Promoting Healing and Restoring Trust: Policy Recommendations for Improving Behavioral Health Care for American Indian/Alaska Native Adolescents

American Indian/Alaska Native youth represent the strength and continued survival of many Nations and Tribes. However, they currently experience numerous health disparities and challenges, including the highest rate of suicide among 15–24 year-olds in the United States. Our comprehensive review of the literature on the mental health of AI/AN youth highlighted seven focal causes of behavioral health disparities: (1) high levels of violence and trauma exposure and traumatic loss, (2) past and current oppression, racism, and discrimination, (3) underfunded systems of care, (4) disregard for effective indigenous practices in service provision, policy, and funding, (5) overreliance on evidence-based practices, (6) lack of cultural competence among systems of care and providers, and (7) barriers to care. Seven policy recommendations that recognize the importance of moving beyond exclusive reliance on western models of care and that seek to foster transformation of individuals, families, communities, behavioral health service systems of care, and social structures are presented, supported, and discussed.     

Health services and health care economics: the health psychology marketplace.

In an effort toward cost containment, the health care system in the United States has undergone radical changes in the last decade. These changes have influenced the delivery of clinical health psychology services. This article reviews several economic and marketing factors salient to the clinical health psychology marketplace. For example, these economic changes have placed greater emphasis on the need for cost-effectiveness and accountability in the health psychology field. Implications for education and training, collaboration with other health care specialties, new practice initiatives, and public relations are reviewed. Future challenges and opportunities for clinical health psychology are discussed.     

The mental health care revolution. Will psychology survive?

Managed mental health care, which encompasses a wide variety of approaches, is a response to precipitous increases in health care expenditures, particularly as they relate to mental health care. The shift from what seemed certain to become a national health insurance program only 15 years ago to the profit-driven corporate health care industry of today is truly revolutionary. These profound changes are beginning to have a major impact on the independent practices of psychologists. In this article, psychologist practitioners are exhorted to recognize this new development in the marketplace. Data are cited that show the rapid shift from free choice care to various forms of managed care, and practitioners are urged to participate in shaping the changes that are now in process in order to develop a humane and effective system of mental health care.     

Extending the influence of positive psychology interventions into health care settings: Lessons from self-efficacy and forgiveness

The goal of this article is to explore strategies to extend the influence of positive psychology interventions into environments where strength-promotion is not generally embraced. Particularly, we are interested in examining the potential benefits and barriers to extending positive psychology interventions into health care settings (really illness-treatment settings), such as hospitals, community mental health centers, and disorder-focused psychotherapy practices where psychologists increasingly work. Patients primarily come to these settings to reduce suffering rather than to develop strengths. We argue that positive psychology interventions and concepts may become more valued within such contexts if they can be shown to be cost-effective in improving important health care targets. By examining positive psychology-based interventions that have already become relatively mainstream within health care (e.g., self-efficacy-based interventions), we identify strategies for making promising but less-influential positive psychology interventions (e.g., forgiveness training) more valued in today's health care marketplace. Through these examples, we suggest that extending the influence of positive psychology into health care settings is desirable, but will involve several conceptual, evidentiary, and educational or marketing challenges.     

Intervening in the Lives of Youth with Complex Behavioral Health Challenges and Their Families: The Role of the Wraparound Process

Wraparound is an individualized, team-based service planning and care coordination process intended to improve outcomes for youth with complex behavioral health challenges and their families. In recent years, several factors have led wraparound to become an increasingly visible component of service systems for youth, including its alignment with the youth and family movements, clear role within the systems of care and public health frameworks, and expansion of the research base. In this paper, we provide a review of the place of the wraparound process in behavioral health, including a discussion of the opportunities it presents to the field, needs for further development and research, and recommendations for federal actions that have the potential to improve the model’s positive contribution to child and family well-being.     

Clinician Perspectives of Diagnosis and Perceived Client Change in “Real World” Psychotherapy for Youth Emotional and Behavioral Disorders

We investigated the extent to which clinician-assigned diagnoses of emotional and behavioral disorders and clinicians’ perceptions of client change are consistent with structured measures of youth clinical functioning and parent/family characteristics within the context of usual care or “real world” psychotherapy. A total of 54 therapists from two publicly-funded youth outpatient mental health clinics and 128 youths and parents from the therapists’ combined caseloads were included in the study. Clinician-assigned diagnosis and youth and family demographics were collected at the initial visit, clinician-reported perceived client change was collected at 6-month follow-up, and structured measures of youth clinical functioning and parent/family characteristics were collected at both time points. Results indicate some overlap between clinician-assigned diagnosis, clinician-reported perceived client change, and structured measures of youth clinical functioning and parent/family characteristics after controlling for demographic factors. Results are discussed in terms of implications for the implementation of evidence-based practices in real world community settings.     

Urban youth disruptive behavioral difficulties: exploring association with parenting and gender

The current study will examine behavioral difficulties among a sample of African American urban youth who were exposed to violence. Possible gender differences in disruptive behavioral difficulties, as well as possible associations between parental practices, family relationships, and youth disruptive behavioral difficulties are examined. A secondary data analysis from baseline data for 125 African American urban mothers and their children collected as part of a large-scale, urban, family-based, HIV prevention research study was analyzed. Findings reveal that externalizing behavioral problems in youth are associated with exposure to violence. Girls displayed significantly higher levels of externalizing behavioral difficulties than boys. Mothers' parenting practices and family relationships were associated with youths' externalizing behavior problems. Implications for interventions to reduce youths' exposure to violence and to develop gender sensitive interventions for youth and supportive interventions for their parents are discussed.     

Development of a Brief Group CBT Intervention to Reduce COVID-19 Related Distress Among School-Age Youth

School-aged youth have been significantly impacted by the COVID-19 pandemic. The effects of the pandemic will likely have long-standing effects on the well-being of youth, and access to mental health care is even more critical during this time. For the past 5 years, TRAILS (Transforming Research into Action to Improve the Lives of Students) has been working throughout the state to increase utilization of evidence-based mental health practices among K-12 school mental health professionals (SMHPs). By leveraging SMHPs who are widely accessible to students, TRAILS seeks to improve youth access to effective mental health care and reduce current mental health inequities. In March 2020, TRAILS responded to the COVID-19 pandemic by developing a group manual designed to be delivered virtually by SMHPs to help students develop effective coping skills to mitigate the impact of COVID-19. TRAILS focuses on promoting use of CBT and mindfulness, as these skills are ideally suited for school-based delivery, and thus the new manual, Coping with COVID-19 (CC-19), was grounded in these modalities. This article will describe the design, development, and deployment of the CC-19 program to address the mental health needs of students in the context of the pandemic. Early acceptability and penetration data will also be discussed.     

Medical Ethics Research Between Theory and Practice

The main object of criticism of present-day medical ethics is the standard view of the relationship between theory and practice. Medical ethics is more than the application of moral theories and principles, and health care is more than the domain of application of moral theories. Moral theories and principles are necessarily abstract, and therefore fail to take account of the sometimes idiosyncratic reality of clinical work and the actual experiences of practitioners. Suggestions to remedy the illnesses of contemporary medical ethics focus on re-establishing the connection between the internal and external morality of medicine. This article discusses the question how to develop a theoretical perspective on medical ethical issues that connects philosophical reflection with the everyday realities of medical practice. Four steps in a comprehensive approach of medical ethics research are distinguished: (1) examine health care contexts in order to obtain a better understanding of the internal morality of these practices; this requires empirical research; (2) analyze and interpret the external morality governing health care practices; sociological study of prevalent values, norms, and attitudes concerning medical-ethical issues is required; (3) creation of new theoretical perspectives on health care practices; Jensen's theory of healthcare practices will be useful here; (4) develop a new conception of bioethics that illuminates and clarifies the complex interaction between the internal and external morality of health care practices. Hermeneutical ethics can be helpful for integrating the experiences disclosed in the empirical ethical studies, as well as utilizing the insights gained from describing the value-contexts of health care practices. For a critical and normative perspective, hermeneutical ethics has to examine and explain the moral experiences uncovered, in order to understand what they tell us.     

Justice and the market for health insurance

After reviewing some of the insurance-related obstacles to access to health care, some ethical criteria for evaluating proposals aimed at reforming the health insurance marketplace to achieve universal access are developed. The additional reforms needed to eliminate many of the deficiencies in the current health insurance marketplace are discussed. It is suggested that without such substantial reforms some of the other goals such as expanded consumer choice and overall societal health care cost savings may not be effectively promoted.     

Physician-Assisted Suicide in the United States: The Underlying Factors in Technology,Health Care and Palliative Medicine – Part One

In an age of rapid advances inlife-prolonging treatment, patients and caregivers areincreasingly facing tensions in making end-of-lifedecisions. An examination of the history of healthcare in the United States reveals technological,economic, and medical factors that have contributed tothe problems of terminal care and consequently to themovement of assisted suicide. The movement has itsroots in at least two fundamental perceptions andexpectations. In the age of technological medicineenergized by the profit motive, dying comes at a highprice in suffering and in personal economic loss. Thefailure to provide affordable resources for terminalcare is the result of the marketplace in health care. The medical profession has been painfully slow inresponding to the challenges of terminal care, mainlybecause of the pressures of the marketplace and lackof adequate training. This has occurred at a time ofrapid advances in life-sustaining treatment and ofexpanding public awareness of personal rights underthe law. Overly aggressive treatment in the finalstages of terminal illness has enhanced anxieties overa painfully prolonged and expensive dying. Thesefactors have promoted the movement to assistedsuicide. In the U.S. debate of the issues, ethiciststend to argue abstractly without examiningadequately the context of terminal care that is thehealth care system. It is a system in dire need of areform that will remove it from the marketplace.     

Care Like Kin: Community Based Youth Serving Organizations and the Social Reproduction of Disconnected Youth in Rural America

Increasing economic insecurity faced by older youth in rural America presents a crisis of social reproduction for disconnected youth in these areas. Increasingly community based youth serving organizations (CBYSOs) are recognizing and responding to the social reproduction needs of this particularly vulnerable youth population. Such responses are often hidden from funders, government agencies, and community residents. Yet these institutions play an important substitution function for disconnected youth and provide critical social support and social leverage for this population. Based on case studies of three CBYSOs in the San Joaquin Valley of California, this article explores how and why CBYSOs play a substitution function for disconnected youth in rural communities. It is the argument of this article that the social reproduction work of CBYSOs is undertaken with a ethic of care that may have the capacity to transform the political, social, and economic contexts that face this marginalized youth population.     

Supporting the Need for an Integrated System of Care for Youth with Co-occurring Traumatic Stress and Substance Abuse Problems

Adolescents are at high risk for violence exposure and initiation of drug use. Co-occurring substance use and trauma exposure are associated with increased risk of mental health disorders, school underachievement, and involvement with multiple systems of care. Coordination and integration of systems of care are of utmost importance for these vulnerable youth. This study delineates the negative sequelae and increased service utilization patterns of adolescents with a history of trauma, substance abuse, and co-occurring trauma and substance abuse to support the need for integrated mental health and substance abuse services for youth. Data from two national sources, the National Child Traumatic Stress Network and Center for Substance Abuse Treatment demonstrate the increased clinical severity (measured by reports of emotional and behavioral problems), dysfunction, and service utilization patterns for youth with co-occurring trauma exposure and substance abuse. We conclude with recommendations for an integrated system of care that includes trauma-informed mental health treatment and substance abuse services aimed at reducing the morbidity and relapse probability of this high-risk group.     

System-Level Change in Cultural and Linguistic Competence (CLC): How Changes in CLC are Related to Service Experience Outcomes in Systems of Care

As US demographic trends shift toward more diversity, it becomes increasingly necessary to address differential needs of diverse groups of youth in mental health service systems. Cultural and linguistic competence (CLC) is essential to providing the most appropriate mental health services to youth and their families. The successful implementation of CLC often begins at the system level. Though various factors may affect change and system-level factors set the tone for broad acceptance of CLC within systems, there is limited empirical evidence linking culturally competent practices to outcomes. The purpose of the present study was to examine system-level CLC changes over time within systems of care and their associations with service experiences among youth and their families. Participants were 4,512 youth and their families enrolled in the national evaluation of the Children’s Mental Health Initiative (CMHI). Results suggest that implementation of CLC at the system level improves over time in funded systems of care. Further, variation exists in specific system-level components of CLC. In addition, the changes in CLC at the system level are related to family/caregiver participation in treatment. Implications for supporting positive changes in CLC among systems of care communities, and specific strategies for community psychologists, are discussed.     

Mixed-Design Training Outcomes for Fellows Serving At-Risk Youth Within Integrated Care Settings

We used an exploratory mixed-methods design with single-case comparative analysis and analysis of covariance to evaluate the potential effectiveness of an interprofessional clinical training in a mental health counseling program. Initial findings indicate those engaging in specialized learning experiences that attended to critical aspects of youth behavioral health care experienced benefits with regard to their professional development, interprofessional socialization and valuing, and counseling self-efficacy. Implications for the usefulness of trainings focused on interprofessional experiences are framed in relation to professional trends concerning integrated health care.     

Mental Health Diagnostic Considerations in Racial/Ethnic Minority Youth

Misdiagnoses of racial/ethnic minority youth’s mental health problems can potentially contribute to inappropriate mental health care. Therefore, we conducted a systematic review that focuses on current theory and empirical research in an attempt to answer the following two questions: (1) What evidence exists that supports or contradicts the idea that racial/ethnic minority youth’s mental health problems are misdiagnosed? (2) What are the sources of misdiagnoses? Articles were reviewed from 1967 to 2014 using PsychINFO, PubMed, and GoogleScholar. Search terms included “race”, “ethnicity”, “minority”, “culture”, “children”, “youth”, “adolescents”, “mental health”, “psychopathology”, “diagnosis”, “misdiagnosis”, “miscategorization”, “underdiagnosis”, and “overdiagnosis”. Seventy-two articles and book chapters met criteria and were included in this review. Overall, evidence was found that supports the possibility of misdiagnosis of ethnic minority youth’s emotional and behavioral problems. However, the evidence is limited such that it cannot be determined whether racial/ethnic differences are due to differences in psychopathology, mental health biases, and/or inaccurate diagnoses. Cultural and contextual factors that may influence misdiagnosis as well as recommendations for research and practice are discussed.     

An Exploration of the Relationship Between Spirituality,Religion and Mental Health Among Youth Who Identify as LGBT+: A Systematic Literature Review

There is a growing interest in addressing spirituality in health care with evidence emerging that personal spiritual and religious practices, and support of these, can influence mental health in a positive way. However, there can be distinct challenges to spiritual expression and mental health issues for youth who identify as LGBT+. The goal of this paper was to undertake a systematic review of the available evidence to investigate the relationship between mental health, spirituality and religion as experienced by LGBT+ youth. A comprehensive literature search was conducted using medical and psychological databases that focused on spirituality, mental health and LGBT+ youth. The search yielded a total of ten articles published in English between May 2008 and June 2018. The key findings highlighted issues around discriminatory attitudes, shame related to disclosure, spirituality as a supportive resource, internalised conflict and external factors around sexual orientation concerns. The psychological, social and health implications are presented and discussed.