Gordon L. Paul

Involuntary commitments to public mental institutions: issues involving the overrepresentation of blacks and assessment of relevant functioning

This article contributes to the debate in the mental health and legal systems concerning involuntary commitments to mental hospitals. The focus is on issues involving the overrepresentation of Black people among adults committed to U.S. public mental institutions and issues involving the assessment of relevant behavioral functioning in particular. Empirical findings, legal principles and procedures, and methodological limitations are reviewed to identify problems in current practice and relevant evidence bearing on those problems. Special emphasis is placed on the possible explanations for the overrepresentation of Blacks and on dependable assessments of relevant functioning that are needed to justify the states coercive power to involuntarily confine people, regardless of race. The article concludes with a summary and recommendations for research and practice.

Effectiveness of inpatient treatment programs for mentally ill adults in public psychiatric facilities

Abstract This article updates the current state of knowledge and research on the effectiveness of inpatient treatment programs for mentally ill adults in the public sector to provide guidance for improving both research and services. National figures show inpatient facilities to still be predominant in the U.S. public mental health system; the populations and programs in these facilities are in serious need of science-based assistance. We summarize the major conceptual factors that influence the conduct and interpretation of inpatient outcome studies, clinical trials, or program evaluations (relevant domains and classes of variables, unit of analysis and effectiveness criteria, empirical findings on moderator variables). The major inpatient treatment approaches are described, and the empirical literature on effectiveness is reviewed. We conclude with a summary of the substantial accumulated evidence and recommendations for use of new assessment technology to assist with implementation of effective approaches and for advancing promising lines of research. The time seems ripe for exciting science-based advances in research and services.

Systems use to objectify program evaluation, clinical, and management decisions

The utility of the observational assessment systems at different levels — from local clinical to systemwide management — is outlined. An overview is provided of TSBC information applied to individualized problem identification and programming/monitoring, discharge and competency determinations, and both absolute and comparative program evaluation. The utility of SRIC information for prgoramming/monitoring and for staff training and evaluation is outlined in addition to the applied uses of the information of the assessment systems in combination. Once implemented, the continuous data from the systems allow for empirically based self-corrective improvements in the quality of mental health services while automatically providing a basis for legal documentation and accurate cost/effectiveness comparisons of mental health programs.

Can pregnancy be a placebo effect?: Terminology, designs, and conclusions in the study of psychosocial and pharmacological treatments of behavior disorders

This paper discusses several salient issues in the clinical research enterprise which were stimulated by chapters on research methods and placebo phenomena in White, Tursky and Schwartz (1985), Placebo: Theory, Research, and Mechanisms. These issues include the commonalities of questions, domains and classes of variables, and research strategies needed for the discovery, accumulation and application of knowledge regarding effective clinical treatments. Problems of unwarranted uniformity assumptions and absolute design requirements as well as the failure to attend to the conceptual relevance, strength and integrity of procedures are noted with examples from the systematic desensitization literature. Meta-analyses and indexes of effect size are also examined with examples demonstrating the need for especially cautious interpretation of these procedures. A re-emphasis of the construct validity approach with better designed and executed individual studies is endorsed as the best means to improve progress.

Real-world inpatient programs: Shedding some light—A critique

Abstract This critique is a response to an article by Morisse, Batra, Hess, Silverman, and Corrigan (1996) , in which “a token economy for the real world” is promulgated as an alternative to the comprehensive social-learning program and assessment technology presented by Paul and Lentz (1977) . The article misrepresents the treatment-and-assessment procedures that have been empirically validated as the most effective and cost-efficient for inpatient programs. The article also inappropriately cites the results of prior reports as support for an oversimplified approach to the development and implementation of inpatient programs. The promoted approach is in direct opposition to the widely recognized need for empirically validated interventions and evaluations in mental health services. Not only are data lacking to support assertions of effectiveness for the resulting program but illustrative examples demonstrate technically unsound procedures as well as an ethically questionable emphasis on staff desires to the exclusion of patient needs. We attempt to correct Morisse et al.s inaccuracies and misconceptions regarding the work of Paul and colleagues, note the major problems with their perfunctory approach, and provide recommendations for implementation and maintenance of empirically validated procedures for inpatients.

New assessment systems for residential treatment, management, research, and evaluation: A symposium

An introduction and overview are presented to new observational assessment systems for ongoing assessment and monitoring of both staff and resident (client or patient) functioning in residential treatment programs for emotionally disturbed and mentally retarded adults.

Evaluation of self-contained training procedures for the Time-Sample Behavioral Checklist

The comparative effectiveness of two time-limited modes of training observers to code the behavior of clients in residential treatment programs on the Time-Sample Behavioral Checklist (TSBC) was evaluated. The susceptibility of training procedures to consensual observer drift and the predictability of TSBC mastery from trainee characteristics were also examined. Two equated groups of undergraduate students (N=15 each) participated in full-time training on the TSBC and another instrument for 27 days, followed by criterion testingin vivo and on videotapes. One group was trained by experienced personnel using procedures known to be effective but potentially subject to consensual observer drift. The other group was trained using a previously untested set of written and videotape procedures that do not rely on experienced personnel. Comparative effectiveness and observer drift were evaluated by multivariate and univariate ANOVAs on mastery scores reflecting both pattern agreement and level differences between each trainee and criterion codings. The new, more efficient training procedures were found to be as effective as the original training procedures in the degree of mastery achieved by trainees. Original training procedures were found to be resistant to consensual observer drift, with such a phenomenon appearing in only 1 instance of 156 opportunities. The high degree of mastery achieved by trainees during the time-limited training period was comparable to that previously achieved with the original training procedures. No meaningful predictions of coding mastery were found, with only one trainee characteristic being significantly related to one of six mastery criteria. The results document procedures that are both efficient and resistant to invalidity for training observers in the use of multidimensional observational systems, as well as providing guidelines for the development of standardized procedures.

The comparative effectiveness of two modes of observer training on the Staff-Resident Interaction Chronograph

The comparative effectiveness of two time-limited modes of training observers to code activity on the Staff-Resident Interaction Chronograph (SRIC) in residential treatment programs for mentally disabled adults was evaluated. The susceptibility of training procedures for consensual observer drift was also examined, as was the predictability of SRIC mastery from trainee characteristics. Two equated groups of undergraduate student trainees (N=15 each) participated in full-time training for 27 days, followed by two weeks of criterion testing in vivo and on videotapes. One group received training by experience personnel using procedures known to be effective (original method). The other group received training via a previously untested set of written and videotaped procedures that do not rely on experienced personnel (package method). Multivariate and univariate analyses of variance found both methods to be equally effective in the degree of mastery achieved by trainees, without evidence of observer drift. No meaningful predictions of coding mastery were found, but conceptual mastery was predictable from individual characteristics. Differences were obtained for both groups between in vivo versus videotaped criterion tests. The results document procedures that are both efficient and resistant to invalidity for complex observational methodology as well as feasible for standardizing assessment of staff functioning across residential settings.

Staff performance: do attitudinal "effectiveness profiles" really assess it?

Performance differences were examined for mental hospital staff with divergent profiles on the Opinions About Mental Illness (OMI) that have been purported to reflect differential staff effectiveness. Two staff groups (N = 40 each) were selected, in pairs, from 19 treatment programs serving adult mental patients to provide extremes of “OMI-effective” vs. “OMI-ineffective” profiles while equating groups on demographic, experiential, and program characteristics that had previously been found to influence OMI scores or staff performance. Actual on-the-floor performance was assessed by direct hourly observations obtained on the Staff-Resident Interaction Chronograph over a full week in each program. The OMI-effective group was found to perform greater amounts of overall activity and greater amounts of interaction with institutionalized residents than did the OMI-ineffective group. These differences in public job-relevant activity, likely, provide the basis for earlier reports of positive evaluations for staff who score in the OMI-effective direction. However, the groups did not differ in the specified nature and pattern of their staff-resident interactions when the overall rate of interactions was controlled. Such differences would be required for the OMI to be a measure of staff effectiveness in improving resident functioning. These results, in combination with previous studies, provide little support for the OMI as a measure of effectiveness or as an indirect measure of the goodness of staff performance. The OMI-effective group did produce a higher frequency of interactions, and, thus, the OMI appears to serve as a useful descriptor of staff characteristics that might interact with other variables influencing effectiveness; but the absence of discrimination regarding the more crucial specific nature of interactions indicates that the OMI cannot substitute for direct assessment of actual staff performance.

Consensus judgments of discharge readiness based on paranoid behavior: to what are clinical staff responding?

BackgroundSalinas et al. (J Consult Clin Psychol 4:1029–1039, 2002) found that, contrary to widely held beliefs, paranoid behavior was a positive prognostic indicator for psychiatric inpatients only due to artifactual restrictions on overall level of functioning that result from traditional classification procedures. Paranoid functioning, in fact, negatively impacted consensus staff discharge-readiness judgments. This discrepancy between clinical lore and empirical findings raises a question about the aspects of paranoid functioning to which staff responds.MethodThose aspects of paranoid functioning are examined in this study, using the same sample of 469 inpatients from 19 treatment units reported in the Salinas et al. investigation.ResultsBoth dimensionally measured paranoid functioning and overall level of disability were independently associated with negative discharge-readiness decisions. However, rather than delusions or hallucinations, hostility entirely accounted for the contribution of paranoid functioning to these prognostic judgments.ConclusionWe discuss implications of an alternative approach to classifying patients’ problem behavior for clinical research and practice.