relationship of satisfaction to symptom change, follow-up adjustment, and clinical significance

8/13/2019 Relationship of satisfaction to symptom change, follow-up adjustment, and clinical significance.

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Profess iona l Psychology: Resea rch and Prac t ice Copyrig h t 1996 by the Am erica n Psycholog ica l Assoc iat ion , Inc .1996 , Vol. 27 , No . 2 , 202-20 8 0735-7028/96 / 3 .00

Relat ionship o f Sat is fac tion to Sy m pto m ChangeFol low-U p Ad justment and C l in ica l S igni fi canceGene PekarikAntioch New England Graduat e School hristian B WolffWashburn University

The relationship of client satisfaction to outcome was investigated for adult outpatients (N = 152)from 3 urban community mental health centers. Clients completed a problem self-rating and theBrief Symptom Inventory (BSI) at intake, 10 weeks later, and 5 months later. Therapists' ratingsof client adjustment were obtained at intake and termination. Clients' ratings of satisfaction withtreatment were obtained at 10-week and 5-month follow-up. Correlations between satisfaction andclient measures of outcome (client rating and BSI) based on pre-post changes, posttreatment ad-justment, and Jacobson and Truax's (1991) method of measuring clinical significance were notsignificant.Correlations between satisfaction and therapist outcome ratings were significant but lowfor pre-post changes and clinical significance.The utility of client satisfaction as an outcome mea-sure is discussed.

Professionals in the menta l health fields, inclu ding clinicalpsychologists, have shown an ambivalence toward the forma lassessment of psychotherapy outcome. Although an increas-ingly large n umb er of outcome studies have appeared in recentdecades, there has been a distinct lack of published outcomeresearch originating from standar d practice settings (Lin denWen, 1990; Stiles, Shapiro, Elliott, 1986 ).

The debate over health care reform a nd managed-c ompetitionsolutions appears to be giving impetus to increased evaluation ofpsychotherapy outcome (Sleek, 1994). As occur red dur ing thelast era o f federal initiatives relevant to assessing qualit y of care(i.e., the extension and expansion of the community mentalhealth centers program through the Public Health Service Actamme ndme nts in 1975 and the Mental Health Systems Act in1980), it is likely that client satisfaction will become a popularmeans of evaluating psychotherapy services. Indeed, there is al-ready evidence that satisfaction assessment is the core of manycurrent quality-assurance procedures (Greenfield Attkisson,1989; Lambe rt, Shapiro, Bergin, 1986; Winegar, 1992).

Satisfaction measures have several virtues, i nclud ing ease ofadministration, high face validity, and appeal as indexes of

GENE PEKARIK eceived his PhD in clinical psychology rom State Uni-versity of New York at Stony Brook in 1977. He is currently the directorof the Center for Research on Psychological Practice and a core facultymember of the clinical psychology doctoral program at Antioch NewEngland Graduate School, Keene, New Hampshire. His main researchinterests concern psychosocial treatment process and outcome in ap-plied settings.CHRISTIAN . WOLFF eceived his MA in psychologywith an emphasisin clinical skills from Washburn University in 1993. He is currentlyemployed as a family reunification counselor at Youthworks, Inc., inMedford, Oregon.C O R R E S P O N D E N C E C O N C E R N I N G T H I S AR T I C LE should be addressed toGene Pekarik, Department of Clinical Psychology,Antioch New EnglandGraduate School, 40 AvonStreet, Keene, New Hampshire 03431-3516.

tre atm ent accept ability (Berger, 1983; Lebow, 1982). One ofthe weaknesses of satisfaction measures is that there has be enlittle systematic investigation of their rela tionship to other out-come measures (Greenfield Attkisson, 1989), although theiruse as a quality-assurance measure pr esumes a high relation-ship with other, more traditional measures of outcome. Re-search has indicated that the correlations between satisfactionand other outcome measures are low to modest, with corre-lations generally ranging approximately from zero to .40(Attk isson Zwick, 1982; Carscaddon, George, Wells, 1990;Edwards, Yarvis, Mueller, Langsley, 1978; Fiester, 1979; Gar -field, Prager, Bergin , 1971; Greenf iel d Attk isson, 1989;Nguyen, Attkisson, Stegner, 1983; Pekarik, 1992; WilierMiller, 1978).

Advocates of satisfaction assessment (e.g., Berger, 1983;Green field Attkisson , 1989; Larsen, Attkisson, Hargreaves,

Nguyen, 1979) have cited comp elling logical reasons to assessclient satisfaction, but research done to date suggests that it isquite independent of traditional outcome measures. Much fur-ther research is needed to under stand the nat ure of client satis-faction and its relation to outcom e, for there are several limita-tions of the curr ent research literature. A general and im port antlimi tati on is that relatively few studies have addressed this rela-tionship. A second limitation is that most research has beenconducted in inpa tien t or college counseling -clinic settings. Inaddition to this general need for further study of satisfactionand outc ome in st andard practice settings, there are other spe-cific issues that wa rrant investigation:

1. There is evidence that therapist and cli ent ratings of out-come at treatment termination or follow-up are heavily influ-enced by absolute adjust ment at that poin t regardless of degreeof improvement from pretreatment (Lambe rt Hill, 1994;Lambert , Shapiro, Bergin, 1986). It is quite plausible thatsatisfaction, vir tual ly always assessed at t ermin at ion or follow-up, would be similarly influenced by such end-point adjust-ment. The meani ng of the construc t satisfaction could be clari-

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S A T I S F A C T I O N A N D O U T C O M E 2 3f le d b y a d d r e s s i n g t h e r e l a t i v e r e l a t i o n s h i p o f e n d - p o i n t a d j u s t -m e n t v e r su s d e g r e e o f i m p r o v e m e n t ( p r e - to p o s t t r e a t m e n tc h a n g e s ) t o s a t is f a c ti o n .

2 . A l t h o u g h a f e w s t u d i e s h a v e i n v e s t i g a t e d t h e r e l a t i o n s h i po f s a ti s f a c ti o n t o d if f e r e n t o u t c o m e m e a s u r e s , n o n e h a s i d e n t i-f ie d th e d e g r e e o f r e l a t i o n s h i p b e t w e e n s a t i s f a c t i o n a n d e a c h o fs e v e ra l o u t c o m e m e a s u r e s b y u s i n g m u l t i v a r i a t e s t a t is t i ca l p r o -c e d u r es . T h a t i s, a t p r es e n t , w e d o n o t k n o w w h i c h o u t c o m em e a s u r e s a r e m o s t a n d l e a s t re l a t e d t o s a t is f a c t io n .

3 . R e c e n t ly , r e s e a r c h e r s h a v e n o t e d t h a t s t a ti s ti c a ll y s i g n i fi c a n tc h a n g e m a y n o t b e c l i n i c a l ly si g n i f i c a n t c h a n g e a n d h a v e d e v i s e dw a y s to i d e n t i f y t h e l a t te r ( J a c o b s o n & T r u a x , 1 9 9 1 ) . B y m o r er i g o r o u s l y i d e n t i f y i n g c l i n ic a l s u c c e ss e s a n d f a i l u r es t h r o u g h t h eu s e o f J a c o b s o n ' s c li n i c a l s i g n i f i ca n c e p r o c e d u r e , a m o r e v a l i d r e -l a t io n s h i p b e tw e e n s a t i sf a c ti o n a n d o u t c o m e m a y b e f o u n d . T h et r u e r e l a t i o n s h ip b e t w e e n s a t is f a ct i o n a n d o u t c o m e m a y h a v e b e e no b s c u r e d i n p r e v i o u s s tu d i e s b y r e l ia n c e o n w e a k m e t h o d s o f d e-f i n i n g c l i e n t i m p r o v e m e n t . I n d e e d , a r e c e n t s t u d y a t a u n i v e r s i tyc l in i c f o u n d s a t is f a ct io n w a s m o r e r e l a te d t o s y m p t o m c h a n g ew h e n m e a s u r e d b y c l in i c al si g n if i ca n c e p r o c e d u r e s t h a n b y m o r et r a d i ti o n a l m e t h o d s ( A n k u t a & A b e l e s , 1 9 9 3 ) .

I n v e s t i g a t i o n o f t h e i s s u es j u s t o u t l i n e d m a y a i d o u r u n d e r -s t a n d i n g o f t h e r e l a t i o n s h i p b e t w e e n s a ti s fa c ti o n a n d o u t c o m ea n d o u r u n d e r s t a n d i n g o f t h e n a t u r e o f c l ie n t s a ti s fa c ti o n . T h ep u r p o s e o f t h is s t u d y w a s t o i n v e s t i g a t e s a t is f a c t i o n b y a d d r e s s -i n g t h e s e i s s u e s, s p e c i f ic a l l y t h e r e l a t i o n s h i p o f s a t i s f a c t i o n t od i f f e re n t o u t c o m e m e a s u r e s a n d d i f f e r e n t p r o c e d u r e s f o r d e fi n -i n g o u t c o m e , a n d t o d o s o i n a s t a n d a r d p r a c t i c e s e t ti n g .

M e t h o dC l i e n t s

C o n s e c u t iv e n o n e m e r g e n c y o u t p a t i e n t a d m i s s i o n s w e re r e c r u i t e d f o rt h i s s t u d y a t t h r e e u r b a n c o m m u n i t y m e n t a l h e a l t h c e n t e r s i n t h e M i d -we s t. Of 247 who a gre e d t o pa r t i c i pa t e , 176 (71 % ) pro v i de d 10-wee kf o ll o w - u p d a t a. T w e n t y - fo u r o f t h e p a r t i c i p a n t s w e r e c h i l d r e n ( a g e 1 7a n d y o u n g e r ) . F o r t h e p u r p o s e s o f th i s s tu d y , o n l y d a t a o b t a i n e d f r o ma dul t s we re use d .

T he 152 a du l t c l i e n t s wh o supp l i e d fo l l ow-up i n forma t i o n ha d t h e fo l-l owi ng c ha ra c te r i s ti c s : 47% we re f e m a l e , 91% w e re W hi t e , a ve ra ge e duc a -t i on wa s 14 ye ar s, 35% we re ma r r i e d , a ve ra ge i nc om e wa s $15 ,000 , a nda verage a ge wa s 32 . Us i ng c r i t e r i a f rom t he r e v i s e d t h i rd e d i t i on o f t heDiagnostic and Statis tical Manual of Mental Disorders DS M -III -R ;Am e r i c a n P syc h i a t r i c Assoc i a t i on , 198 7) d i sorde r s we re ge ne ral l y mi l dt o m o d e r a t e i n s e ve ri ty . M o s t c o m m o n w e r e a d j u s t m e n t d i s o r d er s ( 4 8 % ) ,d y s t h y m i a ( 1 3 % ) , a n d p e r s o n a li t y d i s o rd e r s ( 8 % ) . N o o t h e r d i s o r d e r o rg r o u p o f d i s o rd e r s a c c o u n t e d f o r m o r e t h a n 6 % o f t h e c as es .

D e m o g r a p h i c a n d d i a g n o s t i c c h a r a ct e r i st i c s o f a r a n d o m c l i e n t s a m -p l e w h o t e r m i n a t e d i n t h e 6 m o n t h s p r e c e d i n g th e s t u d y ( n = 8 7 9 )w e r e c o m p a r e d w i t h th e c l i e n t s w h o p r o v i d e d s t u d y i n f o r m a t i o n . N od i f fe r e n ce s w e r e f o u n d e x c e p t t h a t s t u d y p a r t i c i p a n t s h a d h i g h e r i n c o m e( M = $ 1 5 , 0 0 0 , S D = 1 ,100 fo r pa r t i c i pa n t s ; M = 12 ,900 , S D = 337 fo rr a n d o m s a m p l e ) , t ( 1 , 0 5 3 ) = 4 6 . 6 7 , p < . 0 0 1 .T h e r a p i s t s

T w e n t y -t w o t h e r a p i s ts v o l u n t e e r e d t o p a r t i c i p a te i n t h i s s t u d y a n dha d t h e fo l lowi ng c ha ra c t e r i s t i c s : 12 we re ma l e a n d l 0 f e m a l e ; t he y a v-e ra ge d 7 ye a r s o f pos t g ra du a t e e xpe r i e nc e ; 19 ha d ma s t e r ' s de gre e s , a nd3 h a d P h D s . T h e i r t h e o r e t ic a l o r i e n t a t io n s w e r e f a m i l y s y s t e m s ( n = 8 ) ,

c o g n i t i v e - b e h a v i o r a l ( n = 6 ) , e c l e c t ic ( n = 4 ) , g e s t a lt ( n = 2 ) , A d l e r i a n(n = 1 ) , a nd re a l i t y t he ra py ( n = 1 ) .D e p e n d e n t M e a s u r e s a n d P r o c e d u r e s

A t t h e i r i n t a k e a p p o i n t m e n t , c l i en t s w e r e g iv e n a c o n s e n t f o r m , a n dw h e n c o n s e n t w a s g r a n t e d , w e r e a sk e d t o c o m p l e t e a s e t o f m e a s u r e s o fa d j u s t m e n t T h e s a m e m e a s u r e s w e r e r e a d m i n i s t e r e d 1 0 w e e k s a n d 5m o n t h s a f t e r i n t a k e , a t w h i c h t i m e t h e y a l s o c o m p l e t e d a s a t i s f a c ti o nm e a s u r e . R e a d m i n i s t r a t i o n s w e r e d o n e b y r e s e a r c h a s s i st a n t s o v e r t h ep h o n e o r b y m a i l ( a b o u t 5 0 % b y e a c h m e t h o d ) , d e p e n d i n g o n th e p r e f -e r e n c e e x p r e s se d b y c l i e n t s o n t h e c o n s e n t f o r m s . D e r o g a t i s ( 1 9 7 7 ) r e -p o r t e d t h a t n a r r a ti v e ( o r a l) a n d w r i tt e n a d m i n i s t r a t io n o f t h e S y m p t o mC h e c k l i s t - 9 0 ( S C L - 9 0 ) , a l o n g e r v e r s i o n o f t h e B S I m e a s u r e u s e d i nt h i s s tu d y , y i el d s c o m p a r a b l e r e s u l ts . A t i n t a k e a n d t e r m i n a t i o n o f t r e a t -m e n t , t h e r a p i s t m e a s u r e s o f c l i e n t a d j u s t m e n t w e r e o b t a i n e d .

T h e B r i e f S y m p t o m I n v e n t o r y ( B S I ; D e r o g a t i s & S p e n ce r , 1 9 8 2 ) w a sa d m i n i s t e r e d t o a l l c l i en t s a t i n t a k e , a t l 0 w e e k s, a n d 5 m o n t h s a f t e ri n t a k e. T h e B S I i s a 5 3 - i t em l is t o f p s y c h i at r i c s y m p t o m s d e r i v e d f r o mt h e l o n g e r S C L - 9 0 , w i t h w h i c h i t c o r r e l a te s h i g h ly : B S I a n d S C L - 9 0s y m p t o m d i m e n s i o n s c o r e c o r r e l a t io n s r a n g e f r o m . 9 2 t o . 9 9 ( D e r o g a t i s& S p e n c e r , 1 9 8 2 ) . C l i e n t s a r e a s k e d t o r a t e t h e d e g r e e t o w h i c h t h e yh a v e e x p e r ie n c e d e a c h i t e m i n t h e p r e c e d i n g w e e k . R a t i n g s r a n g e f r o m0 not at al l) t o 4 ex t remely ) . B S I s co r e s w e re o b t a i n e d b y s u m m i n gt he d i s t r e s s l e vel r e po r t e d fo r e a c h i t e m .

T h e t h e r a p i s t p r o b l e m r a t i n g w a s o b t a i n e d a t i n t a k e a n d a g a i n a t t e r -m i n a t i o n . T h i s m e a s u r e a n d t h e c l i e n t p r o b l e m r a t i n g w e r e d e r i v e df r o m t h e t a r g e t c o m p l a i n t s d e s c r i b e d b y M i n t z a n d K i e s l er ( 1 9 8 2 ) . T h et h e r a p i s t w a s a s k e d t o N a m e t h e o n e o r t w o p r o b l e m s t h a t a r e m o s tl ik e ly t o b e t r e a t m e n t t a r g e t s fo r t h i s cl i e n t. T h e t h e r a p i s t w a s t h e na s k ed t o i n d i c at e o n a 1 3 - p o in t c o n t in u u m h o w m u c h e a c h p r o b l e mb o t h e r e d t h e c l i e n t. R a t i n g s r a n g e d f r o m 1 ( n o t at al l) t o 1 3 ( c o u l d n ' tbe worse). I f a s e c o n d m a j o r p r o b l e m w a s i n d i c a te d , t h i s p r o c e d u r e w a sa g a i n im p l e m e n t e d .

T h e c l i e n t p r o b l e m r a t i n g w a s o b t a i n e d a t i n t a k e . T h e c l i e n t w a sa s k e d , N a m e t h e o n e o r t w o p r o b l e m s f o r w h i c h y o u a r e m o s t s e e k in ga s s is t a n c e. T h e c l i e n t w a s t h e n a s k e d t o u s e t h e s a m e 1 3 - p o i n t c o n t i n -u u m u s e d b y t h e ra p i st s t o r a t e h o w m u c h t h e p r o b l e m b o t h e r e d t h e m .I f a s e c o n d s i g n if i c an t d i ~ c u l t y w a s i n d i c a te d , t h i s p r o c e d u r e w a s a g a i ni m p l e m e n t e d . E a c h p r o b l e m w a s r e r a t e d a t 1 0 w e e k s a n d 5 m o n t h s a f te ri n t a ke .

T h e c l i e n t s a t is f a c ti o n r a t in g w a s o b t a i n e d 1 0 w e ek s a n d 5 m o n t h sa f t e r i n t a ke . T he c l i e n t wa s a ske d , ( a ) Ov e ra l l , how sa ti s f ie d a re youw i t h th e s e r v ic e s y o u r e c e i v ed ? ; ( b ) W o u l d y o u r e c o m m e n d t h i sa g e n c y t o o t h e r s s e e k in g h e l p ? ; ( c ) I f y o u w e r e t o s e ek h e l p ag a i n ,w o u l d y o u r e t u r n t o t h i s a g e n c y ? ; a n d ( d ) H o w w o u l d y o u r a t e y o u rt he ra p i s t ? R a t i ngs we re ob t a i ne d on 5 -p o i n t L i ke r t s c al es . T he se que s -t i o n s e n c o m p a s s t h o s e r e c o m m e n d e d b y B e r g e r ( 1 9 83 ) a n d L a r s e n e ta l . ( 1979 ) i n t he i r r e v i e ws o f s a t i s f a c t ion t e c hn i que s .

C l i n i c a l S i g n i f i c a n ce A n a l y s e sClinically significant chang e. D e t e r m i n i n g w h e t h e r a c l i e n t h a s i m -prove d t o a c l i n i c a l ly s i gn i f ic a n t (C S ) de gre e i nvo l ve d a t wo-s t e p p ro-c e ss a s o u t l in e d b y J a c o b s o n a n d T r u a x ( 1 9 91 ) . F i r s t, i t w a s d e t e r m i n e d

wh e t he r a c l i e n t ha d i m prov e d t o a s t a t i s t ic a l l y s i gn i f i c a n t de gre e byc a l c u l a ti n g r el i ab l e c h a n g e ( R C ) f o r e a c h o f t h e o u t c o m e m e a s u r e s . T h eform ul a t ha t wa s use d fo r c a l c u l a t i ng R C i s a s fo l lows :

R C = x2 - x l /S d~ . 1T h a t i s , p r e t e s t - p o s t t e s t d i f fe r e n c e sc o r e s w e r e d i v i d ed b y t h e s t a n d a r de r ro r o f d i f f e re nc e be t we e n t he t wo t e s t s c ore s .

T h e s t a n d a r d e r r o r o f d i ff e r e n ce b e t w e e n t h e t w o s c o r es w a s e a i cu -


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2 0 4 P E K A R I K A N D W O L F Fl a t ed d i r e c tl y f r o m t h e s t a n d a r d e r r o r o f m e a s u r e m e n t SE) u s i n g t h efo l lowing formula :

Sd~ = 2 ( S E ) 2 . ( 2 )A n R C o f 1 .9 6 o r g re a t e r w a s c o n s i d e re d t o b e a s t a t i s t ic a l l y s i g n i f i c a n tc h a n g e ( i . e ., a r e l i a b l e c h a n g e ) .

T h e s e c o n d s t e p i n v o l v ed i n d e t e r m i n i n g C S w a s t o d e t e r m i n ew h e t h e r a c l i e n t h a d c ro sse d a n e s t a b l i sh e d c u t o f f p o i n t i n t o a fu n c -t i o n a l p o p u l a t i o n ra n g e f ro m a d y s fu n c t i o n a l p o p u l a t i o n ra n g e . Fo re a c h o f t h e o u t c o m e m e a su re s u se d i n t h i s s tu d y , t h e c u t o f f p o i n t w a se s t a b li s h e d u s i n g m e t h o d s d e r i ve d f r o m t h o s e r e c o m m e n d e d b y J a c o b -so n a n d Tru a x ( 1 99 1 ) . Fo r c l i e n t a n d t h e ra p i s t r a t i n g s , t h e c u t o f f fo r t h efu n c t i o n a l r a n g e w a s t h e sc o re t h a t f e l l tw o s t a n d a rd d e v i a t i o n s b e l o wt h e m e a n i n t a k e s c o re f o r e a c h m e a s u r e . B e c a u se n o n p a t i e n t n o r m a t i v ed a t a w e re a v a i l a b l e fo r t h e B S1 , t h e se d a t a w e re u se d i n d e t e rmi n i n gt h a t m e a s u r e ' s c u to f f sc o r e, a s r e c o m m e n d e d b y J a c o b s o n a n d T r u a x( 1 9 91 ) . Th e c u t o f f s c o re fo r t h e B SI w a s 1 .5 s t a n d a rd d e v i a t i o n s a b o v et h e n o n p a t i e n t m e a n . T h e l o gi c a n d m e t h o d s u s e d t o a r r i v e a t t h i s c u to f fa re d e sc r i b e d i n t h e A p p e n d i x .

B o t h c r o s s ov e r i n to t h e f u n c t i o n a l p o p u la t i o n a n d t h e a c h i e v e m e n t o fR C w e re re q u i re d fo r a c l i e n t t o b e c o n s i d e re d t o h a v e i mp ro v e d t o ac l i n ic a l l y s i g n i f ic a n t d e g re e . Th e sp e c if i c me t h o d s u se d t o d e t e rm i n eR C a n d C S d e p e n d e d o n t h e n a t u r e o f t h e d a t a a v a il a b le a n d a r e d e -sc r i b e d i n d e t a i l i n t h e A p p e n d i x . Th e R C a n d C S sc o re s p ro v i d e d b yt h e se c a l c u l a t i o n s a re a s fo ll ow s : B SI R C = 3 3 , C S c u t o f f = 4 0 ; c l i e n tra t i n g s R C = 5 , C S c u t o f f = 5 ; t h e ra p i s t r a t in g s R C = 4 , C S c u t o f f = 6 .Clinicallysignificant ailure. C l i e n t s w h o b o t h f a il e d to a c h i e ve R Ca n d h a d a fo l l o w -u p sc o re h i g h e r t h a n t h e c u t o f f s c o re ( t h a t s e p a ra t e dt h e fu n c t i o n a l a n d d y s fu n c t i o n a l p o p u l a t i o n s ) w e re re g a rd e d a s p ro v i d -i n g n o i n d i c a t i o n o f t r e a t m e n t b e n e f i t o n a g i v e n me a su re . I t w o u l d b eu n re a s o n a b l e t o c l a ss i fy su c h c l i e n t s a s t r e a t me n t fa i l u re s i f t h e y e n -t e re d t r e a t m e n t w i t h i n t a k e sc o re s o r r a t i n g s a l re a d y i n o r n e a r t h e fu n c -t i o n a l r a n g e , h o w ev e r. Fo r su c h c l i e n t s , a c h i e v e m e n t o f R C w o u l d e n t a i lf o ll o w -u p s co r e s in t h e s u p e r i o r e n d o f th e n o r m a l r a n g e - - s u p e r n o r -ma l fu n c t i o n i n g . To a c c o u n t fo r su c h c l i e n t s i n i d e n t i fy i n g c l i n i c a ll ys i g n i f ic a n t f a i l u re s (C S F) , m i n i m u m i n t a k e d y s fu n c t i o n w a s c a l c u l a t e dfo r e a c h me a su re so t h a t C S w o u l d n o t e n t a i l fo l lo w -u p fu n c t i o n i n g i nt h e s u p e r i o r e n d o f t h e n o r m a l ( f u n c t i o n a l ) r a ng e . M i n i m u m i n t a k ed y s fu n c t i o n sc o re s o r r a t i n g s t h a t ma d e c l i e n t s e l i gi b l e fo r c a te g o r i z a -t i o n a s C SF w e re 5 7 , 8 , a n d 7 fo r t h e B SI , c li e n t r a t in g s , a n d t h e ra p i s tra t ings, respect ive ly . The method used to ca lcu la te these scores i s p re-se n t e d i n t h e A p p e n d i x . C l i e n t s w e re c l a ss i f ie d a s C SF fa i l u re s o n a me a -su re i f t h e y me t t h e m i n i m a l i n t a k e d y s f u n c t i o n sc o re o r r a t i n g , f a i le dt o a c h i e v e R C , a n d fa i le d t o c ro ss o v e r th e c u t o f f sc o r e .Unclassified. C l i e n t s w e re c a t e g o r i z e d a s u n c l a s s i f i e d a n d e x c l u d e df ro m c l i n i c al s i g n if i c a n c e a n a l y se s i f t h e y (a ) a c h i e v e d R C b u t d i d n o tc ro ss o v e r i n t o t h e fu n c t i o n a l r a n g e , (b ) c ro s se d f ro m t h e d y s fu n c t i o n a lt o t h e fu n c t i o n a l r a n g e w i t h o u t a c h i e v i n g R C , o r ( c ) h a d i n t a k e sc o re si n t h e fu n c t i o n a l r a n g e .

L a r s e n e t al ., 1 9 7 9 ; L e b o w , 1 9 8 2 ; N g u y e n , A t t k i s s o n , & S t e g n e r ,1 9 8 3 ) , s u g g e s ti n g t h a t t h e s a t i s f a c ti o n d a t a w e r e r e p r e s e n t a t i v eo f p u b l i c c l i n ic s e t ti n g s. I n t e r c o r r e l a t i o n s a m o n g i t e m s w e r ef a ir l y h i g h , r a n g i n g f r o m . 5 8 t o . 82 . T h e s e d a t a a r e p r e s e n t e d i nT a b l e 1 . T h e s a t i s f a c t i o n s c o r e s o b t a i n e d 1 0 w e e k s a f t e r in t a k ew e r e f o u n d t o b e s i g n if i c a n tl y a n d h i g h l y c o r r e l a t e d w i t h s a t is -f a c t i o n s c o r e s o b t a i n e d 5 m o n t h s a f t e r i n t a k e ( r = . 7 9 , p < . 01 ) ,i n d i c a t i n g t h a t 1 0 - w e e k s a t i s f a c t i o n is r e p r e s e n t a t i v e o f l o n g e rt e r m s a t i s f a c t i o n . B e c a u s e d a t a w e r e s o m e w h a t m o r e c o m p l e t ea t 1 0 w e e k s t h a n 5 m o n t h s , a l l s u b s e q u e n t a n a l y s e s u s e d 1 0 -w e e k i n f o r m a t i o n .R e l a t i o n s h i p o f S a t i sf a c ti o n t o T h e r a p e u t ic C h a n g e

F o r e a c h i n d i v i d u a l o u t c o m e m e a s u r e ( c l i e n t r a t i ng , t h e r a p i s tr a t in g , B S I ), i n t a k e t o f o l l o w - u p r a t i n g ( p r e - p o s t ) c h a n g e s w e r ec a l c u l a t e d f o r e a c h i n d i v i d u a l p a r t i c i p a n t . A s i g n if i c a n t b u ts m a l l r e l a t i o n s h i p w a s f o u n d b e t w e e n i n t a k e t o 1 0 - w e e kc h a n g e s i n t h e r a p i s t r a t in g s a n d c l i e n t s a t is f a c t io n ( r = - . 2 1 ,p < . 0 5 ) . T h a t i s, as t h e r a p i s t - r a t e d c h a n g e s i n c r e a s e d , c l ie n ts a t i sf a c t i o n i m p r o v e d ( a n u m e r i c a l l y l o w s a t is f a c t io n s c o r e r e p -r e s e n t e d h i g h c l i e n t s a t i s f a c t io n ) .

N o s i g n i fi c a n t r e l a t i o n s h i p w a s f o u n d b e t w e e n c l i e n t r a t i n gc h a n g e a n d s a t is f a c t i on ( r = - . 0 7 ) o r b e t w e e n B S I s c o r e c h a n g ea n d s a t i s f a c t i o n ( r = - . 0 6 ) .R e l a t i o n s h i p o f F o l l ow - U p A d j u s t m e n t W i t h S a t i s f a c ti o n

P e a r s o n c o r r e l a t i o n s c a l c u l a t e d b e t w e e n s a t i s f a c t io n a n d 1 0 -w e e k f o l l ow - u p s c o r e s a n d r a t i n g s f o r e a c h o u t c o m e m e a s u r er e v e a l e d n o s i g n i f i c a n t r e l a t i o n s h ip s . T h e c o r r e l a t i o n s b e t w e e ns a t i s f a c t i o n a n d f o l l o w - u p t h e r a p i s t r a t i n g s , c l i e n t r a t i n g s , a n dB S I s c o r e s w e r e , r e s p e c t i v e l y , r = . 1 8 , . 1 0 , a n d . 0 8 .R e l a t i o n s h i p o f S a t i s f a c t i o n t o C l i n i c a l l y S i g n i f i c a n tI m p r o v e m e n t

J a c o b s o n a n d T r u a x ' s ( 1 99 1 ) m e t h o d f o r c a l c u la t i n g c l in i c a ls i g n i fi c a n c e w a s a p p l i e d t o e a c h o u t c o m e m e a s u r e i n o r d e r toi d e n t i f y c l i e n t s w h o a c h i e v e d a n d f a i l e d t o a c h i e v e c l i n ic a l l y s i g -n i f i c a n t c h a n g e f o r e a c h m e a s u r e . T h e r e s u l t s o f th e a p p l i c a t i o na r e p r e s e n t e d i n T a b l e 2 .

P o i n t - b i s e r i a l c o r r e l a t i o n s w e r e p e r f o r m e d w i t h c l i n i c a ll y s ig -n i f i c a n t s u c c e s s v e r s u s c l i n i c a ll y s i g n i f i c a n t f a i lu r e a s a d i c h o t o -m o u s v a r i a b l e a n d d e g r e e o f s a t i s f a c ti o n a s a n o r d i n a l v a r i a b l ef o r e a c h o u t c o m e m e a s u r e . T h e y r e v e a l e d a s i g n i fi c a n t b u t l o w

R e s u l t sD e s c r i p t iv e S t a t i s t i c s a n d S a t i s fa c t i o n S u r v e y R e s u l t s

C o r r e l a t io n s a m o n g t h e o u t c o m e m e a s u r e s w e r e l ow t o m o d -e r a t e . A t i n t a k e , B S I s c o r e s c o r r e l a t e d . 3 8 a n d . 2 0 w i t h c l i e n ta n d t h e r a p i s t r a t i n g s , r e s p e c t i v e l y . C l i e n t a n d t h e r a p i s t r a t i n g sc o r r e l a t e d . 1 9 w i t h e a c h o t h e r . T h e s e c o r r e l a t i o n s i n d i c a t e t h a tt h e s e m e a s u r e s a r e r e l a ti v e ly i n d e p e n d e n t o f o n e a n o t h e r .

T h e o v e r a l l s a ti s f a c t i o n r a t i n g s w e r e h i g h ( M = 1 . 8 8 p e r i t e m ,S D = . 9 2 ) a n d s i m i l a r t o th o s e r e p o r t e d b y o t h e r i n v e s t ig a t o r s( B e r g e r , 1 9 8 3 ; E s s e x , F o x , & G r o o m , 1 9 8 1 ; F i e s te r , 1 9 7 9 ;

T a b l e 1In tercorrela t ions Am ong I tem s on the Clien t Sa tisfact ionRatin g Obta ined 10 W eeks After In takeI tem l 2 3 4

I . I t e m l2 . I t e m 2 . 71 - -3 . I t e m 3 .67 * .8 2 * - -4 . I tem 4 .58* .58* .60* - -* p < . 0 1 .


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2 6 PEKARIK AND WOLFFtion. This strongly suggests that satisfaction is not meaningfullyrelated to tradit ional client measures of outcome.

The high satisfaction scores may indica te that client satisfac-tion occurs without client regard to degree of symp tom change.Clients may be able t o discern a difference between satisfactionand success, as suggested by Larsen et al. (1979). It is conceiv-able that clients have rated their degree of satisfaction on thebasis of something other than their satisfaction with the symp-tom or presenting problem change. General likability of thetherapist, perceived earnest efforts of the therap ist or agency, orsimply the availability of services are b ut a few reasons why cli-ents may rate t heir therapy experience as satisfactory indepen -dent of degree of problem change (Sloane, Staples, Cristol,Yorkston, Whipp le, 1975 ).

The high satisfaction scores, however, may be due to low va-lidity of the instrum ent and client response: Clients may be un-willing or unable to identify dissatisfaction. This prospect iscontradicted by extensive research o n the satisfaction questionsused in this study (Nguyen et al., 1983).

As in other satisfact ion research, rat ings were skewed towardhigh satisfaction. At present, 15 years after the development ofthe Client Satisfaction Questionnaire (CSQ) by Larsen et al.( 1979; which served as the source o f items used i n the pr esentstudy), the CSQ conti nues as the most widely used and highlyregarded satisfaction measure report ed in the literature. It maybe that clients do tend to be highly satisfied with menta l healthservices, as suggested by Nguyen et al. (1983), but other mea-sures could and should be developed to attempt to furtherdifferentiate degrees of satisfaction. Futu re research could ad-dress this by generating satisfaction items that facilitate the re-porting of dissatisfaction. One way to do t his would be to useitems that assess a wider range of clinical phenomen a. For ex-ample, rather tha n simply ask about satisfaction with the thera-pist, items could assess specific aspects of therapist behavior(e.g., therapist advice on how to cope with p roblem s outside thesession).

Although not the pri mary goal of this study, it does provideinteresting data on the p roportio n of clients who achieved clin-ically significant impro veme nt at co mmu nit y clinics. Althoughthere were more failures than successes with all measures, itshould be noted that the study did not restrict the sample totreat ment completers, that is, it include d those who termina tedprematurely.

This research has confirmed the findings of much previousresearch: Correl ations between client satisfaction and therapeu-tic outcom e measures were low. Satisfaction surveys shouldcontinue, therefore, to be considered a distinct cont ribu tio n tooverall assessment of quality of services provided but not a sub-stitute for traditional measures of outcome.

eferencesAmerican Psychiatric Association. ( 1987 ). Diagnostic a nd statisticalmanual of m ental disorders ( 3rd ed., rev.). Washington, DC: Author.Ankuta, G. Y., Abeles, N. (1993). Client satisfaction, clinical sig-nificance,and meaningful change in psychotherapy.Professional Psy-chology. Re search a nd Practice, 24, 70-74.

Attkisson, C. C., Zwick, R. (1982). The Client SatisfactionQuestion-naire: Psychometric properties and correlations with service utiliza-tion and psychotherapyoutcome. Evaluation andProgram Planning,5, 223-237.Berger, M. ( 1983 ). Toward maximizing the utility of consumer satisfac-tion as an outcome measure. In M. J. Lambert, E. R. Christensen,S. S. Dejulio (Eds.), The assessment o f psychotherapy outcome (pp.56-80). New York: Wiley.Carscaddon, D. M., George, M., Wells, G. (1990). Rural communitymental health consumer satisfaction and psychiatric symptoms.Com munity Mental Health Journal 26, 309-318.Derogatis, L. ( 1977 ). SCL-90:Administration, scoring, and proceduresma nua l- l for the R(evised) version. Baltimore, MD: Johns HopkinsUniversitySchool of Medicine.Derogatis, L., Spencer, P. (1982). The b rief symptom inventory: Ad-ministration, scoring and procedures manual-l. Baltimore, MD:Clinical Psychometric Research.Edwards, D., Yarvis, R., Mueller, D., Langsley, D. (1978). Does pa-tient satisfaction correlate with success? Hospital and CommunityPsychiatry, 29, 188-190.Essex, D. W., Fox, J. A., Groom, J. M. (1981). The development,factor analysis, and revision of a client satisfaction form. Communi tyMe ntal Health Journal, 17. 226-235.Fiester, A. R. ( 1979 ). Goal attainment and satisfaction for CMHC cli-ents.American Journal of Com mun ity Psychology, 7, 181-188.Garfield, S. L., Prager, R. A., Berg, n, A. E. (1971). Evaluation ofoutcome in psychotherapy. Journal of Consulting and Clinical Psy-chology, 37, 307-313.Greenfield, T. K., Attkisson, D. D. (1989). Steps toward a multifac-torial satisfaction scale for primary care and mental health services.Evaluation and Program Planning, 12, 271-278.Jacobson, N. S., Truax, P. ( 1991 ). Clinical significance:A statisticalapproach to defining meaningful change in psychotherapy research.Journal o f Consulting and C linical Psychology, 59, 12-19.Lambert, M. J., Hill, C. E. (1994). Assessing psychotherapy out-comes and processes. In S. L. Garfield A. E. Bergin (Eds.), Hand-book of psychotherapy an d behavior change ( 4th ed., pp. 72-113 ).New York: Wiley.Lambert, M. J., Shapiro, D. A., Bergin, A. E. (1986). The effective-ness of psychotherapy. In S. L. Garfield A. E. Bergin (Eds.), Hand-book of psychotherapy and behavior change ( 3rd ed., pp. 157-212).New York: Wiley.Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., Nguyen, T. D.(1979). Assessment of c lient /patient satisfaction: Development of ageneral scale.Evaluation an d Program Planning, 5, 233-237.Lebow, J. (1982). Consumer satisfaction with mental health treatment.Psychological Bulletin, 91, 244-259.Linden, W., Wen, E K. (1990). Therapy outcome research, health

care policy, and the continuing lack of accumulated knowledge. Pro-fessional Psychology: Research and Practice, 21,482-48 8.Mental Health Systems Act of 1980, Pub. L. No. 96-398.Mintz, J., Kiesler, D. J. ( 1982 ). Individualized measures of psycho-therapy outcome. In P. C. Kendall J. N. Butcher (Eds.), Handbookof research methods in clinical psychology (pp. 491-534). New York:Wiley.Nguyen, T, D., Attkisson, C. C., Stegner, B. L. ( 1983 ). Assessmentofpatient satisfaction: Development and refinement of a service evalua-tion questionnaire. Evaluation and Program Planning, 6, 299-314.Pekarik, G. (1992). Relationship of clients' reasons for dropping out oftreatment to outcome and satisfaction. Journal o f Clinical Psychol-ogy, 48, 91-98.


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S A T IS F A C TI O N A N D O U T C O M E 2 0 7P u b l i c H e a l th S e r v ic e A c t a m m e n d m e n t s o f 1 97 5, P u b . L . N o . 9 4 - 6 3 .Sleek, S. ( 1994, February). Psychologists, lawyers facing similar changes:

Rise of corp ora te en t i t ies b rings changes. TheAPA Monitor , pp. , 28 .S l o a n e , R . B ., S t a p l e s, E E , C r i s t o l, A . H. , Y o rs t o n, N. J . , & Wh i p p l e ,

K. ( 1 9 75 ) . Sh o r t - t e rm a n a l y t i c a l l y o r i e n t e d p sy c h o t h e ra p y v e rsu s b e -h a v i o r t h e ra py . Am erican Jou rnal of Psychiatry , 132, 3 7 3 - 3 7 7 .

S t il es , W. B . , Sh a p i ro , D . A. , & E l l i o t t , R . K , (1 9 8 6 ) . "A re a l l p sy c h o -t h e ra p i e s e q u i v a l e n t ? " Am erican Psychologis t , 41, 1 6 5 -1 8 0 .

We i sz , J . R . , & We i ss , B . (1 9 8 9 ) . Asse ss i n g t h e e f fe c t s o f c l i n i c -b a se dp sy c h o t h e ra p y wi t h c h i l d re n a n d a d o l e sc e n t s . Journa l o f Consult ingand Clinical Psychology , 5 7 , 7 4 1 -7 4 6 .

Wi li er , R . D . , & M i l l e r , G . H. (1 9 7 8 ) . On t h e re l a t i o n sh i p o f c l ie n t s a t-i s f ac t io n t o c l i e n t c h ar a c t e r is t i c s a n d o u t c o m e o f t r e a t m e n t . J ournalof Clinical Psychology , 34, 1 5 7 -1 6 0 .

W i n e g a r, N . ( 1 9 9 2 ) . The c l in ic ian s guide to manag e d me nta l he al thcare. B i n g h a m t o n , N Y : H a w o r t h P r e s s.

A p p e n d i xD e t e r m i n a t i o n o f C r i t e r i o n S c o r e s f o r R e l i a b l e C h a n g e ( R C ) a n d C l i n i c a l S i g n i f i c a n c e ( C S )

B S IA l l t h e d a t a n e e d e d t o c a l c u l a te R C u s i n g th e f o r m u l a s s h o w n i n t h eM e t h o d se c t i o n we re a v a i l a b le fo r t h e B SI , so R C w a s c a l c u l a t e d a s d e -

sc r i b e d i n t h a t s e c t i o n .Ja c o b s o n a n d Tru a x ( 1 9 91 ) i d e n t if i e d two me t h o d s fo r f i n d i n g t h ec u t o f f b e t w e e n f u n c t i o n a l a n d d y s f u n c t i o n a l p o p u l a t i o n s w h e n d a t a

f ro m b o t h p o p u l a t i o n s a re a v a i la b l e . Th e f i r s t me t h o d i n v o l v e s u se o ft h e f o r m u l a

c = (soMa + s lM o) /So + s l ,w h e r e c = t h e c u t o f fs c o r e , M 0 = t h e m e a n o f t h e f u n c t i o n a l p o p u l a t io n ,M ~ = t h e me a n o f t h e d y s fu n c t i o n a l p o p u l a t i o n , So = t h e s t a n d a r d d e v i -a t i o n o f th e fu n c t i o n a l p o p u l a t i o n , a n d s~ = t h e s t a n d a rd d e v i a t i o n o ft h e d y s fu n c t i o n a l p o p u l a t i o n . No n p a t i e n t d a t a su p p l i e d b y De ro g a t i sa n d S p e n c e r ( 1 9 8 2 ) a n d p a t i e n t d a t a f r o m t h i s s t u d y p r o v i d e t h efo l lowing: Mo = 16 , So = 16 , M , = 70 .4 , s~ = 39 .7 . Us ing th is da t a in thef o r m u l a p r o v i d e d a c u t o f f sc o r e ( c ) o f 3 2 . T h e i r s e c o n d m e t h o d u s e s th es c o r e t h a t i s tw o s t a n d a r d d e v i a ti o n s a b ov e t h e n o n p a t i e n t m e a n a s t h ecutoff , whic h i s 48 .

T h e c u t o f f s c o r es p r o v i d e d b y t h e s e t w o m e t h o d s a r e q u i t e f a r a p a r t( 3 2 v s . 4 8 ) - - a f u ll s t a n d a r d d e v i a t io n ( o f t he n o n p a t i e n t g r o u p ) . J a -c o b so n a n d Tru a x ( 1 9 91 ) a d v i se d u se o f t h e f i r s t me t h o d w h e n t h e n o r -m a l a n d d y s f u n c t i o n a l p o p u l a t i o n s o v e r l a p a n d t h e s e c o n d m e t h o dwh e n t h e y d o n o t . In t h i s s tu d y , t h e t wo p o p u l a t i o n s o v e r l a p , b u t b a re ly ,ma k i n g n e i t h e r me t h o d i d e a l : Th e f i r s t me t h o d i s t o o s t r i n g e n t , r e q u i r -i n g t h a t c l ie n t s b e w i t h i n o n e s t a n d a r d d e v i a ti o n o f t h e n o n p a t i e n t m e a n( r a t h e r t h a n t h e 2 s t a n d a r d d e v i a t io n s J a c o b s o n a n d T r u a x p r e s c r i b e da s t h e c u t o f f w h e n n o n p a t i e n t d a t a a r e r e l ie d o n ) ; t h e s e c o n d m e t h o d i st o o l e n i e n t b e c a u se i t i d e n ti f i e s a s fu n c t i o n a l a s c o re t h a t i s o n l y a p p ro x -i m a t e l y o n e - h a l f a s t a n d a r d d e v i a t io n ( o f t h e p a t i e n t p o p u l a t i o n i n t a k esc o re ) b e l o w t h e me a n i n t a k e sc o re o f t h e p a t i e n t g ro u p . T h e so l u t i o nt o t h i s p r o b l e m w a s t o u s e a s c u t o f f a s c o r e o f 4 0 , w h i c h i s t h e m i d p o i n tb e t w e e n t h e c u t o f fs c o r e s p r o v i d e d b y t h e t w o m e t h o d s . T h e u s e o f t h i sc u t o f f i s su p p o r t e d b y a n u mb e r o f s t a t i s ti c a l j u s t i f i c a ti o n s . Th i s s c o re i so n e - h a l f s t a n d a r d d e v i a t i o n ( o f t h e n o n p a t i e n t p o p u l a t i o n ) h i g h e r ( i. e .,mo re l e n i e n t ) t h a n t h e o v e r l y s tr i c t c u t o f f p ro v i d e d b y t h e f i r st me t h o da n d o n e - h a l f s t a n d a r d d e v i a t i o n ( o f t h e n o n p a t i e n t p o p u l a t i o n ) l o w e r( i . e. , mo re s t r i c t ) t h a n t h e t o o - l e n i e n t c u t o f f p ro v i d e d b y t h e se c o n dme t h o d . I t i s q u i t e c o n se rv a ti v e , r e q u i r i n g a fo l l o w-u p sc o re wi t h i n o n ea n d a h a l f s t a n d a r d d e v i a ti o n s o f th e n o n p a t i e n t p o p u l a t i o n, w h i c h i s . 5s t a n d a r d d e v i a t io n l o w e r ( b e t t e r a d j u s t e d ) t h a n p r e s c r i b e d b y J a c o b s o na n d T r u a x .

d e v i sed . Ot h e r r e se a rc h e rs (We i sz & We is s , 1 9 8 9 ) h a v e c l a i me d t h a te a r ly d r o p o u t s r e c e i ve v i r t u a ll y n o t r e a t m e n t a n d t h e r e f o r e c a n b e c o n -s i d er e d a s a s u b s t i t u te f o r a n o - t r e a t m e n t c o n t r o l g r o u p i n o u t c o m e r e -se a rc h . Us i n g s i mi l a r l o g ic , i n t a k e a n d 1 0 -we e k fo l l o w-u p ra t i n g s fo rc l i e n t s wh o a t t e n d e d o n e o r t wo se s s i o n s c o u l d se rv e a s a n e s t i ma t e o ftest -re test re l iab i l i ty .

U s i n g t h e f o r m u l a f o r R C a s d e s c r ib e d e a r li er , w e d e t e r m i n e d t h a t ap r e - p o s t t e s t c h a n g e o f 5 p o in t s o r m o r e w o u l d b e r e q u i r e d f o r a c l ie n tt o b e c o n s i d e re d re l i a b l y c h a n g e d o n t h i s me a su re .

T h e c u t o f f p o i n t s e p a r a t i n g f u n c t i o n a l f r o m d y s f u n c t i o n a l p o p u l a -t i o n s w a s d e t e r m i n e d b y c a l c u l a t in g a p o i n t t w o s t a n d a r d d e v i a t i o nsb e l ow t h e m e a n o f t h e d y s f u n c t io n a l p o p u l a t i o n ( i. e ., m o r e f u n c t i o n a l )a s o u t l in e d b y J a c o b s o n a n d T r u a x ( 1 9 9 1 ) . T h i s r e s u l te d i n a c u t o f fp o i n t o f 5 , m e a n i n g t h a t a c l i e n t w a s re q u i r e d t o h a v e h a d a p r e t r e a t -m e n t ra t i n g o f 6 o r h i g h e r ( i. e . , i n t h e d y s fu n c t i o n a l r a n g e ) a n d a p o s t -t r e a t m e n t r a t i n g o f 5 o r l o w e r t o h a v e c r o s s e d o v e r f ro m t h e d y s f u n c -t i o n a l p o p u l a t io n r a n g e i n t o t h e f u n c t i o n a l p o p u l a t i o n r a n g e o n t h i sme a su re . Th i s c h a n g e p a t t e rn , a l o n g wi t h a n R C o f 5 o r g re a te r , wa s t h ec r i t e r i o n fo r a c h i e v i n g c l i n i c a l s i g n if i c a n c e .

T h e r a p i s t R a t i n g sAs wi t h c l i e n t r a t i n g s , a t r a d i t i o n a l m e a su re o f t e s t - re t e s t r e l i a b i l i ty

i s v i r t u a l l y i mp o ss i b l e t o se c u re fo r t h e ra p i s t r a t i n g s . An e s t i m a t e o f t h i swa s a v a i l a b le , h owe v e r : Th e ra p i s t r a t i n g s a t i n t a k e a n d t e rm i n a t i o n fo rs i n g l e - se s s i o n c l i e n t s we re b o t h b a se d o n t h e t h e ra p i s t ' s a s se s sme n t o ft h e c l i e n t a t t h e i n t a k e i n te rv i e w. Th e t h e ra p i s t r a t e d t h e sa m e b e h a v i o ro n t wo o c c a s i o n s ( i n t a k e a n d wh e n a sk e d t o re c a l l in t a k e 1 0 we e k s l a t e ra t t h e f i r st fo l l o w-u p ) . Th i s a p p e a rs t o b e a re a so n a b l e e s t i ma t e o f t e s t -re t e s t r e l ia b i l i t y a n d w a s so u se d i n t h e R C fo rm u l a fo r t h e ra p i s t r a ti n g s .U s i n g t h e f o r m u l a f o r R C t h e n , i t w a s d e t e r m i n e d t h a t a p r e - p o s t t e s tc h a n g e o f 4 o r m o r e p o i n t s w o u l d b e r e q u i r e d f o r a c l i e n t t o b e c o n s i d -e re d re l i a b l y c h a n g e d o n t h i s m e a su re .

T h e c u t o f f p o i n t s e p a r a t i n g f u n c t io n a l f r o m d y s f u n c t i o n a l p o p ul a -t i o n s w a s d e t e r m i n e d i n t h e s a m e m a n n e r a s u s e d f o r c l i e n t r a t in g s . T h i sre su l t e d i n a c u t o f f p o i n t o f 6 , me a n i n g t h a t a c l i e n t wa s re q u i re d t oh a v e h a d a p r e t r e a t m e n t ( i n t a k e ) s c o r e o f 7 o r h i g h e r ( i . e . ,d y s fu n c t i o n a l ) a n d a p o s t t r e a t m e n t ( 1 0 -we e k fo l l o w-u p ) sc o re o f 6 o rl o we r t o h a v e c ro sse d o v e r f ro m t h e d y s fu n c t i o n a l p o p u l a t i o n ra n g e i n t ot h e f u n c t i o n a l p o p u l a t i o n r an g e . T h i s c h a n g e p a t t e r n , a l o n g w i t h a n R Co f 4 p o i n t s o r g re a te r , wa s t h e c r i t e r i o n fo r a c h i e v i n g c l i n ic a l s i g n i f ic a n c efo r t h i s me a su re .

C l i e n t R a t i n g sB e c a u se t e s t - re t e s t r e l i a b i li t y , r e q u i re d b y t h e R C fo rmu l a , i s v i r t u -

a l l y i mp o ss i b l e t o se c u re fo r c l i e n t r a t i n g s , so me e s t i ma t e o f i t h a d t o b e

F a i l u r eTh e f i r st c r i te r i o n fo r c a t e g o r i z a t i o n a s a " fa i l u r e " wa s t h e fa i l u re t o

a c h i e ve R C . S o m e c l i e n ts b e g a n t r e a t m e n t w i t h a n i n t a k e s c o r e o r r a t i n g


7/7

2 8 P E K A R I K A N D W O L F Fi n o r n e a r t h e f u n c t i o n a l r a n g e ; h o w e v e r, i t w o u l d b e i n a p p r o p r i a t e t oc o n s i d e r s u c h c a s e s fa i lu r e s . T o a d d r e s s t h is , m i n i m u m i n t a k e s c o r e sw e r e e s t a b li s h e d f o r e a c h m e a s u r e o n t h e b a s i s o f th e n u m b e r o f c h a n g eu n i t s r e q u i r e d t o a c h i e v e R C a n d t h e s c o r e s fo r d e f in i n g th e d y s f u n c -t i o n a l a n d f u n c t i o n a l r a n g e s . T h e g o a l w a s t o e x c l u d e a s f a i l u re s c l i e nt sw h o b e g a n t r e a t m e n t i n t h e n o r m a l r a n g e o r so c lo s e to t h e n o r m a lr a n g e t h a t a c h i e v e m e n t o f R C w o u l d e n ta i l a s u p e r n o r m a l f o l lo w - u p .

F o r c li e n t r a t in g s , t h e m i d p o i n t o f t h e n o r m a l r a n g e w a s s u b t r a c t e df r o m t h e p r e v i o u s l y e s t a b l is h e d c r o s s o v e r p o i n t . T h e e s t a b l i s h e d m i n i -m u m c h a n g e r e q u i r e d f o r R C w a s t h e n a d d e d t o t h e r e s u lt to a r r i v e a t am i n i m u m d y s f u n c t i o n s c o r e r e q u i r e d b y a c l ie n t in o r d e r t o be c o n s i d -e r e d a p o t e n ti a l f a i lu r e . T h i s p r o c e d u r e e n s u r e d t h a t c l i e n ts w h o w o u l dh a v e t o a c h i e v e a b e t t e r - t h a n - n o r m a l s c o r e a t f o l l o w - u p (i . e ., b e t t e r t h a nt h e m i d p o i n t o f t h e n o r m a l p o p u l a t i o n r a n g e ) i n o r d e r t o a c h ie v e R C

w o u l d n o t b e c l a ss i fi e d as f a i lu r e s . S i m i l a r p r o c e d u r e s w e r e u s e d f o rt h e r a p i s t r a t in g s , a n d B S I s c o r e s , r e s u l ti n g i n m i n i m a l i n t a k e d y s f u n c -t i o n s c o r e o f 8 , 7 , a n d 5 7 f o r c l ie n t r a t i n g s , t h e r a p i s t r a t i n g s , a n d B S Is c o r e s , r e s p e c t i v e ly . C l i e n t s w i t h o u t t h e s e m i n i m u m s c o r e s a t i n t a k ew e r e e x c l u d e d f r o m t h e f a i l ur e c a t e g o r y .

C l i e n t s w e r e c l a s s i fi e d a s f a i lu r e s f o r e a c h m e a s u r e i f t h e y f a i l e d t oa c h i e v e R C , h a d t h e i d en t i fi e d m i n i m u m i n t a k e s c o r e, a n d f a i l e d t oc r o s s o v er th e c u t o f f p o i n t s e p a r a t i n g f u n c t i o n a l a n d d y s f u n c t i o n a l s c o r ea n d r a t i n g r a n g e s.

R e c e i v e d N o v e m b e r 8 , 1 9 9 4R e v i s i o n r e c e i v e d J u n e 6 , 1 9 9 5

A c c e p t e d O c t o b e r 2 0 , 1 9 9 5

N e w E d i to r S o u g h t f o r N e w ontemporary PsychologyThe Publ ications an d Comm unicat ions P&C) Bo ard has opened nominat ions for the edi torshipo f ontemporary P sychology or the years 1 999-200 4. John H. Harvey, PhD, i s the incum benteditor.Beginn ing wi th the new edi torship , the P&C Board intends to increase the t imeliness of rev iewsand to implement a new, more selective co vera ge policy, indicated in the follow ing statement:

ontemporary P sychology s a journal of review and evaluat ion. Al though i t i ssustained b y a varied intellectual diet, i ts ma in staple is ideas as they are reflected inbooks. Not al l books nourish the review process, bu t books that provoke thoughtabout the broad a rena of psychology, monographs that in tegrate ne w empir ical w ork,wo rks that enhanc e clinical practice, treatises that are likely to influence publicthinking, and textbooks that will be used in colleges and universities are grist forthe evaluative process.ontemporary Psychology ndeavo rs o provide a m eaty fare of sophist icated, evenopinionated a nd controversial reviews that emphasize evaluation ra ther than mere

pr6cis an d summary. (A s protection a gainst occasional gross bnas, there may becom pet ing reviews a nd occasional responsa.) Often a book wi l l serve as a spr ing-board for we ighing compet ing posit ions. Just a s of ten, i t wi l l p lum b the ful l depthand impl icat ions of an idea. In each assessment, the review er wi ll be enco uraged obring the ful l pa noply of scholarship in to play.Beyon d reviewing individual books a nd groups of related books, ontemporaryPsychologywil l provide occasion al essays on the state of the media in psychol -ogy, including com men t on new informat ion technologies ( Intemet and the WorldWide Web, fo r example) a nd new product ion modes fo r books and journals (elec-t ronic ournals, for example) .In sum, ontemporary Psychology endea vors to take psycho logical ideas ser i -ously and to provide a foru m in which they can be examined w i th spice, wi t , andintelligence.

Candidates should be memb ers of APA and should be avai lable to work wi th the P&C B oard ondeveloping new procedures in 1997. The successful c andidate wi l l s tar t receiving books onJan u ary 1 , 1 9 9 8. P l ease n o t e t h a t th e P&C B o ard en co u rag es p ar t i c i p a t i o n b y me mb er sof underrepresented groups in the publ icat ion process and wo uld par ticular ly w elcom e suchnominees.To nominate candidates, prepare a statement of one page or less in support of each candidate andsend to:

Donn a M. Gel fand, PhD, Sea rch Commit tee Chai rc/o Lee Cron, P&C Board Sea rch LiaisonR o o m 2 0 0 4Am erican Psyc hological Associat ion750 Fi rst St reet , NEWashington, DC 20002-4242Members of the search commit tee are Norm an Abeles, PhD; Joe L. Mart inez, Jr ., PhD; Richa rdM. Suinn, PhD; a nd Judith P. Worell, PhD.Fi rst review of nominat ions wi l l begin June 1 , 1996.

relationship of satisfaction to symptom change, follow-up adjustment, and clinical significance

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