Consumer Operated Service Providers (COSPs) are programs that are directed and administratively controlled by mental health consumers for their peers. As such, many mental health consumers have been placed in the position of serving on a COSP and often with unclear descriptions and no training. As a result, there is often a disconnect between the will of the board and the vision of the executive director, leading to tension and the possibility of failed mission. Using servant leadership as the guide, the goal of this case study was to explore the experiences of executive directors who operate Consumer Operated Service Providers (COSPs) in Texas that specialize in mental health recovery support services to better understand how they work with mental health consumers serving as their governing board members. Data were collected through semi-structured interviews with 7 executive directors of COSPs in Texas. Interview data were inductively coded, then subjected to a thematic analysis procedure. Findings revealed that the concept of servant leadership is commonly used to empower board members and create healthy working relationships between boards and executive directors, particularly around the area of motivating board members to engage with the organization. It was also revealed that the existence of COSPs, in conjunction with traditional governing boards, provides a good balance and perspective relative to strategic planning activities and fundraising. Positive social change implications include recommendations to executives of COSPs to more adequately mobilize and train consumer board members in order to achieve organizational goals that often include consumer focused care and treatment for a wide range of mental health issues.

Active duty personnel as well as combat veterans of the United States often engage in military operations during their service that require deployments to participate in missions, which may lead to extended periods away from home. When active duty men and women are appointed to combat zones, they may return with psychological burdens such as post traumatic stress disorder, which can complicate their reintegration into civilian life. This study explored the experiences of combat veterans who faced challenges when returning home from a war zone, along with the experiences of their family members. The study involved 26 combat veterans, spouses, significant others, and parents. In data analysis, semistructured interview responses were given concerning personal experiences. The interviews produced a vast amount of information with manual notes. Participants discussed treatment, interventions, and strategies for family reintegration. Many of the veteran participants shared that family members did the 'best they could' to help them reintegrate. The themes received for the study were family reintegration, command strategies and intervention, community services, and mental health services. The study showed how combat veterans and family members can successfully complete family reintegration with social support as well as support from mental health professionals. In association with social change, psychologists, psychiatrists, mental health practioners, and licensed professional counselors may benefit from the findings of this study. Professionals involved with mental health treatments and assessments would learn how to connect with combat veterans and family members. This study supports the recommendation that combat veterans and family members receive services from mental health professionals.

Depression is a prominent issue in the African American community. However, there are significant gaps in the literature on the delivery and outcomes of culturally relevant mental health psychotherapy to African Americans. Cultural variables, such as worldview, have been noted to impact an individual's overall psychosocial functioning and have significant implications for mental health service delivery. The purpose of this study was to use archival data to analyze the impact of African-centered therapeutic services on depressive symptoms and on Africentric worldview among African Americans. Archival data on 38 African American adults, recorded from 2012-2015, were obtained from a community mental health agency in the Midwest. Each of the adults received therapy via an African-centered treatment modality. The study was grounded in the cognitive theory of depression and optimal theory. The dependent treatment outcome variables were (a) depressive symptomology, as measured with the depression subscale of the Symptom Checklist-90-Revised and (b) Africentric worldview as measured by the Belief Systems Analysis Scale. The dependent variables were measured twice: once in the beginning and once at the end of a year's treatment. A dependent, paired t tests indicated a significant reduction in depressive symptoms but no significant increase in adherence to Africentric worldview. This study has implications for positive social change by: providing increased insight on the need for culturally relevant services to African Americans, which can subsequently lead to culturally relevant social change in the delivery of mental health services to diverse populations.

Patients presenting to the emergency department (ED) often suffer from more than physical ailments when seeking care and treatment. Some of these patients have emotional ailments and suicidal ideation when they come to the local ED. The lack of recognition of at-risk patients by health care providers can lead to poor patient outcomes and death. The focus of this project was to understand which valid and reliable suicide assessment tools described in the literature were considered the best evidence-based instruments to identify ED patients who were at risk for suicide. Peplau's theory of interpersonal relations guided this project. A systematic review of the literature was conducted to assess tools that were used for the identification of at-risk patients. Analysis of the included literature was conducted using Melnyk's levels of evidence and a preferred reporting items for systematic reviews and meta-analyses tool to catalog the articles retrieved. Ten articles were included in the study. Final analysis of the articles identified the need for 100% of patients to be assessed for suicide risk upon arrival at the ED. The instrument identified to meet the need for the local organization was the Columbia-Suicide Severity Rating Screening tool. The findings of this project might promote social change by providing insights into best practice assessment tools to support improved assessment of suicide risk for ED patients.

This non-experimental, quantitative study explored the effects of the Buddhist-derived practices of mindfulness and loving-kindness meditations on the wellness of lesbian, gay, and bisexual (LGB) people. LGB people are at higher risk of mental illness and increased social isolation due to minority stress; Buddhist-derived mindfulness practices mediate these effects in other groups. Lazarus and Folkman's transactional model of stress and coping was the theoretical model explaining how positive cognitive appraisal induced by meditation can mediate effects of stress. This study examined whether mental health scores on the Emotional Symptoms Checklist (ESC), social attitudes measured on the Unjust World Views Scale, and self-perception measured by the Remoralization Scale improved individually and collectively after LGB participants engaged in 1 of 3 meditation conditions: mindfulness practice, loving-kindness practice, or a relaxation control group. ANOVA analyses revealed no significant improvements in participants' scores on the 3 measures as a result of either one of the meditation conditions or the control group. An unexpected finding emerged between participants who reported a history of depression and those who did not; ESC scores among those with depression significantly improved after the meditation or relaxation interlude regardless of group assignment, possibly due to disruption of ruminative thought processes. Future studies could build upon this study by training participants to meditate using more interactive means than online videos used here. The mental health needs of LGB people remain urgent, and further explorations of promising techniques such as mindfulness are the foundation of future social change.

African Americans have a higher proclivity to depression than other ethnic groups in the United States and also have a greater propensity to avoid seeking professional mental health treatment. The available research has shown that racial and cultural barriers such as perceived discrimination and self-concealment are the primary factors that negatively affect African Americans' attitudes toward mental health itself and mental health treatment. Perceived discrimination and self-concealment may also negatively affect whether African Americans seek help for depression and from whom, but further investigation was needed. The quantitative survey study provided answers to which factors influence whether and where African Americans seek help for major depression. A total of 147 participants were recruited through word of mouth, local churches, community organizations, and virtual venues such as electronic mail and social media. Multivariate analysis of variance revealed the mean scores of African Americans' use of natural supports and their use of outpatient treatment (dependent variables) were not equal across all levels of their self-concealment, perceived discrimination, and depressive symptoms (independent variables). Multivariate analysis of covariance revealed that the mean scores remained the same when controlling for gender, income, education, and relationship status (covariates). The results suggest that the latter factors influence African Americans' decisions on where to seek help for depression regardless of their gender and socioeconomic status. Increasing the propensity of African Americans to seek professional help for depression should improve the mental health of the population as a whole and reduce the incidents of serious mental illness of those who are treated.

The prescription rate of antipsychotics in patients with dementia varies between 20% and 50% for the common and troubling neuropsychiatric symptoms experienced by patients with dementia. The use of these antipsychotic medications has been linked with increased risk of morbidity and mortality due to associated Parkinsonism, over sedation, gait disturbances, cognitive decline, and cardiovascular adverse events. The purpose of this project was to assess whether development of an evidence-based clinical practice guideline (CPG) for a long-term care facility would increase awareness about issues that govern the safe use of antipsychotic medications. The conceptual framework for the project was Watson's model of caring. The Fineout-Overholt tool was used to rank and score information retrieved following an extensive literature review. An expert panel made up of 2 medical doctors and 4 nurse practitioners had 100% agreement that objectives were clear; content was relevant and easy to understand; the CPG was well-organized and easy to follow; and knowledge learned would be used in practice. From 66.6% to 83.3% agreed that the CGP led to an improved understanding of dementia, neuropsychiatric symptoms, medication adverse events, and nonpharmacologic interventions. The expert panel agreed to launch the CPG upon implementation of an educational program for frontline nursing staff and a behavioral log to track occurrence and frequency of behaviors and the use of nonpharmacologic interventions and their effectiveness in managing behaviors. Safe implementation of this CPG might be adapted to other long-term facilities to optimize dementia care, which would bring about a positive social change.

In the United States, over three million adults, age 50 and older, reported a diagnosis of serious mental illness (SMI) in the past year. Most of them live in community-settings and are less likely than younger adults to utilize mental health treatment. Lack of and insufficient treatment for SMI places them at increased risk of morbidity, earlier mortality, cognitive decline, and diminished quality of life. The current study aimed to: (1) examine the factors that influence Black and White older adults, who live with SMI, to seek and engage in outpatient mental health treatment; (2) identify the perspectives of Black and White older adults, who live with SMI, on the issues of accessibility, affordability, appropriateness, and availability of outpatient mental health services; and (3) determine whether the perspectives of Blacks and Whites are different on the issues of accessibility, affordability, appropriateness, and availability of outpatient mental health services. I developed a qualitative, interview-based study using the health belief model (HBM) as the theoretical framework. Individual semi-structured interviews were conducted with 19 participants, between the ages of 50-70 years (mean age 58.9), who had a clinical diagnosis of bipolar disorder, schizoaffective disorder, and schizophrenia. The interviews were audiotaped, transcribed verbatim, coded and analyzed using thematic analysis. Data themes related to factors that influenced outpatient mental health treatment and services were identified and organized based on the six HBM constructs. Perceived barriers to mental health treatment engagement included lack of knowledge about available treatment and services in the community, poor mental health literacy, and stigma. Improved sense of well-being and increased socialization were perceived benefits of mental health treatment engagement. Risk of homelessness emerged from the data as the main influence for Black and White older adults, who live with SMI, to seek and engage in outpatient mental health treatment. For all participants, access to and availability of mental health services were not current issues. All except one participant had some type of medical coverage for their treatment and most of them felt that their current treatment was appropriate. There were no differences between Black and White older adults on the issues of accessibility, affordability, appropriateness, and availability of outpatient mental health services. In addition, Black participants did not feel a need for mental health services to be specifically tailored to Black older adults, and instead indicated they saw no differences in Blacks and Whites related to mental health services. These findings are contrary to existing research and may be indicative of the gravity of mental illness-related stigma, compared to racial stigma. Better promotion of available mental health services in the community, mental health outreach, and community education about mental illness may be helpful for earlier identification of symptoms related to mental illness, earlier treatment and intervention, stigma reduction, and improved health and quality of life for community-residing older adults who live with SMI.

Adults with mental illnesses are at an increased risk to be diagnosed with one or more comorbid physical illnesses compared to the general population. Much of the disparities faced by adults with serious mental illnesses (SMI) can be attributed to medication side effects, increased risk for metabolic diseases, inability to communicate about severity and monitor physical health symptoms, poor health behaviors, high rates of smoking, and poor quality health care. The rate of physical illnesses for adults with mental illnesses are even higher among those who have been involved with the criminal justice system. In order to understand the relationship between physical and mental illnesses, longitudinal study designs are needed. Longitudinal studies can provide greater understanding of the temporal relationship of physical and mental illnesses. Despite the benefits of longitudinal studies, there also are challenges, including missing data. The first manuscript of this dissertation explores the physical and mental health status of adults with mental illnesses. Secondary data were used from three different studies: a sample of adults with SMI enrolled in a mental health court jail diversion program (n=91); a sample of Medicaid enrollees with SMI in Florida (n=688) who were part of a larger Substance Abuse and Mental Health Services Administration (SAMHSA) study; and a sample of inpatient and outpatient adults with SMI from five different study sites (n=969). The samples were combined into two data sets, consisting of the jail diversion sample and the SAMHSA sample, and the jail diversion sample and the 5-site sample. Participants in these samples answered questions on the Short-Form Health Survey (SF-12), recent arrests, drug and alcohol use, socio-demographic information, and mental illness symptom severity (measured only in the criminal justice and 5-site samples). Overall, the mental and physical health status scores were significantly lower for all of the participants compared to the general population mean scores. The participants reporting a recent arrest had a higher physical health score compared to those who did not have a recent arrest, and in the jail diversion and 5-site sample, had a lower mental health status score than those without a recent arrest. After taking age, drug and alcohol use, and psychiatric symptom severity into account, arrest was no longer associated with the physical health status score in either of the data sets. In the jail diversion and 5-site data set, arrest was still significantly associated with mental health status score after controlling for age, drug and alcohol use, and psychiatric symptom severity. The second manuscript of this dissertation explores the analysis of missing data in a longitudinal study to determine the missing data mechanisms and missing data patterns, and subsequently, how to prepare the data for analysis by using multiple imputation or maximum likelihood estimation. Secondary data were drawn from the same jail diversion sample as in the first manuscript. Data were collected at baseline, three months, six months, and nine months. Only participants with the potential to have data collected at these time points were included (n=50). Analysis revealed missing data due to missing item-level information, missing participant data at one time point but complete data at a subsequent time point, and missing participant data for those who dropped out of the study completely. The missing data mechanism for the missing item-level data were missing completely at random, whereas the participant-level missing data were missing at random. Multiple imputation was used for the item-level data and for the participant-level missing data. Maximum likelihood estimation was also used for the participant-level missing data and compared to the multiple imputation results. Findings suggest that multiple imputation produced more accurate parameter estimates, possibly due to the small sample size. The findings from this study indicate that more research needs to be done to fully understand the physical illnesses experienced by adults with mental illnesses who are involved with the criminal justice system. Understanding mental and physical illness comorbidity is important in public health as it dictates appropriate treatments and training for behavioral health practitioners and staff. In addition, missing data in longitudinal studies cannot be ignored, as it can bias the results, and appropriate techniques for exploring the missing data must be used. When missing data is ignored in analyses, the subsequent results can be incorrect and unable to detect treatment effects, thereby preventing effective programs from receiving necessary funding. In addition, ignoring missing data can impact funding for behavioral health services by underestimating the prevalence and severity of mental illnesses. Future research should focus on exploring how mental and physical health are related in adults with a recent arrest compared to the general population, and ways to integrate services to address both mental and physical health.

End of life (EOL) caregiving can be a daunting and challenging endeavor as caregivers adjust to the ever-changing care demands associated with dying. Increased personal care, assisting with symptom and medication management, and attending to the emotional and spiritual needs of the dying person require caregivers to learn new tasks and to assume new roles such as social worker, nurse, and chaplain. As families continue to play an essential role in meeting the health care needs of their dying loved ones, it is imperative for social workers to understand the complexities of the end of life caregiving experience in order to better serve this population. One way to better understand this experience is by examining it within the context of the stress process model of caregiving. This model provides a comprehensive way to examine the relationship among multiple risk and protective factors within the "caregiver-in-environment" context. Using a secondary dataset, the best fit predictive model of caregiver depression included a mix of sociodemographic characteristics, primary objective and subjective stressors, and mediating variables. Two protective factors, social support and the fulfillment of spiritual needs lessened the effects of caregiver depression among the most vulnerable caregivers. Findings from this study help to bridge the gap between theory and social work practice. The stress process model of caregiving is a well-tested theoretical model, which can be utilized to guide social workers in developing comprehensive assessment measures and interventions that target specific aspects and sources of stress within the EOL caregiving experience.