Chapter 12
Monitoring Client Progress
Monitoring Client Progress
• For several decades researchers have
urged practitioners to use single case
designs to evaluate their practice.
– Because of feasibility constraints in
implementing these designs, very few
practitioners actually use these designs in
practice.
• These constraints include the need to collect a
large number of data points across multiple
phases.
• Most problematic is the baseline phase because it
requires the delay of treatment.
Monitoring Client Progress
• If practitioners follow the full five-step EBP
process, the use of single case design
techniques can be streamlined.
– Once practitioners reach step 5, they do not
need to derive internally valid inferences to
establish the effectiveness of the intervention.
That concern is addressed in earlier steps
leading to the selection of the intervention with
the best available evidence.
Monitoring Client Progress
• Step 5 in the EBP process is focused on
monitoring whether the client achieved
desired outcomes and:
– Determining whether the selected intervention
is working, or in need of adjustment.
– Supporting client commitment to the process
– Gathering additional information from the
client to explore any blips or unexpected
changes in targeted outcomes.
A Practitioner-Friendly Design
• Because the key purpose of step 5 in the
EBP process is to monitor client progress,
a simplified variation of the single subject
design approach can be used.
A Practitioner-Friendly Design
• The client and practitioner should discuss
a target level as a goal for treatment.
– If this target is reached, then the chosen
intervention was sufficient.
– If not, the treatment can be adjusted.
The B+ Design
• This design is simply the B phase of an AB
design, with the possible addition of one
pre intervention data point.
• When the desired level of progress is
reached and sustained long enough to
justify discontinuing the intervention, the B
phase can be discontinued in a manner no
different from usual practice.
Monitoring Progress With the B+
Design
• Results suggesting that the desired
reduction in problem behavior is achieved
during the intervention (phase B).
Monitoring Progress With the B+
Design
• Results indicating that the initially selected
intervention was not appropriate for the
client, and a different intervention was
successful.
Monitoring Progress With the B+
Design
• This approach is not intended to establish
internal validity.
– Rather, it provides a way to determine
whether the intervention isn’t working for the
client.
– Recall that even among empirically supported
interventions, some clients will not benefit
from the intervention, or will not benefit to a
satisfactory level.
Feasible Assessment Techniques
• Before generating graphed data, a plan for
monitoring progress is needed.
• This requires answering four questions:
– What to measure?
– Who should measure?
– With what measurement instrument?
– When and where to measure?
What to Measure?
• The choice of what to measure requires
that the problem or treatment goal:
– Be translated into something that is
observable,
– Be feasible to measure, and
– Have a reasonable chance of changing from
one data point to the next.
A Simple Scale
• If an appropriate and feasible existing
measurement instrument is not available,
a simple scale can be created. This scale
can be modified to fit different clients and
programs by changing the word
depression to anxiety, worry, confidence,
etc.
Measuring Frequency or Duration
• Instead of measuring an overall
approximation of a mood or other emotion
over time, the frequency or duration of
actual behaviors or cognitions can be
tracked.
– Example: A depressed client can track the
number of hours slept each night, the number
of suicidal thoughts each day, etc.
Who Should Measure?
• There are four options regarding who
should measure:
– The practitioner.
– The client.
– A significant other (e.g. parent, partner,
teacher).
– Existing records.
Who Should Measure?
• Each of these approaches has trade-offs
in terms of advantages and
disadvantages.
• Any approach may be used on its own or
in combination with others.
• Choose an approach that is most feasible
and clinically useful given your practice
situation.
Who Should Measure?
• Practitioner
– Advantage: The practitioner can ensure that
the measurement is completed and performed
properly.
– Disadvantages:
• Measurement requires the practitioner’s presence.
• The practitioner’s observation may be obtrusive
and bias the client’s report of behaviors.
• The burden is on the practitioner.
Who Should Measure?
• Client
– Advantages:
• There are some phenomena that only the client
can observe and report on (e.g., thoughts).
• This approach saves the practitioner time.
– Disadvantages:
• The client might not follow through consistently
with measurement.
• Self-report can be biased.
Who Should Measure?
• Significant other
– Advantages:
• This saves practitioner time.
• For very young, or impaired clients, this may be
the only feasible option.
• The significant other may be able to observe less
obtrusively than the practitioner.
– Disadvantages
• The significant other might not follow through
consistently.
• The measurement can be biased.
Who Should Measure
• Available records
– Advantages:
• This is less obtrusive than other options.
• Feasibility because the data are already collected.
• It enables developing a reconstructed baseline.
– Disadvantages:
• Measurement is limited to those pieces of
information that are available.
• There may be difficulty gaining access to some
types of records.
• The data may not be collected accurately or
systematically.
With What Measurement
Instrument?
•
There are three main instrument options:
1. Behavioral recording forms.
2. Individualized rating scales.
3. Standardized scales.
Behavioral Recording Forms
• An instrument is needed to record actual
behaviors by clients or significant others.
• There are two options:
– Frequency recording, which is recording the number
of times the target behavior occurs.
– Duration recording, which is recording how long the
behavior lasts when it does occur.
• The key is select or construct a form that is
simple and nonaversive for the person who will
use it.
Behavioral Recording Forms
• Clients and significant others can use
simple techniques to track the behavior
throughout the day, such as:
– Moving coins from one packet to the other.
– Using an inexpensive golf score counter.
– Keeping a small card or notepad with them.
• Regardless of the technique used, a form
will be needed to record these numbers
over time.
Other Tips for Behavioral
Observation
• Limit the number of things being recorded
to no more than one or two.
• Establish clear guidelines as to when and
where to record.
• Train the observer to make sure he or she
knows how, when, where, and for how
long to record the behavior.
Individualized Rating Scales
• When the focus is on the magnitude of a
target problem or treatment goal, an
individualized rating scale can be used
such as the one below.
Tips for Constructing Individualized
Rating Scales
• The number of scale points should not exceed
11, and it may be best to keep the number
between 5 and 7.
• Fewer than 5 scale points may not be
adequately sensitive to small, but meaningful
changes.
• The length of the blank spaces between points
should be equal.
• Label at least the lowest, middle, and highest
scale points with terms like none, moderate, and
severe.
• Include a space where the client can record the
time of day the scale was completed.
Tips for Using Individualized Rating
Scales
• Scales should be completed often enough
to detect changes, but not so often as to
be a burden.
• If they are easy to use, they can be
completed up to several times a day.
A daily score can be calculated as the average
of the day’s scores.
• Scales should be completed at roughly the
same predesignated times each day.
Standardized Scales
• Whether measuring behaviors, cognitions,
moods, or attitudes, a standardized scale
may be used.
• These scales involve the uniform
administration of the same scale items in
the same way for different people.
• They can vary in length and complexity.
Standardized Scales
• Advantages:
– Typically, standardized scales have had their
reliability or validity tested.
– They may have also been tested for
sensitivity.
– They may have also been tested with different
populations and cultures.
– This saves the practitioner the time and
burden of constructing a scale or other
measure.
Standardized Scales
• Disadvantages:
– Existing standardized scales may not fit the
set of problems or goals specific to your client.
– Some standardized scales are copyrighted
and expensive.
– Some scales require special training to use
and interpret.
– They can also be lengthy.
Standardized Scales
• Should you choose to use a standardized
scale, it should be evaluated in terms of
its:
– Reliability.
– Validity.
– Sensitivity.
– Applicability to your client’s culture and other
characteristics.
– Feasibility.
When and Where to Measure
• Deciding when and where to measure is
influenced by decisions on what, who, and how
you will measure.
– Example: If a standardized scale is used, the scale
probably will be administered during your session with
a client no more than once a week
• In general, measurement should occur as often
as possible without becoming too burdensome
for the practitioner or client. Pinpointing changes
over time provides a better basis for ascertaining
the factors responsible for the change
Summary
• As an evidence-based practitioner:
– Employ critical thinking and question authority
– Seek the best scientific evidence to inform
your practice decisions by engaging in the
steps of the EBP process. Keep in mind that
the research evidence does not dictate what
you should do; you must also integrate this
evidence with your expertise and the unique
realities of your practice situation.
Summary
• Start by formulating your EBP question,
such as:
– What factors predict desirable or undesirable
outcomes?
– What’s it like to have had my client’s
experiences?
– What assessment tool should be used?
– What intervention, program or policy has the
best effects?
Summary
• Next, search for the best research evidence
pertaining to your question.
– You probably will need to rely heavily on electronic
literature databases.
– Use search terms and strategies such as Boolean
operators.
– Keep in mind that you need not read every study you
find–use titles and abstracts to focus on the ones that
seem most relevant.
– To save time, first search for systematic reviews and
meta-analyses.
Summary
• Once you find relevant research evidence,
critically appraise its quality and relevance
to your clients and practice situation.
– Distinguish between limitations and fatal
flaws.
– Critically appraise the research by using
standards appropriate to your EBP question of
interest and the type of study conducted.
– Use those studies with less serious flaws to
guide your practice.
Summary
• Once an intervention, assessment tool,
program, or policy is selected and
implemented construct a plan to measure
outcomes and consider making
adaptations as needed. Recall that even
the best interventions, programs, and
policies don’t work for everyone.
Looking Ahead
• Various efforts are under way to make
EBP more feasible for practitioners such
as:
– Partnerships between researchers and
practitioners to address barriers.
– Training and education efforts to help
practitioners and agencies implement EBP.
– Increased attention to implementation issues
in research and practice.
Looking Ahead
• Remember that EBP can present challenges,
but it is consistent with a client-centered and
ethical approach to practice.
• EBP is relatively new, and more resources and
supports are constantly being developed.
• Do the best you can, even if it means cutting
corners when necessary.
• Ultimately the goal of EBP is to empower clients
and communities and enhance their well-being.
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