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Smoking remains the single most preventable cause of death worldwide and primary cause of several types of cancer, cardiovascular disease, and respiratory illness (USDHHS, 2014). Although the prevalence of smoking among the general population continues to decline, the prevalence of smoking among the veteran population remains high. In addition, the prevalence of smoking among veterans with substance and alcohol use disorders is 2 to 3 times higher than in the general population. Over the years, the VA has implemented empirically-based treatments for smoking cessation to address the cigarette smoking epidemic. These services, however, are greatly underutilized. Motivational interviewing (MI) has traditionally been used to treat alcohol dependence; however, its efficacy for smoking cessation has been mixed. There is some evidence, however, suggesting that MI could be used to motivate smokers to seek treatment. The purpose of this study was to use a brief MI intervention to motivate veteran smokers undergoing treatment for substance use to seek smoking cessation services at the VA. We recruited 60 veterans undergoing substance and alcohol use treatment at the Substance Use Disorders/Intensive Outpatient Program (SUDs/IOP) at the James A. Haley VA. Participants were randomized to one of two groups: MI vs. active control. We hypothesized that veterans in the MI condition would be more likely to seek services for smoking cessation compared to those in the control condition. Our findings supported our hypothesis: 40% of participants in the MI condition sought treatment to quit smoking after the intervention compared to 23% of participants in the control condition (p = .03, controlling for baseline differences in cessation motivation). In addition, we found that the MI intervention was most beneficial for individuals with lower baseline motivation to quit smoking. Although we did not find significant mediators of the effect of the intervention on our primary outcome, this study showed that a brief MI intervention can promote seeking of smoking cessation resources.

Individuals who sell drugs are often mandated by legal forces to substance abuse treatment because of their criminal offenses and the belief they may have a drug problem. Previous researchers have noted this population may be disruptive in the treatment process, but it has not been explored in depth. The purpose of this phenomenological study was to learn the lived experiences of counselors who work with individuals who report a primary problem of selling drugs, not substance abuse, who are mandated to a substance abuse treatment program. Thirteen semi structured interviews were conducted with counselors who have worked with individuals who sell drugs that were mandated to participate in a correctional-based therapeutic community substance abuse treatment program. Interviews were transcribed and analyzed with the assistance of NVivo for meaning and themes. Data were examined through the theoretical lens of the social learning theory (SLT). The results of the study indicated counselors were prepared for their jobs through education and training to have longevity in working in a correctional environment and provided treatment services. The counselors found that individuals who sell drugs had a history substance use, which the individuals minimized. During treatment, counselors sought to challenge individuals who sell drugs to think and explore the effects of their behaviors. Counselors found individuals who sell drugs were able to engage in treatment to avoid negative consequences. The results of this research can encourage positive social change by initiating a discussion about assessments prior to drug treatment, characteristics of drug treatment program participants, and counselor training to improve quality of drug treatment services provided.

This thesis is an exploration of professional behaviour in health care settings, using a Model of Treatment Engagement that is developed as a tool for ethics critique. The Model is tested and refined using data on: a psychiatric ???treatment??? carried out on over 1,127 occasions in a 15 - 40 bed non-acute hospital during the period 1961-1979; the problematic withdrawal of all life-support from a 37 year old man who had suffered acute brain trauma some five days previously, in a tertiary hospital in March 2000; and a clinical experiment recently proposed for the emergency setting and intended to encompass five hospitals and the NSW Ambulance Service. In each case, the Model proves useful in identifying the shift from the treatment paradigm and the ethical imperative of ensuring the patient (or his/her agent) appreciates the difference between what is proposed and what would normally be done. It reveals how doctors who dealt with the patient but did not decide on treatment contributed to ethically troublesome practice. It clarifies how having multiple doctor players in the treatment situation gave rise to the need to suppress dissenting views. Doctors who were close enough to the action to comprehend its nature, by not dissenting, reinforced the problematic choice for the actor and validated it in the eyes of observers. The lack of dissent at the level of doctors working under supervision, appeared to be a function of institutional arrangements. At the consultant level, there was evidence of pressure to concur from other consultants and indirect evidence of a fear of ostracism. The public responses in the two modern cases point to there being a strong idea in Sydney???s medical community that dissent should not be publicly displayed once a decision on how to treat has been made. I conclude there are two steps to reviewing ethically problematic treatment situations. The first consists of identifying the shift from the treatment paradigm. The second consists of establishing why the problematic choice is translated into action. The Treatment Engagement Model is put forward as a useful tool for both these analyses.

This randomized-controlled pilot study explored the impact of a pretreatment, telephone engagement intervention on adolescents’ (ages 13-19) initial mental health service attendance (i.e., the first 3 counseling sessions) and four secondary outcome variables (i.e., autonomous/ controlled treatment motivation, self-efficacy, and working alliance). Twenty-seven adolescents received the engagement intervention and completed assessments and 24 adolescents completed assessments only. Both groups completed follow-up assessments 6 weeks after study enrollment. Associations between the outcome variables and initial treatment attendance were explored. The extent to which demographic variables (i.e., age, gender, race, immigration status, and residence in low income neighbourhoods), psychological distress, and self-reported barriers (i.e., mismatched treatment expectations and external demands) were associated with treatment attendance was also explored. The primary findings from this pilot study indicated that adolescents who received the engagement intervention had greater initial treatment attendance (M=2.11, SD=1.01) than the assessment only group (M=1.54, SD=1.22), but the difference only approached significance. Moreover, no significant between-group differences in the secondary outcome variables were found. Paired samples t-tests were used to examine changes in autonomous/controlled treatment motivation and self-efficacy within groups between baseline and follow-up. The results of the paired samples t-tests indicated that that the experimental and control groups both demonstrated a significant decrease in controlled motivation at follow-up. In addition, the control group demonstrated a significant decrease in autonomous treatment motivation at follow-up. Post hoc analyses, using correlation and linear regression analyses, explored the associations between initial attendance and the secondary outcome variables, psychological distress, self-reported barriers, and demographic variables. A negative association between age, self-reported barriers and initial attendance was found. A positive association was found between working alliance and initial attendance. While the majority of adolescents who participated in this research lived in low income neighbourhoods and nearly half were second generation immigrants, these demographic variables were not associated with initial treatment attendance. Although the engagement intervention had a medium effect on initial treatment attendance, this difference was not statistically significant. Future research with a larger sample size and longer follow-up is needed to determine the effectiveness of the engagement intervention.

This randomized-controlled pilot study explored the impact of a pretreatment, telephone engagement intervention on adolescents’ (ages 13-19) initial mental health service attendance (i.e., the first 3 counseling sessions) and four secondary outcome variables (i.e., autonomous/ controlled treatment motivation, self-efficacy, and working alliance). Twenty-seven adolescents received the engagement intervention and completed assessments and 24 adolescents completed assessments only. Both groups completed follow-up assessments 6 weeks after study enrollment. Associations between the outcome variables and initial treatment attendance were explored. The extent to which demographic variables (i.e., age, gender, race, immigration status, and residence in low income neighbourhoods), psychological distress, and self-reported barriers (i.e., mismatched treatment expectations and external demands) were associated with treatment attendance was also explored. The primary findings from this pilot study indicated that adolescents who received the engagement intervention had greater initial treatment attendance (M=2.11, SD=1.01) than the assessment only group (M=1.54, SD=1.22), but the difference only approached significance. Moreover, no significant between-group differences in the secondary outcome variables were found. Paired samples t-tests were used to examine changes in autonomous/controlled treatment motivation and self-efficacy within groups between baseline and follow-up. The results of the paired samples t-tests indicated that that the experimental and control groups both demonstrated a significant decrease in controlled motivation at follow-up. In addition, the control group demonstrated a significant decrease in autonomous treatment motivation at follow-up. Post hoc analyses, using correlation and linear regression analyses, explored the associations between initial attendance and the secondary outcome variables, psychological distress, self-reported barriers, and demographic variables. A negative association between age, self-reported barriers and initial attendance was found. A positive association was found between working alliance and initial attendance. While the majority of adolescents who participated in this research lived in low income neighbourhoods and nearly half were second generation immigrants, these demographic variables were not associated with initial treatment attendance. Although the engagement intervention had a medium effect on initial treatment attendance, this difference was not statistically significant. Future research with a larger sample size and longer follow-up is needed to determine the effectiveness of the engagement intervention.

This thesis is an exploration of professional behaviour in health care settings, using a Model of Treatment Engagement that is developed as a tool for ethics critique. The Model is tested and refined using data on: a psychiatric ???treatment??? carried out on over 1,127 occasions in a 15 - 40 bed non-acute hospital during the period 1961-1979; the problematic withdrawal of all life-support from a 37 year old man who had suffered acute brain trauma some five days previously, in a tertiary hospital in March 2000; and a clinical experiment recently proposed for the emergency setting and intended to encompass five hospitals and the NSW Ambulance Service. In each case, the Model proves useful in identifying the shift from the treatment paradigm and the ethical imperative of ensuring the patient (or his/her agent) appreciates the difference between what is proposed and what would normally be done. It reveals how doctors who dealt with the patient but did not decide on treatment contributed to ethically troublesome practice. It clarifies how having multiple doctor players in the treatment situation gave rise to the need to suppress dissenting views. Doctors who were close enough to the action to comprehend its nature, by not dissenting, reinforced the problematic choice for the actor and validated it in the eyes of observers. The lack of dissent at the level of doctors working under supervision, appeared to be a function of institutional arrangements. At the consultant level, there was evidence of pressure to concur from other consultants and indirect evidence of a fear of ostracism. The public responses in the two modern cases point to there being a strong idea in Sydney???s medical community that dissent should not be publicly displayed once a decision on how to treat has been made. I conclude there are two steps to reviewing ethically problematic treatment situations. The first consists of identifying the shift from the treatment paradigm. The second consists of establishing why the problematic choice is translated into action. The Treatment Engagement Model is put forward as a useful tool for both these analyses.

Background: Treatment providers have applied contingency management (CM) treatment, an intervention that often rewards individuals for drug abstinence (i.e., ABS CM), to treatment engagement as well. However, we know little about the magnitude of treatment effects when providers target attendance behaviors (i.e., ATT CM). Methods: This study conducted a systematic search to identify studies that included ATT CM, either in isolation or in combination with ABS CM. The study used meta-analysis to estimate the effect size of ATT CM and ABS CM + ATT CM on treatment attendance and drug abstinence. We identified a total of 10 studies including 12 CM treatments (6 ATT CM and 6 ABS CM + ATT CM) with 1841 participants. Results: Results indicated a moderate effect (d = 0.47, 95% confidence interval (CI) [0.25, 0.69]) of ATT CM on attendance relative to non–reward active comparison conditions. Frequency of rewards was significantly associated with larger effect sizes. Results also indicated a small effect (d = 0.22, 95% CI [0.12, 0.33]) of ATT CM on abstinence outcomes relative to nonreward comparisons, p < 0.001. The study found no significant differences in attendance or abstinence between ATT CM and ABS CM + ATT CM (p's > 0.05). Conclusion: Overall, the results supported ATT CM for increasing treatment engagement, with smaller effects on abstinence. Effects on abstinence were smaller than those observed in prior meta-analyses focused on ABS CM. No significant differences existed in attendance or abstinence outcomes between ATT CM and ABS + ATT CM. However, future studies are needed to experimentally compare ABS CM + ATT CM to ABS CM, and ATT CM to determine additive effects. Clinics implementing CM should consider the differential effects between ATT CM and ABS CM when selecting target behavior(s).

Migration is on the rise as Haitians seek economic and educational opportunities for their progeny in the U.S. Though migration to a new country often introduces a new set of immigration and acculturation-related stressors that can lead to mental health problems, Haitians remain underrepresented in clinical mental health settings. Previous studies with ethnic minority populations have enumerated several barriers to seeking mental health services. However, research on barriers to help-seeking is sorely lacking for specific migrant groups, including Haitians. Thus, this study examined barriers to seeking help for mental health problems among Haitians. Participants were recruited using purposive and snowball sampling methods. Specifically, recruitment flyers were used to recruit participants meeting specific inclusion criteria, and these participants identified other participants who qualified for this study. Data were collected via four focus groups from 26 Haitian adults, ranging from 18 to 52 years old. A semi-structured focus group protocol developed from research literature was used to conduct these focus groups. Qualitative data analysis was used to organize focus group data into themes. Three major themes emerged: (a) beliefs related to seeking mental health services, (b) cultural values and help-seeking, and (c) education and awareness of services and help-seeking. More specifically, participants noted that Haitian’s beliefs (e.g., religious/spiritual beliefs and beliefs about therapy, therapists, social consequences, and trustworthiness of institutions), cultural values (e.g., minimization of mental health problems, accepting problems as part of life), and education and awareness of mental health and mental health services contribute to Haitians’ likelihood to seek services. In addition, participants noted that these factors likely vary for first and second generation Haitian Americans, which further influences likelihood to seek services. These results suggest that both Haitians (first and second generation) and mental health professionals must take an active role to address barriers to help-seeking related to Haitians’ beliefs, cultural values, and education and awareness of mental health services, and subsequently, enhance treatment engagement.

No description available.