Client Population Research Articles

Intersectional Advocacy with LGBTQ+ Clients in Counseling

Advocacy and multicultural counseling researchers have helped establish competencies for working with today’s diverse client populations. However, advocacy competencies may not fully account for the intersecting identities and unique concerns of LGBTQ+ individuals. Counselors working with LGBTQ+ client populations therefore need specific skills to address client intersectionality. The authors present the Intersectional Advocacy Counseling Framework (IACF) and discuss its application in counseling with LGBTQ+ clients and its use within counselor supervision.

Peer Association and Routine Activities in Sex Worker Patronage among Male Migrant Workers

ABSTRACT Studies of people who buy sex often focus on psychological and personality factors with less attention paid to the role of social contexts. This study integrates the two lines of inquiry, routine activity theory and peer deviance, to examine the social process of paying for sex. We argue that deviant peer association may shape buying sex due to peers’ role in shifts in the three components of routine activity theory: motivation, targets, and lack of guardians. With rich information on sexual behaviors from the China Migrant Sexual Health Survey (n = 1,521), we conducted a series of regressions and structural equation models on commercial sex behaviors among male migrants. Our findings demonstrate that having more peers engaged in deviance is significantly associated with buying sex; the three routine activity components are also significantly associated with buying sex; the peer effect on buying sex is significantly (39% of the variance) mediated by routine activities. These results help understand the role of routine activities in mediating peer association and buying sex, and also contributes to the literature of sex work on the less-studied population of sex work clients in China. Theoretically, the results provide evidence for the role of peers in shaping routine activities.

Toward a human-centered use of technology: a stakeholder analysis of harm reduction and CBO staff

BackgroundTechnology can enable syringe service programs (SSPs) and other community-based organizations (CBOs) operating under a harm reduction framework to work with an increased number of clients and can also enable organizations to offer services more effectively (e.g., offering HIV testing in ways participants may be more likely to accept). In the current time of COVID-19 social distancing, technology can also help organizations more safely provide services to people with compromised immune systems and to clients who might otherwise not be reached. However, technology projects implemented in harm reduction settings are frequently conceptualized and developed by researchers or technology specialists rather than by SSP staff or clients.MethodsTo more effectively meet the needs of SSPs and other CBOs across the USA, our team conducted qualitative interviews with 16 individuals who have extensive backgrounds working in the field of harm reduction. Interviews were digitally recorded and professionally transcribed, and the transcripts were checked for accuracy by the interviewers. The resulting transcripts were coded and analyzed to determine emerging themes.ResultsInterviewees mentioned the ability of technology to deliver consistent quality messaging to multiple clients at the same time and the potential to customize or tailor technology-based messaging to specific client populations as positive benefits. Clear barriers to technology use also emerged, in particular regarding privacy, data security, and the need to maintain client trust when discussing sensitive issues (e.g., illicit drug use).ConclusionsTechnology offers the potential to deliver consistently high-quality health communication and maintain contact with clients who may have no other access to care. If designed and managed effectively, technology can also address issues related to providing services during times when physical contact is limited due to COVID-19 social distancing measures.

Therapeutic interventions in Australian primary care, youth mental health settings for young people with borderline personality disorder or borderline traits

BackgroundThis study aimed to investigate what therapeutic interventions were being applied by clinicians working with young people with a diagnosis of Borderline Personality Disorder or borderline traits in Australian primary mental health care settings. Given the current lack of evidence-based guidelines for treatment with this client population, investigating what is being implemented is needed. The study also aimed to determine whether the interventions clinicians are using are effective in reducing distress and increasing functioning for these clients.MethodsParticipant data came from the national minimum data set for headspace youth mental health centers across Australia. Young people’s data were included in the study if the young person was diagnosed with Borderline Personality Disorder or borderline traits during their first episode of care (N = 701). Clinician data that indicated the type of intervention used at each client session and outcome measures routinely captured were analyzed to determine interventions used and outcomes achieved.ResultsResults demonstrated that CBT was the most frequently used modality of intervention followed by supportive counselling and IPT, but that most clients received a variety of intervention types. There were no or only weak relationships between changes in outcomes and the amount of any type of intervention that was provided. No significant relationship was found with the amount of CBT a client received and changes in symptoms or functioning, despite being the most commonly employed modality.ConclusionsThe study highlights the need for evidence-based treatment guidelines for early intervention in young people with borderline personality disorder traits.

Stability in a large drug treatment system: Examining the role of program size and performance on service discontinuation

BackgroundLittle is known about the stability of public drug treatment in the United States to deliver services in an era of expansion of public insurance. Guided by organizational theories, we examined the role of program size, and performance (i.e., rates of treatment initiation and engagement) on discontinuing services in one of the largest treatment systems in the United States. MethodsThis study relied on multi-year (2006–2014) administrative data of 249,029 treatment admission episodes from 482 treatment programs in Los Angeles County, CA. We relied on survival regression analysis to identify associations between program size, treatment initiation (wait time) and engagement (retention and completion rates) and discontinuing services in any given year. We examined program differences between discontinued versus sustained services in pre- and post-expansion periods. ResultsSixty-two percent of programs discontinued services at some point between 2006 and 2014. Program size and rates of treatment retention were negatively associated with risk of discontinuing services. Proportion of female clients was also negatively associated with risk of discontinuing services. Compared to residential programs, methadone programs were associated with reduced likelihood of discontinuing services. Two interactions were significant; program size and retention rates, as well as program size and completion rates were negatively associated with risk of discontinuing services. ConclusionsProgram size (large), type (methadone), performance (retention) and client population (women) were associated with stability in this drug treatment system. Because more than 70% of programs in this system are small, it is critical to support their capacity to sustain services to reduce existing disparities in access to care. We discuss the implications of these findings for system evaluation and for responding to public health crises.

Mental health nurses' perceived preparedness to work with adults who have child sexual abuse histories.

WHAT IS KNOWN ON THE SUBJECT?: The high prevalence of adults presenting to the mental health services places mental health nurses (MHNs) in a unique position to help to identify and support the person with the associated challenges of child sexual abuse (CSA). Feelings of discomfort have been identified by mental health nurses (MHNs) when working with survivors of CSA due to a lack of knowledge, poor confidence and feeling unprepared to inquire and respond to such a sensitive topic. WHAT DOES THE STUDY ADD TO EXISTING KNOWLEDGE?: MHNs are willing to engage in CSA dialogue; however, the level of engagement is often conditional with clear parameters set by participants. Whilst all participants reported they were willing to engage in conversation initiated by the service user, some were unwilling to listen to details of the CSA and used strategies to censor service users from providing details of the CSA. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Whilst self-protecting boundaries helped MHNs to engage in CSA dialogue, strategies to censor aspects of the service user's dialogue may reinforce the belief that their experience of CSA is too shameful to talk about, hence denying the reality of their experience and contributing to feelings of re-shaming. MHNs need a combination of theoretical knowledge and psychosocial skills to achieve clinical competence when working with CSA; therefore, training should not only include information pertaining to facts and statistics but also case presentations, clinical training and supervision. Clinical supervision was highlighted by all participants as a necessary means of formal support, more specifically group clinical supervision whereby peer support can also be availed of in a formalized setting. ABSTRACT: Introduction The high prevalence of adults presenting to the mental health services places mental health nurses (MHNs) in a unique position to support the person with the associated challenges of CSA, yet little is known about the preparedness of MHNs to work with this client population. Aim To explore MHNs' perceived preparedness to work with adults who have CSA histories, and to elicit their views, skills and confidence in relation to working with this sensitive issue. Method In-depth semi-structured interviews were conducted with five consenting MHNs. A qualitative descriptive methodology informed the study. A thematic analysis framework guided the data analysis. Results The findings assert that MHNs are willing to work with survivors of CSA despite feeling unprepared to so, MHNs described feeling ill-prepared in how to respond to CSA, calling for not just education and training specific to CSA but also citing the need for clinical supervision and additional guidelines to enhance their preparedness. Discussion Results of this study further highlighted the omission of CSA within nursing curricula and the absence of role models within clinical practice as a major barrier to preparedness to work with survivors of CSA. Recommendations are made for training, education and the inclusion of clinical supervision.

Virtual Music Therapy: Developing New Approaches to Service Delivery

As the global Coronavirus disease (COVID-19) pandemic transforms our society, music therapists must adapt service delivery models that ensure client safety. Given the prevalence of COVID-19 in our communities and lack of personal protective equipment in many settings, music therapists are faced with the need to shift delivery models in order to provide safe and relevant services. Telehealth is one solution to these current service delivery challenges. Music therapists possess a depth of practice-based knowledge and understanding of client populations, which enables them to develop virtual services, matching both the clinicians’ and clients’ technical capabilities. Developed during the initial wave of COVID-19 infections in the United States, this article describes the coauthors’ three-tiered scaffold model intended to support the program development and deployment of virtual music therapy (VMT) services. The model describes an approach to developing VMT services that directs the clinician’s goals of care in formats that are accessible, appropriate, and best meet the patient/client’s needs and abilities. The severity and lasting nature of this worldwide health crisis and its disruption of traditional service delivery models require clinicians and researchers to develop the most effective uses of VMT while considering its limits with regard to clinical populations and need areas.

Clustered Federated Learning: Model-Agnostic Distributed Multitask Optimization Under Privacy Constraints.

Federated learning (FL) is currently the most widely adopted framework for collaborative training of (deep) machine learning models under privacy constraints. Albeit its popularity, it has been observed that FL yields suboptimal results if the local clients' data distributions diverge. To address this issue, we present clustered FL (CFL), a novel federated multitask learning (FMTL) framework, which exploits geometric properties of the FL loss surface to group the client population into clusters with jointly trainable data distributions. In contrast to existing FMTL approaches, CFL does not require any modifications to the FL communication protocol to be made, is applicable to general nonconvex objectives (in particular, deep neural networks), does not require the number of clusters to be known a priori, and comes with strong mathematical guarantees on the clustering quality. CFL is flexible enough to handle client populations that vary over time and can be implemented in a privacy-preserving way. As clustering is only performed after FL has converged to a stationary point, CFL can be viewed as a postprocessing method that will always achieve greater or equal performance than conventional FL by allowing clients to arrive at more specialized models. We verify our theoretical analysis in experiments with deep convolutional and recurrent neural networks on commonly used FL data sets.

Characteristics of Clients Seeking Yoga Therapy in a University-Based Student Clinic.

Yoga therapy is an emerging profession with recent development of educational competencies, training program accreditation, and practitioner certification. In the United States, most yoga therapy training programs are studio-based and data on mentored clinical encounters are lacking. This study aimed to characterize the client population in a university-based mentored student clinic. As part of a larger feasibility study, data were collected at all clinic visits for 70 consenting clients. Data collected included demographic characteristics, reasons for pursuing care, use of other healthcare approaches, and the Patient-Reported Outcomes Measurement Information System (PROMIS) for physical and mental health. Participants were mostly middle-aged, White, and highly educated. Common reasons for pursuing care were pain and mental health. Most used multiple healthcare approaches. Average scores for most patient-reported outcomes fell within normal range at baseline. Future studies are needed to better characterize yoga therapy users and to expand access for populations in whom the modality is underutilized despite emerging evidence of relevance.

Skill mix of nurses and primary health care professionals: a systematic review

RESUMOObjetivo.Avaliar a efetividade da estratégia de combinação de tarefas dos profissionais de saúde, e do enfermeiro na Atenção Primária de Saúde.Método.Revisão sistemática da literatura alinhada com as recomendações do protocolo dos Principais Itens para Relatar Revisões Sistemáticas e Metanálises, incluindo estudos observacionais e de intervenções, sem estabelecimento de período de publicação, independentemente do país de origem e publicados nos idiomas espanhol, inglês e português. As buscas ocorreram nas bases de dados eletrônicas da MEDLINE, CINAHL, LILACS, EMBASE e Web of Science.Resultados.Incluídos 18 estudos, dos quais 6 foram desenvolvidos nos Estados Unidos; 3 na Holanda; 2 no Reino Unido; um na África do Sul, Austrália, Coreia do Sul, Escócia, Haiti e Japão; e um estudo com desenho observacional prospectivo em 8 países. Os estudos relataram que, a combinação de tarefas entre os profissionais de saúde, possibilita melhor aproveitamento de recursos materiais, otimização do tempo gasto no atendimento, retenção do paciente no tratamento, melhora na qualidade do trabalho com diminuição dos níveis de sofrimento psicológico do enfermeiro e comprometimento e satisfação com o trabalho.Conclusão.A expansão de tarefas do enfermeiro, assim como de outras categorias de profissionais da saúde, a combinação de tarefas, bem como o desenvolvimento de equipes interprofissionais, são estratégias que podem ser empregadas em situações de escassez de recursos humanos e de má distribuição em áreas urbanas e não urbanas com resultados positivos na melhoria da atenção em saúde da população e satisfação dos profissionais e clientes.

The use of off-label medications in substance abuse treatment programs

Background: Substance use disorder (SUD) treatment centers serve a population of clients who have diverse needs, and may desire or require access to varied treatments while seeking care for their SUDs. While pharmacotherapies have increased in popularity for the treatment of SUDs, adoption rates do remain quite low. But a wider array of pharmacotherapies has become available in recent years which may shift the trend. This article helps shed light on how variations in SUD treatment centers develop and persist with regard to the adoption and delivery of off-label medications. Methods: We use a nationally representative and longitudinal sample of SUD treatment centers in the US (N = 196). We use a logistic regression to analyze the relationship between organizational characteristics and offering any medications, off-label. We also use a negative binomial regression to analyze the relationship between organizational characteristics and the number of medications that were used off-label. Results: Our findings reveal that older centers, accredited centers, and centers that offer mental health screenings are all positively associated with the provision of off-label medication in SUD treatment. We also find a positive relationship between private funding and offering a greater number of off-label medications. Conclusions: Our results suggest that SUD clients who seek treatment from centers that offer medications off-label, may have access to a greater number of medication-assisted treatment options.

Preserving User Privacy for Machine Learning: Local Differential Privacy or Federated Machine Learning?

The growing number of mobile and IoT devices has nourished many intelligent applications. In order to produce high-quality machine learning models, they constantly access and collect rich personal data such as photos, browsing history, and text messages. However, direct access to personal data has raised increasing public concerns about privacy risks and security breaches. To address these concerns, there are two emerging solutions to privacy-preserving machine learning, namely local differential privacy and federated machine learning. The former is a distributed data collection strategy where each client perturbs data locally before submitting to the server, whereas the latter is a distributed machine learning strategy to train models on mobile devices locally and merge their output (e.g., parameter updates of a model) through a control protocol. In this article, we conduct a comparative study on the efficiency and privacy of both solutions. Our results show that in a standard population and domain setting, both can achieve an optimal misclassification rate lower than 20% and federated machine learning generally performs better at the cost of higher client CPU usage. Nonetheless, local differential privacy can benefit more from a larger client population ($>$> 1k). As for privacy guarantee, local differential privacy also has flexible control over the data leakage.

A Qualitative Study of Nursing Students' Experiences in Fall Prevention for Older Home Care Clients.

The aim of this study was to describe the experiences of nursing students in fall prevention during clinical practice in the context of older home care clients. This was a qualitative focus group study of nursing students (n = 9) who had completed clinical practice in older clients' home care. The data were analysed using inductive content analysis. The nursing students described their experiences regarding falls and fall prevention in older clients' home care from two perspectives: evaluation of falls at older people's homes and fall prevention during home visits. Systematic evaluation of falls was based on physical examination and is the basis of fall prevention. However, evaluation of nutrition and adverse drug effects seemed to be ignored. In addition, fall prevention during home visits included concrete fall prevention in authentic client situations, confidential relationships with older clients, and evidence-based knowledge. From the perspective of fall prevention, there was a lack of comprehensive evaluation and understanding of the meaning of psychological factors, such as fear of falling. In order to be able to prevent falls in the older client population, students need more guidance regarding a comprehensive approach based on evaluation of falls. In addition, there is a need for continuous collaboration between education and home care services to develop educational approaches that interlink knowledge and skills in fall prevention.

“Take Your Kung-Flu Back to Wuhan”: Counseling Asians, Asian Americans, and Pacific Islanders With Race-Based Trauma Related to COVID-19

Following the outbreak of COVID-19, reports of discrimination and violence against Asians and Asian Americans and Pacific Islanders (AAPIs) have increased substantially. The present article offers a timely conceptualization of how public and societal fears related to COVID-19 may contribute to unique mental health disparities and the presence of race-based trauma among AAPIs residing in the United States. The relationships between media, increasing rates of xenophobia and sinophobia, and racial discrimination are provided. Next, the deleterious effects of race-based discrimination on the emotional and physical well-being of people of color and Indigenous groups (POCI) and AAPIs are described. Finally, the article identifies the clinical implications of counseling AAPI clients, encourages a decolonization of current trauma-focused interventions, and presents specific strategies to heal race-based trauma in AAPI client populations. (PsycInfo Database Record (c) 2021 APA, all rights reserved)

The perceptions of community-based organizations collaborating with nursing faculty to promote students’ public health nursing competencies

Collaborative community-based organizations (CBOs) and academic partnerships are a prerequisite for the creation of quality learning environments for undergraduate nursing students. However, the explicit nature of the relationship between academic and CBO partners is not as well-defined as the one between hospitals and their clinical settings. The aim of this study was to describe and evaluate the implementation and impact of a 3-year-long partnership between a nursing school and 20 different CBOs. Semi-structured individual interviews were conducted with 11 CBO partners throughout June and July of 2018. Interview questions explored the collaborative process, its benefits, and areas for improvement. Study participants reported that the partnerships brought several benefits, including familiarizing students with marginalized populations, demystifying the health care system for the populations served by the CBOs, and the students’ development of sustainable health promotion tools that contributed positively to the CBOs’ overall mission. Challenges identified by the CBOs included finding resources to provide adequate student supervision and population access, and some students’ challenges with adapting to the CBOs’ client population or community environment. Collaborative partnerships were mutually beneficial for populations, students and the community organizations. These results support the establishment and long-term development of these types of partnerships.

A qualitative study examining the quality of working alliance as a function of the social identifies of clients and therapists during the mental health intake

Therapists are faced with the challenge of developing effective ways to advance cross-cultural engagement with a rapidly growing diverse client population. In this qualitative study, we characterized the way clients and therapists described the quality of working alliance during the mental health intake and examined whether these descriptions vary as a function of their social identities. We conducted in-depth interviews with Ashkenazi (socially advantaged group; n = 22) therapists and their Mizrahi (socially disadvantaged group n = 29) or Ashkenazi (n = 26) clients immediately following their intake session in four mental health clinics in Israel. We performed a thematic analysis. Overall, interrater reliability among three raters who coded the narratives was high (kappa = 0.72, therapist; 0.70, client). Across all client and therapist interviews, we identified eight central themes detailing different qualities of the working alliance: (1) feeling understood, (2) feeling comfortable, (3) openness and cooperation, (4) trust, (5) empathy and identification, (6) frustration and disappointment, (7) anger and hostility, and (8) emotional disengagement. On average, clients reported 2.56 (standard deviation = 1.17) and therapists described 2.65 (standard deviation = 1.45) themes in each session. Overall, concordant and discordant dyads described similar themes with few exceptions. In particular, being part of a discordant dyad may affect the client’s interpretation of non-verbal communication as well as the therapist’s evaluation of the client’s openness and trustworthiness. Although less frequent, when anger and hostility were described by therapists, these characterized the interaction with Mizrahi clients. We discuss implications to care including the need to promote a culturally humble approach to providing care for minorities.

End of Life Care's Ongoing Evolution.

PRIMARY PRACTICE SETTINGS:: Applicable to all settings across the transitions of care where case management practice occurs. Continuing shifts in society's cultural landscape, ongoing emphasis on value versus volume, and other industry fiscal imperatives continue to evoke an evolution in end-of-life care. The attainment of successful outcomes by professional case managers with those populations will be dependent on awareness and comprehension of regulations, legislation, and reimbursement; the influences of ongoing industry trends; availability of emerging resources; and ongoing technological advances. Ethical excellence remains at the core of case management across the interprofessional workforce and the transitions of care. The professional case management workforce is tasked to effectively intervene across diverse client populations, with their caregivers and support systems. This action spans every life stage and illness course. With end-of-life care treatment and processes continuing to receive prime industry attention, case managers must be knowledgeable of the moving parts of this arena. Awareness of the ethical edges of each professional's sandbox is essential to quality-driven case management practice.

Compassion Focused Art Therapy for people diagnosed with a cluster B/C personality disorder: An intervention mapping study

A key concern of Compassion Focused Therapy (CFT) is to develop inner warmth, safeness and soothing. The aim of the current study was to develop a compassion focused art therapy programme for clients diagnosed with Personality Disorders (PDs), the goal being to strengthen compassion skills and achieve more adaptive emotion regulation.The Intervention Mapping Method was used for this purpose, based on: 1) determining needs, 2) goals for behavioural change, 3) theoretical art therapy methods and practical applications, 4) translation into an art therapy intervention, 5) planning adaption, implementation and durability, and 6) an evaluation plan. Use was made of a number of literature studies, focus groups with clients and occupational group professionals, questionnaires and a feasibility study.The study resulted in the development of a Compassion Focused Art Therapy (CFAT) intervention for clients diagnosed with PDs, in which the most important goal was strengthening their compassion for themselves and for others. Key topics of CFT are found here as well, such as mindfulness, imagery and emotion regulation systems. The programme is based on a number of potentially effective methods that were specifically combined and tailored for this client population. Further research with a larger sample is needed to substantiate the intervention.

Building Nutrition into a Falls Risk Screening Program for Older Adults in Family Health Teams in North Eastern Ontario.

Approximately 30 per cent of those over the age of 65 living in the community fall at least once each year, and a similar proportion are at nutrition risk. Screening is an important component of prevention. The objective of this study was to understand how to add nutrition risk screening to a falls risk screening program in family health teams (FHTs). Interview participants (n = 31) were staff/management, regional representatives, and clients from six FHTs that had started integrating screening. Thematic analysis was conducted. Themes identified how to develop screening programs: setting up for successful screening, making it work, and following up with risk. An overarching theme recognized "it's about building relationships". Adding nutrition risk to a falls risk screening program takes effort, and is different for each FHT based on their work flow and client population. Determining how to integrate screening into the work flow and planning to address identified risk are necessary components.

Characteristics of health care related to mental health and substance use disorders among Community Health Centre clients in Ontario: a population-based cohort study.

Community Health Centre (CHC) client populations with a history of mental illness or substance use disorders, or both, are not described well in the literature. We identified CHC clients in Ontario with a history of health care related to mental health or substance use disorders, or both, and describe their demographic characteristics, health system use and related health risks in comparison to other people in the province with similar diagnoses who did not use CHC services. We conducted a population-based cohort study using provincial health administrative data among Ontario residents aged 21-105 years with a previously established medical history of a mental illness or substance use disorder, or both. We examined 3 groups: clients of CHC sites that serve at-risk priority populations (PPCHCs) who presented for care at a CHC between Apr. 1, 2014, and Mar. 31, 2015, clients of CHC sites that serve nonpriority populations (NPPCHCs) who presented for care at a CHC over the same period, and a community control group of patients with a history of health care use related to mental illness or substance use disorders, or both, in the 2 years before the index date who were not CHC clients. We used descriptive statistics and multivariable logistic regression to estimate the odds of psychiatric care and emergency department use within 1 year of the index date. Compared to the community control patients (n = 1 673 200), clients of PPCHCs (n = 6575) and NPPCHCs (n = 15 208) were younger, experienced more residential instability and had an increased prevalence of medical comorbidities; they had higher odds of receiving care from a psychiatrist (adjusted odds ratio [OR] 1.26, 95% confidence interval [CI] 1.20-1.33, and 1.47, 95% CI 1.41-1.53, respectively) and visiting an emergency department (adjusted OR 1.15, 95% CI 1.10-1.20, and 1.13, 95% CI 1.09-1.17, respectively) in the 1-year follow-up period. Ontario CHC clients with mental health or substance use disorders had medically complex needs and were intensive users of the health care system. Specific interventions should be developed to better serve this vulnerable population.