PROGRAM EVALUATION

Program Evaluation

Dedicated to Ongoing Evaluation and Continuous Improvement

Our program maintains a steadfast commitment to evaluating the effectiveness of the treatments we provide. We recognize the importance of continuously assessing and refining our program to ensure the best possible outcomes for our participants. Through rigorous outcome data analysis and program evaluation, we aim to continually enhance and optimize our unique program.

To measure the success of our program, we utilize a comprehensive assessment approach. At the outset of the program, we gather information on participants’ symptoms and functioning levels. This initial data serves as a baseline for comparison. Upon completion of the program, we assess participants again to gauge the progress made during their time with us. Additionally, we conduct follow-up assessments to track the sustainability of the achieved results over time.

We are thrilled to report that data from participants is highly impressive. Significant gains in resolving PTSD and depression symptoms have been observed, underscoring the effectiveness of our approach (details provided below). Moreover, client satisfaction with the program has been overwhelmingly positive (see “What People Say” section).

These encouraging findings not only validate the impact of our program but also motivate us to continuously improve and refine our services. By collecting and analyzing outcome data, we can identify areas for growth and tailor our program to better meet the needs of our participants. Our commitment to ongoing evaluation ensures that we remain at the forefront of providing the most effective, evidence-based treatments.

At our program, we are dedicated to your success and well-being. Our relentless pursuit of excellence drives us to continually evolve and deliver the highest standard of care. We value your feedback and take your experiences into account as we strive to improve the program and make a lasting positive impact on your journey to healing.

Standardized clinical assessment tools

Beck Depression Inventory – Second Edition
The BDI-II is a 21-item self-report instrument that assesses the cognitive, affective, and behavioural symptoms of depression that the client has experienced over the past two weeks. The client will complete a BDI-II upon program registration to establish a baseline score and a repeat assessment upon discharge to calculate change.
 Measurable goals after the 4-week program:

  • Client reports reduction in depressive symptoms (improved quantity and quality of sleep, mood, increased feelings of self-worth, and decreased feelings of self-harm).
  • The minimal clinically important difference (MCID) is unknown for the BDI-II but is estimated at a 17.5% reduction in scores from baseline. Therefore a 10-20% reduction in scores on the BDI-II post-program would evidence improvement in depression.

 
PTSD Checklist for DSM-5
The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including:

  • Monitoring symptom change during and after treatment
  • Screening individuals for PTSD
  • Making a provisional PTSD diagnosis

The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5). When necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis. The client will complete an assessment upon program registration to establish a baseline score and a repeat assessment upon discharge to calculate change.
 
Measurable goals after the 4-week program:

  • Client reports improvement in PTSD symptomatology (reduction in intrusive thoughts, overwhelming emotions and/or emotional numbing). A clinically significant amount of change is approximately 10 points or more [5*1.96 (equivalent to p < .05 significance) on the PCL-5.
  • Clinically significant PCL-5 score at program conclusion.


Adult Hope Scale

The adult hope scale (AHS) measures Snyder’s cognitive model of hope which defines hope as “a positive motivational state that is based on an interactively derived sense of successful (a) agency (goal-directed energy), and (b) pathways (planning to meet goals)” (Snyder, Irving, & Anderson, 1991, p. 287). The adult hope scale contains 12 items. Four items measure pathways thinking, four items measure agency thinking, and four items are fillers. Participants respond to each item using an 8-point scale ranging from definitely false to definitely true. The client will complete an AHS assessment upon program registration to establish a baseline score and a repeat assessment upon discharge to calculate change.
 
Measurable goals after the 4-week program:

  • The client reports improvement in hopefulness (having goal-oriented thoughts, developing strategies to achieve goals, and motivation to expend effort to achieve goals) as evidenced by an improvement in the Adult Hope Scale.

 
Generalized Anxiety Disorder Assessment

The Generalised Anxiety Disorder Assessment (GAD-7) is a seven-item instrument that is used to measure or assess the severity of generalized anxiety disorder (GAD). Each item asks the individual to rate the severity of his or her symptoms over the past two weeks. The client will complete a GAD-7 assessment upon program registration to establish a baseline score, and a repeat assessment upon discharge to calculate change.
 
Measurable goals after the 4-week program:

  • Client reports improvement in reduction in anxiety symptoms (fatigue, concentration, tension, sleep, etc.)
  • Reliable change index for the GAD-7 is a 4-6-point improvement at the conclusion of the program.

National Stressful Events Survey Short Scale (NSESS)
The National Stressful Events Survey PTSD Short Scale is a measure of nine items which report the occurrence of PTSD symptomatology over the past seven days. The score is indicated using a 5-point scale, which allows the clinician to think of the severity of the individual’s posttraumatic stress disorder in terms of none (0), mild (1), moderate (2), severe (3), or extreme (4). A total score of 16 or more can be regarded as having probable post-traumatic stress disorder. 
 
Dyadic Adjustment Scale (DAS)

The Dyadic Adjustment Scale (DAS) is a 32-item questionnaire that measures an individual’s perceptions of his/her relationship with an intimate partner.
 
Target Complaints as Criteria of Improvement

The client expresses presenting complaints (target complaints) as criteria for evaluating response to psychotherapy using a Likert-type scale. Practitioners and clients revisit target complaints upon discharge to evaluate improvement. 

Participants Satisfaction Survey
This survey asked the client about their level of satisfaction with the service they have received, both from their practitioner and their experience in general. It is designed for practices to gain feedback on how they might improve their services.

Research on Instruments Utilized and Relevance for OSR Program Outcome Measures

PCL-5
PTSD Checklist for DSM-5
The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including:

  • Monitoring symptom change during and after treatment
  • Screening individuals for PTSD
  • Making a provisional PTSD diagnosis

 The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5). When necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis. The client completes an assessment upon program registration to establish a baseline score and a repeat assessment upon discharge to calculate change.

Measurable goals after the 4-week program:

  • Client reports improvement in PTSD symptomatology (reduction in intrusive thoughts, overwhelming emotions and/or emotional numbing). A clinically significant amount of change is approximately 10 points or more [5*1.96 (equivalent to p < .05 significance) on the PCL-5.
  • Clinically significant PCL-5 score at program conclusion.

Recent OSR participant data displays an improvement of 22.6 points, or 49% improvement on average.

PCL-5 Research

Wortmann et al., (2016) investigated the psychometric properties of PCL-5 scores in a
large cohort of military service members seeking PTSD treatment. The PCL-5 scores exhibited high internal consistency. The PCL-5’s sensitivity to clinical change, pre- to post treatment, was comparable with that of the PSS-I. The results indicate that the PCL-5 is a psychometrically sound measure of DSM–5 PTSD symptoms that is useful for identifying provisional PTSD
diagnostic status, quantifying PTSD symptom severity, and detecting clinical change over time in PTSD symptoms among service members seeking treatment. (PsycInfo Database Record (c)
2020 APA, all rights reserved).

Using the PCL-5 scale, Wortmann et al., (2016) found that participants at baseline
averaged a score of 74, and a score of 24.1 at follow up (having a significance/cut off score of 33). They found that the PCL-5 overall severity and subscale scores demonstrated high internal consistency at baseline and follow-up, with Cronbach’s alpha values ranging from .75 at baseline to .95 for the overall scale at follow-up.

Bovin et al., (2016) evaluated the psychometric properties of PCL-5 scores in two independent samples of veterans who were receiving care at a VA Medical Center. The researchers found the test-retest reliability to be very strong (r = .86). They found that the PCL-5 is psychometrically sound and, with the establishment of a valid cut off score, well-suited for
assessing PTSD diagnostic status and symptom severity in veterans. Consistent with their hypotheses, PCL-5 scores had excellent internal consistency.

References

Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P.
P., &amp; Keane, T. M. (2016). Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391. https://doi.org/10.1037/pas0000254

Wortmann, J. H., Jordan, A. H., Weathers, F. W., Resick, P. A., Dondanville, K. A., Hall-Clark, B., Foa, E. B., Young-McCaughan, S., Yarvis, J. S., Hembree, E. A., Mintz, J., Peterson, A. L., &amp; Litz, B. T. (2016). Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment- seeking military service members. Psychological Assessment, 28(11), 1392–1403. https://doi.org/10.1037/pas0000260

DAS-32
The Dyadic Adjustment Scale (DAS) is a 32-item questionnaire that measures an individual’s perceptions of his/her relationship with an intimate partner.

Spanier (1976) reported an appropriate level of internal consistency for the whole scale
(Cronbach’s alpha = 0.96) and each of the individual subscales (Cronbach’s alpha: Dyadic Consensus = 0.90, Dyadic Satisfaction = 0.94, Dyadic Cohesion = 0.86, Affective Expression = 0.73).

According to the developers, who examined the DAS-32 against the Marital Adjustment Scale (MAT), the DAS-32 showed a sufficient level of construct validity. The DAS-32 is often used as a gold standard to test the validity of new relationship quality measures.

This measure is high in brevity as it can be completed in 5-10 minutes. Total DAS scores have been consistently shown to discriminate between distressed and non-
distressed couples and have been shown to identify couples with a high likelihood of divorce.

GAD-7
The Generalised Anxiety Disorder Assessment (GAD-7) is a seven-item instrument that is used to measure or assess the severity of generalized anxiety disorder (GAD). Each item asks the individual to rate the severity of his or her symptoms over the past two weeks. The client completes a GAD-7 assessment upon program registration to establish a baseline score, and a repeat assessment upon discharge to calculate change.
 Measurable goals after the 4-week program:

  • Client reports improvement in reduction in anxiety symptoms (fatigue, concentration, tension, sleep, etc.)
  • Reliable change index for the GAD-7 is a 4-6-point improvement at the conclusion of the program.

GAD-7 Research
The use of GAD-7 across various anxiety disorders is warranted as GAD is an anxiety
disorder with a high degree of comorbidity (Kessler et al., 2012). Further, the main feature of GAD is worry, which is a process that is found across psychological disorders and is therefore transdiagnostic (Harvey et al., 2004).

Psychometric evaluations of the GAD-7 suggest that it is a reliable and valid measure of GAD symptoms in the psychiatric (Kertz et al., 2013; Rutter and Brown, 2017) and general population (Lowe et al., 2008; Hinz et al., 2017) samples. The GAD-7 has demonstrated good psychometric properties, including sensitivity and specificity for diagnosing GAD (Spitzer et al.,
2006).

In the study by Spitzer et al., (2006), 965 patients underwent diagnostic interviews to
determine the presence of GAD-diagnosis. The optimal balance between sensitivity and
specificity for the GAD-diagnosis was found to be a cut-off point of &gt;10. Most patients (89%) with GAD had scores of 10 or greater, whereas most patients (82%) without GAD had scores less than 10.

Johnson et al., (2019) state that above a threshold of 10, the GAD-7 has a sensitivity of 89% and specificity of 82%. The GAD-7 also has strong psychometric properties when screening for 3 other anxiety disorders: panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%), and post-traumatic stress disorder (sensitivity 66%,
specificity 81%).

The GAD-7 should be used to establish the presence of anxiety disorders using self
reported symptoms experienced in the 2 weeks prior to the assessment. The effectiveness of the GAD-7 has been proven in outpatient settings. It should not be used to determine historical symptoms, acute psychosis, depression or suicidal symptoms. It can be used as a diagnostic tool
alongside professional clinical assessment. It may be used to help medical professionals
categorise anxious symptoms, or to deduce the pathway of treatment required for an individual. The GAD 7 is a widely used, well-validated and highly useful clinical measure of anxiety disorder symptoms. It has been validated for use in primary care and for use with the general
population. It is favoured due to its brevity and excellence in predicting and grading anxiety related disorders.

In the study by Johnson et al., (2019), both outpatients and inpatients undergoing
treatment for extreme anxiety completed the GAD-7 at pre-and post-treatment. Measures of depression, well-being, and other anxiety measures were also completed, making it possible to investigate convergent and divergent validity. Data was taken from 9 clinics. The alpha for GAD
was α= 0.88 at the start of therapy for the total sample and ranged from 0.83 to α= 0.93 across units and pre- and post-treatment. The GAD-7 demonstrated good internal consistency and convergent validity as hypothesized. The alphas were all above 0.82 at intake and post-treatment,
and correlations were large with other measures of anxiety and well-being, indicating high reliability and validity. The correlations found in this study, ranging from r= 0.70 for anxiety
disorders and from r= 0.62 for related construct are comparable to other studies (Spitzer et al., 2006; Löwe et al., 2008). Thus, the GAD-7 demonstrated convergent validity. Furthermore,
GAD-7 discriminates well between an anxious and a more general psychiatric population indicating discriminant validity.

References

Johnson, Sverre &amp; Ulvenes, Pål &amp; Oktedalen, Tuva &amp; Hoffart, Asle. (2019). Psychometric
Properties of the General Anxiety Disorder 7-Item (GAD-7) Scale in a Heterogeneous
Psychiatric Sample. Frontiers in Psychology. 10. 10.3389/fpsyg.2019.01713.

BECK-2
Beck Depression Inventory – Second Edition
​The BDI-II is a 21-item self-report instrument that assesses the cognitive, affective, and behavioural symptoms of depression that the client has experienced over the past two weeks. OSR clients complete a BDI-II upon program registration to establish a baseline score and a repeat assessment upon discharge to calculate change.
 
Measurable goals after the 4-week program:

  • Client reports reduction in depressive symptoms (improved quantity and quality of sleep, mood, increased feelings of self-worth, and decreased feelings of self-harm).
  • The minimal clinically important difference (MCID) is unknown for the BDI-II but is estimated at a 17.5% reduction in scores from baseline. Therefore a 10-20% reduction in scores on the BDI-II post-program would evidence improvement in depression.

Current OSR participant data is an improvement on 15.4 points, or 58% improvement on average.

Beck-2 Research
Current treatment guidelines for posttraumatic stress disorder (PTSD) recognize that
severe depression may limit the effectiveness of trauma-focused interventions, making it
necessary to address depression symptomatology first. Posttraumatic stress disorder has also
been found to be comorbid with depression. Therefore, it is important to look for potential
depression in patients coming for treatment with PTSD.
Wang et al., (2013) conducted a metanalysis to analyze the psychometric properties of
the Beck Depression Inventory-ll as a self-report measure of depression in a variety of settings and populations. The internal consistency was described as around 0.9 and the retest reliability ranged from 0.73 to 0.96. The correlation between BDI-II and the Beck Depression Inventory
(BDI-I) was high and substantial overlap with measures of depression and anxiety was reported. The criterion-based validity showed good sensitivity and specificity for detecting depression in
comparison to the adopted gold standard. The BDI-II is a relevant psychometric instrument,
showing high reliability, capacity to discriminate between depressed and non-depressed subjects, and improved concurrent, content, and structural validity. Based on available psychometric
evidence, the BDI-II can be viewed as a cost-effective questionnaire for measuring the severity of depression, with broad applicability for research and clinical practice worldwide.

The study conducted by Bryant et al., (2005) found the BDI-ll to be sensitive to
intervention effects in randomized trials with individuals diagnosed with PTSD. Prior to
treatment, participants averaged a score of 17.75 on the BDI-II scale. Post treatment, patients averaged 8.50. Bryant et al., (2005) found the scale had great detectability and specificity.

References

Wang, Y.-P., &amp; Gorenstein, C. (2013). Psychometric properties of the Beck DepressionInventory-II: A comprehensive review. Revista Brasileira de Psiquiatria, 35(4), 416–431.
https://doi.org/10.1590/1516-4446-2012-1048

20-day Treatment Expectations
Although evidence-based treatments (EBTs), such as cognitive processing therapy (CPT),
have been shown to be effective for the treatment of PTSD in veterans, only a relatively small number of veterans receive these treatments. Although research has shown that providers are likely to offer EBTs as first-choice interventions when they are trained in them (Hundt, Harik,
Barrera, Cully, &amp; Stanley, 2016), data from outpatient settings in the Department of Veterans Affairs (VA) report the national average for EBT penetration to be around 20% (Sayer et al., 2017). Other studies have suggested that between 6.3% and 11.4% of veterans seen in VA clinics receive EBTs (Mott et al., 2014; Shiner, Drake, Watts, Desai, &amp; Schnurr, 2012). However,
research suggests that even among those who initiate treatment, the majority of individuals
receiving cognitive–behavioral interventions for PTSD discontinue treatment prior to receiving an adequate dose, which has been defined as eight or more sessions. Thus, it is important to identify alternative methods to deliver EBTs to improve treatment uptake and completion.

One alternative is to deliver EBTs in intensive treatment programs (ITPs). Through ITPs, veterans have the opportunity to receive EBTs in a shorter amount of time (i.e., 2 to 3 weeks)
compared to outpatient care where EBTs are commonly delivered once per week over several months. Recent research has demonstrated that ITPs can produce similar PTSD symptom reductions to those obtained in relatively highly controlled EBT efficacy trials with weekly therapy sessions (Beidel et al., 2017; Foa et al., 2018; Zalta et al., 2018).

Brief ITPs may reduce barriers to treatment that have been identified both in standard outpatient settings and in longer-term residential programs, including avoidance, and practical barriers, including
employment and transportation (Hundt et al., 2014; Johnson et al., 2016; Keller &amp; Tuerk, 2016). Housing veterans at the treatment facility during the course of an ITP may reduce logistical concerns that
are often raised as reasons for not initiating EBTs (Keller &amp; Tuerk, 2016) and may increase veterans’ ability to focus on treatment by reducing psychosocial stressors as well as reducing opportunities for avoidance and missed treatment sessions.

Similar to longer-term residential programs, ITPs also provide an opportunity to offer adjunctive treatments that may improve retention, such as mindfulness, yoga, and skills groups (Cushing &amp; Braun, 2018; Staples, Hamilton, &amp; Uddo, 2013). Compared to longer term residential treatment programs, which often
span over the course of several weeks (i.e., 4 –12 weeks; Cook et al., 2013), participating in a brief ITP for 3–4 weeks may be more feasible for veterans, as there is less potential for conflict with other responsibilities, such as family duties or work schedules. Moreover, the short timeframe may seem less daunting for veterans compared to longer-term residential programs or
weekly therapy for several weeks and may provide veterans with a sense of being able to
accomplish treatment relatively quickly, which in turn may reduce treatment avoidance.