing behavioral health challenges and making a difference in the field by preparing me to become a serious business owner. Through the DBH program, I understand now that becoming a business owner not only assists me in reaping the financial benefits of working for myself, but the program also offers me a sense of freedom to make a difference in an individual’s life.”
Dr. Rebecca K. Wright, DBH, LBA, BCBA, QBADBH Alumna, Cummings Graduate Institute for Behavioral Health Studies - December 18, 2024

“I have always wanted to pursue a higher degree but never found a program that met my needs. When I investigated the DBH program, I can honestly say I was excited. It was a program that would expand my knowledge in behavioral health but also how it relates to physical health. The philosophy of treating the whole person was exactly what I was looking for.”
Elizabeth Nekoloff, M.Ed., LPCC-S, NCCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - January 16, 2025

“Prior to obtaining my DBH, I practiced behavioral health within the boundaries of behavior analysis. The DBH degree has given me the ability to broaden my scope of competence allowing me to provide a higher quality of care to my clients through a person-centered approach, while still staying within my scope of practice. I was in the beginning stages of opening my business when I enrolled in the DBH program which set my trajectory towards being a stronger leader. The program equipped me with essential healthcare leadership and entrepreneurial skills, allowing me to ensure high-quality services for my clients and foster a supportive work environment for our staff. It has also given me the confidence to expand my business and pursue other healthcare ventures, reaching a broader range of patients in need.”
Dr. Pauline Tolentino Pablo, DBH, BCBA, IBADBH Alumna, Cummings Graduate Institute for Behavioral Health Studies - January 21, 2025

“Although I have worked with many patients who have mental health diagnoses, or behaviors which make managing their medical diagnoses and day to day life difficult, the DBH program at CGI is broadening that knowledge and providing a deeper understanding of behavioral health and how best to help these individuals manage their health and improve their quality of life. This will allow me to provide and advocate for more meaningful and seamless integrated care, providing new tools for my intervention toolbox, and the confidence and skills to collaborate within and lead whole person focused interdisciplinary teams. I also anticipate building upon my knowledge as a nurse case manager and long time caregiver, as well as my personal passions and professional vision, learning about processes and operations, to be in position to start up and lead my own company one day, offering the services and care I know every person should have access to.”
Hollie Wilson, MSN, RN, CCMDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - February 11, 2025

“The Doctor in Behavioral Health (DBH) program has changed my understanding of the subject and career path. Before this academic journey, my knowledge of behavioral health was primarily theoretical, including essential ideas and methods. However, the DBH curriculum combined intense academic research with practical application, helping me understand behavioral health from multiple angles. Recognizing mental health as part of total health changed my perspective. The biopsychosocial model, which showed how biological, psychological, and social variables affect mental health, was stressed in the DBH curriculum. This comprehensive approach made me realize how complex human behavior is and how important it is to address mental health issues. Effective interventions must target the individual’s surroundings, relationships, and life experiences, not just symptoms. The curriculum also gave me enhanced evidence-based practice training to execute successful solutions. Studies methods and data analysis classes improved my critical thinking and allowed me to evaluate and apply behavioral health studies. This gave me the confidence to contribute to the field’s knowledge base through practice and research.”
Dr. Rhea Hill, DBH, LPCDBH Alumna, Cummings Graduate Institute for Behavioral Health Studies - February 17, 2025

“The DBH program will open opportunities for me to contribute to healthcare system innovation, particularly through trauma-informed care and integrated behavioral health settings. I will be better positioned to advocate for and implement holistic care models that improve health outcomes for underserved populations. Ultimately, this program will help me transition into higher-level roles, such as a director or consultant in behavioral health, where I can influence broader system changes and contribute to the future of healthcare delivery.”
DeKyn Rashad Peters, MPH-CHES,BSW/BA,APCDBH Candidate, Cummings Graduate Institute for Behavioral Health Studies - March 4, 2025

“The DBH program has been integral in preparing me for leadership roles by providing a solid foundation in both the theoretical and practical aspects of leadership within the behavioral health sector. Through coursework, case studies, and hands-on experiences, I have learned to lead with empathy, data-driven decision-making, and strategic planning. The program has also honed my skills in organizational development, communication, and policy advocacy, equipping me to effectively lead teams, drive impactful change, and foster environments that promote positive behavioral health outcomes. With this training, I am confident in my ability to lead initiatives that address systemic barriers and improve care delivery.”
Dr. Jerrika Henderson, DBH, CMHCDBH Alumna, Cummings Graduate Institute for Behavioral Health Studies - March 18, 2025