Psychotherapist perceptions of engagement-building behaviours with youth clients across developmental levels.

Building a positive therapeutic relationship is a challenging, yet critical, first step in conducting youth psychotherapy. A number of studies in the youth treatment literature have indicated that a positive therapeutic alliance is related to increased treatment attendance, participation, and outcome. Some research has examined therapist behaviours for engaging therapy clients; however, developmental differences in alliance formation have had limited exploration. The current study surveyed clinicians about their use of specific engagement strategies and the developmental stage of their youth clients. It was hypothesised that participants would differentially rate the importance of different aspects of therapeutic engagement based upon a youth client's developmental stage and that these would correspond with differences in specific engagement strategies. A total of 64 clinicians with experience treating youth completed the study. The participants completed a questionnaire administered online that asked them to rate the importance of developmental differences to forming a therapeutic relationship and provide example client behaviours from their clinical experience for each developmental stage. Results showed clinicians felt the relative importance of collaboration, advocacy, and trustworthiness increased with age. These differences were also evidenced in the specific strategies clinicians endorsed in relation to each engagement factor across developmental stages. This program of research will eventually aid in the development of new guidelines for engaging clients in youth psychotherapy. In addition, the results may be used to enhance psychotherapy training for those working with children and adolescents.

Examining Individual and Service Delivery Context Variables and Their Association with the Effectiveness of QPR Suicide Prevention Gatekeeper Training.

Suicide prevention training programs have spread rapidly within child and public-serving organizations, due to the alarming increase in youth suicide rates. Yet, within these organizations, roles and responsibilities can shape attitudes and intentions related to suicide prevention, thereby influencing the uptake of prevention efforts. As such, various organizational and individual factors can predict uptake, adoption, and maintenance of prevention efforts (Fixsen et al., 2005). To date, few studies have examined the service delivery context in understanding training effectiveness, especially as it relates to QPR (Question Persuade and Refer), one of the most widely disseminated suicide prevention gatekeeper programs. The purpose of this longitudinal study was to evaluate whether individual and organizational characteristics influenced the effectiveness and sustainability of training outcomes, and whether such differences existed among diverse child and public-serving delivery sectors. Several training outcomes that align with the Theory of Planned Behavior (Ajzen, 1991) were examined, including confidence, attitudes, social norms, and suicide prevention behaviors. Measures were assessed prior to and 90 days after the QPR program among a sample of 858 professionals. Community support personnel uniquely showed improvements on social norms while juvenile justice and child welfare workers engaged in more suicide prevention behaviors post training. While trainees across sectors had improved suicide prevention attitudes, law enforcement personnel were the exception. Organizational climate predicted change in suicide prevention attitudes, confidence, and social norms. Trainees who were older, Latinx, and Black had the most improvement on several training outcome variables, but these findings also varied within service sectors.

A systematic review and meta-analysis of clinician behaviors and characteristics related to alliance building with youth clients.

The literature on developing alliance with youth clients has severely lagged behind that of adults. To date, there has been no meta-analytic review and limited qualitative synthesis of clinician variables which may contribute to the alliance with youth clients. Systematic literature search found a total of 49 relevant citations. Of the identified articles, 13 (27.08%) reported quantitative methods. Results of the qualitative review suggested that the majority of this research has focused on developing an emotional bond and a sense of collaboration. Meta-analysis found significant relations between alliance building and reducing variables and alliance (ralliance building = 0.17; ralliance reducing = -0.24). This analysis revealed specific behaviors particularly facilitative to youth alliance development, including collaborating with the client, finding common ground, exploring subjective experiences, orienting to treatment, providing praise, and enhancing facilitative conditions. In contrast, clinician lapse and pushing the client to talk were most predictive of a worse alliance. These results indicate certain behaviors which may be particularly important for clinicians to facilitate and not impair youth alliance formation. There is a need for greater youth alliance formation research to better determine how alliance formation may differ across stages of development and treatment modalities.

Evaluating Dialectical Behavior Therapy Training With Mental Health Clinicians.

A substantial body of research supports dialectical behavior therapy (DBT) as an evidence-based treatment for those with borderline personality disorder (BPD); however, there remains a lack of mental health clinicians trained in this modality, resulting in limited clinician competencies and skills. Furthermore, the effectiveness of DBT trainings with mental health clinicians remains understudied. The present study evaluated a comprehensive 5-day DBT-Linehan Board of Certification training program. Informed by the Theory of Planned Behavior, this study assessed changes in clinician knowledge, attitudes, perceived behavioral control (PBC), intentions, and behaviors relevant to DBT at baseline, posttraining, and 6-month follow-up. Results showed large, significant pre-to-post training improvements in clinicians' knowledge, attitudes, PBC, and intentions related to DBT implementation. Large improvements in knowledge, attitudes, and PBC were sustained at follow-up. A significant improvement in actual behaviors was also found at follow-up. Implications of the present study and directions for future research are discussed.

Caring Transitions - A Care Coordination Intervention to Reduce Suicide Risk Among Youth Discharged From Inpatient Psychiatric Hospitalization.

Background: Suicide risk following youth psychiatric hospitalization is of significant concern. This study evaluated Linking Individuals Needing Care (LINC), a theory-driven, comprehensive care coordination approach for youth discharged from crisis services. Aims: To pilot LINC's potential effectiveness in increasing service utilization and decreasing suicide risk. Method: Participants were 460 youth patients who received LINC for approximately 90 days following discharge from crisis services. Service utilization, depressive symptoms, and suicide-related variables were measured at baseline and 30, 60, and 90 days after baseline. Results: Patients significantly increased the use of various beneficial, least restrictive services (individual therapy, medication management, and non-mental health supports) over the 90-day intervention. Significant decreases were observed in depressive symptoms, suicide ideation, and engagement in suicide-related behaviors. Limitations: Absence of a comparison group and nonparticipating families limit causal conclusions and generalizability. Conclusions: LINC may be a promising new approach following inpatient hospitalization that can engage and retain youth in services, likely resulting in improved treatment outcomes. This approach was designed emphasizing patient engagement, suicide risk assessment and management, safety planning, community networking, referral/linkage monitoring, coping and motivational strategies, and linguistic/culturally responsive practices to meet service and support needs of high-risk suicidal youth.

Exploring Service Use Disparities among Suicidal Black Youth in a Suicide Prevention Care Coordination Intervention.

OBJECTIVE: The aim of this study is to examine service utilization disparities among Black youth participating in Linking Individuals Needing Care (LINC), a 90-day research-informed suicide care coordination intervention. METHODS: An open trial pilot was conducted to examine the effectiveness of LINC in increasing access to and engagement in mental health and non-mental health services among suicidal youth (N = 587). Other variables of interest included service use facilitators and service use barriers. Generalized linear mixed models with binomial distribution and logit link were performed to ascertain if service use facilitators and barriers were associated with service utilization and if disparities in service use and engagement existed between Black and White suicidal youth through a comparative analysis. RESULTS: Service utilization differences were found between Black and White youth. While Black and White youth were both likely to engage in individual therapy (OR = 1.398, p < .001) and non-mental health services (OR = 1.289, p < .001), utilization rates for mental health and medication management services were lower for Black (55.1% to 60.6%) youth compared to White (66.0% to 71.0%) youth. Specifically, Black youth were significantly less likely than Whites to receive medication management (OR = .466, p = .002). Systemic barriers such long waitlists for care (OR = 1.860, p = .039) and poor relationship with providers (OR = 7.680, p = .028) increased odds of engagement in non-mental health services. Clinical disorders and engagement in suicide-related behaviors increased the likelihood of obtaining care from both medication management and non-mental health services. CONCLUSION: Care coordination services for suicidal youth can increase access and engagement in mental health and non-mental health services. Culturally adapted models attending to cultural and social assets of Black families are needed to reduce disparities and suicide risk among Black youth.

Under the Surface: The Role of Covert Cues in Peer Suicide Risk Referrals.

Suicidal thoughts and behaviors are highly prevalent among adolescents, and peers are often the first, and sometimes only, people to know about youth suicidality. Since many adolescents do not directly disclose suicidal thoughts, school-based suicide prevention programs aim to train youth to recognize warning signs of suicide in their peers that serve as "cues" to refer at-risk peers to an appropriate adult. However, peer-presented cues vary widely in presentation, and adolescents are more likely to recognize overt (i.e., obvious or explicit) as opposed to covert (i.e., hidden or implied) cues. The type of cue exhibited may, in turn, affect whether adolescents make a referral to an adult. The current study examined whether training suicide prevention influences referral intentions for overt and covert suicide cues. Participants included 244 high school students (54% female; M age = 16.21) in the Southeastern United States who received suicide prevention training (SOS; Signs of Suicide) as part of their health curriculum. Prior to training, students endorsed higher referral intentions for peers exhibiting overt compared to covert cues. Training was associated with increased intentions to refer peers across cue type, but referral intentions for covert cues improved significantly from pre to post-training while those for overt cues remained high and stable. Findings suggest that suicide prevention training might differentially improve students' ability to detect and respond appropriately to less obvious indicators of suicide risk. These findings may inform the adaptation and development of future, more nuanced school-based suicide prevention programming.

LINC to Life: Evaluation of a Safety Planning Training Program with Clinicians and Mental Health Staff.

Suicide rates continue to rise, and clinicians and mental health staff play a critical role in keeping suicidal clients safe. Safety planning, including means safety, may help to decrease suicide risk. Unfortunately, availability and evaluation of safety planning training for these providers are scarce. The goal of the present study was to evaluate a safety planning training, LINC to LIFE Safety Planning (L2L SP). L2L SP is a 150-minute, face-to-face training program that teaches providers to engage clients in collaborative safety planning and means safety efforts, facilitate diverse client coping strategies, problem-solve, and involve close others, among other skills. These objectives are achieved through interactive content delivery, role-play, and corrective feedback. L2L SP was administered to 95 participants. Key determinants of behavioral change (e.g., knowledge, attitudes, perceived behavioral control [PBC]) were measured at pre, post, and six-month follow-up. Additionally, participants' behaviors and emotions in working with suicidal clients were measured at pretest and six-month follow-up. Paired sample t-tests, repeated measures MANOVA, and univariate ANOVAs with post-hoc testing using Bonferroni correction were conducted. Results supported significant improvements in knowledge, PBC, and intentions at post-test, and attitudes, PBC, and effective emotional responses at follow-up. Exploratory analyses suggested significant improvements in behaviors among clinicians and mental health staff who saw clients reporting suicidal ideation. The present study provides promising results regarding brief safety planning training. Declines in knowledge and PBC following the training highlight the potential need for booster sessions or more intensive initial training in these areas.HighlightsThe present study evaluated a comprehensive, interactive safety planning training.Knowledge, PBC, and intentions were significantly improved at post-test.Attitudes, PBC, and emotions were significantly improved at follow-up.

Are they ready yet?: A theory-driven evaluation of suicide risk assessment trainings in psychology graduate programs.

OBJECTIVES: The present study sought to understand the state of suicide risk assessment trainings in clinical psychology graduate programs. METHODS: We surveyed 167 clinical psychology doctoral students' behavioral competency in responding to suicidal clients and their attitudes, perceived behavioral control, subjective norms, and intentions related to suicide risk assessment. Hypotheses were tested using path analysis. RESULTS: Ninety six percent of participants reported receiving some type of suicide risk assessment training at their program. Results provided partial support for significant relationships between attitudes, perceived behavioral control, subjective norms, and intentions. Unexpectedly, amount of training in suicide risk assessments was not related to theory of planned behavior variables including behavioral competency. CONCLUSION: These findings have implications regarding the effectiveness of current suicide risk assessment training practices and ways to improve trainings to help increase the number of clinical psychologists competent in suicide risk assessment and management.

Ambient Discrimination, Victimization, and Suicidality in a Non-Probability U.S. Sample of LGBTQ Adults.

Individuals who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) are at a higher risk for suicidality compared to the general population. A growing body of research has investigated this risk, particularly with attention to systemic factors such as discrimination and harassment. Unfortunately, research has only examined the impact of direct discrimination on suicidality and has neglected to examine how ambient discrimination (i.e., witnessing or being made aware of discriminatory behaviors directed at someone other than yourself in your group) relates to suicidality. Additionally, although some links exist between discrimination and suicidality, the mechanisms by which these are related are understudied. This study aimed to address these gaps by exploring the effect of ambient discrimination on suicidal ideation and examining psychological pain as a mediator in this relationship. Data were collected from a sample of 200 LGBTQ-identified individuals (M age = 35 years; 53.5% female; 86% White). Results of independent t tests and a one-way multivariate ANOVA revealed greater vulnerability for ambient/direct discrimination and psychache among individuals identifying as transgender, queer, and other. Regression and mediation analyses revealed that while both ambient and direct discrimination predicted suicidal ideation, only direct discrimination accounted for unique variance in the outcome; however, both ambient and direct discrimination contributed unique variance to psychological pain, which fully mediated their relationships to suicidal ideation. Results of this study may begin to provide insight into the pathways of risk and points of intervention for suicidality in the LGBTQ community.

Don't Invite Everyone! Training Variables Impacting the Effectiveness of QPR Trainings.

Gatekeeper trainings have been increasingly utilized in response to rising suicide rates in youths. However, the extent to which common factors inherent to gatekeeper trainings impact training outcomes is largely understudied. As such, the present study explored how factors such as training size and trainer engagement abilities influenced trainee participation and outcomes (i.e. changes in attitudes, perceived behavioral control (PBC), and knowledge regarding suicide prevention). All trainees participated in a gatekeeper training; trainers were not randomly assigned. Mediation and moderation analyses were completed using the PROCESS macro for SPSS (Hayes in Introduction to mediation, moderation, and conditional process analysis: a regression-based approach, Guilford Press, New York, 2013). Trainee participation in a training was examined as a mediator of the relationship between the training size and training outcomes, while trainer engagement was examined as a moderator of the relationship between size of training and trainee participation. Size of training was significantly related to lower changes in participant knowledge, along with lower trainee participation in gatekeeper trainings. Trainee participation significantly mediated the relationship between size of training, attitudes, and PBC. Additionally, trainer engagement significantly moderated the association between size of training and trainee participation. The results of this study suggest that general gatekeeper training-related variables may influence participant outcomes, specifically through trainee participation.

Examining the effects of role play practice in enhancing clinical skills to assess and manage suicide risk.

Background: Mental health professionals (MHPs) often lack skills necessary to effectively manage suicide risk. Training designed to combat this deficiency tend to rely on passive techniques, despite research suggesting active methods may better facilitate skill development.Aim: This study examines the effect of a role-play training on MHPs' attitudes, subjective norms and perceived behavioral control surrounding suicide risk assessment behaviors.Methods: Two hundred and three MHPs participated in a 4.5 hour role-play training after participation in an online suicide risk assessment training. The training utilized active learning and behavioral modification strategies. MHPs completed questionnaires assessing attitudes, subjective norms, perceived behavioral control and training variables.Results: MHPs endorsed positive attitudes, social norms and perceived behavioral control in suicide risk assessment and management skills, especially in assessing/determining the severity of risk, establishing rapport, documenting risk assessment information and developing a treatment plan. Results also revealed support for the feasibility of disseminating role-play training utilizing active learning methods.Conclusion: Factors found to be associated with participation in the role-play training are discussed. Findings may inform future development and improvement of suicide risk assessment training and practices that target risk and protective factors to effectively reduce suicide-related behavior.

Adolescent Decision-Making: The Value of Perceived Behavioral Control in Predicting Engagement in Suicide Prevention Behaviors.

Adolescent perceived behavioral control (self-efficacy) plays a key role in influencing decision-making processes within the context of suicide prevention programming. Guided by Theory of Planned Behavior, models tested attitudinal and social factors predicting adolescent intentions and actual engagement in suicide prevention behaviors. Participants included 233 racially and ethnically diverse high school students (54% female) in a southwestern U.S. school district. Measures included attitudes, norms, perceived behavioral control, intentions, and behavior over follow-up. Structural equation modeling indicated that perceived behavioral control, rather than intentions, was the direct predictor of behaviors. For adolescents, beliefs about effectively utilizing learned suicide prevention behavior may be more important than intentions. The design of suicide prevention efforts should account for this important influence on adolescent decision-making.

Frustration with feeling: Latent classes of non-suicidal self-injury and emotion regulation difficulties.

Although emotion regulation has been identified as a key function of non-suicidal self-injury (NSSI), it is unclear how specific indices of emotion regulation are associated with particular NSSI methods as markers of risk. This study used latent class analysis (LCA) to identify subgroups of individuals who engage in NSSI and their patterns of emotional regulation difficulties. Undergraduate students in the southeastern United States (N = 326) completed an online survey. LCA was used to identify subgroups of individuals engaging in NSSI and their associated emotion regulation difficulties. These subgroups were then compared across a variety of behavioral health outcomes (e.g. impulsive behavior, disordered eating, problematic alcohol use, suicide attempt history) to characterize specific risk profiles. The LCA revealed four subgroups who engage in NSSI and have specific emotion regulation difficulties. These subgroups were differentially associated with behavioral health outcomes, including suicide risk, disordered eating, and impulsive behavior. Results of this research could aid in clinical identification of at-risk individuals.

Benchmarking the "Question, Persuade, Refer" Program Against Evaluations of Established Suicide Prevention Gatekeeper Trainings.

Gatekeeper training is a common approach for aiding suicidal youth. This study utilizes comparative effectiveness "benchmarks" from established programs to evaluate the Question, Persuade, Refer (QPR) program. The QPR program was implemented with adults (N = 2,389) working in youth-serving community agencies. Questionnaires assessed suicide prevention knowledge, attitudes, subjective norms, perceived behavioral control, and behaviors. Consistent with benchmarked studies, participants in QPR demonstrated knowledge and suicide prevention behavior gains compared with control groups. Future research should utilize benchmarking methods as a measure of effectiveness, and more thoroughly assess mechanisms that promote behavior change.

Life after loss: Comparing student service member/veteran and civilian mental health characteristics among individuals exposed to death by suicide.

OBJECTIVE: This study evaluated the mental health characteristics and beliefs of student service members/veterans (SSM/Vs) who have been exposed to another's death by suicide. PARTICIPANTS: A total of 39 SSM/Vs exposed to suicide and 32 SSM/Vs not exposed to suicide were sampled from a larger, epidemiological survey. An age- and gender-matched group of 39 civilian (C) students was drawn from a larger sample of individuals exposed to suicide. METHODS: Data were collected as part of an Internet-based, campus needs survey that occurred in Fall 2014. Participants were asked to complete measures about suicide-related behaviors, suicide prevention, help-seeking, and demographics. RESULTS: SSM/Vs exposed to suicide had more positive mental health/suicide prevention beliefs than SSM/Vs not exposed to suicide. Cs exposed to suicide were not significantly different from either group. Unique help-seeking patterns were also identified. CONCLUSIONS: The current study identifies unique characteristics of SSM/Vs exposed to suicide that may inform prevention programming.

The Role of Youth Trainee-Trainer Alliance and Involvement in School-Based Prevention: A Moderated-Mediation Model of Student Gatekeeper Suicide Prevention Training.

This study examined the roles that youth involvement and youth trainee-trainer alliance play in school mental health prevention within the context of youth suicide gatekeeper training. Measures included youth involvement in programming, trainee-trainer alliance, and intentions to refer at-risk youth at pre- and post-training. A moderated-mediation design was used to examine associations among these factors. Results show alliance mediating pre- and post-training referral intentions, and involvement moderating the relationship between alliance and post-training intentions. On average, trainee intentions improved from pre- to post-training, but trainees reporting high alliance endorsed higher post-training referral intentions regardless of involvement level. Low alliance resulted in lower than average post-training referral intentions, even with active involvement in programming, and those with both low alliance and involvement showed the lowest post-training referral intentions. Given these findings, fostering the youth trainee-trainer relationship may be an avenue to optimize prevention program effectiveness.

Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy.

In the youth treatment literature, the alliance has been defined and measured as a consensual or collaborative bond. In this article, we review varied definitions of the alliance, enumerate its frequent measures, and present clinical examples. We provide a meta-analytic review on the relation between the therapeutic alliance and treatment outcome in child and adolescent psychotherapy. In particular, this review only includes prospective studies of youth therapy that used an explicit measure of alliance. The meta-analysis of 28 studies revealed a weighted random effect size of r = .19 (k = 28, N = 2419, p < .01, 95% confidence interval [.13, .25]), which is a small to medium effect (equivalent to d = 0.39) consistent with the adult alliance literature and with prior youth meta-analyses. Given that a medium-large amount of heterogeneity was observed in effect sizes (I2 = 64.19%), theory- and method-based moderators were examined. Multiple moderators of the alliance-outcome association were found, including diagnosis class, type of therapy, study design (randomized controlled trials [RCT] vs. nonrandomized trials [non-RCT]), and treatment setting (inpatient vs. outpatient). Research limitations, patient contributions, and diversity considerations follow. The article concludes with research-informed practices for building and maintaining the therapeutic alliance with youth. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The Role of the Therapeutic Relationship in Psychopharmacological Treatment Outcomes: A Meta-analytic Review.

OBJECTIVE: Patient nonadherence to psychopharmacological treatment is a significant barrier to effective treatment. The therapeutic relationship is known to be a critical component of effective psychological treatment, but it has received limited study. A meta-analysis was conducted to examine the role of the therapeutic relationship in the delivery of effective psychopharmacological treatment. METHODS: PubMed, PsycINFO, CINAHL, Google Scholar, Ingenta, and the Web of Science-Science Citation Index were searched, including reference lists of found articles. Meta-analytic methods were used to examine the association between the physician-patient therapeutic relationship and outcomes in psychopharmacological treatment. RESULTS: Eight independent studies of psychopharmacological treatment reported in nine articles met the inclusion criterion (1,065 participants) of being an empirically based study in which measures of the therapeutic relationship were administered and psychiatric treatment outcomes were assessed. The overall average weighted effect size for the association between the therapeutic relationship and treatment outcomes was z=.30 (95% confidence interval=.20-.39), demonstrating a statistically significant, moderate effect. CONCLUSIONS: Findings indicate that a positive therapeutic relationship or alliance between the physician and the psychiatric patient is associated with patient improvement over the course of psychopharmacological treatment. Results suggest that more attention should be paid to psychiatrist communication skills that may enhance the therapeutic alliance in psychopharmacological treatment.

A Silenced Population.

BACKGROUND: Given challenges that exceed the normal developmental requirements of adolescence, deaf and hard-of-hearing (DHH) youth are believed to be at elevated risk for engaging in suicide-related behavior (SRB). Unfortunately, little is known about the mechanisms that put these youth potentially at risk. AIMS: To determine whether peer relationship difficulties are related to increased risk of SRB in DHH youth. METHOD: Student records (n = 74) were retrieved from an accredited educational center for deaf and blind students in the United States. RESULTS: Peer relationship difficulties were found to be significantly associated with engagement in SRB but not when accounting for depressive symptomatology. LIMITATIONS: The restricted sample limits generalizability. Conclusions regarding risk causation cannot be made due to the cross-sectional nature of the study. CONCLUSION: These results suggest the need for future research that examines the mechanisms of the relationship between peer relationship difficulties, depression, and suicide risk in DHH youth and potential preventive interventions to ameliorate the risks for these at-risk youth.