Table 7: An Example of a Goal Attainment Scale Form Goal Attainment Scale Goal 1 Call parents on the phone three times per week (Weighted 25%)
Goal 2 Meet with friends once per week (Weighted 50%)
Goal 3 Spend less than 3 hours on computer per day (Weighted 25%)
Did not attempt (–2)
X
Completed the goal partially (–1) Reached goal (0)
X
Did a little better than the goal (1) Did much better than the goal (2)
X
Adapted from Bard-Pondarré, R., Villepinte, C., Roumenoff, F., Lebrault, H., Bonnyaud, C., Pradeau, C., Bensmail, Da, Isner-Horobeti, M.-E., & Krasny-Pacini, A. (2023). Goal attainment scaling In rehabilitation: An educational review providing a comprehensive didactical tool box for implementing goal attainment scaling. Journal of Rehabilitation Medicine , 55 , 6498. https://doi.org/10.2340/jrm.v55.6498
Another way to measure client progress is to develop a frequency count form (AccuPoint, 2020). This form tracks the number of times a particular symptom (e.g., crying) or adverse event (e.g., conflict with a spouse) occurs within a particular time frame. The clinician can ask the client to simply record on a calendar the number of times a symptom occurs on a daily basis until the next session. Over time, the client and clinician can understand the pattern of symptoms and discuss triggers and events surrounding the occurrence (AccuPoint, 2020). Finally, another way to measure client progress is to use a subjective rating form (Rosa et al., 2013) based upon the work of Wolpe’s (1969) Subjective Units of Distress Scale (SUDS). A subjective rating form allows a client to subjectively rate a particular symptom or adverse event. In a
notebook, the client can describe an event, identify the day and time, and rate the experience on a scale from 1 (best or most) to 10 (worst or least; Rosa et al., 2013). For example, a client records on a particular day and time that she and her spouse had a conflict. The client writes down a ten because the altercation escalated into a physical confrontation. The clinician and client can review these events, recorded over the course of a week or longer, and discuss their meanings. In summary, a clinician has a variety of tools for measuring client progress. A tool for one client may be different from a tool for another client. A clinician can use several assessment tools for a particular client. By evaluating practice outcomes, a clinician and client can be better assured that progress is being made.
RELAPSE PREVENTION
Relapse prevention is an important part of maintaining stability and enhancing the quality of life for clients who suffer from major depression since depression may be chronic and recurrent (Krijnen-de Bruin et al., 2019). Although most clients do get better with treatment, the probability of another depressive episode (often years after initial treatment) can still be high. About half of people experiencing a first episode of depression will experience a recurrence, most within the first six months. Those who experience symptoms of a relapse are at a higher risk for subsequent relapse and possibly higher risk for treatment resistance (Moriarty et al., 2022). Studies also show that an individual is less likely to go into remission if the initial depressive episode goes untreated for six months or longer (Domino et al., 2022; Bukh et al., 2013; Ghio et al., 2015). A comparison of the literature suggests that residual symptoms of depression and number of previous depressive episodes are prognostic for relapse or recurrence (Moriarty et al., 2022). Additional factors correlated with relapse include: “childhood maltreatment, comorbid anxiety, neuroticism, age at first onset, rumination, experiencing a higher number of dependent chronic stressors, or a severe independent life event post-treatment” (Moriarty et al., 2022, p. 53), in addition to “younger age at onset, residual symptoms and shorter duration of remission” (Moriarty et al., 2022, p. 53). “For adult patients with depression who have achieved remission the panel suggests clinicians offer psychotherapy (cognitive-behavioral therapy, mindfulness-based
cognitive therapy, or interpersonal psychotherapy) rather than antidepressant medication or treatment as usual to prevent relapse” (APA, 2019, p. 12). These experiential and relationship-based psychotherapies offer skills and interpersonal connection which add to resilience and decrease the likelihood of relapse. In addition, they offer a connection to a mental health provider for monitoring of symptoms and early identification of returning symptoms. Both cognitive-behavioral therapy and interpersonal therapy suggest that maintenance sessions, scheduled less frequently than sessions during an acute phase, can help to prevent relapse (Bleiberg & Markowitz, 2014; Young et al., 2014). Community-based prevention, incorporating interventions with families, peer networks, and local agencies can also contribute to longer periods of remission (Cruwys et al., 2013). Clinicians can be helpful in the prevention of relapses by harnessing all possible resources, whether they are biological, psychological, or social, and making them available for clients, including encouraging active self-monitoring and management (Krijnen-de Bruin et al., 2019). Historically, maintenance antidepressant medication has been a gold standard in recurrent depression. Researchers have questioned this maintenance model, suggesting a sequential model. The sequential model offers intermittent antidepressants and the addition of psychotherapy to antidepressants as a viable option to maintenance antidepressants (Cosci et al., 2020).
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