This study examined the role of multiple types of victimization and resources on co-occurring MH problems as well as the potential mediating effects of psychological and social coping resources on the relationship between multiple types of victimization and co-occurring MH among victimized substance-using adolescents. As anticipated, adolescents with multiple types of victimization experiences were more likely to have co-occurring MH problems than were adolescents with a single type of victimization experiences. The findings are in line with research that shows multiple types of victimization relate to a greater number of, and more severe, negative outcomes than do single types of victimization (Finkelhor et al., 2007
). The traumagenic dynamics (Finkelhor, 1987
) involved in multiple victimization experiences (e.g., powerlessness and betrayal) or repeated negative messages that something is wrong with the victim, or he or she is at fault for the abuse, may increase the likelihood of both internalizing and externalizing behavior problems.
It was hypothesized that adolescents with fewer psychological and social resources would be more likely to exhibit a co-occurring MH problem than they would be to exhibit an internalizing-only, an externalizing-only, or neither an internalizing nor an externalizing problem. This hypothesis was supported for psychological resources. A lower level of psychological resources (self-efficacy related to substance use and global self-efficacy beliefs) were associated with a higher risk for co-occurring MH problems. Self-efficacy is an important variable in studies on victims. Victimized children and adolescents have more negative representations of self (Kim & Cicchetti, 2003
), and they often show learned helplessness and hopelessness. Such negative self-perceptions may explain why adolescents reported helplessness in their ability to control their drug use. Low self-efficacy was significantly related to greater likelihood of co-occurring MH problems. Adolescents with low global self-efficacy and low self-efficacy related to substance use were more likely to have co-occurring MH problems (vs. neither internalizing nor externalizing problem) than did adolescents with high self-efficacy. Other studies have also found an association of low self-efficacy with poorer MH. For instance, in a study comparing maltreated children younger than age 8 years with those children 8 years old and older, lower levels of social self-efficacy (self-efficacy in conflict situations) were related to higher levels of internalizing problems (Kim & Cicchetti, 2003
As expected, received support for victimization issues appeared to have a beneficial effect on reducing the likelihood of co-occurring MH problems among adolescents. Support has a greater influence on MH if it is the support required to deal with particular stressors (Cohen & Willis, 1985
). Available problem-solving support, however, was not associated with co-occurring MH problems. More sources for emotional support increased, not decreased, the likelihood of co-occurring MH problems. Adolescents with a larger number of people available for emotional support were more likely to have internalizing-only problems versus neither internalizing nor externalizing problems and were more likely to have an externalizing-only problem versus neither internalizing nor externalizing. These findings are contrary to our hypothesis.
In this study, available sources of emotional support were evaluated in general terms, not in relation to multiple victimization experiences, which may be more important in understanding co-occurring MH. The measures could not cover multiple support systems available for victims to specifically address their abuse issues. In addition, the measures used were insufficient to evaluate the receipt of support, the context of the support provided, and the type of support in detail.
Another possible explanation for the increase in co-occurring MH problems with the increase in the number of sources of emotional support is differences in characteristics of providers and recipients of support and the valence of the support. Characteristics of both support providers and adolescents may influence adolescents’ coping and adjustment to stress and may be related to co-occurring MH. Adolescents’ display of negative emotions under stress, such as frustration and anxiety, can lead support providers to make unhelpful comments or show discomfort or rejection (more negative interactions). Support providers’ reactions can have negative effects on victims’ MH (Westmaas & Silver, 2001
). This study did not examine negative exchanges, but they may explain the positive relationship between the number of sources of emotional support and greater likelihood of co-occurring MH problems. This research could not determine the nature of interactions adolescents had with their sources of emotional support.
If adolescents are able to develop and maintain positive relationships with support providers and are able to receive desired support, the support may have beneficial outcomes. Adolescents who experience more stress, however, may have more people who they can turn to for support, but because of their overreliance on these people, they may not be able to maintain these relationships over time (Muller & Lemieux, 2000
; Osborne & Rhodes, 2001
). Some research suggests support providers may not invest effort in supporting individuals who cope poorly or do not attempt to help themselves. In contrast, individuals who work hard to overcome their problems motivate others to help them (Shwarzer & Knoll, 2007
Finally, the findings that the numbers of sources of support were associated with greater likelihood of co-occurring MH problems indicate adolescents’ support systems may not have been adequate for them to address their mental health needs. Adolescents in more distress or adolescents with internalizing and externalizing problems may be more likely to have more support providers after these problems emerge. Consequently, the cross- sectional nature of the study may have accounted for the relationships observed. Longitudinal research may be useful to study how support influences problem development.
Self-efficacy is one of the mechanisms through which social support facilitates better coping with stress and positive outcomes (Schwarzer & Knoll, 2007
). Although adolescents with multiple victimization experiences had higher mean scores on available sources of emotional support than those who did not have these experiences, they had lower scores on self-efficacy. The analysis in this study did not examine the mediation effect of self-efficacy on the relationship between social support and mental health and, therefore, should be examined in future studies.
This study has several limitations that may have affected the results. This research is based on pooled data from multiple individual site studies. The sample included adolescents who were assessed at the time of intake for substance abuse treatment and therefore is not representative of the nonclinical population. This study is only generalizable to substance-using adolescents with histories of victimization and who were referred to substance abuse treatment. As many adolescents assessed for substance abuse treatment are court ordered, they may have responded in socially desirable ways and may have underreported externalizing behavior problems. This may have resulted in biased prediction of externalizing-only problems and co-occurring internalizing and externalizing problems.
Another limitation relates to the study’s focus on a limited number of psychological and social resource variables. Also, some of the variables tested for mediation may have been too general and not specific to victimization experiences. Because of the limitations of secondary data analysis, the study could not include victimization-specific variables such as attributions of blame, perception of threat, and coping processes that have empirical support for their mediating effects on the relationship between victimization and outcomes. For instance, studies show that victimization-specific negative appraisals such as blaming oneself for the experience increase the risk of internalizing and externalizing symptoms (Bal et al., 2009
). Furthermore, the social resources tested for their mediation effect in this study did not capture the full range of perceived and received support that victims may desire, and that could explain variability in their MH outcomes. The full range of support may include such factors as feeling supported and believed by someone they trusted to share their experiences, immediate safety plans developed to prevent their further victimization, and level of satisfaction with the support provided.
Because of the cross-sectional nature of this research, we could not establish causality between the studied variables. The cross-sectional design limited the argument for temporal conclusions about the direct effects examined, and, therefore, the results of this study should be interpreted with caution. For example, MH problems may be contributing factors to victimization experiences. Longitudinal studies are necessary to examine processes that explain the trajectory of victimization experiences to comorbidity of internalizing and externalizing disorders. Despite the cross-sectional nature of this research, however, and other limitations discussed in this section, the existing theoretical literature that establishes a relationship between victimization and negative outcomes provides a strong support for the effects of multiple types of victimization on co-occurring MH problems among adolescents.
This study contributes to the knowledge of co-occurring disorders by identifying multiple types of victimization experiences as significant risk factors for co-occurring internalizing and externalizing problems among substance-using adolescents. It underscores the need to consider the contribution of psychological and social resources in protecting adolescents from developing severe co-occurring problems.