As many as one in five adolescents in the United States has been diagnosed with an Axis-I psychiatric disorder. Adolescents with Axis-I psychiatric disorders face significant short- and long-term consequences if they do not obtain mental health treatment. There remains a significant gap in the literature when it comes to understanding adolescent perspectives on mental health care. Research to date has focused on child and adult populations with little focus on the unique issues that are likely to impact adolescent mental health treatment. The theoretical underpinnings for understanding adolescent mental health treatment are explored in relation to adolescent psychological development, the working alliance, the Theory of Planned Behavior/Theory of Reasoned Action and the Health Belief Model. This dissertation aimed to clinically characterize adolescents seeking mental health treatment and explore their perceptions of being referred to and attending mental health treatment. This mixed methods study explores adolescent perspectives of mental health treatment and examines the relationship between psychosocial functioning, treatment utilization and symptom abatement. The study sample consists of adolescents who were referred to mental health treatment by a school based referral program: the Student Assistance Program (SAP). Twenty-eight adolescents participated in the baseline interview and twenty-five participated in the follow-up interview. The quantitative data analysis indicated that there was a significant difference in the symptomatology between participants who obtained treatment and those who did not at the baseline time point. There were no main effects for time, and the time x treatment interaction only approached significance for one measure- the Columbia Impairment Scale. In the qualitative interviews, adolescents identified a number of themes that related to their referral and treatment experience. These themes highlight the importance of adolescent development, the working alliance and certain theoretical underpinnings for understanding adolescent actions and perceptions of mental health treatment. Study findings suggest social work professionals can bring clarity to the referral process. Training specifically focused on meeting the unique needs of adolescents in the referral and treatment process will enhance social workers abilities to improve service delivery. Future directions for research include the creation of an adolescent-specific treatment engagement interview.

Mental health courts (MHC) are treatment oriented court diversion programs that seek to redirect individuals with severe mental illnesses (SMI), such as those with schizophrenia, bipolar disorder, and major depression, who have committed a crime, into court mandated treatment programs instead of the criminal justice system. It is believed that individuals with SMI commit and re-commit offenses as a result of their illness and if directed to the appropriate treatments, would be less likely to offend. Currently, there are over 150 MHCs nationally operating in at least 35 states, yet a gap remains in the scientific literature concerning their ability to reduce recidivism and clinical outcomes. To determine their effectiveness in reducing recidivism and improving clinical outcomes, the first meta-analytic study of these courts was conducted. A systematic search of the literature through May 2008, as well as an e-mail survey, generated 23 studies representing 129 outcomes with over 11,000 MHC participants. Aggregate effects for recidivism revealed a mean effect size of -0.52. MHCs had a small to medium positive effect of 0.28 on a participants quality of life. Among quasi-experimental studies, there was a small effect size of - 0.14 for clinical outcomes indicating a positive improvement. Based on this analysis, MHCs are effective interventions for reducing recidivism and improving clinical and quality of life outcomes.

Research suggests that the concurrent use of alcohol and medications can lead to a number of health problems. This is of importance for older adults, who take more medication than any other age group. Despite older adults increased risk of alcohol-medication interaction there has been limited research focused on the patterns and correlates of simultaneous alcohol and medication use in older adults. The purpose of this study was to examine the prevalence and patterns of concurrent use among community-dwelling older adults by gender, race and age. The impact of group membership on health status was also examined. Data from the Cardiovascular Health Study (CHS), a population-based longitudinal study of older adults, were analyzed for this study. The CHS cohort consists of 5,888 individuals ages 65 and older. Participants completed a series of face-to-face and telephone interviews along with clinical examinations. This analysis utilizes CHS data from waves 1 through 6. Univariate analyses were conducted at baseline to determine the prevalence rates and correlates of concomitant use among older adults. Group-based logit modeling was used to chart longitudinal patterns of use over the course of the study. Finally, multinomial logistic regression analyses were employed to assess the relationship between various patterns of concurrent use and health outcomes. Results demonstrated that concurrent use is fairly common among community-dwelling older adults. Men, Whites, younger individuals and problem drinkers were significantly more likely to concurrently use than women, African Americans, older respondents and low to moderate alcohol users. Furthermore, group-based logic analysis revealed four distinct patterns of concurrent use: a no to low use group, a decreasing use group, an increasing use group, and a high use group. Males and Whites had the highest probability of being in the high use group. Group membership was found to be related to physical and mental health. Furthermore, concurrent use was found to increase the risk of mortality among study participants. These findings indicate a significant need for social work and health care professionals to educate older adults about the dangers of concurrent alcohol-medication use. Additionally, it appears that there is a need for health campaigns that focus on the promotion of safer use of alcohol and medications by older adults.

Alzheimers Disease (AD) and other dementias are one of the most critical public health problems in elderly populations. Whereas the financial, emotional and physical costs of the disease for the caregiver are enormous, support for the caregiver becomes more and more important. One aspect of caregiver support, however, religious coping and well-being in caregivers of AD has been relatively unexplored. Using baseline data from the Resources for Enhancing Alzheimers Caregiver Health (REACH) II study, this study examined the relationship between religious coping, burden, depression and race among 211 African-American, 220 White and 211 Hispanic caregivers. Structural Equation Modeling was used to test our path model and Multi-sample SEM was used for a test of moderating effect of race. Caregiver burden mediated the effect of religious coping on depression with higher religious coping resulting in lowering caregiver burden and thereby reducing depression. The only path that was not predicted and had to be added to the model was between religious attendance and depression. While the overall MSEM test was not significant, separate analyses showed some variations in relationships among groups. The religious coping mediation model was better supported by African Americans than Hispanic and White caregivers. The findings suggest that religiosity plays an important role in decreasing caregiver burden and thereby decreasing depression. The findings also suggest that it may be culturally sensitive and appropriate to encourage African American caregivers to utilize religious coping resources. Greater understanding of religious coping and its role in the caregiving process helps researchers discover better ways to assist racially diverse caregivers in dealing with burdens of AD caregiving.

The older adult population continues to grow in numbers and in diversity. In preparing for this increasingly larger and more diverse older adult population, it is important to understand what their long-term care needs, wants and expectation are. This research focuses on immigrant elder women and their long-term care plans. This is a descriptive study which utilized qualitative and quantitative research methods by interviewing 13 immigrant elder women. They were recruited primarily through the International Womens Club in Monroeville, Pennsylvania. This research has four major findings regarding immigrant elder womens long-term care plans. These immigrant elder women plan to remain living in the United States instead of returning to their county of nativity during older adulthood. These immigrant elder women plan to remain living in their own home for as long as possible, financially and medically. Immigrant elders do not wish to be dependent on their families to meet their long-term care needs. When the time arises that they may need paid care, these immigrant elder women are more concerned with having competent caregivers than with cultural issues. These findings parallel trends regarding long-term care plans and concerns of the general older adult population. This may be due to a combination of factors, such as: country of nativity, socio-economic status, availability of children as social supports, a multicultural identity, and level of acculturation and cultural allegiance. Recent policy developments support increasing home and community based long-term care services. These changes in policies and programs should continue to be expanded to better meet the needs current and future older adults, including immigrant elder women.

This study aims to longitudinally examine relationship patterns among attitude, criminal associates, and recidivism among Black (n = 109) and White men (n = 107) released from Allegheny County Jail in Pittsburgh, Pennsylvania. Attitude and criminal associates belong to the big four risk factors for recidivism (Andrews & Bonta, 1998). Review of studies reveals that different dimensions of attitude predict different measures of recidivism in different offender populations. This study examines two new attitudinal dimensions autosuggestion and attitude toward community-based services (CBS attitude in the following). Autosuggestion measures the reported likelihood of ex-inmates future offending. CBS attitude is a meaningful measure among jail populations given short jail stays and the critical role played by community-based services in jail ex-inmates reintegration. The original path model with three-wave data was split into four hypotheses because of inadequate bivariate correlations among focal variables. Longitudinal relationships between attitude and recidivism, and criminal associates and recidivism, and longitudinal reciprocal relationships between attitude and criminal associates were investigated. Each hypothesis was tested in the entire sample (with interactions) and in each subgroup by race, age, and offense type. Findings indicated that criminal associates predicted recidivism and attitude, but attitude failed to predict recidivism and associates with an exception that CBS attitude predicted recidivism in some groups. This latter finding illuminates the importance of the community-based services and CBS attitudes. Autosuggestion interacted with age and CBS attitude with race in predicting recidivism. Results suggest that very likely response of autosuggestion may contain two different meanings criminal intention and acknowledgement of vulnerability, possibly leading to two different recidivism results. Improvement of the two attitude measurements is suggested necessary considering the double meaning contained in autosuggestion and cultural competency of CBS attitude measure. In addition, attitude was shown to change over time, and attitude change may make a better predictor for recidivism and criminal associates than attitude measured at a time. The original path model may be tested with attitude change as a predictor. Factors for attitude change, possibly including criminal associates, should also be investigated. Other points of discussion, and significance and limitations of the study are discussed.

When social workers empathically engage with their clients traumatic recollections, they sometimes experience strong emotional reactions, such as grief or rage. These reactions may reflect secondary traumatic stress, i.e. negative emotional reactions resulting from knowledge of traumatizing events experienced by others. Many clinical social workers in New York City who provided counseling, debriefing and support to 9/11/01 witnesses, survivors, victims family members, and rescue workers were at risk for developing secondary traumatic stress, with such risk elevated by their personal experiences of stress during and following the terrorist attacks. This study explored predictive factors of secondary traumatic stress for social workers assisting 9/11/01 clients, including extent of exposure to traumatized clients, and protective factors that were tested as direct and interactive (buffering) influences. These effects were tested controlling for demographic factors (age, marital status, income, hours per week in the field, and years in the field). Data, in which Doctoral and MSW level members of the Manhattan Chapter of the NASW (N=1257) were surveyed, were drawn from the Post 9/11/01 Quality of Professional Practice Survey (Tosone & Moore, 2007), yielding a 38% return rate (N=481). The primary independent variable, exposure to trauma in practice was measured by a block of three indicators: being 9/11/01 mental health provider/total work hours of exposure to 9/11/01 related events, percent of time working with traumatized clients generally, and number of different types of trauma client worked with. Hierarchical multiple regressions of secondary traumatic stress symptoms included a block of controls, the exposure block, and additional protective variables (receiving supervision, peer support, family and friend support, disaster training before and after 9/11/01) examined separately for their direct and interactive effects with exposure. The results indicated that social workers level of exposure to traumatized clients significantly increased secondary traumatic stress. Also, peer support marginally buffered the negative consequences of trauma exposure. Further, older and more experienced social workers had somewhat lower levels of secondary traumatic stress, at least in part because they had less exposure to traumatized clients; older and more experienced workers may have been more negatively impacted by exposure to traumatized clients. The results have implications for all direct providers who may experience secondary traumatic stress symptoms: administrators and practitioners in social agencies, clinics, and hospitals; the findings also apply to students in schools of social work who need to learn how to effective treat traumatized clients.

The Department of Health and Human Services report, Healthy People 2010 (HP2010), recommends elimination of healthcare disparities for reasons such as sexual orientation, gender, racial or ethnic background, education level, income, disability status, and geographic location. The 2000 Federal Census revealed that same-sex couples live in 99.3 percent of all counties in the United States. Sexual minorities, throughout their lifetime, access our healthcare system and interact with healthcare professionals. Lesbians and gay men experience substantial disparities in health outcomes. Lesbian and gay human rights issues are intricately linked to social, cultural, and political issues in society. HP2010 notes that health professionals attitudes about sexual orientation may contribute to existing healthcare disparities. Access to unbiased healthcare could be a factor in these disparities, yet little is known about the attitudes of healthcare trainees, who will eventually provide the care for sexual minorities and others. This study explores attitudes towards lesbians and gay men and support for lesbian and gay human rights among first year health care students in the Master of Social Work, School of Medicine, Master of Nursing programs, and School of Dental Medicine at the University of Pittsburgh. This study examines four predictors of attitudes, including academic preparation, personal experiences, political orientation, and frequency of spiritual practice. Social work students scored higher than other healthcare students in academic preparation, personal experience with non-heterosexual orientation, support for lesbian and gay human rights, and diversity training. First year medical and social work students had more positive attitudes than nursing and dental students toward lesbians and gay men. Simultaneous multiple regression analysis revealed political identification, personal experience, and frequent spiritual practices were the strongest predictor variables of personal attitudes toward lesbians and gay men and support for lesbian and gay human rights. When the academic preparation scale score was replaced in the regression analysis with the sexual orientation academic preparation item from that scale, it was a significant predictor of personal attitudes toward lesbians and gay men and support for lesbian and gay human rights.

Serious and persistent mental illnesses (SPMI) are the most costly diagnoses in the United States (Insel, 2003). There are significant financial costs associated with these psychiatric disabilities, including the costs associated with treatment and loss of wages, as well as significant social costs, including lack of social support, poverty, and inadequate available treatment services. Case managers are the mental health staff members who spend the greatest amount of time in direct contact with people with SPMI in the community. There are widespread problems in the case management workforce. Case managers have inadequate education, work experience, and on-the-job training for the amount of responsibilities that are required in their jobs. It is a career that offers limited opportunities for advancement, low salaries, and low retention. In Allegheny county, a major mental health system reform was implemented called SPA (Single Point of Accountability). One of its goals was the implementation of a Case Management Mentor Program, which was designed to provide consistent training for behavioral health case managers, develop a career ladder in case management, and help new case managers learn their jobs. This dissertation was a mixed methods study using semi-structured interviews, focus groups, and survey data to understand the barriers and facilitators to implementation of the program from the perspectives of the case managers and how the type of mentoring they received contributed to the mentee job satisfaction. The study sample consisted of 18 mentors who participated in the Service Coordination Mentor Certificate Course and 30 mentees that were trained in their new jobs at their respective agencies. Overall, mentoring was associated with higher job satisfaction. Support from a mentor during crisis situations was most significantly associated with job satisfaction. All of the participants reported that mentoring is needed and beneficial in case management. Over the course of implementation, most mentees consistently participated in a variety of mentoring activities with their mentors and overall, reported that these were very helpful. The activity that that participants reported to be most helpful, but occurred the least frequently, was the mentor having the opportunity to observe the mentee in the field.

Thousands of children throughout the United States are currently awaiting placement with adoptive families. The literature indicates that gay- and lesbian-headed households can well meet the needs of these children. Research suggests that sexual prejudice, religious fundamentalism and attitudes about gay and lesbian adoption may influence practice decisions regarding placement. This dissertation study examined the influences of religious fundamentalism, sexual prejudice, contact with sexually diverse individuals, and attitudes towards gay men and lesbians as adoptive parents on intent to place children in need with gay and lesbian couples. A random sample of National Association of Social Workers (NASW) members was surveyed; 1000 surveys were distributed and 303 usable surveys were returned. Religious fundamentalism was measured using the Revised Religious Fundamentalism Scale (Altemeyer & Huntsberger, 2004), sexual prejudice was measured using the Attitudes toward Gay Men and Lesbians (Herek, 1994) and attitudes towards gay and lesbians as adoptive parents was measured using Attitudes toward Gay Men and Lesbians as Adoptive Parents scale (Ryan, 2000). To assess willingness to use gay or lesbian couples as adoptive parents, respondents were asked to rank first and second choices on ten scenarios; two scenarios reflected easy to place children and eight hard to place children. A sizable minority of respondents failed to respond to the scenarios. Those opting out tended to score lower on religious fundamentalism, sexual prejudice, and held more positive attitudes towards gay and lesbian adoption. Further, some respondents never included gay or lesbian couples; these respondents tended to score higher on religious fundamentalism, sexual prejudice, and negative attitudes to gays and lesbian couples as adoptive parents than those choosing at least one gay/lesbian response. Religious fundamentalism predicted sexual prejudice, which predicted negative attitudes towards gays and lesbians as adoptive parents. Religious fundamentalism also directly influenced attitudes towards gay and lesbians as adoptive parents. In addition, personal contact with sexually diverse individuals partially influenced sexual prejudice. Overall, the results indicate that some professionals are inappropriately influenced by their personal values.