Thesis (M.S.)--Boston University

The dissertation aims to enhance knowledge about bereavement support-seeking among older adults with Complicated Grief (CG) and/or depression and to examine the outcomes of support received. This three-paper dissertation uses data from two studies of bereaved older adults: the Changing Lives of Older Couples (CLOC) Study and the Complicated Grief Treatment in Older Adults (CGTOA) Study. The dissertation draws upon Pescosolido and colleagues' Network Episode Model to frame the exploration of support-seeking. Paper 1 is based on qualitative interviews with eight older adults with CG who completed participation in a National Institute of Mental Health (NIMH) funded randomized clinical trial of CG treatment, the CGTOA study, and seeks to better understand the bereavement support- seeking process. Several primary themes arose, including observing that grief was causing a great deal of emotional distress and role impairment, grief not meeting their own or others' expectations of what grief "should be," influences of social relationships on support-seeking, and a lack of effectiveness of support groups and/or care from mental health professionals. Papers 2 and 3 use secondary analyses of longitudinal surveys from the CLOC Study, a representative community sample of widowed older adults. Paper 2 describes support sought for grief at 6, 18, and 48 months post-widowhood, including religious leader, support group, and family doctor support, and examines the influence of social network variables, the presence of CG and depression, and other demographic (gender, education, age, race, income, and home ownership) and clinical variables (health satisfaction, anxiety severity, attachment anxiety, attachment avoidance) on support sought. Approximately 20% of the sample sought multiple types of support concurrently. Social network, clinical and demographic variables also varied across types of support sought. For example, the presence of CG was associated with a greater likelihood of seeking support, and low instrumental support increased the odds of going to family doctors for support with grief. There were also significant associations between types of support sought. Paper 3 determined whether utilization of bereavement supports at 6 months post-loss was associated with reductions in emotional distress (grief, depression, or anxiety) at 18 months in widows with CG or depression in the CLOC sample. Using a self-help or support group reduced grief symptoms, but did not significantly alter depression or anxiety symptoms. Seeking support from a religious leader decreased depression, but not grief or anxiety. Seeking support from a family doctor did not impact anxiety, depression or grief. Discussion sections for each paper and a conclusion section for the entire dissertation summarize study findings, identify limitations, and detail implications for practice, research, and policy.

Bullying, harassment, and horizontal violence (BHHV) is commonly reported by student nurses during their clinical education. Despite decades of mention in the literature, no instrument is available to specifically measure the student nurse's experience of BHHV during clinical education. Purpose: The purpose of this dissertation is to examine the experience of BHHV in a population of student nurses matriculating during their clinical education in New York. The experience of BHHV is measured with the BEHAVE Survey, the instrument developed and tested for this purpose. Methods: This dissertation is presented in three manuscripts: (1) a comprehensive review of the literature using The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement as the methodological guide, (2) the initial psychometric testing of BEHAVE (Bulling, harassment, and HorizontAl ViolencE) for validity and reliability at a university-based school of nursing in New York, and (3) a descriptive, quantitative survey of baccalaureate nursing students at a university-based school of nursing in New York completed as a field test of the BEHAVE. Results: Despite variations in methodology, measurement, terms, definitions, and coding of behaviors and sources of BHHV, the findings of this literature review indicate that student nurses are common targets of BHHV during clinical education, regardless of demographic characteristics, disability, sexual orientation, geography location, academic institution or program type. Psychometric testing indicated: scale-level content validity index among experts 0.89, r = 0.97, a Cronbach's á 0.94, and percent agreement 93% in test-retest reliability. BEHAVE was administered to a total of 32 participants (96.7% participation rate). Approximately 72% reporting current experienced or observed BHHV with 46.8% (36/77) of incidents originated from a nurse. Conclusions: The evidence from both the literature and this field trial suggests that BHHV is a common experience among nursing students. This is significant because student nurses are vulnerable to BHHV and studies including students have been limited to date. Therefore, it behooves the research community to continue to explore the impact of BHHV on the student nurse's socialization into the professional nursing role. Further knowledge may inform targeted interventions to reduce BHHV and improve the ability of nursing students to minimize the impact of BHHV should it occur.

This dissertation presents an ethnography of equine-assisted psychotherapy (EAP) based on nine months of fieldwork at "Equine Healers," a non-profit organization in central Colorado that specialized in various therapeutic modalities associated with EAP. In bridging scholarly work around animals, a literature suffused with the notion of "companion species," as well as scholarly work around psychotherapy, and most especially the idea of "psychotherapy as conversation," the connective conflict these two interests share, and from which this dissertation emerges, is over questions of language and communication. Specifically, the overarching problem that this dissertation addresses is: what counts as talking, in the context of "the talking cure," when beings that do not share human language are necessarily implicated in human conversations. Beginning with Das' (1997) encouragement to understand "pain as the beginning of a language game," most of this dissertation will therefore be about dropping the reader into the silences between the humans and the horses, and between the words the humans use to talk about their experiences with the horses, thereby raising fundamental questions about the communicational dialectics that can transform human experiences. I argue that anthropologists must re-arrange our analytical frames around humans and animals, beginning with how we understand language, in the context of communication, to be organized. Rather than privileging subjects and objects, I suggest returning to Bateson (1972) and attempting to privilege relationships. To explore these ideas, this dissertation will attend to a particular therapeutic modality employed at Equine Healers, a set of practices called a "group sculpture." To set up and make it possible to appreciate the complexity of this modality, this dissertation will first consider framing conversations among humans and horses as rhythmically ordered interactions. To do this, I generate a model of conversation based less on grammatical rules derived from the use of words, or the possibilities offered by subject-object "thing" relationships, and instead lean on musical relationships of rhythm. Initially emerging through conversation, I then trace out rhythms carried between horses and humans by particular physical, material pieces of their world. These brushes, clickers, and bridles ultimately bridge vocal and pneumatic rhythms; and it is movement along this connection, an ebb and flow of voice and breath that, in aligning, generate opportunities for iconic relationships with one's self.

Prenatal maternal depression and anxiety are associated with poor infant health, behavioral and achievement outcomes. The impacts of prenatal maternal mental health on the development of particular brain-based neurocognitive systems in children are less clear. This dissertation examines the association between prenatal maternal depression and anxiety and infant memory and language outcomes. 179 infant mother dyads were recruited in South Dakota. Ninety infants were followed at 9- and 15-months, and 89 were followed at 15- and 21-months of age. These data were used to understand more clearly the association between prenatal maternal depression and anxiety and changes in infant memory and language over the first two years of life. Additionally, by measuring the interaction between prenatal mental health and parenting and the direct association of parenting on changes in infant memory and language, we can better understand if the pathway between prenatal maternal mental health and infant memory and language is biological, social or both. Results demonstrated no significant direct association between prenatal maternal depression and anxiety symptoms and changes in infant memory or language from 9 to 21 months. The HOME language and literacy subscale was associated with changes in memory and language from 9 to 21 months; the HOME parental warmth subscale was associated with changes in language from 9 to 21 months. These results were independent of prenatal maternal social risk. Implications for additional screening measures, interventions, and considerations for future research are discussed.

Working with HIV-positive individuals may present a particular challenge to clinicians because of the phenomenon of stigma. Researchers have proposed that HIV stigma is layered with people's prejudiced attitudes toward already-stigmatized groups (e.g., sexual orientation, gender, race and ethnicity) in which people living with HIV/AIDS may have membership. Previous research has suggested that, clinicians' attitudes and reactions toward HIV and sexual orientation may significantly impact their therapeutic impressions, yet questions remain with regard to how clients' HIV status and racial identity may operate in confluence to influence clinicians' therapeutic impressions. This question may be particularly significant with regard to mental health professionals, as research also suggests that racial/ethnic minority clients can be perceived by their clinicians as more disturbed as a result of clinicians' biased racial attitudes. In the present study, case vignettes featuring hypothetical Black or White men who are either HIV-positive or HIV-negative were presented to participants to explore the influence of a client's HIV status and race upon participants' therapeutic impressions. Results indicated that participants' expectations of therapeutic process and evaluations of the clients' symptomatology were influenced by the clients' race and HIV status. Participants expected slightly greater session depth for the Black clients than the White clients in the vignettes, and their initial impressions of symptomatology were also slightly more negative toward the White clients in the vignettes. With regard to the main effect of client HIV status, participants expected slightly greater session depth for the HIV-positive clients than the HIV-negative clients in the vignettes. However, participants expected slightly less session smoothness for the HIV-positive clients in the vignettes, and they also reported lower assessment of psychological, occupational, and social functioning toward the HIV-positive clients in the vignettes. The potential interaction of the hypothetical client's race and HIV status and its effect upon participants' clinical impressions was not found significant. Implications for research and practice are discussed.

In recent years, problem use of classified prescription drugs in the United States has become a critical public health concern garnering increased attention and resources. Although the focus has primarily been on problem use of prescription drugs with the highest abuse potential, evidence of the increasing prevalence and growing burden of problem benzodiazepine use in the United States is mounting. Most epidemiological research on problem prescription drug use, including benzodiazepines, has focused on use among individuals without a prescription. However, problem use also includes use with a prescription, but in ways, or for reasons, not recommended by a doctor. Of particular importance are individuals with a benzodiazepine prescription who experience clinically significant impairment or distress as a result of using their prescription in problematic ways. Several prescription-related risk factors could increase the risk of problem benzodiazepine use among individuals prescribed benzodiazepines. These include characteristics of the benzodiazepines prescribed (including dosage and abuse liability of the prescribed benzodiazepine), the amount of benzodiazepine prescribed over time (including medication possession ratio [i.e. whether the benzodiazepine recipient has more medication than is medically necessary] and days supply of medication) and prescription contextual variables (including whether the prescription recipient also receives other controlled substances and utilizes psychotherapeutic services). In addition, characteristics of the benzodiazepine prescription recipient (including alcohol disorders, drug disorders, anxiety disorders and mood disorders) could also predict problem benzodiazepine use. This dissertation aims to consider the independent and joint roles of these factors in the risk of problem benzodiazepine use among individuals with a prescription. To this end, the current dissertation consists of three parts: a systematic literature review and two analytic research papers investigating risk factors for the development of problem benzodiazepine use, using prospective individual-level medical and pharmacy claims information in the 2003-2004 Thompson Reuters MarketScan® Commercial Claims Databases. Modifiable variables including prescription characteristics, the amount of benzodiazepine prescribed over time and prescription contextual factors independently increased the risk of problem benzodiazepine use among individuals with a prescription. Psychiatric disorders, for which benzodiazepines are indicated (alcohol and anxiety disorders), or used off-label (drug and mood disorders), independently increased the risk of problem benzodiazepine use among individuals with a prescription. Further, psychotherapy and opioid prescriptions modified the increased risk of problem benzodiazepine use conferred by an anxiety disorder. This information can be used to develop specifically targeted prevention and treatment interventions, such as surveillance systems, to address the burden of problem benzodiazepine use in the U.S.

Eighty-five sponsors in a Veterans Administration family care program were interviewed for the purpose of ascertaining whether or not the social environment provided a viable alternative to institutional living for the chronic mentally ill. Also, the impact of various descriptive factors of the setting on the social characteristics in the home was estimated. A level of restrictiveness scale (areas in which the freedom of the residents is restricted) and a level of deviation from normative living scale (areas in which residents are excluded from family activities) were utilized to measure the social characteristics of the family care environment. A high degree of each of these factors has been linked with a custodial care type of arrangement and a low degree of these dimensions has been associated' with a rehabilitative type of dwelling. Fifteen per cent of the homes scored above 80% on the level of restrictiveness and only 5% of the residences fell into the same category on the level of deviation from normative living (maximum score 100%), indicating that only a small minority of homes could be placed in a custodial care type category in relation to each of these dimensions. Moreover, a sizeable proportion of homes, approximately 40% of the sample, scored under 50% on the level of deviation from normative living demonstrating that some opportunities are provided for residents to experience different facets of family living. The lack of association found between the level of restrictiveness and degree of deviation from normative living would seem to indicate that the pattern of care is less consistently structured than other dwellings dealing with a similar population. This inconsistency may be the result of a variety of "cross-pressures" on the sponsors related to the decentralized manner in which the program is administered. Sponsors who were previously employed in a custodial care setting scored significantly lower on the level of deviation from normative living scale than sponsors lacking such experience. Sixty-nine per cent of the "trained" sponsors as compared with 39% of the "untrained" sponsors scored below the median on the level of deviation from normative living (p < .01), indicating that the former group may be more involved in "rehabilitative" tasks than the latter group. Younger sponsors appeared to maintain more restrictive homes than older caretakers. Sixty-seven per cent of the caretakers under 40 years of age scored above the median on the level of restrictiveness whereas only 29% of caretakers over 60 years of age scored above the median on the same dimension (p < .12), indicating that there may be more restrictions in homes managed by younger sponsors than in those managed by older ones. Comments obtained from the sponsors seem to suggest that the motivation of the individual for participating in the family care program may play an important role in shaping the structure of the setting. Such individuals as the older person who joins the program for companionship and the former employee of a custodial care facility who desires to take on a broader, more active role with psychiatric patients, may tend to establish settings consistent with these needs. What is noteworthy is the lack of relationship between size of the home and the social dimensions in the environment. This negative finding brings into question a modification in family care programs which has been considered by some or already implemented by others, namely, limiting the number of ex-patients in a home. Based upon the findings different hypotheses were formulated to be tested in future research.

An increasing number of clients are seeking admission to state mental hospitals to satisfy non-psychiatric needs. The study describes this phenomenon, its possible causes and its consequences. The study draws profiles of these clients' characteristics, problems, needs, and level of functioning. Clients' expectations from the state hospital and differences between them and the hospital inpatient population are explored. The study was conducted on a time sample of 100 clients who sought admission to a New York State psychiatric center. The client sample were found not in need of inpatient treatment and were referred to an emergency housing program. Data were gathered through structured and unstructured questionnaires, interviews with clients, staff, center officials, and the center's statistical and patients' records. Chi-Square Test and Spearman Correlation were used to test relationships between variables. Study data indicated that: (1) The majority of clients were young, white, single, males, unemployed, educated below high school level, and were living with a relative or a friend at the time they appeared for admission. (2) Client's self assessment and staff assessment of clients' needs suggested that housing and financial aid were significant to more clients than psychiatric treatment. (3) Client's self assessment and staff assessments of individual client's level of functioning indicated that the majority of clients were able and willing to live independently in community settings. (4) The majority of clients sought admission to the psychiatric center expecting help with housing, financial and emotional problems in that order. (5) Client sample and patients admitted to the center during the same period did not differ significantly with regard to age, sex, race, religion and marital status. The two populations differed in admission status, educational level, employment status, and sources of referral to the Center. The study recommended a clear boundary distinction of psychiatric and non-psychiatric services and that psychiatric admission be based on psychiatric rather than social factors. The study also recommended several policy and planning options in dealing with the problem. A major option was the initiation of local personal social service centers to service clients with non-psychiatric problems.

Introdução: O atual modelo de saúde mental infantojuvenil tem como um dos seus pilares a transformação da postura dos profissionais da área. Espera-se que eles se coloquem de corpo inteiro e se impliquem subjetivamente no trabalho. Esses profissionais têm papel fundamental nas direções tomadas ao longo dos anos, contudo são historicamente desvalorizados e pouco estudados. Objetivo: Descrever e analisar a subjetividade, as experiências de formação e a trajetória de vida de trabalhadores de Centros de Atenção Psicossocial Infantojuvenis (CAPSi) e suas relações com o processo de inserção e prática nesse campo. Método: Foi realizado um questionário com perguntas semi abertas e entrevistas narrativas com 8 trabalhadores de diferentes categorias profissionais lotados em 2 CAPSis do Município de São Paulo, um deles gerenciado diretamente pela Prefeitura e outro por Organização Social de Saúde (OSS). Para análise das entrevistas narrativas foi utilizada a proposta de Shutze. O Referencial Teórico foi construído a partir de diferentes autores que dialogam entre si, dentre eles Dejours e Schwartz. Resultados: Constaram-se importantes diferenças entre os trabalhadores do CAPSi gerenciado por OSS e pela Prefeitura no que se refere ao perfil profissional, às motivações para o trabalho, ao tipo de formação que buscam e aos sentidos atribuídos ao trabalho. No entanto, todos os trabalhadores revelam características comuns: impacto recíproco que a vida pessoal e o trabalho na saúde mental exercem entre si; passagem prévia por hospital, escola ou consultório, de forma que essas instituições marcam sua atuação profissional; carência de capacitação oferecida pelos serviços e grande distância entre as necessidades reais do serviço e os treinamentos oferecidos. Conclusão: A tendência atual do mundo do trabalho caminha em sentido oposto às propostas da Reforma Psiquiátrica, fazendo com que os profissionais mais antigos encontrem dificuldades e os mais jovens se afastem dos pressupostos da Reforma Psiquiátrica. Junto a isso, a complexidade das propostas de tratamento nos CAPSis e a falta de espaços de discussão e potencialização do trabalho, que deviam ser oferecidos pelas instituições, faz com que ambos os grupos de profissionais sintam-se perdidos e sozinhos. A formação transcende o espaço técnico no qual ela se delimita inicialmente e se espraia para diversos setores da vida do indivíduo / Introduction: The current model of child and adolescents Mental Health Care are in transformation concerning the professionals approach. It is expected that they get deeply involved in a subjective way in their work. These professionals are very important in the directions taken in that field over the years, however, they are historically unevaluated and understudied. Objective: Describe and analyze subjectivity, as well as training experiences and life trajectories of employees of Psychosocial Care Centers for Children and Adolescents (CAPSi) and their relation to the process of professional insertion and practice in this field. Method: A semi-structured questionnaire and narratives interviews were conducted with 8 workers from 2 CAPSi from São Paulo City, Brazil; one managed directly by the City and one managed by Social Health Organizations- OSS. The narratives interviews have been subjected to Shutze analysis techniques. The Theoretical Framework was built from different authors who interact with each other, including Dejours and Schwartz. Results: It was found important differences between work team from CAPSi managed by the OSS and CAPSi managed directly by the City concerning professional profile, motivations for work, type of training searched and meanings attributed to work. However, all employees reveal common features: reciprocal impact that personal life and work in mental health influences on each other; previous works in hospitals, schools and office, so these institutions marked their professional performance; lack of training services and large distance between the real needs of the service and the training offered. Conclusion: It was found that the current trend in the field goes in opposite direction to the proposals of the Psychiatric Reform, causing the older professionals do not fit in and younger professional deviate from the Psychiatric Reform proposed. Along with this, the complexity of treatment proposed in CAPSi and lack of opportunities for discussion and empowerment work team of labor, which should be offered by institutions, makes both groups of professionals feel lost and alone. The technical training transcends space in which it delimits initially and spreads to various sectors of the life of the individual