Introduction of the EuropASI in Norway: Clinical and research experiences from a cost‐effectiveness study

Diverse approaches to treatment research in Norway have hampered comparative studies. The European Addiction Severity Index (EuropASI) was chosen as the main instrument in the first comprehensive study of drug abusers undergoing treatment. The study comprises 482 drug abusers in 20 different treatment programmes who were interviewed at intake to inpatient modalities, substitution programmes and outpatient clinics. They were interviewed twice again at 1‐year intervals with a follow‐up rate of 90%. The clients' response to the EuropASI was positive, and it has been found to be beneficial as an instrument for clinical use and for research purposes. This paper focuses on the broad interest in the EuropASI in the Norwegian drug and alcohol treatment field and recommends some changes that would improve its construct validity and bolster its reliability.     

Effects of counsellor race on racial stereotypes of rehabilitation counselling clients

Purpose:?This study investigated perceptions of European American, African American, and Asian American rehabilitation graduate students in rehabilitation counselling by assessing their clinical impressions of African American, European American, and Asian American clients. This investigation is a continuation of several studies investigating clinical perceptions and client race.

Method:?Rehabilitation graduate students in rehabilitation counselling participating in this study were randomly assigned to one of three groups and were asked to review case materials for a client portrayed either as African American, European American, or Asian American. In pursuit of the main effect of client race, three separate MANOVA analyses were conducted: one for African American graduate students in rehabilitation counselling, one for Asian American graduate students in rehabilitation counselling, and one for European American graduate students in rehabilitation counselling.

Results:?Contrary to previous findings from comparable research, MANOVA results did not reveal a significant main effect of bias by European American, Asian American, and African American graduate students in rehabilitation counselling against any of the three groups.

Conclusions:?Understanding of the conditions in which racial biases and subsequent judgmental errors are likely to occur (or not occur) should allow clinicians to recognise tendencies for their assessments to be influenced by client characteristics that elicit stereotypes and thereby to make more accurate judgements.     

What do speech–language pathologists describe as most important when trying to achieve client participation during aphasia rehabilitation? A qualitative focus group interview study

Abstract

Purpose: The aim of this study was to investigate what speech–language pathologists describe as most important when trying to achieve client-oriented participation during aphasia rehabilitation.

Method: A qualitative study including semi-structured focus group interviews with 11 speech–language pathologists. Interviews were analysed with the use of systematic text condensation.

Result: Four main themes emerged from the analysis. (1) It is important to take the vulnerability of the client group into account. (2) It is important to address the client’s process of realisation by navigating around unrealistic wishes and goals. (3) It is challenging to involve clients when the evidence-base for clinical practice is limited. (4) It is crucial to make therapy meaningful to the client.

Conclusion: This study showed that speech–language pathologists perceived prediction of a clinical course in aphasia rehabilitation as challenging due to the vulnerable client group and the perceived need to guide the clients through the rehabilitation process. They talked about how unrealistic client goals, and the lack of a solid evidence-base to guide their clinical practice, made collaborative goal setting and treatment planning challenging. Due to these barriers, the speech–language pathologists struggled to achieve client participation, and thereby aphasia rehabilitation could not be described as fully client-oriented.     

Report from University of Birmingham

Objective To evaluate prerequisites, practicalities, attitudes and limitations related to the collection of structured clinical data in everyday general practice for use in the future establishment of a national registration network.

Design Prospective study.

Setting Primary health care centres in south-western Sweden.

Subjects Fourteen participating general practitioners in five primary health care centres.

Main outcome measures Feasibility and workload involved in structured data entry and in the retrieval of data from different record systems. The accuracy of clinical data in terms of clinical variables, correctness and representativeness.

Results All four record systems could deliver basic data on the patient population. One centre had to be excluded from further data retrieval because of limitations in the data retrieval export format. Collecting data in everyday practice was feasible with acceptable data accuracy and moderate workload.

Conclusion It was feasible to collect, retrieve and store structured clinical data with respect to accuracy and extra workload. Interest in a national registration network and an increasing demand for information about primary health care in order to optimise clinical practices and support research, creates prerequisites for establishing a valid and reliable database. However, developmental work focusing on classification limitations, coding tools and routines for data retrieval is necessary.     

Hungarian adaptation of the European Addiction Severity Index

The Council of the Professional Federation of Drug Treatment Centres was established in Hungary in 1997. Within the frame of a multi‐stage quality‐development programme for drug‐treatment centres, the Council attempted a Hungarian adaptation of the European version (EuropASI) of the widely used Addiction Severity Index (ASI). The empirical background for our research were the data obtained from ASI ratings for 266 alcohol‐ and drug‐using patients presenting for treatment in addiction medicine clinics operating in different regions of the country. The reliability indicators for measurement tool rating (inter‐rater) and time (test‐retest) are high, with the exception of the correlation value for employment and support. The internal consistency of the test is good. The extent of links between the individual items does not exceed that found internationally. The psychometric results correspond to the results obtained in international investigations. The Hungarian version of the ASI can be regarded as a useful and reliable measuring tool, which can be used to identify the problems of patients with addiction and to evaluate the effectiveness of treatment. Therefore, we started to develop a Hungarian Drug Evaluation Network System (HUDENS) with 12 drug outpatient clinics on the basis of the American DENS. The first step to build up such a system was the validated ASI implementation in clinical practice. Our common database system is facing a country‐wide extension.     

Theoretical and clinical approaches to the treatment of adolescent drug addiction.

Psychologists, social workers, addiction specialists, and occupational therapists often find themselves faced with clients who not only are addicted but also have personal, family, and social problems. These combined problems make the drug-abusing client an extremely difficult one to work with. Occupational therapists have a particular challenge in that they must not only understand and analyze their clients' occupational behavior but also their needs as addicts. This paper describes an approach to adolescent addiction that presents a clinical and theoretical consideration that could be helpful to professionals who work with addicted or drug-abusing clients. In the approach a fusion must be made between the client and the therapist or treatment program. The fusion is temporary but long enough to provide opportunities for clients to work through their feelings of anger, aggression, and sadism, as well as their ego and superego problems. To understand all aspects of their use of drugs, an easily memorized two-dimensional scheme is drawn by the client and therapist together and is used to formulate a treatment plan. Separation from the therapist or program is an essential part of treatment. At this time the client is given the kind of emotional support required to establish new relationships.     

Differences in client and therapist views of the working alliance in drug treatment

Background: There is growing evidence that the therapeutic alliance is one of the most consistent predictors of retention and outcomes in drug treatment. Recent psychotherapy research has indicated that there is a lack of agreement between client, therapist and observer ratings of the therapeutic alliance; however, the clinical implications of this lack of consensus have not been explored.

Aims: The aims of the study are to (1) explore the extent to which, in drug treatment, clients and counsellors agree in their perceptions of their alliance, and (2) investigate whether the degree of disagreement between clients and counsellors is related to retention in treatment.

Methods: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Client and counsellor ratings of the therapeutic alliance (using the WAI‐S) were obtained during weeks 1–12. Retention was in this study defined as remaining in treatment for at least 12 weeks.

Results: Client and counsellor ratings of the alliance were only weakly related (correlations ranging from r = 0.07 to 0.42) and tended to become more dissimilar over the first 12 weeks in treatment. However, whether or not clients and counsellors agreed on the quality of their relationship did not influence whether clients were retained in treatment.

Conclusions: The low consensus between client and counsellor views of the alliance found in this and other studies highlights the need for drug counsellors to attend closely to their clients' perceptions of the alliance and to seek regular feedback from clients regarding their feelings about their therapeutic relationship.     

Documenting client attendance norms: raw data and implications for treatment practice

Aim: The present study sought to document client attendance norms at a multi‐site outpatient alcohol and other drug (AOD) treatment service located in Auckland, New Zealand.

Method: Service attendance data were retrospectively analysed for two client cohorts: consecutive admissions over the period 1 January 2001 to 31 March 2001 (n = 501) and a sub‐sample of admissions who were entering the treatment service for the first time over the same period (n = 325). Data from the former cohort were analysed over a single episode of care. Data from the latter sample were analysed over a period of five calendar years (1 January 2001 to 31 March 2005).

Results: Across a single episode of care, 73% of the respective client cohort exited treatment having attended four or fewer appointments. Furthermore, 61% of these clients exited treatment against clinical advice or prior to completing a scheduled treatment appointment. Only 15% of the ‘new to treatment’ sub‐sample initiated a second episode of care during the next five calendar years and only 4% initiated a third.

Conclusions: Patients attending a large outpatient AOD service in Auckland, New Zealand, typically attend few appointments and are unlikely to return for further treatment following discharge. These findings suggest outpatient AOD services should strive to impart the maximum benefit in the shortest possible time frame and/or increase client attendance duration.     

Current European data collection on emergency department presentations with acute recreational drug toxicity: Gaps and national variations

Background. The number of new (novel) psychoactive substances (NPS) available in the illegal market is increasing; however, current monitoring of the drug situation in Europe focuses mainly on classical drugs of abuse, with limited emphasis on clinical presentation in the emergency department (ED). The European Drug Emergencies Network (Euro-DEN) is a European Commission-funded project that aims to improve the knowledge of acute drug toxicity of both classical recreational drugs and NPS. As a baseline for this project, we performed a study to establish which data are currently being collected and reported in Europe on ED presentations with acute toxicity related to NPS and classical drugs of abuse. Methods. We used a three-pronged approach to identify any systematic collection of data on NPS toxicity in Europe by i) performing a literature search, ii) utilising an online survey of the European Monitoring Centre for Drugs and Drug Addiction Re seau Europe en d’Information sur les Drogues et les Toxicomanies national focal points and iii) exploiting the knowledge and resources of the Euro-DEN network members. Results. The literature search revealed 21 papers appropriate for assessment, but only one described a systematic collection of clinical data on NPS. Twenty-seven of thirty countries responded to the online survey. More than half of all the countries (52%) did not perform any registration at all of such data, 37% collected systematic clinical data on NPS at a national level, while 44% collected data on classical drugs. A few examples for good practice of systematic collection of clinical data on ED presentations due to acute toxicity were identified. Conclusion. The systematic collection of data on ED presentation of toxicity related to NPS and classical drugs in Europe is scarce; the existing collection is limited to single centres, single countries, groups of patients or not focused on novel drugs; the collection of data is highly variable between the different countries. Euro-DEN, a European Commission funded project, aims at closing some of these gaps.     

Therapist effects in substance abuse treatment: a naturalistic study

Objective: The purpose of this naturalistic study was to investigate between-therapist variation in the working alliance, treatment effectiveness and client satisfaction.

Methods: The subjects were Finnish outpatients (N = 327) with various substance use disorders and their therapists (N = 33). The clients were randomly assigned to the therapists, and they were followed-up for 6 months. Regression analyses with mixed models were used.

Results: The findings indicated that between-therapist variation was wider in the therapists’ ratings of the alliance than in the clients’ ratings. The therapist effect was present at follow-up in prolonged abstinence period and client satisfaction with the therapist. According to the clients’ ratings of the alliance and post-treatment satisfaction, the therapist effect on satisfaction in general increased as treatment progressed. The therapists’ and clients’ ratings of the alliance differed significantly from each other, the clients’ ratings being more positive than the therapists’ ratings, although correlations showed that they were significantly interrelated.

Conclusions: It can be concluded that the size of the therapist effect varied with regard to the treatment aspects measured.     

Implementing ASI and other instruments to professionalize treatment across national borders: Experiences from the IPTRP project

This paper describes experiences of implementing different standardized assessment tools for research and treatment needs in 29 residential treatment centres in nine countries in Europe, within the IPTRP (Improving Psychiatric Treatment in Residential Programs for emerging dependency groups). Four instruments were obligatory for all centres participating: the EuropASI, the SCID, the Maastricht Social Network Analysis MSNA and the BioMAPS. The implementation process was prolonged, since extensive and repeated training was needed and the instruments had to be translated and adapted, and comparability in data discussed. The data collection had to deal with both coding and language problems before any analysis could be made. The experiences show several prerequisites for the success of this kind of project: an understanding of the treatment framework as a system, to anticipate and plan for problems and blockages; active involvement of staff in the project and intensive training, consultancy and support.     

Effectiveness of the video-based education in the retention of addiction treatment

Background: In recent years, a range of innovative interventions for drug abuse treatment has been developed. The aim of the present study was to evaluate the effectiveness of video-based education on prevention of relapse and to investigate the factors that play important roles.

Methods: This is a before–after interventional design which was carried out on 40 addict clients who were admitted in the three addiction clinics in the city of Bojnourd, North East of Iran. All participants completed the questionnaire before watching the educational package digital video/versatile disc (DVD)1 and booklet1 as a pretest and one month after watching the DVD2 and reading booklet2 as a post test. The questionnaire contained 25 questions covering five factors, including family’s roles, items, treats, attitude toward behavior, friend’s roles, and self-efficacy. The Statistical Package for the Social Sciences (SPSS)-16 software was applied for data analysis

Results: The results showed that 73% of clients have remained without a history of drug intake during treatment. Family roles (U = 62.5, p = 0.011) and self-efficacy (U = 63.5, p = 0.013) were significant determinant factors for the effectiveness of the addiction treatment program. Conclusion: This study emphasized the effectiveness of the video-based education in retention of addiction treatment. It showed that the video-based education was an effective tool to increase family roles and self-efficacy in the clients.     

Predictors of starting and remaining in treatment at a specialist alcohol clinic

Aims: To identify factors that predict attendance for the start of treatment following assessment, and factors that predict retention in treatment, at a specialist alcohol treatment clinic.

Participants: The sample consisted of 419 consecutive clients (272 male and 147 female) who had attended for assessment over a two‐year period and had chosen out‐patient care. These included 141 who did not attend treatment (non‐starters), 106 who attended only once (starters), and 172 who attended more than one session (retainers).

Design: We recorded factors that previous research or clinical experience suggested might influence attendance, including: demographic factors, clients' support and mental state, substance use and aspects of clinical practice.

Analysis: Univariate analyses and multiple logistic regression analyses were conducted to identify factors predicting whether clients attended the first treatment session and whether they continued to remain in treatment.

Findings: Clients most likely to start treatment following assessment were those who were older, lived with others, drank fewer units of alcohol daily, did not use illegal drugs, had waited a shorter time between assessment and the start of treatment, lived nearer the clinic and made contact with the clinic before the start of treatment. Clients who were most likely to be retained in treatment were also older, had waited a shorter time between assessment and the start of treatment, and had chosen to attend the 6‐week structured day programme rather than the open support sessions.

Conclusions: Clients who were most likely to start treatment were the “less complex” of those who access the clinic.

Strategies to promote engagement of and retention in treatment might include: incorporating more motivational work with clients during initial assessment; telephoning each client before the start of treatment to remind them to attend; and providing more satellite clinics for those clients who have further to travel.     

What is most and least useful in residential rehabilitation? A qualitative study of service users and professionals

Aims: Explore client and staff views of the most and least useful aspects of residential rehabilitation.

Methods: A qualitative study, involving interviews with clients who had attended residential rehabilitation and a range of relevant staff, conducted in the Wiltshire and Swindon areas of the UK.

Findings: All interviewees agreed there were many benefits to be gained from Residential Rehabilitation. There was considerable diversity of clients' experiences of the help provided to them in the community, and most criticism was reserved for what happened before and after residential rehabilitation.

Conclusions: Arrangements for care need to be considered before admission, not just before discharge, taking a comprehensive holistic approach to client needs, including childcare, housing, training and education, employment, family and relationship concerns. This implies skilled key‐working, effective inter‐agency collaboration and the setting of clear standards of quality. Residential rehabilitation has evolved from a service provided mainly for older people with alcohol problems, to those with heroin addiction and now those with dual or multiple addictions, notably involving crack cocaine. It may be that different types of ‘therapeutic community’ are needed for different problems.     

Service,advocacy and adjudication: Balancing the ethical challenges of multiple stakeholder agendas in the rehabilitation of chronic pain

Purpose. To highlight potentially conflicting roles of the rehabilitation professional in the treatment of clients with persistent pain conditions. In assisting clients requiring rehabilitation, the role of the rehabilitation professional is usually fairly clear and unambiguous. If however questions about the authenticity of the client's presenting disability have been raised, then a major role conflict can arise. Many clients present with symptoms of pain and disability yet there is no objectively discernible disease, and in these cases, the authenticity of the condition may be questioned. As rehabilitation professionals we may thus find ourselves acting in different roles: (i) We might be a clinical service provider working to reduce the client's suffering, (ii) We might become the client's advocate working to protect the client in conflicts with an insurer, (iii) We might become an adjudicator working to help the insurer detect evidence of our client's fraudulent behaviour. The principal objective of this paper is to distinguish these roles, and highlight their incompatibility. It is stressed that accreditation for and competence in clinical intervention does not guarantee or legitimize competence in advocacy or adjudication.

Conclusions and recommendations. The paper concludes by suggesting that the primary role of the rehabilitation professional should be the provision of clinical service and that the adoption of the role of advocate or adjudicator may cross unacceptable ethical boundaries resulting in bringing harm, intentionally, or unintentionally, to the client.     

Speech pathologists’ experience of involving people with stroke-induced aphasia in clinical decision making during rehabilitation

Purpose: Although client participation has been part of legislation and clinical guidelines for several years, the evidence of these recommendations being implemented into clinical practice is scarce, especially for people with communication disorders. The aim of this study was to investigate how speech pathologists experienced client participation during the process of goal-setting and clinical decision making for people with aphasia. Methods: Twenty speech pathologists participated in four focus group interviews. A qualitative analysis using Systematic Text Condensation was undertaken. Results: Analysis revealed three different approaches to client participation: (1) client-oriented, (2) next of kin-oriented and (3) professional-oriented participation. Participants perceived client-oriented participation as the gold standard. The three approaches were described as overlapping, with each having individual characteristics incorporating different facilitators and barriers. Conclusions: There is a need for greater emphasis on how to involve people with severe aphasia in goal setting and treatment planning, and frameworks made to enhance collaboration could preferably be used. Participants reported use of next of kin as proxies in goal-setting and clinical decision making for people with moderate-to-severe aphasia, indicating the need for awareness towards maintaining the clients’ autonomy and addressing the goals of next of kin.

• Implications for Rehabilitation

• Speech pathologists, and most likely other professionals, should place greater emphasis on client participation to ensure active involvement of people with severe aphasia.

• To achieve this, existing tools and techniques made to enhance collaborative goal setting and clinical decision making have to be better incorporated into clinical rehabilitation practice.

• To ensure the autonomy of the person with aphasia, as well as to respect next of kin's own goals, professionals need to make ethical considerations when next of kin are used as proxies in collaborative goal setting and clinical decision making.

     

Can we address depression in vision rehabilitation settings? Professionals’ perspectives on the barriers to integrating problem-solving treatment

Purpose: Low vision rehabilitation (LVR) is a pertinent context for integrating early, evidence-based psychological interventions given the high prevalence of untreated depression in adults with vision impairment. This study aims to identify the perceived barriers and facilitators to staff-delivered telephone-based problem-solving treatment for primary care (PST-PC) offered as an integrated component of LVR.

Methods: Qualitative semi-structured interviews, developed using the theoretical domains framework (TDF) and Consolidated Framework for Implementation Research (CFIR), were conducted with 21 LVR professionals and a clinical psychologist involved in the delivery of PST-PC. Barriers and facilitators at the practitioner, client, intervention, and organizational level were identified with thematic analysis using a “theoretical” approach.

Results: Prominent barriers were a lack of role recognition for PST-PC practitioners (n?=?32), unmet client expectation with PST-PC (n?=?28), dissatisfaction with telephone delivery (n?=?27), and limited organizational awareness of PST-PC (n?=?39). Facilitating factors included a recognized need for evidence-based psychological services (n?=?28), clients experiencing benefits in early sessions (n?=?38), PST-PC promoting practical skills (n?=?26), and comprehensive PST-PC training (n?=?36).

Conclusions: PST-PC may provide an accessible early intervention for LVR clients with depressive symptoms. Ongoing practitioner training, clinical support, and screening potential LVR clients for treatment suitability are likely to enhance delivery in this setting.

• Implications for rehabilitation

• Depression is highly prevalent in adults engaged in low vision rehabilitation (LVR) programs, yet few receive support.

• Clinical guidelines recommend integrated models of care be offered within rehabilitation settings as early intervention for mild to moderate levels of depressive symptoms.

• Integrated telephone-based problem-solving treatment for primary care (PST-PC) delivered by trained LVR practitioners is a practical, skills-based model that has potential to increase access to an early psychological intervention in LVR clients with depressive symptoms.

• LVR clients are often older in age, have multiple comorbid health conditions and a significant level of functional disability, requiring flexibility in the delivery of PST-PC and specialized staff training, and support in working with older and more complex clients.

     

The development of an upper limb stroke rehabilitation robot: identification of clinical practices and design requirements through a survey of therapists

Purpose.?Timely and adequate rehabilitation after a stroke is crucial to maximising recovery. A way of increasing treatment access could be through robots, which would aid therapists in providing post-stroke rehabilitation. This research sought to discover the needs and preferences of therapists with respect to a robot that focuses on upper limb rehabilitation. Understanding requirements for devices could help to increase integration into clinical practice.

Methods.?An international online survey was distributed through professional organisations and e-mail list services to therapists. The survey contained 85 items covering topics such as therapist background and treatment approach, rehabilitation aims and robotic rehabilitation device attributes.

Results.?Data were analysed for 233 respondents, most of whom were physiotherapists and occupational therapists from Australia, Canada and USA. Top attributes included: facilitating a variety of arm movements, being usable while seated, giving biofeedback to clients, having virtual activities specific to daily living, being useful in-home and having resistance adjustable to client needs. In addition, the device should cost under 6000 USD.

Conclusions.?Findings from this survey provide guidance for technology developers regarding therapists' specifications for a robotic device for upper limb rehabilitation. In addition, findings offer a better understanding of how acceptance of such devices may be facilitated.