Experience of associative stigma in parents of adolescents at risk for psychosis.

AIM: This qualitative study examined the lived experience of associative stigma for parents of adolescents at clinical high risk for psychosis. A central goal was to empower families to tell their stories and to use the themes that emerge from this narrative data to make recommendations that might support families coping with a loved one being diagnosed with risk for psychosis. METHODS: Twelve parents of adolescents diagnosed with the clinical high risk for psychosis syndrome were interviewed using a semi-structured approach. The qualitative study employed Interpretative Phenomenological Analysis (IPA) to focus on experiences of associative stigma and the way parents make sense of these experiences. RESULTS: From these interviews, the researcher identified themes and subthemes categorized into major domains that represent topics particularly relevant to these 12 parents. Two main domains emerged as particularly salient to parents' experiences with associative stigma: perceptions of stigma and coping with stigma. CONCLUSIONS: Participants' insights demonstrated increased experience of stigma associated with psychotic-like symptoms as compared to other psychiatric symptoms, attempts to balance fighting against stigma with the privacy needs of adolescents, and participation in research as less stigmatizing than non-specialty care. Stigma impacted treatment-seeking and participation in family groups that were seen as both potentially supportive and threatening. The interviews provided an opportunity for these families to voice their unique experiences, which expands the literature on the topic of caregivers of adolescents at risk for psychosis as treatment programs for the clinical high risk syndrome expand across the United States.

MEASUREMENT ISSUES IN HOME-VISITING RESEARCH WITHIN TRIBAL COMMUNITIES: CHALLENGES AND STRATEGIES.

In this article, Tribal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grantees share strategies they have developed and adopted to address the most common barriers to effective measurement (and thus to effective evaluation) encountered in the course of implementation and evaluation of their home-visiting programs. We identify key challenges in measuring outcomes in Tribal MIECHV Programs and provide practical examples of various strategies used to address these challenges within diverse American Indian and Alaska Native cultural and contextual settings. Notably, high-quality community engagement is a consistent thread throughout these strategies and fundamental to successful measurement in these communities. These strategies and practices reflect the experiences and innovative solutions of practitioners working on the ground to deliver and evaluate intervention programs to tribal communities. They may serve as models for getting high-quality data to inform intervention while working within the constraints and requirements of program funding. The utility of these practical solutions extends beyond the Tribal MIECHV grantees and offers the potential to inform a broad array of intervention evaluation efforts in tribal and other community contexts.

APPROACHES TO THE EVALUATION OF CULTURAL ADAPTATIONS OF HOME VISITING IN TRIBAL COMMUNITIES.

The research that underlies evidence-based practices is often based on relatively homogenous study samples, thus limiting our ability to understand how the study findings apply in new situations as well as our understanding of what might need to be adapted. In a preliminary effort to address those gaps, the requirements for the Tribal Maternal Infant and Early Childhood Home Visiting Program (MIECHV) included the expectation that grantees design and implement rigorous evaluations to address local priorities and to help build the knowledge base regarding the use of evidence-based home-visiting programs in tribal communities. A priority that emerged across many Tribal MIECHV grantees was to determine the added benefit of the cultural adaptations that they were making to their home-visiting programs. While there is literature to describe recommended processes for making cultural adaptations to evidence-based programs themselves, there are very few guidelines for evaluating these adaptations. In this article, we review the varied evaluation approaches utilized by Tribal MIECHV grantees and provide three case examples of how evaluators and tribal communities worked together to articulate evaluation questions and choose appropriate and feasible evaluation designs. The lessons derived from these Tribal MIECHV evaluation experiences have implications for the role of the evaluator in diverse communities across the country evaluating home visiting and other evidence-based practices in settings characterized by unique cultural contexts.

Clinical and functional outcomes after 2 years in the early detection and intervention for the prevention of psychosis multisite effectiveness trial.

OBJECTIVE: To test effectiveness of the Early Detection, Intervention, and Prevention of Psychosis Program in preventing the onset of severe psychosis and improving functioning in a national sample of at-risk youth. METHODS: In a risk-based allocation study design, 337 youth (age 12-25) at risk of psychosis were assigned to treatment groups based on severity of positive symptoms. Those at clinically higher risk (CHR) or having an early first episode of psychosis (EFEP) were assigned to receive Family-aided Assertive Community Treatment (FACT); those at clinically lower risk (CLR) were assigned to receive community care. Between-groups differences on outcome variables were adjusted statistically according to regression-discontinuity procedures and evaluated using the Global Test Procedure that combined all symptom and functional measures. RESULTS: A total of 337 young people (mean age: 16.6) were assigned to the treatment group (CHR + EFEP, n = 250) or comparison group (CLR, n = 87). On the primary variable, positive symptoms, after 2 years FACT, were superior to community care (2 df, p < .0001) for both CHR (p = .0034) and EFEP (p < .0001) subgroups. Rates of conversion (6.3% CHR vs 2.3% CLR) and first negative event (25% CHR vs 22% CLR) were low but did not differ. FACT was superior in the Global Test (p = .0007; p = .024 for CHR and p = .0002 for EFEP, vs CLR) and in improvement in participation in work and school (p = .025). CONCLUSION: FACT is effective in improving positive, negative, disorganized and general symptoms, Global Assessment of Functioning, work and school participation and global outcome in youth at risk for, or experiencing very early, psychosis.

A Process-Oriented Approach to Teaching Religion and Spirituality in Psychiatry Residency Training.

OBJECTIVES: Although the importance of addressing issues of spirituality and religion is increasingly acknowledged within psychiatry training, many questions remain about how to best teach relevant knowledge, skills, and attitudes. Current literature on curricula highlights the importance of maintaining a clinical focus and the balance between didactic content and process issues. The authors present findings from a program evaluation study of a course on religion, spirituality, and psychiatry that deliberately takes a primarily process-oriented, clinically focused approach. METHODS: Two six-session courses were offered. The first course targeted fourth-year psychiatry residents and the second targeted third-year psychiatry residents. Teaching sessions consisted of brief didactics combined with extensive process-oriented discussion. A two-person faculty team facilitated the courses. Clinical case discussions were integrated throughout the curriculum. A panel of chaplains was invited to participate in one session of each course to discuss the interface between spiritual counsel and psychiatry. A modified version of the Course Impact Questionnaire, a 20-item Likert scale utilized in previous studies of spirituality curricula in psychiatry, assessed residents' personal spiritual attitudes, competency, change in professional practice, and change in professional attitudes before and after the course (N = 20). Qualitative feedback was also elicited through written comments. RESULTS: The results from this study showed a statistically significant difference between the pre- and post-test scale for residents' self-perceived competency and change in professional practice. CONCLUSION: The findings suggest improvement in competency and professional practice scores in residents who participated in this course. This points toward the overall usefulness of the course and suggests that a process-oriented approach may be effective for discussing religion and spirituality in psychiatric training.

Training psychiatrists for rural practice: a 20-year follow-up.

OBJECTIVE: This report describes the Rural Psychiatry Residency Program at the University of New Mexico (UNM RPRP) and presents findings from a survey of program graduates. METHODS: Current practice location of residency graduates was identified to learn whether graduates of the UNM RPRP continued to practice in rural communities compared to the graduates of the traditional residency program. Additionally, a web-based survey was completed by 37 of the 60 graduates who participated in the UNM RPRP since its inception in 1991 through 2010. Questions addressed current practice, perceived barriers, and perceptions of experiences. RESULTS: Thirty-seven percent of the graduates from the UNM RPRP currently practice in rural communities compared to 10 % of the graduates from the traditional residency track. Of the survey respondents, 95 % continue to work with underserved individuals. Reported barriers to practice in rural areas include professional isolation, lack of referral resources, and travel distances. Respondents reported valuing education about systems based practice and telepsychiatry. CONCLUSION: Purposeful and well-coordinated educational opportunities situated in rural community health clinics can address some of the barriers for recruiting and retaining practicing psychiatrists in rural areas. Practical skill building at the individual, agency, and system level is integral in training psychiatrists for work in these communities. In particular, the use of telepsychiatry emerged as an important practical application for the provision of rural mental health care.

Wicasa Was'aka: restoring the traditional strength of American Indian boys and men.

We examined health disparities among American Indian men and boys within the framework of historical trauma, which incorporates the historical context of collective massive group trauma across generations. We reviewed the impact of collective traumatic experiences among Lakota men, who have faced cross-generational challenges to enacting traditional tribal roles. We describe historical trauma-informed interventions used with two tribal groups: Lakota men and Southwestern American Indian boys. These two interventions represent novel approaches to addressing historical trauma and the health disparities that American Indians face. We offer public health implications and recommendations for strategies to use in the planning and implementation of policy, research, and program development with American Indian boys and men.

Expanding the vision: the strengths-based, community-oriented child and adolescent psychiatrist working in schools.

Because the majority of children with mental health needs are most likely to receive treatment in a school setting, there is a long history of linking child and adolescent psychiatrists to schools. Psychiatrists traditionally have been involved in assessing, diagnosing, and treating the severely mentally ill or consulting with school-based providers. With no end in sight to the dearth of child and adolescent psychiatrists, not to mention child and adolescent behavioral health providers in other disciplines, this role has been broadened in recent years by several programs in which the child and adolescent psychiatrist provides flexible, population-based, systemic, and context-specific approaches to working in schools. In this article, the authors first review some of the traditional roles for child and adolescent psychiatrists working in school mental health settings. Then 2 national programs are highlighted, which successfully integrate psychiatrist trainees into comprehensive school mental health programs. The theoretical approach to a specific community-oriented, strengths-based model for school mental health support used in New Mexico by the University of New Mexico (UNM) Psychiatry Department's Center for Rural and Community Behavioral Health school telepsychiatry program, which supports rural and frontier school mental health programs and school-based health centers, is discussed in detail. The UNM model involves a strength-and resiliency-based collaboration between the child and adolescent psychiatrist, students, families, educators, and those who support them. The psychiatrist co-creates a "community of concern" and support for students, including not only customary participants such as parents, educators, and health care providers but also peers, families of choice, lay professionals, community gatekeepers, and others identified by the student as critical to his or her well-being. The advantages for child and adolescent psychiatry trainees being exposed to a wider variety of potential roles working with schools are also discussed.

HPV and cervical cancer prevention counseling with younger adolescents: implications for primary care.

PURPOSE: Primary care clinicians will continue to play an important role in cervical cancer prevention, particularly with regard to administration of the newly licensed human papillomavirus (HPV) vaccine and continued administration of Papanicolaou tests. Little is known about the factors that influence cervical cancer prevention counseling, particularly in the adolescent encounter. We conducted a qualitative study to better understand the implications for counseling about cervical cancer prevention by primary care clinicians who care for adolescents. METHODS: We conducted in-depth interviews with 37 primary care clinicians in New Mexico to understand the context in which they provide anticipatory guidance about sexual health risks as well as their attitudes about counseling for the forthcoming HPV vaccine. RESULTS: Clinicians identified 4 categories of factors related to their counseling experiences with adolescents about HPV: (1) the need to build rapport with adolescent patients, (2) the presumption that adolescent patients engage in high-risk behaviors, (3) the situational delivery and complexity of HPV counseling, and (4) perceptions of clinician and community receptivity to the HPV vaccine. CONCLUSION: Our findings show that conditions of the preadolescent and young adolescent visit pose a challenge to the successful integration of counseling about cervical cancer prevention in primary care. Counseling strategies that are designed to emphasize a preventive focus while including parents in the discussion at the time of vaccination and that are appropriate to populations with different cultural values and beliefs will help to enhance communication about cervical cancer prevention and the particular role of the HPV vaccine.

Brief reports: Unequal treatment: mental health care for sexual and gender minority groups in a rural state.

OBJECTIVE: This qualitative study examined the social dynamics of communities and clinic settings that impede the delivery of culturally relevant services to lesbian, gay, bisexual, and transgender (LGBT) people living in rural areas. METHODS: Ethnographic interviews were conducted with 20 providers in rural areas to document their perceptions of LGBT mental health care. RESULTS: A majority of rural providers claimed that there is no difference between working with LGBT clients and non-LGBT clients. This neutral therapeutic posture may be insufficient when working with rural LGBT clients. Despite providers' claims of acceptance, lack of education about LGBT mental health issues, and homophobia influenced services for rural LGBT people. LGBT clients had been denied services, discouraged from broaching sexuality and gender issues by providers, and secluded within residential treatment settings. CONCLUSIONS: The challenges of ensuring access to quality care for this population are magnified by provider discourses of "therapeutic neutrality."

Pragmatic help seeking: How sexual and gender minority groups access mental health care in a rural state.

OBJECTIVE: This qualitative study examined how lesbian, gay, bisexual, and transgender (LGBT) people in rural areas of the poor and multiethnic state of New Mexico access secular (professional and lay) and sacred (indigenous and Christian) mental health care resources. METHODS: In-depth, semistructured interviews were used to document the help-seeking processes of 38 rural LGBT people. RESULTS: Obtaining assistance was complicated by the ideal of self-reliance and the view of mental illness as a sign of weakness. Financial considerations and a lack of and community-based LGBT social networks also exerted substantial influence on help seeking. Many LGBT people would strategically remain silent about their sexuality or gender status and rely on their family ties to access the range of secular and sacred resources that are most commonly available in medically underserved rural communities. CONCLUSIONS: Although persons from sexual and gender minority groups often experience positive outcomes as a result of help seeking, some LGBT people remain vulnerable to anti-LGBT sentiments that persist within secular and sacred sectors of rural health care systems.