Counseling Center and Therapist Effects on Changes in Suicidal Ideation among College Students Receiving Services on Campus: Comparisons across International Status, Race, Gender, and Sexual Orientation.

OBJECTIVE: Examine center- and therapist-level factors that may impact suicide ideation outcomes for college students with minoritized identities. METHOD: Data were drawn from a 2015-2017 data set collected from 136 university counseling centers that were part of the Center for Collegiate Mental Health. This study used a three-level model in hierarchical linear modeling with clients (Level 1; N = 122,212), clients nested in therapists (Level 2; N = 2,574), and therapists nested in counseling centers (Level 3; N = 120). RESULTS: Racially/ethnically minoritized students were 20%, LGBQ + students were 100% more likely, and women students were 20% less likely to have suicidal ideation at the first session, compared to White, male, heterosexual domestic students. LGBQ + students were 20%, and international students were 50% more likely to have suicidal ideation in the last session, compared to White, male, heterosexual domestic students. Cross-level interactions revealed that when therapists had a higher percentage of international students on their caseload, international students had decreased suicidal ideation. Similarly, when therapists had a higher percentage of male students on their caseload, their male students had decreased suicidal ideation. CONCLUSIONS: Findings from this study support the importance of experience and competence in working with minoritized students, as therapists who had more international and men students on their caseload fared better in decreasing the suicide ideation of respective students. This suggests that continued exposure to the unique challenges faced by particular minoritized groups of college students can enhance the quality of care delivered by therapists.

Social support and psychotherapy outcomes for international students in university/college counseling centers.

Objective: To explore the relationship between international students' social support at intake and international student distress at end of treatment. Participants: Data was collected from participants (n = 40,085) from 90 United States universities using the Center for Collegiate Mental Health (CCMH) database. Methods: Participants completed measures of psychological distress and perceived social support. Using multilevel modeling, we predicted participants' distress at end of treatment by international student status, social support, race, and length of therapy. Results: We found that international students who reported lower social support at intake ended treatment with higher levels of psychological distress when distress at intake was controlled compared to United States peers. Conclusions: Understanding the significance of social support for international students can help to inform mental healthcare professionals' approach to psychotherapy.

Single-handed versus multiple-handed General practices: A cross-sectional study of quality outcomes in England.

OBJECTIVES: As general practice increasingly moves towards large group practices, there is debate about the relative benefits, safety and sustainability of different care delivery models. This study investigates the performance of single-handed practices compared to practices with multiple doctors in England, UK. METHODS: Practices in England with more than 1000 patients were included. Workforce data and a quality control process classified practices as single-handed or multiple-handed. Outcomes were (i) GP patient survey scores measuring access, continuity, confidence in health professional and overall satisfaction; (ii) reported diabetes and hypertension outcomes; and (iii) emergency department presentation rates and cancer detection (percentage of cancers diagnosed by a 2-week wait). Generalised linear models, controlling for patient and practice characteristics, compared outcomes in single and multiple-handed practices and assessed the effect of GP age in single-handed practices. RESULTS: Single-handed practices were more commonly found in areas of high deprivation (41% compared to 20% of multiple-handed practices). Single-handed practices had higher patient-reported access, continuity and overall satisfaction but slightly lower diabetes management and cancer detection rates. Emergency department presentations were higher when controlling for patient characteristics in single-handed practices but not when also controlling for practice rurality and size. Increased deprivation was associated with lower performance in seven out of eight outcomes. CONCLUSIONS: We found single-handed practices to be associated with high patient satisfaction while performing slightly less well on selected clinical outcomes. Further research is required to better understand the association between practice size, including increasing multidisciplinary working, on patient experience and outcomes.

Psychotherapy outcomes with Latinx clients attending Hispanic-serving institutions and predominantly White institutions.

In the present study, we used a large, national data set to examine psychotherapy outcomes from 9,515 Latinx clients seeking treatment in 71 college or university counseling centers in the United States, 13 of which were in Hispanic-serving institutions (HSIs) and 58 in predominantly White institutions (PWIs). We examined the hypothesis that Latinx clients in HSIs, compared to Latinx clients in PWIs, would experience greater relief in symptoms of depression, generalized anxiety, and academic distress over the course of psychotherapy. Results of multilevel modeling offered partial support for our hypothesis. Compared to their counterparts in PWIs, Latinx clients in HSIs were found to experience significantly greater relief in academic distress over the course of psychotherapy, but there were no significant differences between Latinx clients in HSIs and PWIs in terms of changes in depression or generalized anxiety over time. We offer recommendations for future research and discuss the practical implications of these findings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A preliminary examination of therapist hope as a predictor of clients' distress over treatment.

Therapist and client hope have both been conceptualized and empirically examined as factors that contribute to the reduction of clients' distress in treatment. That is, clients may come to therapy demoralized and without hope per Frank and Frank's contextual model of psychotherapy. Therapy can serve to increase their hope and thereby contribute to the reduction of distress; however, therapists also bring their own individual hope to the therapeutic process. Despite both parties contributing their hope as treatment factors, no research has yet simultaneously examined therapist and client hope. The purpose of this preliminary study was to test the relationships between therapist and client hope with the clients' distress to assess if these relationships hold when both perspectives are modeled. Naturalistic psychotherapy data from 99 clients receiving treatment in a community-serving, doctoral-training clinic were included. Multilevel modeling results indicated that therapist and client hope both significantly and negatively predict clients' distress over the course of treatment. Cross-lagged panel modeling demonstrated that therapists' hope predicted reductions in future sessions' psychological distress. Implications of these significant findings are discussed in connection with therapist and client factor literature, and future directions for the co-occurring examination of therapist and client hope are described. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Measurement invariance and psychometric properties of the CCAPS-62 and -34 for international student clients.

OBJECTIVES: International students attending universities in the United States may encounter psychological distress related to their adjustment and experiences studying in a new context and seek services from university counseling centers. Many centers use the Counseling Center Assessment of Psychological Symptoms (CCAPS) to measure psychological distress in college counseling centers. However, this scale has not been tested for measurement invariance with international students. Our purpose was to explore the measurement invariance of the CCAPS-62 and -34 for international students. METHODS: We tested measurement invariance for both versions of the scale using data from over 107,000 university students in psychotherapy at university counseling centers. We also examined construct validity and internal consistency. RESULTS: Invariance testing indicated the measurement models of the CCAPS-62 and -34 are equivalent between both groups. CONCLUSION: These findings are discussed in light of utilizing this widely-used scale in United States university/college counseling centers with international student clients.

"How could I not bring it up?": A multiple case study of therapists' comfort when Black clients discuss anti-Black racism in sessions.

Anti-Black racism is often overlooked in predominantly White spaces such as psychotherapy. This pervasive disregard and dehumanization reflects the perpetuation of ongoing racial trauma that can influence the psychological health of Black people seeking psychotherapy. Therapists, therefore, ought to be equipped and comfortable to have conversations about anti-Blackness and anti-Black racism in sessions, though evidence suggests they are often uncomfortable discussing race and racism in practice. To understand therapists' comfort when clients discuss anti-Black racism, we used a multiple case study approach to interview five practicing clinicians (two White, two Black, one biracial Asian and White). Within-case analysis elicited a sense of participants' personal experiences of being comfortable, and at times less so, when clients discussed having endured anti-Black racism. Cross-case analysis led to the identification of four themes: (a) Beyond Acknowledgment, (b) Drawing Personal Awareness into the Moment, (c) Engaging with One's Own Emotional Responses, and (d) I Am versus I Should: Proactive and Reactive Comfort. These findings are discussed within the scope of multicultural competence, multicultural orientation, and the value of cultural comfort when clients' discuss anti-Black racism. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Center effects, therapist effects, and international student clients' drop out from psychotherapy.

In 2019-2020, 1,075,496 international students pursued higher education in the United States. Many of these students endure unique experiences of psychological distress that accompanies their shared experience of studying abroad in the United States. Researchers have explored clinical experiences within this diverse group, with some suggesting that international students are at greater risk than students from the United States for dropping out of psychotherapy. This issue is underexplored in the extant psychotherapy literature. Therefore, we used a large, national data set and multilevel analyses to test if international students are more likely than students from the United States to drop out of psychotherapy, defined in this study as failure to attend one's last scheduled session. Data from 65,293 clients (n = 3,970 international students), 2,735 therapists, and 131 university/college counseling centers were included in the analysis. Results revealed that (a) international students are no more likely to drop out than United States domestic students, (b) on average, centers (ICC = 0.045) and therapists (ICC = 0.071) are differentially effective at preventing drop out, and (c) therapist effects on drop out differ for international students. We discuss these findings with respect to therapist and center roles in international students' drop out from treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Therapist and counseling center effects on international students' counseling outcome: A mixed methods study.

We employed a convergent mixed methods design to examine therapist and counseling center effects on international student clients' (ISCs) counseling outcomes. Using the Center for Collegiate Mental Health (CCMH) data set (2015-2017), we conducted a three-level hierarchical linear model with clients (N = 85,110) nested in therapists (N = 1,267), and therapists nested in counseling centers (N = 111), with clients' international status predicting distress (DI) in their last sessions while controlling for initial DI. Compared to domestic students, the average last session DI was significantly higher among ISCs. Random effects were significant, suggesting that some therapists and centers were more effective in their work with ISCs than others. When the proportion of ISCs seen was accounted into the model, we found a cross-level interaction in which the last session DI differences between ISCs and domestic students were significant for centers seeing a small percentage of ISCs but not for centers with large percentages of ISCs in the caseload. Grounded theory analysis of qualitative data from 11 therapists with international backgrounds revealed therapist and center factors that converged with our quantitative findings. Participants reported adhering to general clinical frameworks when working with ISCs given the lack of training on international competence (which may help explain the effectiveness gap), but also noted nuanced culturally-informed components that likely contribute to more effectively working with ISCs. Findings around center effects were complemented by qualitative results emphasizing systemic representation and engagement with diversity, creative outreach efforts, and administrative/leadership support. Implications for practice and research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Clients in context: Environment, class, race, and therapists' perceptions of generalized anxiety disorder.

Evidence-based practice necessitates the inclusion of client identity and contextual information when conceptualizing diagnosis. OBJECTIVE: To examine how therapists' perceptions of Generalized Anxiety Disorder is influenced by client environmental contextual and identity factors, like class and race. METHOD: Therapists (n = 138; 76% women; Mage = 38.3) were randomly assigned three of six client vignettes and asked to provide diagnostic recommendations, confidence in diagnosis, and perception of client's concerns. Vignettes differed in their description of client class, race, and contextual factors. A linear mixed-model was used to test confidence in diagnosis and generalized linear mixed-models were conducted to predict diagnosis and client concerns. RESULTS: Therapists altered diagnosis, confidence, and client concerns based on client contextual factors-but not identity factors. CONCLUSIONS: Therapists consider contextual factors in making clinical decisions, with overall tendency towards diagnosis regardless of if symptoms met the diagnostic criteria of being "excessive" given the environmental context.

Is it ethical to incentivize mammography screening in medicaid populations?- A policy review and conceptual analysis.

Mammography screening is controversial, as screening decisions are preference-sensitive: equally well-informed women do not universally get mammograms. Offering financial incentives for screening risks unduly influencing the decision-making process and may undermine voluntariness-yet incentives are being used in 4 US states (Arizona, Indiana, Kentucky, Michigan) under Section 1115 waivers. These initiatives are especially problematic in Medicaid populations who typically have lower health literacy and face the potential threat of disenrollment if they opt out. From June 2018 to January 2019, we analyzed publicly-available information on mammography incentives from the Centers for Medicare and Medicaid Services (CMS) and identified criteria (i.e. starting age and frequency of mammography) for incentive eligibility; income brackets of the affected beneficiaries; whether incentives were financial rewards or penalties; and evaluation arrangements. Several ethically relevant differences emerged: all states except Michigan incentivize screening at starting ages and frequencies that conflict with the US Preventive Services Task Force guidelines. Some incentives are rewards (e.g. reduced cost-sharing), and some penalties (e.g. disenrollment). Across states, rewards range from the equivalent of <1 min of work at state minimum wage to 9 days, and penalties range from 2 to 8 h. Political objectives, rather than evidence and ethics, appear to drive mammography incentive design. Programs risk harming vulnerable low-income populations. CMS and US states should therefore review variations and prevent unjustifiable practices, such as incentivizing 35-year-old women. Large incentives should be offered only if accompanied by robust studies. Incentives for using evidence-based mammography decision-aids, instead of mammography completion, better realize the intended goals.

Therapists' cultural comfort and clients' distress: An initial exploration.

The extent to which therapists are comfortable discussing clients' cultural identities in psychotherapy has been considered a valuable component of how therapists integrate clients' cultures into treatment. Cultural comfort specifically reflects a therapist's way of being at ease, relaxed, and open when discussing clients' cultural identities in treatment. Some initial research has demonstrated the relationships between cultural comfort and clinical outcomes, yet this work has relied largely on cross-sectional designs. The purpose of this preliminary study was to use longitudinal psychotherapy data to explore the relationships between clients' perceptions of their therapists' cultural comfort and clients' distress over the course of psychotherapy. Data were collected from 48 clients who attended 476 sessions in a doctoral training clinic. Multilevel modeling was used to account for the nested nature of the data. Results showed that, when session number was held constant, within-client increases in their perceptions of their therapists' cultural comfort were predictive of decreases in psychological distress. We discuss these findings in light of the multicultural orientation literature and with respect to the implications for therapists striving to be comfortable with culture in sessions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

"How Can We Help You": Mental Health Practitioners' Experiences of Service Provision in Northern Namibia.

Although 12-13% of Namibians are reported to struggle with psychological distress, very few practitioners are available to provide mental health services in Namibia. Those practitioners who are available are often trained from Western counseling and psychiatric perspectives that may not readily align to beliefs about illness held constructed in Namibian cultures. Institutional effort is invested in the education and use of mental health practitioners, including counselors, social workers, nurses, psychologists, and psychiatrists. However, little is known about the experiences of these providers. Therefore, this study, a grounded theory ethnography, was undertaken as part of broader ethnographic work to understand how mental health practitioners (N = 7) in Northern Namibia view their work with Aawambo Namibians given that Namibian mental health practitioners are few but embedded in the country's health care system. Four categories were identified in analyses: Provision of Mental Health Services in the North, Practitioners' Conceptualizations of Psychological Distress: Western and Aawambo Influences, Beliefs about Mental Health Services in the North, and Integration of Traditional Treatment and Counseling. Results are discussed with respect to cultural competence in Namibian mental health practice and potential for integrating traditional practices and mental health services.

Development and initial validation of the Therapist Cultural Comfort Scale.

The development and initial validation of a client-rated measure of therapist cultural comfort (the Therapist Cultural Comfort Scale [TCCS]) is reported. The first phase of the study involved content validation of the initial pool of items via consultation with (a) focus groups of doctoral student therapists and (b) experts in the field of multicultural counseling and psychotherapy. A 56-item pool generated during this phase, together with instruments used to gauge convergent and incremental validity, were administered to a community adult sample of current psychotherapy clients (N = 889). Exploratory factor analysis suggested 2 subscales representing negative and positive indicators of therapist cultural comfort. Item response theory principles guided final selection of subscale items. Analyses suggested good factor stability and reliability of the 13-item TCCS as well as strong measurement invariance across racial/ethnic minority status and gender. Total and subscale scores related as expected with other measures of multicultural constructs (cultural humility, missed cultural opportunities, and multicultural competencies). Generally, TCCS total and subscale scores also predicted working alliance and treatment progress above and beyond the effects of therapist general comfort. There were few differences in clients' perceptions of therapist cultural comfort based on client demographic characteristics. Implications for research and practice are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The meaning of therapists' hope for their clients: A phenomenological study.

Hope is often identified as a central process in psychotherapy, with researchers supporting links between clients' hope, symptom distress, and process variables. However, this body of literature is yet to specifically ask what it means for psychotherapists to have hope for their clients. Our purpose, with this descriptive phenomenological study, was to understand the meaning of therapists' hope for their clients. This information has the potential to better inform how therapists think about their own hope for clients and the ways in which this is transmitted to clients who may enter therapy in a state of hopelessness. To accomplish this, we interviewed psychologists (N = 8) using a semistructured interview protocol. Interviews were transcribed then analyzed in accordance with descriptive phenomenology guidelines. Four themes were identified: (a) a sense of holding and possibility; (b) fundamental, dynamic, and reflective practice; (c) client influence (positive and negative) on hope; and (d) connection through hope. The findings are discussed in light of therapist effects in psychotherapy, the internal world of therapists, and training implications. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Pretreatment counseling experiences, stressors, and support differences between transgender and cisgender university students seeking mental healthcare.

OBJECTIVES: Our aim was to explore rates of prior counseling experiences as well as pretreatment stressors and supports among transgender university students seeking psychotherapy services in university counseling centers. METHODS: We used regression models to explore relationships between gender identity and prior mental health experiences, risk-related experiences, traumatic experiences, and support among clients (cisgender: n = 162,305; transgender: n = 545) seeking treatment at 136 university counseling centers. RESULTS: Results demonstrate more previous mental health service utilization and greater frequency of some prior stressors transgender clients. Findings indicate the odds of transgender clients reporting drug and alcohol concerns are lower than the reference group. Additionally, transgender clients report less familial support but more social support than cisgender clients. CONCLUSION: We discuss the importance of these findings through a more holistic lens that recognizes both stressors as well as positive factors that may more accurately characterize the experiences of transgender clients.

Mixed methods in psychotherapy research: A review of method(ology) integration in psychotherapy science.

OBJECTIVE: Mixed methods can foster depth and breadth in psychological research. However, its use remains in development in psychotherapy research. Our purpose was to review the use of mixed methods in psychotherapy research. METHOD: Thirty-one studies were identified via the PRISMA systematic review method. Using Creswell & Plano Clark's typologies to identify design characteristics, we assessed each study for rigor and how each used mixed methods. RESULTS: Key features of mixed methods designs and these common patterns were identified: (a) integration of clients' perceptions via mixing; (b) understanding group psychotherapy; (c) integrating methods with cases and small samples; (d) analyzing clinical data as qualitative data; and (e) exploring cultural identities in psychotherapy through mixed methods. CONCLUSION: The review is discussed with respect to the value of integrating multiple data in single studies to enhance psychotherapy research.