Developing and established programs always seek to satisfy the needs of specific stakeholders,

Developing and established programs always seek to satisfy the needs of specific

stakeholders,

Running head: THE RESULTS: COMMUNICATION TO STAKEHOLDERS

The Results: Communication to Stakeholders

Dr. Holly Scott

09.09.19

Capella University

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 1

Introduction

The following analyzes data collected from 26 hypothetical clients participating in an

outpatient-based program geared toward rehabilitating female survivors of intimate partner

violence (IPV) suffering with PTSD and/or depression. This study evaluated the effectiveness of

trauma-focused cognitive behavioral therapy (TF-CBT) compared to treatment as usual (TAU).

The main program-evaluation question was identified as, Is TF-CBT more effective than TAU

(where TAU equals a person-centered approach) at decreasing the symptoms of PTSD and

depression (i.e., symptoms less severe, decrease in frequency of episodes, overall improvement of

functioning)? Two additional program-evaluation questions were also identified: 1) Is there a

statistically significant difference on change scores of outcome measurements by race (white or

non-white)? and 2) Is there a correlation between total change scores of outcome measurements

and the level of satisfaction with treatment?

Method

Participants

Data from this study was collected from women over the age of 18 who were seeking

treatment following the experience of intimate partner violence. The intended number of women

to be treated in this study was 29, but the total number of participants who completed treatment

was 26 (nTFCBT = 13, nTAU =13).

The age range of participants was 19-64 years (M=34.96, SD = 13.307) (table 1; figure 1;

table 5). This sample consisted of 37% Caucasian, 29.6% Hispanic, 18.5 % Black, 3.7% Asian,

3.7% Native/Alaskan American, and 3.7% Pacific Islander. Of the participants, only 46.2% of

participants identified as being employed (table 2, figure 2). The religious beliefs of the

participants was sampled with 26.9% of participants identifying with Christianity, 7.7% with

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 2 Islam, 3.8% with Hinduism, 11.5% with Buddhism, 7.7% with Judaism, 11.5% with other,

11.5% with spirituality, and 19.2% identifying with no religious beliefs (table 3, figure 3). Of the

total number of participants who completed treatment (n=26), 50% of participants had been in

one IPV relationship prior to treatment, 26.9% of participants had been in two IPV relationships,

19.2% of participants had been in three IPV relationships, and 3.8% of participants had been in

four IPV relationships (M = 1.77, SD = .908) (table 4, figure 4, table 5).

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 3

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 4 Measures

Several variables were analyzed in this study including participant age, race, the number

of IPV relationships, treatment group, employment status, and religious beliefs, as reported

above. The Beck-Depression Inventory-II (BDI-II) and the Posttraumatic Diagnostic Scale

(PDS) were given to participants of both treatment groups before and after the intervention. A

satisfaction with treatment survey (1= very dissatisfied, 5 = very satisfied) was also given at the

end of treatment.

Results

The main alternative hypothesis was that participants who completed the TF-CBT group

would demonstrate statistically significant differences on outcomes measures (dependent

variable) after the intervention (independent variable) when compared with pre-test scores as

compared to the TAU control group (H0= µTF-CBT – µTAU ≤ 0; H1= µTF-CBT – µTAU > 0).

A between-subjects repeated measures of analysis of variance (ANOVA) was conducted

on the pre-intervention scores of both the PDS, F (1, 24) = .119, p = .734 (tables 6a and 7), and

the BDI-II, F (1, 24) = .004, p = .948 (tables 6b and 8). Both analyses indicated that there was no

significant differences in the scores of the measures between the two groups prior to treatment.

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 5 Table 7 PDS pre-treatment scores between groups

Table 8 BDI-II pre-treatment scores between groups

A between-subjects repeated measures of analysis of variance (ANOVA) was conducted

on both the PDS and the BDI-II to assess the treatment effects between the groups (nTFCBT =

13, nTAU =13). A significant main effect of treatment type on the difference scores of the PDS,

F (1, 24) = 11.108, p = .003 was evident (see table 9, figure 9). A significant main effect of

treatment type on the difference scores of the BDI-II, F (1, 24) = 5.885, p = .023 was also

evident (see table 10).

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 6 Table 9 Pretreatment and Posttreatment Results for PDS Outcome Measure Between Groups

Figure 9 Mean Difference Scores for PDS Between Groups

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 7 Table 10 Pretreatment and Posttreatment Results for BDI-II Outcome Measure Between Groups

Figure 10 Mean Difference Scores for BDI-II Between Groups

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 8 A between-subjects repeated measures of analysis of variance (ANOVA) indicated a significant

main effect of the type of treatment on the reported level of satisfaction with the treatment, F (1,

24) = 12.522, p = .002 (see table 11, figure 11).

Table 11 Level of Satisfaction with Treatment Between Groups

Figure 11 Mean Level of Satisfaction with Treatment Between Groups

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 9 The second alternative hypothesis was that change scores on outcome measurements

(dependent variable) completed by participants would differ by race (independent variable) (H0:

µwhite = µnon-white ; H1: µwhite ≠ µnon-white). An independent-samples t-test was conducted to

evaluate whether race (white or non-white) significantly influenced change scores on outcome

measurements. The test revealed that non-white participants had significantly better change

scores on outcome measurements (M=16.88; SD = 10.118) than white participants (M=9.50; SD

= 3.598), t(24) = -2.205, p = .037 (see table 12).

Table 12 Change Scores on Outcome Measurements by Race (white or non-white)

The third alternative hypothesis was that there would be a positive correlation between

the change scores (independent variable) and the level of satisfaction with treatment (dependent

variable) (H0: r = 0 ; H1: 0 < r ≤ +1.0). Results of the Pearson correlation indicated that there

was a significant positive correlation between change scores and treatment satisfaction, r= .460,

n = 26, p = .018 (see table 13).

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 10 Table 13 Relationship between Total Change Scores and Treatment Satisfaction

Of the scaled variables analyzed (i.e., participant age, number of IPV relationships

experienced prior to treatment, difference scores of outcome measures, and the level of

satisfaction with treatment), all yielded asymmetry and kurtosis within acceptable ranges,

demonstrating normal univariate distribution. Based on this data set, there do not appear to be

any significant outliers affecting the distribution.

Discussion

As expected, TF-CBT had a significant effect on the symptoms of PTSD and depression

of participants as assessed by pre-test and post-test scores of outcome measurements compared

to TAU (i.e., person centered approach). The TF-CBT model uses psychoeducation, stress

management, affect modulation, cognitive coping, trauma narratives, cognitive processing, and

behavior management to decrease symptoms related to trauma (MUSC, 2005). While a person-

centered approach is not typically utilized by clinicians who are exclusively treating trauma

(Joseph, 2004), this clinical approach to treatment is common for intimate partner violence

agencies in conjunction with an empowerment model as a way to meet the client where they are.

Future qualitative research that analyzes the experiences of the treatment interventions might

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 11 help clarify this further and might point to the appropriateness of the intervention for this specific

population.

Communicating Results to Stakeholders

Developing and established programs always seek to satisfy the needs of specific

stakeholders, or individuals/agencies/organizations with vested interest in the service(s), being

offered (Royse, Thyer, & Padgett, 2016). The upstream stakeholders for this program (i.e., those

who had a hand in the development and/or implementation/management of the program) include

policy makers, funding organizations, and the program itself. Downstream stakeholders for this

program (i.e., those who are impacted either directly or indirectly by the program) include the

clients; their children; other local, state, and national domestic violence coalitions (which, in this

case, might also be considered an upstream stakeholder); and the community (Briere & Scott,

2006).

When presenting results to external stakeholders – which in this case would likely

include funding and accreditation organizations – it will be important to deliver the results in an

understandable, ethical, and transparent manner, even when the results are undesirable or

uncertain (Broughton, 1991; ACC, 2003; Longest & Rohrer, 2005; ACA, 2013; Han, 2013).

According to Broughton (1991), finding this balance can be confusing and can require the

evaluator to judge the target audience’s preferences before communicating the results.

Depending on who or what the intended target is, often overlooked aspects like language and

generalizations can significantly impact the future of the program. Guiffrida, Douthit, Lynch, and

Mackie (2011) suggest that a clear description of an existing knowledge gap should be included

in the report to demonstrate a need for continued research. Once the data has been analyzed, a

report should be drawn up to organize the information and conclusions effectively. Presenting

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 12 the results also poses a degree of difficulty. Some evaluators may find that it is necessary to

develop several presentations in order to appeal to the various audiences (Broughton, 1991). The

evaluator should be prepared to handle questions about bias, methodology, and data

interpretation. Since there is very little empirical evidence demonstrating the effectiveness of TF-

CBT with the adult population, there is likely to be several questions regarding the adaptability

of the intervention and its appropriateness for this population. Finally, the evaluator should

present the study’s limitations and implications for the future that do not overstate the data in

favor of the program or intervention being evaluated (Guiffrida et al., 2011).

Ethical and Cultural Considerations

The American Counseling Association’s (ACA) Code of Ethics (2014) contains an entire

section devoted to evaluation, assessment, and interpretation (Whiston, 2012). Section E of the

ACA Code of Ethics is comprised of various sub-and sub-sub-sections that provide several

competencies and professional standards for counseling practitioners to refer to during the

evaluation process including: client welfare, limits of competence, appropriate use, informed

consent, release of data, diagnosis, cultural sensitivity, instrument selection, referral information,

conditions of assessment, multicultural issues, scoring and interpretation, security, and forensic

evaluation (ACA, 2014). The American Evaluation Association (AEA) provides more

evaluation-specific guidelines for evaluators. These guidelines are comprised of five principles:

A) systematic inquiry; B) competence; C) integrity/honesty; D) respect for people; and E)

common good and equity (AEA, 2018). While working with the IPV survivor population, there

are several ethical and legal issues that can arise during the evaluation process; specifically,

confidentiality and informed consent. Unfortunately, confidentiality can be limited based on

reports of child abuse and intent to harm (self or others) – potentially damaging the established

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 13 rapport between client and counselor (if the counselor is also the evaluator). Respecting both the

evaluation guidelines and the client-evaluator relationship will likely increase cooperation from

the client and, subsequently, the significance of the measured data.

When conducting an evaluation, it is imperative that it demonstrate cultural sensitivity so

as to not exclude (either intentionally or unintentionally) any particular individual or group

(AEA, 2018; ACA, 2014). This requires that the evaluating body be knowledgeable about

cultural norms (Royse et al., 2016). With this particular program, there are many challenges

related to cultural sensitivity. First and foremost, the IPV culture (i.e., victims, perpetrators, other

innocent bystanders) has a very unique culture that is, to some degree, based on maintenance

and/or survival. Often times, one will see that the communication style, gender roles, and family

structure of this culture share certain characteristics despite cultural or ethnic differences that

unite this population; making it a culture all its own. Secondly, while some commonalities might

be expressed throughout the population, there are differences in age, gender, socioeconomic

status, culture, ethnicity, and language that require an evaluator to consider the risk of

generalizing the evaluation process. These two considerations pose significant issues for the

program. Cultural barriers such as language or religious beliefs may very well deter or hinder a

potential client from participating in the services offered by the program. And while it is a great

idea to employ staff who speak other languages or have difference cultural

influence/experience/knowledge, this isn’t always a realistic option for employers. As far as

needy but unserved clients go, this population is notorious being inadequately served, either

because of limited resources of community agencies or individual unwillingness/inability to

participate. Attrition rate is also very high and can occur at any time of treatment. However, this

is likely to be a result of IPV risk (i.e., risk for assault, continued assault, severe assault, frequent

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 14 assault, assault after intervention, treatment attrition, domestic homicide) than unmet cultural

needs (Sartin, Hansen, & Huss, 2006).

When communicating results, it is important to clearly identify the population and

demographics relevant to the study. Historically, treatment interventions have been developed

with a primarily white, English speaking sample base (Royse et al., 2016). However, if validity

cannot be established because the intervention is not cross-culturally adaptable, it is unlikely to

be funded or supported as appropriate intervention for general counseling. In this particular

study, the sample consisted of 37% Caucasian, 29.6% Hispanic, 18.5 % Black, 3.7% Asian,

3.7% Native/Alaskan American, and 3.7% Pacific Islander. TF-CBT has demonstrated

considerable cultural adaptability, and the assessment measures (PSD and BDI-II) have

demonstrated reliability and validity measures that suggest considerable cross-cultural relevance.

These factors suggest that this study can be considered culturally sensitive. Furthermore, the

Association for Assessment in Counseling (2003) maintains that communicating results in a way

that can be understood by a variety of people is crucial to the helping others understand the

implications of the results. This absolutely includes cultural considerations that should be

occurring at every stage before, during, and after the evaluation (Section E.5.b, E.8, and E.9.a)

(ACA, 2014).

Using Results to Improve the Program

Based on the quantitative data, it appears as though TF-CBT is highly effective at

reducing symptoms associated with both posttraumatic stress and depression. Compared to TAU,

TF-CBT was significantly more effective at reducing symptoms of posttraumatic stress and

moderately more effective at reducing symptoms of depression. In order to improve the

effectiveness of the program, it is recommended that further research be conducted that compares

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 15 other treatment interventions (such as CBT). In the interim, it might also be beneficial for all

counselors to be thoroughly trained on TF-CBT. A third recommendation based on these

preliminary results would be to replicate this study with a semi-structured interview at the

conclusion of treatment to expand on the treatment experience to help evaluate the

appropriateness of the TF-CBT intervention with the intimate partner violence survivor

population. Collecting qualitative data that can speak to the effect of race on change scores

would also support the development of a cross-culturally appropriate program.

Using Results to Advance the Counseling Field

Innovative research has the ability to generate new intervention models and techniques

that can stimulate an improvement in mental health and general wellness (Longest & Rohrer,

2005; Guiffrida et al., 2011). TF-CBT has been proven to address symptoms of trauma, including

PTSD and depression with statistical significance (Bradley, Greene, Russ, Dutra, & Westen,

2005; Seidler & Wagner, 2006; Bisson, Ehlers, Matthews, Pilling, Richards, & Turner, 2007;

Shearing et al., 2011; Watts, Schnurr, Mayo, Young-Xu, Weeks, & Friedman; 2013). During the

literature review segment of this evaluation, it became evident that because TF-CBT was

originally designed as a means to reduce trauma-related symptoms in children, significant data

for the success of this model for the adult population would be extremely limited (d’Ardenne,

Farmer, Ruaro, & Priebe, 2007; Shearing, Lee, & Clohessy, 2011; Ehring, Welboren, Morina,

Wicherts, Freitag, & Emmelkamp, 2014). However, the author maintains that, with some

modifications, this approach would be highly applicable for the adult population as well. The

results from this study indicated that TF-CBT was, in fact, effective at reducing symptoms of

posttraumatic stress and depression for the adult population. Continued exploration of this

therapy model with this population will help to bridge the knowledge gap that exists for this

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 16 intervention. If effectiveness can be established, it may encourage other counseling agencies to

integrate TF-CBT not just with domestic violence survivors, but with an array of clients

experiencing trauma-related symptoms. Successful integration of TF-CBT could possibly reduce

counseling duration, eliminate the necessity of pharmacological dependence, and improve

overall wellness to a greater degree than TAU alone.

Conclusion

The purpose of this study was to determine if TF-CBT was more effective than TAU in

treating posttraumatic stress disorder and depression in women over the age of 18 receiving

treatment at an outpatient-based program geared toward rehabilitating female survivors of

intimate partner violence. Analysis revealed that symptoms of PTSD and depression in

participants in this sample did, in fact, decrease significantly after the TF-CBT treatment

intervention was applied as compared to TAU. Additionally, on average, participants rated their

level of satisfaction with the TF-CBT treatment higher than TAU. Further analysis of data

yielded that race significantly influenced change scores on outcome measurements and that the

level of treatment satisfaction was positively correlated with change scores.

As a result of this study, three recommendations were provided for stakeholders: 1)

conduct additional research that tested the effectiveness of TF-CBT against other treatment

modalities; 2) provide thorough TF-CBT training for employees; and 3) replicate this study with

a mixed methods design to expand the data with qualitative information.

THE RESULTS: COMMUNICATION TO STAKEHOLDERS 17

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