Military service members (SMs) and veterans who sustain mild traumatic brain injuries (mTBI) duri... more Military service members (SMs) and veterans who sustain mild traumatic brain injuries (mTBI) during combat deployments often have co-morbid conditions but are reluctant to seek out therapy in medical or mental health settings. Efficacious methods of intervention that are patient-centered and adaptable to a mobile and often difficult-to-reach population would be useful in improving quality of life. This article describes a new protocol developed as part of a randomized clinical trial of a telephone-mediated program for SMs with mTBI. The 12-session program combines problem solving training (PST) with embedded modules targeting depression, anxiety, insomnia, and headache. The rationale and development of this behavioral intervention for implementation with persons with multiple co-morbidities is described along with the proposed analysis of results. In particular, we provide details regarding the creation of a treatment that is manualized yet flexible enough to address a wide variety of problems and symptoms within a standard framework. The methods involved in enrolling and retaining an often hard-to-study population are also highlighted.
Several sexual counseling and education programs exist for the disabled population. Some of these... more Several sexual counseling and education programs exist for the disabled population. Some of these focus upon staff awarness and desentization about sexuality, while others are specifically designed to provide sexual information and counseling for disabled individuals. These programs represent significant advances in the area of sexuality and disabiltiy. However, reliance upon outcome variables like "much improved" or "no change" has moderated the accurate evaluation of such approaches. This paper describes a group treatment program for sexual behavior and attitude change in spinal cord injured couples. Also, preliminary data from objective outcome measures relevant to this intervention is presented.
There have been a number of sexual counseling programs for spinal cord injured individuals, but l... more There have been a number of sexual counseling programs for spinal cord injured individuals, but little attempt has been made to assess the impact of such programs. One reason for this has been the lack of reliable and valid assessment devices. The present paper attempted to evaluate the reliability and validity of the Sexual Attitude and Information Questionnaire (SAIQ) as a measure of specific sexual information and attitudes in spinal cord injured patients. Eleven recent onset and 23 remote onset spinal cord injured persons completed the SAIQ on one occasion. Twenty of these subjects (five with remote and 15 with recent onset) completed the SAIQ on two occasions, two or three weeks apart. Seven of the remote onset subjects also completed the Sexual Interaction Inventory. Statistical analysis indicated the SAIQ to have good reliability, internal consistency, and temporal stability. The validity of the SAIQ as a measure of specific sexual information and attitudes in SCI was evaluat...
Back-pain patients with onset in the preceding 1-10 days and comparable on a back examination wer... more Back-pain patients with onset in the preceding 1-10 days and comparable on a back examination were randomly assigned to traditional management (A regimen) and behavioral treatment methods (B regimen). Patients were compared at 6 weeks and 9-12 months on a set of "Sick/Well" scores derived from patient reported vocational status (V), health-care utilization (HCU), claimed impairment (CI), and pain drawings (D) and on two measures of activity level. No differences were found at 6 weeks, but at 9-12 months, A-group S's were more "sick." No A/B differences were found on activity-level measures. Group A S's showed significant increases in claimed impairment from preonset to follow-up, whereas Group B S's had returned at follow-up to preonset levels.
Page 1. Effectiveness of a Sex Education and Counseling Program for Spinal Cord Injured Patients ... more Page 1. Effectiveness of a Sex Education and Counseling Program for Spinal Cord Injured Patients Jo Ann Brockway, Ph.D. Jeffrey C. Steger, Ph.D. Rosemarian Berni, MN Vione V. Ost, RN Thomas E. Williamson-Kirkland, MD Connie L. Peck, Ph.D. ...
Archives of Physical Medicine and Rehabilitation, 2011
Objective: To evaluate the effect of a Scheduled Telephone Intervention (STI) compared with usual... more Objective: To evaluate the effect of a Scheduled Telephone Intervention (STI) compared with usual care (UC) on function, health/emotional status, community/work activities, and wellbeing at 1 and 2 years after traumatic brain injury (TBI). Design: Two group, randomized controlled trial. Setting: Telephone contacts with subjects recruited in inpatient rehabilitation. Participants: Eligible subjects (Nϭ433) with TBI (ageϾ16y) were randomly assigned to STI plus UC (nϭ210) or UC (nϭ223) at discharge. STI subjects (nϭ169) completed the outcome at year 1 (118 at year 2) and 174 UC subjects at year 1 (123 at year 2). Interventions: STI subjects received calls at 2 and 4 weeks and 2, 3, 5, 7, 9, 12, 15, 18, and 21 months consisting of brief training in problem solving, education, or referral. Main Outcome Measures: A composite outcome at 1 year was the primary endpoint. Analysis on intent-to-treat basis used linear regression adjusted for site, Glasgow Coma Scale, race/ ethnicity, age, FIM, sex, and Disability Rating Scale (DRS). Secondary analyses were conducted on individual and composite measures (FIM, DRS, community participation indicators, Glasgow Outcome Scale [Extended], Short Form-12 Health Survey, Brief Symptom Inventory-18, EuroQOL, and modified Perceived Quality of Life). Results: No significant differences were noted between the groups at years 1 or 2 for primary (Pϭ.987 regression for year 1, Pϭ.983 for year 2) or secondary analyses. Conclusions: This study failed to replicate the findings of a previous single center study of telephone-based counseling. While telephone mediated treatment has shown promise in other studies, this model of flexible counseling in problem solving and education for varied problems was not effective over and above usual care.
Archives of Physical Medicine and Rehabilitation, 2012
To develop a self-efficacy scale for people living with multiple sclerosis (MS) and spinal cord i... more To develop a self-efficacy scale for people living with multiple sclerosis (MS) and spinal cord injury (SCI) that can be used across diagnostic conditions. The scale was developed using modern psychometric methods including item response theory. Items were administered at 3 time-points of a longitudinal survey of individuals with MS and SCI. Survey participants with MS were recruited from the National MS Society, and participants with SCI were recruited from the Northwest Regional Spinal Cord Injury Model System and the Shepherd Center at the Virginia Crawford Research Institute in Atlanta, GA. Adults aged 18 years and older reporting a definitive diagnosis of MS (N=473) or SCI (N=253). None. Evaluation of the new self-efficacy measure called the University of Washington Self-Efficacy Scale (UW-SES) included comparisons with the Chronic Disease Self-Efficacy Scale and other patient-reported outcome measures. UW-SES has excellent psychometric properties including well-functioning response categories, no floor effects, and low ceiling effects. A long form (17 items) and a short form (6 items) are available. The correlation between the score on the newly developed scale and the Chronic Disease Self-Efficacy Scale was high (.83), providing support for convergent validity. Higher self-efficacy scores were statistically significantly associated with better mental health, better physical health, less fatigue, less stress, less pain interference, less pain, fewer sleep problems, and lower depressive symptoms. The UW-SES is a psychometrically sound instrument for measuring self-efficacy, validated in MS and SCI, and can be used across both conditions. Both the long form and the short form are available free of charge.
This is a follow-up study of the 20 junior students admitted into an occupational therapy educati... more This is a follow-up study of the 20 junior students admitted into an occupational therapy educational program under a selection process described in a previous article in AJOT in 1974. It reports the outcome resulting from the use of the selection process and t test findings between the upper ten ranked students and the remaining lower ranked students. Academic achievements and employment patterns of the 19 students completing the program are presented.
PM & R : the journal of injury, function, and rehabilitation, 2013
In the treatment of conversion disorder, the inpatient rehabilitation setting supports interdisci... more In the treatment of conversion disorder, the inpatient rehabilitation setting supports interdisciplinary functional goals and a structured approach consistent with encouraging psychological well-being. This case presentation illustrates 1 approach to the rehabilitation of hemiparesis secondary to conversion disorder that includes a behavioral management plan, as well as protocols for "learning to walk" and "learning to use your arm." We provide a practical starting point for advancing function in patients with conversion disorder when functional loss is present in both upper and lower extremities.
Archives of physical medicine and rehabilitation, 1983
A 44-year-old patient with cerebrovascular accident and resulting total occlusion of the right in... more A 44-year-old patient with cerebrovascular accident and resulting total occlusion of the right internal carotid artery and severe cognitive impairments was seen as an inpatient. Impulsivity, general inattention, left side neglect, decreased concentration and visual-spatial-perceptual difficulties were clinically evident. A conventional approach to training this patient in wheelchair transfer skills met with little success. An individualized training program based on the patient's specific cognitive strengths and deficits was developed. The major elements of the program were (a) careful observation of task performance, (b) task analysis of the skill to be taught, (c) utilization of the patient's learning strengths to guide performance, (d) small step hierarchical programming to meet the desired goal, (e) intense repetition of the skill and (f) data collection procedures to monitor change and program adjustments. Six weeks after the program was implemented the patient was able...
Archives of physical medicine and rehabilitation, 1984
Behavioral science theorists who study pain have advocated the development of measures designed t... more Behavioral science theorists who study pain have advocated the development of measures designed to assess aspects of behavior. Recently, Diller , Fordyce , Jacobs, and Brown developed a 64-item self-report activity measure. Assessment of functional impairment associated with pain is a potentially appropriate application for the Activity Pattern Indicators (API). The API provides a description of actual functioning; frequency of behavior is the unit of measurement. Currently, no agreed upon scoring protocol is available for this measure. We propose to design, in accordance with measurement theory, a psychometrically sound yet practical scoring protocol. The API data presented allow an acceptable degree of reliability and sensitivity to group differences. Results of the present study support continued psychometric exploration of: the current scoring protocol, alternative scoring protocols, and the Activity Pattern Indicators.
To develop reliable coding for five treatment ingredients hypothesized to be &amp... more To develop reliable coding for five treatment ingredients hypothesized to be "active" in a scheduled telephone intervention (STI) for traumatic brain injury (TBI); to examine factors associated with delivery of ingredients over the first year post-injury. Operational definitions of directive and non-directive action planning; TBI education; reinforcement; and reframing, were refined until kappa >0.80 across multiple coders. Codes were assigned for presence/absence of ingredients in 253 recorded calls delivered to 49 participants in a randomized controlled trial on effects of STI versus usual care. Using multivariate analyses, we tested hypotheses about effects of TBI severity, time and other factors on delivery of ingredients. Longitudinal analyses revealed that TBI education decreased over time, as expected. Non-directive action planning increased over time, according to hypotheses; unexpectedly, directive action planning did not concurrently decline. Reinforcement and reframing both increased over time, with reframing also increasing with TBI severity. Therapist differences were pronounced, despite extensive supervision designed to promote uniform treatment delivery. Reliable operational definitions of therapist behavior for each ingredient were achieved, but at the sacrifice of sensitivity in the coding scheme. Behavioral operational definitions of ingredients may be useful for treatment specification, for therapist training and supervision, and for testing hypotheses about the strength of specific components within the "black box" of rehabilitation. Operationally defining active ingredients of rehabilitation can allow measurement of adherence to specified treatment protocols, and can facilitate the study of the relationship between delivery of specific ingredients and resulting outcomes. In this study, there were strong differences in delivery of ingredients by different clinicians despite frequent joint supervision and a shared treatment philosophy. Defining active ingredients in advance may help focus training and supervision on specific clinician behaviors that convey key ingredients of treatment. Complex treatments such as counseling, where the therapist's behavior is partly determined by the client's behavior and vice versa, are particularly challenging to define operationally since the opportunity to deliver certain ingredients varies with the problems the client presents and the way they are presented.
Anger and irritability are important and persistent clinical problems following traumatic brain i... more Anger and irritability are important and persistent clinical problems following traumatic brain injury (TBI). Treatment options include medications, behavioral modification, and psychotherapies, but some are impractical and none have proven efficacy with this population. We describe a randomized multi-center clinical trial testing a novel, one-on-one, 8-session psychoeducational treatment program, Anger Self-Management Training (ASMT), designed specifically for people with TBI who have significant cognitive impairment. The trial is notable for its use of a structurally equivalent comparison treatment, called Personal Readjustment and Education (PRE), which was created for the study and is intended to maximize equipoise for both participants and treaters. Fidelity assessment is conducted in real time and used in therapist supervision sessions. The primary outcome is change in self-reported anger on validated measures from pre-treatment to 1 week after the final session. Secondary outcomes include participant anger as reported by a significant other; emotional distress in domains other than anger/irritability; behavioral functioning; and quality of life. An interim assessment after the 4th session will allow examination of the trajectory of any observed treatment effects, and a follow-up assessment 2 months after the end of intervention will allow examination of persistence of effects. A treatment enactment phase, in which participants are interviewed several months after the last therapy session, is designed to provide qualitative data on whether and to what extent the principles and techniques learned in treatment are still carried out in daily life.
Military service members (SMs) and veterans who sustain mild traumatic brain injuries (mTBI) duri... more Military service members (SMs) and veterans who sustain mild traumatic brain injuries (mTBI) during combat deployments often have co-morbid conditions but are reluctant to seek out therapy in medical or mental health settings. Efficacious methods of intervention that are patient-centered and adaptable to a mobile and often difficult-to-reach population would be useful in improving quality of life. This article describes a new protocol developed as part of a randomized clinical trial of a telephone-mediated program for SMs with mTBI. The 12-session program combines problem solving training (PST) with embedded modules targeting depression, anxiety, insomnia, and headache. The rationale and development of this behavioral intervention for implementation with persons with multiple co-morbidities is described along with the proposed analysis of results. In particular, we provide details regarding the creation of a treatment that is manualized yet flexible enough to address a wide variety of problems and symptoms within a standard framework. The methods involved in enrolling and retaining an often hard-to-study population are also highlighted.
Several sexual counseling and education programs exist for the disabled population. Some of these... more Several sexual counseling and education programs exist for the disabled population. Some of these focus upon staff awarness and desentization about sexuality, while others are specifically designed to provide sexual information and counseling for disabled individuals. These programs represent significant advances in the area of sexuality and disabiltiy. However, reliance upon outcome variables like "much improved" or "no change" has moderated the accurate evaluation of such approaches. This paper describes a group treatment program for sexual behavior and attitude change in spinal cord injured couples. Also, preliminary data from objective outcome measures relevant to this intervention is presented.
There have been a number of sexual counseling programs for spinal cord injured individuals, but l... more There have been a number of sexual counseling programs for spinal cord injured individuals, but little attempt has been made to assess the impact of such programs. One reason for this has been the lack of reliable and valid assessment devices. The present paper attempted to evaluate the reliability and validity of the Sexual Attitude and Information Questionnaire (SAIQ) as a measure of specific sexual information and attitudes in spinal cord injured patients. Eleven recent onset and 23 remote onset spinal cord injured persons completed the SAIQ on one occasion. Twenty of these subjects (five with remote and 15 with recent onset) completed the SAIQ on two occasions, two or three weeks apart. Seven of the remote onset subjects also completed the Sexual Interaction Inventory. Statistical analysis indicated the SAIQ to have good reliability, internal consistency, and temporal stability. The validity of the SAIQ as a measure of specific sexual information and attitudes in SCI was evaluat...
Back-pain patients with onset in the preceding 1-10 days and comparable on a back examination wer... more Back-pain patients with onset in the preceding 1-10 days and comparable on a back examination were randomly assigned to traditional management (A regimen) and behavioral treatment methods (B regimen). Patients were compared at 6 weeks and 9-12 months on a set of "Sick/Well" scores derived from patient reported vocational status (V), health-care utilization (HCU), claimed impairment (CI), and pain drawings (D) and on two measures of activity level. No differences were found at 6 weeks, but at 9-12 months, A-group S's were more "sick." No A/B differences were found on activity-level measures. Group A S's showed significant increases in claimed impairment from preonset to follow-up, whereas Group B S's had returned at follow-up to preonset levels.
Page 1. Effectiveness of a Sex Education and Counseling Program for Spinal Cord Injured Patients ... more Page 1. Effectiveness of a Sex Education and Counseling Program for Spinal Cord Injured Patients Jo Ann Brockway, Ph.D. Jeffrey C. Steger, Ph.D. Rosemarian Berni, MN Vione V. Ost, RN Thomas E. Williamson-Kirkland, MD Connie L. Peck, Ph.D. ...
Archives of Physical Medicine and Rehabilitation, 2011
Objective: To evaluate the effect of a Scheduled Telephone Intervention (STI) compared with usual... more Objective: To evaluate the effect of a Scheduled Telephone Intervention (STI) compared with usual care (UC) on function, health/emotional status, community/work activities, and wellbeing at 1 and 2 years after traumatic brain injury (TBI). Design: Two group, randomized controlled trial. Setting: Telephone contacts with subjects recruited in inpatient rehabilitation. Participants: Eligible subjects (Nϭ433) with TBI (ageϾ16y) were randomly assigned to STI plus UC (nϭ210) or UC (nϭ223) at discharge. STI subjects (nϭ169) completed the outcome at year 1 (118 at year 2) and 174 UC subjects at year 1 (123 at year 2). Interventions: STI subjects received calls at 2 and 4 weeks and 2, 3, 5, 7, 9, 12, 15, 18, and 21 months consisting of brief training in problem solving, education, or referral. Main Outcome Measures: A composite outcome at 1 year was the primary endpoint. Analysis on intent-to-treat basis used linear regression adjusted for site, Glasgow Coma Scale, race/ ethnicity, age, FIM, sex, and Disability Rating Scale (DRS). Secondary analyses were conducted on individual and composite measures (FIM, DRS, community participation indicators, Glasgow Outcome Scale [Extended], Short Form-12 Health Survey, Brief Symptom Inventory-18, EuroQOL, and modified Perceived Quality of Life). Results: No significant differences were noted between the groups at years 1 or 2 for primary (Pϭ.987 regression for year 1, Pϭ.983 for year 2) or secondary analyses. Conclusions: This study failed to replicate the findings of a previous single center study of telephone-based counseling. While telephone mediated treatment has shown promise in other studies, this model of flexible counseling in problem solving and education for varied problems was not effective over and above usual care.
Archives of Physical Medicine and Rehabilitation, 2012
To develop a self-efficacy scale for people living with multiple sclerosis (MS) and spinal cord i... more To develop a self-efficacy scale for people living with multiple sclerosis (MS) and spinal cord injury (SCI) that can be used across diagnostic conditions. The scale was developed using modern psychometric methods including item response theory. Items were administered at 3 time-points of a longitudinal survey of individuals with MS and SCI. Survey participants with MS were recruited from the National MS Society, and participants with SCI were recruited from the Northwest Regional Spinal Cord Injury Model System and the Shepherd Center at the Virginia Crawford Research Institute in Atlanta, GA. Adults aged 18 years and older reporting a definitive diagnosis of MS (N=473) or SCI (N=253). None. Evaluation of the new self-efficacy measure called the University of Washington Self-Efficacy Scale (UW-SES) included comparisons with the Chronic Disease Self-Efficacy Scale and other patient-reported outcome measures. UW-SES has excellent psychometric properties including well-functioning response categories, no floor effects, and low ceiling effects. A long form (17 items) and a short form (6 items) are available. The correlation between the score on the newly developed scale and the Chronic Disease Self-Efficacy Scale was high (.83), providing support for convergent validity. Higher self-efficacy scores were statistically significantly associated with better mental health, better physical health, less fatigue, less stress, less pain interference, less pain, fewer sleep problems, and lower depressive symptoms. The UW-SES is a psychometrically sound instrument for measuring self-efficacy, validated in MS and SCI, and can be used across both conditions. Both the long form and the short form are available free of charge.
This is a follow-up study of the 20 junior students admitted into an occupational therapy educati... more This is a follow-up study of the 20 junior students admitted into an occupational therapy educational program under a selection process described in a previous article in AJOT in 1974. It reports the outcome resulting from the use of the selection process and t test findings between the upper ten ranked students and the remaining lower ranked students. Academic achievements and employment patterns of the 19 students completing the program are presented.
PM & R : the journal of injury, function, and rehabilitation, 2013
In the treatment of conversion disorder, the inpatient rehabilitation setting supports interdisci... more In the treatment of conversion disorder, the inpatient rehabilitation setting supports interdisciplinary functional goals and a structured approach consistent with encouraging psychological well-being. This case presentation illustrates 1 approach to the rehabilitation of hemiparesis secondary to conversion disorder that includes a behavioral management plan, as well as protocols for "learning to walk" and "learning to use your arm." We provide a practical starting point for advancing function in patients with conversion disorder when functional loss is present in both upper and lower extremities.
Archives of physical medicine and rehabilitation, 1983
A 44-year-old patient with cerebrovascular accident and resulting total occlusion of the right in... more A 44-year-old patient with cerebrovascular accident and resulting total occlusion of the right internal carotid artery and severe cognitive impairments was seen as an inpatient. Impulsivity, general inattention, left side neglect, decreased concentration and visual-spatial-perceptual difficulties were clinically evident. A conventional approach to training this patient in wheelchair transfer skills met with little success. An individualized training program based on the patient's specific cognitive strengths and deficits was developed. The major elements of the program were (a) careful observation of task performance, (b) task analysis of the skill to be taught, (c) utilization of the patient's learning strengths to guide performance, (d) small step hierarchical programming to meet the desired goal, (e) intense repetition of the skill and (f) data collection procedures to monitor change and program adjustments. Six weeks after the program was implemented the patient was able...
Archives of physical medicine and rehabilitation, 1984
Behavioral science theorists who study pain have advocated the development of measures designed t... more Behavioral science theorists who study pain have advocated the development of measures designed to assess aspects of behavior. Recently, Diller , Fordyce , Jacobs, and Brown developed a 64-item self-report activity measure. Assessment of functional impairment associated with pain is a potentially appropriate application for the Activity Pattern Indicators (API). The API provides a description of actual functioning; frequency of behavior is the unit of measurement. Currently, no agreed upon scoring protocol is available for this measure. We propose to design, in accordance with measurement theory, a psychometrically sound yet practical scoring protocol. The API data presented allow an acceptable degree of reliability and sensitivity to group differences. Results of the present study support continued psychometric exploration of: the current scoring protocol, alternative scoring protocols, and the Activity Pattern Indicators.
To develop reliable coding for five treatment ingredients hypothesized to be &amp... more To develop reliable coding for five treatment ingredients hypothesized to be "active" in a scheduled telephone intervention (STI) for traumatic brain injury (TBI); to examine factors associated with delivery of ingredients over the first year post-injury. Operational definitions of directive and non-directive action planning; TBI education; reinforcement; and reframing, were refined until kappa >0.80 across multiple coders. Codes were assigned for presence/absence of ingredients in 253 recorded calls delivered to 49 participants in a randomized controlled trial on effects of STI versus usual care. Using multivariate analyses, we tested hypotheses about effects of TBI severity, time and other factors on delivery of ingredients. Longitudinal analyses revealed that TBI education decreased over time, as expected. Non-directive action planning increased over time, according to hypotheses; unexpectedly, directive action planning did not concurrently decline. Reinforcement and reframing both increased over time, with reframing also increasing with TBI severity. Therapist differences were pronounced, despite extensive supervision designed to promote uniform treatment delivery. Reliable operational definitions of therapist behavior for each ingredient were achieved, but at the sacrifice of sensitivity in the coding scheme. Behavioral operational definitions of ingredients may be useful for treatment specification, for therapist training and supervision, and for testing hypotheses about the strength of specific components within the "black box" of rehabilitation. Operationally defining active ingredients of rehabilitation can allow measurement of adherence to specified treatment protocols, and can facilitate the study of the relationship between delivery of specific ingredients and resulting outcomes. In this study, there were strong differences in delivery of ingredients by different clinicians despite frequent joint supervision and a shared treatment philosophy. Defining active ingredients in advance may help focus training and supervision on specific clinician behaviors that convey key ingredients of treatment. Complex treatments such as counseling, where the therapist's behavior is partly determined by the client's behavior and vice versa, are particularly challenging to define operationally since the opportunity to deliver certain ingredients varies with the problems the client presents and the way they are presented.
Anger and irritability are important and persistent clinical problems following traumatic brain i... more Anger and irritability are important and persistent clinical problems following traumatic brain injury (TBI). Treatment options include medications, behavioral modification, and psychotherapies, but some are impractical and none have proven efficacy with this population. We describe a randomized multi-center clinical trial testing a novel, one-on-one, 8-session psychoeducational treatment program, Anger Self-Management Training (ASMT), designed specifically for people with TBI who have significant cognitive impairment. The trial is notable for its use of a structurally equivalent comparison treatment, called Personal Readjustment and Education (PRE), which was created for the study and is intended to maximize equipoise for both participants and treaters. Fidelity assessment is conducted in real time and used in therapist supervision sessions. The primary outcome is change in self-reported anger on validated measures from pre-treatment to 1 week after the final session. Secondary outcomes include participant anger as reported by a significant other; emotional distress in domains other than anger/irritability; behavioral functioning; and quality of life. An interim assessment after the 4th session will allow examination of the trajectory of any observed treatment effects, and a follow-up assessment 2 months after the end of intervention will allow examination of persistence of effects. A treatment enactment phase, in which participants are interviewed several months after the last therapy session, is designed to provide qualitative data on whether and to what extent the principles and techniques learned in treatment are still carried out in daily life.
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