International Journal of Behavioral and Consultation Therapy Volume 3, No. 1, 2007 Cost Effectiveness of the Instrumentalism in Occupational Therapy (IOT) Conceptual Model as a Guide for Intervention with Adolescents with Emotional and Behavioral Disorders (EBD) Moses N. Ikiugu & Lynne Anderson Abstract The purpose of this paper was to demonstrate the cost-effectiveness of using the Instrumentalism in Occupational Therapy (IOT) conceptual practice model as a guide for intervention to assist teenagers with emotional and behavioral disorders (EBD) transition successfully into adulthood. The cost effectiveness analysis was based on a project involving 15 teenagers treated by the first author and a colleague in a Day Treatment Center in a small town in northeast Pennsylvania. The analysis revealed that the cost of intervention per positive effect realized per teenager was US$162.88. Further research is indicated to determine how this effect translates into monetary benefits. Keywords: cost-effectiveness, Instrumentalism, adolescence, emotional and behavioral disorders, Cognitive-Behavioral Therapy. Introduction Adolescence is an age of transition in which an individual leaves childhood and prepares to enter adulthood (Bruce & Borg, 1993). While many adolescents make the transition without significant difficulties (Haiman, Lambert, & Rodrigues, 2005), others find adolescence to be a stressful and challenging phase of development. Even well adjusted adolescents experience the tasks of this developmental stage as difficult (Ikiugu, 2007; Ikiugu & Ciaravino, 2006). The strain of adolescence likely increases the susceptibility to what developmental theorists call internalizing problems such as depression, anxiety, and withdrawal, as well as externalizing problems, such as aggressiveness and delinquent behavior (Ronnlund & Karlsson, 2006) According to Eckstein, Rasmussen, and Wittschen (1999), the transition into adulthood may cause instability in an adolescent’s life that may result in insecurity, confusion, alienation, and identity problems. For adolescents who have emotional or behavioral disturbances, making this transition into adulthood may be especially challenging (Ikiugu & Ciaravino). The normative tasks of adolescence include developing an identity, disengaging from the family, and being included in peer groups (Patterson & McCubbin, 1987), yet it also includes creating a healthy sexual identification, planning for future work and relationship endeavors, and developing a moral value system (Malekoff, 2004). According to Hauser and Greene (1991), when the individual transitions from adolescence to young adulthood, he/she: forms an initial adult identity and develops a value system, forms relational commitments, and makes vocational commitments. White, Labouvie, and Paradaratsakis (2005) indicated that the adolescent must master the tasks of identity formation and establishment of mature relationships for the successful transition into emerging adulthood; however, problems that prevent accomplishment of tasks at this stage include drug abuse, which is especially problematic for youth transitioning from high school to college. White et al. suggested that changed roles, socialization patterns, and decreased family and social control due to decreased proximity to family members are factors that are linked to substance use in college. The authors of the present paper suggest that the IOT model can offer an effective guide to intervention aimed at preventing such problems of transition by providing adolescents with a mission in life to which they can focus rather than using substance abuse. 53 International Journal of Behavioral and Consultation Therapy Volume 3, No. 1, 2007 Further review of the literature by White et al. (2005) revealed that alcohol and marijuana use were not related to college status; rather, college-bound adolescents used marijuana and cigarettes less than non-college bound adolescents and reported fewer incidences of marijuana and alcohol related problems. Additionally, those who left high school but did not go to college tended to have more alcohol- related problems. College status was found to be a predictor of both alcohol and marijuana use patterns (White et al.). It appears that transitioning from high school to college increases the risk of alcohol related problems but not use of other substances, whereas dropping out of high school placed the adolescents at highest risk of alcohol and other substance related problems. College seemed to insulate participants particularly from using marijuana and cigarettes, which suggested the need for prevention/cessation programs for non-college bound students to prevent these problems. IOT might be well placed to accomplish this objective by focusing adolescents on a vision of adult roles which would decrease the likelihood of dropping out of high school and increase the likelihood of going to college or other tertiary institutions. This is particularly crucial since as White et al. point out, there are few prevention programs aimed at intervention in this developmental stage outside of college campuses. Since adolescents with emotional and behavioral disorders (EBD) are at a higher risk than their typical peers for experiencing problems during the transition into adulthood (Ellisckson, Saner, & McGuigan, 1997), there is a justified need to develop particular programming to address their special needs. Specifically, there is a need to provide comprehensive and integrative services for adolescents with EBD to facilitate their successful transition into adulthood (Armstrong, Dedrick, & Greenbaum, 2003). As the distinct changes associated with adolescence introduce a set of stressors and strains, there are unique opportunities for intervention (Sherrod, Haggerty, & Featherman, 1993). Review of the literature revealed that there are several interventions that have been proven effective in the treatment of various problems of adolescence, such as anxiety disorders, depression, eating disorders, disruptive behavior disorders, health risk behaviors, and multiple problems of adolescence (Roberts, Lazicki-Puddy, Puddy, & Johnson, 2003); however, specific programs designed for assisting adolescents to make the developmental transition to adulthood are limited. Roberts et al. investigated the efficacy of treatments of various conditions and noted that “Studies of clinical effectiveness in adolescent psychotherapy are limited” (p. 1178). They found treatments carried out in the clinical settings to be more effective than those conducted in school settings. Furthermore, they found counseling to be more effective than psychoeducation. Particularly, Roberts et al. (2003) found Cognitive Behavioral Therapy (CBT) to be effective in the treatment of anxiety, and obsessive compulsive disorder (OCD). Specific interventions included cognitive restructuring which is comprised of problem-solving, self-monitoring, and self instruction. Additionally, Roberts et al. reported that CBT is utilized in treating depression and posttraumatic stress disorder (PTSD), as is cognitive restructuring in treating PTSD. Individual therapy, family therapy, and education are used to treat bulimia nervosa, and CBT has been shown to help with dietary restraint and improve attitudes about weight. Behavioral strategies such as modeling, reinforcement, and systematic desensitization have been found to be effective in treating phobias and disruptive behavioral disorders. Roberts et al. (2003) reported that multisystemic therapy (MST) is a comprehensive approach that addresses problems of adolescents with multiple problems. MST addresses issues related to the adolescent’s life at home, in the community, and in the school. Factors within the adolescent’s family, peer, school, and social networks which are associated with problem areas are taken into account during the intervention (Henggeler & Sheidow, 2003). Thus, MST is more inclusive and focuses on the adolescent’s world more holistically. This is of particular interest as adolescent problems rarely present as single isolated issues. As Roberts et al.state: “The majority of treatment outcome research has been conducted on single disorders, but as seen in everyday practice, the majority of psychopathology occurs 54 International Journal of Behavioral and Consultation Therapy Volume 3, No. 1, 2007 in the presence of other conditions in addition to family, peers, and other psychosocial stressors” (p. 1185). IOT may be considered to be similar to MST, except that it does not particularly focus on the home and family. It differs from MST and many other approaches because it focuses on helping the adolescent restructure his/her life in general rather than concentrating on specific problems. The IOT is also comparable to the Functional Family Therapy (FFT) approach which comprises of 5 phases: 1) Engagement – identifying factors that would prevent risky consequences; 2) Motivation – the adolescent and family become committed to creating lasting change; 3) Assessment – identifying relationships between the individual, family, and community, and social service factors that may be included in change strategies; 4) Behavior change – initiating strategies to facilitate actual change; and 5) Generalization (Roberts et al., 2003). FFT compares with the phases of IOT guided therapy, which are belief establishment, action, and consequence appraisal (Ikiugu, 2004b, 2004c, 2007). However, Roberts, et al. infer that “adolescent psychotherapists need to be involved in the clinical research to evaluate effectiveness of approaches not yet fully supported” (p. 1189). IOT falls in this category. The challenge is now to conduct further research to demonstrate the clinical effectiveness of IOT. Ikiugu and Ciaravino (2006) argued that Instrumentalism in Occupational Therapy (IOT) is well suited to help adolescents with EBD manage the tasks of adolescence, thereby facilitating their successful progression into adulthood. As mentioned earlier, IOT is in many ways similar to MST. However, since it is based on the occupational therapy perspective, it has a unique focus on doing, and it aims to assist the adolescent reorganize his/her life in general (Ikiugu & Ciaravino). Specifically, it’s focus is on assisting the client develop a life mission statement and develop a strategy to modify occupational performance as needed to participate effectively in the family, school, work, social, and community settings in order to achieve the stated mission. Further, this conceptual model endeavors to help the adolescent negotiate the tasks of thinking about future education and work roles, establish mature relationships, and establish self- identify (Ikiugu & Ciaravino, 2006). The purpose of the present paper is to demonstrate the cost-effectiveness of IOT as a guide to therapeutic intervention to assist individuals in the adolescent developmental stage transition more successfully into adulthood. Specifically, the IOT conceptual model will be outlined including a step-by- step description of the therapeutic protocol based on the model’s guidelines. Further, the use of IOT as a therapeutic guide for intervention for adolescents with EBD will be described, and the relationship of IOT to other approaches used to treat adolescents with EBD will be discussed. Finally, the cost-effective analysis of the model will be completed based on the preliminary findings by Ikiugu and Ciaravino (2006) in their pilot study. Description of the Instrumentalism in Occupational Therapy Conceptual Model Instrumentalism in Occupational Therapy (IOT) was developed as a result of a search for a method of practicing occupational therapy that was authentic. The first author had observed (his observations were confirmed by others in occupational therapy literature) that occupational therapists often seemed to resemble physical therapists (when working with clients with physical disabilities) or social workers (when working in mental health) in practice (Ikiugu, 2001; Ikiugu & Rosso, 2003; Ikiugu & Schultz, 2006). This loss of identity was confirmed by the fact that few occupational therapists chose to practice in psychosocial settings although the profession actually originated from mental health (Ikiugu, 2004a; Ikiugu & Rosso, 2003). He argued that this loss of identity could be alleviated by identifying the philosophical basis of the profession. In his subsequent research, he reviewed and analyzed historical occupational therapy literature to determine the profession’s self-definition by explicating its narrative genres (Detweiler & Peyton, 1999). He used Bakhtin’s method of identifying and analyzing the profession’s time-periods (referred to as chronotopes). This investigation led to the conclusion that consistent with what others had argued (Breines, 1986; Cutchin, 2004; Wilcock, 1998), there was 55 International Journal of Behavioral and Consultation Therapy Volume 3, No. 1, 2007 evidence that pragmatism was the philosophical foundation of occupational therapy (Ikiugu, 2001; Ikiugu & Schultz, 2006). The philosophical discourses of William James and John Dewey were found to be particularly instructive in helping occupational therapists conceptually understand their practice. He created IOT as an attempt to offer a conceptual model of practice that was consistent with the philosophical principles of pragmatism in order to provide a way of doing occupational therapy that was conceptually consistent with the philosophical underpinnings of the profession and therefore authentic. It is therefore essential that the reader understand the basic propositions of pragmatism in order to comprehend the arguments of IOT. Pragmatism was founded by Charles Sanders Peirce based on the primary proposition that belief is a rule for action (Peirce, 1955). According to Peirce, the mind has a need to dispel doubt and establish belief. When one has a belief, he/she acts in a manner that is consistent with that belief. For example, if you believe that the object in front of you is a chair, you are likely to attempt to sit on it. If however the consequences of your action, based on the belief that the object in front of you is a chair, are different from what was expected, e.g., if in an attempt to sit down you fall through the supposed object, there is a sense of doubt in the mind. You then act to dispel the sense of doubt and re-establish belief (for instance by investigating the phenomenon more closely in order to determine what it is that you thought was a chair) which is the preferred state of the mind. According to Peirce, this is the basis of all human action, including scientific inquiry. We act in order to verify our beliefs in the laboratory of experience. Furthermore, as one repeats certain actions that are consistent with a particular belief, a habit is formed. William James, another influential pragmatist further developed the idea of habit formation as a basis of efficacious functioning in our environment (James, 1977). He argued that habits are formed by etching within the neurons traces of human experiences. He postulated that habits are so important that they actually determine the well-being of entire societies. He therefore proposed that we should pay close attention to the habits that we form. Furthermore, habits are not formed in isolation, but rather in the context of other habits. For instance, if you want to quit smoking, you cannot succeed by focusing on the behavior of smoking alone. You need to stop all related behaviors, for instance visiting bars and other environments where smoking and activities that encourage smoking, such as drinking occur. You may even have to alter your socialization patterns so that you make new friends who do not smoke and keep away from those that smoke, at least until you have successfully quit. Furthermore, the new habit patterns that one wishes to form must be nurtured carefully, because a moment of weakness could lead to undoing what may have taken a long time to cultivate. For instance, it takes only one puff from a cigarette for someone who has almost succeeded in quitting smoking to revert to being a full-pledged smoker. Habit formation has always been a fundamental part of occupational therapy practice and is emphasized in the IOT model (Ikiugu, 2004c, 2007; Kilehofner, 2002). Furthermore, James (1977, 1981; see also McDermott, 1977) extended Peirce’s idea of belief as a rule for action by arguing that human beings are not apart from nature, but are part of nature. This idea was also influenced by the theory of evolution which was influential in the development of the philosophy of pragmatism as indicated by Peirce’s (1955) reverence of Charles Darwin, whom he thought was the greatest intellect of his time. Similarly, James (1977) expressed his view that Darwin’s ideas are a given and used them to support his theory of habit formation and human instincts. Therefore, according to James, the human mind is nothing more than a tool that the human being uses by acting on his/her beliefs to solve environmental problems that pose a challenge to comfortable existence. This notion was used by John Dewey (1996, 1981) to develop his doctrine of instrumentalism. By instrumentalism is meant use of the mind, including its products such as social and cultural institutions, and theories, to solve problems and fashion the environment so that it becomes “home” for human beings. This was the notion that the author of the IOT thought was most applicable to occupational therapy and which was operationalized in the model for application in clinical practice. 56 International Journal of Behavioral and Consultation Therapy Volume 3, No. 1, 2007 The idea of instrumentalism (that the human mind is a tool like any other that human beings use to solve environmental problems and shape the environment to support human survival) implied that individuals can be taught to use their minds more efficiently to respond to challenges in their environment through appropriate choice and performance of daily occupations in order to achieve valued goals just like they can be taught to use other tools, such as computers or hammers. Therefore, the author conceptualized the IOT as a model designed to operationalize the construct of instrumentalism. In this perspective, the role of the occupational therapist was seen as that of teaching clients to use their minds more effectively by identifying what they want to achieve in life (desired consequences), identifying beliefs that are consistent or inconsistent with those consequences, changing beliefs that are inconsistent with desired outcomes and substituting them with more consistent ones, and committing to act through occupational performance in accordance with the newly established set of beliefs until habits that are consistent with one’s goals in life are formed (Ikiugu, 2004b, 2004c). The model was conceptualized to consist of three phases (Ikiugu, 2004 b): a) Belief establishment – The client is guided to identify beliefs that support (are adaptive) or impede (are maladaptive) actions consistent with desired life goals, and to develop or establish those that may be more supportive of those goals (are adaptive); b) Action phase – The client is encouraged to identify occupations that are consistent with the more adaptive beliefs whose regular performance would lead to achievement of desired goals in life, and to commit to regular participation in those occupations. Occupation is used in the IOT model as defined in occupational therapy literature to refer to “doing” those things that one wants, needs, or is required to do in his or her everyday life in order to participate effectively in life (American Occupational Therapy Association, [AOTA], 2002; Law et al., 2002). Such occupations can be classified into three categories; self maintenance (occupations that one needs to do in order to survive and live with dignity, such as toileting, bathing, dressing, feeding oneself, etc.), productivity (occupations that one has to do to contribute to the welfare of one’s community and/or earning a living such as paid work, volunteering, taking care of others, home management, etc.), and leisure pursuits (occupations that one does for pleasure such as reading for recreation, watching movies, playing sports, going out with friends, etc.). c) Consequence Appraisal phase – This refers to regular evaluation of consequences of participation in occupations in order to determine if one’s actions are consistent with progress towards life goals. The three phases are illustrated in figure 1 below. Phase 1 Phase 2 Phase 3 Belief Establishment Action Appraisal of Consequences Clarifying beliefs Designing activities Evaluating consequences that guide actions that strengthen to determine if they are appropriate beliefs and what was expected committing to their performance Feedback loop: Using consequences to adjust beliefs Figure 1. Adapted from, “Instrumentalism in occupational therapy: A theoretical core for the pragmatic conceptual model of practice”, in M.N. Ikiugu, International Journal of Psychosocial Rehabilitation, 8, p. 151. Copyright, 2004 by the Hampstead Psychological Associates, Ltd. 57 International Journal of Behavioral and Consultation Therapy Volume 3, No. 1, 2007 The above three phases are clinically applied through the following steps, guided by an instrument (Assessment and Intervention Instrument for Instrumentalism in Occupational Therapy [AIIIOT]) that was developed for use with the model (Ikiugu, 2004c, see appendix A): I) Establishing a personal mission statement. The statement should incorporate participation in the following four areas of the client’s life – family, work/school, socialization, and community. II) Identifying occupations performed in a specified period of time (e.g. four days) prior to the day of assessment using the Daily Occupational Inventories (DOIs, see appendix B). To complete the instrument, the individual being assessed enters in the inventory occupations in which he/she is engaged every hour from 6:00 am to 12:00 midnight every day for the specified number of days. Use of this instrument is based on the hypothesis derived from chaos/complexity/dynamical systems theory that the occupational human being is a complex, dynamical, adaptive system (Ikiugu, 2004b, Ikiugu & Rosso, 2005). The author of the IOT model proposed that chaos/complexity/dynamical systems theory is an improved version of the theory of evolution. Therefore, since the theory of evolution significantly informed the conceptual development of occupational therapy through the influence of the philosophy of pragmatism, complexity theory (an improved explanatory version of the theory of evolution) should be the primary theoretical framework of occupational therapy. One of the constructs borrowed from chaos theory that was postulated to be useful in occupational therapy was fractality (Ikiugu, 2007a; Ikiugu & Rosso, 2005). This is the notion that a trajectory of a complex system consists of self-similar patterns. For instance, a person’s occupational life examined over time would reveal self-similar performance patterns (e.g., giving up every time when faced with a challenge, or being engaged in certain types of occupations at a certain time on a certain day every week). It was postulated that documentation of occupations performed over a specified period of time would reveal patterns of performance within that time period and give the therapist and indication as to whether those patterns are adaptive or maladaptive. Ikiugu and Rosso (2005) developed an algorithm (P =∑P=∑[FxPI]) for use in an Occupational Performance Calculation Guide (OPCG), where P=Total t i t performance score, P=Performance score for each of the five occupations used to calculate the score, i which is the product of the frequency with which the occupation is performed and the performance index, F=The frequency of performance of each of the occupations as indicated in the number of entries in the DOI, and PI=Performance Index for each of the top 5 occupations ranked in order of their importance in helping the person achieve the stated personal mission in life (I=5 for occupation ranked number 1 in importance, 4 for number 2, 3 for number 3, 2 for number 4, and 1 for number 5). The algorithm allows calculation of daily performance scores that could be graphed to indicate performance patterns or compared mathematically to determine an individual’s progress in the frequency of participation in occupations perceived to be important for achievement of personal mission in life. Occupations in each of the four areas of the mission statement (2 each for participation in family, work/school, socialization, and community respectively, for a total of 8 occupations) whose regular performance would lead to achievement of the stated personal mission in life are also identified. III) Rating self on 4 scales (each scale anchored at 1 and 4) – frequency, perceived adequacy, satisfaction, and belief about ability to perform each of the 8 occupations identified using the AIIIOT with desired frequency and adequacy. IV) Establishing reasonable, understandable, measurable, behavioral, and attainable goals to facilitate satisfactory performance of each of the 4 occupations whose satisfaction with performance is rated at less than perfect. V) Committing to regular performance of the occupations related to established goals both during intervention sessions and in the client’s daily life in between sessions. VI) Reassessment of performance by rating self on the 4 scales (frequency, adequacy, satisfaction, and belief) to determine the extent to which the established goals are being met. The 6 steps may be classified under each of the three phases of the IOT model as follows: Phase 1 – Belief establishment (Steps I, II, and III); Phase 2 - Action (Steps IV and V); and Phase 3 – Consequence appraisal (Step VI). 58 International Journal of Behavioral and Consultation Therapy Volume 3, No. 1, 2007 Application of IOT Guidelines in a Program to Assist Adolescents with EBD Transition into Adulthood The IOT conceptual model was clinically tested in a pilot study involving teenagers attending a Day Treatment Center in a small town in northeast Pennsylvania (Ikiugu & Ciaravino, 2006). The adolescents ranged in age from 13 to 19 years, and they were referred to the Day Treatment Center either by the teachers or by the Court system for therapy due to drug problems, trouble with the law (e.g. involvement in physical violence), or other emotional and behavioral problems. Because some of the participants in the study were 18 and 19 years old, they will subsequently be referred to as teenagers rather than adolescents in this paper from this point on. Specific formal EBD diagnoses of the teenagers were not available to the investigators. Both the investigators were licensed occupational therapists at the time of the study. The first author holds a master’s degree in counseling psychology in addition to a doctorate in occupational therapy and has practiced counseling for about five years. The co-investigator at the time of the pilot project was also a licensed clinical psychologist in addition to occupational therapy credentials. In this pilot project, the program was conducted as follows: 1) Assessment: Assessment instruments (the AIIIOT and DOI) were administered. Other assessment instruments used were the Canadian Occupational Performance Measure (COPM) which is used to guide the client to identify occupations that he wants, needs, or is required to do and to identify performance issues associated with those occupations, the Allen Cognitive Level Screen (ACLS) test, and phenomenological interviews. The COPM was crucial to identifying changes in occupational performance patterns. The phenomenological interviews were important for helping identify the teenagers’ visualization of their desired future as adults and clarity of actions needed in the present to increase the likelihood of realizing that future. During the interviews, the teenagers were requested to state how they imagined their lives to be 10 years from the time of the interview, including the kind of work they would be doing, friends with whom they saw themselves socializing, whether or not they had a family and what kind of family, etc. They were also requested to explain what they were doing or could do at the present time in order to achieve that visualized future. The interviews were rated on a scale ranging from zero to 4 with regard to how clear the visualized future was, and clarity of the verbalized plan to achieve that future. The ACLS was for research purposes only and will not be described in this paper since it is not central to clinical application of IOT. The AIIIOT and DOI have already been described above, and samples of completed instruments are shown in appendixes A and B. The AIIIOT takes about 1 hour 15 minutes to administer (1 hour to establish a personal mission statement and identify occupations whose performance would lead to achievement of that mission, and 15 minutes for self rating on the 4 scales and establishment of goals). The instruments can be administered in a group setting. The DOI takes approximately 20 minutes to complete every day. A 4 day inventory would take about 80 minutes to complete. It takes the occupational therapist about 15 minutes (depending on how many days the inventories were completed) to generate a list of occupations in which the client engaged over the specified period of time, classify them into categories of occupational performance as defined in the American Occupational Therapy Association’s (2002) practice framework (Activities of Daily Living [ADLs], Instrumental Activities of Daily Living [IADLs], Education, Work, Play, Leisure, and Social Participation), tally the frequency with which each occupation was entered in the inventories, request the client to rank the occupations in the list in order of importance in helping him/her achieve the stated mission in life, and calculate the client’s occupational performance score. Therefore, client assessment using the IOT guidelines takes about 2.8 to 3.5 hours, depending on the number of days that the client completes the DOIs. 59 International Journal of Behavioral and Consultation Therapy Volume 3, No. 1, 2007 2) Goal setting: Based on self ratings on the AIIIOT, individual goals were established for each teenager in collaboration with him/her. A short term goal (to be achieved in no more than 4 weeks) was set for each of the 8 occupations identified in the AIIIOT assessment whose rating of satisfaction was less than 4. Establishing goals took approximately 10 minutes for each client. 3) Intervention: Based on the postulations of developmental theorists who argue that adolescence is a stage in which individuals learn to develop personal identity and mature relationships among other things (Gay, Williams, & Flagg-Williams, 1997; Roisman et al., 2004; Schiller, 1998; Shulman & Ben-Artzi, 2003), it may be beneficial to use group interventions to facilitate interaction with peers leading to learning of mature socialization behaviors. Therefore, in the program by Ikiugu and Ciaravino (2006), the group intervention format was used. Individual group participant’s (teenagers in the program) goals were used to develop a group protocol for each session based on the guidelines by Cole (2005) (see appendix C for an example of a group protocol used in one of the sessions). The goal that was common to most teenagers was used to establish the protocol for the first session, the next most popular goal for the second session, and so forth until all participants’ goals were addressed. Group sessions were conducted once a week for 1 hour each. Each session consisted of explaining to participants the purpose of the group, describing the activities (occupations) in which participants would be engaged during the group session (examples of group occupations included creating a poster to teach younger elementary students the dangers of drug abuse, creating a collage depicting what each teenager could do to facilitate family participation in leisure occupations, how to go about searching and preparing for a career, etc.), participation in the group activity (occupation), processing of participants’ experiences while engaging in the group activity, and discussion about how they would apply what was learned in the group to their lives in general. Depending on the number of participants in the group and how varied group members’ goals are, it may take between 5 and 12 weeks to address all participants’ short term goals. Therefore, group interventions may take between 5 and 12 hours. According to the investigators’ experience, 8 teenagers constituted the optimum number of participants with whom they could intervene effectively. Less than 8 participants would work well but more than that may be challenging especially when dealing with teenagers with significant emotional challenges. It is recommended that clients be seen individually as well, in order to reinforce lessons learned during the group sessions. However, due to time limitations, individual sessions were not conducted during this pilot test of IOT guidelines, except for assessment. 4) Reassessment: Ideally, clients should be re-assessed every week or 2 weeks. However, due to time limitations, the investigators in this pilot project were not able to assess clients frequently. Instead, DOI, COPM, and AIIIOT instruments, and the phenomenological interviews were administered to every teenager after the 6 week group interventions to determine any progress attained. Pre-test scores were subtracted from post-test scores to determine change in visualization of future and actions needed to achieve that future and also change in occupational performance patterns. Relationship of IOT to other interventions used to treat adolescents with EBD The 1997 re-authorization of the Individuals with Disabilities Education Act (IDEA) required that students (including teenagers) with significant behavioral difficulties be provided assistance (Waguespack, Vaccaro, & Continere, 2006). This requirement called for development of methods of assessing their function. Functional Behavioral Analysis (FBA) strategies were developed to address this need. The behavioral analysis emphasizes identification of problem behaviors, assessment of antecedents 60 International Journal of Behavioral and Consultation Therapy Volume 3, No. 1, 2007 to those behaviors (answering the question of why problem behavior is occurring), and development and implementation of appropriate interventions. The specific steps of FBA include “(a) Information gathering, (b) hypothesis formation, and (c) hypothesis testing” (p. 464). Consistent with FBA, IOT is an individualized intervention that also emphasizes thorough information gathering as a basis for intervention planning. However, the model does not focus on specific problem behaviors. Rather, information gathering and subsequent intervention planning addresses the broader issue of the teenager’s vision of him/herself in the future while acknowledging that there is a significant discrepancy between the visualized future and present circumstances. Also, Cognitive Behavioral Therapy (CBT) principles have been found to be the most effective as a guide to interventions to address various psychosocial issues of teenagers, from anxiety and obsessive Compulsive Disorders to substance abuse problems (Gosch, Flannery-Schroeder, Mauro, & Compton, 2006; Roberts, et al., 2003). Cognitive-Behavioral Therapy strategies involve identifying distorted cognitions that lead to maladaptive behaviors, disputing those cognitions through carefully designed experiments where maladaptive beliefs are challenged, and providing the client with experiences to help increase his/her sense of efficacy (Bandura, 1977, 1986; Ellis, 1962; McGinn, 1997; Patterson, 1980). Instrumentalism in Occupational Therapy has similarities to CBT approaches. For instance, like CBT, IOT guided intervention incorporates both the cognitive (visualization of one’s desired future) and behavioral (performance of occupations consistent with visualized future) strategies. Similarly, just as therapy based on Bandura’s social learning theory emphasizes establishment of the “sense of self- efficacy” by increasing “perceived self-efficacy” and “belief” in efficacious functioning and coping through “performance accomplishments” (Gosch et al., 2006, p. 250), IOT guided assessment evaluates the client’s belief in ability to perform occupations crucial to attainment of life mission with satisfactory adequacy (where adequacy is defined as performance with efficiency and effectiveness) and frequency, and intervention involves presenting the client with opportunities to perform desired occupations so as to experience a sense of accomplishment. Other intervention strategies used with teenagers that are conceptually similar to IOT include Multisystemic Therapy (MST) which is a comprehensive approach and like IOT focuses on the teenager’s world holistically (including the family, peers, school, and broader community participation contexts), and Functional Family Therapy (FFT) whose primary goal is to improve family communications and supportiveness and in the process decrease the negativity within the family system (Roberts et al., 2003). However, IOT is unique in comparison to all the above therapeutic approaches in that it is an occupation- based intervention. Therefore, its emphasis is on enhancement of participation in daily occupations that the teenager wants, needs, or is expected to perform in order to function effectively according to cultural and developmental stage expectations. Furthermore, rather than focusing on specific problem behaviors, IOT aims at helping the teenager restructure his/her life in general, hence, the need to establish a personal mission statement around which daily occupational pursuits can be organized. This is consistent with the pragmatic proposition as advanced by James (1977) that if we want to facilitate meaningful change so that the individual transitions from a maladaptive to an adaptive state of existence, then we have to aim at changing the entire lifestyle rather than specific behaviors piecemeal. Helping the teenager establish a personal mission statement aims at achieving such a lifestyle re-organization which might be the most effective way of addressing the emotional and behavioral challenges of adolescents which according to Roberts et al. often present as multiple problems rather than single discreet issues that may be addressed sequentially one after another. Cost-Effectiveness of the IOT model as a Guide to Intervention to Assist Adolescents with EBD Transition Successfully to Adulthood 61 International Journal of Behavioral and Consultation Therapy Volume 3, No. 1, 2007 Cost-effectiveness analysis in mental health refers to an attempt to determine the ratio of effectiveness of providing services to the cost of those services (Frank, McGuire, Normand, Goldman, 1999; Haby, Carter, Mihalopoulos, Sanderson, & Vos, 2004; Yates, 1999). Effectiveness is estimated from indicators such as change in the quality of life, decreased rates of relapse and avoidance of illness, accessibility of services, applicability of services, quality of therapeutic interventions, and research evidence supporting clinical efficacy of those interventions. In the present paper, indicators of effectiveness were the teenage participant’s change in visualization of the desired future adult self, and occupational performance patterns as evidenced by findings from the pilot study by Ikiugu and Ciaravino (2006). According to Yates (1999) cost-benefit analysis refers to the measurement of both costs and outcomes and expressing them in monetary terms; however, certain effects cannot be assigned monetary values (National Institute on Drug Abuse [NIDA], 2005). In the present paper, the gain from intervention can be assessed from teenagers’ change in visualization of their desired future adult lives and subsequent change in occupational performance behavior and attitudes. The only evidence that the authors have supporting this gain is from the pilot study by Ikiugu and Ciaravino (2006), which was a test-retest investigation with no control group. Also, the sample was small (only 15 participants). It was therefore a level IV study [according to the widely accepted levels of evidence as outlined in the criteria for evidence-based practice (Trombly & Ma, 2002). In that criteria, the strongest evidence (Level I) is considered to be based on a meta-analysis of Randomized Control Trials. Level IV studies consist of a single sample with no control group, measured two or more times over time. Furthermore, the sample size was at the weakest level (Level C, less than 20 persons in the sample)]; therefore, the evidence provided by Ikiugu and Ciaravino’s study for effectiveness of intervention using guidelines from the IOT model would be considered inconclusive according to Yates. However, this judgment of inconclusiveness is only from the perspective of quantitative research. When the phenomenological portion of the study was taken into account, there was reason to believe that the intervention was somewhat effective. Therefore, while Yate’s proposed method of calculating the cost of the program described in Ikiugu and Ciaravino’s study was used to calculate the cost-effectiveness analysis in this paper, it was acknowledged that there were limitations regarding the confidence with which the effectiveness of the intervention as deduced from that study may be interpreted. Based on the guidelines by Yates, the following were calculated in this paper: the cost of providing services as described in the program by Ikiugu and Ciaravino; the effectiveness of the intervention as deduced from the findings of the study; and the value of intervention as indicated by the number of dollars invested in the program per positive effect realized from the intervention per teenager involved. The American Heritage Dictionary of the English Language defines cost as “The expenditure of something, such as time or labor, necessary for the attainment of a goal”. Cost is estimated from the price of service provision, such as the cost of: hospitalization, services provided directly to the client by a provider, organization and operation of services, and time (Yates, 1999). Cost-effectiveness analysis represents a calculation of the cost of services and dividing it by effectiveness to obtain a cost- effectiveness ratio in terms of cost per unit of input/value per unit output. Cost-Effectiveness analysis can be calculated at both the individual (micro) and system (macro) levels. In the present paper, the focus will be on the individual level. To calculate the cost, the worksheet provided by Yates (1999, p. 24) was used. All resources used in the process of intervention in the pilot study by Ikiugu and Ciravino (2006) were recorded to ascertain the specific cost of each item of the resources. Included in the list were: time spent by all personnel in ensuring success of the program (including the time invested by two occupational therapists, two Day Treatment Center teachers, two graduate student occupational therapists, and the Day Treatment Center administrator); supplies and equipment needed for assessment of each of the teenagers and for group 62