Empathy is a critical component of high-quality healthcare. When present in the clinical encounter, empathy is important to physicians (empathy is correlated with reductions in physician anxiety and burnout) and to patients (empathy is correlated with better medical decision making, enhanced trust, and improved treatment adherence). Unfortunately, there is an empathy gap in healthcare–physicians often miss opportunities to demonstrate empathy to their patients. This leaves patients feeling unheard, less likely to bring up details important to their care, and less likely to follow treatment guidelines from physicians, thus disrupting the physician-patient relationship. Luckily, communicating with empathy is a skill that can be taught and learned. With the right tools, learners can strengthen their empathic muscle and become better prepared for responding in difficult situations. The present thesis aims to validate a new tool for teaching empathy to medical trainees. This tool, an empathic communication guide, is drawn from social work as well as medical expertise. It is catered specifically to how medical trainees are accustomed to learning and provides the actual words to say in order to respond with empathy in difficult situations. A group of 8 palliative care fellows at MD Anderson Cancer Center in Houston, Texas received a copy of this guide and participated in an accompanying communication workshop. To gauge empathic responding ability, fellows completed pre- and post- surveys and patient simulations. These data were analyzed using a combination of novel and established methods for quantifying empathic behaviors. Fellows’ empathic communication skill significantly improved after exposure to the guide opening avenues for future study and application.

Health care in the United States has been undergoing significant changes since the 2010 passage of the Patient Protection and Affordable Care Act. One of the outcomes of this policy was an attempt to bring physical health care and behavioral health care together in an effort to provide more coordinated care for patients. This change created an opportunity to improve the quality of care for patients, and as a result reduce high cost emergency service that could be prevented through better maintenance of chronic conditions. Three studies were conducted to examine challenges behavioral health agencies face in implementing two models of coordinated care (co-located and fully integrated), staff and organization capacity and needs, and patient service utilization by model of care coordination. The first study used site visits and interviews to capture the challenges faced by agencies. Results from this study indicated that behavioral health agencies faced a number of challenges in providing coordinated care including financial barriers, regulations, information sharing, inadequate technology, and provider training needs. The second study used a staff survey to assess agency and staff capacity and needs in providing coordinated care. The results from this study found differences in capacity based on model of coordination in multiple dimensions related to inter-agency coordination and communication, role clarity, and team cohesion. The third study examined patient service utilization for outpatient visits, inpatient visits, and emergency visits. The results indicated that patients receiving care from co-located agencies were more likely to have at least one encounter in each of the three service utilization categories compared to patients at fully integrated agencies. Overall, the three studies suggest that agencies that have or will implement models of coordinated care face significant barriers that may impact the sustainability or feasibility of such care. Given the findings on patient service utilization, it seems that coordinated care has great potential for patient level outcomes which makes addressing agency barriers even more critical.

This thesis examines the demographic, clinical, and criminal characteristics and discharge dispositions of pre-trial defendants deemed incompetent to stand trial and non-restorable (IST/NR) in Pinal County Arizona. Currently, there is limited research on defendants who are deemed IST/NR and even less so on discharge dispositions. The study utilized comparative descriptive analysis of secondary data collected by the Pinal County Attorney Offices on IST/NR defendants and restored defendants. It employed chi-square analyses to compare key variables between defendant groups. The study found few variations in clinical, legal, and criminal characteristics observed by previous studies and no statistical differences amongst IST/NR and restored defendants. However, it found the re-offense rate of IST/NR defendants in Pinal County was considerably lower than the general prison population. Moreover, it identified a narrow use of civil commitment procedures and guardianship amongst the IST/NR defendants who have a mental illness. Implications for further research and policy for Pinal County and Arizona are made.

In the wake of the wars in Iraq and Afghanistan, courts and social service systems across the country have begun establishing veterans treatment courts (VTC). The first VTC was created in 2004 and there are now over 300 in at least 35 states. Yet, their underlying assumptions have not been clearly articulated and their functioning and outcomes have not been well tested. These courts aim to reduce rates of incarceration and recidivism among justice-involved veterans and draw heavily on the structure and assumptions of drug and mental health courts. However, VTCs are different in important ways. Unlike other problem solving courts, VTCs actively express gratitude to criminal defendants (for past military service) and have the ability to connect participants to a socially-esteemed identity. Earlier problem solving courts have drawn on Tyler’s theory of procedural justice to predict a path from procedurally fair treatment and social bonds with court personnel through changes in social identity to increased perceptions of legal legitimacy and, ultimately, program completion and reduced recidivism. The present study tested a modified, version of Tyler’s theory that incorporates gratitude and focuses on veteran identity as the mediating construct between fair treatment and perceptions of legal legitimacy. A cross-sectional survey design was used with a convenience sample (N = 188) of participants in two Arizona VTCs. The results indicate that perceptions of procedural justice, perceived social bonds and receipt of gratitude are positively associated with both veteran identity and perceptions of legal legitimacy. Further, veteran identity was found to be a significant mediator between the first three constructs and legal legitimacy. Finally, neither recidivism risk nor race/ethnicity moderated the relationships. The study supports the importance of acknowledging past military service and enhancing the level of veteran identity among VTC participants. Implications for practice and future research are discussed.

Families with intellectually disabled caregivers are more likely than families without intellectually disabled caregivers to experience poor child welfare outcomes, including high rates of substantiation. However, little research has examined child maltreatment re-reports among this population. The objectives of this study were to begin to address this gap by examining maltreatment re-report rates, and factors associated with maltreatment re-reports, among child welfare-involved families with intellectually disabled caregivers. Survival analysis was conducted using restricted release data from the National Survey of Child and Adolescent Well-Being (NSCAW) to examine the hazard rate and survival rate of maltreatment re-reports for cases with, and without, intellectually disabled caregivers. Multivariate discrete-time hazard models were run using logistic regression to examine the relationship between various predictors and the hazard of maltreatment re-reports. Results revealed that child protection cases involving caregivers with intellectual disabilities were no more likely than cases without intellectually disabled caregivers to experience maltreatment re-reports. Predictors of maltreatment re-reports varied based on whether or not a case involved a caregiver with an intellectual disability. Child gender, child disability, and child race/ethnicity were significant predictors for cases involving caregivers with intellectual disabilities, whereas prior involvement with CPS, caretaker drug problems, and initial allegation substantiation were significant predictors for cases not involving caregivers with intellectual disabilities. These preliminary findings suggest that prevention, screening, and intervention strategies should consider variability of predictive factors based on caregiver intellectual disability status.