At the start of the twenty-first century, U.S. Environmental Protection Agency (EPA) officials can look back on nearly thirty years of meaningful accomplishments. Toxic releases are down, the air and water are cleaner, and waste disposal methods are greatly improved. Although this is a record of which EPA officials should be proud, is it sufficient to carry them into the next century? Conventional wisdom among scholars, environmental policy advocates, and even EPA officials indicates that it is not. The new century is bringing complex challenges and, in some cases, the changing conditions are threatening the progress EPA has struggled to achieve. Some of the tools and approaches this agency has relied upon historically, such as notice and comment rulemaking, single stakeholder consultations, and positional leadership, are no longer adequate to address existing environmental challenges and new emerging environmental problems. The Common Sense Initiative (CSI) was launched by EPA in mid-1994 as a fundamentally different approach to environmental protection. Its sector-based, multistakeholder, consensus decision-making process was counter to EPA's traditional command-and-control approach. CSI was created with the intent to heal the growing dysfunctional relationships that exist among government co-regulators (i.e., EPA and state and local agencies), the regulated industry, and non-governmental organizations (i.e., environmentalists and environmental justice organizations). Even though EPA officials realized the limitations of the existing regulatory approach, they had trouble "giving up control." Nonetheless, during the four-year history of the CSI process, EPA personnel had an opportunity to see themselves in a different light and to operate in a new organizational regime. Rather than being just regulators, they were able to become solvers of environmental problems. Rather than being position-oriented, they were able to become person-oriented. Instead of seeking ownership and control, they were able to obtain leverage through partnerships and collaboration. In short, EPA officials were building social capital and a new style of management"facilitative leadership. A facilitative leader leads without controlling, communicates without being condescending, and uses synergism to help groups achieve "win-win" results. This new paradigm has the potential to help EPA better adapt in the next generation system of environmental protection. / Ph. D.

The counseling relationship has long been considered an essential part of the foundation of positive client outcomes in counseling. While many factors play a role in the therapeutic relationship, the facilitative conditions of empathy, unconditional positive regard, and genuineness have been the most-researched components of the Person-Centered construct of the therapeutic relationship. The supervisory relationship parallels the therapeutic relationship in many ways, and as the therapeutic relationship is critical to counseling, the supervisory relationship is foundational to effective supervision. While the facilitative conditions are empirically proven to contribute to positive client outcomes within the therapeutic relationship, the role of the counselor’s supervisory relationship has been largely unexplored in its association to client outcomes. The purpose of this study was to determine if there is a relationship between the facilitative conditions perceived by the client during counseling, and the facilitative conditions perceived by the counselor-in-training during supervision. Additionally, these variables were tested for their ability to predict client outcomes. The sample of this study consisted of 88 clients and 55 counselors-in-training at a large university in the southeastern United States. Both clients and counselors-in-training completed two instruments to ascertain the quality of their counseling and supervision relationships. The Outcomes Questionnaire-45 was utilized to collect client outcomes data. Results validate a correlation between the client’s perception of the therapeutic relationship and client outcomes, however there appears to be no relationship between the supervisory relationship and client outcomes. Further results of the study and limitations were discussed

Bakgrund: Inom primärvården tillämpas vanligtvis hemträningsprogram som behandling. Flera studier har undersökt underlättande faktorer för följsamhet till hemträning. Sedan fysioterapeutprogrammet på Uppsala Universitet hösten 2014 utvecklade utbildningsplanen till ett mer biopsykosocialt inriktat lärande återfinns ingen forskning på hur fysioterapeuterna med den nya utbildningsplanen upplever att de kan underlätta patientens följsamhet. Syfte: Undersöka hur nyexaminerade fysioterapeuter, som påbörjat utbildningen på Uppsala Universitet höstterminen 2014 eller senare, upplever att de kan underlätta följsamheten till hemträningsprogram för patienter i primärvården. Metod: Kvalitativ deskriptiv design. Datan insamlades genom fem semistrukturerade intervjuer med nyexaminerade fysioterapeuter och bearbetades sedan med hjälp av en kvalitativ innehållsanalys. Resultat: Analysen resulterade i sju kategorier samt 19 underkategorier. De sju kategorierna bestod av “Individanpassa träningsupplägg och uppföljning”, “Öka patientens förståelse av hemövningar”, “Tillämpa socialt stöd vid hemträning”, “Kartlägga och framkalla motivation till hemträning”, “Utforska patientens beteende och mående”, “Etablera god patientkontakt” och “Tillgångar på arbetsplatsen”. Konklusion: Resultatet framställde många strategier som redan beforskats. Samtliga kategorier förutom ”Tillgångar på arbetsplatsen” speglar ett beteendemedicinskt perspektiv. Detta kan indikera på att framtidens fysioterapeuter är behjälpliga av denna typ av perspektiv vid bemötande av patienter för att underlätta följsamheten till hemträningsprogram inom primärvården. / Background: In primary care, it is common to apply home-based exercise programs as treatment. Several studies have investigated facilitating factors that affect adherence to home-based exercise. Since the physiotherapist program at Uppsala University in autumn 2014 developed the syllabus into a more biopsychosocial-oriented learning, no research can be found on how the physiotherapists with the new syllabus experience can facilitate the patient's adherence. Purpose: Examine how newly graduated physiotherapists, who began their education at Uppsala University in the autumn 2014 or later, experience that they can facilitate adherence with home-based exercise programs for patients in primary care. Method: Qualitative descriptive design. Data was collected through five semi-structured interviews with five newly graduated physiotherapists and was conducted with a qualitative content analysis. Results: The data resulted in seven categories and 19 subcategories. The seven categories consisted of "Personalizing training arrangements and follow-up", "Increasing the patient’s understanding of home-based exercise", "Applying social support in home-based exercise", "Chart and incite motivation for home-based exercise", "Explore patient behavior and well-being", "Establish good patient contact" and "Workplace assets". Conclusion: The result presented many strategies that already have been explored. All categories except "Workplace assets" reflected a behavioral medicine perspective. This perspective might be of value for future physiotherapists to facilitate adherence with home-based exercise programs in primary care.

Caregiver-child conversation is an important platform for children’s development of language and conversational skills and can form the basis for an approach to intervention for children with pragmatic difficulties. While most intervention studies have focused on reporting overall improvements in children’s language and conversational skills as a result of changes in caregiver behaviour, there is limited fine-grained understanding of children’s ability to achieve conversational topic contingency as a result of specific changes in their caregivers’ use of conversational topic turns and/or the facilitative techniques employed by therapists. The studies described in this thesis aim to address this limitation. The following questions are raised: (i) What is the impact of caregiver training intervention programmes on caregivers’ conversational topic turns and facilitative techniques? (ii) What is the impact of caregiver training intervention programmes on children’s conversational topic turns? and (iii) How do specific facilitative techniques impact children’s conversational skills? The first part of this thesis involves establishing the methodology for data transcription and data coding used in the four studies conducted for this thesis. Conversational recordings were transcribed using the CHAT format and conventions. Then a conversational coding system and a facilitative technique coding system were used to code the communicative acts transcribed. The conversational acts coded were topic change (TC), topic extension (TE), topic maintaining responses (TM), and non-relevant responses (NR). The facilitative techniques coded were imitation, expansion, follow-in questions, and follow-in cloze procedures. Inter-rater reliability levels of the transcription and coding of conversational acts and facilitative techniques were high. Study 1 (presented in Chapter 3) was designed to investigate changes following an ‘It Takes Two to Talk’ Hanen programme in the conversations of four caregiver-child dyads where the children had identified language delay. It employed a single subject design and the outcome measures were analysed in three phases: baseline, intervention and follow-up. The outcome measures were the rates of (i) caregivers’ conversational topic turns (i.e., TC, TE and TM), (ii) caregivers’ facilitative techniques (i.e., imitation, expansion, follow-in questions, and follow-in cloze procedures) and (iii) children’s conversational topic turns (i.e., TC, TE and TM). Results showed that all caregivers produced fewer TCs and higher rates of facilitative techniques, while all children produced significantly more TEs following intervention. Individual caregiver patterns of change appeared to be reflected in their children’s conversational skills. This study supports the effectiveness of caregiver group training programmes in improving the quality of caregiver-child conversations and highlighted the importance of investigating individual variations in intervention. Study 2 (presented in Chapter 4) was designed to investigate the changes in conversational skills of three children with features of autism spectrum disorders (ASD) following the dyads’ participation in caregiver-child individual training as part of a multidisciplinary programme for children with ASD. This study employed a case series design and the outcome measures were analysed in two phases (i.e., intervention and follow-up). Similar to Study 1, the outcome measures were rates of the (i) caregivers’ conversational topic turns (i.e., TC, TE and TM), (ii) caregivers’ facilitative techniques (i.e., imitation, expansion, follow-in questions, and follow-in cloze procedures) and (iii) children’s conversational topic turns (i.e., TC, TE and TM). Results of Study 2 showed that one of the three caregivers decreased the rates of TC, and one of them increased the rates of TM following intervention. The caregivers also increased their rates of facilitative techniques (i.e., imitation, expansion and follow-in questions). Concurrently, the children whose caregivers showed positive changes following intervention increased their rates of TCs and TMs. Consistent with the findings of Study 1, high individual variations were observed in the changes exhibited by the caregivers. Study 2 supports the effectiveness of individual training programmes in improving the quality of caregiver-child conversations and emphasizes the importance of investigating individual variations in intervention. Study 3 (presented in Chapter 5) was designed to investigate the qualitative changes made by a child from each of the first two studies. The two children presented with different language levels and aetiologies but both were receiving individualised programmes designed to enhance their conversational abilities. Taking a functional approach to communication development, Study 3 examined how each child (i) collaborated on an activity; (ii) expanded an activity; and (iii) returned to a previous activity or proposed a new activity, through conversational topic turns. Results suggest that the children learnt to collaborate on and expand activities through their caregivers’ repeated use of contingent topic turns (i.e., TM and TE) and facilitative techniques (i.e., expansion, follow-in questions and follow-in cloze procedures). However, they tended to return to a previous activity or propose a new activity when they did not attend to the preceding act or topic, seemed to not comprehend or were not interested in the preceding act or topic, or when their caregivers failed to attend to their preceding act or topic. These findings highlights that while caregivers’ topic turns that are contingent and facilitative help children to advance their activities, caregivers’ topic turns that are non-contingent have the potential to cause the children to end the preceding activity and switch to another activity. Study 4 was designed to compare the effectiveness of expansion, as a technique for facilitating children’s conversational topic turns, with expansion combined with other techniques when implemented by speech and language therapists (SLTs). Using a repeated measures design, this study aimed to compare the effects of expansion alone (EA); expansion combined with wh-questions (EQ); and expansion followed by a cloze procedure (EC) on the conversational skills of eight preschool children with conversational difficulties in conversation with their regular speech-language therapists (SLTs). Results showed that while there were no significant differences in child verbal topic maintaining responses across all techniques, EA elicited a significantly higher number of TEs, more non-verbal TMs and fewer NRs from the children, than either EQ or EC. The positive effects of each technique on the pragmatic appropriateness in conversations suggest that they could be used strategically in language intervention to enhance therapeutic effect. This thesis suggests that caregiver training programmes that focus on following the child’s lead and support caregivers and therapists to use contingent topic turns and facilitative techniques have positive outcomes for children’s conversational development. It also suggested that caregivers’ and therapists’ facilitative strategies that do not obligate responses from the child (i.e., expansion) have better potentials to help the child to expand the scope of conversations than strategies that obligate a response from the child (i.e., wh-questions and cloze procedures). Finally this thesis suggests that family-focussed intervention that follows the child’s lead appears likely to improve the conversational skills of children with a range of diagnoses by helping to address the common underlying features of conversational difficulties.

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<p>Successful navigation requires an accurate mental spatial representation of the environment that can be updated during movement. Experiments with animals and humans have demonstrated the existence of two forms of spatial representation: egocentric (observer-centered) and allocentric (environment-centered). Unfortunately, specifically how humans use these two systems is not well understood. The current dissertation was focused on providing evidence differentiating human use of egocentric and allocentric spatial reference frames, specifically examining the characteristics and contributions from body-based sources. Two empirical chapters are presented that include experiments involving two common spatial tasks. In Chapter 2, updating of feature relations within a room-sized environment was examined by having observers provide directional judgments to learned features with respect to an imagined orientation that was either congruent or incongruent with their physical orientation. The information available for updating the physical orientation was manipulated across experiments. Performance differences between congruent and incongruent conditions demonstrated the reliance on egocentric representations for updating, and differentiated body- and knowledge-based components of the egocentric updating process. The specificity of the body-based component was examined in Chapter 3 by having observers detect changes made to a tabletop spatial scene following a viewpoint shift resulting from their movement, scene rotation or both. The relation between the extent of observer movement and the magnitude of the experienced viewpoint shift was manipulated. Change detection performance was best when the extent of observer movement most closely matched the viewpoint shift, and declined as the match declined. Thus, body-based cues contributed specific information for updating self-to-feature relations that facilitated scene recognition. Throughout the course of the research program it has become clear that humans rely on egocentric representations to complete these tasks, and sensory and motor modalities involved in self-motion are integrated for updating spatial relations of novel environments.</p> / Doctor of Philosophy (PhD)

Systemic glucose regulation is essential for human survival as low or chronically high glucose levels can be detrimental to the health of an individual. Glucose levels are highly regulated via inter-organ communication networks that alter metabolic function to maintain euglycemia. For example, when nutrient levels are low, pancreatic α-cells secrete glucagon, which signals to the liver to promote glycogen breakdown and glucose production. In times of excess nutrient intake, pancreatic β-cells release insulin. Insulin signals to the liver to suppress hepatic glucose production, and signals to the adipose tissue and the skeletal muscle to take up excess glucose via insulin-regulated glucose transporters. Defects in this inter-organ communication network including insulin resistance can result in glucose deregulation and ultimately the onset of type-2 diabetes (T2D). To identify novel regulators of insulin-mediated glucose transport, our laboratory performed an siRNA-mediated gene-silencing screen in cultured adipocytes and measured insulin-mediated glucose transport. Gene silencing of Mitogen-activated protein kinase kinase kinase kinase 4 (Map4k4), a Sterile-20-related serine/threonine protein kinase, enhanced insulin-stimulated glucose transport, suggesting Map4k4 inhibits insulin action and glucose transport. Thus, for the first part of my thesis, I explore the role of Map4k4 in cultured adipose cells and show that Map4k4 also represses lipid synthesis independent of its effects on glucose transport. Map4k4 inhibits lipid synthesis in a Mechanistic target of rapamycin complex 1 (mTORC1)- and Sterol regulatory element-binding transcription factor 1 (Srebp-1)-dependent mechanism and not via a c-Jun NH2-terminal kinase (Jnk)-dependent mechanism. For the second part of my thesis, I explore the metabolic function of Map4k4 in vivo. Using mice with loxP sites flanking the Map4k4 allele and a ubiquitously expressed tamoxifen-activated Cre, we inducibly ablated Map4k4 expression in adult mice and found significant improvements in metabolic health indicated by improved fasting glucose and whole-body insulin action. To assess the role of Map4k4 in specific metabolic tissues responsible for systemic glucose regulation, we employed tissue-specific knockout mice to deplete Map4k4 in adipose tissue using an adiponectin-cre transgene, liver using an albumin-cre transgene, and skeletal muscle using a Myf5-cre transgene. Ablation of Map4k4 expression in adipose tissue or liver had no impact on whole body glucose homeostasis or insulin resistance. However, we surprisingly found that Map4k4 depletion in Myf5-positive tissues, which include skeletal muscles, largely recapitulates the metabolic phenotypes observed in systemic Map4k4 knockout mice, restoring obesity-induced glucose intolerance and insulin resistance. Furthermore these metabolic changes were associated with enhanced insulin signaling to Akt in the visceral adipose tissue, a tissue that is nearly devoid of Myf5-positive cells and does not display changes in Map4k4 expression. Thus, these results indicate that Map4k4 in Myf5-positive cells, most likely skeletal muscle cells, inhibits whole-body insulin action and these effects may be mediated via an indirect effect on the visceral adipose tissue. The results presented here provide evidence for Map4k4 as a potential therapeutic target for the treatment of insulin resistance and T2D.

Undersökningar visar att 34 000 människor i Sverige är hemlösa. Detta trots att kommunerna har ett lagstadgat ansvar att tillhandahålla dess innevånare stöd och hjälp. Syftet med studien var att identifiera och beskriva upplevelser av hindrande respektive underlättande faktorer vid utträde ur hemlöshet samt erfarenheter av samhälleligt stöd kopplat till detta. Narrativa intervjuer genomfördes med två personer vilka tagit sig ur långvarig hemlöshet. Resultatet, som analyserades med stämplingsteorin och exitteorin, visade att missbruk var det mest framträdande hindret tillsammans med exempelvis svaga nätverk, skam, att ej vara berättigad till försörjningsstöd samt psykiska problem. Underlättande faktorer beskrevs bland annat som; stödjande nätverk, undvikande av tidigare umgänge samt andlig upplevelse. Socialtjänstens stöd framställdes som bristfälligt och en djup frustration uttrycktes över motkraven på drogfrihet. Merparten av resultatet gick i linje med tidigare forskning, men studiens resultat påvisade även nya påverkansfaktorer såsom ”att ej vara berättigad till försörjningsstöd” samt ”andliga upplevelser”.