Article

PURPOSE: 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. METHOD: 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. RESULTS:
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.
CONCLUSIONS: 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. IMPLICATIONS FOR 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.

Langue : ANGLAIS