Purpose: Therapists are often charged with the seemingly impossible task of predicting their client’s future behavior, particularly behavior that may result in harm or death. Adverse events (AE) refer to a constellation of behaviors or events that interfere with treatment and exhibit a risk to the safety of the patient, which include suicide attempts, non-suicidal self injury (NSSI) and suicidal ideation. This is the first study that seeks to identify and associate in-session markers in DBT prior to AEs. Method: The proposed study sought to identify whether ruptures in therapeutic alliance (3RS; Eubanks-Carter, Muran & Safran, 2015), the frequency and intensity of negative-self referential speech (LIWC2015; Pennebaker, Booth, Boyd & Francis, 2015) and periods of psychomotor agitation are associated with AEs within a course of Dialectical Behavior Therapy (DBT). By coding videotaped psychotherapy sessions (n = 98) across 21 patients diagnosed with Borderline Personality Disorder (BPD), the researchers prospectively examined the association between in-session phenomena during the session prior to an AE. Exploratory logistic multilevel modeling, mean comparison and latent profile analysis (LPA) techniques were used to identified in-session markers associated with adverse events across the course of DBT treatment. Results: Using a multilevel model building approach to account for the nested structure, increases in content/affect split was associated with increased likelihood (36% increase in log-odds) of NSSI occurrence reported in the subsequent session when controlling for frequency of past NSSI episodes. When controlling for prior suicide attempts, withdrawal and confrontation ruptures did not predict the occurrence of suicide attempts in the subsequent session. To further examine the heterogeneity of the Level 1 variables (i.e., in-session markers), the LPA fitted afive-profile solution that captured relative differences in mean frequencies of coded markers.The latent “session types” were named based on their in-session characteristics, with AEs identified post-hoc within the identified profiles. While AEs were distributed across multiple profiles, visual inspection aligned with the findings in the multilevel model. Sessions characterized by elevations in content/affect split and behaviors that distance from the therapist preceded NSSI during treatment. The majority of the sessions prior to suicide attempts (70%) during the study period were assigned to the profile with the lowest mean frequency of in-session markers. Clinical implications: The strength of the therapeutic alliance in DBT is an essential component of effective treatment. Therapeutic ruptures, particularly withdrawal ruptures, occur frequently in DBT treatment. Attending to these ruptures, especially occasions when a patient’s affect and verbal content are not congruent, may signal to the therapist that the patient requires additional support. In-session content/affect split may represent a vulnerability factor that puts the patient at increased risk of NSSI behavior due difficulty attuning to their internal experiences and limitations in their emotional flexibility. Limitations: Similar to other studies that examine self-harm, the low base-rate of suicide attempts and NSSI behavior complicates empirical study. Since the study utilized strict inclusion criteria for only individuals diagnosed with BPD, findings cannot be generalized to patients with other psychiatric diagnoses. While some therapist effects are controlled for in the study since one therapist treated all the patient included in the study, the study does not account for therapist factors that may influence the therapy dyad. Given the limited sample size, there was not adequate power to fit more complicated models (e.g., inter-level and intra-level interactions, random effect predictor variables, etc.).

While a great deal of theoretical work affirms the importance of spirituality in hospice care, the manner in which organizational members communicate about spirituality in hospice organizations, and most other health care organizations, remains under-explored and under-theorized. The purpose of this dissertation is twofold. First, this dissertation seeks to understand how hospice members talk about spirituality with one another and with care recipients. Second, this dissertation explores the antecedents and consequences of hospice members' communication strategies. To explore these issues, an ethnographic study was conducted in two branches of a mid-sized hospice. Over 200 hours of participant observation and 42 interviews were completed. Results showed that organizational discourse about spirituality was strategically ambiguous in response to multiple internal and external demands. Strategically ambiguous communication was successful in allowing for a wide range of actions and interpretations; however, it was also problematic in that it served as a source of discomfort and disconnection for some organizational members. Further, results demonstrated that communication about spirituality in interactions between care providers and care recipients was influenced by both organizational discourse and personal understandings of spirituality. Organizational and professional discourse and personal understandings created dialectical tensions between leading and following in care provider-care recipient interactions. Further analysis demonstrated five different strategies for managing the leading-following dialectic. Finally, results suggested that organizational discourses affected the personal identity and outcomes experienced by hospice workers. The preferred organizational identity of the "Gracious Servant" required hospice workers to perform spiritual labor which increased the care providers' propensity to experience stress and burnout. In total, these results demonstrate the importance of examining spirituality from an ecological perspective that considers community, organizational, and interpersonal discourse about spirituality.

Heavy drinking puts college students at risk for academic failure, alcohol use disorders, and even death. Although several interventions have proven moderately successful, overall rates of collegiate heavy drinking and consequences have significantly increased since 1998, as interventions may not adequately address underlying reasons for drinking. Research has consistently shown that college students who drink primarily to regulate emotions (i.e., internal drinking motives) are heavier drinkers, experience more consequences, and are likely to continue drinking heavily after college. Further, internal drinking motives are indicative of emotion dysregulation and associated personality traits. Dialectical Behavior Therapy (DBT) is empirically supported and includes a group-based component designed to teach concrete behavioral emotion regulation, mindfulness, and distress tolerance skills. DBT skills training alone has been shown to reduce substance abuse and binge eating and is a promising, but untested, strategy for reducing collegiate alcohol abuse. The aims of the current study were threefold: (a) examine the efficacy of a DBT-based emotion regulation skills training (ERST) as an intervention for college student drinking, (b) examine theoretically-informed mechanisms of change (i.e., changes in mindfulness, emotion regulation, and distress tolerance), and (c) examine intervention moderators (i.e., gender, readiness to change, and internal drinking motives). After completing pre-test measures, college students reporting two or more heavy drinking episodes during the past month were randomly assigned to an ERST or assessment-only control (AO) condition. ERST participants completed a single 3-hour group session of ERST within 7 days of completing pre-intervention measures and all participants completed two additional assessments. The current study found that ERST participants showed significantly greater reductions in heavy drinking and alcohol-related consequences relative to AO control participants. Contrary to hypotheses, intervention participation did not increase hypothesized mechanisms of change (i.e., mindfulness, emotion regulation, or distress tolerance) although emotion regulation and distress tolerance moderated intervention efficacy. Finally, ERST participation appeared to serve as a protective factor against heavy drinking and consequences for internally motivated drinkers. Overall findings provide preliminary support for the feasibility of ERST as a new intervention for reducing problematic drinking by college students and suggest future directions for mechanisms of change and moderation hypotheses. / text

Diss.--Fribourg. / Bibliography: p. [xiii]-xxviii.

Thesis (D. Phil.(New Testament Studies))--University of Pretoria, 2000. / Summary in English. Includes bibliographical references.

Diss.--Fribourg. / Bibliography: p. [xiii]-xxviii.

Thesis (Ph. D.)--Albert-Ludwigs-Universität zu Freiburg i. Br., 1933. / Vita. Includes bibliographical references (p. 76-78).

Thesis (Ph. D.)--Catholic University of America, 1938. / Vita. Description based on print version record. Bibliography: p. 200-206.

Thesis (doctoral)--Frankfurt am Main, 1974. / Vita. Includes bibliographical references (p. 209-217).

Thesis (Ph.D.)--University of Nebraska-Lincoln, 2010. / Title from title screen (site viewed July 6, 2010). PDF text: ca. 125 p. ; Mb. UMI publication number: AAT 3397968. Includes bibliographical references. Also available in microfilm and microfiche formats.