Quality assurance of outcome in mental health care: a model for routine use in clinical settings

A problem-oriented method of quality assurance of clinical outcome was used in 1,384 patients who were assessed and treated over 8 years by 41 nurse therapist trainees. The clinical audit suggested that for most diagnoses patients' improvement after treatment was usually satisfactory. Though the system was developed to monitor the progress of patients with anxiety, sexual and habit disorders having behavioural psychotherapy, it could also be applied to other disorders like depression and to other treatments. The method is simple enough for routine use, and computerisation would put it within the grasp of most clinics and training programs for all mental health care professionals.

Use of a concurrent treatment design to analyze the effects of a peer review system in a residential setting

An experiment was carried out in which the recording practices of individual case managers at a residential treatment facility were improved using feedback from the overnight therapists at the facility. The overnight therapists, who were not associated with the daytime management of the individual clients, conducted weekly reviews of the data that were compiled by case managers during the day. Four particular standards were observed across each case manager, and specific written feedback was delivered to the case manager who was responsible for compiling the data for each child. The written feedback referred to the presence and accuracy of particular details for each program, including introductory cover pages, labeled experimental conditions, operational definitions, and adequate interobserver agreement. The experiment analyzed and verified the feedback procedure through concurrent treatment of different elements across I I cases. The results suggested that significant changes in the recording practices of therapists can be accomplished through feedback generated by the night therapists of the agency.

The right to effective behavioral treatment

We propose that individuals who are recipients or potential recipients of treatment designed to change their behavior have the right to a therapeutic environment, services whose overriding goal is personal welfare, treatment by a competent behavior analyst, programs that teach functional skills, behavioral assessment and ongoing evaluation, and the most effective treatment procedures available.

The importance of checking the assumptions of the professional referral source

Behavior therapy has at times been portrayed as simply an assemblage of therapeutic "techniques". However, central to its practice is a behavioral analysis which eventually leads to the selection of the most efficacious intervention. Wolpe has repeatedly warned against reliance upon either patients' assumptions or one's own "too facile" interpretations. From this excerpt from an initial consultation it is apparent that one must also be wary of the assumptions made by professional referral sources. It is easy to be led astray by seductively "obvious" correlations between environmental events and psychophysiological reactions. Different etiologies call for different treatment strategies, and careful behavioral analysis is needed for an appropriate decision.

An inventory to measure staff knowledge of behavioral methods with inpatient children and adolescents

A 35-item multiple choice inventory to assess inpatient staff's knowledge of behavioral methods with children and adolescents is described. The instrument appears to possess satisfactory content validity for basic behavioral principles and good internal consistency and reliability. It appears useful for research and staff inservice educational assessment in inpatient treatment settings where a measure of this type in needed. The inventory may also be useful in identifying newly employed staff who may benefit from behavioral training before assuming direct services roles on inpatient wards.

Reliability of a measure of the quality of cognitive therapy

This study investigates some of the psychometric properties of the Cognitive Therapy Scale (CTS) using a sample of experienced psychotherapists. Four raters, experienced in cognitive therapy, rated a total of 21 independent, videotaped psychotherapy sessions, and provided ratings along the dimensions of therapist competence measured by the CTS. Analyses included item intercorrelations, item-total correlations, and two assessments of inter-rater reliability. Inter-rater reliabilities showed a significant positive correlation for all items of the CTS and the internal reliability was strong. The potential of the CTS to address both the competency of cognitive therapists and trainees is discussed.

Therapist success and its determinants

This study examined the relatively unexplored contribution of the therapist's performance in determining outcomes of treatment. Nine therapists were studied: three performed supportive-expressive psychotherapy; three, cognitive-behavioral psychotherapy; and three, drug counseling. Profound differences were discovered in the therapists' success with the patients in their case loads. Four potential determinants of these differences were explored: patient factors; therapist factors; patient-therapist relationship factors; and therapy factors. Results showed that patient characteristics within each case load (after random assignments) were similar and disclosed no differences that would have explained the differences in success; therapist's personal qualities were correlated with outcomes but not significantly (mean r = .32); an early-in-treatment measure of the patient-therapist relationship, the Helping Alliance Questionnaire, yielded significant correlations with outcomes (mean r = .65); among the therapy techniques, "purity" provided significant correlations with outcomes (mean r = .44), both across therapists and within each therapist's case load. The three therapist-related factors were moderately associated with each other.

Ethics in behaviour therapy: historical aspects and current status

Ethical problems in clinical practice arise when clinicians confront competing value systems. Historically, behaviour therapy has been criticized because of alleged special ethical, moral and legal problems. These problems are no greater or smaller than in other forms of psychotherapeutic practice. But they can differ in emphasis. This article describes partial responses to selected ethical dilemmas facing general psychotherapy, and outlines relatively novel issues raised by certain features of behavior therapy practice.

Recommended therapeutic guidelines for professional weight control programs

At the present time there are no established guidelines to serve as standards for the operation of weight control programs. This increases the possibility that some programs may be conducted in a fashion that is unethical, jeopardizes patient health, and lacks credibility. As a first step toward developing such standards, a panel was organized by the International Congress on Obesity to describe minimum recommended features of professional weight control programs. The present report served as a supporting document for the summary statement and describes recommended guidelines for the treatment of obesity encompassing diet, physical activity, and behavior modification with psychological support. The role of drugs and surgery is not considered in this report. For the average patient it is suggested that three components of therapy--diet, exercise, and behavioral/psychological support--be prescribed together since they are closely interrelated, interdependent and mutually supportive.

Data over time: how much tells the story

Observational data on self-injurious behavior spanning 34 mo. is presented to illustrate the importance of a longitudinal analysis across multiple treatments. Five interventions were implemented to increase a subject's positive interactions and decelerate incidents of self-injurious behavior. Although data indicate a continual, steady decrease in the targeted self-injurious behavior, conclusions based on shorter segments of time, as are often reported, would possibly result in different interpretations. The importance of longitudinal analysis of low frequency, high intensity behaviors is discussed in relation to the impact that short-term data analysis can have upon decision-making and treatment.

Probable superiority of behavioral interventions--II: Empirical status of the equivalence of therapies hypothesis

The equivalence of therapies hypothesis was examined in the present article by a review of five major areas of research. Contrary to the hypothesis, evidence from all five areas favored behavioral interventions over non-behavioral interventions in the treatment of a variety of disorders.

The problem-oriented system and record keeping in the behavioral therapies

The Problem-Oriented System (POS) provides systematic guidelines for health care record keeping. Behavioral therapy records share, with health care records in general a quality of inadequacy for contemporary needs. Likewise, behavior therapy training shares with other health care training inadequate attention to record-keeping. This conclusion arises from a search of recent journals and books concerned with behavior therapy issues. This article reviews the POS and proposes that is guidelines and advantages are suited for incorporation into behavioral therapy training. The expected result of such training should be records more amenable to audit or review for such purposes as third party payment, supervision, and peer review. Research is needed to help select the record-keeping training methods that would best meet these contemporary needs for increased quality in the documentation of health care provision.

After the dance is over: some issues and suggestions for follow-up assessment in behavior therapy

Behavioral intervention programs have thus far failed to provide sufficient follow-up information for the evaluation of long-term effects. This omission is believed to be related to an inadequate conceptualization of follow-up assessment, as well as to the methodological and practical difficulties inherent in assessing behavior over long time periods. A framework for follow-up assessment that is consistent with current behavioral efforts to program generalization is described and is contrasted with traditional views of follow-up that look for effects following the termination of treatment. Several methodological features of follow-up assessment are discussed, along with research recommendations, including the determination of length of appropriate follow-up intervals, the frequency of follow-up assessments, the need for standardization of measures both within and between studies, reactivity of follow-up assessment, the selection of follow-up measures and attrition of subjects.

Issues and implications of establishing guidelines for the use of behavioral techniques

Several guidelines surrounding the use of behavioral procedures have recently appeared, the best of which is that of the National Association of Retarded Citizens (NARC). Some issues and implications of the establishment of guidelines are briefly reviewed in the context of the NARC guidelines. Issues include the factual versus opinion bases for guidelines and the need to continue the development of explicit behavioral criteria for assessing staff competence. Implications for programs include the impact of guidelines on the professional boundaries, administrative decision-making, and budgeting, together with the dangers of expanding the regulatory bureaucracy. Several miscellaneous impacts are noted, including a potential for curbing innovative behavioral technology.

Why no guidelines for behavior modification?

This paper reviews the guidelines for behavioral programs published by the National Association of Retarded Children. The review discusses a number of reasons why guidelines should not be enunciated for behavior modification, e.g., the procedures of behavior modification appear to be no more or less subject to abuse and no more or less in need of ethical regulation than intervention procedures derived from any other set of principles and called by other terms. The review recommends alternative methods for protecting the rights of clients who participate in behavioral programs. Specifically, behavioral clinicians, like other therapists, should be governed by the ethics codes of their professions; also, the ethics of all intervention programs should be evaluated in terms of a number of critical issues.

The behavior therapies: therapeutic breakthrough or latest fad?

The author critically examines the evidence for the effectiveness of the behavior therapies as described in the American Psychaitric Association's task force report on behavior therapy. He concludes that current attempts to evaluate behavior therapy suffer from inadequate methodology and that the claims for its therapeutic efficacy are excessive and unsupported by the controlled clinical evidence.

Some ethical considerations of short-term workshops in the principles and methods of behavior modification

Workshops and seminars to expose different sectors of the professional community to the principles and applications of behavior modification are briefly discussed. The possible misapplication of procedures by conference participants, whose only exposure to behavioral methods has been at these workshops is viewed as a potentially serious ethical issue. It is suggested that the goals of such seminars and workshops must be clarified, and methods of evaluation of the participants' skills devised, lest we contribute to the misapplication of procedures and to the criticism that behavioral methods are unethical approaches to treatment.