Home⇛Psychology and Education: A Multidisciplinary Journal⇛vol. 33 no. 4 (2025)

Secondary Traumatic Stress and Internalizing Symptoms of Mental Health Practitioners: The Mediating Role of Rumination

Jireh Joy Albania | John Mark S. Distor

Discipline: psychology (non-specific)

 

Abstract:

Based on the transdiagnostic model of rumination and empathy-based stress process, this study examined the mediating role of rumination components (reflection and brooding) in the association of secondary traumatic stress with internalizing symptoms of depression and anxiety among Filipino psychosocial mental health practitioners such as psychometricians, psychologists, guidance counselors, and social workers. A total of 192 practitioners recruited from their respective professional organizations answered the online survey. The means and standard deviations were calculated to describe the levels of the study variables. Pearson Product Moment Correlation was employed to examine correlations. Standard (Delta) method was used to examine the multiple mediator model, and bias-corrected (BC) bootstrapping was employed to test the significance of the reflection and brooding indirect effects. The results showed practitioners’ mild levels of secondary traumatic stress (M = 36.40, SD = 10.60), reflection (M = 11.00, SD = 3.54), brooding (M = 10.20, SD = 3.48), and internalizing symptoms (M = 12.00, SD = 9.98). All variables were significantly and positively associated with each other (r = 0.40 – 0.77, p <.001). Brooding (B = 0.15, 95% CI = 0.08, 0.25, p <.001), and not reflection (B = 0.02, 95% CI = - 0.02, 0.06, p = 0.47), was a significant partial mediator in the association of secondary traumatic stress with internalizing symptoms, suggesting that managing brooding tendencies may help prevent internalizing symptoms when secondary traumatic stress pre-exists. The findings supported brooding as a maladaptive component of rumination, while it is argued that reflection is more neutral than adaptive when it concurrently happens with brooding, and depending on the contents of reflective thinking determines its nature and well-being outcomes. Theoretical implications, methodological limitations, and ways forward in the Philippine context were also offered.



References:

  1. Abdul Rahim, H. F., Fendt-Newlin, M., Al-Harahsheh, S. T., Campbell, J. (2022). Our duty of care: A global call to action to protect the mental health of health and care workers. World Innovation Summit for Health. https://www.who.int/publications/m/item/wish_report
  2. Acuña, J. E., & Rodriguez, R. A. (1995). Value orientations of Filipinos. Philippine Management Review, 6(1), 1-23. https://pmr.upd.edu.ph/index.php/pmr/article/view/74
  3. Andrade, C. (2020). The limitations of online surveys. Indian Journal of Psychological Medicine, 42(6), 575–576. https://doi.org/10.1177/0253717620957496
  4. Albert, J. R. G, Santos, A. G. F., & Vizmanos, J. F. V. (2018). Defining and profiling the middle class (Publication No. 2018-18). https://pidswebs.pids.gov.ph/CDN/PUBLICATIONS/pidspn1818.pdf
  5. Allen, J., Balfour, R., Bell, R., & Marmot, M. (2014). Social determinants of mental health. International Review of Psychiatry, 26(4), 392–407. https://doi.org/10.3109/09540261.2014.928270
  6. Al-Sharbati, Z., Hallas, C., Al-Zadjali, H., & Al-Sharbati, M. (2012). Sociodemographic and clinical characteristics of patients attending psychotherapy in a tertiary care hospital in Oman. Sultan Qaboos University Medical Journal, 12(1), 25–32. https://doi.org/10.12816/0003084
  7. Blume-Marcovici, A. C., Stolberg, R. A., & Khademi, M. (2015). Examining our tears: Therapists’ accounts of crying in therapy. American Journal of Psychotherapy, 69(4), 399–421. https://doi.org/10.1176/appi.psychotherapy.2015.69.4.399
  8. Bride, B. E. (2007). Prevalence of secondary traumatic stress among social workers. Social Work, 52(1), 63–70. http://www.jstor.org/stable/23720708
  9. Bride, B. E., Robinson, M. M., Yegidis, B., & Figley, C. R. (2004). Development and validation of the secondary traumatic stress Scale. Research on Social Work Practice, 14(1), 27–35. https://doi.org/10.1177/1049731503254106
  10. Burwell, R. A., & Shirk, S. R. (2007). Subtypes of rumination in adolescence: Associations between brooding, reflection, depressive symptoms, and coping. Journal of Clinical Child and Adolescent Psychology, 36(1), 56–65. https://doi.org/10.1207/s15374424jccp3601_6
  11. Carlson, C., Cordisco Tsai, L., Baylosis, R., Hentschel, E., Bonachita, C. L. O., Fishbach, J., & Wainberg, M. L. (2023). Cultural perceptions of suicide in the Philippines reported by service providers from the anti-trafficking sector: a qualitative study. International Journal of Mental Health, 1–18. https://doi.org/10.1080/00207411.2023.2290224
  12. Civil Service Commission. (2017). Amendment to CSC MC No. 16, s. 2011 on the education and training requirements for Guidance Counselor positions (CSC MC No. 2, s. 2017). https://www.csguide.org/files/original/c4c6488cfe31e815bc7072835dc0de2b.pdf
  13. Civil Service Commission. (2019). Amendment to the qualification standards of the Psychologist I, II and III positions (CSC MC No. 14, s. 2019). https://www.csguide.org/files/original/fb7e4aae0633d0a609d9997a63226fc3.pdf
  14. Chattu, V. K., Manzar, M. D., Kumary, S., Burman, D., Spence, D. W., & Pandi-Perumal, S. R. (2018). The Global Problem of Insufficient Sleep and Its Serious Public Health Implications. Healthcare, 7(1), 1. https://doi.org/10.3390/healthcare7010001
  15. Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). SAGE Publications.
  16. Devynck, F., Rousseau, A., & Romo, L. (2019). Does repetitive negative thinking influence alcohol use? A systematic review of the literature. Frontiers in psychology, 10, 1482. https://doi.org/10.3389/fpsyg.2019.01482
  17. Department of Budget and Management (2024). Upgrading of Psychologist Positions (DBM BC No. 2024-5). https://www.dbm.gov.ph/wp-content/uploads/Issuances/2024/Budget-Circular/BUDGET-CIRCULAR-NO.-2024-5.pdf
  18. Department of Health (2019). Implementing rules and regulations of Republic Act No. 11036, otherwise known as the Mental Health Act. https://www.officialgazette.gov.ph/downloads/2019/01jan/20190122-IRR-RA-11036-RRD.pdf
  19. Department of Health (2020). Your mind matters: DOH calls for unified response to mental health. https://doh.gov.ph/press-release/YOUR-MIND-MATTERS-DOH-CALLS-FOR-UNIFIED-RESPONSE-TO-MENTAL-HEALTH
  20. Ewer, P. L., Teesson, M., Sannibale, C., Roche, A., & Mills, K. L. (2015). The prevalence and correlates of secondary traumatic stress among alcohol and other drug workers in Australia. Drug and Alcohol Review, 34(3), 252–258. https://doi.org/10.1111/dar.12204
  21. Fernandez, R., Sikhosana, N., Green, H., Halcomb, E. J., Middleton, R., Alananzeh, I., Trakis, S., & Moxham, L. (2021). Anxiety and depression among healthcare workers during the COVID-19 pandemic: A systematic umbrella review of the global evidence. BMJ Open, 11, 1 - 9. https://doi.org/10.1136/bmjopen-2021-054528
  22. Field, A. (2009). Discovering statistics using SPSS. SAGE Publications.
  23. Frazier, P. A., Tix, A. P., & Barron, K. E. (2004). Testing moderator and mediator effects in counseling psychology. Journal of Counseling Psychology, 51(1), 115-134. 10.1037/0022-0167.51.1.115
  24. Fredrickson B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56(3), 218–226. https://doi.org/10.1037//0003-066x.56.3.218
  25. Fredrickson B. L. (2004). The broaden-and-build theory of positive emotions. Philosophical transactions of the Royal Society of London. Series B: Biological Sciences, 359(1449), 1367–1378. https://doi.org/10.1098/rstb.2004.1512
  26. Fredrickson, B. L., & Branigan, C. (2005). Positive emotions broaden the scope of attention and thought-action repertoires. Cognition & Emotion, 19(3), 313–332. https://doi.org/10.1080/02699930441000238
  27. Ge, J., Wu, J., Ke-Sheng, L., & Zheng, Y. (2019). Self-compassion and subjective well-Being mediate the impact of mindfulness on balanced time perspective in Chinese college students. Frontiers in Psychology, 10. https://doi.org/10.3389/fpsyg.2019.00367
  28. Gilroy, P. J., Carroll, L., & Murra, J. (2002). A preliminary survey of counseling psychologists’ personal experiences with depression and treatment. Professional Psychology: Research and Practice, 33(4), 402–407. https://doi.org/10.1037/0735-7028.33.4.402
  29. Gossmann, K., Schmid, R. F., Loos, C., Orthmann, A. B. A., Rosner, R., & Barke, A. (2023). How does burnout relate to daily work-related rumination and well-being of psychotherapists? A daily diary study among psychotherapeutic practitioners. Frontiers in psychiatry, 13, 1003171. https://doi.org/10.3389/fpsyt.2022.1003171
  30. Hair, J. F., Hult, G. T. M., Ringle, C. M., & Sarstedt, M. (2022). A primer on partial least squares structural equation modeling (PLS-SEM) (3 ed.). Thousand Oaks, CA: Sage.
  31. Harrington, M. O., & Cairney, S. A. (2021). Sleep loss gives rise to intrusive thoughts. Trends in Cognitive Sciences, 25(6), 434–436. https://doi.org/10.1016/j.tics.2021.03.001
  32. Henderson, A., Jewell, T., Huang, X., & Simpson, A. (2024). Personal trauma history and secondary traumatic stress in mental health professionals: A systematic review. Journal of Psychiatric and Mental Health Nursing, 32, 13 - 30. https://doi.org/10.1111/jpm.13082
  33. Hodgetts, J., McLaren, S., Bice, B., & Trezise, A. (2020). The relationships between self-compassion, rumination, and depressive symptoms among older adults: The moderating role of gender. Aging & Mental Health, 25(12), 2337–2346. https://doi.org/10.1080/13607863.2020.1824207
  34. Hothorn, T., Zeileis, A., Millo, G., & Mitchell, D. (2009). Testing linear regression models (Version 0.9-24). https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=3a594b8a5f2ba9c51a8abf148d208611bef88b8c
  35. Jamovi Project (2022). Jamovi. (Version 2.3) [Computer Software]. Retrieved from https://www.jamovi.org.
  36. Jha, S., Martínez, A., Quising, P., Ardaniel, Z., & Wang, L. (2018). Natural disasters, public spending, and creative destruction: a case study of the Philippines (ADBI Working Paper Series 817). Asian Development Bank Institute. https://doi.org/10.2139/ssrn.3204166
  37. Jin, M. J., Kim, J. S., Lee, H., Kwon, Y. J., Shim, S. H., Choi, B., Lee, D., Paik, J., Lee, B. C., Jung, S., & Lee, H. (2020). The Impact of Emotional Exhaustion on Psychological Factors in Workers with Secondary Traumatic Experiences: A Multi-Group Path Analysis. Psychiatry Investigation, 17(11), 1064–1072. https://doi.org/10.30773/pi.2019.0313
  38. Kaiser, R. H., Snyder, H. R., Goer, F., Clegg, R., Ironside, M., & Pizzagalli, D. A. (2018). Attention bias in rumination and depression: Cognitive mechanisms and brain networks. Clinical psychological science: A journal of the Association for Psychological Science, 6(6), 765–782. https://doi.org/10.1177/2167702618797935
  39. Key, N. A., & Rider, N. K. (2018). Secondary Traumatic stress among Mental health professionals: Implications for graduate training programs. Graduate Student Journal of Psychology, 17, 68–77. https://doi.org/10.52214/gsjp.v17i.10921
  40. Kim, B. N., & Kang, H. S. (2022). Differential roles of reflection and brooding on the relationship between perceived stress and life satisfaction during the COVID-19 pandemic: A serial mediation study. Personality and individual differences, 184, 111169. https://doi.org/10.1016/j.paid.2021.111169
  41. Kim, H., Turiano, N. A., Forbes, M. K., Kotov, R., Krueger, R. F., Eaton, N. R., & HiTOP Utility Workgroup (2021). Internalizing psychopathology and all-cause mortality: A comparison of transdiagnostic vs. diagnosis-based risk prediction. World psychiatry: Official journal of the World Psychiatric Association (WPA), 20(2), 276–282. https://doi.org/10.1002/wps.20859
  42. Kleespies, P. M., Van Orden, K. A., Bongar, B., Bridgeman, D., Bufka, L. F., Galper, D. I., Hillbrand, M., & Yufit, R. I. (2011). Psychologist suicide: Incidence, impact, and suggestions for prevention, intervention, and postvention. Professional psychology, research and practice, 42(3), 244–251. https://doi.org/10.1037/a0022805
  43. Kocsel, N., Köteles, F., Galambos, A., & Kökönyei, G. (2022). The interplay of self-critical rumination and resting heart rate variability on subjective well-being and somatic symptom distress: A prospective study. Journal of Psychosomatic Research, 152, 1 - 11. https://doi.org/10.1016/j.jpsychores.2021.110676
  44. Kokonyei, G., Szabo, E., Kocsel, N., Edes, A., Eszlari, N., Pap, D., Magyar, M., Kovacs, D., Zsombok, T., Elliott, R., Anderson, I. M., Deakin, J. F. W., Bagdy, G., & Juhasz, G. (2016). Rumination in migraine: Mediating effects of brooding and reflection between migraine and psychological distress. Psychology and Health, 31(12), 1481–1497. https://doi.org/10.1080/08870446.2016.1235166
  45. Kroenke, K., Wu, J., Yu, Z., Bair, M. J., Kean, J., Stump, T., & Monahan, P. O. (2016). Patient Health Questionnaire Anxiety and Depression Scale: Initial validation in three clinical trials. Psychosomatic medicine, 78(6), 716–727. https://doi.org/10.1097/PSY.0000000000000322
  46. Labarda, C., & Chan, C. S. (2018). Sleep disturbances, posttraumatic stress, and psychological distress among survivors of the 2013 Super Typhoon Haiyan. Psychiatry Research, 266, 284–290. https://doi.org/10.1016/j.psychres.2018.03.019
  47. Lally, J., Samaniego, R. M., & Tully, J. (2019). Mental health legislation in the Philippines: Philippine Mental Health Act. BJPsych international, 16(3), 65–67. https://doi.org/10.1192/bji.2018.33
  48. Lathren, C., Bluth, K., & Park, J. (2019). Adolescent self-compassion moderates the relationship between perceived stress and internalizing symptoms. Personality and individual differences, 143, 36–41. https://doi.org/10.1016/j.paid.2019.02.008
  49. Li, T., Petrik, M. L., Freese, R. L., & Robiner, W. N. (2022). Suicides of psychologists and other health professionals: National Violent Death Reporting System data, 2003–2018. American Psychologist, 77(4), 551–564. https://doi.org/10.1037/amp0001000
  50. Luca, M. (2019). Maladaptive rumination as a transdiagnostic mediator of vulnerability and outcome in psychopathology. Journal of Clinical Medicine, 8(3), 1 - 10. https://doi.org/10.3390/jcm8030314
  51. Lyubomirsky, S., Layous, K., Chancellor, J., & Nelson, S. K. (2015). Thinking about rumination: The scholarly contributions and intellectual legacy of Susan Nolen-Hoeksema. Annual Review of Clinical Psychology, 11(1), 1–22. https://doi.org/10.1146/annurev-clinpsy-032814-112733
  52. Mullen, P. R., Backer, A., Chae, N., & Li, H. (2020). School counselors’ work-related rumination as a predictor of burnout, turnover intentions, job satisfaction, and work engagement. Professional School Counseling, 24(1), 1 - 10. https://doi.org/10.1177/2156759x20957253
  53. Nath, P., Pradhan, R. K., & Mohanty, S. N. (2021). Are positive people more flexible in cognitive processing? Addressing the conceptual and empirical inconclusiveness. In Springer eBooks (pp. 13–25). https://doi.org/10.1007/978-3-030-66869-3_2
  54. Neff, K. D. (2023). Self-Compassion: Theory, method, research, and intervention. Annual Review of Psychology, 74(1), 193–218. https://doi.org/10.1146/annurev-psych-032420-031047
  55. Nolen-Hoeksema, S., & Watkins, E. R. (2011). A heuristic for developing transdiagnostic models of psychopathology: Explaining multifinality and divergent trajectories. Perspectives on Psychological Science, 6(6), 589–609. https://doi.org/10.1177/1745691611419672
  56. Onifade, O.C. and Olanrewaju, S.O. (2020) Investigating performances of some statistical tests for heteroscedasticity assumption in generalized linear model: A Monte Carlo Simulations study. Open Journal of Statistics, 10, 453-493. https://doi.org/10.4236/ojs.2020.103029
  57. Posluns, K., & Gall, T. L. (2019). Dear mental health practitioners, take care of yourselves: A literature review on self-care. International Journal for the Advancement of Counselling, 42(1), 1–20. https://doi.org/10.1007/s10447-019-09382-w
  58. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40(3), 879–891. doi:10.3758/brm.40.3.879
  59. Price, D., Carr, S., & Howard, M. (2013). Caring for the carers: role of the chaplain in an interprofessional academic family medicine practice. PubMed. https://pubmed.ncbi.nlm.nih.gov/24235181
  60. Professional Regulation Commission. (2022). Overall statistics for selected profession: Registered as of October 31, 2022 (FOI Request - PRC-247384759185). https://foi.gov.ph/requests/number-of-registered-psychologists-psychometricians-guidance-counselors-and-social-workers/
  61. Quinn, A., Ji, P., & Nackerud, L. (2018). Predictors of secondary traumatic stress among social workers: Supervision, income, and caseload size. Journal of Social Work, 19(4), 504–528. https://doi.org/10.1177/1468017318762450
  62. Raes, F. (2010). Rumination and worry as mediators of the relationship between self-compassion and depression and anxiety. Personality and Individual Differences, 48(6), 757–761. 10.1016/j.paid.2010.01.023
  63. Raine, A., Chen, F. R., & Waller, R. (2022). The cognitive, affective and somatic empathy scales for adults. Personality and individual differences, 185, 111238. https://doi.org/10.1016/j.paid.2021.111238
  64. Rauvola, R.S., Vega, D.M. & Lavigne, K.N. (2019). Compassion fatigue, secondary traumatic stress, and vicarious traumatization: A qualitative review and research agenda. Occupational Health Science, 3, 297–336. https://doi.org/10.1007/s41542-019-00045-1
  65. Rayner, S., Davis, C., Moore, M., & Cadet, T. (2020). Secondary traumatic stress and related factors in Australian social workers and psychologists. Health & Social Work, 45(2), 122–130. https://doi.org/10.1093/hsw/hlaa001
  66. R Core Team (2021). R: A Language and environment for statistical computing. (Version 4.1) [Computer software]. Retrieved from https://cran.r-project.org. (R packages retrieved from MRAN snapshot 2022-01-01).
  67. Rezaei, S., Hoseinipalangi, Z., Rafiei, S., Dolati, Y., Hosseinifard, H., Asl, M. T., Mejareh, Z. N., Deylami, S., Abdollahi, B., Ardakani, M. F., Ghadimi, N., Dehnad, A., Kan, F. P., Raoofi, S., & Ghashghaee, A. (2022). The global prevalence of depression among health workers during the COVID-19 pandemic: A systematic review and meta-analysis. Journal of affective disorders reports, 8, 1 - 8. https://doi.org/10.1016/j.jadr.2022.100326
  68. Rijnhart, J. J. M., Lamp, S. J., Valente, M. J., MacKinnon, D. P., Twisk, J. W. R., & Heymans, M. W. (2021). Mediation analysis methods used in observational research: A scoping review and recommendations. BMC Medical Research Methodology, 21(1), 1 - 17. https://doi.org/10.1186/s12874-021-01426-3
  69. Rilveria, J. R. C. (2018). The development of the Filipino Coping Strategies scale. Asia-Pacific Social Science Review, 18(1). https://doi.org/10.59588/2350-8329.1151
  70. Rumsey, A. D., McCullough, R., & Chang, C. Y. (2020). Understanding the secondary exposure to trauma and professional quality of life of school counselors. Professional School Counseling, 24(1), 1 - 11. https://doi.org/10.1177/2156759x20973643
  71. Ryan, R. M., & Deci, E. L. (2017). Self-determination theory: Basic psychological needs in motivation, development, and wellness. The Guilford Press. https://doi.org/10.1521/978.14625/28806
  72. Sahin, M. D., & Aybek, E. C. (2019). Jamovi: An easy to use statistical software for the social scientists. International Journal of Assessment Tools in Education, 6(4), 670–692. https://eric.ed.gov/?id=EJ1243495
  73. Schoofs, H., Hermans, D., & Raes, F. (2010). Brooding and Reflection as Subtypes of Rumination: Evidence from Confirmatory Factor Analysis in Nonclinical Samples using the Dutch Ruminative Response Scale. Journal of Psychopathology and Behavioral Assessment, 32(4), 609–617.10.1007/s10862-010-9182-9
  74. Siebert, D. C. (2004). Depression in North Carolina social workers: Implications for practice and research. Social Work Research, 28(1), 30–40. https://doi.org/10.1093/swr/28.1.30
  75. Smith, A. J. M., Kleijn, W. C., & Hutschemaekers, G. J. M. (2007). Therapist reactions in self-experienced difficult situations: An exploration. Counselling and Psychotherapy Research, 7(1), 34–41. doi:10.1080/14733140601140865
  76. Smith, K. E., Mason, T. B., & Lavender, J. M. (2018). Rumination and eating disorder psychopathology: A meta-analysis. Clinical psychology review, 61, 9–23. https://doi.org/10.1016/j.cpr.2018.03.004
  77. Søvold, L. E., Naslund, J. A., Kousoulis, A. A., Saxena, S., Qoronfleh, M. W., Grobler, C., & Münter, L. (2021). Prioritizing the mental health and well-being of healthcare workers: An Urgent Global Public Health Priority. Frontiers in Public Health, 9, 1 - 12. https://doi.org/10.3389/fpubh.2021.679397
  78. Sprang, G., Ford, J., Kerig, P., & Bride, B. (2018). Defining secondary traumatic stress and developing targeted assessments and interventions: Lessons learned from research and leading experts. Traumatology an International Journal, 25(2), 72–81. https://doi.org/10.1037/trm0000180
  79. Stack, S. (2004). Suicide among social workers: a research note. Archives of Suicide Research, 8(4), 379–388. 10.1080/13811110490476789
  80. Treynor, W., Gonzalez, R., & Nolen-Hoeksema, S. (2003). Rumination reconsidered: A psychometric analysis. Cognitive Therapy and Research, 27(3), 247–259. https://doi.org/10.1023/A:1023910315561
  81. Turliuc, M. N., Măirean, C., & Turliuc, M. D. (2015). Rumination and suppression as mediators of the relationship between dysfunctional beliefs and traumatic stress. International Journal of Stress Management, 22(3), 306–322. https://doi.org/10.1037/a0039272
  82. United Nations Children’s Fund. (2018). Operational guidelines on community based mental health and psychosocial support in humanitarian settings: Three-tiered support for children and families (field test version). United Nations Children’s Fund. https://www.unicef.org/media/52171/file
  83. United Nations Children’s Fund. (2019). Mental health and psychosocial technical note. United Nations Children’s Fund. https://www.unicef.org/media/73726/file/UNICEF-MH-and-PS-Technical-Note-2019.pdf.pdf
  84. Vahle-Hinz, T., Mauno, S., de Bloom, J., & Kinnunen, U. (2017). Rumination for innovation? Analysing the longitudinal effects of work-related rumination on creativity at work and off-job recovery. Work & Stress, 31(4), 315–337. https://doi.org/10.1080/02678373.2017.1303761
  85. Vandevala, T., Pavey, L., Chelidoni, O., Chang, N-F., Creagh-Brown, B. & Cox, A.  (2017). Psychological rumination and recovery from work in intensive care professionals: Associations with stress, burnout, depression, and health.  Journal of Intensive Care, 5(16), 1 - 8. 10.1186/s40560-017-0209-0
  86. Watkins, E., & Roberts, H. (2020). Reflecting on rumination: Consequences, causes, mechanisms, and treatment of rumination. Behaviour Research and Therapy, 127, 1–28. https:// doi. org/ 10. 1016/j.brat. 2020. 103573
  87. Weathers, F.W., Blake, D.D., Schnurr, P.P., Kaloupek, D.G., Marx, B.P., & Keane, T.M. (2013). The Life Events Checklist for DSM-5 (LEC-5). Instrument available from the National Center for PTSD at www.ptsd.va.gov.
  88. Wiebenga, J. X., Dickhoff, J., Mérelle, S. Y., Eikelenboom, M., Heering, H. D., Gilissen, R., Van Oppen, P., & Penninx, B. W. (2021). Prevalence, course, and determinants of suicide ideation and attempts in patients with a depressive and/or anxiety disorder: A review of NESDA findings. Journal of Affective Disorders, 283, 267–277. https://doi.org/10.1016/j.jad.2021.01.053
  89. World Health Organization. (2019). Suicide worldwide in 2019: Global health estimates. https://www.who.int/publications/i/item/9789240026643
  90. World Health Organization. (2022).  WHO Special Initiative for Mental Health: Updates and achievements in the Philippines [Infographic]. https://cdn.who.int/media/docs/default-source/mental-health/special-initiative/philippines---who-special-initiative-for-mental-health-2022.pdf?sfvrsn=a774402a_3
  91. World Health Organization. (2023). WISN Workload of staffing need User’s manual, second edition. https://iris.who.int/bitstream/handle/10665/373473/9789240070066-eng.pdf?sequence=1
  92. World Health Organization & Department of Health. (2006). WHO-AIMS report on mental health system in the Philippines. World Health Organization.  https://cdn.who.int/media/docs/default-source/mental-health/who-aims-country-reports/philippines_who_aims_report.pdf?sfvrsn=479112f_3
  93. World Health Organization & Department of Health. (2020). Philippines WHO special initiative for mental health situational assessment. World Health Organization.  https://www.who.int/publications/m/item/philippines---who-special-initiative-for-mental-health
  94. Wu, M., Zhao, K., & Fils-Aime, F. (2022). Response rates of online surveys in published research: A meta-analysis. Computers in Human Behavior Reports, 7, 1 - 11. https://doi.org/10.1016/j.chbr.2022.100206
  95. Wu, Q., Cao, H., & Du, H. (2023). Work stress, work-related rumination, and depressive symptoms in university teachers: Buffering effect of self-compassion. Psychology research and behavior management, 16, 1557–1569. https://doi.org/10.2147/PRBM.S403744
  96. Zarei, S., & Fooladvand, K. (2022). Mediating effect of sleep disturbance and rumination on work-related burnout of nurses treating patients with coronavirus disease. BMC Psychology, 10(1), 1 - 9. https://doi.org/10.1186/s40359-022-00905-6

Tools


Copyright © 2026  KITE Digital Educational Solutions |  Exclusively distributed by CE-Logic