Community treatment environments. Patient vs. staff evaluations

Treatment goals and their attainment: a structured approach to assessment and evaluation

Treatment goals are considered a vital part of therapeutic work, and their role is often emphasized in cognitive behavioural therapy (CBT). However, the attainment of goals is rarely accounted for in terms of treatment outcome. In this study, we set out to investigate a structured format for goal assessment and goal attainment in CBT delivered as routine care. We were especially interested in the sensitivity to change in perceived goal attainment. Patients completed a self-administered version of the Bern Inventory of Treatment Goals (BIT-C) and rated their perceived attainment on a maximum of five prioritized goals before and after 12 weeks of treatment, along with measures on anxiety, depression and health-related quality of life. The results indicated that the prioritized goals only partially correspond to disorder-specific concerns, and that perceived proximity to treatment goals is clearly associated with improvements following treatment. The results are discussed in terms of the BIT-C being a promising tool for use in clinical settings in assessing treatment goals as well as in evaluating the attainment of these goals.

On Having a Goal: Goals as Representations or Behavior

The present article discusses the concepts of having a goal and of goal-directed behavior from a behavior-analytic perspective. In clinical psychology as well as in the study of human behavior at large, goals delineate an important area of investigation when it comes to health, well-being, and behavioral change. While concepts like goals and goal-directed behavior may be more frequently used outside the theoretical boundaries of behavior analysis, we argue that by incorporating recent behavior analytic research on verbal behavior, new and fruitful ways open up for approaching the phenomenon of having a goal. A behavior-analytic approach thereby may increase both precision in understanding and the potential for influencing essential aspects of human behavior. This analysis starts with the concept of rule-governed behavior and develops that analysis by using the concept of derived relational responding.

Staff and member perceptions of the clubhouse environment

Several studies have been conducted about Clubhouse operations and the users of Clubhouses (i.e., members); however none have sought to weigh the importance of both staff and member perceptions of the Clubhouse environment. A measure assessing the program climate as well as service components was administered to both members and staff across a representative sample of Clubhouses. In addition, level of program fidelity was included to examine differences between high and low fidelity clubhouses and ratings of the program environment. Two overarching questions were explored in this study: (1) to what extent do staff and members share common perceptions of the Clubhouse environment, and (2) is fidelity to the Clubhouse model relevant to rating of the program environment? Members and staff were concordant on 68% of the environmental assessments. Across all program environment domains, staff ratings of the clubhouse environment were higher than those of clubhouse members. Staff endorsed items reflecting the philosophy of the psychosocial program whereas consumers perceived the environment in terms of the actual services or lived experiences. Members of relatively high fidelity Clubhouses rated the program environment higher on five dimensions.

Perceived reasons for substance misuse among persons with a psychiatric disorder

The etiology of substance use among persons with severe mental illness remains unclear. This study investigates stated reasons for substance use among persons in recovery from co-occurring disorders of serious mental illness and substance abuse and dependence. The desire to fit in with peers played a key role in the initiation of substance use; boredom, loneliness, temptations to use, and stress were cited most as relapse triggers. The authors discuss the need for dually diagnosed persons to develop sobriety-supporting peer networks to help them learn adaptive strategies to deal with the stress of recovery; further, treatment programs should instill hope for recovery and provide opportunities for meaningful activities and relationships.

Perceptions of the real and the ideal ward atmosphere among trainees and staff before and after the introduction of a new work rehabilitation model

Changes in the ward atmosphere of a psychiatric work rehabilitation unit were investigated. Both trainees and staff filled in the Community-Oriented Programs Environment Scale (COPES) before and after a new rehabilitation model was implemented. It was hypothesised that the levels of autonomy and practical orientation would increase from both the trainees' and staff's perspective concerning the real ward atmosphere and that the staff's perceptions of an ideal ward atmosphere would change in the same way. The staff perceived an increased level of autonomy with respect to both the real ward atmosphere and to what constitutes an ideal ward atmosphere, which partly confirmed the hypotheses, but the level of practical orientation was stable. Concerning the staff's estimate of an ideal ward atmosphere, further changes were an increased level of involvement and a decrease in spontaneity, which was not hypothesised, but was not in conflict with the philosophy behind the new model. From the trainee's perspective there was no change of either autonomy or practical orientation. Instead, there was a decrease in personal problem orientation. Compared to an optimal profile, the ward atmosphere was beneficial, before as well as after implementation of the new programme. Differences were found between the staff and the trainees, but they were not large enough to separate the groups according to what is considered an optimal profile. The few changes found support earlier conclusions that the ward atmosphere is a stable phenomenon over time.

Clients' reflections on relationships with nurses: comparisons from Canada and Scotland

It has been suggested that the crucial elements in nursing situations are the nurse, the client, and what goes on between them. This paper examines what goes on between clients and nurses during interpersonal relationships, from the perspective of the clients. Data are presented from studies conducted in Canada and Scotland. It is shown that what clients want, or do not want, during relationships with their nurses, is similar on both sides of the Atlantic. The findings reported in this paper are relevant to transcultural nursing, ethical care, the growth in consumerism, and client advocacy. The findings suggest also that there is a need for nursing research to focus on clinical outcomes in order to establish whether clients' perceptions of helping relationships have any relevance to favourable health outcomes, and the evidence base for clinical nursing.

Preconceptions in the nurse-client relationship

Nursing theorist, Hildegard Peplau (1952) has identified the concept of preconceptions as critical in the development of the therapeutic nurse-client relationship. Although stereotypes exist for both nurses and chronic psychiatric clients, very little research has been reported on the preconceptions nurses and psychiatric clients have of each other. This investigation utilized non-probability, purposive sampling of 20 newly formed nurse-client dyads within programmes serving a chronically mentally ill population in Canada. Subjects were asked to give descriptions of each other. Semantic differentials based on this feedback were then developed and administered to 124 nurse-client dyads. Clients' statements generally evaluated their nurses positively. The generally positive views expressed by nurses and clients did not reflect public stereotypes for either group. The preconceptions the clients had of their nurses, and nurses had of their clients were related to both the quality of the emerging relationship (task, bond and goals) and the duration of the orientation phase. The preconceptions were virtually unchanged over the initial 6 months of the relationship.

Perceived importance of caring behaviors to Swedish psychiatric inpatients and staff, with comparisons to somatically-ill samples

The present study identified psychiatric inpatient (N = 61) and staff (N = 63) perceptions of most and least important nurse caring behaviors using a modified Swedish version of the CARE-Q instrument (Larson, 1981) and compared the results with data from somatic care (von Essen & Sjödén, 1991a, 1991b). The results demonstrated 13 significant mean between-group differences in the rating of 50 specific CARE-Q behaviors. Two significant mean value differences out of six subscales combining individual items were demonstrated between groups. Psychiatric inpatients considered the cognitive aspect, and somatic inpatients the task-oriented aspect of caring as the most important. Staff, in psychiatric as well as somatic care, considered the emotional aspect of caring as the most important. The results suggest that staff has a relatively invariant, human-oriented perception of caring, irrespective of subdisciplines, while patients' perceptions of caring vary more over specialties.

Factors related to integrating persons with chronic mental illness into a peer social milieu

Client characteristics and their perceptions of the milieu in a psychosocial rehabilitation program were used to predict the clients' level of involvement in the peer-based social network. 81 clients in a psychosocial rehabilitation program participated in the study. The results indicated that client perceptions of higher support and clarity in the staff-client milieu, and being female, were strongly related to higher peer social involvement. Milieu factors were generally more important than client characteristics in predicting client social functioning. The implications of these findings for psychosocial intervention and for research on the social functioning of this population are discussed.

A model for measuring the implementation of community support programs: results from three sites

We present and test a model for measuring the implementation of Community Support Programs (CSPs) for persons with severe mental illnesses. The model is intended to facilitate the description and replication of these programs and the future study of their critical ingredients. The model defines important implementation variables in seven areas of program functioning; we then suggest instruments to measure each of these variables. Results of a study examining the application of the model and measures to three conceptually distinct CSPs illustrate the utility of the model and measures for implementation analysis of CSPs. Importantly, findings revealed that a priori hypotheses about how the programs were expected to differ on the implementation variables were largely supported.

An evaluation of two systems of in-patient care in a general hospital psychiatric unit I: staff and patient perceptions and attitudes

This study reports a comparison of a single ward versus a two-ward system of acute in-patient care in a general hospital psychiatric unit. It focuses on staff and patient perceptions and attitudes towards the two types of ward. A continuous care ward system was preferred by the majority of staff who described an improvement in 'ward atmosphere'. Patients who had experienced both ward systems also preferred the continuous care system. Both patients and staff felt that the continuous care system still needed to place greater emphasis on 'ward atmosphere' dimensions of involvement, support and spontaneity. The implications of these findings for improving the functioning of the preferred ward are discussed.