Luận án Tiến sĩ: Thay đổi Đánh giá Thay đổi Đại học Rhode Island theo Giai đoạn Thay đổi

A Dissertation Entitled Changes of University of Rhode Island Change Assessment Over Time Associated with Stages of Change By Tamara Shank Harden Submitted to the Graduate Faculty as a partial fulfillment of the requirements for the Doctor of Philosophy Degree in Counselor Education ______________________________________________________ Dr. Christopher Roseman, Committee Chair ______________________________________________________ Dr. John Laux, Committee Member ______________________________________________________ Dr. Yanhong Liu, Committee Member ______________________________________________________ Dr.

Wendy Cochrane, Committee Member ______________________________________________________ Dr. Amanda Bryant-Friedrich Dean, College of Graduate Studies The University of Toledo May 2017 Copyright 2017, Tamara Shank Harden This document is copyrighted material. Under copyright law, no parts of this document may be reproduced without the expressed permission of the author. An Abstract of Changes of University of Rhode Island Change Assessment Over Time Associated with Stages of Change By Tamara Shank Harden Submitted to the Graduate Faculty as a partial fulfillment of the requirements for the Doctor of Philosophy in Counselor Education The University of Toledo May 2017 Approximately one-quarter of the American population are affected by their own mental illness each year (National Alliance on Mental Illness [NAMI], 2013).

Of those who take part in counseling, one-third to one-half do not see treatment gains and approximately 50% leave counseling prematurely (Duncan, Miller & Hubble, 2007). Research examining immediate feedback on the therapeutic alliance and therapeutic progress has shown statistically significant therapeutic improvements (Reese, Norworthy, & Rowlands, 2009). In addition, the client’s stage of change has been shown through research to correlate with progress in counseling (Ogrodniczuk, Joyce, & Piper, 2005). Clients who have not met their goals and leave counseling prematurely have described a reduction in therapeutic improvement and more emotional distress and are two times as likely seek out mental health services again, often becoming “chronic” clients (Ogrodniczuk, Joyce, and Piper (2005).

Premature termination, along with other factors, leads to 10% of clients being the source of 60-70% of expenses (Miller, n. The purpose of this research was to determine whether completing Feedback Informed Treatment (FIT) moved clients through the Stages of Change more quickly, discouraging iii premature termination and lowering mental health expenses. Participants were mental health clients 18 and over assigned to four counselors for counseling at a community counseling center. Half of the participants were given FIT and half were not.

The intent was for the URICA scores of the two groups to be compared to determine if FIT moves people through the Stages of Change more quickly. URICA scores were measured at the beginning of counseling and at 30 days and 60 days when possible. Six participants consented to the research so descriptive statistics are presented. This study showed it would be worthwhile to rerun the study with a larger sample.

iv This dissertation is dedicated to Bob, mom, Molly, and Abby. Although I lost all of you during this process, your love, encouragement, support, and companionship made this project possible. Acknowledgements This signifies the end of many years of dedication. I did not accomplish alone.

I would like to acknowledge several of the people who believed in me and offered support. Martin Ritchie was my first advisor and staunch believer in my capabilities, even through times of great loss, ensuring I kept momentum toward the ultimate goal. John Laux provided support and feedback, ensuring my comprehensive exams were completed, and also served on my dissertation committee. Christopher Roseman, chairperson of my dissertation committee, encouraged and guided me through some tough deadlines.

I would like to thank the other members of my dissertation committee: Dr. Yanhong Liu and Dr. Wendy Cochrane for their feedback and encouragement. Sue Martin, department secretary, has been a source of smiles, encouragement, support, and information.

Her help has been invaluable. Graduating from the Counselor Education program at the University of Toledo is a great source of pride. This project would not have been possible without the team of professionals at Behavioral Connections of Wood County. Clancy, I don’t have words to thank you for your support and all the assistance you have provided.

Tiffany and Julie you have become my friends and I am forever grateful to you. Bob- we made it. You knew it would happen all along. Mom- I hope you can see and are proud.

Molly and Abby your constant companionship and love kept me going. I wish you were all here to see the culmination. Scott, what can I say? You put up with me, fed me, edited, and were always here. Dad, Tonya, and Bob, I did do it.

Karen, your support means everything. Shawn and Patty, thanks for listening. vi Table of Contents Abstract iii Acknowledgements vi Table of Contents vii List of Tables xii I. Chapter One: Introduction 1 A.

Background of the Problem 1 C. Statement of the Problem 4 D. Purpose of the Study 5 E. Significance of the Study 7 G.

Definition of Terms 9 I. Organization of Chapters 10 J. Chapter 2: Literature Review 12 A. Prevalence of Mental Health Issues in the United States 12 a.

Effect of Caring for the Mentally Ill on the American Economy and How We Can Manage It 13 b. “The Age of Accountability. Ethical Responsibilities of Mental Health Professionals 16 vii D. History of Outcomes 18 E.

Importance of Outcomes 19 F. Reluctance of Counselors to Use Outcomes 20 G. Patient-Focused Research 27 H. Use of Feedback/Outcomes 28 a.

Evidence- Based Practice 29 b. Practice-Based Evidence 30 I. Overview and History of FIT 31 J. Measures of Client Functioning and Effect on Outcomes 34 K.

Therapeutic Alliance as it Relates to the Outcome of Counseling 34 L. Measures of Feedback on Client Functioning 36 a. Behavior and Symptom Identification Scale (BASIS-24) 37 b. Clinical Outcomes in Routine Evaluation (CORE-OM) 38 c.

Patient Reported Outcomes Management Information System (PROMIS) 40 e. Symptom Checklist-Revised (SCL-90-R) 42 f. Brief Symptom Inventory (BSI) 43 g. Outcome Rating Scale (ORS) 43 M.

Measures of the Therapeutic Alliance 45 a. California Counseling Alliance Scale (CALPAS) 45 b. Helping Alliance Questionnaire (HAQ) 46 viii c. Working Alliance Inventory (WAI) 47 d.

Session Rating Scale (SRS) 48 N. Stages of Change 49 a. Measures of Stages of Change 52 a. Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) 53 b.

Readiness to Change Questionnaire 53 c. Scale for the Multiperspective Assessment of General Change Mechanisms in Counseling (SACiP) 54 d. University of Rhode Island Change Assessment (URICA) 54 P. Chapter 3: Overview of Study 58 A.

Overview of the Method 58 C. Description of Participants 60 E. Feedback Informed Treatment (FIT) 63 i. Outcome Rating Scale (ORS) 64 ii.

Session Rating Scale (SRS) 66 iii. University of Rhode Island Change Assessment ix (URICA) 68 H. Statement of Limitations 71 M. Explanation of Descriptive Statistics 75 C.

Descriptive Statistics for Study Sample 76 D. Summary of Results 80 V. Implications for Counselors 87 D. Threats to Internal Validity 92 b.

Threats to External Validity 93 E. Recommendations for Further Research 94 References 97 Appendices A. Informed Consent to Participate in Research 116 xi List of Tables Table 1 Demographic Information for Sample………………………….62 Table 2 Demographics for Initial URICA Readiness for Change Scores……….77 Table 3 Demographics for 30-day URICA Readiness for Change scores………….79 Table 4 Demographics for 60-day URICA Readiness for Change scores………….79 xii Chapter One Introduction General Introduction Chapter One will explain the problem addressed in this study. Chapter One will introduce the topic of Feedback Informed Treatment (FIT) and provide an argument that feedback is a necessary component of counseling.

Chapter One will then address the purpose of the study, hypotheses, significance of the study, research design, and important terms. Chapter One will end with the organization of the dissertation and a summary. FIT is a therapeutic approach that involves the use of two forms during the counseling session (Tartakovsky, n. The Session Rating Scale (SRS) is used at the beginning of the session to assess the client’s functioning during the time between the current session and the last counseling session.

It assesses overall functioning, social and interpersonal functioning, and general personal wellbeing. This information allows the counselor to discuss any progress or setbacks the client has experienced. The SRS is given at the end of the session and it assesses the therapeutic relationship, whether goals and topics were relevant to the client, whether the counselor’s approach was appropriate, and whether the overall session was a fit for the client. Background of the Problem Approximately one-fifth of the American population, or 43.8 million people, are affected by their own mental illness each year (National Alliance on Mental Illness [NAMI], 2013).

According to Mojtabai and Jorm (2015) the United States experienced a large upsurge in the consumption of mental health services in the 1990s, however, they 1 report the pervasiveness of mental disorders did not wane in spite of the increased use of mental health services. Mojtabai and Jorm (2015) further state these perplexing trends raise questions about the efficacy of mental health treatments. In addition, the use of psychiatric medications grew significantly in the 1990s and continues to grow. The Substance Abuse and Mental Health Services Administration (SAMHSA, 2013) found that an average of approximately 24.6 million people who have a mental illness in the United States receive treatment every year, Mental health treatment costs Americans $113 billion per year ($4593 per person per year), with $3.7 billion allocated to outpatient counseling (Kliff, 2012).

A typical level of reimbursement is 50% resulting in a large financial burden being placed on the client themselves (Harvard University, 2004). According to Szabo (2013) the recession, starting in 2009 and lasting until 2012, saw states reducing money for mental health services by $5 billion. According to the U. Department of Health and Human Services (n.) as of 2014 most individual and group health insurance plans are required to at least cover mental health.

Even after mental health parity was passed into law through The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) behavioral health care providers still regulate how many sessions a person may have for a particular problem or limit overall expenses (U. Department of Labor, 2010). Of those that take part in outpatient counseling, one-third to one-half do not see treatment gains and approximately 50% leave counseling prematurely (Duncan, Miller & Hubble, 2007; Duncan, 2012; Hatchett, 2011). Leaving counseling early, or premature termination, has been defined in several ways over the years (Renk & Dinger, 2002).

For the purposes of this study, premature termination will be defined as leaving counseling 2 before the counselor and client agree goals have been met. Clients who have not met their goals and leave counseling prematurely have a tendency to seek out mental health services again. According to Ogrodniczuk, Joyce, and Piper (2005), clients who terminate counseling prematurely describe a reduction in therapeutic improvement and more emotional distress than they presented with, they also access mental health services two times as much as those who do not terminate prematurely. Ogrodniczuk et al.

(2005) report those who terminate counseling early often become repeat or “chronic” clients, thus placing an additional burden on the mental health system. Premature termination, along with other factors, leads to 10% of clients being the source of 60-70% of expenses (Miller, n. In addition, when clients terminate counseling prematurely it is demoralizing and often causes further deterioration in their mental health (Duncan et al., 2007; Ogrodniczuk et al. Westmacott, Hunsley, Best, Rumstein-McCean, and Schindler (2010) found that counselors were not aware of any difficulty in the therapeutic relationship and the fact that the clients were not progressing as clinicians hoped the clients were.

As a result, counselors were likely to underestimate the likelihood of premature termination and the reasons for early termination (Westmacott et al. In addition, Miller, Duncan, Sorrrell, and Brown (2005) claim clients prematurely terminate counseling before discussing any issues with the counselor. Barrett et al.