The impact of the relationship (therapeutic alliance) between patients and physical warmth, and support between the client and therapist,11 Contemporarily, The randomization schedule was generated in Microsoft Excel (Microsoft Subjective outcome of brain injury rehabilitation in relation to the therapeutic. [PDF] Learnkey Session 3 Answers Excel PDF Books this is the book you are looking for, from the Support On The Relationship Between Cancer-related Intrusive orgJune 22, The New England Journal Of Medicine Table 1. Since Its Inception In The Late s, More Than 18 Therapists. Good communication skills make the difference between average and excel- lent nursing care. The therapeutic relationship between the patient and the nurse. Chapter Five The purpose of the therapeutic relation- ship is to support In addition, the nurse will encounter many new patients, some with values and behaviors.
To be eligible for inclusion, patients had to have had nonspecific LBP for at least 3 months and be between the ages of 18 and 80 years. Potential participants were excluded prior to randomization if they had known or suspected serious low back pathology eg, cancer, infection, fracture or contraindications to exercise or spinal manipulative therapy.
Participants gave written informed voluntary consent prior to study commencement. Physical Therapists A total of 7 experienced physical therapists appointed by the physiotherapy outpatient departments of 3 public hospitals in Sydney, Australia, were responsible for treating the participants. Training and monitoring were provided to ensure best practice administration of general exercise, motor control exercise, and spinal manipulative therapy.
Although the same physical therapist could be involved in the application of motor control exercise and spinal manipulative therapy, a predetermined clinician administered the general exercise program. Patients had the same interventionist throughout the treatment period. Randomization Baseline measures were taken of the outcomes prior to randomization.
Subsequently, each participant was allocated to 1 of the 3 treatment groups via sealed opaque envelopes containing the allocation code. The randomization schedule was generated in Microsoft Excel Microsoft Corporation, Redmond, Washington with randomly permuted blocks of sizes 6, 9, and Interventions Participants in the general exercise group received the program described by Klaber Moffet and Frost.
It included strengthening and stretching exercises for the main muscle groups of the body and was implemented in groups of up to 8 patients. Participants allocated to the motor control exercise group were prescribed exercises individually aimed at improving the coordination of trunk muscles thought to control intersegmental movement of the spine, including transversus abdominis, multifidus, diaphragm, and pelvic-floor muscles.
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Participants attended up to 12 treatment sessions over an 8-week period. Participants in both exercise groups were encouraged to exercise at home at least once a day, and those allocated to the spinal manipulative therapy group were advised to avoid pain-aggravating activities. Outcome Measures There were 2 primary outcome measures: The secondary outcome measures were pain visual analog scale, score ranges from 0 to 10 35 and disability Roland-Morris Disability Questionnaire [RMDQ], score ranges from 0 to Participants' outcomes were collected by a trial physical therapist blinded to allocation.
The second session of treatment was chosen to allow for an interaction between physical therapists and patients to form and to assess the alliance early in the study to minimize contamination associated with effects of interventions. Data Analysis Separate linear regression models were used to investigate whether the therapeutic alliance was a nonspecific predictor of outcome main effect of therapeutic alliance and whether it moderated the effect of treatment interaction of treatment group and therapeutic alliance.
The models to evaluate nonspecific prediction of outcome included the baseline value of the outcome as a covariate and therapeutic alliance measured at baseline.
The models to evaluate moderation of treatment effect included the baseline value of the outcome as a covariate, therapeutic alliance measured at baseline, treatment contrast, and the interaction between treatment and therapeutic alliance. Analyses were carried out separately for each treatment contrast eg, general exercises versus motor control exercises.
Given the clinical context in which VCT often occurs, test counselors are mostly nurses, medical assistants, and paraprofessionals such as outreach workers and volunteers with little more than a few days of formal training in HIV prevention counseling. Counseling is thus a condition for receiving the test. Because clients are primarily seeking the test result, not a counseling session, any discussion about risk with the counselor is experienced as an unpleasant but necessary requirement for getting the test.
In this light, test counseling in a public clinic may be more accurately described as a service encounter in which the client provides personal information in exchange for a clinical screening test that is provided free of charge or for a nominal fee. Client-centered counseling was developed by Carl Rogers in the s. Rogers' approach was a radical rejection of the dominant model of counseling practice of the time that was concerned largely with psychometric testing.
In Rogers' new, humanist model of counseling, each individual is endowed with an organic capacity for growth and change. The primary technique of client-centered counseling is to actively listen and reflect the client's statements in a nondirective, nonjudgmental manner, thereby providing a safe environment for the client's self-exploration. Client-centered counseling hinges on the development of a counselor-client relationship based on unconditional regard, often over multiple hour-long sessions.
This relationship enables the counselor to clarify the client's feelings without imposing external assessments or values. HIV counseling is not a lecture. An important aspect of HIV counseling is the counselor's ability to listen to the client in order to provide assistance and to determine specific prevention needs.
Although HIV counseling should adhere to minimal standards in terms of providing basic information, it should not become so routine that it is inflexible or unresponsive to particular client needs. Counselors should avoid providing information that is irrelevant to their clients and should avoid structuring counseling sessions on the basis of a data-collection instrument or form.
These data-collection instruments can be simple forms consisting of a few risk categories that the counselor can fill in after the client is gone, or they can be quite elaborate, such as the one used in California, where the form has become so complex and lengthy that test counseling sessions have increasingly come to resemble research interviews.
Yet the guidance that accompanies the most recent California risk assessment form asserts that completing the Client Information Form CIF is synonymous with client-centered counseling: With the exception of a few administrative items, the content of this form is essential for adequate client-centered HIV counseling. HIV counseling cannot be client centered unless the counselor has a complete understanding of the client's risks and current issues.
The information is recorded to insure that it is obtained and available for reference during HIV risk assessment, disclosure and post disclosure HIV counseling sessions. It is the basis for service documentation and reimbursement. It also provides program planners with information about the HIV counseling process and our clients. This information is critical to the continuous improvement of primary HIV prevention in California While strict reliance on the CIF results in poor counseling, many counselors glance at it occasionally for support, prompts and recording information at convenient points during the interview Blanks represent incomplete risk assessments and can affect the level of payment for counseling and testing services and reflect the adequacy of the service provided.
Sheon used conversation analysis, a method of process analysis further described below, to examine 40 VCT sessions recorded in and another 30 recorded in Counselors manage this dynamic by treating the data collection form as a routine and bureaucratic formality, thereby mitigating the moral upshot of the questions.
This depersonalized approach can also be seen as a strategy for managing the repetitive and tedious nature of form-based counseling. As a result of these constraints, counselors employed a routine script with a fixed sequence of topics that varied little from client to client. Despite the emphasis on accurate data collection in the guidance provided for the form cited above, recordings of test sessions revealed that counselors combine, phrase, and omit questions on the form in creative ways, thus compromising the validity of the data collected.
The point here is not to criticize test counselors but to suggest that the roles of client-centered counselor and data collector are incompatible. By spending so much of the session interrogating clients about past risk behaviors, actions that clients are powerless to change, counselors may unwittingly create an awkward confessional dynamic in which clients feel compelled to emphasize their contrition for "sins" elicited and inscribed on the risk assessment form.
Plans for change should be realistically assessed in terms of potential sources of support for change as well as obstacles to change and ways to overcome them. Despite the emphasis on negotiating risk reduction plans in CDC guidelines and local training curricula, few of the recorded VCT sessions include any discussion of risk reduction plans aside from future testing to account for the antibody window period.
Besides limiting the scope of counseling about future behavior, the form's focus on past risk behavior may unwittingly re-enforce risk behavior by highlighting the discontinuity of past risks divulged on the data collection form and a client's current negative test result. Clients receiving a negative result after engaging in high-risk behavior may conclude that they are somehow lucky, that they are immune to HIV, or that the risk associated with their behaviors has been overstated.
Process studies focus on the actual testing experience of a small sample of test clients, usually by audio-recording the test counseling interaction or by interviewing clients about their motivations to seek testing. Outcome and process studies complement each other by posing the question of effectiveness in different ways.
Outcome studies use controls to isolate the effects of the intervention, whereas process studies raise fundamental questions about the nature of the interaction between counselor and client. Outcome studies tell us whether or not an intervention succeeds, whereas process analysis tells us how an intervention succeeds or fails.
While randomized control trials are based on the assumption that counselors have adhered to a "counseling" protocol, process analysis measures the counseling "dose" empirically. To date, most research on test counseling has relied on outcome measures with very little attention to the counseling process. Little research has examined different counseling styles and approaches, or the degree to which these approaches resemble the client-centered model outlined in CDC guidelines and trainings.
This lack of process research has left policy makers, counselors, trainers, and test clinic administrators with little information about appropriateness and feasibility of research-tested approaches in real-world clinical and outreach settings.
For example, Weinhardt et al conducted a meta-analysis of 27 outcome studies conducted between and their analysis confirmed the conclusions of previous reviews of the literature.
In fact, some clients receiving a negative test result increased their risk behavior.
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The authors point out that it is difficult to draw firm conclusions from this body of work because studies used different approaches to counseling as well as different criteria for measuring risk.
Two multisite outcome trials published after the meta-analysis conducted by Weinhardt et al were successful in reducing risk behavior and STD rates among heterosexual couples in Kenya, Tanzania, and Trinidad, as well as heterosexual patients at STD clinics in 6 U. Protocols of these interventions are available online. Research on this population is badly needed as it comprises some of the heaviest users of VCT services and epidemiological trends show a steep rise in STD rates among some subgroups in this population, suggesting that, in time, HIV incidence may also rise.
This approach differs markedly from traditional VCT in that the client is asked to construct a detailed account about a single incident of unprotected sex and the self-justifications that supported the decision to have risky sex.
The results of this trial suggested that the intervention was both effective in reducing risk and acceptable to clients and counselors.
A second trial, called RED2, is currently under way to determine whether a streamlined version of the self-justifications questionnaire and cognitive counseling intervention can be effective when incorporated into a pretest session with paraprofessional test counselors. A combination of process and outcome measures described further in the following section on time charts is being used to compare the intervention against the standard client-centered model and describe the most effective way for counselors to select and elicit a narrative account of a particular risk incident during the counseling session.
Our process analysis suggests that focusing the session around a detailed narrative of a risk incident ensures that the intervention counselors listen attentively to the clients' own assessments of their behavior.
In standard VCT sessions, counselors rely more on the risk assessment form and thereby elicit less-personalized accounts of the clients' risks. Should the trial show effectiveness, process measures will also provide tools to develop training and supervision guidelines so that the intervention can be successfully adapted in real-world VCT practice.
Process Analysis of VCT Although it provides a measure of the effectiveness of an intervention, outcome research is of limited use for refining counseling practice because it tells us little about what specific techniques or client experiences produced the behavioral effects measured.
For example, outcome research does not reveal how much of the effect is due to the counselor's particular style, the client's readiness to change, or a reaction to the test result itself. Accordingly, Beardsell and Coyle have called for process research on VCT in order to illuminate the black box of counseling and examine what it is and why it succeeds or fails to produce the desired outcomes.
Specifically, we need to examine how counselors working in real-world clinics allocate time to counseling tasks in the face of pervasive workload issues such as time pressures, surveillance forms, and clients' resistance to counseling they did not expect or request.
These issues are less likely to be factors in a research study wherein the counselor's task is made easier by having willing participants and a more clearly defined role thanks to more elaborate training and supervision. Conversation Analysis Process research examining recorded VCT sessions has identified a number of barriers to implementing the client-centered approach. One method of process research is conversation analysis CA. CA is an approach to linguistic analysis that illuminates the sequential, turn-taking structure of talk to examine how the counselor and the participant interpret each other's utterances and display their interpretations in subsequent turns.
Counselors commonly packaged advice as information delivered in depersonalized monologues, often framed in terms of "We tell everyone that it's best to However, such an approach permitted counselors to avoid the negative implications of personally directing advice to clients who had not requested any, while allowing the discussion to quickly cover a wide range of topics within a short period of time. In another CA study of VCT sessions recorded in the United States, Kinnell and Maynard found that counselors' advice sequences frequently glossed over clients' actual behaviors and instead provided information that was clearly not relevant to them.MARSHA LINEHAN - The Need for a Relationship of Equality Between Therapist and Client
Counselors justified this practice by viewing the clients as conduits for risk reduction information to the broader community. CA has proven particularly useful as a method for analyzing the effectiveness of various counseling strategies by examining participants' responses during the sessions.
Silence or minimal uptake by participants, such as the occasional "m hm" or "yeah" between counselors' advice sequences, displays resistance to advice deemed irrelevant by the participants. By contrast, participants responded to relevant and empathic advice sequences with overlapping speech that completed or elaborated upon counselors' utterances. Time Charts It is difficult to visualize patterns in audio-recorded data unless the information is indexed and tabulated in some manner.
Sheon developed time charts as a way to display the chronological sequence and distribution of tasks performed during a VCT session. Time charts provide a measure of how time and effort are allocated in the session, and offer a valuable tool for training and supervision.
Time charts provide an overview or map to the counseling session data, and help reveal outliers in the data set. Time charts are created by indexing digital recordings of VCT sessions using qualitative analysis software called Atlas. Patterns of interaction can be further examined using conversation analysis. By coding the tasks across the data set, we can easily compare different counselor strategies or participant responses, for example how sessions start and end, what types of referrals are offered, how the risk assessment form is administered, or how reasons for testing are elicited.
The time chart in Figure 1 depicts the sequence of tasks for 10 pretest sessions recorded by 2 counselors, C1 and C2. Each color represents a task, such as reason for testing, filling out paperwork, making referrals, and discussing oral sex risk. The tasks in blue and violet shades are "counseling" tasks, defined here as interaction where the client is talking about personal views, feelings, concerns, questions, reasons for testing, etc.
The yellow, orange, and green tasks relate to risk assessment and health education tasks during which the client listens passively or provides only short responses to close-ended questions. The lengthy stretches of orange represent paperwork tasks such as the CIFs and STD test forms that contain data collected for county and state health departments for surveillance purposes. For example, if we reduce the myriad tasks displayed in Figure 1 into only 3 categories, we can show the distribution of time among clinical, counseling, and surveillance or data gathering tasks.
This ratio provides a useful measure of the degree to which sessions are "client centered," or focused on the personal concerns, interests, and meanings that the client assigns to risk behavior.
Figure 2 contrasts the same sessions displayed in Figure 1 in terms of the distribution of time for the 3 categories of tasks. Time Chart Displaying Percentage of Clinical, Counseling, and Surveillance Tasks see larger image of Figure 2 The 2 counselors have similar levels of training and experience.
Theory and Practice of Client-Centered Counseling and Testing
Yet, as we see in Figure 1, counselor C1 employs a relatively fixed and shorter sequence of tasks that includes very little counseling with the exception of client PACT 01, who was particularly distressed and talkative when compared with counselor C2, who devotes a greater proportion of the sessions to counseling tasks. Figure 2 also highlights the enormous proportion of the sessions that counselors spend on clinical and data-gathering tasks. As the CA studies reviewed above suggest, not only do these tasks take up precious time, they also create a bureaucratic dynamic whereby clients may feel less able or willing to articulate their personal concerns.
Time charts provide a valuable training and supervision tool by showing--in a nonthreatening manner--how counselors allocate effort within sessions. This enables counselors to think critically about how they manage the session and transition from one communication format to another.
Time charts provide an objective way to compare the approaches of different counselors or those of one counselor who has different types of clients. Counselors also can compare their approaches in light of client-centered guidelines that suggest they focus on developing custom-tailored plans for future risk reduction, while minimizing time spent providing clinical lectures and completing surveillance forms.
A survey conducted in California in showed that more than two thirds of MSM presenting for testing had previously tested 3 or more times, with half of that group having previously tested 5 or more times. In light of these findings, it is crucial to understand why high-risk clients test and how testing relates to subsequent risk behavior. Research on motivations for behavior is difficult to conduct because there is no way to judge the accuracy of an account for a particular action, such as seeking an HIV test.
Accounts are always mediated by the social context of the interaction. It is therefore difficult to extricate reasons for testing suggested by public health messages from clients' "own" motivations. One way to explore motivations for testing is to examine recordings of test sessions to hear how clients describe their reasons for testing to test counselors. This can be supplemented with in-depth qualitative research interviews to elicit accounts of past testing behavior and descriptions of how the decision to test related to clients' HIV prevention strategies, risk behaviors, relationships, or other factors.
At best, we can describe some of the interactional and moral constraints on replies to the question, "What brought you in to get tested? The following is a typical excerpt from the first few moments of a test session recorded by Sheon. But I've been with my partner for about four years and it's been monogamous 6 but 0. For example, when asked the ostensibly neutral question of "What brings you in?
He or she must present enough risk to warrant a test, yet simultaneously avoid the implication of irresponsible behavior. As we see from the client's first response line 2clients typically account for their tests as a part of a routine practice, not as a response to a particular risk incident.
In this way, the client's minimal and somewhat vague reply invites the counselor to specify the preferred type of response through a follow-up question about specific risks. The client's initial "No" in line 5 is immediately followed by an account relating to his monogamous relationship with his partner.
In addition to providing an account for testing, the client's statement serves to portray him as both faithful and ever-vigilant against HIV risk.
This statement can be seen as an example of identity work, ie, self-characterizations that serve to bolster a person's moral status. However, the client's response "it's been monogamous" is a problematic response to the question about specific risk, and that is demonstrated by the counselor's continuer in line 7 and later in the session when the counselor continues to probe about the client's possible infidelity see Table 2.
The client produces another account for his testing in line 8 that demonstrates a possible misconception about the length of the antibody window period. That leads the counselor to digress into an explanation of the window period, thus temporarily shifting the format from a morally charged interrogation of fidelity to a more neutral and didactic format. Attention to the turn-by-turn construction of motivations at the start of the counseling session reveals the moral implications embedded in any account about a client's decision to test.
The session excerpt above reveals an assumption that has dominated much of the existing literature and practice of VCT: Clients seek testing in response to specific risk incidents. This assumption is most evident at the start of almost every VCT session when clients are asked to describe what specific risk incidents prompted them to seek testing.
Initially, clients almost always describe the stimulus for testing not in terms of a specific risk incident but in terms of calendrical cycles "it's that time," or "it's been about a year since my last test". Routine testing is reinforced by the uncertainty created by the window period, and counselors often recommend regular testing every 3 to 6 months.