To assess a wide range of stressors and traumas, we developed a trauma and stressors exposure checklist for adults to capture a wide variety of potential trauma exposure. This study details the extensive development and validation process of the Comprehensive Trauma and Stressors Checklist (CTSC). Study 1 consisted of item pool generation, review of existing trauma measures, content analysis, and expert review and input. Study 2 analyzed reliability and validity of the updated checklist. Participants were recruited from college and community samples (N = 200) and completed the CTSC along with five additional measures. The CTSC demonstrated high internal consistency (α =.96). Good temporal stability was established with a subset of participants (n = 28) who completed the survey twice for test-retest reliability (r = 0.86, p < .001). Significant correlations between scores on the CTSC and the Stressful Life Events Screening Questionnaire, Life Events Checklist for the DSM-5, Intersectional Discrimination Index, and Spiritual Abuse Questionnaire are evidence of strong convergent validity. Finally, the lack of significant correlations between CTSC scores and theoretically unrelated constructs supported the discriminant validity of the CTSC. This study provides preliminary evidence that the CTSC is a reliable and valid measure of exposure to traumas …

In Miranda v. Arizona (1966), the Supreme Court of the United States required that custodial arrestees be informed of their constitutional and continuous rights to silence and to legal counsel. Moreover, the ruling mandated that waivers be considered valid only if they were made knowingly, intelligently, and voluntarily. However, in the decades that followed, evidence from both caselaw and empirical scholarship clarified that, for many vulnerable populations, these rights are in jeopardy. Among these vulnerable populations, those with limited cognitive capacities (LCCs) have been functionally excluded from research which primarily focused on persons with intellectual disabilities. This thesis offers a novel exploration of the role of specific cognitive impairments on Miranda comprehension and reasoning, with a focus on verbal intelligence (VIQ). Using a large archival sample of pretrial defendants (N = 820), current results suggest that defendants struggled with Miranda abilities regardless of other, individual characteristics. However, verbal intelligence emerged as a very strong predictor of Miranda comprehension such that those with lower VIQ were considerably more vulnerable to impaired comprehension. More so, data suggest that several compounded vulnerabilities (i.e., minoritized racial/ethnic identity status, limited academic achievement, illiteracy) are essential to understanding the extent of vulnerability in the criminal legal …

The current study examined the nature and extent of endorsement of PMIEs, the nature and severity of MI symptoms related to endorsement of a PMIE, and the relations between extent of endorsement of PMIEs and MI symptoms. We hypothesized that (1) PMIEs perpetrated by others would be endorsed to a greater extent than PMIEs perpetrated by oneself; (2) medical professionals who endorsed a PMIE would report significantly greater severity on all MI symptoms compared to medical professionals who did not endorse a PMIE; (3) experiencing PMIEs (perpetrated by oneself and/or others) to a greater extent would predict higher levels of MI symptom severity, and MI symptom severity would specifically be most strongly predicted by PMIEs perpetrated by oneself. Hypotheses were examined using t-tests, Pearson's r correlations, and multiple multivariate regression analyses. First, the current study found that PMIEs perpetrated by others were endorsed to a greater extent than those perpetrated by themselves; second, greater exposure to PMIEs was associated with significantly greater severity of 10 of the 14 outcomes. Third, PMIEs perpetrated by oneself predicted more MI symptomatology than PMIEs perpetrated by others, indicating that while PMIEs perpetrated by others are more common, PMIEs perpetrated by oneself are more strongly …

Socioeconomic status (SES) has been shown to reliably predict parenting practices, family well-being, and psychological outcomes throughout the lifespan. The current study employed a cross-sectional, quantitative design in which adult participants (N = 336) completed an online survey measuring demographic variables, financial stress, attachment security, and psychological well-being. The study results suggest that (a) both current and family history of financial stress negatively predicted attachment security, (b) SES positively predicted general psychological well-being, although individual SES factors (e.g., income, subjective SES, financial stress) demonstrated nuanced relationships with well-being, life satisfaction, and resilience, (c) family history of financial stress and attachment security mediated the relationship between calculated social status and psychological well-being, and (d) the mediated relationship between calculated social status and psychological well-being via the pathway of attachment security was significant for racial/ethnic minorities, but not for White participants. The present findings contribute to the current literature by (1) including multidimensional measurements of SES, (2) addressing nuances in the relationship between SES and attachment, (3) emphasizing the role of financial stress on attachment security, and (4) providing initial cross-cultural considerations in the relationships among SES, attachment, and psychological well-being. Future researchers are encouraged to conduct longitudinal analyses, amplify sample recruitment …

We ran three MANOVAs in a sample of 422 young adults to examine differences in eating, shape, and weight concerns (i.e., ESW concerns) between gender diverse individuals, ciswomen, and cismen. Additionally, we examined the effects of self-esteem and sense of belonging on ESW concerns. We also tested for interaction (moderation) effects between gender and self-esteem and gender and sense of belonging. Findings indicated that gender diverse individuals experience ESW concerns at a significantly higher rate than cisgender men. There were no differences, however, in ESW concerns between gender diverse people and ciswomen. Self-esteem and sense of belonging significantly predicted ESW concerns, but no interaction effects were observed. Limitations of the current study include using one large gender diverse group rather than exploring each individual gender identity as well as limited recruitment. Future studies should recruit more participants across the gender spectrum in order to better understand the unique experiences of each gender group as it relates to eating, shape, and weight concerns and expand recruitment across broader regions of the United States.

The current study aimed to explore the direct effect of insecure adult attachment on subjective wellbeing and its indirect effect via racial-ethnic identity. Additionally, the present study examined the extent to which racial-ethnic socialization practices may moderate adult attachment and racial-ethnic identity link. The final sample included 213 emerging adults (M = 20.94; SD = 2.96) with diverse racial-ethnic backgrounds. PROCESS Model 4 and 1 were used to examine the direct and indirect effect of insecure attachment on subjective wellbeing via racial-ethnic identity variables and the interaction effect between insecure attachment and racial-ethnic socialization on racial-ethnic identity variables. Results indicated the direct effect of insecure attachment on subjective wellbeing but did not support hypotheses for the indirect effect of insecure attachment on subjective wellbeing via the racial-ethnic identity variables. Additionally, results indicated that overt socialization buffered the negative impact of attachment avoidance on racial-ethnic identity exploration. Furthermore, racial-ethnic identity variables and subjective wellbeing significantly differed across racial-ethnic groups and socioeconomic statuses. Findings provide insight on the distinct concepts of attachment and racial-ethnic identity as they highlight inter- and intra-personal components, respectively. Mental health professionals may utilize overt socialization to help clients develop a sense of purpose and meaning related to …

Racial and ethnic diversity representation in the field of health service psychology is neither equitable nor reflective of the increasingly diverse population nationwide. This discrepancy is endemic to widespread problems associated with mental health care: Minorities are severely underrepresented in the workforce, in psychology training programs, and in treatment populations. The longstanding lack of diversity among trainees in doctoral programs and among professionals in the workforce is associated with poorer mental health outcomes among minority patients; however, the specific contributors that facilitate and maintain racial/ethnic diversity constriction appear to be understudied. Based on the extant literature, a reasonable hypothesis might be that admission of qualified underrepresented minorities to doctoral training is constricted by ineffective and/or outdated recruitment and admissions practices. The proposed study sought to investigate whether impostor feelings or self-reported resilience might be predictive of intent to apply to graduate programs among underrepresented minority students earning their bachelor's degree in psychology. Results indicated that resilience was the most impactful variable in undergraduate students' intent to apply to graduate programs. Hypothesized ethnic differences in impostor feelings and self-perceived resilience were not observed in the study sample. The larger implications of these findings underscore the need for more culturally informed measures …

Due to their influential roles in the lives of their players, understanding coaches' attitudes and perceptions toward LGBQ+ student-athletes is essential for assessing how safe collegiate sport environments are for LGBQ+ athletes. However, the research in this area has been limited. The present study aims to address this gap by investigating coaches' perceptions of LGBQ+ athletes to inform policy and education for promoting inclusive sport environments for these athletes. Participants were 1,533 collegiate coaches (Mage = 39.65 years; women = 41.3%; White = 83.7%; non-Hispanic = 86.4%; heterosexual = 74.9%) drawn from all three NCAA Divisions. In an open-ended, text response question, coaches were asked to identify the extent to which they would support and accept athletes on their teams being open about their sexual orientation and/or gender identity, and to describe the reasoning for their beliefs. Through reflexive thematic analysis, six higher order themes capturing coaches' rationales were identified: (a) levels of acceptance, (b) i coach, therefore i am…, (c) supportive environments are essential, (d) as a queer coach…, (e) limiting queerness, and (f) sexual orientation does not provide a competitive advantage. Analyses illuminate avenues for LGBQ+ athlete inclusion policies and training for coaches.

This investigation utilized data from a previous laboratory-based study to examine the interactive contributions of trait involuntary stress responses (ISRs, e.g., rumination) and perceived familial social support (SS) on the hypothalamic-pituitary-adrenal axis (HPA; as indexed via salivary cortisol) response to acute stress in a sample of 128 adolescent girls ages 12 to 16. Participants completed a modified Trier Social Stress Test (TSST), and physiologic stress response was indexed via six salivary cortisol samples. Dimensions of ISRs and familial social support were entered into regression models to predict total cortisol circulation defined by area under the curve with respect to ground (AUCG; Pruessner et al., 2003) following the TSST. Neither ISRs or SS were associated with cortisol AUCG, nor was there an interactive effect of SS on relationships between ISRs and AUCG. Implications of present results and methodological recommendations for future investigations are discussed. This may be the first investigation to consider the interactive effects of ISRs and social support on adolescent girls' HPA responses. Greater understanding of these factors in this understudied demographic will improve translational science as well as inform risk assessment and intervention development.

Narcissism is currently being redefined as a multidimensional construct. While some researchers hold that narcissism remains a unidimensional phenomenon, others have suggested that bi- and tridimensional conceptualizations may better represent the construct as well as align more succinctly with the experiences of individuals with varying levels of narcissistic traits. Also, since the latter conceptualizations offer a broader assessment of narcissistic tendencies, they may provide greater accuracy in identifying differing narcissistic phenotypes (e.g., malignant vs vulnerable). Given the variety in conceptualizations of narcissism, it remains an open area as to how their respective domains are associated with various risk factors and behavioral outcomes, particularly within antagonistic forms of narcissism. This thesis explored the multidimensional approaches to defining narcissism and examined the associations between narcissistic traits and attachment style, self-concept, self-esteem, emotion regulation, and aggression. Also, the current study explored how differences in college degree (business vs. psychology) and gender may influence the expression of narcissism and associations with attachment style. Overall, the study provides results relevant for a tridimensional view of narcissism and adds to the literature on narcissism's link with factors involved in personality pathology, gender, and choice of college degree.

The current study consisted of 4,116 student-athletes (Mage = 19.84; women = 66.9%; White = 78.2%) to achieve two purposes when considering the disrupting effects of the COVID-19 pandemic and the cancellation of collegiate sports. First, I examined the relationship between gender, race/ethnicity, competition level, and athletic identity. Though there were no significant differences across NCAA Divisional levels, I found a significant gender by race interaction with Black male athletes reporting stronger athletic identities compared to White male and female athletes as revealed by post-hoc analyses. Second, I examined the relationship between athletic identity and psychological distress and found that when social support and self-compassion are both low, there is a moderate, positive relationship between athletic identity and psychological distress for the White female athletes. Additionally, there were main effects for self-compassion and social support where higher levels were related to lower psychological distress among the White female athletes and Latino/a athletes. For the Black male athletes, there was a main effect for only self-compassion. There was a significant self-compassion by social support interaction for the Black female athletes and White male athletes, suggesting that when self-compassion is low, or high, there are higher levels of psychological distress experienced when …

Developmental psychology aims to elucidate how children's early relationships influence their interactions with the world. Piaget's cognitive development theory is often noted when discussing development, and although his cognitive descriptions of decentering (i.e., perspective taking) were compelling, they neglected interpersonal contexts. Accordingly, Feffer conceptualized decentering within a social context. To expand on Feffer's consideration of the social context, the current study explored early parent-child bonds and their impact on child development, specifically interpersonal decentering, in adolescence. In the present secondary analysis of data from the Institute of Human Development longitudinal Guidance Study at the University of California, Berkeley, I hypothesized that, for both boys and girls, conflict with relatives and a parent's nervous instability would moderate the association between early strong parental bonds and more mature decentering at ages 12.5 and 18 years, and that more imaginative play, introspection, and better physical health would moderate the relationship between strong father-son bonds at age 21 months and the son's more mature decentering at age 12.5 and 18 years. The findings revealed that the association between strong father-son bonds at 21 months and the son's more mature decentering at age 12.5 was strongest when the son was less introspective compared to when …

Little is known about the current state of multicultural training within sport psychology master's programs. The study explored students' perceptions of their multicultural training and program climate. Importantly, differences in perceptions were investigated based on students' demographic factors, given that students with marginalized identities tend to report less favorable perceptions of and experiences in graduate training. Participants (N = 107) consisted of students and recent graduates of master's level sport psychology programs. Participants reported moderate levels of feeling safe, valued, and comfortable within their master's program, low to moderate levels of multicultural training integration within their curriculum and supervision, and low to moderate satisfaction with their multicultural training. Asian, Asian American, bi/multiracial, Black, African American, Hispanic, and Latino/a/e students, compared to their White peers, reported less satisfaction with their multicultural training, felt less safe, comfortable, and valued within their programs, and perceived less integration of multiculturalism into curriculum and supervision. A multiple regression analysis revealed that, for all students, perceptions of multicultural training integration and reports of feeling safe, comfortable, and valued was significantly related to students' satisfaction with their multicultural training. Discussion focuses on possible explanations for these findings, training implications, and future research directions.

Unipolar depression is a leading cause of disability and overall burden of disease for millions of individuals across the world. Depressive symptoms (e.g., depressed mood, anhedonia, fatigue, feelings of worthlessness, difficulties concentrating, etc.) can drastically affect an individual's life leading to occupational, social, and personal impairment. Past research shows significant ethnic and racial differences in depression rates and treatment. Moreover, previous literature has also begun to explore the multidimensional nature of depression, investigating its occasion-like (or episodic) and trait-like (or stable) factors. However, prior studies have not explored differences in occasion and trait depression by race or ethnicity, nor have they explored these questions in nurses, a group that faces substantial workplace stressors. To redress these gaps, the current study investigated trait and occasion depression in a large sample of nurses (N = 390) tracked across 12 months and aimed to understand whether trait versus occasion rates of depression differed by racial and ethnic minority status. Findings indicated substantially more trait depression (65.93%) than occasion depression (34.11%) across the year in nurses. However, there were no significant differences based on racial and ethnic minority status. Results highlight the importance of understanding depression as a much more stable aspect of an …

Past research demonstrates that participants who label themselves as ‘victims' experience worse trauma-related outcomes than those who label themselves as ‘survivors.' Self-labeling in trauma research is typically measured using a dichotomous measure where participants choose either victim or survivor, but this construct may be better conceived as more continuous. The current study assessed self-labeling as a possible continuous construct and explored its predictive validity. To capture self-labeling as a continuous construct, we created and utilized a new scale, the Trauma Self-Labeling Measure. Two hundred eleven participants completed a battery of questionnaires to measure self-labeling and four trauma-related outcomes: posttraumatic stress symptoms (PTSS), depression, anxiety, and resilience. When tested on the continuous trauma self-labeling measure, an overwhelming number of participants chose in-between victim and survivor (78.9%) which suggests self-labeling is better assessed using a continuous measure than dichotomous. However, correlation analyses revealed that the continuous self-labeling measure was not significantly correlated to the four trauma-related outcomes, whereas the dichotomous self-labeling, continuous victim, and continuous survivor measures were. When conducting post-hoc analyses, we found an unexpected positive correlation between the continuous victim and survivor self-labeling measures. This unexpected positive correlation suggests that self-labeling is not a singular construct, as previously assumed, but …

Family functioning has long been a focus of research in psychopathology. Decades of research has shown that family factors are associated with symptom severity, relapse, functional outcomes, and conversion to psychosis among at-risk individuals. Previous studies suggest family functioning varies across cultures, which raises the possibility that associations between family factors and psychopathology may also differ by culture. Furthermore, family functioning assessment generally involves instruments that have not been systematically validated for use with individuals from diverse cultural backgrounds. The current study used data from the Adolescent Brain Cognitive Development study (N = 11,138) to: (1) evaluate three family functioning scales (i.e., Family Environment Scale, Child's Report of Parental Behavior Inventory, Parental Monitoring Survey) and the Prodromal Questionnaire – Brief Child version for measurement invariance across racial/ethnic groups; (2) investigate the relations between family factors and psychosis; and (3) compare relations derived from Step 2 between racial/ethnic groups. Full scalar invariance was tenable for the CRPBI and the PQ-BC, providing statistical support for mean comparisons across groups. The FES and the PMQ lacked scalar invariance, which suggests mean comparisons across groups may not be appropriate. The CRPBI and the PMQ are significantly associated with the PQ-BC, and all three family …

The data surrounding barriers to student-athletes seeking mental health care are limited, but show that stigma is one of the most frequently reported barriers. Further, the effect of sharing demographic identities (i.e., race, gender) between a student-athlete and their mental health treatment provider has not been fully explored. The purpose of this study was to determine the frequency of reported barriers and facilitators to mental health as well as the importance of sport psychologist characteristics as a facilitator of mental health treatment. Participants consisted of student athletes from an NCAA Division I university, representing 11 sports. A series of two-way, repeated measures ANOVA analyses were conducted to determine within-subjects differences in overall reporting of barriers and facilitators, as well as between groups differences in race and gender. Significant differences were found in the rating of barriers and facilitators. Female student-athletes rated sharing a gender identity with their mental health treatment provider as more important than did male student-athletes. The findings of the study may aid athletic departments in developing targeted interventions to lower barriers and increase use of mental health resources to promote psychological well-being among student-athletes.

Client pre-treatment expectations have a significant impact on psychotherapy outcome, therapeutic alliance, and attendance. Client expectations are thought to account for approximately 11-14% of variance in premature termination from psychotherapy. However, measures that conflate treatment beliefs and distinct measurement techniques for the same outcome construct obscure the relationship between expectations and psychotherapy outcomes. Clarifying these associations is necessary to support development of useful methods and processes that support client retention in evidence-based treatments. With drop-out rates of approximately 20% across treatment settings, and as high as 69.4% in psychology training clinics, risk of attrition is a significant liability to effective treatment. The meta-analytic findings presented herein clarify the association of pre-treatment expectations with psychotherapy outcome, considering competing definitions for client expectations and discrepant psychotherapy outcome measurement. Implications for attrition, treatment outcomes, and therapeutic alliance are discussed.

Bipolar disorder (BD) is a serious mental illness characterized by dramatically differing mood states and marked costs for the individual and society, making it important to find factors associated with the condition. Deficits in emotion regulation have been found across a wide range of mental health disorders and may represent an important risk factor for BD. Literature in this area has large methodological inconsistencies and many conclusions are mixed. Therefore, the current study sought to conduct a meta-analytic review of literature related to emotion regulation in BD. Results suggest that people with BD broadly report more frequent use of maladaptive emotion regulation strategies and less frequent use of adaptive emotion regulation strategies than healthy controls. Of these strategies, the largest effect sizes were found for risk-taking, rumination, impulsivity, catastrophizing, and self-blame. Comparisons to other clinical groups suggest that emotion regulation in BD is largely similar to major depressive disorder and less severely impaired than borderline personality disorder. Moderator analyses of BD samples in different mood states suggest mood state plays a limited role in emotion regulation strategy usage, although some maladaptive strategies may be more common in samples with depressive symptoms. Among emotion regulation strategies, increased positive rumination and suppression …

Breakups within emerging adulthood (EA) are associated with heightened distress because of individuals' tendency to be preoccupied by and prioritize romantic relationships. Global narrative scoring systems, such as Boals et al.'s meaning making (MM) and Feffer et al.'s interpersonal decentering, can be a useful for analyzing the activated cognitive processing in narratives about stressful events and have been linked to positive adjustment from those events. Attachment may moderate the benefits of processing a breakup. While avoidantly-attached people report lower breakup distress because of their tendency to suppress attachment-related thoughts and emotions, anxiously-attached individuals report prolonged distress due to their tendency to ruminate about the past relationship and to experience continued attachment to their ex-partner. The current study assessed the cross-sectional effects of MM and decentering on depression and breakup non-acceptance, as well as how attachment moderates the relationship between decentering and breakup adjustment. Results found higher MM was associated with higher depression and non-acceptance. More mature decentering was related to lower non-acceptance, but was unrelated to depression. Initial MM efforts may evoke more distress as individuals focus on distressing thoughts or emotions previously avoided. Initial decentering maturity may help with breakup adjustment as one effectively reflects on their own and …

Interpersonally aversive, antagonistic, or "dark" traits have been the focal point of research for decades. In more recent personality research, affiliative, prosocial, or "light" traits have become an area of emerging interest. Examining both domains may allow for a more comprehensive perspective to understanding behaviors and social attitudes involved in human nature related to social dominance and authoritarianism. The purpose of this study was to explore the associations among aversive versus affiliative personality traits with social dominance orientation (SDO) and right-wing authoritarianism (RWA). Both SDO and RWA are robustly tied to prejudice and discrimination, as well as other negative interpersonal characteristics. In this way, the current study will help address if expression of SDO and RWA are primarily linked with presence of a negative (aversive traits) or more so with the absence of a positive (affiliative traits) The current study involved a large general population sample of males who were assessed with Self-Report Psychopathy Scale-Short Form (SRP-SF), subscales from the Short Dark Tetrad (SD4), and the Light Triad Scale (LTS), along with variables tapping the multifaceted domains involved in SDO and RWA. In addition to a series of multiple regression analyses, an exploratory structural equation model (ESEM) was tested to …

South Asians are the third fastest growing racial/ethnic minority group in the United States with distinct cultural characteristics. The coronavirus disease 2019 (COVID-19) pandemic has disproportionately impacted racial and ethnic minorities in the U.S, including South Asians, across several life domains: work, home life/education, social activities, economic, emotional and physical health, infection, quarantine, and positive changes. The COVID-19 pandemic may have critically impacted South Asians with traumatic event experiences and posttraumatic stress disorder (PTSD) symptom severity across several life domains. Limited work suggests high rates of interpersonal traumas and substantial PTSD symptom severity in the South Asian community. Uniquely, the current study examined which life domains impacted by the COVID-19 pandemic associated with a greater count of traumatic event types, interpersonal vs. non-interpersonal traumas, and PTSD symptom severity. Results revealed that negative experiences in social activities, as well as distress in economic, emotional, and physical health domains, were significantly associated with the count of traumatic event types. Negative social activity experiences, and distress in the economic and emotional health domains, were also significantly associated with PTSD symptom severity. Quarantine and physical health domains significantly associated with the count of interpersonal traumas, while COVID-19-related experiences (in social, quarantine, and infection domains) …

The recent inclusion of complex posttraumatic stress disorder (CPTSD) within the International Classification of Diseases, eleventh edition (ICD-11) prompted scholars to re-evaluate treatment guidelines for traumatic disorders. The present study aimed to conceptualize dyadic, community, and systemic connections within the context of ICD-11 traumatic disorders and investigate unique associations between factors capturing relational quality. The current study additionally utilized a novel network modeling approach to explore the CPTSD symptom network structure using a college sample of trauma survivors. Consistent with generations of theory and research, relational quality factors associated with the disturbances in self-organization (DSO) symptom cluster, and anticipated discrimination associated with both relational disturbance and sense of threat. Affect dysregulation, re-experiencing, and relational engagement emerged as most central within the CPTSD symptom network, providing evidence towards the role of affect regulation in relational functioning, while intersectional discrimination associated with both the PTSD and DSO symptom clusters. Findings from the present study provide context to the potential application of a relational and systems focused intervention.

The onset of COVID-19 and cancellation of collegiate sports may have exacerbated student-athletes' psychological distress. Within a national sample of collegiate student-athletes (N = 5755; 66.7% women; 72.3% White), I determined how gender, race, and sport season related to rates of depression, stress, and counseling use. I used a cross-sectional methodology and collected data in April/May 2020. Overall, 26.5% (n = 1526) and 10.6% (n = 612) of the collegiate student-athletes endorsed clinical and high levels for depression and stress, respectively; 25.1% (n = 1443) and 69.7% (n = 4014) reported subclinical and moderate levels of depression and stress, respectively. Few student-athletes reported counseling use before (17.1%) or after (2.3%) the onset of COVID-19; those who reportedly used services endorsed higher levels of depression and stress than those who did not. Female student-athletes reported higher rates of depression, stress, and counseling use than male student-athletes. There were no race or sport season effects. Student-athletes who competed in spring sports endorsed higher levels of counseling use than student-athletes who participated in a fall season sport. Athletic departments must address their student-athletes' psychological distress by facilitating a higher use of mental health services.