Client Progress Research Articles

How Substance Abuse Recovery Skills, Readiness to Change and Symptom Reduction Impact Change Processes in Wilderness Therapy Participants

Previous research has demonstrated that wilderness therapy is effective, yet very few studies have attempted to discern quantitative factors responsible for change that occur during wilderness therapy. This study aimed to tease apart specific factors that impact client progress and outcome. A sample of 189 adolescent clients in a wilderness therapy program completed the Youth Outcome Questionnaire Self-Report, the University of Rhode Island Change Assessment (URICA), and the Adolescent Relapse Coping Questionnaire (ARCQ) at pre-treatment, post-treatment, and follow-up intervals. Analysis of the complete data sets of 41 adolescents indicated that client Y-OQ scores improved significantly at post and follow-up assessments. URICA scores were not significantly related to such changes, while the ARCQ subscale of abstinence-focused coping strategies accounted for a significant proportion of the variance in Y-OQ change. These results indicate that clients in wilderness therapy do not necessarily need to want to change in order to do so. Furthermore, helping adolescents in wilderness therapy settings gain abstinence-focused coping strategies may be the most effective tool to improve treatment outcomes.

Health Care Change Ahead: Are You Ready?

Health Care Change Ahead: Are You Ready?

Blurring practice–research boundaries using progress monitoring: A personal introduction to this issue of Canadian Psychology.

Progress monitoring (PM) consists of using standardized measure to follow client progress and give clinicians feedback about response to treatment. PM systems have shown great promise in helping therapists identify when clients are not progressing, which improves both retention and client outcomes, but only if therapists use them. This article traces the story of the author's halting and sceptical adoption of PM and the questions that were raised along the way. Beginning at the point of seeing PM as a good thing for others, the author presents a series of questions that centre around the issue of how PM fits with a therapeutic philosophy that values conversation over numbers. Case vignettes illustrate some of the challenges and things learned along the way. Rather than diminishing the importance of therapeutic conversation as a vehicle for change, PM data have opened up new conversations and presented opportunities to broaden and deepen therapy sessions. The author suggests that working with a new kind of data in practice has developed her identity as a scientist-practitioner and increased her appreciation of how practitioners can contribute to the development of knowledge in our field. Keywords: progress monitoring, patient-focused research, practice-based evidence, outcome measure, scientist-practitioner I recently read a study that assessed methods of transferring research knowledge into practice in which 742 practitioners were divided into three groups and given information about an empirically supported treatment for bulimia (Stewart & Chambless, 2010). The three different information packages included: a research review, a case study, or the research review plus the case study. After reading their package, each practitioner was asked how much time they were willing to devote to learning about the treatment. Perhaps not surprisingly, the practitioners were more compelled by the case study - the story - than the data. Those who read the case were willing to invest more time in learning about the treatment than those who only saw the research. More surprising perhaps was the fact that those who read both data and story were no more likely than those who just read the story to invest in learning. Clearly, stories are powerful to those of us who work with clients. They are our data - the things that we observe, assess, and interpret. They are also our tools. In helping clients revisit, reassess, reframe, and retell their stories in new ways, we help them to change. In deciding to organise this special issue, the awareness of how I struggled to begin progress monitoring (PM) - my personal story - has motivated me to undertake the project. I have framed my ideas within that story and highlighted the ideas of the other contributors to this special issue that have helped me to understand and contextualize it. It is the story of my gradual, sometimes hesitant, sceptical adoption of practice monitoring. I tell it in the hope that some of my experiences will resonate with practitioners and stimulate interest in what I have come to value as an important dimension of my practice. I was a clinician first and a researcher second. I obtained an MA in counselling psychology, practiced for several years as a counsellor, and returned to school to complete a PhD and do research in psychotherapy processes. After my doctoral training, I accepted an academic position. Today I am both an associate professor of counselling psychology in a research-intensive university and a psychologist in independent practice. That certainly sounds like a scientist-practitioner, the identity embraced by most psychology training programs today (Horn et al., 2007). I graduated from, and teach in, such a program. Yet in spite of my training and my experience, I have not found the blending of these identities to be very natural or seamless. Yes, there has always been some bleeding of the boundaries: when I talk to clients about how their struggle or change strategy is supported by research, when I do clinical supervision and offer students a research-based rationale for my suggestions, when I draw on clinical experience to write a discussion that makes sense of my data. …

Administration of the Canadian Occupational Performance Measure: Effect on practice

The Canadian Occupational Performance Measure (COPM) is recommended as a systematic approach to identify issues and determine client progress in occupational therapy, yet little empirical evidence is available that supports this practice. To determine if COPM administration was associated with changes in eight dimensions of occupational therapy practice. Twenty-four occupational therapists on eight geriatric rehabilitation sites completed a before-and-after study with a repeated baseline. The eight practice dimensions were assessed after three months of usual care (no COPM use) and after three months of intervention (COPM use) using chart stimulated recall (CSR) interviews and chart audit. Mean practice scores for CSR interviews indicated a statistically significant practice improvement (p < .0001) across the eight dimensions, including knowledge of client perspective, clinical decision making, clinician ability to articulate outcomes, and documentation. Chart audit indicated that COPM use resulted in identifying more occupation-focused issues. COPM administration could improve occupational therapy practice.

The relationship between progress feedback and therapeutic outcome in student counselling: A randomised control trial

Objective: Stimulated by findings that continuous feedback on client progress improves therapy outcomes (Lambert, Whipple, & Smart, 2001a, Patient-focused research: Using patient outcome data to enhance treatment effects. Journal of Consulting and Clinical Psychology, 69, 159–172) and by arguments that any instrument taking more than 5 min to implement is impractical, this study was a randomised controlled trial investigating the effects of session-by-session progress feedback using the ultra-brief Outcome Rating Scale. Method: A between-subjects design was used. Participants (n = 110) were randomly assigned ‘feedback’ or ‘no feedback’ status, and attended one of eight therapists in a university counselling service. Results: The results showed that there was not a significant difference between the feedback and no-feedback conditions. Both conditions improved therapeutically; however, the feedback condition had a greater effect size (0.85 vs. 0.64), suggesting that with a larger sample statistical significance may have been attained. Between the two conditions there was not a significant difference found in participants classified as reliably changed, unchanged, or deteriorated. However, when the clients were divided into groups on the basis of their presenting issue, the clients with anxiety whose therapists used feedback had significantly better outcomes at the end of therapy than the clients whose therapists did not receive the feedback. Conclusion: Contrary to previous studies, the feedback on the client's progression provided to the therapist had only a small effect on improving therapy outcome. The feedback, however, improved outcomes of the clients presenting with anxiety.

Obtaining clinical writing informed consent versus using client disguise and recommendations for practice.

Clinical writing about psychotherapy clients has long been a part of didactic texts and research articles because it allows new treatments and interventions to be presented in an effective and memorable way. The main ways that clinicians write about their clients include obtaining informed consent, using client disguise, or creating case composites. Although many clinicians use a combination of all three approaches, this article specifically addresses the implications of using clinical writing informed consent. The present article begins with a brief history of clinical writing and an examination of the relevant standards in the current APA Ethics Code and the Health Insurance Portability and Accountability Act; this is followed by a discussion of the benefits of engaging in the clinical writing informed consent process. Subsequently, the limitations of using clinical writing informed consent are explored, including the potentially negative impact on the therapeutic alliance and the client's progress. The article concludes that clinicians should be cautious when deciding to engage in clinical writing informed consent. Recommendations in the form of a checklist are provided to help clinicians identify when it is most appropriate to use client disguise or case composites, and how to do so, as well as when it is appropriate to engage in clinical writing informed consent. Future directions are considered.

Clinical Group Supervision in Yoga Therapy: Model Effects, and Lessons Learned

Clinical supervision is an integral component of therapist training and professional development because of its capacity for fostering knowledge, self-awareness, and clinical acumen. Individual supervision is part of many yoga therapy training programs and is referenced in the IAYT Standards as "mentoring." Group supervision is not typically used in the training of yoga therapists. We propose that group supervision effectively supports the growth and development of yoga therapists-in-training. We present a model of group supervision for yoga therapist trainees developed by the New England School of Integrative Yoga Therapeutics™ (The NESIYT Model) that includes the background, structure, format, and development of our inaugural 18-month supervision group. Pre-and post-supervision surveys and analyzed case notes, which captured key didactic and process themes, are discussed. Clinical issues, such as boundaries, performance anxiety, sense of self efficacy, the therapeutic alliance, transference and counter transference, pacing of yoga therapy sessions, evaluation of client progress, and adjunct therapist interaction are reviewed. The timing and sequence of didactic and process themes and benefits for yoga therapist trainees' professional development, are discussed. The NESIYT group supervision model is offered as an effective blueprint for yoga therapy training programs.

Defusion: a behavior-analytic strategy for addressing private events.

Applied behavior analysts encounter situations in which private events hinder client progress, and additional techniques to address these issues are needed. By conceptualizing private events as verbal rules, we provide a behavior-analytic framework for understanding and addressing these events. Relational frame theory (RFT) is the basis for this conceptual foundation; the empirically based principles of RFT are presented along with direct implications for understanding private events. Defusion, an RFT-based technique for addressing private events, is then described and empirical studies that evaluate the effects of defusion are reviewed. Finally, potential clinical applications for practicing behavior analysts are offered.

Triangulating Findings from an Instruction-Based Community Engagement Project

This paper reports on the assessment of initial data from an ongoing, award-winning service learning project called “Computer Training for Persons with Intellectual Disabilities.” The project was researched, designed, and implemented by Masters in Library Science (MLIS) students at a large southeastern university. The two explicit goals of the project were to assess the effectiveness of the core curriculum in preparing students to undertake such a project and to provide technology literacy to clients with intellectual disabilities. However, the three implicit goals were to benefit the students, the clients, and the community partner through the process of engagement. The data reported are based on the first eighteen months of the project and are gathered from an exercise mapping the students’ perceptions of the usefulness of the core curriculum, their written reflections concerning their participation in the project, and their records concerning client progress through the instruction. The student data are corroborated through an interview session with the community partner. The methods and results reflect a qualitative text analysis protocol since the first phase of the project was exploratory and the population was limited. Quantitative data reflect only simple descriptive statistics due to sample size and lack of comparative data. Results indicate that the goals of the original project are being met, and other corollary effects, such as students’ attitudes concerning underrepresented populations were affected positively and constructively. We also identify necessary revisions and challenges as the project progresses, and numerous avenues for further research.

A Normative Study of the Person Picking an Apple From a Tree (PPAT) Assessment

The Person Picking an Apple from a Tree (PPAT) is an art therapy assessment task that is scored using the Formal Elements Art Therapy Scale (FEATS) to identify a client's mental health symptoms and progress in art therapy. Normative data are needed to empirically validate assumptions about the PPAT. This report summarizes a normative study of the PPAT from a sample of 100 non-client participants. Analysis of the data confirmed the scores for all of the 14 FEATS scales as hypothesized with the exception of the Developmental Level scale. The study also found differences in the PPAT with respect to participants’ mood, gender, race, and artistic experience.

Quality criteria for group work

This paper reports on a practical rather than a scholarly exploration of how quality assurance in career learning for groups is approached across the different sectors of career guidance largely in the UK. In some sectors (career education in schools is an obvious example) group work is a main mode of delivery and we would expect all quality criteria to address it. In others, where the one-to-one interview is seen as the professional’s key contribution to client progression, we could expect that group work would be sufficiently different to require its own set of quality criteria. With these expectations I conducted a small exploration across the spectrum of career help that was available in early 2010.

Measuring Treatment Change in Sex Offenders

The main purpose of this study was to assess treatment change at both the group level and the individual level with a sample of 313 adult male sex offenders. Generally, the results from the group-level analyses were more positive than those from the individual-level analyses. The group-level analyses revealed significant change of medium magnitude on most of the measures, whereas the individual-level analyses indicated more modest gains, with approximately one third of participants showing reliable change and reaching functional levels posttreatment. When representative norms are available, clinical significance provides a clear and established method not only for assessing the effectiveness of sex offender treatment programs but also for evaluating the progress of individual clients.

Efficacy of psychosocial rehabilitation program: The RFS experience

Background:People with severe and persistent mental illness need help in most aspects of their lives, as the disability associated with these diseases can be debilitating. Psychosocial rehabilitation interventions aim to help them relearn skills that would reduce disabilities so that they can be reintegrated into society.Objective:To study the efficacy of the rehabilitation program at the Richmond Fellowship Society (RFS) ‘ASHA’ half-way home.Subjects:Fifty-four clients diagnosed with either schizophrenia or affective disorder who stayed at the half-way home for more than 6 months.Materials and Methods:A retrospective evaluative approach was followed. An evaluation checklist was developed for the purpose and this was used to assess the level of functioning of the clients. A paired sample t-test was used to score changes in client progress between admission and discharge.Results:Significant improvement ( P≤.05 level) was noticed on all the parameters from baseline to discharge.Conclussion:The psychosocial rehabilitation program at the RFS half-way home has a beneficial effect.

Meeting Them Where They Are: An Exploratory Study of Staff and Shelter Resident Perceptions of Homeless Women's Needs

Only a small number of studies have surveyed homeless people about their needs, and none has compared these perceptions with those of homeless service providers. In this small, preliminary, exploratory investigation, both shelter residents and staff at one homeless shelter dedicated to serving dually-diagnosed adult women were queried about shelter resident need. Residents and staff agreed on the need for immediate, non-change-oriented services (such as assistance with overdue bills and housing) and some shorter-term services (such as education and job skills training). The two groups disagreed on the need for longer-term, change-oriented services, such as substance abuse treatment, education about activities of daily living, and health/counseling services (with more staff than residents perceiving such need). Two potential recommendations are discussed. Staff could consider altering the timing of treatment plan creation to increase engagement with homeless clients. Shelter directors and funders could consider modifying the measurement of client outcomes to include client progression toward longer-term change.

Client attachment orientations, working alliances, and responses to therapy: A psychology training clinic study

The authors examined the associations between client attachment orientations, working alliance, and progress in therapy. Ninety-five clients at two university-based training clinics completed measures of adult attachment, attachment to therapist, and working alliance immediately preceding the third counseling session with therapists-in-training. A standardized measure of progress in therapy was administered at intake, third counseling session, and termination. Hierarchical linear modeling findings indicated that stronger working alliances and secure attachment to therapist were significantly associated with greater reductions in client distress over time. Higher levels of adult attachment anxiety were significantly associated with greater distress ratings at the outset of treatment. Directions for future research and suggestions for developing therapeutic relationships in the context of specific client attachment orientations are discussed.

Work Roles and Functions of Undergraduate Rehabilitation Services Alumni: A Pilot Study

A modified Delphi procedure was used to identify frequency and perceived importance of professional roles and functions that undergraduate rehabilitation services alumni perform. After a series of focus groups with alumni to develop task statements and subsequent input by rehabilitation educators who teach in undergraduate rehabilitation services programs, a final list of 102 job task statements was identified. In an online survey, 179 respondents from 19 undergraduate programs indicated that providing emotional support to clients, writing client progress and summary notes, advocating for clients, conducting interviews with clients and/or family members to obtain background information, and identifying and securing community resources for clients are job tasks they perform frequently and perceive as very important to their work. Conversely, administrative duties associated with recruiting and hiring staff and other volunteers, preparing budget reports, securing funding to support agency or facility activities, assessing programs to ensure compliance for accreditation reviews and conducting hiring interviews of staff were seen as work tasks/functions performed less frequently and not particularly germane to their work roles. These findings may be useful to develop accreditation standards for undergraduate rehabilitation services training. Recommendations for future research are addressed. et al.

Toward Successful Postbooking Diversion: What Are the Next Steps?

Toward Successful Postbooking Diversion: What Are the Next Steps?

Tradução e adaptação cultural do Outcome Questionnaire (OQ-45) para o Brasil

O Outcome Questionnaire (OQ-45) é um instrumento desenvolvido com a finalidade de avaliar o progresso do paciente, repetidamente, durante a psicoterapia. Não é um instrumento teoricamente orientado, podendo ser aplicado a psicoterapias de diferentes fundamentações teóricas. Apresenta evidências de validade e consistência interna, em sua versão original. O objetivo geral deste trabalho foi traduzir e adaptar culturalmente o OQ-45 para o contexto da cultura brasileira. O processo consistiu de cinco estágios: tradução, síntese, back-translation ou tradução regressiva, revisão por especialistas e pré-teste. Teve como base duas versões: a original, em inglês e a portuguesa. Os resultados sugerem que o OQ-45 é um instrumento de fácil compreensão e aplicação, mesmo em pessoas com baixo grau de instrução escolar formal. Serão necessários estudos de validade e precisão da versão brasileira, comparando-se amostras clínicas com não-clínicas.

Prevention and Drug Treatment

Evidence linking alcohol and other drug abuse with child maltreatment, particularly neglect, is strong. But does substance abuse cause maltreatment? According to Mark Testa and Brenda Smith, such co-occurring risk factors as parental depression, social isolation, homelessness, or domestic violence may be more directly responsible than substance abuse itself for maltreatment. Interventions to prevent substance abuse-related maltreatment, say the authors, must attend to the underlying direct causes of both. Research on whether prevention programs reduce drug abuse or help parents control substance use and improve their parenting has had mixed results, at best. The evidence raises questions generally about the effectiveness of substance abuse services in preventing child maltreatment. Such services, for example, raise only marginally the rates at which parents are reunified with children who have been placed in foster care. The primary reason for the mixed findings, say Testa and Smith, is that almost all the parents face not only substance abuse problems but the co-occurring issues as well. To prevent recurring maltreatment and promote reunification, programs must ensure client progress in all problem areas. At some point in the intervention process, say Testa and Smith, attention must turn to the child's permanency needs and well-being. The best evidence to date suggests that substance-abusing parents pose no greater risk to their children than do parents of other children taken into child protective custody. It may be sensible, say the authors, to set a six-month timetable for parents to engage in treatment and allow twelve to eighteen months for them to show sufficient progress in all identified problem areas. After that, permanency plans should be expedited to place the child with a relative caregiver or in an adoptive home. Investing in parental recovery from substance abuse and dependence, the authors conclude, should not substitute for a comprehensive approach that addresses the multiple social and economic risks to child well-being beyond the harms associated with parental substance abuse.

A Reliability Analysis of Goal Attainment Scaling (GAS) Weights

Goal attainment scaling (GAS) has been considered to be one of the most versatile and appealing evaluation protocols available for human services. Aspects of the protocol that make the method so appealing to practitioners—that is, collaboratively working with individual clients to identify and assign weights to goals they will work to achieve—have produced critical psychometric challenges that have threatened the method's acceptance by funders and researchers. This interrater reliability study of weighted goals contributes to their psychometric validation and therefore to the continued use of a methodology so attractive to practitioners. The subjective clinical impressions of 43 students trained in using GAS has statistically significant scorer reliability. These findings suggest that use of GAS composite scores (weight times the problem level) is a reliable tool and therefore not a reason to discourage the use of GAS as a means for monitoring a client's progress over time.