Parents’ Cannabis-Related Attitudes and Emerging Adult Offspring Cannabis Use: Testing the Mediating Effect of Perceived Parental Approval
Background: Contrary to parental alcohol use and expectancies work, little is known about how parent’s cannabis use (CU) and expectancies influence offspring CU. This is a notable gap in the literature given increasing acceptability and use of cannabis, especially among emerging adults (EA). Moreover, limited work has tested mechanisms of transmission of risk from these parent factors. This study addresses these gaps by testing prospective associations of parental CU and expectancies with offspring CU and CU problems, and perceived parental approval of offspring CU as a potential mediator. Method: A community sample of 314 EA and caregiver dyads completed three annual assessments (mean age = 19.13). The sample was 54% female and majority White/non-Hispanic (76%). Caregivers reported on their cannabis expectancies and use, and EA reported on their CU, CU-related problems, and perceived parental approval of CU. Results: Longitudinal structural equation modeling supported a mediated pathway such that high parental positive cannabis expectancies were associated with perceived parental approval of CU, which in turn, predicted increases in EA CU and CU problems. Parental negative expectancies had a significant indirect effect but in the opposite direction. Indirect effects were found above and beyond parental CU, which was not associated with offspring CU. Conclusions: This is the first study to test prospective indirect effects of parental cannabis expectancies on offspring CU. Findings suggest parents’ attitudes, even in the absence of parental use, confer risk for offspring use by shaping perceived acceptance of CU, suggesting parental expectancies as targets for parent-based CU interventions.
Diverse Spirituality Revisited: Lessons Learned
Chapters included in this volume highlight the vibrancy of research into diverse spiritualities. As shown by many of the book’s chapters, culturally specific measures enhance our ability to explain and understand the complexities of spiritual phenomena and help us appreciate religious traditions other than our own and humanize “the other.” The book includes chapters describing measures of Eastern forms of meditation, spiritual Jihad, afterlife beliefs associated with the three main religious worldviews, spirituality among Latin American youth, and Muslim religiousness. The case for particularism is not in conflict with that for universalism as some of the measures have been used cross-culturally. The challenge is to productively fuse these two research traditions. A second set of chapters explores the complex spiritual terrain of the Western world in the post-1960s era. These chapters illuminate a common theme of spirituality decoupled from traditional religiousness—all measures reflect a belief in interconnectedness between the person and the world at large—and articulate differences dependent on socio-cultural and historic contexts (e.g., the U.S. versus Western Europe) and field of inquiry (e.g., the psychology of religion versus transpersonal psychology). Other chapters demonstrate the empirical utility of assessing spirituality related concepts including spiritual support, modeling, struggle, well-being, as well as, prayer coping, faith, and meaning making. The new tools described in this book expand the understanding of the role played by spirituality in our rapidly changing and interconnected world while, at the same time, highlighting the aspects of spirituality common among all peoples and cultures.
The Interpersonal and Psychological Impacts of COVID-19 on Risk for Late-Life Suicide
Older adults experience increased risk for suicide compared to the general population, and the circumstances surrounding the Coronavirus Disease 2019 (COVID-19) may potentiate this risk. We discuss how current COVID-19 pandemic-related policies are likely to harm older adults disproportionately. COVID-19 pandemic social distancing policies and ethical guidelines for COVID-19 treatment may exacerbate experiences of social isolation, perceived expendability, and exposure to suffering, which are related to the 3 main components of the Interpersonal Theory of Suicide (i.e., thwarted belongingness, perceived burdensomeness to society, and capability for suicide). The COVID-19 pandemic poses a drain on services and has drawn ethical debates about policies around treating younger adults first. These experiences may lead older adults to have reduced access to needed medical and psychiatric services and may convey damaging messages of expendability. Furthermore, the potential prolonged stress associated with the COVID-19 pandemic may affect neurological, immunological, and health functioning—exacerbating suicide risk. Potential venues to increase treatment options and decrease social isolation are discussed. We acknowledge optimistic effects as well, such as “pulling together” as a society and the many valuable ways older adults may contribute during this crisis.
The Perceived Spiritual Support Scale (PSSS): Measuring Support from the Deep Connection with Diverse Sacred Entities
The concept of perceived spiritual support (PSS) centers on an internalized resource derived from perception of an intimate relationship with a higher power, be it God, Jesus, a cosmic force, ancestral spirits, or a psychologically functional equivalent. The literature has indicated the increasing importance of spiritual support in crises and medical care, but previous assessments tended to focus on mainstream religions with inadequate validation. To meet the gap and based on related scientific theories, three crises-based studies were conducted to develop and validate a 12-item scale of perceived spiritual support (the PSSS) for assessing the spiritual resource of individuals with diverse belief systems. This endeavor was also a response to a long-standing call for measuring consciousness-related faith experience and to an assessment problem—the use of simple frequency measures in large-scale epidemiological or sociological surveys. Participants in the three studies reflect varied makeups of age, gender, generation, race, belief systems, and cultural backgrounds. The findings provide the adequate psychometric information for the PSSS and its predictive value for various outcomes. Multivariate analyses demonstrated the indirect mediating or pathway effect of the PSSS, simultaneously evaluated the effects of other established factors, and tested an explanatory mechanism underlying its predictive value. The results suggest that the PSSS, as a short and easy to use tool, can be used to predict important outcomes in crises and across different populations. More cross-cultural studies are warranted for further validation.
“It really presents a struggle for females, especially my little girl”: Exploring father’s experiences discussing body image with their young daughters
Body dissatisfaction in children, particularly young girls, is a growing concern around the world. The home environment can have a strong influence on children’s well-being, and parents may contribute to their children’s positive or negative body image development. Nearly all research on parent influence on body image has focused on mothers, leaving fathers’ attitudes and experiences poorly-understood. To address this gap in the literature, we interviewed 30 fathers (Mage = 40.30; SD = 7.48) of girls between the ages of 5 and 10 about the conversations they have with their daughters regarding body image. Through thematic analysis, we identified three primary themes: barriers to effective communication, combatting negative influences, and strategies for discussing body image. Fathers recognized the importance of talking about body image with their daughters, yet many did not feel confident or competent to do so effectively. They engaged in a variety of strategies to combat adverse cultural influences and encourage self-expression, character development, and mental and physical health in their daughters. However, messages about health were sometimes conflated with messages about thinness or food restriction. Implications for families and future research are discussed.
Methods of visual assessment in children with cortical visual impairment
Purpose of review: Cortical visual impairment (CVI) is the leading cause of pediatric visual impairment in developed countries. Currently, there is no standardized method of visual assessment in these children, who usually cannot participate in tests designed for typically developing children. A reproducible method of visual assessment that accurately reflects the multitude of visual deficits in CVI is critical to evaluate proposed therapies for this disorder. This review analyzes current research on methods of visual assessment in children with CVI. Recent findings: Earlier studies focused on measuring visual acuity in children with CVI. More recent studies have emphasized other aspects of visual function, such as contrast sensitivity, motion detection, and visual search. Current research topics include questionnaires, functional vision assessment (CVI Range), neuropsychological tests of visual perception, and eye tracking. Eye tracking shows promise for visual assessment in both clinical and research settings because it is objective and quantitative, with the ability to assess diverse visual parameters. Summary: Current research on visual assessment in children with CVI focuses on measuring deficits of visual function beyond visual acuity. This research represents an important step toward designing clinical trials to identify effective therapeutics for this increasingly prevalent disorder with heterogeneous manifestations.
The impact of a diversity intervention on White college students’ colour-blind racial attitudes
This research explored the impact a 3-day pre-college diversity intervention had on incoming White college students’ (N = 63) colour-blind racial attitudes (COBRAS), or their unawareness of racial privilege, blatant racial issues, and institutional discrimination. Repeated measures analysis of variance tests indicated that students reported a greater awareness of racial privilege and blatant racial issues immediately after the programme. Students’ awareness of institutional discrimination – a potentially more abstract and complex understanding of racism – did not change after the program. To isolate the effects of the intervention, independent sample t-tests between White college students who did not undergo the intervention and intervention participants were conducted. Results indicated that both samples did not have significantly different COBRAS before the intervention, providing evidence that the intervention likely contributed to changes in intervention participants’ COBRAS. These results suggest that the pre-college diversity intervention impacted forms of COBRAS differently. Implications for diversity interventions on predominantly White college campuses are discussed.
Teaching Social Work Practice in the Shared Trauma of a Global Pandemic
Unique clinical dynamics occur when both clinician and client are exposed to the same community traumatic event or reality. This reflection explores the applicability of the concept of shared trauma for social work educators in the context of the COVID-19 pandemic. The author describes her experiences shifting suddenly to teaching social work direct practice courses online, against the backdrop of a rapidly escalating coronavirus pandemic. Several parallels to the clinical concept of shared trauma are described, including a stronger emphasis on the mutuality of the teaching relationship, heightened emotional identification with students, and blurred professional boundaries in the student-teacher relationship. The author also describes significant differences between her own experiences and those of her students, recognizing that shared trauma is not always shared proportionately in environments of persistent racial and economic inequality. The chapter concludes with implications for educators working in shared trauma contexts, including the importance of self-care and administrative support. Teaching in a shared traumatic reality requires social work educators to stay cognizant of our connections to our students, as well as the disproportionate tolls of this pandemic.
“Don’t Know where to Go for Help”: Safety and Economic Needs among Violence Survivors during the COVID-19 Pandemic
The COVID—19 pandemic and related quarantine has created additional problems for survivors of interpersonal violence. The purpose of this study is to gain a preliminary understanding of the health, safety, and economic impacts of the COVID-19 pandemic on people that are experiencing or have previously experienced violence, stalking, threats, and/or abuse. An online survey, open from April to June 2020, was taken by people with safety concerns from interpersonal violence. Participants were recruited from IPV and sexual assault-focused agencies, state coalitions, and social media. Quantitative data were summarized using descriptive methods in SPSS and coding methods from thematic and content analysis was used to analyze qualitative data from open-ended questions. A total of 53 participants were recruited for the survey. Individuals with safety concerns have experienced increased challenges with health and work concerns, stress from economic instability, difficulties staying safe, and access resources and support. Over 40% of participants reported safety had decreased. Use of social media and avoidance strategies were the most common safety approaches used. Participants reported mixed experiences with virtual services. The COVID-19 pandemic has exacerbated existing structural concerns for survivors of violence like IPV and sexual assault. Increased support and economic resource access, coupled with modified safety planning and improved virtual approaches, would better help meet survivor needs.
“We’re just two people in a relationship”: A qualitative exploration of emotional bond and fairness experiences between transgender women and their cisgender partners
Trans‐including couples experience systemic marginalization impacting their relationships, yet studies on these relationships or narratives of strength are few. The purpose of this qualitative study was to explore emotional bonding and perceptions of fairness between transgender women and their cisgender partners. Interpretative Phenomenological Analysis was utilized to answer the research question: What are the experiences of emotional bond and fairness between transgender women and their cisgender partners? This research was situated within frameworks of minority stress, romantic attachment, and contextual therapy. Seven couples of transgender women and cisgender partners were interviewed. Three themes emerged: Minority Stress Contexts and Relational Strengths; The Experience of Emotional Bond; and Negotiating Balance. Processes of boundary creation, attunement, affirmations, and balance of care were noted. Findings reframe partner relationships as opportunities to construct transphobia‐resistant and resilient narratives. Recommendations for clinicians include prioritizing the couple subsystem as an avenue for building resilience against minority stress.
What Gets Measured in Reentry Research? A Scoping Review on Community Reentry From Jail and Prison for Persons With Mental Illnesses
Research on reentry for individuals with mental illnesses leaving jails and prisons lacks outcome specificity and standardization needed to advance knowledge about the efficacy and effectiveness of interventions. This scoping review aims to provide clarity about reentry outcomes by: (a) ascertaining what outcomes are a focus in reentry research, (b) explicating how outcomes are defined, and (c) identifying commonalities or gaps in outcomes reported. A search of multiple databases yielded 415 articles for potential inclusion. After independent document review by two of the authors, 61 articles were included in the review. Recidivism was the most used construct, accounting for 58% of total outcomes and 95% of criminal legal outcomes. Behavioral health indicators were reported the second most frequently and other outcomes were rarely reported. Increasing the specificity of commonly used concepts while also expanding the breadth of outcomes considered is needed to build an evidence base this area of research.
Can Precision Medicine Actually Help People Like Me? African American and Hispanic Perspectives on the Benefits and Barriers of Precision Medicine
To better understand African American and Hispanic perspectives on the potential benefits of precision medicine, along with the potential barriers that may prevent precision medicine from being equally beneficial to all. We also sought to identify if there were differences between African American and Hispanic perspectives. Six semi-structured focus groups were conducted between May 2017 and February 2018 to identify benefits and barriers to precision medicine. Three groups occurred in Nashville, TN with African American participants and three groups occurred in Miami, FL with Hispanic participants. At community-based and university sites convenient to community partners and participants. A total of 55 individuals participated (27 in Nashville, 28 in Miami). The majority of participants were women (76.5%) and the mean age of participants was 56.2 years old. Both African Americans and Hispanics believed precision medicine has the potential to improve medicine and health outcomes by individualizing care and decreasing medical uncertainty. However, both groups were concerned that inadequacies in health care institutions and socioeconomic barriers would prevent their communities from receiving the full benefits of precision medicine. African Americans were also concerned that the genetic and non-genetic personal information revealed through precision medicine would make African Americans further vulnerable to provider racism and discrimination in and outside of health care. While these groups believed precision medicine might yield benefits for health outcomes, they are also skeptical about whether African Americans and Hispanics would actually benefit from precision medicine given current structural limitations and disparities in health care access and quality.
The role of elementary school and home quality in supporting sustained effects of pre-K
Using data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (NICHD SECCYD), we used 2-level random effects models to examine whether the quality of school and home environments during elementary school moderated associations between pre-K quality and math, reading, and vocabulary achievement from first through fifth grade. Results showed that the quality of the home environment moderated the association between pre-K quality and children’s vocabulary achievement. Supportive home environments during elementary school had an additive effect over and above the positive effects of pre-K quality in predicting children’s vocabulary achievement. In contrast, when children experienced high levels of pre-K quality and lower quality home learning environments, the positive effects of pre-K were less likely to be sustained. Findings suggest the importance of considering programs and policies to support home-based learning as one potential mechanism to sustain early effects of pre-K.
Cognitive behavioral intervention for trauma in adolescent girls in child welfare: A randomized controlled trial
Objective This study tested the effectiveness of Cognitive Behavioral Intervention for Trauma in Schools (CBITS) in adolescent girls involved in the child welfare system. Three outcomes were evaluated: symptoms of posttraumatic stress disorder (PTSD), depression, and social problem-solving skills. Method A randomized controlled trial was utilized to compare the effects of an adapted version of CBITS with usual care (UC) services. Participants were ages 12 to 19 (N = 249), the majority of whom (69.5%) were African American. Participants’ symptoms of PTSD, depression, and social problem-solving skills were evaluated at pre, post (3 months), and follow-up (6 months) assessments. Linear mixed models were used to compare condition by time interactions using all available data. Control variables were demographics, service use, and number of types of traumas. Treatment fidelity, participant acceptability, and satisfaction with the intervention were also examined. Results Analyses indicated that participants in the CBITS condition showed significantly greater increases in social problem-solving than the UC condition. For both PTSD and depression symptoms, there were no significant differences between the two conditions. Both the CBITS and UC participants showed significant reductions in symptoms. Results also indicated that this intervention is an acceptable model for this population. Conclusions Despite the growth of trauma-focused, evidence-supported interventions for reducing PTSD and depression, knowledge of effective interventions in child welfare youth lags behind. Because CBITS is more effective than UC in increasing social problem-solving skills, this intervention may be an important treatment option for this population.
Co-occurring risk factors among U.S. high school students at risk for suicidal thoughts and behaviors
Background: Suicidal thoughts and behaviors (STBs) are increasing among adolescents in the United States and are challenging to predict and prevent. The current study identifies subtypes of youth at risk for suicidal thoughts and behaviors (STBs) in school-based settings. Method: Data are from the CDC’s 2015 and 2017 National Youth Risk Behavior Survey of US high school students. Among students reporting depression symptoms, latent class analysis is used to identify subtypes at risk for STBs based on personal characteristics, risk behaviors and environments. Results: Two distinct subtypes of youth were found to be at high risk for STBs: The first, larger subtype (22%) is predominately females in early high school, many of whom identify as bisexual, experienced past-year bullying, and are likely to have experienced sexual victimization. These students have low levels of externalizing risk behaviors making them difficult to detect. The second high-risk subtype (7%) is characterized by students with significant social integration challenges, with extremely high levels of substance abuse, fighting, physical and sexual victimization and poor academic performance. Many of these students have low English fluency, and identify as sexual minority. Limitations: Due to attrition or language barriers, experiences of some students at high-risk for STBs may not have been captured by this survey. Conclusion: Universal screening in clinical settings, and universally focused suicide prevention programs in school-based settings are needed and should be introduced early on. Interventions should be tailored to reach high-risk students with language, cultural and social integration challenges.
Utilizing Crisis Intervention Teams in Prison to Improve Officer Knowledge, Stigmatizing Attitudes, and Perception of Response Options
People with mental illness (MI) are overrepresented in prisons, in part, because people with MI stay in prison longer. Correctional officers (COs) use discretion in force, violations, and segregation. Crisis intervention teams (CITs) are being used in corrections to reduce disparities in sanctioning and improve safety. This quasi-experimental, mixed-methods study includes 235 CIT COs who were surveyed before and after training on knowledge of MI, stigmatizing attitudes, and perception of response options. Non-CIT (n = 599) officers completed the same survey. Randomly selected CIT COs completed interviews 6 to 9 months following training (n = 17). CIT COs had significantly lower stigmatizing attitudes, more mental health knowledge, and better perceptions of options following CIT training compared with non-CIT COs. This preliminary work on CIT use in prison is promising; additional work is needed to determine whether these changes result in behavior change among COs and improvements in outcomes for people with MI.
Characterizing the predictive validity of measures of susceptibility to future use of combustible, vaporized and edible cannabis products in adolescent never-users
Background and aims: The construct of susceptibility to substance use initiation (i.e. cognitive proclivity to future use) is critical for prevention efforts in adolescent populations. This study aimed to provide empirical evidence for the validity of the susceptibility construct for different cannabis products (i.e. combustible, edible or vaporized cannabis), and evaluate whether susceptibility measures are predictive of subsequent initiation. Design: Prospective cohort study including baseline data (Spring 2015) and four follow-up surveys administered every 6 months through Spring 2017. Setting: Ten schools in the Los Angeles, California metropolitan area. Participants: Adolescents [n = 2100; mean age = 16.1; standard deviation (SD) = 0.41; 54% female] who reported never having used any cannabis product at baseline.Measurements: We assessed five indices of a susceptibility to use cannabis composite index at baseline, adapted from a validated tobacco use index (intention to use, willingness, curiosity and positive/negative cannabis use outcome expectancies, with four response categories, definitely not  to definitely yes ), by cannabis product (combustible, edible or vaporized). A composite index was created for each product by averaging responses across the five susceptibility items. Subsequent initiation of use of each cannabis product was assessed at each follow-up wave. Findings: Factorial validity for unidimensionality for each five-item index (by product) was confirmed. The composite index for susceptibility to cannabis use was greatest for combustible (mean = 1.44; SD = 0.58), moderate for edible (mean = 1.37; SD = 0.53) and lowest for vaporized cannabis (mean = 1.30; SD = 0.44). The associations of each composite susceptibility index with subsequent initiation of that product and each of the other cannabis products over follow-up (i.e. cross-product associations) were statistically significant, with hazard ratios ranging from 2.30 to 2.80 across 24 months of follow-up (all Ps < 0.05). Conclusions: A five-item susceptibility to cannabis use composite index (by product) appears to be useful for characterizing and predicting youth at risk for cannabis use initiation across a spectrum of cannabis products.
Collective Threat: Conceptualizing Blumer’s Threat as a Collective Emotion
This manuscript lays the groundwork for considering racial threat as a collective emotion. Although sociologists regularly study racial threat, a disconnect exists between Blumer’s theoretical framework (1958) and modern empirical measurement. Research has largely measured racial threat as perceptions of competition or increases in racism. Neither, however, squarely fits the symbolic interactionist framework that Blumer championed. This manuscript frames racial threat as an affective group response that is generated through sustained interaction with social groups and group representations. After showing how Blumer’s threat conceptualization fits the parameters of a collective emotion, I demonstrate how quantitative measurement and experimental research design can be used to capture threat as Blumer outlines it. Then, using factor analyses and regression, I illustrate that collective threat is distinct from other collective emotions and operates according to Blumer’s theoretical predictions. The manuscript concludes with a discussion of how ongoing attempts to measure collective threat and the evolution of racism in the United States highlight the continued relevance of Blumer’s work.
Putting Quality Metrics in Context: A Novel Index Approach to Measuring Inpatient Utilization
To determine the preliminary feasibility and reliability of a novel health plan‐level quality index reflecting multiple aspects of inpatient utilization currently measured by separate quality metrics. Analysis of three Healthcare Effectiveness Data and Information Set (HEDIS) measures: Acute Hospital Utilization (AHU), Hospitalizations for Potentially Preventable Conditions (HPC), and Plan All‐Cause Readmissions (PCR). Proportion of plans able to report these measures were examined within and between measurement years. Individual measure performance was scored on the observed‐to‐expected (O/E) ratio: O/E = 1 “as expected” (score of 0), O/E < 1 “better than expected” (score of +1), and O/E > 1 “worse than expected” (score of ‐1). Measure scores were summed to create an index (‐3 to +3). Performance variation was examined. Index unidimensionality and reliability were evaluated using coefficient omega (total and hierarchical) and explained common variance (ECV). Medicare Advantage (MA) plans reporting HEDIS in measurement years (MY) 2017 (505 plans) and 2018 (525 plans). To align reporting strata across the three metrics, analysis was restricted to beneficiaries age 65 and older. A majority of plans were able to report measures in both MY2017 and MY2018 (AHU: 67.0%, HPC: 65.7%, PCR: 60.7%). In MY2018, 71.4% of plans reported all three measures. The strongest correlation in O/E ratios was observed between AHU and HPC (Pearson: 0.29, Spearman: 0.64), the weakest between AHU and PCR (Pearson: 0.19, Spearman: 0.17). A moderate correlation was observed between PCR and HPC (Pearson: 0.31, Spearman: 0.36). “Better than expected” (+1) was the most common measure‐level score on AHU (48.0%) and HPC (51.4%). “As expected” (0) was the most common score (58.5%) on PCR. The most common index score was +2 (25.1%), and mean score was 0.3. HPC performance scores were most likely to contribute to an increased index score (52.4% of cases), and AHU performance was most likely to contribute to a decreased index score (42.1% of cases). PCR performance was as likely to increase (20.5%) as decrease (21.1%) the index score. When the original O/E ratio for each measure was retained, moderate‐to‐good reliability was observed. Omega hierarchical approached the minimum 0.50 threshold (0.49), and ECV met the 0.85 threshold for unidimensionality. Omega hierarchical decreased significantly (0.33), and ECV no longer achieved the 0.85 threshold when the composite was scored as an ordinal index (‐3 to +3). A composite inpatient utilization index is feasible and demonstrates meaningful variation. Index‐style scoring is useful for visualization and identification of trends; however, composite reliability is achieved only when original O/E ratios are maintained. Alternative scoring approaches should be examined. Inpatient utilization is a primary driver of health care costs and critical target for quality improvement. Current health plan accountability metrics focus on different components of utilization separately and may miss the relationships between them. Interventions to improve one metric may overlap into another, while over‐focusing on one aspect in isolation may lead to perverse incentives (eg, keeping total hospitalizations high to make readmission rates appear low). The proposed composite approach provides a more complete representation of inpatient care, improving transparency and accountability.
The Influence of Implicit Theories of Depression on Treatment-Relevant Attitudes
Implicit theories (beliefs about the malleability of self-relevant traits) of emotion are associated with various motivational and emotional responses. Less is known about implicit theories of depression. The present study examined the effects of a manipulation of implicit theories of depression on depression symptom severity, engagement in a self-help task, and treatment-relevant attitudes. Participants experiencing clinically significant levels of depression (N = 142) were randomly assigned to receive education about depression emphasizing either the malleability of depression (incremental condition) or depression as a chronic condition (entity condition). Participants subsequently completed a self-help task for depression. Symptom severity, stigma, prognostic pessimism, psychotherapy and antidepressant credibility, psychological flexibility, and time spent on the self-help task were assessed. Participants in the incremental condition endorsed a greater incremental theory of depression than did those in the entity condition. To the extent that the experimental condition was associated with the adoption of an incremental theory of depression, depression symptom severity and stigma decreased, and treatment-relevant attitudes were more favorable. The experimental condition had no effect on self-help task persistence. Presenting depression as malleable may be associated with more positive attitudes towards treatment, although the impact on actual treatment engagement warrants future investigation.