AIDS and Behavior

, Volume 22, Issue 5, pp 1446–1460 | Cite as

Psychopathology Subgroups and HIV Risk Among Women in Psychiatric Treatment

  • Robert C. McMahon
  • John M. Abbamonte
  • Jessy G. Dévieux
Original Paper


Among individuals with mental illness, the HIV infection rate is generally found to be substantially higher than in the general population. Understanding dimensions or subtypes of psychopathology linked with HIV risk behavior may enable development of targeted interventions to reduce HIV transmission. This study identified subgroups of women (n = 243) receiving outpatient psychiatric treatment based upon cluster analysis of indices of personality disorder and clinical symptom syndromes. High, medium, and low psychiatric severity cluster subgroups were found to differ significantly on key HIV risk variables. The high psychopathology subgroup revealed greater AIDS anxiety, more sexual partners, more sexual trading behaviors, less risk reduction self-efficacy, and less skill in condom usage than was found in one or both cluster subgroups characterized by less psychiatric severity. Results suggest that subgroups differentiated on the basis of levels of personality disorder and clinical symptom severity display differences in types and levels of HIV risk-related attitudes, beliefs, expectancies, skills, and behaviors that might guide development of tailored prevention intervention.


Sex risk behaviors Personality Cluster analysis Psychopathology 



This study was funded and made possible by grant #1R01DA018916-01 (HIV Prevention Groups for AOD Using SMI Women) awarded to Dr. Robert M. Malow.

Compliance with Ethical Standards


This study was funded by grant #1R01DA018916-01 (HIV Prevention Groups for AOD Using SMI Women) to Dr. Robert M. Malow.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional review board at Florida International University, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Lundberg P, Nakasujja N, Musisi S, Thorson AE, Cantor-Graae E, Allebeck P. HIV prevalence in persons with severe mental illness in Uganda: a cross-sectional hospital-based study. Int J Ment Health Syst. 2013;7(1):20. doi: 10.1186/1752-4458-7-20.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    McKinnon K, Cournos F, Herman R. HIV among people with chronic mental illness. Psychiatr Q. 2002;73(1):17–31. doi: 10.1023/A:1012888500896.CrossRefPubMedGoogle Scholar
  3. 3.
    Rosenberg SD, Goodman LA, Osher FC, et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness. Am J Public Health. 2001;91(1):31–7.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Blank MB, Mandell DS, Aiken L, Hadley TR. Co-occurrence of HIV and serious mental illness among medicaid recipients. Psychiatr Serv. 2002;53(7):868–73. doi: 10.1176/ Scholar
  5. 5.
    Carey MP, Weinhardt LS, Carey KB, Deleon PH. Prevalence of Infection With HIV Among the Seriously Mentally Ill: review of Research and Implications for Practice. Prof Psychol Res Pr. 1995;26(3):262–8.CrossRefGoogle Scholar
  6. 6.
    Weiser SD, Wolfe WR, Bangsberg DR. The HIV epidemic among individuals with mental illness in the United States. Curr HIV/AIDS Rep. 2004;1(4):186–92.CrossRefPubMedGoogle Scholar
  7. 7.
    Rossler W, Koch U, Lauber C, et al. The mental health of female sex workers. Acta Psychiatr Scand. 2010;122(2):143–52. doi: 10.1111/j.1600-0447.2009.01533.x.CrossRefPubMedGoogle Scholar
  8. 8.
    Kalichman S, Malow R, Dévieux J, Stein JA, Piedman F. HIV risk reduction for substance using seriously mentally ill adults: test of the information-motivation-behavior skills (IMB) model. Community Ment Health J. 2005;41(3):277–90. doi: 10.1007/s10597-005-5002-1.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Pitpitan EV, Kalichman SC, Garcia RL, Cain D, Eaton LA, Simbayi LC. Mediators of behavior change resulting from a sexual risk reduction intervention for STI patients, Cape Town, South Africa. J Behav Med. 2015;38(2):194–203. doi: 10.1007/s10865-014-9591-4.CrossRefPubMedGoogle Scholar
  10. 10.
    Carey MP, Carey KB, Maisto SA, Gordon CM, Vanable PA. Prevalence and correlates of sexual activity and HIV-related risk behavior among psychiatric outpatients. J Consult Clin Psychol. 2001;69(5):846–50. doi: 10.1037/0022-006X.69.5.846.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Meade CS, Sikkema KJ. HIV risk behavior among adults with severe mental illness: a systematic review. Clin Psychol Rev. 2005;25(4):433–56. doi: 10.1016/j.cpr.2005.02.001.CrossRefPubMedGoogle Scholar
  12. 12.
    Carey MP, Carey KB, Maisto SA, Schroder KEE, Vanable PA, Gordon CM. HIV risk behavior among psychiatric outpatients: association with psychiatric disorder, substance use disorder, and gender. J Nerv Ment Dis. 2004;192(4):289–96. doi: 10.1097/01.nmd.0000120888.45094.38.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    McKinnon K, Cournos F, Sugden R, Guido JR, Herman R. The relative contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors among people with severe mental illness. J Clin Psychiatry. 1996;57(11):506–13.CrossRefPubMedGoogle Scholar
  14. 14.
    Meade CS, Sikkema KJ. Psychiatric and psychosocial correlates of sexual risk behavior among adults with severe mental illness. Community Ment Health J. 2007;43(2):153–69. doi: 10.1007/s10597-006-9071-6.CrossRefPubMedGoogle Scholar
  15. 15.
    Goodman LA, Salyers MP, Mueser KT, et al. Recent victimization in women and men with severe mental illness: prevalence and correlates. J Trauma Stress. 2001;14:615–32.CrossRefPubMedGoogle Scholar
  16. 16.
    Meade CS, Graff FS, Griffin ML, Weiss RD. HIV risk behavior among patients with co-occurring bipolar and substance use disorders: associations with mania and drug abuse. Drug Alcohol Depend. 2008;92(1):296–300. doi: 10.1016/j.drugalcdep.2007.07.013.CrossRefPubMedGoogle Scholar
  17. 17.
    Grant BF, Stinson FS, Hasin DS, et al. Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry. 2005;66(10):1205–15.CrossRefPubMedGoogle Scholar
  18. 18.
    Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry. 2002;59(6):530–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Lavan H, Johnson JG. The association between axis I and II psychiatric symptoms and high-risk sexual behavior during adolescence. J Pers Disord. 2002;16(1):73–94. doi: 10.1521/pedi. Scholar
  20. 20.
    Newville H, Haller DL. Relationship of axis II pathology to sex- and drug-related risk behaviors among patients in HIV primary care. AIDS Care. 2012;24(6):763–8. doi: 10.1080/09540121.2011.630367.CrossRefPubMedGoogle Scholar
  21. 21.
    Sacks MH, Perry S, Graver R, Shindledecker R, Hall S. Self-reported HIV-related risk behaviors in acute psychiatric inpatients: a pilot study. Hosp Community Psychiatry. 1990;41(11):1253–5.PubMedGoogle Scholar
  22. 22.
    Chen EY, Brown MZ, Lo TTY, Linehan MM. Sexually transmitted disease rates and high-risk sexual behaviors in borderline personality disorder versus borderline personality disorder with substance use disorder. J Nerv Ment Dis. 2007;195(2):125–9. doi: 10.1097/01.nmd.0000254745.35582.f6.CrossRefPubMedGoogle Scholar
  23. 23.
    Kelly JA, Murphy DA, Bahr GR, et al. AIDS/HIV risk behavior among the chronic mentally ill. Am J Psychiatry. 1992;149(7):886–9. doi: 10.1176/ajp.149.7.886.CrossRefPubMedGoogle Scholar
  24. 24.
    Sansone RA, Chu JW, Wiederman MW. Sexual behaviour and borderline personality disorder among female psychiatric inpatients. Int J Psychiatry Clin Pract. 2011;15(1):69–73. doi: 10.3109/13651501.2010.507871.CrossRefPubMedGoogle Scholar
  25. 25.
    Martin AM, Benotsch EG, Perschbacher LS, Green M. Transmission risk behaviors in a subset of HIV-positive individuals: the role of narcissistic personality features. Pers Individ Dif. 2013;54(2):256–60. doi: 10.1016/j.paid.2012.09.006.CrossRefGoogle Scholar
  26. 26.
    Kelley JL, Petry NM. HIV risk behaviors in male substance abusers with and without antisocial personality disorder. J Subst Abuse Treat. 2000;19(1):59–66. doi: 10.1016/S0740-5472(99)00100-2.CrossRefPubMedGoogle Scholar
  27. 27.
    Brooner RK, Bigelow GE, Strain E, Schmidt CW. Intravenous drug abusers with antisocial personality disorder: increased HIV risk behavior. Drug Alcohol Depend. 1990;26:39–44.CrossRefPubMedGoogle Scholar
  28. 28.
    Brooner RK, Greenfield L, Schmidt CW, Bigelow GE. Antisocial personality disorder and HIV infection among intravenous drug abusers. Am J Psychiatry. 1993;150:53–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Gill K, Nolimal D, Crowley TJ. Antisocial personality disorder, HIV risk behavior and retention in methadone maintenance therapy. Drug Alcohol Depend. 1992;30(3):247–52. doi: 10.1016/0376-8716(92)90059-L.CrossRefPubMedGoogle Scholar
  30. 30.
    King VL, Kidorf MS, Stoller KB, Brooner RK. Influence of psychiatric comorbidity on HIV risk behaviors: changes during drug abuse treatment. J Addict Dis. 2000;19(4):65–83.CrossRefPubMedGoogle Scholar
  31. 31.
    Compton WM, Cottler LB, Shillington AM, Price RK. Is antisocial personality disorder associated with increased HIV risk behaviors in cocaine users? Drug Alcohol Depend. 1995;37:37–44.CrossRefPubMedGoogle Scholar
  32. 32.
    Compton WM, Cottler LB, Spitznagel EL, Abdallah AB, Gallagher T. Cocaine users with antisocial personality improve HIV risk behaviors as much as those without antisocial personality. Drug Alcohol Depend. 1998;49(3):239–47. doi: 10.1016/S0376-8716(98)00017-9.CrossRefPubMedGoogle Scholar
  33. 33.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.CrossRefGoogle Scholar
  34. 34.
    Caspi A, Houts RM, Belsky DW, et al. The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clin Psychol Sci. 2004;2(2):119–37. doi: 10.1177/2167702613497473.CrossRefGoogle Scholar
  35. 35.
    Millon T, Davis RD, Millon C. The Millon Clinical Multiaxial Inventory-III manual. 2nd ed. Minneapolis, MN: National Computer Systems; 1997.Google Scholar
  36. 36.
    McMahon RC, Malow RM, Devieux J, Rosenberg R, Jennings T. HIV risk and history of STDs in MCMI-III psychopathology subgroups of comorbid substance abusers. Am J Drug Alcohol Abuse. 2008;34(3):329–37. doi: 10.1080/00952990802010876.CrossRefPubMedGoogle Scholar
  37. 37.
    McMahon RC, Malow RM, Penedo FJ. Substance abuse problems, psychiatric severity, and HIV risk in millon clinical multiaxial inventory-II personality subgroups. Psychol Addict Behav. 1998;12(1):3–13. doi: 10.1037/0893-164X.12.1.3.CrossRefGoogle Scholar
  38. 38.
    McMahon RC, Malow R, Jennings TE. Personality, stress, and social support in HIV risk prevention. AIDS Behav. 2000;4(4):399–410. doi: 10.1023/A:1026410824645.CrossRefGoogle Scholar
  39. 39.
    Ball SA, Nich C, Rounsaville BJ, Eagan D, Carroll KM. Millon clinical multiaxial inventory-III subtypes of opioid dependence: validity and matching to behavioral therapies. J Consult Clin Psychol. 2004;72(4):698–711. doi: 10.1037/0022-006X.72.4.698.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Haller DL, Miles DR, Dawson KS. Factors influencing treatment enrollment by pregnant substance abusers. Am J Drug Alcohol Abuse. 2003;29(1):117–31.CrossRefPubMedGoogle Scholar
  41. 41.
    Carey MP, Carey KB, Maisto SA, Gordon CM, Schroder KE, Vanable PA. Reducing HIV-risk behavior among adults receiving outpatient psychiatric treatment: results from a randomized controlled trial. J Consult Clin Psychol. 2004;72(2):252–68. doi: 10.1037/0022-006X.72.2.252.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Otto-Salaj LL, Kelly JA, Stevenson LY, Hoffman R, Kalichman SC. Outcomes of a randomized small-group HIV prevention intervention trial for people with serious mental illness. Community Ment Health J. 2001;37(2):123–44.CrossRefPubMedGoogle Scholar
  43. 43.
    Malow RM, McMahon RC, Dévieux J, et al. Cognitive behavioral HIV risk reduction in those receiving psychiatric treatment: a clinical trial. AIDS Behav. 2012;16(5):1192–202. doi: 10.1007/s10461-011-0104-y.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    McMahon RC, Stanforth ET, Yocom BE, Devieux JG. HIV Risk in Cluster Subgroups of Women Receiving Psychiatric Treatment. American Psychological Association Annual Conference, Toronto, Canada, 2015.Google Scholar
  45. 45.
    Craig RJ, Bivens A, Olson R. MCMI-III-derived typological analysis of cocaine and heroin addicts. J Pers Assess. 1997;69(3):583–95. doi: 10.1207/s15327752jpa6903_11.CrossRefPubMedGoogle Scholar
  46. 46.
    Craig RJ, Olson RE. MCMI comparisons of cocaine abusers and heroin addicts. J Clin Psychol. 1990;46(2):230–7. doi: 10.1002/1097-4679(199003)46:2<230:AID-JCLP2270460217>3.0.CO;2-7.CrossRefPubMedGoogle Scholar
  47. 47.
    McMahon RC. Substance abuse problems, psychiatric symptoms, and post-treatment status in MCMI psychopathology subgroups of cocaine dependent males. Am J Drug Alcohol Abuse. 2008;34(2):195–202. doi: 10.1080/00952990701877094.CrossRefPubMedGoogle Scholar
  48. 48.
    Carey MP, Braaten LS, Maisto SA, et al. Using information, motivational enhancement, and skills training to reduce the risk of HIV infection for low-income urban women: a second randomized clinical trial. Health Psychol. 2000;19(1):3–11. doi: 10.1037/0278-6133.19.1.3.CrossRefPubMedGoogle Scholar
  49. 49.
    Carey MP, Senn TE, Vanable PA, Coury-Doniger P, Urban MA. Brief and intensive behavioral interventions to promote sexual risk reduction among STD clinic patients: results from a randomized controlled trial. AIDS Behav. 2010;14(3):504–17. doi: 10.1007/s10461-009-9587-1.CrossRefPubMedGoogle Scholar
  50. 50.
    Senn TE, Carey MP, Coury-Doniger P. Self-defining as sexually abused and adult sexual risk behavior: results from a cross-sectional survey of women attending an STD clinic. Child Abuse Negl. 2011;35(5):353–62. doi: 10.1016/j.chiabu.2011.01.013.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Gibson DR, Lovelle-Drache J, Young MT, Chesney M. HIV risk linked to psychopathology in IV drug users. International Conference on AIDS, 1992 [Abstract POC 4691].Google Scholar
  52. 52.
    Devieux J, Malow R, Stein JA, et al. Impulsivity and HIV risk among adjudicated alcohol- and other drug-abusing adolescent offenders. AIDS Educ Prev. 2002;14(5):24–35. doi: 10.1521/aeap. Scholar
  53. 53.
    Malow RM, McMahon RC, Peipman FEW, Jennings TE. Mediators of HIV risk among African-American men. J Artic Support Null Hypothesis. 2002;1(1):8–14.Google Scholar
  54. 54.
    Crosby R, DiClemente RJ, Wingood GM, et al. Correct condom application among African-American adolescent females: the relationship to perceived self-efficacy and the association to confirmed STDs. J Adolesc Health. 2001;29(3):194–9. doi: 10.1016/S1054-139X(01)00273-7.CrossRefPubMedGoogle Scholar
  55. 55.
    Farris CA, Fenaughty AM, Lindemann DF. A condom skill scale: assessing condom skills among female drug users. J Drug Educ. 2003;33(2):217–31.CrossRefPubMedGoogle Scholar
  56. 56.
    Kelly JA. Changing HIV risk behavior: a practical guide. New York, NY: Guilford Press; 1995.Google Scholar
  57. 57.
    Ross D, Schumacher JE. Condom use assessment of persons in drug abuse treatment. J Community Health. 2004;29(6):499–509. doi: 10.1007/s10900-004-3397-1.CrossRefPubMedGoogle Scholar
  58. 58.
    Sorensen JL. Preventing AIDS in drug users and their sexual partners. New York, NY: Guilford Press; 1991.Google Scholar
  59. 59.
    McLellan TA, Kushner H, Metzger D, et al. The 5th edition of the Addiction Severity Index. J Subst Abuse Treat. 1992;9:199–213.CrossRefPubMedGoogle Scholar
  60. 60.
    Mäkelä K. Studies of the reliability and validity of the Addiction Severity Index. Addiction. 2004;99:398–410.CrossRefPubMedGoogle Scholar
  61. 61.
    Graham JM. Congeneric and (essentially) tau-equivalent estimates of score reliability: what they are and how to use them. Educ Psychol Measur. 2006;66(6):930–44. doi: 10.1177/0013164406288165.CrossRefGoogle Scholar
  62. 62.
    Grove WM, Vrieze SI. An exploration of the base rate scores of the Millon Clinical Multiaxial Inventory-III. Psychol Assess. 2009;21(1):57–67. doi: 10.1037/a0014471.CrossRefPubMedGoogle Scholar
  63. 63.
    Hastie T, Tibshirani R, Friedman JH. The elements of statistical learning: Data mining, inference, and prediction. 2nd ed. New York, NY: Springer; 2009.CrossRefGoogle Scholar
  64. 64.
    Agresti A. Categorical data analysis. 3rd ed. Hoboken, NJ: Wiley; 2014.Google Scholar
  65. 65.
    Haller DL, Miles DR. Suicidal ideation among psychiatric patients with HIV: psychiatric morbidity and quality of life. AIDS Behav. 2003;7(2):101–8. doi: 10.1023/A:1023985906166.CrossRefPubMedGoogle Scholar
  66. 66.
    Haller DL, Miles DR. Psychopathology is associated with completion of residential treatment in drug dependent women. J Addict Dis. 2004;23(1):17–28. doi: 10.1300/J069v23n01_02.CrossRefPubMedGoogle Scholar
  67. 67.
    Jaffe AJ, Rounsaville B, Chang G, Schottenfeld RS, Meyer RE, O’Malley SS. Naltrexone, relapse prevention, and supportive therapy with alcoholics: an analysis of patient treatment matching. J Consult Clin Psychol. 1996;64(5):1044–53. doi: 10.1037/0022-006X.64.5.1044.CrossRefPubMedGoogle Scholar
  68. 68.
    McLellan AT, Woody GE, Luborsky L. OʼBrien CP, Druley KA. Increased effectiveness of substance abuse treatment: a prospective study of patient-treatment “Matching”. J Nerv Ment Dis. 1983;171(10):597–605. doi: 10.1097/00005053-198310000-00002.CrossRefPubMedGoogle Scholar
  69. 69.
    Woody GE. Progress in addiction treatment: from one-size-fits-all to medications and treatment matching. Subst Abus. 2014;35(2):110–3.CrossRefPubMedGoogle Scholar
  70. 70.
    Senn TE, Carey MP. HIV testing among individuals with a severe mental illness: review, suggestions for research, and clinical implications. Psychol Med. 2009;39(3):355–63. doi: 10.1017/S0033291708003930.CrossRefPubMedGoogle Scholar
  71. 71.
    Hobkirk AL, Towe SL, Lion R, Meade CS. Primary and secondary HIV prevention among persons with severe mental illness: recent findings. Curr HIV/AIDS Rep. 2005;12(4):406–12. doi: 10.1007/s11904-015-0294-4.CrossRefGoogle Scholar
  72. 72.
    Blank MB, Hennessy M, Eisenberg MM. Increasing quality of life and reducing HIV burden: the PATH+ intervention. AIDS Behav. 2014;18(4):716–25. doi: 10.1007/s10461-013-0606x.CrossRefPubMedPubMedCentralGoogle Scholar
  73. 73.
    Sohler N, Colson PW, Meyer-Bahlburg HF, Susser E. Reliability of self-reports about sexual risk behavior for HIV among homeless men with severe mental illness. Psychiatr Serv. 2000;51(6):814–6. doi: 10.1176/ Scholar
  74. 74.
    Rossini E, Choca J. Interpretation of the MCMI-III. In: Millon T, Bloom C, editors. The Millon inventories: A practitioner’s guide to personalized clinical assessment. 2nd ed. New York: Guilford; 2008.Google Scholar
  75. 75.
    McKinnon K, Cournos F, Meyer-Bahlburg HF, et al. Reliability of sexual risk behavior interviews with psychiatric patients. Am J Psychiatry. 1993;150(6):972–4.CrossRefPubMedGoogle Scholar
  76. 76.
    Malow RM, Rosenberg R, Donenberg G, Dévieux JG. Interventions and patterns of risk in adolescent HIV/AIDS prevention. Am J Infect Dis. 2006;2(2):80–9.CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    Needle R, Fisher DG, Weatherby N, et al. Reliability of self-reported HIV risk behaviors of drug users. Psychol Addict Behav. 1995;9(4):242–50. doi: 10.1037/0893-164X.9.4.242.CrossRefGoogle Scholar
  78. 78.
    Weinhardt LS, Forsyth AD, Carey MP, Jaworski BC, Durant LE. Reliability and validity of self-report measures of HIV-related sexual behavior: progress since 1990 and recommendations for research and practice. Arch Sex Behav. 1998;27(2):155–80. doi: 10.1023/A:1018682530519.CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    Brewer TH, Zhao W, Metsch LR, Coltes A, Zenilman J. High-risk behaviors in women who use crack: knowledge of HIV serostatus and risk behavior. Ann Epidemiol. 2007;17(7):533–9. doi: 10.1016/j.annepidem.2007.01.029.CrossRefPubMedGoogle Scholar
  80. 80.
    Abel-Ollo K, Rahu M, Rajaleid K, et al. Knowledge of HIV serostatus and risk behaviour among injecting drug users in Estonia. AIDS Care. 2009;21(7):851–7. doi: 10.1080/09540120802657522.CrossRefPubMedGoogle Scholar
  81. 81.
    Paxton KC, Myers HF, Hall NM, Javanbakht M. Ethnicity, serostatus, and psychosocial differences in sexual risk behavior among HIV-seropositive and HIV-seronegative women. AIDS Behav. 2004;8(4):405–15. doi: 10.1007/s10461-004-7325-2.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Robert C. McMahon
    • 1
  • John M. Abbamonte
    • 1
  • Jessy G. Dévieux
    • 2
  1. 1.Counseling Psychology ProgramUniversity of MiamiCoral GablesUSA
  2. 2.College of Public Health and Social WorkFlorida International UniversityMiamiUSA

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