Mission, Vision and Strategic Plan

MiStory Strategic Plans

Accomplishments 2019-2024 Defining and measuring Trauma Recovery (Please see our publications)

The WHO has noted that Gender Based Violence (GBV) is widespread globally. “Gender-based Violence is “Any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life (World Health Organization, 2016).” Examining only Intimate Partner Violence, WHO estimates rates of 30% worldwide, 37% in the Mediterranean region, and 36.6% in African countries (Palermo et al., 2014). GBV encompasses harmful threats or acts based on an individual’s sex characteristics, gender identity, sexual orientation, or perceived deviation from societal norms. GBV includes physical, sexual, verbal, emotional, and psychological abuse, threats, coercion, and economic or educational deprivation, and can occur in public or private life. GBV undermines the health, dignity, security, and autonomy of its victims. Yet, it remains shrouded in a culture of silence because GBV is interpersonal social violence connected to normative understandings of gender that support power inequalities between women and men. GBV undermines the health, dignity, security, and autonomy of its victims, yet it remains shrouded in a culture of silence. Since one in three women in society are survivors of GBV, research is needed to understand their recovery (World Health Organization, 2024). It is also imperative to advance intervention to help survivors move on with their recovery and regain their place as autonomous members of society. Trauma recovery is the restoration process, making or becoming sound or healthy again, especially the restoration of functioning and mental, physical, social, emotional, and spiritual well-being (Saint Arnault, Manuscript in preparation).

This project is part of a more extensive set of projects conducted through the Multicultural Study of Trauma Recovery (MiStory) international research group (Saint Arnault, 2024b; Saint Arnault et al., 2017 ). The MiStory group has collaborated for over 5 years, and we have gathered data from survivors in 10 countries (Brazil, Japan, Greece, Israel [Arab Palestinian and Hebrew], Finland, Iceland, Italy, Spain, and the USA). We have collected survey data from over 2000 survivors and around 200 interviews in the survivors’ native languages. We have led the way in creating the trauma recovery research field, supported by the necessary research training and instrumentation to understand the trauma recovery process. Our studies focus on the internalized cultural processes that regulate, support, or hinder recovery after GBV among survivors. Our collective research advances methods, instruments, research processes, and theories that examine cultural similarities and differences in recovery after GBV while empowering vulnerable survivors across numerous cultural regions around the world. This summary will introduce what our collective has learned and outline the next steps needed to translate this research into social action and therapeutic interventions.

Step 1: Understanding Trauma Recovery in Context

The work in Step 1 was to define the concepts we can use to understand the interaction between the trauma recovery process and the cultural context. In this work, we also needed to develop measurements to understand the interactions among crucial trauma recovery variables.

The first phase of this work was to develop a culturally neutral, safe, and compelling interview that could be used with survivors across cultures. The interviewing needed to be trainable, promote safety, security, and control for the survivors (trauma-informed), and improve survivors’ self-awareness and meaning-making, while providing researchers with clinically relevant data to understand gender, culture, and trauma recovery. The Clinical Ethnographic Narrative Interview (CENI) is a 90-minute semi-structured set of activities aimed at the multidimensional analysis of the factors that support survivor recovery as well as data providers can use to evaluate recovery needs (Saint Arnault, 2017; Saint Arnault, 2024a, 2024b; Saint Arnault & Shimabukuro, 2012). It begins with social network mapping to examine social resources and perceived stigma. Next, the body map explores current symptoms and general feelings during daily life. The lifeline looks at high and low points, revealing how events are perceived. The card sort activity reveals the symptoms and symptom clusters of any given low point in great detail, supporting interpretations and meanings about trauma and trauma recovery needs. This interview data gives us multicultural perceptions and has been the primary source of data for the development of our instruments and our theories.

The second phase of this work was to develop an assessment of the lived day-to-day recovery experience. To do that, we developed Photo-experiencing and Reflective Listening (PEARL)(Sinko et al., 2024; Sinko & Saint Arnault, 2021). The PEARL is a photo-elicitation method that asks participants to use photography to document healing and darker moments in their day-to-day lives over a week. Participants then tell the story behind the photographs, develop the meaning of them, and then co-create a Recovery Action Plan.

The efficacy of these interventions has been confirmed with satisfaction ratings and pre-post assessments. Randomized Controlled Trials are ongoing. These assessments have been used in research trials in clinical settings in Brazil, Japan, Greece, and the US. The CENI is licensed (Saint Arnault, 2018), and we are licensing the PEARL.

Cultura is a shared conceptual understanding collectively formed and transmitted across generations. We have also discovered that survivors from different cultures vary in their recovery actions (Sinko et al., In Press). The healing pathways also differ for survivors from individualistic and collectivistic cultures (Kita, Zonp, et al., In press).

We have also discovered that these shared understandings about GBV are normalized and are internalized by survivors. The normalization beliefs cause barriers to recovery but are often not recognized by the survivors. To study the impact of normalization on survivors help seeking and trauma recovery, we developed the Normalization of Gender Based Violence scale (NGBV) (Mughal et al., Under Review; Rodelli et al., 2021). Our research has found that when survivors are given the chance to explore their violence and their recovery, they begin to question the shame and guilt that they feel and start to explore ways that they can begin to recover more fully (Saint Arnault, 2017; Sinko et al., In Press).

The Trauma recovery process is non-linear and uneven, and progress and setbacks are expected (Kita et al., 2022; Koutra et al., 2022; Sinko et al., 2019; L. Sinko, R. James, et al., 2021; Sinko et al., 2020; Sinko & Saint Arnault, 2020). The ultimate goal of trauma recovery is developing or restoring the actions, skills, characteristics, and strengths that restore and enhance health, security, and well-being. We have discovered that survivors can begin to engage in recovery when they make meaning and recognize their barriers and resources. Recovery engagement is a holistic set of activities representing survivors’ strength and resilience.

Recovery engagement includes:

• conscious, realistic, and compassionate engagement with oneself, including identity
• authentic and intentional interaction with others socially, and for healing
• participation in, understanding of, and transformation of one’s culture and society
• identifying and living one’s spiritual purpose and meaning.

Because recovery actions are diverse, we developed a measurement tool to help understand them called the Trauma Recovery Actions Checklist (TRAC) (L. Sinko, L. Goldner, et al., 2021). This tool helps us understand that survivors who engage in recovery carry out diverse recovery actions that extend much farther than using social services and social support.

Trauma recovery actions include:

• sharing/connecting
• building positive emotions
• reflecting and creating healing spaces
• establishing security
• planning for the future

Step 2: Identifying barriers and mobilizing resources for trauma recovery

We have learned that survivors encounter many barriers to help seeking in trauma recovery (BHS-TR) engagement and actions (Saint Arnault & Zonp, 2022; Thorvaldsdottir et al., 2021; Thorvaldsdottir et al., 2022). Barriers to trauma recovery include both internal beliefs as well as external conditions. Internal beliefs are beliefs about how people see themselves and their recovery actions. External barriers to recovery engagement are the social, cultural, and structural factors that impede one’s ability to access or engage in recovery actions.

However, we have also found that trauma recovery can be mobilized by motivators, turning points, and internal and external resources (IMove)(Mughal et al., instrument under development). For example, inner resources include Meaning/Higher purpose, personal development, recognizing worthiness, hope, and finding emotional relief. Motivators include concerns for children, reaching a personal breaking point, and recognizing that others have recovered.

We have learned that meaning is a central facet of a successful trauma recovery journey, and we have adapted the Antonovsky measure for use with GBV survivors, creating the Sense of Meaning Inventory (SOMI) (Saint Arnault, 2024a; Saint Arnault & Zonp, 2024). Meaning-making involves reevaluating the self and the trauma and integrating the trauma into the self. Usually, these involve understanding how one may have normalized the trauma, as well as accepted gender roles that have caused them shame and guilt and decreased their health and autonomy.

Step 3: Identifying Trauma Healing & Recovery Pathways

One critical step in our research plan was identifying the characteristics of survivors’ trauma recovery journey. First, survivors talked about the concept of trauma healing. In addition, we also recognized in our interviews across all the cultures that there were recovery pathways or recovery subgroups. This interacting body of work has significant clinical interest, implications, and applicability.

Trauma Healing is the social, spiritual, cultural, and psychological processes in which one actively strives to find well-being, integrate their traumatic experience into their identity, and move toward a future where their trauma does not limit their ability to connect with others and pursue their goals and aspirations. We measure these with the Trauma Healing after GBV (GBV-Heal) instrument we developed (L.M. Sinko et al., 2021; L. M.  Sinko et al., 2021).

Trauma healing involves:

• Trauma processing and self-advocacy
• Self-connection
• Relating to others
• Regaining hope and power

Diversity in the trauma recovery journey. We have discovered that each survivor’s journey is unique and requires individualized support for the trauma recovery process (Koutra et al., 2022). This work has generated substantial international interest, and we have received a request to include this in the World Health Organization’s trauma recovery clinical resources.

Common core elements of the trauma recovery pathway include how survivors:

• define their trauma as part of circumstances outside of the self
• balancing emotions, body, cognition, and behavior
• accept that trauma has impacted them but does not define them
• see themselves as a whole person
• begin or restore their autonomous functioning
• to begin or restore their engagement with a supportive social network

We developed a multicultural clinician-administered tool that allows the provider to assess the current recovery pathway of their client, called the Trauma Recovery Rubric (TRR) (Koutra et al., 2022). We also adapted this instrument into a self-rated tool that survivors can use to identify their recovery pathway, called the Self-Assessment of Trauma Recovery (START) (Kita, Sinko, et al., In press).

Recovery pathways are:

Table 1: Recovery pathways in the TRR and START
Pathway	Clinical Presentation
Normalizing	• Minimizes or denies traumatic impact • Internalizes violence-accepting beliefs • Resists victim or survivor identity • May express confusion about others’ concerns
Minimizing	• Acknowledges events but downplays impact • Demonstrates resistance to exploring effects • May show a disconnection between stated impact and observed symptoms • May deflect from personal trauma through focus on others’ needs/healing
Consumed	• Trauma dominates identity • Difficulty seeing beyond trauma • Cycles between intense trauma focus and withdrawal • Demonstrates ambivalence about change
Shut Down	• Intellectual recognition without emotional connection • Numbness or dissociation • Difficulty accessing feelings or body sensations
Surviving	• Basic needs take precedence • Crisis-oriented presentation • Limited capacity for trauma processing
Seeking Integration	• Active engagement in healing • Willingness to explore trauma impact • Recognition of recovery challenges • May experience periods of feeling overwhelmed
Integration	• Balanced perspective on trauma • Integration of trauma into a broader life narrative • Acceptance of ongoing journey • Capacity to navigate setbacks with existing tools • Flexible use of support systems

The TRR and the START are receiving international attention because they are helping clinicians and survivors assess their current recovery needs. We are licensing these assessment tools.

Strategic Vision 2025-2030 Translating findings into a practice model

The work of MiStory has developed tools to measure and support trauma recovery (see Table 2 for a summary). We have received vigorous interest from many large, international trauma recovery clinical groups, including the World Health Organization, South Africa, and Australia. We are currently in the second step of our work to finalize some cultural translations of the wealth of material, evaluate the interactions among our instruments, carry out more efficacy trials of our support interventions, and put together culturally and gender-sensitive care guidebooks. Below is a summary of our current projects.

Table 2: MiStory Tools for Trauma Recovery Measurement and Support
Measurement	Barriers to Trauma Recovery	Normalizzazione del GBV	NGBV
		Barriers to Help Seeking-Trauma Recovery	BHS-TR
	Facilitators of Trauma Recovery	Motivators, Turning Points, and Resources Inventory (under development)	IMove
		Sense of Meaning Inventory	SOMI
	Trauma Recovery Processes	Trauma Recovery Actions Checklist	TRAC
		Trauma Recovery Rubric	TRR
		Self-Assessment for Trauma Recovery	START
	Outcomes	Healing after GBV	GBV-Heal
Survivor Support for Recovery	Holistic overview of recovery	Clinical Ethnographic Narrative Interview	CENI
	Current day-to-day healing and goal-setting	Photo Elicitation for Reflective Listening	PEARL

Step 1: Organize an international clinical translation advisory panel

Until recently, violence support agencies have focused on awareness, prevention, and providing survivors with safety. These strategies are central and are ongoing internationally. However, there is a turn toward the recovery piece of the puzzle. Survivor support agencies have struggled to assess the diverse recovery needs of their populations. The diversity has been cultural as well as socioeconomic. Increasingly, international groups are recognizing the need for integrated recovery packages. They are approaching us at conferences via our webpage, asking for training and guidance. We are developing a Clinical Translation advisory panel composed of international clinicians and survivors. This panel will work with us to identify strategies for developing a comprehensive package of materials to support survivor recovery. Our initial group includes agencies from Australia who work with Aboriginal, immigrant, and refugee survivors, and South Africa, working with black and white South African Survivors. In addition, a representative from the WHO gender equity group has expressed interest.

Step 2. Clinical Handbook Development

Because we have identified the recovery pathways, barriers, and facilitators to recovery and healing, we have launched a funded international project to develop a culturally sensitive clinical Care Handbook. We are using survivors’ and providers’ statements of survivors’ cultural and pathway-specific care needs. This care guidebook will then be presented to the clinical translation advisory panel for review and launched in selected sites in Japan and the US.

Step 3: Write papers about the effectiveness of the CENI and the PEARL

Lead investigators Saint Arnault (CENI developer) and Sinko (PEARL developed) are funded to conduct efficacy trials.

The data for the CENI is gathered, and we have 150 international satisfaction ratings (average 2.7 on a 3-point scale), 45 pre-post surveys (from Greece, Finland, Iceland, and Japan), and 17 randomized CENI efficacy datasets at one month. Preliminary analysis shows efficacy in decreasing freezing, shame, and shame-related post-trauma cognitions and increases in trauma coping, meaning, and healing scores (Saint Arnault and Zonp, Manuscript in preparation). We also carried out an 18-month longitudinal evaluation of the CENI in Japan with 9 survivors, finding sustained effects on decreasing shame and trauma symptoms and increased meaning (Kita, Manuscript in preparation).

The PEARL has pre-post data showing the efficacy of the PEARL on trauma healing scores (Sinko et al., 2024). In addition, Sinko is currently carrying out 2 studies on the PEARL with gender and sexual minority and trans women.

Step 4: Embed Trauma Recovery Integrated Practice into practice

The next logical step in this recovery work: embedding these measures and measures into clinical practice and systematically evaluating their value to support providers and survivors.

This work has adapted the comprehensive approach to mental health from the EU into guidelines for trauma recovery and has selected two of these principles for this phase.

Trauma-informed practice has been hailed as necessary in practice with survivors. This practice involves understanding the effects of trauma and the trauma recovery process. However, it is imperative to give survivors a way to learn from their experiences, reject the cultural normalization, shame, and guilt, and develop plans to engage in recovery(Sinko & Saint Arnault, Under review).

These two interacting principles are: 

• Reinforcing trauma recovery systems for better-trained professionals

• Tackling shame, guilt, normalization, and stigma within survivors to enable recovery and reintegration into society after trauma

Step 5: Development of the comprehensive Trauma Recovery Integrated Practice (TRIP) manual

This manual will support the training and evaluation of this application’s trauma recovery pilot programs initiative. This manual will facilitate standardization across clinical settings, helping ensure that all practitioners have access to evidence-based, high-quality resources.

This handbook will include:

• Guidelines on trauma-informed care, narrative interviewing, and therapeutic assessment best practices.
• Case Studies and Practical Examples provide clinicians with real-world scenarios and approaches.
• Tools and Templates for assessments and client-centered treatment planning
• Tools to collect feedback and evaluation collection

Step 6: Evaluate Program at selected evaluation sites

The initiative will identify selected trauma recovery intervention sites. To do this, we will:

• Offer a series of half-day workshops to expose agencies to our work and answer questions.
• Potential evaluation sites will engage in a subsequent workshop to identify initial challenges, select practitioners, and set initial goals.
• Koutra and Saint Arnault will conduct site visits and finalize the pilot site roster.
• Pilot sites will select candidates for a local clinical translation advisory panel.

Step 7: Implement a Training Program for the TRIP model

A robust training module will be developed based on the comprehensive trauma recovery manual. This training will include virtual and in-person workshops, webinars, and supervised practice to build clinician competencies. This training will emphasize a trauma-informed, gender-sensitive approach, equipping clinicians to address the specific needs of individuals affected by trauma.

Step 8: Evaluate Impact, Outcomes, and Continuous Improvement By including measurable outcomes, we ensure the training’s effectiveness can be quantified and adjusted based on real-time feedback. Continuous assessment will be built into the program to monitor impact and make adjustments. This evaluation will include periodic surveys, client outcomes tracking, and clinician feedback.

8.1 Increased Clinician Competency.

By implementing these training programs, clinicians will be equipped to work effectively with trauma survivors, enhancing their ability to provide gender-sensitive, client-centered care. We will measure these with:

8.2 Improved Client Outcomes.

This initiative is anticipated to increase treatment efficacy, reduce symptom severity, and improve overall client satisfaction with mental health services. We will gather qualitative and quantitative measures of care, including:

• Symptom Reduction Measures (e.g., the PCL-5 for PTSD, PHQ-9 for depression) to track improvement over time.
• Perceived Symptom Management capability (SOMI, Trauma Coping Self-Efficacy)
• Trauma recovery pathway movement (START and TTR)
• Reduction of barriers instruments (NGBV, BHS-TR, Posttraumatic Cognitions scale)
• Increase in health and healing (SOMI, IMove, TRAC, GBV-Heal)

8.3 Standardized Regional and National Practices.

Establishing a national approach to trauma-informed care ensures consistency and quality across the country, aligning with public health and gender equality goals. Some of these will come from national and international standard assessments, and others will be adapted from the EU’s comprehensive approach to mental health.

References

European Commission (2021). A comprehensive approach to mental health: Priorities for the EU. Retrieved from A comprehensive approach to mental health – European Commission.

Kita, S., Kamibeppu, K., & Saint Arnault, D. M. (2022, Sep 30). “Knitting Together the Lines Broken Apart”: Recovery Process to Integration among Japanese Survivors of Intimate Partner Violence. Int J Environ Res Public Health, 19(19). https://doi.org/10.3390/ijerph191912504

Kita, S., Sinko, L. M., Koutra, K., & Saint Arnault, D. M. (In press). Development of the Self-Assessment for Trauma Recovery Tool (START) for Survivors of Gender-based Violence: Classification using Latent Class Analysis. Psychology of Violence.

Kita, S., Zonp, Z., Koutra, K., Sorsa, M., Bryngeirsdóttir, H., Thorvaldsdottir, K. B., Beardmore, L., Sinko, L. M., & Saint Arnault, D. M. (In press). Cultural influences on Trauma Recovery after Gender-Based Violence: Multiple-country Structural Equation Modeling. Transcultural Psychiatry.

Koutra, K., Burns, C., Sinko, L., Kita, S., Bilgin, H., & Arnault, D. S. (2022). Trauma Recovery Rubric: A Mixed-Method Analysis of Trauma Recovery Pathways in Four Countries. International Journal of Environmental Research and Public Health, 19(16), 10310.

Mughal, F., Koutra, K., Rodelli, M., & Saint Arnault, D. M. (Under Review). Psychometric testing of the Normalization of Gender Based Violence (NGBV) against women. Violence and Victims.

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Rodelli, M., Koutra, K., Thorvaldsdottir, K. B., Bilgin, H., Ratsika, N., Testoni, I., & Saint Arnault, D. M. (2021, 2021/06/07). Conceptual Development and Content Validation of a Multicultural Instrument to Assess the Normalization of Gender-Based Violence against Women. Sexuality & Culture. https://doi.org/10.1007/s12119-021-09877-y

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