Prospective Study of a Novel Risk Stratification Process for Opioid-Related Harm Reduction in Cancer Patients Seen in an Outpatient Palliative Care Clinic.

Background: Oncologists and palliative specialists prescribe opioids for millions of cancer patients despite limited research on effective screening and mitigation strategies to reduce risk of opioid-related harm in that population. Objective: To evaluate the efficacy of a novel opioid risk stratification process for predicting significant aberrant behaviors (SABs) related to prescribed opioid medications. Design and Setting/Subjects: This is a prospective, longitudinal study of 319 consecutive patients referred to an outpatient palliative care clinic between 2010 and 2012, a period during which prescription opioid-related deaths began to increase in the United States. Measures: Patients completed a psychodiagnostic/substance use risk assessment with a licensed clinical psychologist or social worker at the initial palliative clinic visit. Patients were assigned to Low-, Moderate-, or High-Risk groups based on predetermined stratification criteria and were managed via an opioid harm reduction approach. The primary dependent measure was the presence of at least one SAB after the initial visit. Results: Eighteen percent of patients (n = 56) demonstrated at least one major aberrant behavior. Odds of future aberrant behavior was 15 times greater in the High-Risk versus the Low-Risk category. Five risk factors significantly enhanced our risk model: age 18 to 45 years, job instability, history of bipolar diagnosis, history of substance abuse, and theft. Conclusion: Our risk stratification process provides a useful model for predicting those at greatest risk of future aberrant behaviors and most in need of comanagement. We recommend additional studies to test our proposed streamlined risk stratification tool.

ICU versus Non-ICU Hospital Death: Family Member Complicated Grief, Posttraumatic Stress, and Depressive Symptoms.

BACKGROUND: Family members of patients who die in an ICU are at increased risk of psychological sequelae compared to those who experience a death in hospice. OBJECTIVE: This study explored differences in rates and levels of complicated grief (CG), posttraumatic stress disorder (PTSD), and depression between family members of patients who died in an ICU versus a non-ICU hospital setting. Differences in family members' most distressing experiences at the patient's end of life were also explored. METHODS: The study was an observational cohort. Subjects were next of kin of 121 patients who died at a large, Midwestern academic hospital; 77 died in the ICU. Family members completed measures of CG, PTSD, depression, and end-of-life experiences. RESULTS: Participants were primarily Caucasian (93%, N = 111), female (81%, N = 98), spouses (60%, N = 73) of the decedent, and were an average of nine months post-bereavement. Forty percent of family members met the Inventory of Complicated Grief CG cut-off, 31% met the Impact of Events Scale-Revised PTSD cut-off, and 51% met the Center for Epidemiologic Studies Depression Scale depression cut-off. There were no significant differences in rates or levels of CG, PTSD, or depressive symptoms reported by family members between hospital settings. Several distressing experiences were ranked highly by both groups, but each setting presented unique distressing experiences for family members. CONCLUSIONS: Psychological distress of family members did not differ by hospital setting, but the most distressing experiences encountered at end of life in each setting highlight potentially unique interventions to reduce distress post-bereavement for family members.

Concurrent administration of sexual assault prevention and risk reduction programming: outcomes for women.

The present study describes the 4- and 7-month postintervention outcomes of a sexual assault risk reduction program for women, which was part of an evaluation that included a prevention program for men. Relative to the control group, participants evidenced more relational sexual assertiveness and self-protective behavior, and were more likely to indicate that they utilized active verbal and physical self-defense strategies. Whether or not women experienced subsequent victimization did not differ between groups. Relative to control group women who were victimized, program participants who were victimized between the 4- and 7-month follow-up blamed the perpetrator more and evidenced less self-blame.

Multiplicity of child maltreatment and biopsychosocial outcomes in young adulthood: the moderating role of resiliency characteristics among female survivors.

This study examined the moderating role of resiliency characteristics in the relationship between multiplicity of child maltreatment and biopsychosocial outcomes (i.e., psychological, physical, and interpersonal distress) in young adulthood. Participants included 765 college women who completed surveys. Structural equation modeling showed that resiliency characteristics moderated the relationship between multiplicity of child maltreatment and psychological distress; at high levels of resiliency characteristics, there was a nonsignificant relationship between multiplicity of child maltreatment and psychological distress. There was no evidence of moderation for physical or interpersonal distress. However, for both interpersonal and physical distress, the main effects of multiplicity of child maltreatment were positively related to each form of distress, and the main effect of resiliency characteristics was negatively related to each form of distress. These findings underscore the importance of promoting resiliency characteristics among survivors of multiplicity of child maltreatment to promote optimal functioning.

In Their Own Words: A Content-Analytic Study of College Women's Resistance to Sexual Assault.

The purpose of this study was to utilize a mixed methodological approach to better understand the co-occurrence of perpetrator tactics and women's resistance strategies during a sexual assault and women's reflections on these experiences. College women were recruited from introductory psychology courses and completed both forced-choice response and open-ended survey questions for course credit. Content-analytic results of college women's written responses to an open-ended question suggested that women's resistance strategies generally mirrored the tactics of the perpetrator (e.g., women responded to perpetrator verbal pressure with verbal resistance). However, there were some instances in which this was not the case. Furthermore, a number of women expressed a degree of self-blame for the sexual assault in their responses, as well as minimization and normalization of the experience. These findings suggest that sexual assault risk reduction programs need to directly address victims' self-blame as well as create an atmosphere where societal factors that lead to minimization can be addressed.

Suffering compounded: the relationship between abuse history and distress in five palliative care domains.

BACKGROUND: Research with breast cancer patients suggests that abuse survivors experience more psychological distress and disorders, particularly depression and anxiety, than patients without abuse histories. However, we do not yet understand the impact of abuse on other palliative care domains for individuals with other cancer types. OBJECTIVES: This study explores the relationship between past abuse and distress in a group of cancer patients referred for palliative care. This study also explores differences in distress level and likelihood of meeting diagnostic criteria for major depression and generalized anxiety disorder between patients with and without abuse histories. SETTING/SUBJECTS: Data were from 164 new, palliative care outpatients who completed an initial clinician-administered assessment and the James Supportive Care Screening patient self-report. DESIGN: Multivariate analyses of variance were conducted to explore differences between patients who reported an abuse history and those who did not on the number of items endorsed and associated distress on five palliative care domains. Chi-square tests were conducted to identify differences in diagnosis of depression and anxiety between patients with and without abuse histories. RESULTS: Twenty-eight percent reported abuse histories. Patients with abuse histories endorsed more physical problems, psychological concerns, and spiritual concerns and greater distress related to psychological and spiritual concerns than patients without abuse histories. Patients with abuse histories more frequently received diagnoses of major depression disorder and generalized anxiety disorder. CONCLUSIONS: These differences underscore the impact of abuse on the adjustment of cancer patients referred for palliative care. Assessment of patient abuse history by palliative care teams and referral for psychological treatment may help reduce patient distress.

Women's reactions to interpersonal violence research: a longitudinal study.

This study assessed women's immediate and long-term reactions to completing self-report measures of interpersonal violence. College women completed surveys at the beginning and end of a 2-month academic quarter for course credit. Results showed that 7.7% of participants experienced immediate negative emotional reactions to research participation. Greater immediate negative reactions were related to interpersonal victimization and psychological distress variables. Attrition from the study over the 2-month follow-up was not predicted by participants' immediate negative emotional reactions to the research or anticipation of future distress. Of the participants who returned for the follow-up, 2.1% of participants reported experiencing distress over the interim period as a result of their initial participation in the study. These long-term reactions were bivariately related to a number of victimization, psychological distress, and reaction variables measured at the first study session. However, in the regression analyses, only immediate negative emotional reactions to the research and anticipation of future distress predicted long-term negative emotional reactions.

A qualitative analysis of college women's leaving processes in abusive relationships.

OBJECTIVE: This study assessed the process of leaving an abusive dating relationship utilizing a qualitative design. METHODS: Participants included 123 college women in abusive dating relationships who participated at the beginning and end of a 10-week academic quarter. RESULTS: Qualitative content analyses were used to analyze the transcribed responses to an open-ended question about women's leaving processes over the interim period. A variety of categories and themes emerged for women in different stages of the leaving process, consistent with the Transtheoretical Model of Change and Investment Model. Data also underscored women's lack of acknowledgment, minimization, and normalization of abuse. CONCLUSIONS: These data demonstrate the importance of dating violence intervention and prevention programming on college campuses and offer information that may be useful to college health providers who assist women in abusive dating relationships.

Parent and adolescent satisfaction with mental health services: does it relate to youth diagnosis, age, gender, or treatment outcome?

Consumer satisfaction with treatment is important information for providers of mental health services. The goal of the current study was to examine the relationship between youth and parent satisfaction ratings and the following youth variables: gender, age, primary diagnosis, and changes in functioning and symptomatology after 6 months of services. Results demonstrated that in a large sample of youth receiving community mental health services satisfaction with services differed as a function of the adolescents' clinician-derived primary diagnosis, age, and reported changes in symptoms and functioning. Although significant, these variables accounted for only a small portion of the variance in satisfaction. Additionally, the relationship between parent and youth ratings of satisfaction was low, but significant. The implications of these findings are discussed as well as future directions for clinicians and researchers.

Enhancing supervisee reflectivity in clinical supervision: a case study illustration.

Reflectivity has been described as the cyclical process whereby individuals engage in a critical evaluation of their affective, cognitive, and behavioral experiences to produce insight and fundamental shifts in their original beliefs. Developing reflectivity in supervisees is one of the most challenging, yet important, responsibilities of clinical supervisors, given its link to such skills as critical thinking, ethical decision making, and problem solving. This paper advances the literature by presenting a case example that demonstrates how reflectivity can be emphasized in clinical supervision, highlighting the barriers to reflectivity, and providing strategies that supervisors can utilize to encourage reflectivity within clinical supervision. The strategies and information discussed may be flexibly applied to supervisees of all developmental levels within the context of individual supervision.

Personality, sexuality, and substance use as predictors of sexual risk taking in college students.

Sexual risk taking among college students is common and can lead to serious consequences, such as unintended pregnancies and sexually transmitted infections. This study utilized responses from 310 undergraduate psychology students aged 18 to 23 to examine personality, sexuality, and substance use predictors of sexual risk behaviors over a six-month period. Data were collected from 2005 to 2006 at a medium-sized Midwestern U.S. university. Results indicated that greater alcohol and recreational drug use, higher extraversion, and lower agreeableness were related to sexual risk taking in men. For women, greater alcohol and drug use, higher sexual excitation, and lower sexual inhibition were predictive of sexual risk taking. Among women, but not men, sensation seeking was found to mediate the relationship between the four significant substance use, personality, and sexuality variables and sexual risk taking. Implications for sexual risk behavior prevention and intervention programming are discussed.

Prediction of sexual assault experiences in college women based on rape scripts: a prospective analysis.

Although script theory has been applied to sexual assault (e.g., H. Frith & C. Kitzinger, 2001; A. S. Kahn, V. A. Andreoli Mathie, & C. Torgler, 1994), women's scripts of rape have not been examined in relation to predicting sexual victimization experiences. The purpose of the current study was to examine how elements of women's sexual assault scripts predicted their sexual assault experiences over a follow-up period. The authors used data from a baseline and follow-up session for 339 undergraduate women. The results suggest that women who constructed narratives containing certain elements were more likely to report a sexual assault over the academic quarter. Specifically, narratives containing the woman utilizing nonforceful resistance, the woman having less control over the outcome of the situation, the assault happening outdoors, the assault being more severe, and the woman having known the perpetrator less time were predictive of reported sexual victimization over the 8-week follow-up period. Additionally, having a history of adolescent sexual victimization was also predictive of reported sexual victimization over the quarter. These findings have important implications in sexual assault risk-reduction programming, which are discussed.

An assimilation analysis of clinician-assisted emotional disclosure therapy with survivors of intimate partner sexual assault.

This study examined clinician-assisted emotional disclosure therapy among college women with a history of intimate partner sexual assault. Assimilation analysis, a method for tracking client movement in psychotherapy, was used to document changes in dominant and submissive voices during clients' disclosure of the trauma. Self-blame, traditional gender-role assumptions, and internalized rape myth ideology emerged as prominent themes in clients' formations of problem statements. The two case studies presented illustrate the difficulty in clearly formulating experiences of intimate partner sexual assault as problematic, integrating submissive and dominant voices and empowering adaptive voices that speak for the well-being and self-assertion of the individual. Implications for psychotherapy with survivors of intimate partner sexual assault are discussed.

Factors predicting the type of tactics used to resist sexual assault: a prospective study of college women.

The purpose of the current study was to examine how women's intentions, as well as psychological and situational factors, predicted the actual use of resistance tactics in response to a sexual assault situation over a 2-month follow-up period. Twenty-eight percent of the 378 undergraduate women who participated at the baseline assessment and returned for the follow-up session 8 weeks later were victimized over the interim period. The results suggested that women's reported use of verbally assertive tactics was predicted by the intention to use verbally assertive tactics, concern about injury, greater confidence, and feelings of being isolated or controlled by the perpetrator. The use of physically assertive tactics was predicted by increased severity of the attack, greater confidence, and feelings of being isolated or controlled by the perpetrator. The use of nonforceful tactics was predicted by intentions to use nonforceful tactics, increased self-consciousness, knowing the perpetrator prior to the assault, fears of losing the relationship with the perpetrator, and no history of childhood sexual victimization. These findings have important implications in sexual assault risk-reduction programming.