Please no plagiarism and make sure you are able to access all resource on your own before you bid. Main references come from Neukrug, E. S., & Fawcett, R. C. (2015) and/or Encyclopedia of Counseling (2017). You need to have scholarly support for any claim of fact or recommendation regarding treatment. APA format also requires headings. Use the prompt each week to guide your heading titles and organize the content of your initial post under the appropriate headings. Remember to use scholarly research from peer-reviewed articles that are current. I have attached scoring sheet and test results, so you can see how to make full points. Please follow the instructions to get full credit for the discussion. I need this completed by 02/05/20 at 6pm. 

DISCUSSION POSTS— For your Main discussion posts, I require that all posts be a MINIMUM of 250 words. The main post must contain a minimum of two (2) different references from a peer reviewed journal or scholarly book or scholarly website. It is a good idea to use your Learning Resources each week. Wikipedia does not count as a scholarly website since the information is not validated.

Discussion – Week 11

Top of Form

Using Assessments for Positive Social Change

As a counselor, you are in a unique position to effect positive social change for your clients, your practice, and your community. In reflecting on what you have learned in this course, consider how you can achieve social change.

To Prepare:

• Think of what you have learned      over the past 10 weeks in this course and how this new learning and      knowledge helps you to promote positive social change in your community.

By Day 3 of Week 11

Post and explain how you might be able to apply the content from this course to achieve positive social change in your community.

Be sure to support your postings and responses with specific references to the Learning Resources. Identify current relevant literature to support your work.

Bottom of Form

Required Resources

Neukrug, E. S., & Fawcett, R. C. (2015). Chapter 10: “Career and occupational assessment: Interest inventories, multiple aptitude, and special aptitude tests.” In The essentials of testing and assessment: A practical guide for counselors, social workers, and psychologists (pp. 221-244). Stamford, CN: Cengage Learning.

Neukrug, E. S., & Fawcett, R. C. (2015). Figure 10.2 Strong interest inventory profile sheet for basic interest scales. In The essentials of testing and assessment: A practical guide for counselors, social workers, and psychologists (pp. 226-227). Stamford, CN: Cengage Learning.

Required Media

Alexander Street Videos (n.d.). Retrieved from the Walden Library resources.

Eric Marciano (Author), Eric Marciano (Director), Jill Feyer (Producer), Eric Marciano (Producer), (2010). Teen Depression. Falls Church, VA: Landmark Media. [Streaming Video]. Retrieved from video.alexanderstreet.com/watch/teen-depression database

Firestone Assessment of Self-Destructive Thoughts

Review of the Firestone Assessment of Self-Destructive Thoughts by WILLIAM E. MARTIN, JR., Professor of Educational Psychology, Northern Arizona University, Flagstaff, AZ:

The Firestone Assessment of Self-Destructive Thoughts (FAST) is designed to measure the “Continuum of Negative Thought Patterns” as they relate to a client’s level of self-destructive potential or suicidality. The authors recommend the FAST to be used for screening, diagnosis, treatment progress, treatment outcome, research, and therapy. The FAST is theoretically grounded in what the authors refer to as the “concept of the voice,” which refers to negative thoughts and attitudes that are said to be at the core of maladaptive behavior.

The FAST consists of 84 items that provide self-report information from a respondent on how frequently he or she is experiencing various negative thoughts directed toward himself or herself. Four “composites” and 11 linked “continuum levels” comprise the FAST. One composite is named Self-Defeating and has five continuum levels (Self-Depreciation, Self-Denial, Cynical Attitudes, Isolation, and Self-Contempt). Addictions is another composite with addictions listed as its continuum level. A third composite is Self-Annihilating with four continuum levels (Hopelessness, Giving Up, Self-Harm, Suicide Plans, and Suicide Injunctions). The last composite is Suicide Intent and no continuum levels are identified.

ADMINISTRATION, SCORING, AND INTERPRETATION. The FAST instrument is a seven-page perforated, self-carbon form used for responding to items, scoring responses, and graphing the results. T scores are derived for the 11 continuum levels, four composites, and for the total score. Percentiles and 90% confidence interval bands also are available for use. The T scores are plotted on the T-Score profile graph, which has shaded partitions that indicate if the T scores fall within a nonclinical range, equivocal range, or clinical ranges that include elevated and extremely elevated.

The normative sample for the FAST was a clinical sample of outpatient clients undergoing psychotherapy. A T score of 50 on any scale represents the average performance of an individual who was in outpatient treatment with no suicide ideation from the normative sample. The nonclinical range is a T score between 20 and 41 whereas the equivocal range is 42-48. The two clinical ranges are elevated (42-59) and extremely elevated (60+). Any score that falls above the equivocal range is treated with concern and anyone scoring in the extremely elevated range on levels 7-11, the Self-Annihilating Composite, the Suicide Intent Composite, or the Total score should be immediately assessed for suicide potential.

DEVELOPMENT OF THE SCALES. The items for the FAST were derived from actual statements of 21 clinical outpatients who were receiving “voice therapy” in groups. Nine of the outpatients had a previous history of serious suicide attempts and the others exhibited less severe self-defeating behaviors including self-denial, isolation, substance abuse, and eating disorders. The list of items was further refined from a study conducted to select those factors that significantly discriminated between suicide attempters and nonattempters. Then items were retained or deleted based upon their psychometric relationship to hypothesized constructs, resulting in the current 84-item version of the FAST.

RELIABILITY AND VALIDITY. Cronbach’s alpha reliability coefficients ranging from .76 to .91 (Mdn = .84) are reported for the 11 level scores. Standard errors of measurement and 90% confidence intervals also are provided. However, sample sizes and descriptions are not provided for these measures. Test-retest reliability coefficients (1-266 days) ranged from .63-.94 (M = .82) using a sample (N = 131) of nonclinical, psychotherapy outpatients, and psychiatric inpatients.

Content validity of the FAST was investigated using a Guttman Scalogram Analysis resulting in a coefficient of reproducibility of .91 and a coefficient of scalability of .66. FAST Total Scores were correlated with the Suicide Ideation subscale of the Suicide Probability Scale (r = .72) as indicators of convergent validity. An exploratory factor analysis was conducted using 579 outpatients resulting in a 3-factor solution (Self-Annihilating, Self-Defeating, and Addictions), which provided support for construct validity. Evidence for criterion-related validity was demonstrated from studies showing how FAST scores were able to discriminate inpatient and outpatient ideators from nonideators and to identify individuals who made prior suicide attempts.

SUMMARY. The authors have put forth empirical evidence that supports the psychometric properties of the FAST. However, continuing studies are needed, especially related to the effectiveness of the FAST in diagnosing and predicting chemical addictive behavior. Furthermore, the construct validity of scores from the FAST needs further consideration. First, the items for the FAST were generated from a small (N = 21) somewhat restricted focus group of persons receiving “voice therapy.” Second, the FAST is closely anchored to a theoretical orientation known as “concept of the voice” in which additional studies are needed to validate.

Overall, the FAST is a measure worth considering for professionals working with individuals who have exhibited self-destructive potential or suicidality. However, I encourage professionals to study the theoretical orientation underlying the FAST and determine if it is congruent with their own expectations for clinical outcomes prior to extensive use of the instrument.

Review of the Firestone Assessment of Self-Destructive Thoughts by ROBERT C. REINEHR, Professor of Psychology, Southwestern University, Georgetown, TX:

The Firestone Assessment of Self-Destructive Thoughts (FAST) is a self-report questionnaire intended to provide clinicians with a tool for the assessment of a patient’s suicide potential. Respondents are asked to endorse how frequently they are experiencing various negative thoughts directed toward themselves. The items were derived from the actual statements of clinical outpatients who were members of therapy groups in which the techniques of Voice Therapy were used.

Voice Therapy is a technique developed by the senior test author as a means of giving language to the negative thought processes that influence self-limiting, self-destructive behaviors and lifestyles. The FAST includes items intended to assess each of 11 levels of a Continuum of Negative Thought Patterns. Items were assigned to levels based on the judgments of advanced graduate students and psychologists with training in Voice Therapy.

In the standardization process, the FAST was administered to a sample of 478 clients who were currently receiving outpatient psychotherapy and who did not have any current (within the last month) suicide ideation, suicide threats, or suicide attempts. Standard scores were calculated for the Total Score, for four composite scores derived by factor analysis and other statistical procedures, and for each of the 11 levels of negative thought patterns.

Estimates of internal consistency are based on a single sample, the size of which is not reported in the manual. They range from .76 to .97, with the majority falling between .81 and .88. Test-retest reliability estimates are reported for three samples with intervals from 28-266 days in one study and 1-31 days in another: psychiatric inpatients (n = 28), psychotherapy outpatients (n = 68), and nonclinical college students (n = 35). Reliabilities for the various levels of the negative-thought continuum range from .63 to .94, with the higher coefficients generally being found among the nonclinical respondents. Test-retest reliability estimates for the various composite scores and for the total score are somewhat higher, ranging from .79 to .94.

As an indication of construct validity, FAST scores were compared to scores on the Beck Depression Inventory (BDI), the Beck Suicide Inventory (BSI), and the Suicide Probability Scale (SPS). The FAST Total score had its highest correlations with the BDI (.73), the BSI (.72), and the Suicide Ideations subscale of the SPS (.76). The composite scores and the various level scores had lower correlations with the subscales of the Beck instruments or the SPS.

The FAST was administered to groups of inpatients and outpatients with various diagnoses including Adjustment Disorder, Anxiety Disorder, Bipolar Disorder, Depression, Personality Disorder, Schizophrenia, and Substance Abuse, and to a nonclinical sample of 172 college students. Each of the clinical groups was further subdivided into suicide Ideators and Nonideators. Ideators had higher average FAST Total scores than did Nonideators and clinical groups had higher average FAST Total scores than did the nonclinical group. Information is provided in the manual with respect to the relationships between the various FAST subscales and the diagnostic groups and subgroups.

SUMMARY. In general, it would appear that the FAST is similar in many ways to other depression and suicide inventories. Total Scores tend to be higher for respondents in diagnostic groups than for nonclinical respondents, and within diagnostic groups, Suicide Ideators score more highly than do Nonideators.

Within the limits of these findings, the FAST may be useful to clinicians as an indication of how a given respondent’s answers compare to those of various diagnostic groups. It might also be possible to use the scale as a clinical tool for the evaluation of change during therapy, although use as a psychometric instrument is not justified on the basis of the evidence presented in the manual.

AMCD Multicultural Counseling Competencies

I. Counselor Awareness of Own Cultural Values and Biases

A. Attitudes and Beliefs

1. Culturally skilled counselors believe that cultural self-awareness and sensitivity to one’s own
cultural heritage is essential.

2. Culturally skilled counselors are aware of how their own cultural background and experiences
have influenced attitudes, values, and biases about psychological processes.

3. Culturally skilled counselors are able to recognize the limits of their multicultural competency
and expertise.

4. Culturally skilled counselors recognize their sources of discomfort with differences that exist
between themselves and clients in terms of race, ethnicity and culture.

B. Knowledge

1. Culturally skilled counselors have specific knowledge about their own racial and cultural
heritage and how it personally and professionally affects their definitions and biases of
normality/abnormality and the process of counseling.

2. Culturally skilled counselors possess knowledge and understanding about how oppression,
racism, discrimination, and stereotyping affect them personally and in their work. This allows
individuals to acknowledge their own racist attitudes, beliefs, and feelings. Although this standard
applies to all groups, for White counselors it may mean that they understand how they may have
directly or indirectly benefited from individual, institutional, and cultural racism as outlined in White
identity development models.

3. Culturally skilled counselors possess knowledge about their social impact upon others. They
are knowledgeable about communication style differences, how their style may clash with or
foster the counseling process with persons of color or others different from themselves based on
the A, B and C, Dimensions ,and how to anticipate the impact it may have on others.

C. Skills

1. Culturally skilled counselors seek out educational, consultative, and training experiences to
improve their understanding and effectiveness in working with culturally different populations.
Being able to recognize the limits of their competencies, they (a) seek consultation, (b) seek
further training or education, (c) refer out to more qualified individuals or resources, or (d) engage
in a combination of these.

2. Culturally skilled counselors are constantly seeking to understand themselves as racial and
cultural beings and are actively seeking a non racist identity.

II. Counselor Awareness of Client’s Worldview

A. Attitudes and Beliefs

1. Culturally skilled counselors are aware of their negative and positive emotional reactions
toward other racial and ethnic groups that may prove detrimental to the counseling relationship.

They are willing to contrast their own beliefs and attitudes with those of their culturally different
clients in a nonjudgmental fashion.

2. Culturally skilled counselors are aware of their stereotypes and preconceived notions that they
may hold toward other racial and ethnic minority groups.

B. Knowledge

1. Culturally skilled counselors possess specific knowledge and information about the particular
group with which they are working. They are aware of the life experiences, cultural heritage, and
historical background of their culturally different clients. This particular competency is strongly
linked to the “minority identity development models” available in the literature.

2. Culturally skilled counselors understand how race, culture, ethnicity, and so forth may affect
personality formation, vocational choices, manifestation of psychological disorders, help seeking
behavior, and the appropriateness or inappropriateness of counseling approaches.

3. Culturally skilled counselors understand and have knowledge about sociopolitical influences
that impinge upon the life of racial and ethnic minorities. Immigration issues, poverty, racism,
stereotyping, and powerlessness may impact self esteem and self concept in the counseling
process.

C. Skills

1. Culturally skilled counselors should familiarize themselves with relevant research and the latest
findings regarding mental health and mental disorders that affect various ethnic and racial groups.
They should actively seek out educational experiences that enrich their knowledge,
understanding, and cross-cultural skills for more effective counseling behavior.

2. Culturally skilled counselors become actively involved with minority individuals outside the
counseling setting (e.g., community events, social and political functions, celebrations,
friendships, neighborhood groups, and so forth) so that their perspective of minorities is more
than an academic or helping exercise.

III. Culturally Appropriate Intervention Strategies

A. Beliefs and Attitudes

1. Culturally skilled counselors respect clients’ religious and/ or spiritual beliefs and values,
including attributions and taboos, because they affect worldview, psychosocial functioning, and
expressions of distress.

2. Culturally skilled counselors respect indigenous helping practices and respect help~iving
networks among communities of color.

3. Culturally skilled counselors value bilingualism and do not view another language as an
impediment to counseling (monolingualism may be the culprit).

B. Knowledge

1. Culturally skilled counselors have a clear and explicit knowledge and understanding of the
generic characteristics of counseling and therapy (culture bound, class bound, and monolingual)
and how they may clash with the cultural values of various cultural groups.

2. Culturally skilled counselors are aware of institutional barriers that prevent minorities from
using mental health services.

3. Culturally skilled counselors have knowledge of the potential bias in assessment instruments
and use procedures and interpret findings keeping in mind the cultural and linguistic
characteristics of the clients.

4. Culturally skilled counselors have knowledge of family structures, hierarchies, values, and
beliefs from various cultural perspectives. They are knowledgeable about the community where a
particular cultural group may reside and the resources in the community.

5. Culturally skilled counselors should be aware of relevant discriminatory practices at the social
and community level that may be affecting the psychological welfare of the population being
served.

C. Skills

1. Culturally skilled counselors are able to engage in a variety of verbal and nonverbal helping
responses. They are able to send and receive both verbal and nonverbal messages accurately
and appropriately. They are not tied down to only one method or approach to helping, but
recognize that helping styles and approaches may be culture bound. When they sense that their
helping style is limited and potentially inappropriate, they can anticipate and modify it.

2. Culturally skilled counselors are able to exercise institutional intervention skills on behalf of
their clients. They can help clients determine whether a “problem” stems from racism or bias in
others (the concept of healthy paranoia) so that clients do not inappropriately personalize
problems.

3. Culturally skilled counselors are not averse to seeking consultation with traditional healers or
religious and spiritual leaders and practitioners in the treatment of culturally different clients when
appropriate.

4. Culturally skilled counselors take responsibility for interacting in the language requested by the
client and, if not feasible, make appropriate referrals. A serious problem arises when the linguistic
skills of the counselor do not match the language of the client. This being the case, counselors
should (a) seek a translator with cultural knowledge and appropriate professional background or
(b) refer to a knowledgeable and competent bilingual counselor.

5. Culturally skilled counselors have training and expertise in the use of traditional assessment
and testing instruments. They not only understand the technical aspects of the instruments but
are also aware of the cultural limitations. This allows them to use test instruments for the welfare
of culturally different clients.

6. Culturally skilled counselors should attend to as well as work to eliminate biases, prejudices,
and discriminatory contexts in conducting evaluations and providing interventions, and should
develop sensitivity to issues of oppression, sexism, heterosexism, elitism and racism.

7. Culturally skilled counselors take responsibility for educating their clients to the processes of
psychological intervention, such as goals, expectations, legal rights, and the counselor’s
orientation.

Arredondo, P., Toporek, M. S., Brown, S., Jones, J., Locke, D. C., Sanchez, J. and Stadler, H. (1996)
Operationalization of the Multicultural Counseling Competencies. AMCD: Alexandria, VA

AMCD Multicultural Counseling Competencies
I. Counselor Awareness of Own Cultural Values and Biases
A. Attitudes and Beliefs
B. Knowledge
C. Skills
II. Counselor Awareness of Client’s Worldview

A. Attitudes and Beliefs
B. Knowledge
C. Skills

III. Culturally Appropriate Intervention Strategies
A. Beliefs and Attitudes
B. Knowledge
C. Skills

Corey, Corey, Corey, and Callanan Ethical Decision-Making Model

In addition to the moral model just noted, a number of other ethical decision-making models exist (Neukrug, 2016). One hands-on, practical, problem-solving model espoused by Corey, Corey, and Corey (2019) suggests that the practitioner go through the following eight steps when making complex ethical decisions: 1. Identify the problem or dilemma 2. Identify the potential issues involved 3. Review the relevant ethical guidelines 4. Know the applicable laws and regulations 5. Obtain consultation 6. Consider possible and probable courses of action 7. Enumerate the consequences of various decisions 8. Decide on what appears to be the best course of action Finally, in addition to the moral and practical models mentioned earlier, some suggest that regardless of the approach one takes in ethical decision-making, the ability to make wise ethical decisions may well be influenced by the clinician’s level of ethical, moral, and cognitive development (Lambie, Hagedor, & Ieva, 2010; Levitt & Moorhead, 2013) (see Exercise 2.1). Those who are at higher levels of cognitive development, they state, view ethical decision-making in more complex ways than others. Certainly, this has broad implications for the training that takes place in clinical programs, as it would be hoped that students are challenged to make decisions that are comprehensive and thoughtful (McAuliffe & Eriksen, 2010).

Neukrug, Edward S.. Essentials of Testing and Assessment: A Practical Guide for Counselors, Social Workers, and Psychologists, Enhanced (p. 28). Cengage Learning. Kindle Edition.

ED388883 1995-00-00 Mental Health
Counseling Assessment: Broadening
One’s Understanding of the Client and
the Clients Presenting Concerns. ERIC

Digest.

ERIC Development Team

www.eric.ed.gov

Table of Contents

If you’re viewing this document online, you can click any of the topics below to link directly to that section.

Mental Health Counseling Assessment: Broadening One’s
Understanding of the Client and the Clients Presenting Concerns.
ERIC Digest…………………………………………………………. 2

CONTINUOUS ASSESSMENT………………………………………. 2
QUALITATIVE ASSESSMENT……………………………………….. 3
BEHAVIORAL ASSESSMENT……………………………………….. 4
PAST RECORDS……………………………………………………… 4
SUMMARY…………………………………………………………….. 4
REFERENCES………………………………………………………… 5

ERIC Identifier: ED388883
Publication Date: 1995-00-00
Author: Juhnke, Gerald A.
Source: ERIC Clearinghouse on Counseling and Student Services Greensboro NC.

Mental Health Counseling Assessment:

ED388883 1995-00-00 Mental Health Counseling Assessment: Broadening One’s
Understanding of the Client and the Clients Presenting Concerns. ERIC Digest.

Page 1 of 6

Broadening One’s Understanding of the Client
and the Clients Presenting Concerns. ERIC
Digest.

THIS DIGEST WAS CREATED BY ERIC, THE EDUCATIONAL RESOURCES
INFORMATION CENTER. FOR MORE INFORMATION ABOUT ERIC, CONTACT
ACCESS ERIC 1-800-LET-ERIC
OVERVIEW

Assessment has experienced a resurgence in recent years both in the United States
and abroad (Piotrowski & Keller, 1992; Watkins, 1994). Some continue to use the terms
assessment and testing interchangeably. Both are vitally important to the counseling
process (Lambert, Ogles, & Masters, 1992). Yet, assessment is broader in scope than
testing. Typically, assessment includes gathering and integrating information about a
client in a manner that promotes effective treatment (Cohen, Swerdlik, & Smith, 1992).
This can be accomplished by using testing in conjunction with other methods, such as
qualitative techniques, behavioral assessments and review of past client records.
Testing should not be used as the only source of information about a client (Anastasi,
1992).

Corroborating data from a number of sources helps create a more thorough
understanding of the client and his or her presenting concerns. The counselor can then
interpret these data and formulate hypotheses related to the client’s strengths and
weaknesses. Data gathered and the hypotheses formed, thereby, contribute to the
creation of an effective counseling strategy. This digest discusses how counselors can
use assessment as a continuous process throughout treatment. It also reviews three
common forms of assessment techniques which can be used in conjunction with testing.

CONTINUOUS ASSESSMENT

Vacc (1982) notes, “Assessment in counseling should be viewed not as a one-time
prediction activity but rather as continuous throughout the counseling process…” (p.40).
Continuous assessment influences the direction of treatment in two ways. First,
presenting concerns and client circumstances are not static. Goals identified by the
client during the initial assessment often must be modified or re-ordered to meet new
and urgent client needs. Continuous assessment apprises the counselor of possible
new and urgent needs which have arisen since the initial assessment. These needs can
then be addressed through the counseling process. Second, assessment can aid in
evaluating the efficacy of treatment. Upon entering treatment, an initial assessment
establishes the client’s baseline of functioning. Continuous assessment allows
comparisons between this initial base-line and the client’s current functioning.

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Understanding of the Client and the Clients Presenting Concerns. ERIC Digest.

Improvements suggest treatment efficacy and the benefit of continuing the current
treatment course. Reduction in functioning or a lack of improvement, however, suggests
a need to alter treatment. Continuous assessment, therefore, is important, because it
keeps the counselor apprised of the client’s ever changing needs and indicates
treatment efficacy.

QUALITATIVE ASSESSMENT

Qualitative assessment techniques are compatible with the belief that “…assessment
activities should not stand outside the change process; rather, they should blend into
treatment strategies to guide self-discovery and to inform clients” (Drum, 1992, p. 622).
Unlike standardized tests, qualitative assessments often consist of games or simulation
exercises that are flexible, open-ended, holistic, and nonstatistical (Goldman, 1992).
Typically a debriefing follows the qualitative assessment experience. Clients can
process what they learned from the experience immediately within the counseling
session.
One commonly used qualitative assessment experience is called, “The Life Line”
(Goldman, 1992). The intent of this experience is to help clients reflect upon significant
past events which have influenced them. Clients draw a horizontal timeline on a blank
sheet of paper. They are then asked to recall past significant experiences, relationships,
events or wishes which have influenced their lives, and to plot these along the timeline.
The result gives the counselor detailed information about significant events in the
client’s developmental history.

Similarly, role plays can serve as a qualitative assessment experience. For example, a
mental health counselor may ask a client to role play a recent anxiety provoking
experience (e.g., an argument with a supervisor, receiving a speeding ticket, etc.). The
role play provides the mental health counselor with a sample of the client’s behaviors.
As the role play is being demonstrated the counselor can query the client regarding
possible negative self-talk (e.g., I’m so stupid, he’ll never listen to me, etc.).
Understanding the self-talk used by a client can help the counselor generate effective
intervention ideas. Clients can also practice new counselor-directed behaviors or
self-talk (e.g., I’m intelligent, he’ll want to listen to me) within the counseling session
through role plays.

Another qualitative assessment technique that can provide valuable information is a
photograph safari. Depending upon the presenting concerns, the counselor may request
that the client bring to the session photographs of the client’s family-of-origin or
childhood. The counselor and client can jointly review these photographs. Particular
attention should be paid to: (a) those present in the photographs; (b) those consistently
absent from the photographs (e.g., Are the client’s siblings always included in the
photographs but the client absent?); (c) common themes of the photographs (e.g., Are
all the pictures taken on the family farm? Are pictures only taken during certain
holidays?); (d) proximity to significant others posing in the photographs (e.g., Is the
client consistently posed beside the client’s father? Is the client consistently standing

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Understanding of the Client and the Clients Presenting Concerns. ERIC Digest.

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apart from other family members?); and (e) emotions displayed on family member faces
(e.g., Does the client consistently pout or appear angry in photographs?). Such
qualitative assessment techniques can promote insight for the client and therapeutic
direction for the counselor.

BEHAVIORAL ASSESSMENT

Counselors using behavioral assessments are most interested in recording manifest
behaviors. Emphasis is placed upon identifying antecedents to problem behaviors and
consequences that reduce their frequency or eliminate them (Galassi & Perot, 1992).
Both indirect and direct methods are used for behavioral assessments. Indirect methods
of behavioral assessment might include the counselor interviewing the client or talking
to significant others about the reported problem behavior. Indirect behavioral
assessment provides important information about the client and the client’s presenting
concerns, but the information obtained may be contaminated by misperceptions or
biases about the client or the client’s behaviors. More direct methods reduce the
probability of misperceptions or biases, and might include counselor observation of the
client or client self-monitoring. A behavioral problem checklist or procedures especially
designed to record the client’s concerns directly (e.g., recording the frequency, duration
and intensity of marital arguments) can be used to help clarify possible antecedents to
behavioral problems and record what subsequent interactions result in their
discontinuance.

PAST RECORDS

Reviewing previous client records (e.g., counseling, school, police, medical, military,
etc.) help the mental health counselor identify important patterns which the client may
be unaware of or disinclined to discuss readily (e.g., problems with authority figures,
self-injurious behaviors occurring after the ending of significant relationships, etc.).
These records can be a vital source of information. Often a review of previous
counseling records will indicate what types of treatment were attempted. Previously
ineffective treatments can be ruled out, and treatment regimes found helpful
re-implemented.
Concomitantly, past records link the client’s history to the presenting concern. A
counselor can gain increased clarity of the immediate concern based upon an improved
understanding of previous stressors or transitions leading to the client’s current
condition. The Counselor can then address the cause(s) of the symptoms rather than
the symptoms, themselves.

SUMMARY

Assessment provides direction for treatment and aids in the evaluation process.
Although many methods can be employed to promote a thorough assessment, no one
method should be used by itself. Ultimately, it is the counselor’s responsibility to gain

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Understanding of the Client and the Clients Presenting Concerns. ERIC Digest.

sufficient information regarding the client and the client’s presenting concerns to
establish an effective treatment strategy. Using a combination of assessment
techniques increases the likelihood of positive interventions and promotes successful
treatment.

REFERENCES

Anastasi, A. (1992). What counselors should know about the use and interpretation of
psychological tests. Journal of Counseling & Development, 70(5), 610-615.
Cohen, R. J., Swerdlik, M. E., & Smith, D. K. (1992). Psychological testing and
assessment: An introduction to tests and measurements. Mountain View, CA: Mayfield
Publishing Company.

Drum, D. J. (1992). A review of Leo Goldman’s article “Qualitative assessment: An
approach for Counselors.” Journal of Counseling & Development, 70(5), 622-623.

Galassi, J. P. & Perot, A. R. (1992). What you should know about behavioral
assessment. Journal of Counseling & Development, 70(5), 624-631.

Goldman, L. (1992). Qualitative assessment: An approach for counselors. Journal of
Counseling & Development, 70(5), 616-621.

Lambert, M. J., Ogles, B. M., & Masters, K. S. (1992). Choosing outcome assessment
devices: An organizational and conceptual scheme. Journal of Counseling &
Development, 70(4), 527-532.

Piotrowski, C., & Keller, J. W. (1992). Projective techniques: An international
perspective. (ED 355 273).

Vacc, N. A. (1982). A conceptual framework for continuous assessment of clients.
Measurement and Evaluation in Guidance, 15 (1), 40-47.

Watkins, C. E., (1994). Thinking about “Tests and Assessment” and the career beliefs
inventory. Journal of Counseling & Development, 72(4), 421-423.

Gerald A. Juhnke is an assistant professor and Clinic Coordinator in the Department of
Counseling and Educational Development in the School of Education at the University
of North Carolina at Greensboro.

ERIC Digests are in the public domain and may be freely reproduced and disseminated.
This publication was funded by the U.S. Department of Education, Office of Educational
Research and Improvement, Contract No. RR93002004. Opinions expressed in this
report do not necessarily reflect the positions of the U.S. Department of Education,
OERI, or ERIC/CASS.

ERIC Resource Center www.eric.ed.gov
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Understanding of the Client and the Clients Presenting Concerns. ERIC Digest.

Page 5 of 6

Title: Mental Health Counseling Assessment: Broadening One’s Understanding of the
Client and the Clients Presenting Concerns. ERIC Digest.
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(071); Information Analyses—ERIC Digests (Selected) in Full Text (073);
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Table of Contents

Training Therapists in Evidence-Based Practice: A Critical

Review of Studies From a Systems-Contextual Perspectiv

e

Rinad S. Beidas and Philip C. Kendall, Department of Psychology, Temple Universit

y

Evidence-based practice (EBP), a preferred psychologi-

cal treatment approach, requires training of community

providers. The systems-contextual (SC) perspective, a

model for dissemination and implementation efforts,

underscores the importance of the therapist, client, an

d

organizational variables that influence training and con-

sequent therapist uptake and adoption of EBP. Thi

s

review critiques the extant research on training in EBP

from an SC perspective. Findings suggest that therapist

knowledge improves and attitudinal change occurs fol-

lowing training. However, change in therapist behavio

rs

(e.g., adherence, competence, and skill) and client out-

comes only occurs when training interventions address

each level of the SC model and include active learning

.

Limitations as well as areas for future research are

discussed.

Key words: dissemination and implementation, evi-

dence-based practice, systems-contextual perspective,

therapist training. [Clin Psychol Sci Prac 17: 1–30, 2010]

The American Psychological Association (APA) and the

American Academy of Child and Adolescent Psychiatry

(AACAP) support the provision of evidence-based prac-

tice (EBP; American Academy of Child and Adolescent

Psychiatry, 2006; American Psychological Association,

2005). However, a report by the United States Surgeo

n

General (1999) suggests that the majority of clients with

mental illness do not receive EBP. There are obstacles in

the dissemination and implementation (DI) of EBP into

clinical practice (e.g., criticism of treatment manuals,

inadequate training, and unsupportive organizational

climates). Understanding how to best disseminate EBP is

paramount to reducing the gap between research and

practice (Addis & Krasnow, 2000; Hayes, 2002;

Herschell, McNeil, & McNeil, 2004).

Multiple terms have been used interchangeably, and

at times inaccurately, in this area (Kendall & Beidas,

2007). EBP
1

as defined by the American Psychological

Association (2005) is ‘‘the integration of the best avail-

able research with clinical expertise.’’ ESTs refer to

psychological interventions that have been evaluated

scientifically (e.g., a randomized controlled trial, RCT)

and satisfy the criteria outlined in Chambless and

Hollon (1998). DI research includes the purposeful

distribution of relevant information and materials to

therapists (i.e., dissemination) and the adoption and

integration of EPB into practice (i.e., implementation;

Lomas, 1993). Our focus is on training as it relates to

DI research: How does training influence therapist

knowledge and behavior (adherence, competence, and

skill), and how does the therapist’s context (organiza-

tional support and client population) influence adop-

tion and implementation of interventions?

To understand training as it relates to DI, a systems-

contextual (SC) approach is warranted. The SC per-

spective recommends that when considering the effec

ts

of training on therapist behavior, contextual factors

such as therapist variables, organizational support, qual-

ity of training program, and client variables (Sanders &

Turner, 2005; Turner & Sanders, 2006) should be

Address correspondence to Rinad S. Beidas, Department of

Psychology, Temple University, Weiss Hall, Philadelphia, P

A

19122. E-mail: rbeidas@temple.edu.

This project was supported by the Ruth L. Kirschstein

National Research Service Award (F31 MH083333) awarded

to the first author.

� 2010 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association.
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examined. Studying the outcomes of training without

addressing contextual variables is insufficient becau

se

training and potential implementations occur within a

system. Effective DI may occur when therapists are

trained appropriately and when the context supports

behavior change (Sanders & Turner, 2005). Such an

approach is holistic and provides an understanding of

how training influences an individual within a system.

Each component of the SC model (i.e., quality of

training, practitioner variables, client variables, and

organizational support) will be operationalized and

expanded upon below.

The quality of training provided to therapists refers to

the availability of training for individuals interested in

implementing an EBP, as well as the content and

method of the training. The current ‘‘gold standard’’ of

training in EBP includes a workshop, a manual, and

clinical supervision (Sholomskas, Syracuse-Siewert,

Rounsaville, Ball, & Nuro, 2005). The quality of train-

ing in EBP is likely to vary based on when therapists

received their graduate training. Therapists trained

before 1995 are unlikely to have had an emphasis on

EBP, while those trained after 1995 have had varied

exposure to EBP during training (Karekla, Lundgren,

& Forsyth, 2004). A 1995 survey of training directors

found that doctoral programs in clinical psychology

covered about 50% of EBP (specifically—ESTs) and

that most internships did not require competence in

EBP (specifically—ESTs; Crits-Christoph, Frank,

Chambless, Brody, & Karp, 1995). Similarly, a survey

of 200 trainees in APA-accredited programs found that

32% had no coursework in EBP (specifically—ESTs)

and over 65% had not read any of the major Task

Force reports regarding EBP (specifically—ESTs).

Those who had read the Task Force reports tended to

be cognitive-behavioral in orientation (Karekla et al.,

2004). These findings suggest that experienced thera-

pists are not likely to have received training in EBP,

and that newer therapists may have received training in

some aspects of EBP.

Importantly in our view, the content and method

(i.e., overall quality) of the training program is crucial

to successful DI. Some suggest that training content is

important and prefer a focus on principles, rather than

teaching the details of manuals (Abramowitz, 2006;

Hayes, 2002; Miller, Yahne, Moyers, Martinez, &

Pirritano, 2004). Miller et al. (2004) noted that the

appropriate training approach includes an emphasis on

principles and the ‘‘underlying spirit’’ of a treatment

rather than a focus on techniques. Further empirical

study is needed to determine the appropriate focus of

training content.

Training method is an important vehicle through

which change in therapist behavior may be achieved.

Current training methods include passively delivered

didactic lectures (e.g., the format of a continuing edu-

cation workshop) despite findings that this type of

instruction has limited effects on behavior change

(El-Tannir, 2002). Active learning, an alternative to

passive learning, is an interactive process that uses

action and reflection. Active learning is useful for skills

that must be employed within a clinical context (Cross,

Matthieu, Cerel, & Knox, 2007) and has been

employed successfully in the Triple P-Positive Parent-

ing Program (Triple P) training program (Sanders &

Turner, 2005). Cross et al. (2007) endorse active learn-

ing methods (modeling, practice opportunities, buildin

g

self-efficacy, and interaction among learners), which

may be accomplished through behavioral role-play

s.

Including behavioral role-plays as part of training

improved behavior in both clinical and nonclinical

employees in suicide prevention efforts (Cross et al.,

2007; Matthieu, Cross, Batres, Flora, & Knox, 2008).

Change in behavior may be less robust without the

inclusion of behavioral role-plays in training (Wyman

et al., 2008). Further empirical study of the contribu-

tion of active learning to effective DI efforts is needed.

Therapist attributes may be an important aspect of

whether training produces differential learning and sub-

sequent behavior change. Therapist variables include

individual attributes such as clinical experience, theo-

retical orientation, and therapist attitudes towards EBP.

Conflicting evidence exists regarding whether or not

prior clinical experience influences skill acquisition.

One study found that prior general clinical experience

did not influence therapist skill acquisition in cognitive

therapy (CT), but that prior specific clinical experience

in CT facilitated skill acquisition (James, Blackburn,

Milne, & Reichfelt, 2001). Another study comparing

practicing therapists to trainee therapists suggested that

clinical experience did not moderate skill attainment

(DeViva, 2006).

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 2

Therapist attitudes towards EBP have been exam-

ined in survey format (e.g., Addis & Krasnow, 2000;

Najavits, Weiss, Shaw, & Dierberger, 2000), with

mixed results. Some suggest that therapists hold favor-

able attitudes towards EBP (Najavits et al., 2000),

whereas others suggest that therapists hold unfavorable

attitudes towards EBP (Addis & Krasnow, 2000). The-

oretical orientation may be an individual difference that

explains these mixed results: In the first study, partici-

pants were mainly identified as cognitive-behavioral,

whereas in the second study, a large variety of theoreti-

cal orientations were surveyed. Another therapist dif-

ference explaining these discrepant findings may be

clinical experience: Those earlier on in their careers

(e.g., predoctoral interns) may hold more favorable

attitudes towards EBP when compared with those who

are more advanced in their careers (e.g., practicing

therapists; Aarons, 2004). Few studies have explicitly

examined therapist attributes and attitudes towards EBP

as predictors of training outcomes, which may inform

who will benefit most from training.

Variables relating to organizational support (e.g., clini-

cal supervision and organizational environment) can

also impact therapist training outcomes. Reading a

manual and attending a workshop may start the transfe

r

of knowledge (i.e., dissemination), but ongoing super-

vision may be needed for actual therapist behavior

change and skillful implementation (Bazelmans, Prins,

Hoogveld, & Bleijenberg, 2004; Herschell et al., 2004;

Kendall & Southam-Gerow, 1996). Research on evi-

dence-based supervision is sparse (Ellis, Krengel,

Ladany, & Schult, 1996; Holloway & Neufeldt, 1995),

but it is likely that learning occurs and confidence is

built during the supervisory process. Competent super-

visors may be related to therapist adherence and com-

petence (Henggeler, Schoenwald, Liao, Letourneau, &

Edwards, 2002), two therapist behaviors that are crucial

for fidelity to a treatment (Perpepletchikova & Kazdin,

2005). In addition, continued supervision may decrease

therapist psychological barriers to adoption of EBP

(specifically ESTs; Luoma et al., 2007).

The particulars on supervision differ by intervention,

but one feasible model comes from Turner and

Sanders’s (2006) Triple P approach. Supervision

includes updates on Triple P research through newslet-

ters, conferences, a website, and a question and answer

forum. The approach includes self-monitoring and self-

regulation, which allows therapists to direct their own

learning and skill acquisition following training (Sand-

ers & Turner, 2005). Other organizational support

variables important for therapist behavior change

include organizational openness to change and an orga-

nizational structure that supports implementation of

EBP (Zazzali

et al., 2008).

Client variables must be accounted for when consid-

ering successful therapist training outcomes. Client

variables include a therapist’s belief that a particular

EBP can be useful for his or her client population

when considering the severity and risk factors of such

clients (Turner & Sanders, 2006). Some believe that

research samples are not representative of community

samples because the selection criteria of RCTs are not

generally inclusive and comorbidity is not highly repre-

sented (Westen, Novotny, & Thompson-Brenner,

2004). However, other researchers (e.g., Stirman,

DeRubeis, Crits-Christoph, & Rothman, 2005) have

demonstrated that these differences may be overstated.

Stirman et al. (2005) mapped charts of individuals seek-

ing treatment under managed care to the criteria of

nearly 100 RCTs and identified that 80% of these indi-

viduals would be eligible for at least one RCT, and the

majority did not have more complex diagnostic profiles

than participants included in RCTs. It is important to

address therapists, concerns that a treatment is viable

for their clients and that a treatment allows for flexible

application (Kendall & Beidas, 2007). Additionally,

given the ultimate goal of DI (i.e., client access to

EBP), client outcomes following therapist training are

key dependent variables that must be examined.

This review examines studies that train therapists in

EBP from an SC perspective as recommended by

Sanders and Turner (2005) and Turner and Sanders

(2006). This perspective is ecological in nature in that

it views DI as occurring through complex bidirectional

processes between the practitioner, practitioner’s envi-

ronment, and quality of the training (Sanders &

Turner, 2005). Additionally, the perspective views the

practitioner as embedded within a broader working

environment that influences practitioner implementa-

tion of innovation (Sanders & Turner, 2005).

The

primary aim of this review was to identify training

studies and consider which level of the SC model (i.e.,

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 3

therapist variables, client variables, organizational

support, and training) was addressed. Secondarily, we

characterize the quality of the training, with an empha-

sis on training method (e.g., active and ⁄ or passive
learning strategies) and content (i.e., a focus on

principles or the teaching of a manual session by

session).

METHOD

S

A systematic literature review for the 18-year period

spanning 1990–2008 was conducted. Published journal

articles, abstracts, and books were identified via Psych-

Info and PubMed. Key words included ‘‘training,’’

‘‘dissemination,’’ ‘‘implementation,’’ ‘‘adherence,’’

‘‘competence,’’ and ‘‘therapists.’’ Additionally, reference

lists of relevant articles guided the identification of

appropriate studies. Studies were included if they trained

service providers (e.g., social workers, psychologists,

physicians, substance abuse counselors, secondary school

staff, master’s-level clinicians, and nurses) in EBP or

ESTs for at-risk or clinical populations.
2

Training studies

not affiliated with an evidence base were not included,

nor were trainings in single techniques. All studies

included in this review focused on training in EBP (see

Table 1). Unpublished theses or dissertations were not

included.

We operationalized the four levels of the systems-

contextual approach to DI as follows: (a) therapist vari-

ables: Study included at least one measure of therapist

attitudes and ⁄ or a comprehensive measure of clinical
experience and theoretical orientation,

3
(b) organiza-

tional support: Study included at least one measure of

organizational characteristics and ⁄ or provided ongoing
consultation or supervision, (c) quality of training pro-

cesses:
4

Study provided training and described training

sufficiently so that characteristics of training could be

identified, and (d) client variables: Study included at

least one measure of severity, risk factors, and resiliency

Table 1. Evidence-based practices (EBPs) included in this study

EBP References

Classifying body
deeming the
treatment to be
an EBP

Dialectical behavior therapy for borderline personality
disorder

Hawkins and Sinha (1998) A

Motivational interviewing for substance abuse Baer et al. (2004); Hunter et al. (2005); Miller and Mount
(2001); Miller et al. (2004); Rubel et al. (2000); Schoener
et al. (2006); Saitz et al. (2000)

A

Cognitive behavior therapy for eating disorders McVey et al. (2005) A
Interpersonal therapy for eating disorders McVey et al. (2005) A
Cognitive-behavioral therapy for child anxiety Beidas et al. (2009) A
Behavioral therapy for anxiety Gega, Norman, & Marks (2007) A
Trauma-focused cognitive-behavioral therapy National Crime Victims Research & Treatment Center

(2007)

C

Intervention for youth suicide Chagnon et al. (2007); Cross et al. (2007); Wyman et al.
(2008)

B

Cognitive and ⁄ or cognitive-behavioral therapy for
substance abuse

Crits-Christoph et al. (1998); Morganstern et al. (2001);
Sholomskas et al. (2005); Siqueland et al. (2000);
Watkins et al. (2008)

A

Dynamic therapy for substance abuse Crits-Christoph et al. (1998); Siqueland et al. (2000) A
Drug counseling for substance abuse Crits-Christoph et al. (1998); Luoma et al. (2007);

Siqueland et al. (2000)
B

Triple P parenting program for at-risk youth Sanders, Murphy-Brennan, et al. (2003) B
Time-limited dynamic psychotherapy for adults with Axis I

and II disorders
Bein et al. (2000); Henry, Schacht, et al. (1993); Henry,

Strupp, et al. (1993)
A

Behavioral family therapy for relatives caring for family
member with schizophrenia

Brooker and Butterworth (1993); Fadden (1997) A

Cognitive-behavioral therapy for youth and young adults
presenting to primary care

Maunder et al. (2008) A

Contingency management for youth substance abuse Henggeler, Chapman, et al. (2008); Henggeler, Sheidow,
et al. (2008)

C

Multisystemic therapy for youth substance abuse Henggeler, Sheidow, et al. (2008) C

Note. As cited in A, Chambless & Ollendick (2001); B, Substance Abuse and Mental Health Services Administration (www.nationalregistry.samhsa.gov);
C, Special section of Journal of Clinical Child and Adolescent Psychology (Silverman, Pina, & Viswesvaran, 2008).

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 4

of therapist’s client population, or included a measure of

client treatment outcome (e.g., diagnostic interview).

We operationalized the training method as employ-

ing passive (e.g., didactic presentation, lectures, and

seminars) and ⁄ or active learning strategies (e.g., behav-
ioral role-plays, feedback, coaching, and experiential

exercises). Training content was defined as focusing

on principles of the treatment (i.e., the underlying

foundational principles of the EBP) or teaching the

manual and going through the treatment session by

session.

Outcome measures included both self-reported (e.g.,

therapist attitudes) and independently rated (e.g., thera-

pist adherence) variables. Studies were classified as

using standardized measures if the report indicated ade-

quate psychometric properties (i.e., reliability: intraclass

coefficients or kappa values above 0.60; Landis &

Koch, 1977; adequate validity) and if the measure was

used in more than one research report. Studies were

classified as using nonstandardized investigator-created

measures if psychometric properties were not reported,

were not adequate, or if the measure was only used in

one study. Studies that included the outcome measures

of knowledge,
5

adherence, and skill ⁄ competence were
emphasized given the importance of these constructs in

the transportation of a treatment (Perpepletchikova &

Kazdin, 2005). Additionally, we note whether gains

made in various outcome measures (i.e., knowledge,

adherence, and skill ⁄ competence) suggest therapist pro-
ficiency. An 80% score was used to mark proficiency

in therapist knowledge and behavior. Eighty percent

was used as the cutoff, consistent with training condi-

tions used in other evaluations of EBP as the criterion

to be satisfied prior to being certified to deliver a treat-

ment (e.g., Seng, Prinz, & Sanders, 2006; Sholomaskas

et al., 2005; Walkup et al., 2008).

RESULTS

Many DI studies (32) of training have been reported,

but few (3) assess and measure all domains of the SC

model. Studies in this review are organized as follows:

those that address (a) training, (b) training and organi-

zational support, (c) training and therapist variables, (d)

training and client variables, (e) training, organizational

support, and therapist variables, (f) training, organiza-

tional support, and client variables, and (g) training,

organizational support, therapist variables, and client

variables.
6

Training

Description of Studies. Eight studies focused on train-

ing (see Table 2). The following EBPs were studied:

(a) dialectical behavior therapy (DBT) for borderline

personality disorder (Hawkins & Sinha, 1998), (b)

motivational interviewing (MI) for adult substance

abuse (Baer, Rosengren, Dunn, Wells, & Ogle, 2004),

(c) CBT and interpersonal therapy (IPT) for eating dis-

orders (ED) (McVey et al., 2005), (d) CBT for youth

anxiety (Beidas, Barmish, & Kendall, 2009), (e)

trauma-focused CBT (tf-CBT) for traumatized youth

(National Crime Victims Research & Treatment Cen-

ter, 2007), (f) behavior therapy (BT) for anxiety (Gega,

Norman, & Marks, 2007), (g) the Question, Persuade,

Refer (QPR) prevention program for youth suicide

(Cross et al., 2007), and (h) Triple P for externalizing

behaviors in youth (Sanders, Tully, Turner, Maher, &

McAuliffe, 2003). One study used an RCT design

(Gega et al., 2007), whereas the other studies used a

nonrandomized, convenience-sample, pre–post quasi-

experimental design. Study sample sizes ranged from 20

to 4,387 participants and educational level ranged from

bache

lor’s to postgraduate degrees (e.g., MD, PhD, and

PsyD). Most participants were community mental

health providers.

Training Method and Content. One study exclusively

included passive learning (e.g., didactic presentation;

Gega et al., 2007), whereas four included both passive

and active learning (e.g., experiential learning, inter-

active computer exercises, role-plays; Baer et al., 2004;

Cross et al., 2007; National Crime Victims Research &

Treatment Center, 2007;

Sanders, Tully, et al., 2003).

Two studies did not provide sufficient description of

the training to identify training method (Hawkins &

Sinha, 1998; McVey et al., 2005). When sufficiently

described, training content included a focus on review-

ing each session of the treatment protocol (Beidas

et al., 2009; National Crime Victims Research &

Treatment Center, 2007; Sanders, Tully, et al., 2003)

or a focus on principles and ⁄ or the underlying spirit of
the treatment (Baer et al., 2004; Gega et al., 2007).

Training duration varied widely from one hour (Cross

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 5

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in
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a
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a
ch

in
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a
b

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D
C
o
n
v
e
n
ie
n
ce
sa
m
p
le
;
p
re
–
p
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a
ss
e
ss
m
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n
t;
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f
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cr
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in
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co
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p
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–
p
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st

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 6

et al., 2007) to five days (Hawkins & Sinha, 1998).

Three studies used manuals to supplement the didactic

presentation (Beidas et al., 2009; McVey et al., 2005;

Sanders, Tully, et al., 2003).

Outcome Measures. The outcome measures for the

majority of the studies were self-reports, with the

exception of independently rated adherence and skill.

Self-reported outcomes included knowledge,

satisfaction, level of comfort with providing treatment,

self-efficacy, training experiences, and diffusion of

knowledge. Two studies (Baer et al., 2004; Sanders,

Tully, et al., 2003) used psychometrically sound stan-

dardized measures, whereas the other studies used

investigator-created nonstandardized measures.

Summary of Studies. Studies using only self-report

questionnaires (e.g., knowledge and satisfaction) were

considered less rigorous than studies that included inde-

pendently rated adherence and ⁄ or skill given the find-
ing that knowledge change is often not generalized as

actual behavior change (Miller, Sorensen, Selzer, &

Brigham, 2006). Surveyed mental health professionals

(n = 3,315) reported a statistically significant increase in

perceived knowledge of ED, an increase in level of

comfort in treating ED, and increased comfort teaching

others about ED treatment after receiving differential

doses of training (McVey et al., 2005). Training varied

across participants, ranging from three hours to four

days, and knowledge was not objectively measured.

Another study objectively measured declarative

knowledge and concluded that community mental

health providers (n = 109) were able to reach profi-

ciency in DBT after receiving unspecified dosages of

training (training varied across participants; Hawkins &

Sinha, 1998). In the group that attended the highest dose

of training (n = 36; a five-day intensive workshop), the

highest percentage of correct answers on a knowledge

test was 67.6. Although the authors conclude that partic-

ipants learned the protocol, they did not achieve profi-

ciency according to the 80% criterion. Another study

objectively measuring knowledge found that a multime-

dia web-based distance learning program for mental

health professionals seeking training in tf-CBT signifi-

cantly increased participants’ knowledge (National

Crime Victims Research & Treatment Center, 2007)Ta
b
le

2
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(C
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p
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a
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(e

.g
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–
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m
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t;
n
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co
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tr

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;
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a
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fo
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in
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;
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fo

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co
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in

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a
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p
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u
a
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fe

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cl

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d
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p
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,

d
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a
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b
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h
a
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th
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ra
p
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P
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,
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rl
in

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p
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lit

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d
is

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,

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a
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IP
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,

in
te

rp
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o
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a
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th

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ra
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,
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.

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 7

from 61.9% to 82.1%, which suggests that participants

reached proficiency in their knowledge of tf-CBT.

Five studies measured self-reported knowledge and

independently rated therapist behavior. Following a

one-hour training workshop for nonclinical employees

(n = 76) in the QPR suicide prevention program

(Cross et al., 2007), participants reported satisfaction

with training, and significant increases in both per-

ceived knowledge (from 36% to 62%) and declarative

knowledge (from 69% to 85%). A subset of participants

(n = 26) completed a behavioral role-play from which

skill was coded. Fifty-five percent of participants

reached a satisfactory skill level (a score of 12 of 15),

whereas 45% did not.

Similar findings were observed after 20 trainees read

a manual and attended a 2.5-hour CBT workshop for

youth anxiety (Beidas et al., 2009). Participants showed

significant increases in knowledge (all reached the 80%

criterion). Following training, participants completed a

behavioral role-play from which adherence and skill

were coded. After training, none of the participants

reached 80% adherence, whereas 67% reached profi-

cient levels of skill in CBT for child anxiety. A similar

study compared the effectiveness of differing training

modalities (i.e., computer training versus a workshop)

on BT for anxiety. Following training, nursing stu-

dents (n = 92) showed comparable improvement in

knowledge, skills, and satisfaction in both conditions.

Note that although knowledge improved significantly

after training, participants were below the proficiency

level (average 71%). Additionally, skill was rated on

average as 4.3 of 8 points (Gega et al., 2006).

In a different treatment modality (i.e., MI), addiction

and mental health counselors (n = 22) received 24 hours

of training. After training, 53% of clinicians were rated

as proficient in their MI skills, and at two-month fol-

low-up, 42% were rated as proficient (Baer et al., 2004).

A study that trained general practitioners in the Triple P

program for externalizing youth found that a brief train-

ing emphasizing active learning produced significant

improvements in rated skill. Clinicians also reported

increased satisfaction and confidence in treatment deliv-

ery (Sanders, Tully, et al., 2003).

Conclusions. Both perceived and declarative knowledge

increase after receiving training in an EBP. Change in

declarative knowledge is especially important given the

implications it may have on treatment delivery. How-

ever, it remains unclear if knowledge gains indicate

proficiency in treatment delivery (e.g., Hawkins &

Sinha, 1998), and further empirical study is necessary.

Of those studies that included independently rated

behavior, proficiency in therapist skill ranged from 54%

to 67% at post-training and 42% at follow-up (Beidas

et al., 2009; Cross et al., 2007; Gega et al., 2006,

Sanders, Tully, et al., 2003). After training, none of the

participants reached proficiency in adherence (see

Beidas et al., 2009). This finding is alarming when

considering that skill and adherence (Perpepletchikova

& Kazdin, 2005) are crucial to the transportation of a

treatment from research to practice.

Limitations. Study-specific limitations include high

attrition rates (Beidas et al., 2009; National Crime Vic-

tims Research & Treatment Center, 2007), practice

effects, low content validity (e.g., only four questions

per section to assess knowledge; National Crime

Victims Research & Treatment Center, 2007), partici-

pants receiving differential training collapsed into one

larger sample (Hawkins & Sinha, 1998; McVey et al.,

2005), the examination of skill in only a subset of the

sample (Cross et al., 2007), and an inability to procure

all outcome variables (Baer et al., 2004).

Training and Organizational Support

Description of Studies. Six studies focused on both

training and organizational support (see Table 3). The

EBP training included (a) CBT for adult substance use

(Sholomskas et al., 2005), (b) CT, dynamic therapy

(DP), and drug counseling (DC) for adult substance

abuse (Crits-Christoph et al., 1998), (c) group drug

counseling (GDC) for adult substance abuse (Luoma

et al., 2007), (d) Triple P for youth behavior problems

(Sanders, Murphy-Brennan, & McAuliffe, 2003), (e)

time-limited dynamic psychotherapy (TLDP) for adults

(Henry, Strupp, Butler, Schacht, & Binder, 1993), and

(f) MI for substance abuse (Moyers et al., 2008). Three

studies used a nonrandomized, convenience-sample,

pre–post, quasi-experimental design (Crits-Christoph

et al., 1998; Henry, Strupp, et al., 1993; Sanders,

Murphy-Brennan, et al., 2003). Two studies randomly

assigned participants to a training condition and included

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 8

T
a
b
le

3
.

S
y
st

e
m
s-
co
n
te
x
tu
a
l

le

v
e
l:

T
ra
in
in

g
a
n
d

o
rg

a
n
iz

a
ti
o
n
a
l

su
p
p
o
rt

R
e
fe
re
n
ce
s
n
E
S
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P
a
ti
e
n
t
T
h
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ra
p
is
t
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ra
in
in
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ct
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le
m
e
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ts
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u
tc
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m
e
v
a
ri
a
b
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s
D
e
si
g
n
R
e
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lt
s

C
ri
ts

-C
h
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p
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t
a
l.
(1
9
9
8
)

6
5

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T

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lo
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a
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a
l

+

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tw

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–

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(d
id

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,

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cu
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+
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.
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a
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).
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to

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p

+
tr

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e
n
ri
ch

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p
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a
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co
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I
co
m

p
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n
ce
P
re
–
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o
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ss
e
ss
m
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n
t;
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-m
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th
f
⁄u
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m
p
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ri
so

n
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ro

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p
;
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M
1
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p
ro

v
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d
if
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n
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b
e
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t
f
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n
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rs
,
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rp

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y
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re

n
n

a
n
,

e
t
a
l.
(2
0
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3
)
3
3
1
T
ri
p
le
P
A

t-
ri
sk

y
o
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th

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e
n
e
ra
l
th
e
ra
p
is

ts
R

e
a
d
in
g
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y
w
o
rk

sh
o
p
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1
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a
y
a
cc

re
d

it
a
ti
o
n
,

a
cc
e
ss

to
w

e
b
su
p
p
o
rt

n
e
tw

o
rk

A
ct

iv
e
sk
ill

s
tr

a
in
in
g
1
.

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e
rc

e
iv
e
d
S
2
.
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a
C
o
n
v
e
n
ie
n
ce
sa
m
p
le
;
p
re
–
p
o
st
a
ss
e
ss
m
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n
t;
IC
M
;
n
o
co
n
tr
o
l
g
ro
u
p
;
n
o
f
⁄u
;
n
o
R
A
1
.
H
ig
h
S
a
2
.
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cr
e
a
se

d
p
e
rc

e
iv
e
d
S

S
h
o
lo

m
sk

a
s
e
t
a
l.
(2
0
0
5
)

7
8

C
B
T
A
d
u
lt
su
b
st
.
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se
C
o
m
m
u
n
it
y
cl
in
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n
s

M
a
n
u
a
l

o
n
ly

v
s.

m
a
n
u
a
l
+

2
0
–

h
o
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r

w
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b

tr
a
in
in
g
v
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y
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p

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th

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e

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u
r
su
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n

W
e
b
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se

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ro

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a
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in
v
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o
ro

le
–
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s
1
.
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a
te
d
A
2
.
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a
te
d
S
3
.
K
N
o
t

fu
lly

ra
n
d
o
m

iz
e
d
;

p
re
–
p
o
st
g
ro
u
p
a
ss
e
ss
m
e
n
t;
co
n
tr
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l
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ro
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p
;
n
o
f
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(p
o
st

-S
u
p
);

S
M
1
.
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cr
e
a
se
d
S
a
n
d

A
w

o
rk
sh
o
p
+
su
p
e
rv
is
io

n
w

h
e
n
co
m

p
a
re

d
w

it
h
m
a
n
u
a
l
+
w
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b
a
t
p
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st

+
f

⁄u
.

2
.
In
cr
e
a
se
d
S
,
a
n
d

A
in

M
a
n
u
a
l
+
w
e
b
C
o
m
p
a
re
d
w
it
h
M
a
n
u
a
l
o
n
ly

.
3
.

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o

D
if
fe

re
n
ce
in
K
n
o
w
le
d
g
e
N
o
te

.
C

T
,
co
g
n
it
iv

e
th

e
ra
p
y
;

D

P
,

d
y
n
a
m

ic
p
sy

ch
o
th

e
ra
p
y
;
D
C

,

d
ru

g
co
u
n
se

l

in
g
;

S
,
sk
ill

;
S
M

,
st
a
n
d
a
rd
iz
e
d

m
e
a
su

re
;

R
A
,
ra
n
d
o
m
a
ss
ig
n
m
e
n
t;
f
⁄u
,
fo

llo
w

-u
p
;

T
L
D
P
,
ti
m

e
-l

im
it
e
d

d
y
n
a
m
ic
p
sy
ch
o
th
e
ra
p
y
;
G
D
C
,
g
ro
u
p
d
ru
g
co
u
n
se
lin
g
;
q
⁄a
,
q
u
e
st
io
n
s
a
n
d

a
n
sw

e
rs

;
A

C
T
,

A
cc

e
p
ta

n
ce
a
n
d
C
o
m

m
it
m

e
n
t
T
h
e
ra
p
y
;
S
a
,
sa
ti
sf
a
ct
io
n
;
IC
M
,
in
v
e
st
ig
a
to
r-
cr
e
a
te
d
m
e
a
su
re
;

M
I,

m
o
ti
v
a
ti
o
n
a
l
in
te
rv
ie
w
in
g
;
C
B
T
,
co
g
n
it
iv
e
-b
e
h
a
v
io
ra
l

th
e

ra

p
y
;
A
,

a
d
h
e
re

n
ce
;
K

,
k
n
o
w

le
d
g
e
;
p
o
st

-S
u
p
,

p
o
st
su
p
e
rv
is
io

n
.

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 9

a comparison condition (Luoma et al., 2007; Moyers

et al., 2008), whereas another study attempted random

assignment but was unable to do so (Sholomskas et al.,

2005). Study samples ranged from 16 to 331 therapist

participants, with educational levels ranging from bache-

lor’s to postgraduate degrees (e.g., MD, PhD, and

PsyD). Most were community mental health providers.

Training Method and Content. All training included

passive learning (e.g., didactic presentation). Five studies

included active learning strategies (e.g., experiential

learning, in vivo and ⁄ or computer role-plays, active
learning skills; Crits-Christoph et al., 1998; Luoma

et al., 2007; Moyers et al., 2008; Sanders, Murphy-

Brennan, et al., 2003; Sholomskas et al., 2005). Training

content included a focus on reviewing each session of

the treatment protocol (Crits-Christoph et al., 1998;

Sholomskas et al., 2005) or a focus on principles

(Henry, Strupp, et al., 1993; Moyers et al., 2008).

Training time varied from 6 (Luoma et al., 2007) to

100 hours (Henry, Strupp, et al., 1993). Five studies

required the use of manuals to supplement the didactic

presentation (Crits-Christoph et al., 1998; Henry,

Strupp, et al., 1993; Moyers et al., 2008; Sanders,

Murphy-Brennan, et al., 2003; Sholomskas et al., 2005).

Organizational Support. One study provided peer and

web-based support (Sanders, Murphy-Brennan, et al.,

2003), whereas another used group consultation to

overcome therapist barriers in the use of newly

acquired skills (Luoma et al., 2007). Other work

(Crits-Christoph et al., 1998; Henry, Strupp, et al.,

1993; Sholomskas et al., 2005) included supervision as

part of the training, ranging from 3 one-hour supervi-

sions (Sholomskas et al., 2005) to 50 two-hour weekly

supervisions (Henry, Strupp, et al., 1993). One study

provided supervision that concentrated on feedback on

specific techniques and also provided additional didactic

training

(Moyers et al., 2008).

Outcome Measures. Most studies used self-reported

outcome measures, with the exception of independently

rated adherence and skill. Self-reported outcomes

included knowledge, satisfaction, therapist perception

of alliance, adoption, and burnout. Five studies

(Crits-Christoph et al., 1998; Henry, Strupp, et al.,

1993; Moyers et al., 2008; Sanders, Murphy-Brennan,

et al., 2003; Sholomskas et al., 2005) used standardized

psychometrically sound measures, and Luoma et al.

(2007) used a combination of investigator-created non-

standardized measures and standardized psychometrically

sound measures.

Summary of Studies. Physicians (n = 331) were

trained in Triple P (Sanders, Murphy-Brennan, et al.,

2003) and had access to peer support networks and web-

based support. After training, participants reported a

statistically significant increase in how well they believed

they were trained to manage behavior problems,

increased confidence in conducting parent consultation,

and high satisfaction with the training. In another study,

therapists (n = 30) were randomly assigned to a psycho-

logically focused group consultation after attending a

one-day workshop to overcome psychological barriers

in the use of new treatment techniques (Luoma et al.,

2007). In relation to the comparison group, the inter-

vention group reported more adoption of the treatment

at two- and four-month follow-ups, and a greater sense

of personal accomplishment at four-month follow-up.

Two interventions focused on the effects of EBP

training on therapist behavior as part of larger treat-

ment outcome studies (Crits-Christoph et al., 1998;

Henry, Strupp, et al., 1993). Both studies used manu-

als, didactic workshops, and ongoing supervision as part

of training, although one study provided significantly

more supervision (50 two-hour weekly sessions; Henry,

Strupp, et al., 1993). After receiving training and

supervision in TLDP (n = 16), therapist adherence and

general skills (e.g., greater use of open-ended questions)

were more highly rated. Unexpectedly, certain thera-

pist skills decreased (e.g., less optimistic, less supportive,

and more authoritative; Henry, Strupp, et al., 1993).

By contrast, Crits-Christoph et al. (1998) found that

following training in both DP and DC, therapist skill

increased as each case progressed (i.e., within case),

while CT therapists performed more skillfully across

cases (n = 65; Crits-Christoph et al., 1998). In other

words, only CT therapists were able to transfer their

learning from case to case. By the fourth training case,

CT therapists were scoring an average of 46 out of a

possible 48 points, suggesting great improvement and

proficiency in comparison with their first training case.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 10

The most methodologically rigorous investigations

in this category both included random assignment to

varying training methods. One study employed an

investigation of which condition: (a) manual only,

(b) manual + web-based training, and (c) manual +

didactic training + supervision) was most effective in

improving therapist knowledge, adherence, and skill in

CBT for substance abuse (Sholomskas et al., 2005).

The highest dosage of training (manual + didactic

training + supervision) produced the highest levels of

therapist adherence and skill, with the manual + web

training evidencing intermediate scores and the manual

alone having the lowest levels of adherence and skill

after training and at follow-up. It is of note that in the

highest dosage of training, only 54% of clinicians

reached proficiency levels in adherence and skill

(Sholomskas et al., 2005). Knowledge was not signifi-

cantly different between the three groups. Another

study randomly assigned therapists to one of three con-

ditions: (a) workshop only, (b) workshop + training

enrichments (i.e., six supervision calls, specific feedback

on behavior), and (c) self-directed training (Moyers

et al., 2008). All conditions showed gains in compe-

tence from baseline to post-training with effect sizes in

the medium to large range; however, these gains

declined at four-month follow-up. Contrary to expec-

tations, improved competence was not observed in the

group that received training enrichments (i.e., feedback

and consultation calls).

Conclusions. After receiving training and follow-up

organizational support, therapists’ perceptions of their

behavior (e.g., confidence and personal accomplish-

ment) increase (Luoma et al., 2007; Sanders, Murphy-

Brennan, et al., 2003). In some studies, the perception

of behavior change is matched by actual therapist

behavior change; however, these changes in behavior

are not maintained at follow-up. When considering

specific EBP packages, some evidence supports the

notion that MI competence can be gained after attend-

ing a one-day workshop. However, these gains were

not maintained at follow-up, and a number of training

enrichments did not result in expected increased skill.

Contradictory evidence exists regarding the effect of

training in DP on therapist adherence. One study sug-

gests that certain DP-related skills improve, while

others deteriorate after training, particularly skills that

influence the therapeutic relationship (Henry, Strupp,

et al., 1993). A follow-up study suggests that DP skills

influencing the alliance may decrease in the first train-

ing case following training, but that this effect may

diminish as the therapist treats more clients (Crits-

Christoph et al., 1998). Thus, further supervision and

more than one training case may reverse an initial

awkward phase as the therapist grows comfortable

implementing the EBP.

Similarly, contradictory evidence exists regarding the

effect of CT and CBT training on therapist behavior.

One study demonstrates that CT training plus supervi-

sion allows skills to improve, suggesting that CT thera-

pists are able to apply what they have learned in training

and supervision to new cases. However, in another

study of CBT training, approximately half of the thera-

pists were not trained to an acceptable criterion in

adherence and skill, despite receiving the gold standard

in the field of training (Sholomskas et al., 2005).

Limitations. Study-specific issues include limited data

on supervisory practices, self-reported skill (Luoma

et al., 2007; Sanders, Murphy-Brennan, et al., 2003),

biased skill ratings from supervisors (Crits-Christoph

et al., 1998), comparisons across training interventions

that differ in time, difficulty in randomization

(Sholomskas et al., 2005), and difficulty in procuring

samples of therapist sessions and follow-up assessment

(Moyers et al., 2008).

Training and Therapist

Variables

Description of Studies. Few studies focused on both

training and therapist variables (see Table 4).
3

The

EBP training included (a) MI for adult substance use

(Rubel, Sobell, & Miller, 2000; Saitz, Sullivan, &

Samet, 2000), (b) behavioral family therapy (BFT) for

families caring for a relative with schizophrenia

(Brooker & Butterworth, 1993), and (c) an interven-

tion training program for youth suicide prevention

(Chagnon, Houle, Marcoux, & Renaud, 2007). Three

studies used a nonrandomized, convenience-sample,

pre–post, quasi-experimental design (Brooker &

Butterworth, 1993; Rubel et al., 2000; Saitz et al.,

2000); only one study randomly assigned participants

to a training condition and included a comparison

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 11

T
a
b
le
4
.
S
y
st
e
m
s-
co
n
te
x
tu
a
l

le
v
e
l:

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ra
in
in
g
a
n
d

th
e
ra

p
is

t

v
a
ri
a
b
le

s
R
e
fe
re
n
ce
s
n
E
S
T
P
a
ti
e
n
t
T
h
e
ra
p
is
t
T
ra
in
in
g
A
ct
iv

e
E
le

m
e
n
ts
O
u
tc
o
m
e
V
a
ri
a
b
le
s
D
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si
g
n
R
e
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lt
s

B
ro

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k
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r

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u
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rw

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(1

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9
3
)

8

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T

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ch

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o
.

p
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ti
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n
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a
n
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th
e
ir

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m

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e
s

C
o
m
m
u
n
it
y
p
sy
ch
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tr
ic

n
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rs

e
s
1
.
2
-d
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y
in
tr
o
.
2
.

1
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e
e
k
sk
ill
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tr
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si

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le
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b
a
ck
1
.
R
o
le
-p
la

y
2
.

V
id

e
o
ta

p
e
d

fe
e
d
b
a
ck

co
n
ce

rn
in

g
p
ro

g
re

s

s
in

sk
ill
s.
1
.
R
a
te
d
S
2
.
A
C
o
n
v
e
n
ie
n
ce
sa
m
p
le

;
n
o
n
ra

n
d
o
m
iz
e
d
;

6
–

a
n
d

1
2
-m

o
n
th
f
⁄u
;
n
o
co
n
tr
o
l
g
ro
u
p
;
S
M
1
.
C
o
m
p
e
te

n
t—

v
e
ry

g
o
o
d

S
2
.

6
-m

o
n
th
f
⁄u
sk
ill

im
p
ro

v
e
d
3
.
S
tr

e
n
g
th

e
n

A
h
e
ld

p
ri
o
r

to
tr

a
in
in
g
4
.

C
h
a
n
g
e
d

A
to

B
F
T
a
s

b
e
st

tx
5
.

In
cr
e
a
se

in

h
o
u
rs

sp
e
n
t

w
it
h
fa
m

ily
C

h
a
g
n
o
n

e
t
a
l.
(2
0
0
7
)

7
1

S
A

M
A

t-
ri
sk
y
o
u
th
C
o
m
m
u
n
it
y

m
e
m

b
e
rs

3
-d
a
y
w
o
rk
sh
o
p
R
o
le
-p
la

y
1
.

A
2
.

K
3
.
R
a
te
d
S

R
a
n
d
o
m

iz
e
d
;
co
m
p
a
ri
so
n
g
ro
u
p
;
6
-m
o
n
th
f
⁄u
;
IC

M
a
n
d

S
M
1
.

A
t

p
o
st

-t
ra

in
in
g
,
im
p
ro

v
e
m

e
n
t
in
A

,
K

,
a
n
d

S
2
.
A
t
f
⁄u

,
A

m
a
in

ta
in
s
b
u
t
K
a
n
d

S
d
e
cr

e
a
se

R
u
b
e
l
e
t

a
l.

(2
0
0
0
)

4
4

M
I
A
d
u
lt
su
b
st

.
a
b
u
se

M
e
n
ta

l
h
e
a
lt
h
th
e
ra
p
is
ts
2
-d
a
y
w
o
rk
sh
o
p
(d
id
a
ct

ic
&

e
x
p
e
ri
e
n
ti
a
l)

&
re

co
m

m

e
n
d
e
d

m
a
n
u
a
l
1
.
R
o
le
-p
la
y
2
.

F
is

h
b
o
w

l
e
x
e
rc

is
e
s

1
.
K
2
.
R
a
te
d
S
3
.

A

*

C
o
n
v
e
n
ie
n
ce
sa
m
p
le
;
n
o
n
ra
n
d
o
m
iz
e
d
;
n
o
f
⁄u
;
n
o
co
n
tr
o
l
g
ro
u
p
;
IC
M
a
n
d
S
M
1
.
K
a
n
d

S
im

p
ro
v
e
d
fr
o
m
p
re

–
to

p
o
st

–
tr

a
in
in
g

S
a
it
z

e
t
a
l.
(2
0
0
0
)

7
0

M
I
A
d
u
lt
su
b
st
.
a
b
u
se
H
e
a
lt
h
-c
a
re
p
ro
v
id
e
rs

2
0
0
-m

in
w

o
rk
sh
o
p

(5
0

m
in
d
id
a
ct
ic
,

1
2
0

m
in
ro
le
–
p
la

y
,

3
0
m
in
d
is
cu
ss
io
n
)
R
o
le
-p
la
y
s
w
it
h
fe
e
d
b
a
ck
1
.

S
e
lf
-r

e
p
o
rt
e
d

ch
a
n
g
e

in
cl

in
ic
a
l
p
ra
ct
ic

e
2
.

K
*
*

3
.

A
*
*

4
.

C
*
*

5
.

S
*
*

C
o
n
v
e
n
ie
n
ce
sa
m
p
le
;
n
o
n
ra
n
d
o
m
iz
e
d
;
n
o
f
⁄u
;
n
o
co
n
tr
o
l
g
ro
u
p
;
IC
M
1
.

P
o
st

-t
ra
in
in

g
o

v
e
ra

ll
A

w
e
re

h
ig
h
e
r
2
.
S
e
lf
-r
e
p
o
rt

la
rg

e
im

p
a
ct

o
n
cl
in
ic
a
l
p
ra
ct
ic

e
3
.

N
o
ch
a
n
g
e
in
K

,
S
,

o
r
C
N
o
te

.
B
F
T
,

b
e
h
a
v
io

ra
l
fa

m
ily

th
e
ra
p
y
;

sc
h
iz

o
.
sc
h
iz

o
p
h
re

n
ia

;
S
,
sk
ill
;
A

,
a
tt

it
u
d
e

s;

f
⁄u
,
fo
llo
w
-u
p
;
S
M
,
st
a
n
d
a
rd
iz
e
d
m
e
a
su
re
s;
tx
,
tr
e
a
tm
e
n
t;
S
A

M
,

S
u
ic

id
e
A
ct
io
n

M
o
n
tr

e
a
l;

K
,
k
n
o
w
le
d
g
e
;
IC
M
,
in
v
e
st
ig
a
to
r-
cr
e
a
te
d
m
e
a
su
re
s;
M
I,
m
o
ti
v
a
ti
o
n
a
l
in
te
rv
ie
w
in
g
;

A
*
,

m
e
a
su
re
d
a
t
p
re

,
b
u
t

d
o
e
s

n
o
t

a
p
p

e
a
r

to
h
a
v
e

b
e
e
n

re
a
d
m

in
is

te
re

d
a
t

p
o
st

;
C

,
co
n
fi
d
e
n
ce

;
*
*
o
n
ly

co
lle

ct
e
d

p
re
–
p
o
st
fo
r

a
sa

m
p
le
o
f
th
e

co
h
o
rt

.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 12

condition (Chagnon et al., 2007). Sample sizes ranged

from 8 to 87 therapist participants, with educational

levels ranging from bachelor’s to postgraduate degrees

(e.g., MD, PhD, and PsyD). Participants included psy-

chiatric nurses, mental health clinicians, community

members, and health-care workers.

Training Method and Content. All of the studies

included both passive learning (e.g., didactic presenta-

tion) and active learning strategies (e.g., role-plays with

feedback, experiential learning, and fishbowl exercises).

When sufficiently described, training content included

a focus on principles (Rubel et al., 2000). Training

duration varied from 200 min (Chagnon et al., 2007)

to seven days (Brooker & Butterworth, 1993). One

study recommended a manual to supplement the didac-

tic presentation (

Rubel et al., 2000).

Therapist Variables. Studies measured therapist atti-

tudes and theoretical orientation. Two studies surveyed

substance abuse attitudes (Rubel et al., 2000; Saitz

et al., 2000), one study surveyed attitudes about schizo-

phrenia and its treatment (Brooker & Butterworth,

1993), and another measured attitudes towards inter-

vening with suicidal individuals

(Chagnon et al., 2007).

Two studies assessed theoretical orientation (Brooker &

Butterworth, 1993; Rubel et al., 2000).
3

Outcome Measures. For the majority of the studies,

self-reported outcome measures were used, with the

exception of independently rated skill. Self-reported

outcomes included knowledge, attitudes, and change in

practice. Saitz et al. (2000) used investigator-created

nonstandardized measures, Brooker and Butterworth

(1993) used standardized measures, and two studies uti-

lized both types of measures (Chagnon et al., 2007;

Rubel et al., 2000).

Summary of Studies. A survey of practicing clinicians

(n = 70) trained on MI indicated that training made an

impact on their practice with substance abuse patients,

particularly in regard to asking formal alcohol screening

questions and providing substance abuse counseling

(Saitz et al., 2000). Those participants who completed

pre- and post-training measures showed slightly higher

attitudes towards substance abuse after training,

although knowledge, confidence in ability to take a

substance history, and self-reported skillfulness did not

change.

More methodologically rigorous studies included

independent ratings of skill. Results from a 12-hour

MI training workshop indicated that both knowledge

and rated skill (i.e., percentage of motivational state-

ments to overall statements) improved from pre- to

post-training in mental health therapists (n = 44; Rubel

et al., 2000). However, participants only scored 67%

on the knowledge test—which does not indicate train-

ing to proficiency. Attitudes, measured pretraining,

indicated a psychosocial conceptualization of substance

abuse. A seven-day BFT workshop for community

psychiatric nurses demonstrated that rated skills were at

least satisfactory two months after training, with several

skills improving further at six-month follow-up

(Brooker & Butterworth, 1993). At six-month post-

training, nurses were proficient in both core and adap-

tive skills. Attitudes also changed following training,

such that belief in a psychosocial theory of schizophre-

nia and the usefulness of BFT programs increased.

The most methodologically rigorous study investi-

gated the effects of an intervention training in commu-

nity members who frequently interacted with youth at

risk of suicidal behavior (n = 78). Strengths of this

study included randomization and a comparison group.

In comparison with control subjects, participants in the

intervention group showed significant knowledge, atti-

tude, and skill improvement. At follow-up, knowledge

and skill improvement significantly diminished,

although change in attitudes was maintained. Although

participants improved in knowledge and skill at post-

training, scores were below proficiency level (i.e.,

knowledge 69%, skill 67%).

Conclusions. Survey data suggest that training in an

EBP has a lasting impact on clinical practice and self-

reported skill (i.e., Saitz et al., 2000), but actual behav-

ior change (e.g., rated skill) does not necessarily take

place when studies provide training without taking into

account the different facets of the SC model—provid-

ing training and measuring therapist variables are not

sufficient for DI efforts. Additionally, there appears to

be a lack of therapist proficiency reached after training.

The reported results of three studies indicated that

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 13

training successfully changed knowledge and indepen-

dently rated skill to a proficient level, but in two of

these studies, exploration of the reported means sug-

gests that this was not the case.

Attitudes shifted following training, and were main-

tained at follow-up. Attitudes improved towards EBP

in all studies that included a pre- to post-training

assessment (Brooker & Butterworth, 1993; Chagnon

et al., 2007; Saitz et al., 2000). Attitude change was

also sustained even when other behaviors diminished at

follow-up (Chagnon et al., 2007). It may be that cur-

rent training efforts engender shifts in participant per-

ceptions and attitudes, but are unable to bring about

lasting skill change.

Limitations. Study-specific limitations include small

sample sizes, highly motivated participants (Brooker &

Butterworth, 1993), low participant response rate

(Rubel et al., 2001), and the use of a nonvalidated vid-

eotape technique to assess for skill acquisition

(Chagnon et al., 2007).

Training and Client Variables

Description of Studies. Two studies focused on train-

ing and client variables (see Table 5). The EBP train-

ing included (a) MI for adult substance use (Miller &

Mount, 2001) and (b) QPR for youth suicide pre-

vention (Wyman et al., 2008). One study used a

nonrandomized, convenience-sample, pre–post, quasi-

experimental design (Miller & Mount, 2001), whereas

the other study randomly assigned participants to a

training condition and included a comparison condition

(Wyman et al., 2008). Study sample sizes ranged from

22 to 249 participants, with education levels at the

bachelor or master’s level. Participants included proba-

tion officers, community corrections officers, and

secondary school staff.

Training Method and Content. Both studies included

passive learning (e.g., didactic presentation), whereas

one included active learning (e.g., small group practice;

Miller & Mount, 2001). Training content was not suf-

ficiently described in either study. Training duration

varied from 2 (Wyman et al., 2008) to 15 hours (Miller

& Mount, 2001). Miller and Mount (2001) used a

manual to supplement the didactic presentation. T
a
b
le

5
.
S
y
st
e
m
s-
co
n
te
x
tu
a
l
le
v
e
l:
T
ra
in
in
g
a
n
d

cl
ie

n
t
v
a
ri
a
b
le
s
R
e
fe
re
n
ce
s
n
E
S
T
P
a
ti
e
n
t
T
h
e
ra
p
is
t
T
ra
in
in
g
A
ct
iv
e
e
le
m
e
n
ts
O
u
tc
o
m
e
v
a
ri
a
b
le
s
D
e
si
g
n
R
e
su
lt
s

M
ill

e
r
a
n
d

M
o
u
n
t

(2
0
0
1
)

2
2
M
I
A
d
u
lt
su
b
st
.
a
b
u
se

P
O

a
n
d

C
C

O
1
.

2
-d
a
y
w
o
rk
sh
o
p
2
.
M
a
n
u
a
l
3
.

6
o
p
ti
o
n
a
l

(9
0

m
in

)
f

⁄u
d
is

cu
ss

io
n
*

S
m

a
ll
g
ro
u
p
p
ra
ct
ic
e
1
.
S
e
lf
-r
e
p
o
rt
e
d
S
a
n
d

C
2
.

R
a
te
d
S
3
.

C
lie

n
t
R
C
o
n
v
e
n
ie
n
ce
sa
m
p
le
;
n
o
n
ra
n
d
o
m
iz
e
d
;
4
-m
o
n
th
f
⁄u
;
n
o
co
n
tr
o
l
g
ro
u
p
;
S
M
1
.
In
cr
e
a
se

in
se

lf
-r
e
p
o
rt
e
d
S
a
n
d

C
p
o
st

-t
ra
in
in

g
2
.

M
o
d
e
st

in
cr
e
a
se
s
in
ra
te
d
S
a
t
p
o
st
-t
ra
in
in
g
,

w
h
ic

h
w

e
re
so
m
e
w

h
a
t

m
a
in
ta
in
e
d
a
t
4
-m
o
n
th
f
⁄u
o
n
cl
ie
n
t
3
.
N
o

e
ff

e
ct

re
sp

o
n
se

s
W

y
m

a
n
e
t
a
l.
(2
0
0
8
)

2
4
9

Q
P
R
Y
o
u
th
su
ic
id
e
p
re
v
e
n
ti
o
n

S
e
co

n
d

a
ry

sc
h
o
o
l

st

a
ff

1
.
1
.5

-h
o
u
r

w
o
rk
sh
o
p
2
.

3
0
-m

in
re

fr
e
sh

e
r

co
u
rs

e
se
v
e
ra

l
m

o
n
th

s
la

te
r

N
o
n
e
1
.
K
2
.
S
e
lf
-r
e
p
o
rt
e
d
A
,

B
,

a
n
d
C
o
3
.

S
tu

d
e
n
t

su
rv

e
y
R
a
n
d
o
m
iz
e
d
;
co
m
p
a
ri
so
n
g
ro
u
p
;

1
-y

e
a
r
f
⁄u
;
IC
M
1
.
In
cr
e
a
se
in
K
,
A

,
B

2
.
S
m
a
ll
e
ff
e
ct

in
st

a
ff

a
sk

in
g
st
u
d
e
n
ts

re
:

su
ic

id
e
-r

e
la

te
d

b
e
h
a
v
io
rs
N
o
te
.
M
I,
m
o
ti
v
a
ti
o
n
a
l
in
te
rv
ie
w
in
g
;
P
O

,
p
ro

b
a
ti
o
n

o
ffi

ce
rs

;
C

C
O

,
co

m
m

u
n
it
y

co
rr

e
ct
io
n
s
o
ffi
ce
rs

;
*
N

o
t
a
tt
e
n
d
e
d

b
y

p
a
rt

ic
ip

a
n
ts

;
f

⁄u
,

fo
llo

w
-u

p
;
S
,
sk
ill
;
C
,
co
n
fi
d
e
n
ce
;
R

,
re

sp
o
n
se

s;
S
M

,
st
a
n
d
a
rd
iz
e
d
m
e
a
su
re
s;
Q
P
R
,
q
u
e
st
io
n
,
p
e
rs
u
a
d
e
,
re
fe

r;
K

,
k
n
o
w
le
d
g
e
;
A
,

a
p
p
ra

is
a
ls

;
B
,

B
e
h
a
v
io

r;
C

o
,

C
o
m

m
u
n
ic

a
ti
o
n
;

IC
M
,
in
v
e
st
ig
a
to

r-
c
re

a
te
d
m
e
a
su

re
s.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 14

Client Variables. In one study, client in-session state-

ments were used as a proxy for treatment outcome

(Miller & Mount, 2001), whereas in the other study,

students were surveyed regarding school staff commu-

nication in relation to suicidal ideation (Wyman et al.,

2008). Note that neither study utilized a measure of

severity, risk factors, and ⁄ or resiliency of therapists’
client population as predictor variables for training

efficacy (as recommended by Sanders & Turner,

2005); instead measures of client factors were included

as outcome variables.

Outcome Measures. The outcome measures included

self-report (Wyman et al., 2008) and independently

rated behavior (Miller & Mount, 2001). Self-reported

outcomes included knowledge, skill, appraisals, behav-

ior, and staff-student communication. Independently

rated behavior included rated MI skill. One study

utilized investigator-created nonstandardized measures

(Wyman et al., 2008), whereas the other study utilized

both investigator-created nonstandardized and standard-

ized psychometrically sound measures (Miller &

Mount,

2001).

Summary of Studies. Wyman et al. (2008) measured

the effect of QPR training on therapist knowledge and

behavior. Secondary school staff (n = 249) received

two hours of didactic training on suicide prevention.

In comparison with nontrained staff, knowledge, self-

reported appraisals, and behavior changes were reported

at one-year follow-up. Student responses (i.e., client

variables) suggested a small effect (d = 0.18) in being

asked more frequently about suicide by staff members

(one of the main skills of QPR). Although a statistically

significant effect was present in terms of knowledge

acquisition (d = 0.41), trained staff scored an average of

76% on the knowledge test, while nontrained staff

scored an average of 72% (both below proficiency

levels).

Miller and Mount (2001) investigated the effect of

training in MI on community corrections and proba-

tion officers working with adult substance abusers

(n = 22). Participants received 15 hours of didactic

training, which included small group practice and a

manual. Self-reports by therapists indicated large

increases in MI skills, while observational measures

reflected more modest skill changes after training that

were somewhat retained at four-month follow-up. Cli-

ents did not show the response changes found to be

predictive of better outcome with MI.

Conclusions. The findings suggest that self-reported

perceptions of change are frequently not matched by

actual behavior change. Neither study was able to

engender significant change at the client level, suggest-

ing that the main point of initiating these training

studies (i.e., to improve client response to treatment)

may not be occurring. Lack of therapist behavior

change may help explain this finding. This is concern-

ing given that therapist confidence was very high in

regard to their own skill, suggesting that they may not

feel that they need further training or consultation in

the implementation of the EBP (Miller & Mount,

2001).

An important consideration for both of these studies

is that client response was included as an outcome vari-

able. However, client variables (e.g., severity and resil-

iency) were not considered as moderators of training

effectiveness. Such data need to be co-varied in statisti-

cal analyses to depict the interactions between training

and client variables. For example, a severe population

(such as suicidal youth) may be more difficult to access;

so, while training may have succeeded in therapist

behavior change, client variables may make the treat-

ment more difficult to implement.

Limitations. Study-specific limitations included low

staff enrollment (Wyman et al., 2008) and a small sam-

ple size with participants choosing to not attend

optional follow-up discussion sessions that may have

contributed valuable organizational support (Miller &

Mount, 2001). High therapist attrition and ⁄ or low par-
ticipation in follow-up training in DI research must be

studied systemically due to the frequency of this occur-

rence in research studies (e.g., Baer et al., 2004; Miller

& Mount, 2001).

Training, Organizational Support, and Therapist Variables

Description of Studies. Several studies (n = 5) focused

on training, organizational support, and therapist vari-

ables (see Table 6).
3

The EBP training studied

included (a) BFT for families (Fadden, 1997), (b) CBT

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 15

T
a
b
le
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.
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y
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to
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.,

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su
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.,
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;
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;
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,

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,
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re

;
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n
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,
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tt
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it
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,
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*
n
o
t

in
cl

u
d
e
d

a
s
a
n

o
u
tc

o
m

e
v
a
ri
a
b
le

,
b
u
t
m
e
a
su
re
d
o
rg
a
n
iz
a
ti
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a
l

ch
a
ra

ct
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ri
st

ic
s
a
s
p
re
d
ic
to
rs
.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 16

in primary care (Maunder, Milne, & Cameron, 2008),

(c) CBT for adult substance abuse (Morganstern, Mor-

gan, McCrady, Keller, & Carroll, 2001), (d) contin-

gency management (CM) for youth substance abuse

(Henggeler, Chapman, et al., 2008), and (e) CT, DP,

and DC for adult substance abuse (Siqueland et al.,

2000). Three studies used a nonrandomized, conve-

nience-sample, pre–post, quasi-experimental design

with no comparison group (Henggeler, Chapman,

et al., 2008; Maunder et al., 2008; Siqueland et al.,

2000), whereas one study surveyed participants after

training (Fadden, 1997). The most rigorous study

included randomization and a comparison group (Mor-

ganstern et al., 2001). Sample sizes ranged from 25 to

432 participants. Educational level ranged from bache-

lor to postgraduate level (i.e., PhD or MD), and parti-

cipants included community mental health therapists,

nurses, and physicians.

Training Method and Content. All studies included

both passive learning (e.g., didactic presentation) and

active learning strategies (e.g., experiential role-plays:

Fadden, 1997; Henggeler, Chapman, et al., 2008; Mor-

ganstern et al., 2001; Siqueland et al., 2000; case dis-

cussion groups: Maunder et al., 2008). Training

content included going through session by session

(Henggeler, Chapman, et al., 2008; Siqueland et al.,

2000) and a focus on principles of the treatment

(Maunder et al., 2008), with one study including both

a focus on session-by-session administration and princi-

ples of the treatment (Morganstern et al., 2001). Train-

ing duration varied from one day (Henggeler,

Chapman, et al., 2008) to 100 hours (Morganstern

et al., 2001). All studies used a manual to supplement

the didactic presentation.

Organizational Support. Most studies (Fadden, 1997;

Maunder et al., 2008; Morganstern et al., 2001;

Siqueland et al., 2000) included ongoing supervision as

part of the training intervention. Supervision time

ranged from four 1.5-hour case discussion groups

(Maunder et al., 2008) to 65 hours of supervision

(Morganstern et al., 2001). One study did not include

supervision but included measures of organizational

characteristics (i.e., organizational readiness for change;

Henggeler, Chapman, et al., 2008).

Therapist Variables. Two studies surveyed participant

attitudes towards the patient population before and

after training (Fadden et al., 1997; Morganstern et al.,

2001), and two studies assessed participant attitudes

towards the training received and treatment modality

(i.e., CBT; Maunder et al., 2008; Morganstern et al.,

2001). One study measured pretraining experience

(e.g., number of cases and supervision hours received)

as a potential predictor of post-training competence

(Siqueland et al., 2000), whereas another study mea-

sured pretraining demographics and experience (e.g.,

years of experience and caseload characteristics) and

therapist attitudes towards EBP as a predictor of

adherence, adoption, and implementation of an EBP

(Henggeler, Chapman, et al., 2008).
3

Outcome Measures. Outcome measures included self-

report (Fadden, 1997; Henggeler, Chapman, et al.,

2008; Maunder et al., 2008) or self-report and inde-

pendently rated behavior (Morganstern et al., 2001;

Siqueland et al., 2000). Self-reported outcomes

included declarative knowledge, implementation,

acceptability of treatment, use of treatment, barriers to

use, attitudes towards patient population ⁄ treatment
modality, and adoption. Independently rated behavior

included adherence, skill, and competence. Four studies

used both investigator-created nonstandardized and

standardized psychometrically sound measures (which

were often modified for the purposes of each study;

Henggeler, Chapman, et al., 2008; Maunder et al.,

2008; Morganstern et al., 2001; Siqueland et al., 2000),

and one study used an investigator-created nonstan-

dardized survey (Fadden, 1997).

Summary of Studies. Three studies utilized only self-

report questionnaires to observe the impact of training

on therapist knowledge, attitudes, and behavior. Thera-

pist participants trained in BFT (n = 86) were surveyed

after completing a 39-hour four-phase training

9 months to 3.5 years after completing the training

(Fadden, 1997). No pretraining assessment was com-

pleted. Seventy percent of therapists reported they had

used BFT in their work since training; however, the

average number of families seen was 1.7. Forty percent

of families were seen by 8% of the trained therapists,

indicating that a small proportion of trainees was seeing

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 17

a large percentage of the families. Therapist variables

influencing the number of families receiving BFT

included therapist location (community vs. inpatient

unit) and the number of therapists trained in each

service area. Little attitudinal change was observed, and

did not predict the number of families seen. In a more

recent study, primary care physicians (n = 25) trained

in CBT (i.e., three- to four-hour workshop and four

follow-up case discussions; Maunder et al., 2008)

reported high satisfaction with the training, as well as

an increase in the use of CBT techniques with patients.

Declarative knowledge scores increased after training

(Maunder et al., 2008) to proficiency levels.

Mental health therapists (n = 432) received a one-

day workshop on CM with adolescent substance abus-

ers (Henggeler, Chapman, et al., 2008). Although

supervision was not provided, important organizational

and therapist variables were identified. Fifty-eight per-

cent of workshop attendees attempted to use the treat-

ment post-training and therapist variables predicted

adoption of the treatment: More educated and more

experienced therapists who held favorable attitudes

towards manualized therapy and lacked expertise in the

treatment were more likely to implement the treat-

ment. Self-reported adherence was also investigated.

Therapist variables predicted self-reported adherence:

Adherence was higher for younger therapists certified

in addictions, with larger caseloads, higher numbers of

youth on their caseloads, with and who held more

positive views regarding treatment manuals. Organiza-

tional characteristics, specifically, organizational motiva-

tional readiness to change, and greater organizational

training exposure and utilization were associated with

increased adherence to the treatment modality.

More methodologically rigorous studies included

independent ratings of skill ⁄ competence. Two studies
investigated differing treatment modalities for substance

abuse. One study conducted training (manual and four-

day workshops) in three different treatment modali-

ties—CT, DP, and DC (n = 62; Siqueland et al.,

2000)—and included supervision focusing on feedback

from taped sessions. General experience as a therapist

and specific experience in treating patients in CT had a

positive impact on change in competence post-training,

whereas those having had more previous supervision

showed less change in competence after training.

The most rigorous study included random assign-

ment and a comparison condition, and investigated

CBT training (�100 hours of didactics and supervision)
on independently rated adherence and skill in substance

abuse counselors (n = 29; Morganstern

et al., 2001).

Participants reported high levels of training satisfaction

and also endorsed high ratings for the utility of CBT as

a treatment. Attitudes towards the conceptualization of

substance abuse changed in the intervention group.

Most participants reached independently rated adher-

ence levels of somewhat to extensively adherent and

independently rated skill levels of poor to good.

Conclusions. One important conclusion is the lack of

consensus on the role of therapist variables on compe-

tence and adherence in cognitive and ⁄ or behavioral
approaches (i.e., BFT, CM, and CT). With regard to

therapist competence post-training, it is unclear

whether or not pretraining competence predicts post-

training competence, and may differ by treatment

modality (e.g., CT). Interestingly, multiple studies

report that therapists with more previous supervision

show less change in competence, perhaps due to more

allegiance to their own conceptualizations. When con-

sidering therapist self-reported adherence to CM, sev-

eral therapist and organizational predictors emerged,

but only one study investigated this question, thus

making it difficult to make any conclusions other than

the importance of future replication and study.

Another conclusion emerges: When three levels of

the SC model are addressed (i.e., training, organiza-

tional, and therapist levels), training in CBT may be

more successful as evidenced by two studies (Maunder

et al., 2008; Morganstern et al., 2001). After training in

CBT, participant outcomes included high satisfaction,

attitudinal change, utilization, increased knowledge,

and rated proficiency in adherence and skill (Maunder

et al., 2008; Morganstern et al., 2001).

Limitations. Study-specific limitations include lack of

pretraining measurement of therapist behavior and

inconsistency in survey administration (Fadden, 1997),

low response rates (Maunder et al., 2008), and small

sample sizes (Maunder et al., 2008; Morganstern et al.,

2001; Siqueland et al., 2000). The only study that

utilized a control condition did not compare the

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 18

control group with the intervention group on rated

skillfulness or adherence in delivery of CBT, thus

reducing the internal validity of the study (Morganstern

et al., 2001).

Training, Organizational Support, and Client Variables

Description of Studies. Four studies focused on train-

ing, organizational support, and client variables (see

Table 7). The EBP training included (a) group CBT for

adult substance abuse (Watkins, Osilla, Hepner, Sandres,

& Thompson, 2008), (b) MI for substance abuse (Scho-

ener, Madeja, Henderson, Ondersma, & Janisse, 2006),

(c) TLDP for adults (Bein et al., 2000), and (d) MST for

adolescent substance abuse (Henggeler, Sheidow,

Cunningham, Donohue, & Ford, 2008). Three studies

used a nonrandomized, convenience-sample, pre–post,

quasi-experimental design (Bein et al., 2000; Schoener

et al., 2006), one study did not include pretraining mea-

sures (included a comparison group for client outcomes;

Watkins et al., 2008), and one study used a randomized

design with a comparison group (Henggeler, Sheidow,

et al., 2008). Sample sizes ranged from 5 to 30 partici-

pants. Educational level ranged from bachelor to post-

graduate level (i.e., PhD or MD), and participants

included community mental health therapists, psycholo-

gists, physicians, and substance abuse counselors.

Training Method and Content. All studies included
passive learning (e.g., didactic presentation), whereas

two included active learning strategies (e.g., practice

with feedback; Henggeler, Sheidow, et al., 2008;

Schoener et al., 2006). One study did not include any

active training strategies (Bein et al., 2000), whereas

another did not provide enough of a description to

characterize method (Watkins et al., 2008). Training

content included a focus on principles of the treatment

(Bein et al., 2000), a focus on principles and skills acqui-

sition (Schoener et al., 2006), or a focus on session-by-

session instruction (Henggeler, Sheidow, et al., 2008).

One study did not provide an adequate description of

training content (Watkins et al., 2008). Training dura-

tion varied from a two-day workshop and eight supervi-

sions (Schoener et al., 2006) to 100 hours of seminar

and supervision (Bein et al., 2000). Two studies used a

manual to supplement the didactic presentation (Bein

et al., 2000; Henggeler, Sheidow, et al., 2008).

Organizational Support. All studies included ongoing

supervision as part of the training intervention, ranging

from eight supervision sessions (Schoener et al., 2006)

to 100 hours of supervision (Bein et al., 2000). In one

study, the level of organizational support was manipu-

lated, where following a workshop, therapists received

standard consultation or intensive quality assurance

consisting of weekly consultation and quarterly booster

training (Henggeler, Sheidow, et al., 2008).

Client Variables. Studies measured client in-session

statements or treatment outcome to indicate whether

or not therapist training effected client behavior

change. In one study, client change talk was used as a

proxy for treatment outcome (Schoener et al., 2006).

One study included client ratings of therapist adherence

as the primary outcome measure (Henggeler, Sheidow,

et al., 2008).

Outcome Measures. The outcome measures for two

studies included self-report and independently rated

behavior (Bein et al., 2000; Watkins et al., 2008),

whereas two studies included only independently rated

behavior as the outcome measure (Henggeler,

Sheidow, et al., 2008; Schoener et al., 2006). Self-

reported outcomes included client psychopathology

(Bein et al., 2000; Watkins et al., 2008). Independently

rated behavior included adherence (Henggeler, Shei-

dow, et al., 2008), competence (Watkins et al., 2008),

and skill (Bein et al., 2000; Schoener et al., 2006). All

four studies used a standardized psychometrically sound

measure (albeit adapted for each study; Bein et al.,

2000; Henggeler, Sheidow, et al., 2008; Schoener

et al., 2006; Watkins et al., 2008).

Summary of Studies. Clinicians (n = 30) were trained

in MST through a manual and workshop and then

were randomized to a workshop-only condition (access

to materials and phone access to an MST expert as

needed) or an intensive supervision condition (weekly

supervision and consultation, booster training quarterly,

improvement of skills incorporated into clinician devel-

opment plans; Henggeler, Sheidow, et al., 2008).

Supervisors were also evaluated to augment therapists’

use of the intervention. Significant differences between

youth-reported clinician adherence to MST techniques

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 19

T
a
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v
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ls

.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 20

emerged when comparing the two conditions after

training. Both youth-reported adherence (75%) and

caregiver-reported adherence (65%) were higher in

the intensive supervision condition. However, the

caregiver-reported adherence effect was not sustained

at follow-up.

Schoener et al. (2006) investigated the effect of

therapist behavior on client change talk following

training (i.e., independently coded from actual therapy

sessions). Community clinicians (n = 10) were trained

in MI through a two-day workshop and eight supervi-

sion sessions for patients with co-occurring substance

abuse and Axis I disorders. After training, indepen-

dently rated behavior suggested that therapists showed

improved MI skill (empathy, MI-spirit, and reflective

listening) and decreased MI-inconsistent behavior

(closed-ended questions and advising without permis-

sion). Additionally, change in therapist MI skill was

accompanied by a change in client self-talk, a variable

associated with subsequent client behavior change.

However, therapists exhibited lower average MI profi-

ciency in comparison with past MI training trials and

did not reach the recommended proficiency level (5 ⁄ 7
Likert; Miller, 2000). Organizational and ⁄ or therapist
variables influenced training response: Therapists who

had been employed in the same agencies for long peri-

ods of time appeared less capable of benefitting from

training for certain MI skills (i.e., open-ended ques-

tioning). Poststudy interviews provided contextual

environmental information that may help explain these

results: Many therapists reported high levels of anxiety

and a number of systemic and structural challenges to

the application of newly acquired MI skills.
7

Two studies investigated therapist training effects on

client treatment outcome in differing therapy modali-

ties. Substance abuse counselors (n = 5) received two

days of didactic training, ongoing weekly supervision,

and a one-day booster training for group CBT for

depression (Watkins et al., 2008). Counselors treated

61 clients and 35% of the sessions were coded for

adherence and competence. Therapists demonstrated

91% adherence (two or three on a 0–3 scale) across

coded sessions. Additionally, therapists delivered com-

petent CBT with a mean competence rating of 4.3 (of

6). Client depression scores improved with treatment

when compared with a comparison group. In another

treatment modality, clinicians (n = 16) received 50

weekly two-hour seminars and supervision in TLDP

for adult psychopathology. Training in TLDP did not

improve patient outcome at post-training or at one-

year follow-up. Follow-up analyses examined therapist

proficiency at TLDP by independently rating two cases

for each therapist. Only 9 of the 32 training cases

(28%) were judged to have been conducted with a

minimal level of skill (Bein et al., 2000).

Conclusions. If therapists reach proficient levels in

adherence ⁄ competence, and have adequate consultation
and organizational support, it is possible to elicit behav-

ior change in client outcomes. In three of the four

studies (Bein et al., 2000; Henggeler, Sheidow, et al.,

2008; Schoener et al., 2006), therapists did not reach

proficient levels in adherence and ⁄ or competence. This
is concerning, particularly given that appropriate super-

vision and training seems to have been provided, par-

ticularly in the MST and TLDP studies. Given the

striking amount of intervention, specifically targeting

problem-solving barriers to MST implementation, these

results are surprising. Similarly, in the study of TLDP,

an adequate dosage of supervision was provided (one

year of supervision—approximately 100 hours). How-

ever, this study only included one training case, which

may not have been sufficient for gaining mastery over

the skills needed to administer TLDP.

The importance of examining contextual variables

at the level of therapist and organizational support

becomes clear. What was it about these therapists that

made it difficult for them to reach proficiency levels

in MI, MST, or TLDP? One possibility may be their

lack of experience. In previous studies of MI, thera-

pist participants had prior experience in the treatment

modality, suggesting that training further consolidated

this experience (e.g., Miller & Mount, 2001; Miller

et al., 2004). Similarly, in the study that reported

positive client outcomes, therapists endorsed past

experience with the treatment and high motivation to

learn (Watkins et al., 2008). Perhaps therapists who

are naı̈ve to the fundamental principles of a treatment

may require further training and follow-up supervi-

sion. Other therapist variables may also be important,

such as allegiance to current therapeutic approaches

and commitment to learning a new treatment

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 21

modality. In one study, follow-up interviews sug-

gested that systemic and contextual issues made it dif-

ficult to implement an EBP, highlighting the

importance of organizational variables.

Limitations. Study-specific limitations include the

small sample size of all the studies and the manner in

which client outcome was operationalized—as a change

in either self-talk (Schoener et al., 2006) or self-report

rather than structured interviews (Bein et al., 2000;

Watkins et al., 2008). Additionally, independently rated

adherence from a youth and caregiver perspective only,

without the inclusion of an expert perspective, was a

weakness (Henggeler, Sheidow, et al., 2008).

Training, Organizational Support, Therapist, and Client

Variables

Description of Studies. Few studies focused on all lev-

els of the SC model (see Table 8). The EBP training

included (a) TLDP for adults (Henry, Schacht, Strupp,

Butler, & Binder, 1993), (b) MI for addictions (Miller

et al., 2004), and (c) a comparison of supportive mental

health counseling, MI, and group CBT for substance

abuse and comorbid depression (Hunter, Watkins,

Wenzel, Gilmore, Sheehe, & Griffin, 2005). One study

used a nonrandomized, convenience-sample, pre–post,

quasi-experimental design (Henry, Schacht, et al.,

1993), whereas another study included a comparison

group (Hunter et al., 2005). The most rigorous study

included randomization to one of five groups and a

comparison group (Miller et al., 2004). Study sample

sizes ranged from 13 to 140 participants. Educational

level ranged from bachelor to postgraduate level (i.e.,

PhD or MD), and participants included community

mental health therapists, licensed substance abuse coun-

selors, and medical professionals.

Training Method and Content. All studies included
both passive learning (e.g., didactic presentation) and

two included active learning strategies (e.g., interactive

educational meetings, Hunter et al., 2005; and feedback

and coaching, Miller et al., 2004). Training content

included a focus on principles of the treatment for all

three studies. Training duration varied from two days

(Miller et al., 2004) to 100 hours (Henry, Schacht,

et al., 1993). Two studies used a manual to supplement Ta
b
le

8
.

S
y
st
e
m
s-
co
n
te
x
tu
a
l
le
v
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l:
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ra
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,
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rg
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iz

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ti
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l,

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ie

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t,

a
n
d
th
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ra
p
is
t
v
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ri
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b
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s
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e
fe
re
n
ce
s
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S
T
P
a
ti
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t
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h
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ra
p
is
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ct
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le
m
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u
tc
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CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 22

the didactic presentation (Henry, Schacht, et al., 1993;

Miller et al., 2004).

Organizational Support. Two studies (Henry, Schacht,

et al., 1993; Hunter et al., 2005) included ongoing

supervision as part of the training intervention, ranging

from biweekly supervision (Hunter et al., 2005) to

100 hours of supervision and a training case (Henry,

Schacht, et al., 1993). One study included two training

enhancement procedures (ongoing feedback and coach-

ing), which were considered to be most in line with

organizational support given their similarity to supervi-

sion

(Miller et al., 2004).

Therapist Variables. Hunter et al. (2005) surveyed

participant attitudes towards mental illness, job satisfac-

tion, and job morale pre- and post-training (Hunter

et al., 2005); Miller et al. (2004) measured pretraining

characteristics, history of substance abuse, self-esteem,

and interpersonal style as predictors of post-training

competence and client change outcome; and Henry,

Schacht, et al. (1993) measured pretraining demograph-

ics and experience (e.g., years of experience and prior

competence) as mediators of therapists’ response to

training.
3

Client Variables. Client characteristics were examined

as mediators of therapist training response in two stud-

ies (Henry, Schacht, et al., 1993; Hunter et al., 2005),

whereas in Miller et al. (2004), client change talk was

used as a proxy for treatment outcome.

Outcome Measures. The outcome measures included

self-report only (Hunter et al., 2005) or self-report and

independently rated behavior (Henry, Schacht, et al.,

1993; Miller et al., 2004). Self-reported outcomes

included knowledge, attitudes about mental health, job

satisfaction, and job morale. Independently rated

behavior included interviewing style, adherence, inter-

personal processes (Henry, Schacht, et al., 1993), and

MI competence (e.g., MI-consistent behaviors, reflec-

tion:question ratio; Miller et al., 2004). One study used

an investigator-created nonstandardized survey measure

(Hunter et al., 2005), whereas two studies utilized stan-

dardized psychometrically sound measures (Henry,

Schacht, et al., 1993; Miller et al., 2004).

Summary of Studies. One study used only self-report

questionnaires to assess the effect of training on thera-

pist knowledge, attitudes, and behavior. Mental health

counselors (n = 13) trained in supportive mental health

counseling and MI for addictions received 12 weeks of

training (2.5 hours each) and biweekly supervision

(Hunter et al., 2005). Note that a subset of counselors

received 20 hours of training in group CBT for

depression. Client characteristics were collected.

Although the study included a comparison group, only

descriptive analyses were completed due to high staff

attrition (50%) in both the intervention and compari-

son site and the resulting very small sample. Declarative

knowledge about substance abuse and co-occurring dis-

orders increased in the intervention site after training

(M = 83%) and was sustained over time (M = 81%) in

comparison with the control site (post-training

M = 68%; follow-up M = 74%). Attitudes became

more positive at the intervention site at post-training

and follow-up. Client characteristics were reported but

not analyzed.

More methodologically rigorous studies included

the effect of therapist training on independent ratings

of adherence and competence. TLDP training con-

sisted of 50 weekly two-hour in-person seminar and

supervision sessions including didactic presentations of

principles, a manual, and treatment of a training case

with supervision (n = 16; Henry, Schacht, et al.,

1993). Individual differences were quantified amongst

the two trainers—the better trainer was directive and

specific regarding the learning task, focused on thera-

pist rather than patient dynamics, and provided posi-

tive reinforcement regarding specific therapist action.

Therapist variables influenced training response—

therapists with more prior supervision were less

adherent, while therapists with certain interpersonal

styles showed greatest technical adherence. Client

variables also influenced training response—therapists

showed greater improvements in skill when working

with patients traditionally deemed less suitable for

short-term techniques.

The gold standard for studies conducted in this liter-

ature includes random assignment and a comparison

condition (Miller et al., 2004). Therapists were ran-

domized to one of five training conditions (n = 140):

(a) two-day workshop only, (b) two-day workshop

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 23

plus feedback on tapes, (c) two-day workshop plus six

individual coaching sessions, (d) two-day workshop

plus coaching and feedback, and (e) a control condi-

tion—self-guided learning (therapist manual and train-

ing videotapes). Therapist variables did not predict

therapist training response. All four intervention condi-

tions (i.e., a–d) produced increased competence at

post-training. At four-month follow-up, the work-

shop-only group lost their gains and returned near the

levels of the comparison group. Only the groups

receiving feedback and/or coaching reached profi-

ciency levels in global MI-spirit (five of a seven-point

Likert scale) and MI-consistent responses (95%) at post-

training and follow-up. Client response only improved

in the most intensive training (workshop, coaching,

and feedback). The biggest effect in training was not

an increase in therapist MI-consistent responses but a

reduction in MI-inconsistent responses.

Conclusions. Intervening at all four levels of the SC

model may be the key to producing effective out-

comes. Therapist variables are influenced by training

when measured as outcome variables. For example,

attitudes and job satisfaction can be improved following

training (Hunter et al., 2005). However, when examin-

ing therapist variables as predictor variables or mediat-

ing variables, contradictory evidence exists. One study

found that therapist variables did influence response to

training (Henry, Schacht, et al., 1993), while the most

rigorous study found no effect of therapist variables

(Miller et al., 2004).

Support for client variables as predictors of training

and outcome variables emerges. When examined as a

predictor of training response, it appears that therapist

training improved when the client population was

more difficult and more educated. There may be a

complex relationship with supervision present here—

perhaps more difficult clients call for more supervision

time. In terms of outcomes, clients improved when

therapists received the most intensive training interven-

tion (Miller et al., 2004).

An interesting and important finding implicates the

importance of training and organizational factors.

Training style produced differential outcomes in thera-

pist behavior in one study, suggesting that certain

methods of training are preferential. Further, training

method emerged as an important variable when manip-

ulated—the only training that produced proficiency in

MI at long-term follow-up included active learning

strategies (i.e., coaching and ⁄ or feedback). The only
training to elicit actual client change was the one that

included the highest dosage of active learning strate-

gies—feedback and coaching. This suggests the impor-

tance of studying training method (e.g., active versus

passive) in future studies.

An issue that emerges from these studies is the iden-

tification of the barriers and challenges faced in com-

munity research. Hunter et al. (2005) published a

follow-up article documenting barriers to DI research,

including recruitment falling behind schedule, staff

attrition, a comparison site instituting new practices

that duplicated the intervention site, and the increase

in patients already receiving mental health treatment

when presenting to the intervention site (Wenzel,

Ebener, Hunter, Watkins, & Gilmore, 2005). Follow-

up client outcome research was not published due to

difficulties in recruitment, although the intervention

site continues to use the treatment in the community

(S. Hunter, personal communication). These barriers

make it difficult to disseminate and implement EBP in

the community.

Limitations. Study-specific limitations include very

high staff attrition that precluded the use of statistical

analyses and difficulty in recruitment for client treat-

ment outcome investigations (Hunter et al., 2005).

None of these studies measured client outcome using

the preferred technique of semi-structured interviews.

GENERAL DISCUSSION

The most definitive conclusion (see Table 9) is that

training influences therapist knowledge, attitudes, and

perceived behavior. Therapist behavior change (e.g.,

adherence and skill) can occur following training, but a

number of conditions must be met. First, it is necessary

for training to address most, if not all, levels of the SC

model (the therapist is nested within a context and

organizational, therapist, and client variables all interact

transactionally with training to influence skillful imple-

mentation). Additionally, training must utilize active

learning strategies to influence therapist behavior

change.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 24

Knowledge acquisition follows training. Both per-

ceived and declarative knowledge increase after receiv-

ing training in EBP, and this finding appears to hold

across treatment modalities and therapists. Therapist

attitudes also change and this change is maintained over

time following training. Importantly, training engen-

ders self-reported behavior change that does not always

match actual behavior change—pointing to the impor-

tance of including independently rated behavior in all

future assessments of EBP training. The mismatch in

perception and actual behavior is highly problematic

and has important implications because clinicians may

believe they are implementing a treatment with fidelity

and skill (Miller & Mount, 2001). Additionally, this has

deleterious consequences for client treatment outcome

given the finding that better outcomes are observed in

clients when a treatment is applied with fidelity (Elliot

& Mihalic, 2004).

A most surprising finding is the lack of proficiency in

treatment adherence, competence, and skill reached by

therapists trained in the current gold standard (i.e.,

workshop, manual, and clinical supervision; Sholomskas

et al., 2005). Multiple studies across differing treatments

found that training (workshop, manual, and supervision)

was not enough to produce proficient change in thera-

pist adherence, competence, and skill. This is

concerning, considering the importance of these

constructs in administering a treatment with fidelity

(Perpepletchikova & Kazdin, 2005). In turn, therapists

were not necessarily able to engender client change. If

therapists lack proficiency in a treatment, perhaps linked

to inadequate training, then it is unlikely that clients will

experience the benefits associated with a particular EBP.

Although proficiency in therapist behavior was not

often achieved, when studies intervened at the levels of

training, organizational, and therapist variables, thera-

pists did reach proficiency levels in adherence, compe-

tence, and skill, particularly in CBT. Similarly, when

all levels of the SC model (i.e., Miller et al., 2004)

were addressed and active learning was used, both ther-

apist and client change occurred. As posited by the SC

model, therapist, client, and organizational variables

interplay and influence the effects of training. To

achieve client change, it is necessary for therapists to

reach proficiency levels in knowledge, adherence,

competence, and skill. This perspective speaks to the

importance of training therapists to criteria prior to

implementing treatments.

What occurs within training that may produce dif-

ferential outcomes? An intriguing finding highlights the

quality (i.e., content and method) of training. Active

learning appears to be most effective—the only study

to evidence client change included two active learning

processes (i.e., coaching and feedback).

Most aspects of the SC model were understudied.

An SC perspective dictates consideration of the organi-

zational forces and factors that create the climate for

successful DI efforts. Research that measures ways to

understand organizations (see Organizational Social

Context; Glisson et al., 2008) will inform needed orga-

nizational change for DI efforts. Zazzali et al. (2008)

interviewed administrators of state organizations where

an EBP had been implemented and found that organi-

zational characteristics (e.g., interest in EBP and avail-

able resources) and organizational structures influenced

the adoption and implementation of EBP. Similarly,

low workplace support predicted less utilization of the

Triple P program following training in service

providers (Sanders, Prinz, & Shapiro, 2009). Further

examination of the organizational context in the imple-

mentation of EBP is needed.

Table 9. General conclusions

Across treatment modalities and therapists, perceived and declarative
knowledge increase following training in EBP.

Across treatment modalities and therapists, attitudes improve after
training in EBP and this is maintained at follow-up.

Across treatment modalities and therapists, perceived (self-reported)
therapist behavior change does not match actual behavior change.

Generally speaking, therapists trained in the current format (i.e.,
workshop, manual, and brief supervision) do not reach proficiency in
treatment adherence, competence, and skill.

There is insufficient information about how therapist variables, client
characteristics, and organizational variables influence therapist
behavior following training (adherence, competence, and skill).

Generally speaking, therapist training in EBP does not currently
engender improved client outcomes.

The quality of training is important to engender client change: Active
learning during training is integral to influence both therapist and

client change.

Provisional evidence suggests that when addressing all levels of the
systems-contextual model, therapists reach proficiency levels in
adherence, competence, and skill, particularly in CBT, and in turn
influence client change.

Note. EBP, evidence-based practice.

TRAINING IN EVIDENCE-BASED PRACTICE: A REVIEW • BEIDAS & KENDALL 25

The incomplete literature leaves an absence of

conclusions regarding therapist variables. Consistent

measurement is a needed first step. One measure of ther-

apist attitudes, the Evidence Based Practice Attitude

Scale (EBPAS; see Aarons, 2004), provides a beginning

and may help to identify those therapist variables associ-

ated with adherence to and competence with EBP.

Client characteristics were rarely investigated,

despite the consensus that they are probably important.

The influence of client variables cannot be answered

adequately at this time. Future research needs to

include measures of client risk, resiliency, and symptom

severity. Importantly, future research should occur in

tandem with RCTs as such a step would permit exam-

ining whether variations in therapist training engender

client change.

Future Directions

Future DI research will benefit from addressing organi-

zational, therapist, and client variables to demonstrate

how these important contextual factors interact with

training. RCTs with adequate samples and standardized

measures, regardless of the EBP being studied, are

encouraged. Investigations are needed to assess whether

training on one EBP generalizes to training on other

EBPs, and studies are needed to evaluate whether uni-

form guidelines can be created regarding best practices

for training across treatment modalities.

The following questions regarding best practices for

training require research:

1. What elements (e.g., manual, workshop, and super-

vision) should be included in training?

2. What is the optimal duration of training?

3. What is the optimal focus of training (i.e., general

principles of a treatment or session by session)?

4. What type of active learning methods should be

included?

5. What role does ‘‘training to criteria’’ play? Should

trainees be certified in a treatment when they reach

prespecified levels of competency (Sanders,

Murphy-Brennan, et al., 2003; Sanders, Tully, et

al., 2003)?

6. How much supervision is needed to achieve thera-

pist behavior change and competent administration

of an EBP?

Based on this review, we make the following rec-

ommendations:

1. Future training efforts focus on active learning and

behavioral rehearsal with less emphasis on didactics.

2. Follow the SC model. Influencing one variable (e.g.,

therapist training) within a system is unlikely to result

in effective implementation without addressing con-

textual factors. It is unlikely that training and DI will

succeed without the understanding that therapists

function within a context and that multiple variables

(i.e., organizational support, client factors, and thera-

pist factors) affect this context.

3. To assess that actual behavior change is occurring,

future investigations of training must include direct

measures of therapist behavior (e.g., adherence and

skill) in addition to assessments of knowledge and

perceived behavior change.

4. Standardized measurement is necessary to make cross-

study comparisons. For example, a psychometrically

reliable (Moyers, Martin, Manuel, Hendrickson, &

Miller, 2005) system that is treatment specific includes

the Motivational Interviewing Treatment Integrity

scale (MITI; Moyers, Martin, Catley, Harris, & Ah-

luwalia, 2003). Studies of training in MI could use this

measure rather than investigator-created measures.

Additionally, developing measures that can be used

across treatment programs would be useful.

5. The competencies for each treatment program

should be identified so that it is clear what types of

competencies are necessary for each EBP (see Roth

& Pilling, 2008). For instance, for CBT for child

anxiety, active treatment components could be

identified (e.g., exposure and cognitive restructur-

ing), and therapists trained in this treatment should

achieve competencies in these domains.

6. Identifying the barriers to training and utilization of

treatment is important and may be addressed early

in training to problem-solve perceived barriers

(Seng et al., 2006).

7. Supervision is crucial for skillful treatment delivery,

and understanding the role of supervision and its

key features are valuable areas for future research.

Despite the importance of EBP, we know less than

preferred regarding how to best train therapists in EBP.

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V17 N1, MARCH 2010 26

Training efforts in EBP are underway, yet we are not

informed by how best to proceed. If those who under-

take EBP are not adequately trained in EBP implementa-

tion, will a subsequent evaluation of the benefits of EBP

be unwittingly and unfairly compromised? Evaluations

of training methods and variables, within contextual

variables, will be informative. Without such an undertak-

ing, one’s best EBP intentions may go unfulfilled.

NOTES

1. Going forward, EBP will be used as the terminology of

choice, rather than empirically supported treatments

(ESTs), given that it is a less restrictive term and allows for

a consideration of both rigorous research applied with

clinical judgment. However, when studies explicitly refer

to ESTs rather than EBP, it will be noted in the text.

2. Studies were included if they met criteria as an evidence-

based practice by an external review (e.g., National Regis-

try of Evidence Based Programs and Practice; Chambless

& Hollon, 1998; Chambless & Ollendick, 2001). For a

listing of all treatments reviewed, see Table 1.

3. Studies that just included one question on a demographics

questionnaire were not operationalized as measuring thera-

pist variables.

4. To be included in this review, all studies had to include

training as a variable of interest.

5. Note that certain studies distinguished between perceived

knowledge (e.g., perception of knowledge gained) and

declarative knowledge (e.g., direct measure of knowledge

gained), and we reported on this when this distinction was

made.

6. Direct access to the conclusions can be reached by refer-

ring to the General Discussion section.

7. Note that these were not statistically examined.

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Received February 14, 2009; revised June 8, 2009; accepted

June 10, 2009.

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Articl

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Measurement and Evaluation in
Counseling and Developmen

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43(1) 3 –1

5

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DOI: 10.1177/0748175610362237
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Assessment and
Self-Injury: Implications
for Counselo

r

s

Laurie M. Craigen1, Amanda C. Healey2,
Cynthia T. Walley3, Rebekah Byrd1,
and Jennifer Schuster1

Abstract

This article provides readers with an understanding of self-injury assessment. The article begins
with a critical revi

ew

of a number of self-injury assessments. The latter section of the article
introduces a comprehensive two-tiered approach to accurately assessing self-injury. Implications
for counselors related to the assessment of self-injury are also provided.

Keywords

self-injury, assessment, self-injurious behavio

r

Self-injurious behavior is an increasing issue
among adolescents and young adults. Accord-
ing to current research, self-injurious behavior
occurs in 4% to 39% of adolescents in the
general population and the numbers are pre-
dicted to rise, due to various reasons, ranging
from levels and quality of social interactions
with peers to the availability and assimilation
of coping behaviors through access to the
Internet (Briere & Gil, 1998; Favazza, 1996;
Gratz, 2001; Gratz, Conrad, & Roemer, 2002;
Muehlenkamp & Guiterrez, 2004; Nock &
Prinstein, 2005; Ross & Heath, 2002). Statis-
tics on the incidence of self-injury can be
unreliable, underestimating the true incidence
of self-injury. The reality is that many inci-
dents will be dealt with by the individual, in
private, and will never reach the attention of
medical services or mental health profession-
als (McAllister, 2003). Recently, there has
been a surge in the literature related to defin-
ing and explaining the behavior (Gratz, 2006).
Conversely, very little is known about the
assessment of self-injury, and therefore, a gap
exists between understanding the behavior and
implementing focused counseling interventions
and treatment (White Kress, 2003). The

purpose of this article is to provide readers
with knowledge about the difficulties related
to accurately evaluating self-injury and the
history of self-injury assessments, while also
introducing a comprehensive two-tiered
app roach to assessing self-injury, emphasiz-
ing a holistic perspective.

Review of Self-Injury
Assessments
The development of inventories to evaluate
self-injury began in the early 1990s and con-
tinues today. As the conceptualizations and
definitions of self-injury have evolved, so too
has the focus of the assessments tailored for
its evaluation. Although the newer scales appear
to assess the behaviors and attitudes associated

1Old Dominion University, Norfolk, Virginia, USA
2East Tennessee State University, Johnson City,
Tennessee, USA
3Hunter College, New York City, New York, USA

Corresponding Author:
Laurie M. Craigen, PhD, LPC, Old Dominion University,
110 Education Building, Norfolk, VA 23529 USA
Email: lcraigen@odu.edu

4 Measurement and Evaluation in Counseling and Development 43(1)

with self-injury, many have not been through
the rigorous testing necessary to fully evaluate
their efficacy, reliability, and validity. Thus, when
selecting and administering assessments, it is
necessary for counselors to understand the evolv-
ing nature and continuing development of the
instrument they select for evaluating self-injury.
In the following section, a brief overview of
the inventories available for assessing self-
injurious behaviors is provided (see Table 1).

Self-Injury Trauma Scale (SITS)
One of the first inventories to be developed
for the assessment of self-injurious behaviors
is the SITS created by Iwata, Pace, and Kissel
(1990). It was created to evaluate the extent of
tissue damage caused by self-injury. This inven-
tory examines categories including location,
type, number, and severity of the tissue damage
as well as a summary evaluation of severity and
current risk for continued self-injury. SITS
defines its typical use in terms of quantifying
tissue damage directly. It also permits differ-
entiation of self-injury according to topography,
location of the injury on the body, type of injury,
number of injuries, and estimates of severity
through evaluation of the injuries themselves.
Test-retest reliability was reported at r = .68
(Iwata et al., 1990). This assessment was later
used to evaluate self-injury in conjunction
with physical pain as based on the proposition
that the experience and expression of pain is
somehow different among those individuals who
self-injure, therefore leading to the acceptabil-
ity and tolerability of self-injury as a behavior
(Symons & Danov, 2005).

The SITS was later used in a study to
det ermine the effects of a psychopharmacologi-
cal treatment on those with intellectual
disabilities who engaged in self-injury. In this
study, the SITS inventory was found to be reli-
able when used in conjunction with the
Non-Communication Children’s Pain Check-
list–Revised (NCCPC-R) in recognizing and
tracking self-injury from the perspective of an
outside observer—in this case, the parent
(McDonough, Hillery, & Kennedy, 2000). No
specific data were reported related to concurrent

validity beyond the statement that “the mean
NCCPC-R score was 20.1 for time intervals
scored with self-injurious behavior (SIB) and
2.5 for time intervals scored without SIB” (p.
474) as indicated by the SITS. The initial evalu-
ation of the inventor’s efficacy and subsequent
usage found the scale to be a reliable method for
collecting data on surface tissue damage caused
by self-injury. However, the use of this scale
might not be practical for counselors but could
be useful for professionals who intervene with
the physical consequences of self-injury, such as
school nursing staff or medical professionals.

Self-Harm Inventory (SHI)
The SHI was developed by Sansone, Wiederman,
and Sansone (1998) in the context of screen-
ing for Borderline Personality Disorder (BPD).
It was the belief of the instrument developers
that BPD exists on a continuum in which self-
injury is the most severe manifestation of self-
sabotaging behaviors. With regard to the uses
of the SHI, self-harm is defined as the deliber-
ate, direct destruction of body tissue without
conscious suicidal intent but results in injury
severe enough for tissue damage to occur. The
SHI assesses frequency, severity, duration, and
type of self-injurious behavior. The SHI was
found to be highly related to the Diagnostic
Interview for Borderlines (DIB) at a correla-
tion of r = .76 and the Personality Diagnostic
Questionnaire–Revised at r = .71 with regard
to non-psychotic adults (Sansone et al., 1998).

The developers of this inventory also showed
that the SHI was able to predict the diagnosis
of BPD as based on its convergent validity. This
inventory is made up of 22 items that were
selected due to their correlation with the DIB,
and each question begins with the phrase, “Have
you ever on purpose, or intentionally . . . ,” and
respondents were asked to give a “yes” or
“no” answer (Sansone, Songer, Douglas, &
Sellbom, 2006, p. 976). The final score is a
simple summation of the items endorsed by
the client. In developing and testing the mea-
sure, it showed acceptable levels of clinical
accuracy as a measure for the diagnosis of
BPD by assessing a pattern of self-destructive

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6 Measurement and Evaluation in Counseling and Development 43(1)

behaviors (Sansone, Whitecare, Meier, & Murry,
2001). Additionally, the SHI has been shown to
have an acceptable level of internal consistency
with Cronbach’s α = .80 (Sansone et al., 2006).
The developers have stated that the inventory
could help clinicians identify and distinguish
high-lethality and low-lethality self-injury.

Self-Injury Questionnaire (SIQ)
The SIQ was developed by Alexander (1999)
and later evaluated by Santa Mina, Gallop,
and Links (2006). This inventory was created
to evaluate and differentiate the intentions behind
self-injurious behaviors as based on a history
of childhood physical and/or sexual abuse. The
questionnaire was developed using a guiding
definition of self-injury as simply self-destructive
behaviors without the intent to die. Preliminary
findings of the initial research study that used
the SIQ showed good face validity and ade-
quate test-retest reliability in nonclinical
populati ons. Test-rest reliability over a 2-week
period of the behavioral items ranged from
r = .29 to r = 1.0, with a total correlation of
test-retest of r = .91 (Alexander, 1999). A sep-
arate study also revealed similar results for
the SIQ in acute populations, with the addi-
tion of statistical analysis resulting in findings
of high internal consistency of the total scale
(α = .83; 95% Confidence Interval [CI]) and an
adequate Cronbach’s alpha for each subscale
(α = .72 to .77) (Santa Mina et al., 2006).

Convergent validity analyses were also con-
ducted by Santa Mina et al. (2006) between
the SIQ and the Suicide Intent Scale (SIS), the
Beck Depression Inventory II (BDI II), and the
Self-Inflicted Injury Severity Form (SIISF).
The convergent validity between the SIQ and
the scales was reported to be r = –.37 with
regard to the factor of stimulation and the SIS,
r = .23 with regard to the affect regulation
factor of the SIQ as compared to the BDI II,
and r = –.25 with regard to the dissociation
factor of the SIQ and the SIISF. The SIQ is a
30-item self-report instrument conceptualized
from developments in trauma research. This
questionnaire measures the intent of self-injury
through evaluation methods across various

subscales, including body alterations, indirect
self-injury, failure to care for oneself, and
overt self-injury. The SIQ measures the func-
tions, types, and frequency of self-injuring
behaviors in association with a trauma history.
Questions on the SIQ related to agreement to
engagement in behaviors such as tattooing
and the frequency and number of self-injurious
acts related to these behaviors. Following each
behavioral item, if agreement was stated, par-
ticipants were then asked to circle further
items related to the reason contributing to the
behavior. At the time of this publication, this
inventory was yet to be tested in a clinical
setting; therefore, its efficacy with regard to
counseling is unclear and needs to be tested
further.

Deliberate Self-Harm Inventory (DSHI)
The DSHI was developed using an integrated
definition of self-injury in order to help pro-
vide a clear foundation for the instrument, given
that previous assessments lacked consensus
in definition (Gratz, 2001). It is based on the
notion that self-harm is the deliberate, direct
destruction of body tissue without conscious
suicidal intent but results in injury severe enough
for tissue damage to occur (Fliege et al., 2006).
This measure evaluates various features of self-
injury, including frequency, severity, duration,
and types of self-injurious behaviors. The
inventory consists of 17 items that are behav-
iorally based and reliant on self-report. The
DSHI has been found to be reliable and valid
for assessing self-injury and past suicidal
beh aviors (Gratz, 2006; Gratz & Chapman,
2007; Gratz et al., 2002; Lundh, Karim, &
Quilisch, 2007), with adequate internal reliabil-
ity at α = .62 (Fliege et al., 2006) and adequate
test-retest reliability during a 2- to 4-week
period of φ= .68 (p = .001) (Gratz, 2001). In
the study by Gratz (2001), adequate construct,
convergent, and discriminant reliability was
also found. This assessment is in wide use,
and its brief length lends itself to application
in clinical and outpatient settings. This assess-
ment could be useful in mental health as well
as school settings to determine the need,

Craigen et al. 7

immediacy, and level of intervention needed
with regard to a client or student presenting
self-injurious behaviors.

Suicide Attempt Self-Injury
Interview (SASII)
The SASII was designed to evaluate factors
involved in what the authors referred to as
“nonfatal suicide attempts and intentional self-
injury” (Linehan, Comtois, Brown, Heard, &
Wagner, 2006, p. 304). This measure, once
referred to as the Parasuicide History Inven-
tory, was developed to better understand the
methods involved in self-injury—the motiva-
tions, consequences, ritual, and impulsivity of
the act itself. Its validity and reliability mea-
sures were taken using an inpatient population.
In defining suicidal behavior, this instrument
includes all general definitions pertaining to
parasuicide, fatal and nonfatal suicide, and
self-injury without the intent to die. Therefore,
it does provide descriptive details about self-
injurious and suicidal behaviors but does not
differentiate between the two beyond lethality.

This instrument has been used in several
recent studies that confirm its usability and
importance in assessing the multiple aspects
of suicidal and self-injurious behaviors
(Brown, Comtois, & Linehan, 2002; Koons
et al., 2001). Six scales were developed based
on factor analysis with factors loading at .4 or
above. These six scales evaluated lethality of
the method, suicidal and nonsuicidal intent
associated with an episode, communication of
suicide intent prior to the episode, impulsiv-
ity, physical condition, and level of medical
treatment. The assessment showed high inter-
rater reliability at r = .918 for classification of
suicidality components and r = .843 for epi-
sodes classified as a single event versus a
cluster of self-injurious events (Linehan
et al., 2006). The SASII instrument is useful
in that it provides a rating concerning the
lethality of the act in question in terms of
several com ponents including medical and
other con sequences. This instrument can also
be used to evaluate treatment outcomes
through pre- and postassessment.

Self-Injury Implicit Association
Test (SI-IAT)

The SI-IAT was developed by Nock and Banjai
(2007) to assess self-injury in terms of the
identity with and beliefs surrounding the act
itself. This test was based on the Implicit Asso-
ciation Test (IAT), developed by Greenwald,
McGhee, and Schwartz (1998). To understand
the SI-IAT, it is important to know a little bit
about the test from which it was developed.
The IAT is primarily used for evaluating asso-
ciations to nonclinical constructs and beliefs.
The IAT itself has been shown to have strong
reliability, construct validity, and the capacity
to distinguish clinical changes caused by treat-
ment and attempts to mask feelings. The SI-IAT
was created in order to integrate the advantages
of the IAT in an attempt to assess self-injury
without relying on explicit self-report. The
test measures the implicit associations indi-
viduals have concerning self-injury in terms
of identification with the behavior as well as
attitudes about it.

The research studies conducted by Nock
and Banjai (2007) using the SI-IAT showed
that the assessment was able to strongly predict
recent suicidal ideation and suicide attempts,
with good incremental predictive validity ranging
from .74 to .77 with the participating ado-
lescent population. The assessment could
also distinguish between groups of nonsuicidal
ado lescents who had negative beliefs about
self-injury, adolescents with suicidal ideations
who showed some positive identification, and
adolescents who had attempted suicide while
having strong identification with self-injurious
behaviors. Because of the interpretive nature
of this assessment, it would be important for
counselors to use this in conjunction with mul-
tiple informal assessment techniques to evaluate
the client’s perceptions with regard to his or
her statements. This would help avoid coun-
selor bias in determining the client’s level of
identification with the behaviors. This assess-
ment is also helpful in evaluating how useful the
client views his or her self-injurious behav-
iors in managing symptomology. The level at
which a client integrates self-injury into his or

8 Measurement and Evaluation in Counseling and Development 43(1)

her identity and views self-injury as assistive
to his or her functioning could drastically affect
the approach and interventions the counselor
ultimately decides to use in the process of
treatment. For example, if the client views
self-injury as an effective coping strategy to
reduce stress, the counselor and client could
explore alternative stress-reduction strategies
in counseling sessions.

Self-Injurious Thoughts and
Behaviors Interview (SITBI)
The SITBI was developed by Nock, Holmberg,
Photos, and Michel (2007) as a 169-item
str uctured interview that assesses the pres-
ence, frequency, severity, age-of-onset, and
general characteristics associated with the
thoughts and behaviors of suicidal ideations
and suicide attempts. The SITBI assumes that,
by definition, self-injury does not include the
intent to die and thus differentiates self-injury
from suicidal intent and action. In assessing the
strengths of the interview as an assessment
tool, the authors found it to have strong inter-
rater reliability (Nock et al., 2007), good
test-retest reliability (average k = .70) after 6
months, good construct validity in relation to
suicide measures and suicide attempts (k =
.65), and concurrent validity with measures of
suicidal ideations and gestures. However, it
did have weak reliability in assessing suicide
gestures and plans. Predictive validity for sui-
cidal ideation or future self-injury was not
addressed in the study conducted by Nock et
al. (2007). It is the belief of the authors that
the interview could be used easily in a variety
of clinical settings to get an overview of current
and recent self-injurious behaviors; however,
because of the length of the assessment, there
are time constraints to consider with regard to
the pra cticality of its use.

The self-injury assessment tools that have
been developed over recent years have clear
strengths and weaknesses. For counselors, it is
important to consider the population you are
using before selecting a particular self-injury
assessment tool as well as the setting in which
you will be implementing it. Also, it is critical

to realize that the aforementioned formal assess-
ments are only one piece of the assessment
process. Counselors should never use these
measures in isolation for determining the course
of treatment, outcomes, or need for intervention.
The following section outlines a recommended
approach for assessing self-injury and using
formal assessments in conjunction with addi-
tional evaluation methods.

Comprehensive Assessment
Approach
The need for a comprehensive and multilevel
approach to the assessment and evaluation of
self-injury is clear because of the multifaceted
nature of self-injury. The following section out-
lines a two-tiered process of assessing self-injury.
This process includes the use of both formal and
informal assessment procedures (see Figure 1).

Formal Assessment
The first step in this integrated approach
inv olves the formal assessment of self-injury
(as introduced above) as well as other possi-
bly related concerns, such as depression,
traumatic history, or anxiety. These mental
health concerns necessitate mentioning
because of independent empirical indications
of association with self-injurious behaviors
(Conaghan & Davidson, 2002; Herpertz, Sass,
& Favazza, 1997; Klonsky & Olino, 2008;
Sansone, Chu, & Wiederman, 2007; Sansone
& Levitt, 2002). Overall, formal assessment
measures allow for more accurate diagnoses
and appropriate evaluation and enhance the
formulation of an informed treatment plan.

Self-Injury assessment measures. Many self-
injury assessment tools are available for
con sideration during the implementation of a
formal assessment process as previously pre-
sented (see Table 1). Selecting an appropriate
tool based on population, validity, and reli-
ability is necessary in treating self-injurious
behavior.

Additional formal assessments. Self-injury
rarely occurs in isolation. As stated previously,
many mental health disorders coexist with

Craigen et al. 9

self-injury. Thus, a combination of formal
assessments is fundamental, as it is imperative
to examine the intent behind each act of self-
injury to carefully evaluate which elements of
concern or distress are present for each unique
individual. Because of the complex nature of
self-injury, the more accurate the evaluation,
the better suited and successful the treatment
will be (White Kress, 2003). Thus, it would

behoove counselors to also use standardized
assessments that evaluate areas such as (but
not limited to) suicide, trauma, depression,
anxiety, and eating disorders. The following
are examples of assessments that could address
these indicators. Although this list is not com-
prehensive, other assessments may be selected
and should be matched to the unique needs of
the client:

Self-Injury
Assessment

• Self-Injury Assessment/Inventory

• Suicidality Protocol/Inventory

• Trauma Inventory

• Beck Depression Inventory

Anxiety Scales

Tier One: Formal Assessment

Tier Two: Informal Assessment (all are ongoing):
Formal Assessment

Background

Familial History

Peer Support

Social Support

Negative/Positive
Influences

Emotional Capacity

Verbal Ability to
Express Emotions

Coping Strategies

In Combination withIn Combination with

Figure 1. Two-tier model of assessment

10 Measurement and Evaluation in Counseling and Development 43(1)

• Suicidality Protocol/Inventories: that
is, Inventory of Suicide Orientation-30,
Beck Suicide Inventory, Reasons for
Living Inventory, Hopelessness Scale,
Scale for Suicide Ideation, Suicide
Probability Scale, Suicide Ideation
Questionnaire, and Suicide Probabil-
ity Scale

• Trauma Inventories: that is, Early
Trauma Inventory, Trauma Coping
Inventory, Trauma Symptom Inven-
tory, Trauma Assessment Inventories

• Depression Inventories: that is,
Inv entory of Depressive Symtoma-
tology, BDI, Children’s Depression
Inventory, Major Depression Inven-
tory, Inventory of Depression and
Anxiety Symptoms, Zung Self-Rating
Dep ression Scale

• Anxiety Inventories: that is, Beck
Anxiety Inventory, Spielberger State-
Trait Anxiety Scales, Anxiety Status
Inventory

• Eating Disorder Inventories: that is,
Eating Disorders Inventories, Eating
Attitudes Test, Eating Disorder Exa-
mination, and additional measures
sui ted for the particular client

The aforementioned formal assessments vary
according to reliability and validity. Thus, prior
to selecting a measure, it is important to exa-
mine its strengths as well as the population
being served.

Informal Assessment
The second step in this approach involves
using informal assessment measures. Infor-
mal assessment techniques are subjective and
provide counselors with additional tools for
understanding clients (Neukrug & Fawcett,
2005). The majority of informal assessments
are used in a formative evaluative manner, rather
than through a pretreatment or posttreatment
(summative) evaluation. Informal assessment
techniques combined with formal assessments
allow the clinician to gain a comprehensive,
holistic, and in-depth understanding of the

client and his or her presenting concerns. For
example, gaining an understanding of past and
current familial and relational connections as
well as relational conflicts could lead to greater
insight into the client’s reasoning for his or
her self-injurious behaviors and the structure
of his or her current support network. With all
informal assessment techniques, it is neces-
sary to consistently be aware of cultural context
and how this could be a factor for each client.
Although many techniques can be used to con-
duct informal assessments, only those most
pertinent to the treatment of self-injurious behav-
iors are addressed in this section.

Intakes. Many informal assessment measures
exist and should be used during intake and
also throughout the treatment process for each
individual. At intake, it is important to add a
section or line dedicated to self-injury. This is
an area that is often left off of intakes and is
important in the initial assessment. For exam-
ple, “Have you ever intentionally hurt yourself
for any reason?”

Interviews. Parent and teacher interviews are
a great tool to access valuable information
about your client and his or her experiences
with self-injury. Although many individuals go
to great lengths to hide their self-injury from
parents and teachers, valuable information
can be garnered from speaking with these
individuals, as they may play an important
role in the client’s self-injury and might also
serve as an ally for the client as he or she
explores issues related to his or her behaviors
in counseling. Some questions that might
garner useful treatment information include
the following: “Is the client’s behavior consis-
tent at home and school?” “Does the client
engage in isolative behaviors?” “How does the
client normally express his or her feelings or
needs?” “What type of internalizing or exter-
nalizing behaviors are the parents or teachers
aware of in your client?”

Observations. Observations are an important
assessment tool, providing counselors with an
additional mechanism for understanding the
client (Neukrug & Fawcett, 2005). Although
not all clients who self-injure present in the
same way, there may be consistent behaviors,

Craigen et al. 11

appearances, or nuances that could provide
counselors with helpful information to sup-
plement their understanding of the client. For
example, a client who self-injures may often-
times wear clothes that hide his or her injuries
or have many unexplained cuts, scars, or burns
(White Kress, Gibson, & Reynolds, 2004).
Additionally, clients may avoid conversations
about self-injury or deny their personal expe-
riences with self-injury.

Background information. Acquiring back-
gro und information is a vital aspect of self-
injury assessment and can potentially provide
the counselor with valuable information about
the contributing factors related to the client’s
self-injurious behavior. When obtaining back-
ground information, it is necessary to focus
on all aspects of the individual and not limit
the assessment to the behavior itself. This knowl-
edge provides counselors with valuable
information about what lies beneath the sur-
face of the wounds, a focus of treatment that
has been ignored in the past (Craigen &
Foster, 2009; Walsh, 2006).

Familial history is one aspect of background
information that is often overlooked. Gather-
ing information about an individual’s family
history avoids pathologizing the behavior and
views the presenting behaviors through more
of a systemic lens. Seeking to understand all
contributing factors such as a client’s per-
spectives and experiences regarding his or her
family might not have been considered in the
past; however, it is necessary (McAllister, 2003;
Selekman, 2002). For example, the counselor
may ask, “Who do you talk to in your family
about your feelings?” “How does your family
typically deal with their emotions?” “What
feelings do you have for different members of
your family?” or “What events in your past
family history have affected you negatively?”

In addition to familial information, it is also
important to discuss with the client his or her
peer and social supports (Walsh, 2006). This
is particularly relevant in the adolescent popu-
lation because at this developmental milestone,
peer supports are highly valued. For example,
counselors may say, “Tell me about your
friends.” Or they may ask, “When you are

upset, do you typically talk with your friends?”
“Do your friends know about your self-injurious
behavior?” Other factors that affect the indivi-
dual and need to be assessed are negative
or positive influences that could facilitate
self-injury. These could include Internet sites
ded icated to perpetuating self-injurious behav-
ior, friends who self-injure, and/or media role-
models who self-injure or have self-injured.

Emotional capacity. Evaluating the emotional
capacity of the individual using informal
ass essment techniques is an essential process
in developing effective treatment interven-
tions and conceptualizing the issues related to
the self-injurious behaviors. Examining an indi-
vidual’s ability to outwardly express and
understand his or her feelings involves an
ongoing process of assessment, evaluation,
and treatment with clients who self-injure.
One’s ability to express emotions is a concern
for many but particularly those who self-injure.
Since this is the case, it may be important to
ask clients, “If your wounds could speak,
what would they say about you?” (Levenkron,
1998). Additionally, basic questions that assess
one’s feelings voc abulary can also be benefi-
cial in the informal assessment process.

Coping strategies. In addition to assessing
the emotional capacity of clients who self-injure,
coping strategies can also be assessed by using
informal assessment techniques and can be
incorporated in any treatment approach for
those who self-injure. For example, it may be
important to ask clients, “What do you do
when you feel angry, anxious, or upset?” or
“What function does self-injury serve for you?”
These two questions allow the counselor to
examine how and to what extent that self-injury
serves as a maladaptive coping strategy for
clients presenting with self-injurious behaviors.

Typically, the use of self-injury is seen as an
effective method for dealing with overwhelm-
ing emotions associated with traumatic memories
or other issues occurring in the client’s life
(Gratz, 2007). Therefore, it is necessary to
determine how invested the client is in the
counseling process and how interested he or
she is in working toward a change with regard
to this pattern of behavior. Clients may be

12 Measurement and Evaluation in Counseling and Development 43(1)

fearful that any attempt to alter their current
way of coping could result in an increased
level of instability that would result in hospi-
talization or worse. Evaluating the fear and
anxiety clients may be associating with change
could be critical in determining an effective
treatment approach. Determining a client’s
concerns, commitment, and understanding with
regard to the counseling process is an integral
component of any assessment process and is
particularly crucial with regard to the issue of
self-injury.

Synthesis of Approaches
This article serves to illuminate the benefits of
both a formal and informal approach to assess-
ing self-injury. Although each approach is
important, the integration of both approaches is
vital (see Figure 1). In the comprehensive
two-tiered model of assessment, the formal ass-
essments serve as the first step in evaluating
self-injury; formal assessments provide coun-
selors with a standardized and quantifiable
way of determining the seriousness of the
problem and can also reflect progress or regres-
sion in treatment. The informal assessments,
as described above, serve to support, enhance,
and depict a comprehensive view of self-
injury. In addition to using the perspectives of
others, the informal assessment also widens
the lens in which self-injury has been examined
in the past. Although the formal assessments
focus on the behavior of self-injury, the infor-
mal assessments exa mine context, background,
and emotional cap acities. Thus, although both
approaches are important, counselors will ben-
efit from using them in tandem when assessing
self-injury to focus treatment and hopefully
improve short- and long-term outcomes.

Counselor Implications
Counselors will inevitability encounter individ-
uals who self-injure, creating instances whereby
they may have a responsibility to properly
assess and evaluate self-injury in their clients.
Alth ough the assessment of self-injury is
clearly in the early stages, further research on

new and established assessment tools is
needed. Conceptualization of self-injurious
behaviors is multidimensional; therefore,
assessment of these behaviors needs to be
complementary. For mental health profession-
als, to accurately assess focusing on frequency,
severity (tissue damage and intention), dura-
tion, type, thoughts and attitudes, and age of
onset is essential in treatment. Professionals
must also be aware of culture when assessing
those who self-injury. Cultural considerations
would include, but not be limited to, family
experiences, religion, ethnicity, and gender.

Additionally, qualitative research methods
that examine counselors’ and client’s percep-
tions about self-injury assessment tools as well
as their perceived usefulness could be helpful.
In addition, cultural considerations need to
be included in current research. Cultural dimen-
sions may contribute to the variability of
acc urately assessing those who self-injure,
which would eventually affect treatment. In
addition to research, counselors must begin to
expand their knowledge base on the topic of
assessment and self-injury. Because the defi-
nition of self-injury continues to be debated,
which affects the consistency of assessment,
further research is needed in this area.

Trainings that increase awareness about
self-injury assessment scales are imperative.
Because suicide is often discussed in counselor
education programs, incorporating self-inju-
rious behavior into the curriculum could be a
way to dialogue about this topic. By encom-
passing self-injurious behavior into counseling
programs, students will be exposed to charac-
teristics and features of this behavior that are
vital to assessment and intervention. In addi-
tion, training may also be in the form of
community-wide or in-service trainings that
focus on assessment. Training and practice
must comprise numerous difficulties in assess-
ment of self-injury, such as various nomenclature,
conflicting theoretical definitions, and incon-
sistencies with other disorders. In addition,
training must inc lude the comprehensive
ass essment approach, which includes formal
and informal assessment measures. On a broader
level, the topic of self-injury and assessment

Craigen et al. 13

should be presented at local, regional, and
national counseling conferences.

Given the review of the current self-injury
assessments, there are notable limitations and
weaknesses within these scales. For example,
all of the reviewed inventories were either
developed in conjunction with a diagnosis of
BPD or they assessed a component of suicidal
ideation. Furthermore, the assessments reviewed
failed to consider cultural context and were
normed on homogeneous samples, ignoring
diverse populations. Thus, to accurately assess
self-injury, it is imperative for counselors
and researchers to develop a scale that (a) is
nor med on a heterogeneous sample, (b) is inde-
pendent from the criteria of BPD, and (c)
evaluates self-injury without the inclusion of
suicidal ideations. The development of a scale
like this would benefit clinicians and clients
and would contribute greatly to the accurate
assessment of self-injury.

Summary
The topic of assessment and self-injury is
quickly beginning to gain attention among
mental health professionals and researchers.
Although there are several assessment tools
available to counselors, many have method-
ological flaws (e.g., low reliability and validity
and lack of factor analytic procedures) and are
used solely for a distinct population of indi-
viduals who self-injure. Prior to selecting a
formal self-injury assessment, it is important
to examine the strength of the assessments as
well as the population being served. Addi-
tionally, it is important never to use one
instrument in isolation. Combining additional
formal assessments and using many informal
assessment methods throughout the counsel-
ing relationship is imperative. Future research
and training on the topic of self-injury is clearly
needed.

Declaration of Conflicting Interests

The authors declared no potential conflicts of inter-
ests with respect to the authorship and/or
publication of this article.

Financial Disclosure/Funding

The authors disclosed receipt of the following
financial support for the research and/or authorship
of this article: Institute for the Study of Disadvan-
tage and Disability awarded a student research
honorarium to the second author.

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Bios

Laurie M. Craigen, PhD, LPC, is an assistant pro-
fessor in the Department of Counseling and Human
Services at Old Dominion University in Norfolk,
Virginia. She also works as a Licensed Professional
Counselor at Southside Counseling Center in Suf-
folk, VA. Laurie is actively involved in research on

mental health concerns in women, particularly with
self-injurious behavior. Additionally, she has pre-
sented at local, regional, and national conferences
on the topic of self-injury and is an Assistant Editor
of Human Service Education.

Amanda C. Healey, PhD, LPC-MHSP, NCC, is
currently a temporary fulltime counseling program
faculty member at East Tennessee State University.
She is involved in research pertaining to issues of
self injurious behaviors, professional identity
development in counseling, and burnout in mental
health and has published on these topics. Amanda
works from an Adlerian-Feminist perspective and
this is reflected in her professional and scholarly
activities.

Cynthia T. Walley, PhD, NCC, is an Assistant
Professor in the Educational Foundations and
Counseling Department at Hunter College in New
York, NY. Dr. Walley’s research interest include,
school counseling preparation, adolescent mental
health, and assessment and diagnosis.

Rebekah Byrd, MSEd, LPC, NCC, is a doctoral
candidate at Old Dominion University in Norfolk,
Virginia. She currently works as the Director of
CARE NOW, a middle school based Character
Education Program and also serves as President for
the ODU chapter of Chi Sigma Iota. Rebekah
supervises master’s counseling students and teaches
undergraduate and master’s classes. Over the last
year she has published two book chapters and two
articles; presented at the national, regional, and
state level and won a competitive research grant.

Jennifer Schuster, MEd, is a 2009 graduate of
Master’s Program in School Counseling at Old
Dominion University. Jennifer is currently work-
ing as a school counselor in Newport News,
Virginia and continues to engage in research proj-
ects at Old Dominion University.

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Measurement and Evaluation in
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DOI: 10.1177/0748175610362237
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Assessment and
Self-Injury: Implications
for Counselo

r

s

Laurie M. Craigen1, Amanda C. Healey2,
Cynthia T. Walley3, Rebekah Byrd1,
and Jennifer Schuster1

Abstract

This article provides readers with an understanding of self-injury assessment. The article begins
with a critical revi

ew

of a number of self-injury assessments. The latter section of the article
introduces a comprehensive two-tiered approach to accurately assessing self-injury. Implications
for counselors related to the assessment of self-injury are also provided.

Keywords

self-injury, assessment, self-injurious behavio

r

Self-injurious behavior is an increasing issue
among adolescents and young adults. Accord-
ing to current research, self-injurious behavior
occurs in 4% to 39% of adolescents in the
general population and the numbers are pre-
dicted to rise, due to various reasons, ranging
from levels and quality of social interactions
with peers to the availability and assimilation
of coping behaviors through access to the
Internet (Briere & Gil, 1998; Favazza, 1996;
Gratz, 2001; Gratz, Conrad, & Roemer, 2002;
Muehlenkamp & Guiterrez, 2004; Nock &
Prinstein, 2005; Ross & Heath, 2002). Statis-
tics on the incidence of self-injury can be
unreliable, underestimating the true incidence
of self-injury. The reality is that many inci-
dents will be dealt with by the individual, in
private, and will never reach the attention of
medical services or mental health profession-
als (McAllister, 2003). Recently, there has
been a surge in the literature related to defin-
ing and explaining the behavior (Gratz, 2006).
Conversely, very little is known about the
assessment of self-injury, and therefore, a gap
exists between understanding the behavior and
implementing focused counseling interventions
and treatment (White Kress, 2003). The

purpose of this article is to provide readers
with knowledge about the difficulties related
to accurately evaluating self-injury and the
history of self-injury assessments, while also
introducing a comprehensive two-tiered
app roach to assessing self-injury, emphasiz-
ing a holistic perspective.

Review of Self-Injury
Assessments
The development of inventories to evaluate
self-injury began in the early 1990s and con-
tinues today. As the conceptualizations and
definitions of self-injury have evolved, so too
has the focus of the assessments tailored for
its evaluation. Although the newer scales appear
to assess the behaviors and attitudes associated

1Old Dominion University, Norfolk, Virginia, USA
2East Tennessee State University, Johnson City,
Tennessee, USA
3Hunter College, New York City, New York, USA

Corresponding Author:
Laurie M. Craigen, PhD, LPC, Old Dominion University,
110 Education Building, Norfolk, VA 23529 USA
Email: lcraigen@odu.edu

4 Measurement and Evaluation in Counseling and Development 43(1)

with self-injury, many have not been through
the rigorous testing necessary to fully evaluate
their efficacy, reliability, and validity. Thus, when
selecting and administering assessments, it is
necessary for counselors to understand the evolv-
ing nature and continuing development of the
instrument they select for evaluating self-injury.
In the following section, a brief overview of
the inventories available for assessing self-
injurious behaviors is provided (see Table 1).

Self-Injury Trauma Scale (SITS)
One of the first inventories to be developed
for the assessment of self-injurious behaviors
is the SITS created by Iwata, Pace, and Kissel
(1990). It was created to evaluate the extent of
tissue damage caused by self-injury. This inven-
tory examines categories including location,
type, number, and severity of the tissue damage
as well as a summary evaluation of severity and
current risk for continued self-injury. SITS
defines its typical use in terms of quantifying
tissue damage directly. It also permits differ-
entiation of self-injury according to topography,
location of the injury on the body, type of injury,
number of injuries, and estimates of severity
through evaluation of the injuries themselves.
Test-retest reliability was reported at r = .68
(Iwata et al., 1990). This assessment was later
used to evaluate self-injury in conjunction
with physical pain as based on the proposition
that the experience and expression of pain is
somehow different among those individuals who
self-injure, therefore leading to the acceptabil-
ity and tolerability of self-injury as a behavior
(Symons & Danov, 2005).

The SITS was later used in a study to
det ermine the effects of a psychopharmacologi-
cal treatment on those with intellectual
disabilities who engaged in self-injury. In this
study, the SITS inventory was found to be reli-
able when used in conjunction with the
Non-Communication Children’s Pain Check-
list–Revised (NCCPC-R) in recognizing and
tracking self-injury from the perspective of an
outside observer—in this case, the parent
(McDonough, Hillery, & Kennedy, 2000). No
specific data were reported related to concurrent

validity beyond the statement that “the mean
NCCPC-R score was 20.1 for time intervals
scored with self-injurious behavior (SIB) and
2.5 for time intervals scored without SIB” (p.
474) as indicated by the SITS. The initial evalu-
ation of the inventor’s efficacy and subsequent
usage found the scale to be a reliable method for
collecting data on surface tissue damage caused
by self-injury. However, the use of this scale
might not be practical for counselors but could
be useful for professionals who intervene with
the physical consequences of self-injury, such as
school nursing staff or medical professionals.

Self-Harm Inventory (SHI)
The SHI was developed by Sansone, Wiederman,
and Sansone (1998) in the context of screen-
ing for Borderline Personality Disorder (BPD).
It was the belief of the instrument developers
that BPD exists on a continuum in which self-
injury is the most severe manifestation of self-
sabotaging behaviors. With regard to the uses
of the SHI, self-harm is defined as the deliber-
ate, direct destruction of body tissue without
conscious suicidal intent but results in injury
severe enough for tissue damage to occur. The
SHI assesses frequency, severity, duration, and
type of self-injurious behavior. The SHI was
found to be highly related to the Diagnostic
Interview for Borderlines (DIB) at a correla-
tion of r = .76 and the Personality Diagnostic
Questionnaire–Revised at r = .71 with regard
to non-psychotic adults (Sansone et al., 1998).

The developers of this inventory also showed
that the SHI was able to predict the diagnosis
of BPD as based on its convergent validity. This
inventory is made up of 22 items that were
selected due to their correlation with the DIB,
and each question begins with the phrase, “Have
you ever on purpose, or intentionally . . . ,” and
respondents were asked to give a “yes” or
“no” answer (Sansone, Songer, Douglas, &
Sellbom, 2006, p. 976). The final score is a
simple summation of the items endorsed by
the client. In developing and testing the mea-
sure, it showed acceptable levels of clinical
accuracy as a measure for the diagnosis of
BPD by assessing a pattern of self-destructive

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6 Measurement and Evaluation in Counseling and Development 43(1)

behaviors (Sansone, Whitecare, Meier, & Murry,
2001). Additionally, the SHI has been shown to
have an acceptable level of internal consistency
with Cronbach’s α = .80 (Sansone et al., 2006).
The developers have stated that the inventory
could help clinicians identify and distinguish
high-lethality and low-lethality self-injury.

Self-Injury Questionnaire (SIQ)
The SIQ was developed by Alexander (1999)
and later evaluated by Santa Mina, Gallop,
and Links (2006). This inventory was created
to evaluate and differentiate the intentions behind
self-injurious behaviors as based on a history
of childhood physical and/or sexual abuse. The
questionnaire was developed using a guiding
definition of self-injury as simply self-destructive
behaviors without the intent to die. Preliminary
findings of the initial research study that used
the SIQ showed good face validity and ade-
quate test-retest reliability in nonclinical
populati ons. Test-rest reliability over a 2-week
period of the behavioral items ranged from
r = .29 to r = 1.0, with a total correlation of
test-retest of r = .91 (Alexander, 1999). A sep-
arate study also revealed similar results for
the SIQ in acute populations, with the addi-
tion of statistical analysis resulting in findings
of high internal consistency of the total scale
(α = .83; 95% Confidence Interval [CI]) and an
adequate Cronbach’s alpha for each subscale
(α = .72 to .77) (Santa Mina et al., 2006).

Convergent validity analyses were also con-
ducted by Santa Mina et al. (2006) between
the SIQ and the Suicide Intent Scale (SIS), the
Beck Depression Inventory II (BDI II), and the
Self-Inflicted Injury Severity Form (SIISF).
The convergent validity between the SIQ and
the scales was reported to be r = –.37 with
regard to the factor of stimulation and the SIS,
r = .23 with regard to the affect regulation
factor of the SIQ as compared to the BDI II,
and r = –.25 with regard to the dissociation
factor of the SIQ and the SIISF. The SIQ is a
30-item self-report instrument conceptualized
from developments in trauma research. This
questionnaire measures the intent of self-injury
through evaluation methods across various

subscales, including body alterations, indirect
self-injury, failure to care for oneself, and
overt self-injury. The SIQ measures the func-
tions, types, and frequency of self-injuring
behaviors in association with a trauma history.
Questions on the SIQ related to agreement to
engagement in behaviors such as tattooing
and the frequency and number of self-injurious
acts related to these behaviors. Following each
behavioral item, if agreement was stated, par-
ticipants were then asked to circle further
items related to the reason contributing to the
behavior. At the time of this publication, this
inventory was yet to be tested in a clinical
setting; therefore, its efficacy with regard to
counseling is unclear and needs to be tested
further.

Deliberate Self-Harm Inventory (DSHI)
The DSHI was developed using an integrated
definition of self-injury in order to help pro-
vide a clear foundation for the instrument, given
that previous assessments lacked consensus
in definition (Gratz, 2001). It is based on the
notion that self-harm is the deliberate, direct
destruction of body tissue without conscious
suicidal intent but results in injury severe enough
for tissue damage to occur (Fliege et al., 2006).
This measure evaluates various features of self-
injury, including frequency, severity, duration,
and types of self-injurious behaviors. The
inventory consists of 17 items that are behav-
iorally based and reliant on self-report. The
DSHI has been found to be reliable and valid
for assessing self-injury and past suicidal
beh aviors (Gratz, 2006; Gratz & Chapman,
2007; Gratz et al., 2002; Lundh, Karim, &
Quilisch, 2007), with adequate internal reliabil-
ity at α = .62 (Fliege et al., 2006) and adequate
test-retest reliability during a 2- to 4-week
period of φ= .68 (p = .001) (Gratz, 2001). In
the study by Gratz (2001), adequate construct,
convergent, and discriminant reliability was
also found. This assessment is in wide use,
and its brief length lends itself to application
in clinical and outpatient settings. This assess-
ment could be useful in mental health as well
as school settings to determine the need,

Craigen et al. 7

immediacy, and level of intervention needed
with regard to a client or student presenting
self-injurious behaviors.

Suicide Attempt Self-Injury
Interview (SASII)
The SASII was designed to evaluate factors
involved in what the authors referred to as
“nonfatal suicide attempts and intentional self-
injury” (Linehan, Comtois, Brown, Heard, &
Wagner, 2006, p. 304). This measure, once
referred to as the Parasuicide History Inven-
tory, was developed to better understand the
methods involved in self-injury—the motiva-
tions, consequences, ritual, and impulsivity of
the act itself. Its validity and reliability mea-
sures were taken using an inpatient population.
In defining suicidal behavior, this instrument
includes all general definitions pertaining to
parasuicide, fatal and nonfatal suicide, and
self-injury without the intent to die. Therefore,
it does provide descriptive details about self-
injurious and suicidal behaviors but does not
differentiate between the two beyond lethality.

This instrument has been used in several
recent studies that confirm its usability and
importance in assessing the multiple aspects
of suicidal and self-injurious behaviors
(Brown, Comtois, & Linehan, 2002; Koons
et al., 2001). Six scales were developed based
on factor analysis with factors loading at .4 or
above. These six scales evaluated lethality of
the method, suicidal and nonsuicidal intent
associated with an episode, communication of
suicide intent prior to the episode, impulsiv-
ity, physical condition, and level of medical
treatment. The assessment showed high inter-
rater reliability at r = .918 for classification of
suicidality components and r = .843 for epi-
sodes classified as a single event versus a
cluster of self-injurious events (Linehan
et al., 2006). The SASII instrument is useful
in that it provides a rating concerning the
lethality of the act in question in terms of
several com ponents including medical and
other con sequences. This instrument can also
be used to evaluate treatment outcomes
through pre- and postassessment.

Self-Injury Implicit Association
Test (SI-IAT)

The SI-IAT was developed by Nock and Banjai
(2007) to assess self-injury in terms of the
identity with and beliefs surrounding the act
itself. This test was based on the Implicit Asso-
ciation Test (IAT), developed by Greenwald,
McGhee, and Schwartz (1998). To understand
the SI-IAT, it is important to know a little bit
about the test from which it was developed.
The IAT is primarily used for evaluating asso-
ciations to nonclinical constructs and beliefs.
The IAT itself has been shown to have strong
reliability, construct validity, and the capacity
to distinguish clinical changes caused by treat-
ment and attempts to mask feelings. The SI-IAT
was created in order to integrate the advantages
of the IAT in an attempt to assess self-injury
without relying on explicit self-report. The
test measures the implicit associations indi-
viduals have concerning self-injury in terms
of identification with the behavior as well as
attitudes about it.

The research studies conducted by Nock
and Banjai (2007) using the SI-IAT showed
that the assessment was able to strongly predict
recent suicidal ideation and suicide attempts,
with good incremental predictive validity ranging
from .74 to .77 with the participating ado-
lescent population. The assessment could
also distinguish between groups of nonsuicidal
ado lescents who had negative beliefs about
self-injury, adolescents with suicidal ideations
who showed some positive identification, and
adolescents who had attempted suicide while
having strong identification with self-injurious
behaviors. Because of the interpretive nature
of this assessment, it would be important for
counselors to use this in conjunction with mul-
tiple informal assessment techniques to evaluate
the client’s perceptions with regard to his or
her statements. This would help avoid coun-
selor bias in determining the client’s level of
identification with the behaviors. This assess-
ment is also helpful in evaluating how useful the
client views his or her self-injurious behav-
iors in managing symptomology. The level at
which a client integrates self-injury into his or

8 Measurement and Evaluation in Counseling and Development 43(1)

her identity and views self-injury as assistive
to his or her functioning could drastically affect
the approach and interventions the counselor
ultimately decides to use in the process of
treatment. For example, if the client views
self-injury as an effective coping strategy to
reduce stress, the counselor and client could
explore alternative stress-reduction strategies
in counseling sessions.

Self-Injurious Thoughts and
Behaviors Interview (SITBI)
The SITBI was developed by Nock, Holmberg,
Photos, and Michel (2007) as a 169-item
str uctured interview that assesses the pres-
ence, frequency, severity, age-of-onset, and
general characteristics associated with the
thoughts and behaviors of suicidal ideations
and suicide attempts. The SITBI assumes that,
by definition, self-injury does not include the
intent to die and thus differentiates self-injury
from suicidal intent and action. In assessing the
strengths of the interview as an assessment
tool, the authors found it to have strong inter-
rater reliability (Nock et al., 2007), good
test-retest reliability (average k = .70) after 6
months, good construct validity in relation to
suicide measures and suicide attempts (k =
.65), and concurrent validity with measures of
suicidal ideations and gestures. However, it
did have weak reliability in assessing suicide
gestures and plans. Predictive validity for sui-
cidal ideation or future self-injury was not
addressed in the study conducted by Nock et
al. (2007). It is the belief of the authors that
the interview could be used easily in a variety
of clinical settings to get an overview of current
and recent self-injurious behaviors; however,
because of the length of the assessment, there
are time constraints to consider with regard to
the pra cticality of its use.

The self-injury assessment tools that have
been developed over recent years have clear
strengths and weaknesses. For counselors, it is
important to consider the population you are
using before selecting a particular self-injury
assessment tool as well as the setting in which
you will be implementing it. Also, it is critical

to realize that the aforementioned formal assess-
ments are only one piece of the assessment
process. Counselors should never use these
measures in isolation for determining the course
of treatment, outcomes, or need for intervention.
The following section outlines a recommended
approach for assessing self-injury and using
formal assessments in conjunction with addi-
tional evaluation methods.

Comprehensive Assessment
Approach
The need for a comprehensive and multilevel
approach to the assessment and evaluation of
self-injury is clear because of the multifaceted
nature of self-injury. The following section out-
lines a two-tiered process of assessing self-injury.
This process includes the use of both formal and
informal assessment procedures (see Figure 1).

Formal Assessment
The first step in this integrated approach
inv olves the formal assessment of self-injury
(as introduced above) as well as other possi-
bly related concerns, such as depression,
traumatic history, or anxiety. These mental
health concerns necessitate mentioning
because of independent empirical indications
of association with self-injurious behaviors
(Conaghan & Davidson, 2002; Herpertz, Sass,
& Favazza, 1997; Klonsky & Olino, 2008;
Sansone, Chu, & Wiederman, 2007; Sansone
& Levitt, 2002). Overall, formal assessment
measures allow for more accurate diagnoses
and appropriate evaluation and enhance the
formulation of an informed treatment plan.

Self-Injury assessment measures. Many self-
injury assessment tools are available for
con sideration during the implementation of a
formal assessment process as previously pre-
sented (see Table 1). Selecting an appropriate
tool based on population, validity, and reli-
ability is necessary in treating self-injurious
behavior.

Additional formal assessments. Self-injury
rarely occurs in isolation. As stated previously,
many mental health disorders coexist with

Craigen et al. 9

self-injury. Thus, a combination of formal
assessments is fundamental, as it is imperative
to examine the intent behind each act of self-
injury to carefully evaluate which elements of
concern or distress are present for each unique
individual. Because of the complex nature of
self-injury, the more accurate the evaluation,
the better suited and successful the treatment
will be (White Kress, 2003). Thus, it would

behoove counselors to also use standardized
assessments that evaluate areas such as (but
not limited to) suicide, trauma, depression,
anxiety, and eating disorders. The following
are examples of assessments that could address
these indicators. Although this list is not com-
prehensive, other assessments may be selected
and should be matched to the unique needs of
the client:

Self-Injury
Assessment

• Self-Injury Assessment/Inventory

• Suicidality Protocol/Inventory

• Trauma Inventory

• Beck Depression Inventory

Anxiety Scales

Tier One: Formal Assessment

Tier Two: Informal Assessment (all are ongoing):
Formal Assessment

Background

Familial History

Peer Support

Social Support

Negative/Positive
Influences

Emotional Capacity

Verbal Ability to
Express Emotions

Coping Strategies

In Combination withIn Combination with

Figure 1. Two-tier model of assessment

10 Measurement and Evaluation in Counseling and Development 43(1)

• Suicidality Protocol/Inventories: that
is, Inventory of Suicide Orientation-30,
Beck Suicide Inventory, Reasons for
Living Inventory, Hopelessness Scale,
Scale for Suicide Ideation, Suicide
Probability Scale, Suicide Ideation
Questionnaire, and Suicide Probabil-
ity Scale

• Trauma Inventories: that is, Early
Trauma Inventory, Trauma Coping
Inventory, Trauma Symptom Inven-
tory, Trauma Assessment Inventories

• Depression Inventories: that is,
Inv entory of Depressive Symtoma-
tology, BDI, Children’s Depression
Inventory, Major Depression Inven-
tory, Inventory of Depression and
Anxiety Symptoms, Zung Self-Rating
Dep ression Scale

• Anxiety Inventories: that is, Beck
Anxiety Inventory, Spielberger State-
Trait Anxiety Scales, Anxiety Status
Inventory

• Eating Disorder Inventories: that is,
Eating Disorders Inventories, Eating
Attitudes Test, Eating Disorder Exa-
mination, and additional measures
sui ted for the particular client

The aforementioned formal assessments vary
according to reliability and validity. Thus, prior
to selecting a measure, it is important to exa-
mine its strengths as well as the population
being served.

Informal Assessment
The second step in this approach involves
using informal assessment measures. Infor-
mal assessment techniques are subjective and
provide counselors with additional tools for
understanding clients (Neukrug & Fawcett,
2005). The majority of informal assessments
are used in a formative evaluative manner, rather
than through a pretreatment or posttreatment
(summative) evaluation. Informal assessment
techniques combined with formal assessments
allow the clinician to gain a comprehensive,
holistic, and in-depth understanding of the

client and his or her presenting concerns. For
example, gaining an understanding of past and
current familial and relational connections as
well as relational conflicts could lead to greater
insight into the client’s reasoning for his or
her self-injurious behaviors and the structure
of his or her current support network. With all
informal assessment techniques, it is neces-
sary to consistently be aware of cultural context
and how this could be a factor for each client.
Although many techniques can be used to con-
duct informal assessments, only those most
pertinent to the treatment of self-injurious behav-
iors are addressed in this section.

Intakes. Many informal assessment measures
exist and should be used during intake and
also throughout the treatment process for each
individual. At intake, it is important to add a
section or line dedicated to self-injury. This is
an area that is often left off of intakes and is
important in the initial assessment. For exam-
ple, “Have you ever intentionally hurt yourself
for any reason?”

Interviews. Parent and teacher interviews are
a great tool to access valuable information
about your client and his or her experiences
with self-injury. Although many individuals go
to great lengths to hide their self-injury from
parents and teachers, valuable information
can be garnered from speaking with these
individuals, as they may play an important
role in the client’s self-injury and might also
serve as an ally for the client as he or she
explores issues related to his or her behaviors
in counseling. Some questions that might
garner useful treatment information include
the following: “Is the client’s behavior consis-
tent at home and school?” “Does the client
engage in isolative behaviors?” “How does the
client normally express his or her feelings or
needs?” “What type of internalizing or exter-
nalizing behaviors are the parents or teachers
aware of in your client?”

Observations. Observations are an important
assessment tool, providing counselors with an
additional mechanism for understanding the
client (Neukrug & Fawcett, 2005). Although
not all clients who self-injure present in the
same way, there may be consistent behaviors,

Craigen et al. 11

appearances, or nuances that could provide
counselors with helpful information to sup-
plement their understanding of the client. For
example, a client who self-injures may often-
times wear clothes that hide his or her injuries
or have many unexplained cuts, scars, or burns
(White Kress, Gibson, & Reynolds, 2004).
Additionally, clients may avoid conversations
about self-injury or deny their personal expe-
riences with self-injury.

Background information. Acquiring back-
gro und information is a vital aspect of self-
injury assessment and can potentially provide
the counselor with valuable information about
the contributing factors related to the client’s
self-injurious behavior. When obtaining back-
ground information, it is necessary to focus
on all aspects of the individual and not limit
the assessment to the behavior itself. This knowl-
edge provides counselors with valuable
information about what lies beneath the sur-
face of the wounds, a focus of treatment that
has been ignored in the past (Craigen &
Foster, 2009; Walsh, 2006).

Familial history is one aspect of background
information that is often overlooked. Gather-
ing information about an individual’s family
history avoids pathologizing the behavior and
views the presenting behaviors through more
of a systemic lens. Seeking to understand all
contributing factors such as a client’s per-
spectives and experiences regarding his or her
family might not have been considered in the
past; however, it is necessary (McAllister, 2003;
Selekman, 2002). For example, the counselor
may ask, “Who do you talk to in your family
about your feelings?” “How does your family
typically deal with their emotions?” “What
feelings do you have for different members of
your family?” or “What events in your past
family history have affected you negatively?”

In addition to familial information, it is also
important to discuss with the client his or her
peer and social supports (Walsh, 2006). This
is particularly relevant in the adolescent popu-
lation because at this developmental milestone,
peer supports are highly valued. For example,
counselors may say, “Tell me about your
friends.” Or they may ask, “When you are

upset, do you typically talk with your friends?”
“Do your friends know about your self-injurious
behavior?” Other factors that affect the indivi-
dual and need to be assessed are negative
or positive influences that could facilitate
self-injury. These could include Internet sites
ded icated to perpetuating self-injurious behav-
ior, friends who self-injure, and/or media role-
models who self-injure or have self-injured.

Emotional capacity. Evaluating the emotional
capacity of the individual using informal
ass essment techniques is an essential process
in developing effective treatment interven-
tions and conceptualizing the issues related to
the self-injurious behaviors. Examining an indi-
vidual’s ability to outwardly express and
understand his or her feelings involves an
ongoing process of assessment, evaluation,
and treatment with clients who self-injure.
One’s ability to express emotions is a concern
for many but particularly those who self-injure.
Since this is the case, it may be important to
ask clients, “If your wounds could speak,
what would they say about you?” (Levenkron,
1998). Additionally, basic questions that assess
one’s feelings voc abulary can also be benefi-
cial in the informal assessment process.

Coping strategies. In addition to assessing
the emotional capacity of clients who self-injure,
coping strategies can also be assessed by using
informal assessment techniques and can be
incorporated in any treatment approach for
those who self-injure. For example, it may be
important to ask clients, “What do you do
when you feel angry, anxious, or upset?” or
“What function does self-injury serve for you?”
These two questions allow the counselor to
examine how and to what extent that self-injury
serves as a maladaptive coping strategy for
clients presenting with self-injurious behaviors.

Typically, the use of self-injury is seen as an
effective method for dealing with overwhelm-
ing emotions associated with traumatic memories
or other issues occurring in the client’s life
(Gratz, 2007). Therefore, it is necessary to
determine how invested the client is in the
counseling process and how interested he or
she is in working toward a change with regard
to this pattern of behavior. Clients may be

12 Measurement and Evaluation in Counseling and Development 43(1)

fearful that any attempt to alter their current
way of coping could result in an increased
level of instability that would result in hospi-
talization or worse. Evaluating the fear and
anxiety clients may be associating with change
could be critical in determining an effective
treatment approach. Determining a client’s
concerns, commitment, and understanding with
regard to the counseling process is an integral
component of any assessment process and is
particularly crucial with regard to the issue of
self-injury.

Synthesis of Approaches
This article serves to illuminate the benefits of
both a formal and informal approach to assess-
ing self-injury. Although each approach is
important, the integration of both approaches is
vital (see Figure 1). In the comprehensive
two-tiered model of assessment, the formal ass-
essments serve as the first step in evaluating
self-injury; formal assessments provide coun-
selors with a standardized and quantifiable
way of determining the seriousness of the
problem and can also reflect progress or regres-
sion in treatment. The informal assessments,
as described above, serve to support, enhance,
and depict a comprehensive view of self-
injury. In addition to using the perspectives of
others, the informal assessment also widens
the lens in which self-injury has been examined
in the past. Although the formal assessments
focus on the behavior of self-injury, the infor-
mal assessments exa mine context, background,
and emotional cap acities. Thus, although both
approaches are important, counselors will ben-
efit from using them in tandem when assessing
self-injury to focus treatment and hopefully
improve short- and long-term outcomes.

Counselor Implications
Counselors will inevitability encounter individ-
uals who self-injure, creating instances whereby
they may have a responsibility to properly
assess and evaluate self-injury in their clients.
Alth ough the assessment of self-injury is
clearly in the early stages, further research on

new and established assessment tools is
needed. Conceptualization of self-injurious
behaviors is multidimensional; therefore,
assessment of these behaviors needs to be
complementary. For mental health profession-
als, to accurately assess focusing on frequency,
severity (tissue damage and intention), dura-
tion, type, thoughts and attitudes, and age of
onset is essential in treatment. Professionals
must also be aware of culture when assessing
those who self-injury. Cultural considerations
would include, but not be limited to, family
experiences, religion, ethnicity, and gender.

Additionally, qualitative research methods
that examine counselors’ and client’s percep-
tions about self-injury assessment tools as well
as their perceived usefulness could be helpful.
In addition, cultural considerations need to
be included in current research. Cultural dimen-
sions may contribute to the variability of
acc urately assessing those who self-injure,
which would eventually affect treatment. In
addition to research, counselors must begin to
expand their knowledge base on the topic of
assessment and self-injury. Because the defi-
nition of self-injury continues to be debated,
which affects the consistency of assessment,
further research is needed in this area.

Trainings that increase awareness about
self-injury assessment scales are imperative.
Because suicide is often discussed in counselor
education programs, incorporating self-inju-
rious behavior into the curriculum could be a
way to dialogue about this topic. By encom-
passing self-injurious behavior into counseling
programs, students will be exposed to charac-
teristics and features of this behavior that are
vital to assessment and intervention. In addi-
tion, training may also be in the form of
community-wide or in-service trainings that
focus on assessment. Training and practice
must comprise numerous difficulties in assess-
ment of self-injury, such as various nomenclature,
conflicting theoretical definitions, and incon-
sistencies with other disorders. In addition,
training must inc lude the comprehensive
ass essment approach, which includes formal
and informal assessment measures. On a broader
level, the topic of self-injury and assessment

Craigen et al. 13

should be presented at local, regional, and
national counseling conferences.

Given the review of the current self-injury
assessments, there are notable limitations and
weaknesses within these scales. For example,
all of the reviewed inventories were either
developed in conjunction with a diagnosis of
BPD or they assessed a component of suicidal
ideation. Furthermore, the assessments reviewed
failed to consider cultural context and were
normed on homogeneous samples, ignoring
diverse populations. Thus, to accurately assess
self-injury, it is imperative for counselors
and researchers to develop a scale that (a) is
nor med on a heterogeneous sample, (b) is inde-
pendent from the criteria of BPD, and (c)
evaluates self-injury without the inclusion of
suicidal ideations. The development of a scale
like this would benefit clinicians and clients
and would contribute greatly to the accurate
assessment of self-injury.

Summary
The topic of assessment and self-injury is
quickly beginning to gain attention among
mental health professionals and researchers.
Although there are several assessment tools
available to counselors, many have method-
ological flaws (e.g., low reliability and validity
and lack of factor analytic procedures) and are
used solely for a distinct population of indi-
viduals who self-injure. Prior to selecting a
formal self-injury assessment, it is important
to examine the strength of the assessments as
well as the population being served. Addi-
tionally, it is important never to use one
instrument in isolation. Combining additional
formal assessments and using many informal
assessment methods throughout the counsel-
ing relationship is imperative. Future research
and training on the topic of self-injury is clearly
needed.

Declaration of Conflicting Interests

The authors declared no potential conflicts of inter-
ests with respect to the authorship and/or
publication of this article.

Financial Disclosure/Funding

The authors disclosed receipt of the following
financial support for the research and/or authorship
of this article: Institute for the Study of Disadvan-
tage and Disability awarded a student research
honorarium to the second author.

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Bios

Laurie M. Craigen, PhD, LPC, is an assistant pro-
fessor in the Department of Counseling and Human
Services at Old Dominion University in Norfolk,
Virginia. She also works as a Licensed Professional
Counselor at Southside Counseling Center in Suf-
folk, VA. Laurie is actively involved in research on

mental health concerns in women, particularly with
self-injurious behavior. Additionally, she has pre-
sented at local, regional, and national conferences
on the topic of self-injury and is an Assistant Editor
of Human Service Education.

Amanda C. Healey, PhD, LPC-MHSP, NCC, is
currently a temporary fulltime counseling program
faculty member at East Tennessee State University.
She is involved in research pertaining to issues of
self injurious behaviors, professional identity
development in counseling, and burnout in mental
health and has published on these topics. Amanda
works from an Adlerian-Feminist perspective and
this is reflected in her professional and scholarly
activities.

Cynthia T. Walley, PhD, NCC, is an Assistant
Professor in the Educational Foundations and
Counseling Department at Hunter College in New
York, NY. Dr. Walley’s research interest include,
school counseling preparation, adolescent mental
health, and assessment and diagnosis.

Rebekah Byrd, MSEd, LPC, NCC, is a doctoral
candidate at Old Dominion University in Norfolk,
Virginia. She currently works as the Director of
CARE NOW, a middle school based Character
Education Program and also serves as President for
the ODU chapter of Chi Sigma Iota. Rebekah
supervises master’s counseling students and teaches
undergraduate and master’s classes. Over the last
year she has published two book chapters and two
articles; presented at the national, regional, and
state level and won a competitive research grant.

Jennifer Schuster, MEd, is a 2009 graduate of
Master’s Program in School Counseling at Old
Dominion University. Jennifer is currently work-
ing as a school counselor in Newport News,
Virginia and continues to engage in research proj-
ects at Old Dominion University.

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