Jacqueline Dienemann - Academia.edu (original) (raw)
Papers by Jacqueline Dienemann
Issues in Mental Health Nursing, 2007
Social Policy and Society, 2008
... Socialist feminists view gender and class as compounding factors contributing to male violenc... more ... Socialist feminists view gender and class as compounding factors contributing to male violence (Bailey, 1999 ... increased employment opportunities for women serving as a buffer for IPV (Farmer and Tiefenthaler ... of the long-term well being of the IDA participants, drop outs and a ...
Journal of PeriAnesthesia Nursing, 2013
Under certain conditions specified by law, libraries and archives are authorized to furnish a pho... more Under certain conditions specified by law, libraries and archives are authorized to furnish a photocopy or other reproduction. One of these specified conditions is that the photocopy or reproduction is "not to be used for any other purpose other than private study, scholarship, or research". If a user makes a request for, or later uses a photocopy or reproduction for purposes in excess of "Fair Use", that user may be liable for copyright infringement. R ecently, nonpharmaceutical therapies have been evaluated for use in the treatment of postoperative nausea (PON). 1 Aromatherapy is appealing for use in PON because its noninvasive administration allows use by either medical staff or patients, and its low cost offers greater accessibility to patients. However, to this point, it has been unknown which, if any, aromas or combinations of aromas are actually effective in reducing PON; thus, for purposes of this study, we hypothesized simply that aromatherapy will reduce PON.
Violence Against Women, 2003
Page 1. http://vaw.sagepub.com/ Violence Against Women http://vaw.sagepub.com/content/ 9/9/1072 T... more Page 1. http://vaw.sagepub.com/ Violence Against Women http://vaw.sagepub.com/content/ 9/9/1072 The online version of this article can be found at: DOI: 10.1177/1077801203255291 2003 9: 1072 Violence Against Women Snow Jones and Eiman Jafar ...
Brief Treatment and Crisis Intervention, 2006
The mental health consequences for women who have experienced intimate partner violence (IPV), su... more The mental health consequences for women who have experienced intimate partner violence (IPV), such as major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) and especially their comorbidity, have received little attention in large-scale studies and treatment protocols for affected populations. We compared the association of PTSD, MDD, and PTSD/MDD comorbidity to IPV in two large cohorts, one of military and the other of civilian women. The adjusted prevalence of mental health symptoms, especially PTSD, was higher among abused than nonabused women in both samples. Mental health symptoms were also higher among the civilian sample compared to the military sample. Approximately one-third (34%) of the abused civilian women and one-fourth (25%) of the abused military women had symptoms that met criteria for at least one of the three diagnostic categories employed in this study, compared to 18% and 15% of nonabused women in the two groups. Comorbidity of PTSD and depression affected 19.7% of the civilian abused women versus 4.5% of nonabused civilian women, whereas for active duty military women, the prevalence was 4.6% and 4.2% for abused and nonabused, respectively. To better understand the mental health consequences of IPV and to design the most effective treatment and prevention programs, it is important to examine the presence of comorbidities between mental health disorders. [Brief Treatment and Crisis Intervention 6:99-110 (2006)] KEY WORDS: intimate partner violence, posttraumatic stress disorder, military women, HMO enrollees, comorbidity, mental health symptoms, domestic violence.
Journal of patient safety, 2013
Patient falls are a challenging safety and quality issue in acute care settings. This study compa... more Patient falls are a challenging safety and quality issue in acute care settings. This study compared inpatient falls on medical-surgical units with and without Webcams and assessed the Morse Risk Assessment (MRA) for effectiveness in identifying fall risk. Ten hospitals in one health system that exceeded the benchmark for falls were chosen for a 6-month study. One medical-surgical unit in each of the 10 hospitals was randomly assigned to an intervention or control group. The intervention group used Webcams that viewed the bed with a central monitoring system. A "virtual bed rail" function was used for those patients with a Morse Risk Assessment (MRA) of greater than 25. Consent rate was 20.7% for the intervention group. A significant difference (P ≤ 0.05) between groups was found in fall rate per 1000 admissions, but no significant difference was found in fall rate per 1000 patient days. The Morse Risk Assessment was a significant predictor of risk. Webcams are one option ...
Military medicine, 2006
This study describes active duty military (ADM) women's beliefs and preferences concerning do... more This study describes active duty military (ADM) women's beliefs and preferences concerning domestic violence (DV) policy in the military. Telephone interviews were completed with 474 ADM women from all services, 119 of whom had experienced DV during their military service. A majority (57%) supported routine screening. Although 87% said the military's policy on mandatory reporting should remain the same, only 48% thought abuse should be reported to the commanding officer; abused women were significantly less likely than nonabused women to agree with this aspect of the policy. ADM women's beliefs were similar to those of women in a previously studied civilian sample, except that 73% of ADM compared to 43% of civilian women thought routine screening would increase women's risk of further abuse. ADM women recognized both advantages and disadvantages of current DV policies. More research is urgently needed about actual outcomes of screening and reporting policies.
Women's Health Issues, 2006
To compare costs associated with intimate partner violence (IPV) overall and for selected physica... more To compare costs associated with intimate partner violence (IPV) overall and for selected physical health problems in a non-poor, privately insured sample. We compared 185 women aged 21-55 who were physically and/or sexually abused between 1989 and 1997 and enrolled in a multisite metropolitan health maintenance organization (HMO) to 198 never abused women enrolled in the same plan who had been matched using propensity score stratification. Costs associated with HMO visits, hospital stays, referrals, and emergency room (ER) visits, prescriptions, and radiology are based on the Medicare Resource-Based Relative Value System, expressed in 2005 dollars. Average health care costs for women who reported physical, sexual, and/or emotional abuse exceeded those of never abused women by $1,700 over the 3-year study period. Women who reported abuse within 12 months of interview had higher average costs, as did women who reported physical abuse; however, sexual or emotional abuse and previous abuse also elevated costs. Costs associated with neurologic symptoms, injuries, mental health care, and unclassified symptoms account for most of these differences. IPV elevates health care costs, not only among women currently experiencing abuse, but also among women for whom the abuse has ceased. Efforts to control health care costs should focus on early detection and prevention of IPV.
Women's Health Issues, 1999
Self-reported data from a survey of roughly 1,100 female health maintenance organization enrollee... more Self-reported data from a survey of roughly 1,100 female health maintenance organization enrollees in the Washington, DC, metropolitan area are used to investigate the lifetime and annual prevalence of emotional, physical, and sexual abuse by intimate partners. The sample consists of a racially balanced and, for the most part, well-educated group of working women. Three dimensions of abuse based on
Violence Against Women, 2003
ABSTRACT Intimate partner violence has been demonstrated to be a significant public health proble... more ABSTRACT Intimate partner violence has been demonstrated to be a significant public health problem among African American women. This study provided an opportunity to examine prevalence of intimate partner violence and health consequences among a group of primarily middle-class, employed African American women enrolled in a privately insured HMO (n = 109 abused and 97 never-abused women). Significantly more abused African American women were divorced or widowed and had incomes less than $50,000 a year. Abused women had more health problems (central nervous system, gynecological, STDs, gastrointestinal), more health problems per medical visits, and more emergency room visits (p < .05) compared to never-abused women. The health consequences of abuse and its association with health disparities are discussed.
RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren, 2006
Patient Education and Counseling, 2002
Seeking to end violence and distress in their relationship is the goal of women abused by intimat... more Seeking to end violence and distress in their relationship is the goal of women abused by intimate partners. The theoretical framework guiding development of the domestic violence survivor assessment (DVSA) was Landenburger&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s theory of entrapment and recovery. Social context and need to balance care for others and herself influence women&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s decision-making about abuse. The DVSA was developed collaboratively between researchers and counselors to gain a deeper understanding of battered women&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s cognitive states in order to assist them during counseling to effectively resolve the dilemma of their abusive relationships while experiencing personal growth. Five states are identified which a woman may experience on 11 issues concurrently at the personal, relationship or social context levels. Research to validate the DVSA and suggestions on use with women desiring to preserve their relationship or preserve their self or preserve the resolution of change is described. Using the DVSA for assessment, intervention and measuring intermediate outcomes is delineated.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 2003
The authors developed an interdisciplinary critical pathway for intimate partner violence (IPV) a... more The authors developed an interdisciplinary critical pathway for intimate partner violence (IPV) assessment and intervention for use across health care settings. Intimate partner violence may be emotional, physical, and/or sexual and involves coercion and control by one partner over the other.
JONA: The Journal of Nursing Administration, 2003
JONA: The Journal of Nursing Administration, 2013
Patient satisfaction is an important outcome measurement in the emergency department (ED). When u... more Patient satisfaction is an important outcome measurement in the emergency department (ED). When unavoidable, the negative effect of patient wait time may be lessened by communicating expected wait time, affective support, health information, decisional control, and competent providers. This controlled quasi-experimental design used a convenience sample. The patient questionnaire included demographics, expected and perceived wait time, receiving of comfort items, information and engaging activities and their perceived helpfulness for coping with waiting, and the Consumer Emergency Care Satisfaction Scale measure of patient satisfaction with nursing. Systematic offering of comfort items, clinical information, and engaging activities were statistically analyzed for impact on perceived wait times, helpfulness in waiting, and satisfaction with nursing care. Interventions were supported by the data as helpful for coping with waiting and were significantly related to nursing care satisfaction. Interventions were less helpful for suburban patients who were also less satisfied. Nurses can influence patient satisfaction in the ED through communication and caring behaviors.
Journal of Emergency Nursing, 1999
... Department, Johns Hop-kins Hospital; and Jacquelyn Campbell is Anna D. Wolfe EndowedProfessor... more ... Department, Johns Hop-kins Hospital; and Jacquelyn Campbell is Anna D. Wolfe EndowedProfessor ... Judy B.Shahan, BSN, RN, Karen Pinnella, BSN, MSW, LCSW-C, RN, Priya Krishnan, MSW ... Regarding the best location toscreen for DV, 57.7 indicated that both the triageand ...
Clinical Nursing Research, 2005
Intimate partner violence (IPV) is a major cause of health conditions among women presenting for ... more Intimate partner violence (IPV) is a major cause of health conditions among women presenting for health care. Many physicians and nurses miss potential opportunities to increase battered women's safety. The purpose of this study is to increase health care providers' understanding of abused women's preferences concerning provider response when they do disclose IPV in order to increase effectiveness of interventions. A total of 26 abused women from a larger study participated in five focus groups at three agencies on "how a hospital or doctor's office can be most helpful to a woman who is experiencing domestic violence." Women identified seven preferences for responses: (a) treat me with respect and concern, (b) protect me, (c) documentation, (d) give me control, (e) immediate response, (f) give me options, and (g) be there for me later. These findings indicate that women prefer an active role by health care providers when responding to disclosure.
American Journal of Preventive Medicine, 2000
Background: The purpose of this paper is to describe women's opinions and policy preferences conc... more Background: The purpose of this paper is to describe women's opinions and policy preferences concerning domestic violence screening and mandatory reporting.
ARCHIVES OF INTERNAL MEDICINE, 2002
Background: Domestic violence results in long-term and immediate health problems. This study comp... more Background: Domestic violence results in long-term and immediate health problems. This study compared selected physical health problems of abused and never abused women with similar access to health care.
Archives of Psychiatric Nursing, 2009
Domestic Violence Survivor Assessment (DVSA) assesses the process of change using the Transtheore... more Domestic Violence Survivor Assessment (DVSA) assesses the process of change using the Transtheoretical Model of Change for 12 issues conceptualized as relating to the relationship or the individual. This article presents the psychometric properties of the revised DVSA with a new item, Control of Money. The factor analysis was done for 119 survivors resulting in a three-factor solution explaining 65.06% of the variance with a Chronbach's alpha of .89 and Mental Health as a separate, third factor. The DVSA's use for counseling and implications of the differences in responses by women and their counselors is discussed.
Issues in Mental Health Nursing, 2007
Social Policy and Society, 2008
... Socialist feminists view gender and class as compounding factors contributing to male violenc... more ... Socialist feminists view gender and class as compounding factors contributing to male violence (Bailey, 1999 ... increased employment opportunities for women serving as a buffer for IPV (Farmer and Tiefenthaler ... of the long-term well being of the IDA participants, drop outs and a ...
Journal of PeriAnesthesia Nursing, 2013
Under certain conditions specified by law, libraries and archives are authorized to furnish a pho... more Under certain conditions specified by law, libraries and archives are authorized to furnish a photocopy or other reproduction. One of these specified conditions is that the photocopy or reproduction is "not to be used for any other purpose other than private study, scholarship, or research". If a user makes a request for, or later uses a photocopy or reproduction for purposes in excess of "Fair Use", that user may be liable for copyright infringement. R ecently, nonpharmaceutical therapies have been evaluated for use in the treatment of postoperative nausea (PON). 1 Aromatherapy is appealing for use in PON because its noninvasive administration allows use by either medical staff or patients, and its low cost offers greater accessibility to patients. However, to this point, it has been unknown which, if any, aromas or combinations of aromas are actually effective in reducing PON; thus, for purposes of this study, we hypothesized simply that aromatherapy will reduce PON.
Violence Against Women, 2003
Page 1. http://vaw.sagepub.com/ Violence Against Women http://vaw.sagepub.com/content/ 9/9/1072 T... more Page 1. http://vaw.sagepub.com/ Violence Against Women http://vaw.sagepub.com/content/ 9/9/1072 The online version of this article can be found at: DOI: 10.1177/1077801203255291 2003 9: 1072 Violence Against Women Snow Jones and Eiman Jafar ...
Brief Treatment and Crisis Intervention, 2006
The mental health consequences for women who have experienced intimate partner violence (IPV), su... more The mental health consequences for women who have experienced intimate partner violence (IPV), such as major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) and especially their comorbidity, have received little attention in large-scale studies and treatment protocols for affected populations. We compared the association of PTSD, MDD, and PTSD/MDD comorbidity to IPV in two large cohorts, one of military and the other of civilian women. The adjusted prevalence of mental health symptoms, especially PTSD, was higher among abused than nonabused women in both samples. Mental health symptoms were also higher among the civilian sample compared to the military sample. Approximately one-third (34%) of the abused civilian women and one-fourth (25%) of the abused military women had symptoms that met criteria for at least one of the three diagnostic categories employed in this study, compared to 18% and 15% of nonabused women in the two groups. Comorbidity of PTSD and depression affected 19.7% of the civilian abused women versus 4.5% of nonabused civilian women, whereas for active duty military women, the prevalence was 4.6% and 4.2% for abused and nonabused, respectively. To better understand the mental health consequences of IPV and to design the most effective treatment and prevention programs, it is important to examine the presence of comorbidities between mental health disorders. [Brief Treatment and Crisis Intervention 6:99-110 (2006)] KEY WORDS: intimate partner violence, posttraumatic stress disorder, military women, HMO enrollees, comorbidity, mental health symptoms, domestic violence.
Journal of patient safety, 2013
Patient falls are a challenging safety and quality issue in acute care settings. This study compa... more Patient falls are a challenging safety and quality issue in acute care settings. This study compared inpatient falls on medical-surgical units with and without Webcams and assessed the Morse Risk Assessment (MRA) for effectiveness in identifying fall risk. Ten hospitals in one health system that exceeded the benchmark for falls were chosen for a 6-month study. One medical-surgical unit in each of the 10 hospitals was randomly assigned to an intervention or control group. The intervention group used Webcams that viewed the bed with a central monitoring system. A "virtual bed rail" function was used for those patients with a Morse Risk Assessment (MRA) of greater than 25. Consent rate was 20.7% for the intervention group. A significant difference (P ≤ 0.05) between groups was found in fall rate per 1000 admissions, but no significant difference was found in fall rate per 1000 patient days. The Morse Risk Assessment was a significant predictor of risk. Webcams are one option ...
Military medicine, 2006
This study describes active duty military (ADM) women's beliefs and preferences concerning do... more This study describes active duty military (ADM) women's beliefs and preferences concerning domestic violence (DV) policy in the military. Telephone interviews were completed with 474 ADM women from all services, 119 of whom had experienced DV during their military service. A majority (57%) supported routine screening. Although 87% said the military's policy on mandatory reporting should remain the same, only 48% thought abuse should be reported to the commanding officer; abused women were significantly less likely than nonabused women to agree with this aspect of the policy. ADM women's beliefs were similar to those of women in a previously studied civilian sample, except that 73% of ADM compared to 43% of civilian women thought routine screening would increase women's risk of further abuse. ADM women recognized both advantages and disadvantages of current DV policies. More research is urgently needed about actual outcomes of screening and reporting policies.
Women's Health Issues, 2006
To compare costs associated with intimate partner violence (IPV) overall and for selected physica... more To compare costs associated with intimate partner violence (IPV) overall and for selected physical health problems in a non-poor, privately insured sample. We compared 185 women aged 21-55 who were physically and/or sexually abused between 1989 and 1997 and enrolled in a multisite metropolitan health maintenance organization (HMO) to 198 never abused women enrolled in the same plan who had been matched using propensity score stratification. Costs associated with HMO visits, hospital stays, referrals, and emergency room (ER) visits, prescriptions, and radiology are based on the Medicare Resource-Based Relative Value System, expressed in 2005 dollars. Average health care costs for women who reported physical, sexual, and/or emotional abuse exceeded those of never abused women by $1,700 over the 3-year study period. Women who reported abuse within 12 months of interview had higher average costs, as did women who reported physical abuse; however, sexual or emotional abuse and previous abuse also elevated costs. Costs associated with neurologic symptoms, injuries, mental health care, and unclassified symptoms account for most of these differences. IPV elevates health care costs, not only among women currently experiencing abuse, but also among women for whom the abuse has ceased. Efforts to control health care costs should focus on early detection and prevention of IPV.
Women's Health Issues, 1999
Self-reported data from a survey of roughly 1,100 female health maintenance organization enrollee... more Self-reported data from a survey of roughly 1,100 female health maintenance organization enrollees in the Washington, DC, metropolitan area are used to investigate the lifetime and annual prevalence of emotional, physical, and sexual abuse by intimate partners. The sample consists of a racially balanced and, for the most part, well-educated group of working women. Three dimensions of abuse based on
Violence Against Women, 2003
ABSTRACT Intimate partner violence has been demonstrated to be a significant public health proble... more ABSTRACT Intimate partner violence has been demonstrated to be a significant public health problem among African American women. This study provided an opportunity to examine prevalence of intimate partner violence and health consequences among a group of primarily middle-class, employed African American women enrolled in a privately insured HMO (n = 109 abused and 97 never-abused women). Significantly more abused African American women were divorced or widowed and had incomes less than $50,000 a year. Abused women had more health problems (central nervous system, gynecological, STDs, gastrointestinal), more health problems per medical visits, and more emergency room visits (p < .05) compared to never-abused women. The health consequences of abuse and its association with health disparities are discussed.
RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren, 2006
Patient Education and Counseling, 2002
Seeking to end violence and distress in their relationship is the goal of women abused by intimat... more Seeking to end violence and distress in their relationship is the goal of women abused by intimate partners. The theoretical framework guiding development of the domestic violence survivor assessment (DVSA) was Landenburger&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s theory of entrapment and recovery. Social context and need to balance care for others and herself influence women&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s decision-making about abuse. The DVSA was developed collaboratively between researchers and counselors to gain a deeper understanding of battered women&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s cognitive states in order to assist them during counseling to effectively resolve the dilemma of their abusive relationships while experiencing personal growth. Five states are identified which a woman may experience on 11 issues concurrently at the personal, relationship or social context levels. Research to validate the DVSA and suggestions on use with women desiring to preserve their relationship or preserve their self or preserve the resolution of change is described. Using the DVSA for assessment, intervention and measuring intermediate outcomes is delineated.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 2003
The authors developed an interdisciplinary critical pathway for intimate partner violence (IPV) a... more The authors developed an interdisciplinary critical pathway for intimate partner violence (IPV) assessment and intervention for use across health care settings. Intimate partner violence may be emotional, physical, and/or sexual and involves coercion and control by one partner over the other.
JONA: The Journal of Nursing Administration, 2003
JONA: The Journal of Nursing Administration, 2013
Patient satisfaction is an important outcome measurement in the emergency department (ED). When u... more Patient satisfaction is an important outcome measurement in the emergency department (ED). When unavoidable, the negative effect of patient wait time may be lessened by communicating expected wait time, affective support, health information, decisional control, and competent providers. This controlled quasi-experimental design used a convenience sample. The patient questionnaire included demographics, expected and perceived wait time, receiving of comfort items, information and engaging activities and their perceived helpfulness for coping with waiting, and the Consumer Emergency Care Satisfaction Scale measure of patient satisfaction with nursing. Systematic offering of comfort items, clinical information, and engaging activities were statistically analyzed for impact on perceived wait times, helpfulness in waiting, and satisfaction with nursing care. Interventions were supported by the data as helpful for coping with waiting and were significantly related to nursing care satisfaction. Interventions were less helpful for suburban patients who were also less satisfied. Nurses can influence patient satisfaction in the ED through communication and caring behaviors.
Journal of Emergency Nursing, 1999
... Department, Johns Hop-kins Hospital; and Jacquelyn Campbell is Anna D. Wolfe EndowedProfessor... more ... Department, Johns Hop-kins Hospital; and Jacquelyn Campbell is Anna D. Wolfe EndowedProfessor ... Judy B.Shahan, BSN, RN, Karen Pinnella, BSN, MSW, LCSW-C, RN, Priya Krishnan, MSW ... Regarding the best location toscreen for DV, 57.7 indicated that both the triageand ...
Clinical Nursing Research, 2005
Intimate partner violence (IPV) is a major cause of health conditions among women presenting for ... more Intimate partner violence (IPV) is a major cause of health conditions among women presenting for health care. Many physicians and nurses miss potential opportunities to increase battered women's safety. The purpose of this study is to increase health care providers' understanding of abused women's preferences concerning provider response when they do disclose IPV in order to increase effectiveness of interventions. A total of 26 abused women from a larger study participated in five focus groups at three agencies on "how a hospital or doctor's office can be most helpful to a woman who is experiencing domestic violence." Women identified seven preferences for responses: (a) treat me with respect and concern, (b) protect me, (c) documentation, (d) give me control, (e) immediate response, (f) give me options, and (g) be there for me later. These findings indicate that women prefer an active role by health care providers when responding to disclosure.
American Journal of Preventive Medicine, 2000
Background: The purpose of this paper is to describe women's opinions and policy preferences conc... more Background: The purpose of this paper is to describe women's opinions and policy preferences concerning domestic violence screening and mandatory reporting.
ARCHIVES OF INTERNAL MEDICINE, 2002
Background: Domestic violence results in long-term and immediate health problems. This study comp... more Background: Domestic violence results in long-term and immediate health problems. This study compared selected physical health problems of abused and never abused women with similar access to health care.
Archives of Psychiatric Nursing, 2009
Domestic Violence Survivor Assessment (DVSA) assesses the process of change using the Transtheore... more Domestic Violence Survivor Assessment (DVSA) assesses the process of change using the Transtheoretical Model of Change for 12 issues conceptualized as relating to the relationship or the individual. This article presents the psychometric properties of the revised DVSA with a new item, Control of Money. The factor analysis was done for 119 survivors resulting in a three-factor solution explaining 65.06% of the variance with a Chronbach's alpha of .89 and Mental Health as a separate, third factor. The DVSA's use for counseling and implications of the differences in responses by women and their counselors is discussed.