Treatment dropout among veterans and their families: Quantitative and qualitative findings.

BACKGROUND: Psychotherapy noncompletion rates for veterans and their families are high. This study sought to (a) measure noncompletion rates of such patients at a university-based treatment center, (b) compare veteran and family member attrition rates, (c) identify dropout predictors, and (d) explore clinicians' perspectives on treatment noncompletion. METHOD: Using quantitative and qualitative approaches, we analyzed demographic and clinical characteristics of 141 patients (90 military veterans; 51 family members) in a university treatment center. We defined dropout as not completing the time-limited therapy contract. Reviewing semistructured interview data assessing clinicians' perspectives on their patients' dropout, three independent raters agreed on key themes, with interrater coefficient kappa range .74 to 1. RESULTS: Patient attrition was 24%, not differing significantly between veterans and family members. Diagnosis of major depression (MDD) and exposure-based therapies predicted noncompletion, as did higher baseline Hamilton Depression Rating Scale (HDRS) total scores, severe depression (HDRS > 20), lack of Beck Depression Inventory weekly improvement, and history of military sexual trauma. Clinicians mostly attributed noncompletion to patient difficulties coping with intense emotions, especially in exposure-based therapies. CONCLUSION: Noncompletion rate at this study appeared relatively low compared to other veteran-based treatment centers, if still unfortunately substantial. Patients with comorbid MDD/PTSD and exposure-based therapies carried greater noncompletion risk due to the MDD component, and this should be considered in treatment planning. Ongoing discussion of dissatisfaction and patient discontinuation, in the context of a strong therapeutic alliance, might reduce noncompletion in this at-risk population. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Neighborhood Disorder, Social Support, and Outcomes Among Violence-Exposed African American Women.

Intimate partner violence (IPV) against women, particularly those living in poverty who have multiple marginalized identities, is a significant public health issue. IPV is associated with numerous mental health concerns including depression, hopelessness, and suicidal behavior. The present study examined the ecological determinants of these mental health outcomes in a high-risk sample of 67 low-income, African American women survivors of IPV. Based on an ecological framework that conceptualizes individuals as nested in multiple, interactive systems, we examined, longitudinally, the main and interactive effects of self-reported neighborhood disorder and social support from family members and friends on participants' mental health (i.e., self-reported depressive symptoms, hopelessness, and suicide intent). In multiple regression analyses, neighborhood disorder interacted with social support from family members to predict depressive symptoms and hopelessness over time. Neighborhood disorder also interacted with social support from friends to predict hopelessness and suicide intent over time. High levels of social support buffered against the dangerous effects of neighborhood disorder on depressive symptoms, hopelessness, and suicide intent; at low levels of social support, there was no significant association between neighborhood disorder and those mental health outcomes. Neighborhood disorder and social support did not yield significant main effects. These findings underscore the importance of interventions that target individuals, families, and communities (e.g., community empowerment programs). Group interventions may also be important for low-income, African American women survivors of IPV, as they can help survivors establish and strengthen relationships and social support.

Factor Structure of the Communication Patterns Questionnaire in Violence-Exposed Women.

Understanding and addressing violence among intimate partners requires sound assessment of their communication patterns. In prior research, the 35-item, self-report Communication Patterns Questionnaire (CPQ) has been used to assess communication patterns in violent relationships. To date, psychometric analysis of the CPQ has been examined only among nonviolent couples; no studies have examined the psychometric properties of this measure in a sample of survivors of intimate partner violence (IPV). Using confirmatory factor analysis, the present study evaluated the factor structure of the CPQ in a sample of women survivors of IPV who sought mental health assessments at a university research clinic. Analyses suggested that a modified three-factor solution (constructive communication [CC], self-demand/partner withdraw [SDPW], partner demand/self-withdraw [PDSW]) provided good fit in our sample. Internal consistency estimates for each of the modified scales were acceptable and exceeded reported coefficients in prior IPV studies. Significant bivariate correlations among modified scales, and between communication patterns and aggressive behaviors, provided initial validity evidence for the CPQ scales in our sample. We found CC to be negatively associated with partner psychological aggression, PDSW to be positively associated with all forms of partner aggression and respondent psychological aggression, and SDPW to be positively associated with respondent physical and psychological aggression. The results of this study indicate that the CPQ may be an appropriate measure for assessing communication patterns in violent relationships; however, modified scoring procedures should be used. We contextualize our results within existing models of IPV and address clinical, cultural, and contextual issues in communication patterns assessment.

Ecological Framework for Social Justice Advocacy by Behavioral Health Professionals in Public Healthcare.

In recent years, behavioral health professionals have expressed increased interest in engaging in social justice advocacy in public health care systems. In this article, we use an ecological framework to explore opportunities for social justice advocacy in such systems and challenges associated with such efforts. We propose that ecological models are well-suited to conceptualize and address the various contexts that affect behavioral health needs, and we emphasize the importance of considering the multitude of increasingly superordinate systems within which behavioral health professionals work when pursuing advocacy initiatives. We outline the central tenets of ecological models, apply them to social justice advocacy, and provide examples of advocacy within and across ecological systems. Finally, we reflect on future directions for behavioral health professionals interested in using an ecological framework to guide their own advocacy efforts, with and on behalf of patients and communities, in public health care systems and affiliated institutions.

Learning to be interprofessional advocates in the public sector.

Engaging in advocacy is an ethical responsibility for behavioral health professionals, as reflected in professional competencies across disciplines and in personal accounts of wanting to affect change at various levels of patients'/clients' and communities' ecologies. However, the literature is replete with examples of barriers to routine advocacy engagement, including lack of an organized structure into which efforts can be embedded. There exists the desire among behavioral health professionals to engage in more advocacy work, yet a shared sense of not knowing how to incorporate this work into existing professional roles. One way to address these barriers is to establish more collaborative advocacy work environments within the public sector settings that employ behavioral health professionals. This article offers the first descriptive account of developing, implementing, and maintaining such a collaborative interprofessional advocacy workgroup. To that end, this case study is one example of such a group, the Atlanta Behavioral Health Advocates, based within the Emory University School of Medicine in the Department of Psychiatry and Behavioral Sciences and situated also within Grady Health System, a public health care system. This paper details our experiences forming and engaging in this group, which we believe can serve as a model for others developing similar advocacy workgroups in public sector settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The effects of shame on subsequent reactions to a trauma analog.

The current study examined the effects of experimentally-induced shame on subsequent reactions to a trauma analog. Participants were 88 college-aged women randomly assigned to a shame prime condition or to a control (neutral) condition. Participants then were presented with an analog trauma audiotape depicting dating violence. Participants reported intrusive thoughts relating to the trauma analog in the two days following the procedure. Negative (shame, guilt) and positive (pride, positive affect) emotions were monitored throughout the procedure. Results indicated that the shame prime successfully increased shame in the Shame condition alone. After the trauma analog, increases in shame were noted in both conditions. In contrast, guilt reduced in the Shame condition, while this emotion increased in the Control condition, contrary to hypothesis. Shame and guilt were somewhat volatile for participants in the Shame condition in the two days following the lab procedure, while individuals in the Control condition reported steadily decreasing levels of these emotions. No between-condition differences were noted in the frequency of intrusions in the two days following the laboratory procedure, contrary to hypothesis. Results are discussed in light of our current understanding of shame and its role in PTSD, with suggestions to guide future research.

Does a history of childhood abuse moderate the association between symptoms of posttraumatic stress disorder and borderline personality disorder in survivors of intimate partner violence?

OBJECTIVE: This study examined whether a history of childhood abuse (CA) strengthened the association between borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) in the aftermath of intimate partner violence (IPV). This hypothesis arises from clinical literature but has not been examined empirically. We predicted that a history of CA would enhance associations between BPD features and PTSD symptoms. METHOD: Dimensional assessment of both PTSD and BPD was made in a sample of 211 women who sought mental health services following IPV. Two analyses were conducted using clinician-assessed DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.) PTSD symptoms: (a) total score and (b) symptom clusters. RESULTS: Using path analysis, results indicated significant associations between BPD features and PTSD symptoms, but no significant interaction between BPD and CA in either analysis. CONCLUSIONS: Results are discussed given current understanding of comorbidities involving PTSD, with particular attention to potential implications for clinical practice. Areas for future research are proposed.

For Whom Does Cognitively Based Compassion Training (CBCT) Work? An Analysis of Predictors and Moderators among African American Suicide Attempters.

OBJECTIVES: Both Cognitively-Based Compassion Training (CBCT) and support-based group intervention have been found to be effective for African American suicide attempters in reducing suicidal ideation and depression, as well as enhancing self-compassion. This study aims to further our understanding of effective interventions by exploring participants' responses to both interventions. METHODS: Exploratory analyses were conducted in a sample of low-income African Americans who had attempted suicide (n=82) to determine how baseline demographic and psychological characteristics would (1) predict outcomes (i.e., suicidal ideation, depression, and self-compassion) regardless of intervention conditions, and (2) moderate outcomes in interaction with intervention condition. RESULTS: Non-reactivity, a mindfulness facet, was identified as an intervention moderator for suicidal ideation and depressive symptoms, suggesting that CBCT outperformed the support group for African American suicide attempters who had low baseline non-reactivity (or high reactivity). Individuals who had high non-reactivity at baseline appeared to benefit more from both conditions in self-compassion as an outcome. There was a pattern that homeless individuals benefited less in terms of their levels of depressive symptoms and self-compassion as outcomes regardless of the assigned condition. When applying Bonferroni corrections, only non-reactivity as an intervention moderator for depressive symptoms was significant. CONCLUSIONS: Findings reveal the relevance of mindfulness and to a lesser extent socioeconomic status in informing compassion-based intervention outcomes with this underserved population and the importance of intervention matching and tailoring to maximize treatment effects. Future large trials are needed to replicate findings and directions indicated from the current pilot study.

Demand/withdraw communication in the context of intimate partner violence: Implications for psychological outcomes.

Intimate partner violence (IPV) is associated with symptoms of posttraumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). To clarify the influence of a dyadic conflict pattern that has previously been shown to accompany violence in romantic relationships (partner demand/self withdraw) on these mental health outcomes, we examined the associations between three forms of IPV (physical, emotional-verbal, dominance-isolation), partner demand/self withdraw, and PTSD and GAD symptoms, in a sample of 284 IPV-exposed women. Using structural equation modeling, we found significant associations between dominance-isolation IPV, partner demand/self withdraw, and clinician-assessed GAD symptoms. Associations between emotional-verbal IPV and partner demand/self withdraw were also significant. Associations for physical IPV, partner demand/self withdraw, and clinician-assessed PTSD symptoms were not statistically significant. These results underscore the need for research on the mental health outcomes associated with specific forms of IPV and the long-term psychological consequences of the conflict patterns that uniquely characterize violent relationships.

Deficits in Access to Reward Are Associated with College Student Alcohol Use Disorder.

BACKGROUND: Reward deprivation has been implicated in major depressive disorder and severe substance abuse, but its potential relation to alcohol use disorder (AUD) symptoms in non-treatment-seeking young adult drinkers is less clear. Depression is often comorbid with alcohol misuse, so relations of AUD with reward deprivation might be due in part to the presence of depressive symptoms in young adults. Behavioral economic theory views addiction as a state that is related in part to deficits in drug-free rewards, and therefore requires an investigation into whether reward deprivation has a direct relation to alcohol misuse that is, at least partially, independent of mood. METHODS: This study evaluates the contribution of 2 facets of reward deprivation (reward availability and experience) to alcohol use, AUD symptoms, and depression in a sample of young adult heavy episodic drinkers. Data were collected from 392 undergraduates (60.4% female, 85.1% Caucasian) who reported recent heavy drinking (83.7% with at least 1 AUD symptom). RESULTS: Low reward availability (environmental suppression) was significantly associated with both DSM-5 AUD symptoms and alcohol-related problems after controlling for age, gender, depressive symptomatology, and drinking level. CONCLUSIONS: This study provides support for behavioral economic models that emphasize reward deprivation as a unique risk factor for AUD that is independent of mood and drinking level. Limited access to natural rewards may be a risk and/or maintaining factor for AUD symptoms in college student drinkers.

A behavioral economic analysis of the nonmedical use of prescription drugs among young adults.

The nonmedical use of prescription drugs is a widely recognized public health issue, and young adults are particularly vulnerable to their use. Behavioral economic drug purchase tasks capture an individual's strength of desire and motivation for a particular drug. We examined young adult prescription drug purchase and consumption patterns using hypothetical behavioral economic purchase tasks for prescription sedatives/tranquilizers, stimulants, and opiate pain relievers. We also examined relations between demand, use frequency, and Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) substance use disorder (SUD) symptoms, and sex differences in these relations. Undergraduate students who endorsed past-year prescription drug use (N = 393) completed an online questionnaire for course credit. Measures assessed substance use frequency and DSM-5 SUD symptoms. Hypothetical purchase tasks for sedatives, stimulants, and pain relievers assessed participants' consumption and expenditure patterns for these substances across 25 prices. Past-year prescription sedative, stimulant, and pain reliever use was endorsed by 138, 258, and 189 participants, respectively. Among these users, consumption for their respective substance decreased as a function of ascending price, as expected. Demand indices for a prescription drug were associated with each other and with use frequency and SUD symptoms, with variability across substances but largely not by sex. In addition, demand for prescription pain relievers differentially predicted symptoms independent of use, with differences for females and males. In conclusion, hypothetical consumption and expenditure patterns for prescription drugs were generally well described by behavioral economic demand curves, and the observed associations with use and SUD symptoms provide support for the utility of prescription drug purchase tasks.

Alcohol craving and demand mediate the relation between posttraumatic stress symptoms and alcohol-related consequences.

Posttraumatic stress (PTS) symptoms are associated with alcohol-related consequences, but there is a need to understand mediators that may help explain the reasons for this relationship. Individuals with PTS may experience elevated craving and alcohol reward value (demand), which may contribute to risk for alcohol-related consequences. We examined relationships between PTS status, craving, alcohol demand, and alcohol-related consequences in PTS-positive (n = 64) and PTS-negative (n = 200) college students (M age = 21.7; 77% women; 54% Caucasian; 34% African American) who endorsed past-month alcohol use. We tested craving and alcohol demand as mediators of the relation between PTS status and alcohol-related consequences. Craving (B = .04, SE = .02, 95% CI [.01, .10]), demand intensity (B = .02, SE = .02, 95% CI [.001, .07]), and demand elasticity (B = .05, SE = .03, 95% CI [.006, .12]) significantly mediated the association between PTS symptoms and alcohol-related consequences. Craving remained a significant mediator in a multiple mediators model (B = .08, SE = .04, 95% CI [.03, .19]). Craving and alcohol demand may partially explain the relation between PTS status and alcohol-related consequences. Craving may be especially salient for individuals with PTS symptoms, as it may lead to more severe alcohol-related consequences even in the absence of elevated alcohol consumption.

Elevated alcohol demand is associated with driving after drinking among college student binge drinkers.

BACKGROUND: Alcohol-impaired driving among college students represents a significant public health concern, yet little is known about specific theoretical and individual difference risk factors for driving after drinking among heavy drinking college students. This study evaluated the hypothesis that heavy drinkers with elevated alcohol demand would be more likely to report drinking and driving. METHOD: Participants were 207 college students who reported at least 1 heavy drinking episode (4/5 or more drinks in 1 occasion for a woman/man) in the past month. Participants completed an alcohol purchase task that assessed hypothetical alcohol consumption across 17 drink prices and an item from the Young Adult Alcohol Consequences Questionnaire that assessed driving after drinking. RESULTS: In binary logistic regression models that controlled for drinking level, gender, ethnicity, age, and sensation seeking, participants who reported higher demand were more likely to report driving after drinking. CONCLUSIONS: These results provide support for behavioral economics models of substance abuse that view elevated/inelastic demand as a key etiological feature of substance misuse.