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Full-Text Articles in Rehabilitation and Therapy

Is S-Adenosylmethionine (Same) An Effective Drug To Help Treat Patients With Depression?, Cassidy M. Flanigan Jan 2022

Is S-Adenosylmethionine (Same) An Effective Drug To Help Treat Patients With Depression?, Cassidy M. Flanigan

PCOM Physician Assistant Studies Student Scholarship

 Objective: The objective of the selective EBM review is to determine whether or not “Is Sadenosylmethionine (SAMe) an Effective Drug to Help Treat Patients with Depression?”

Study Design: A systematic review of three randomized controlled trials (RCTs) published between 2016-2020.

Data Sources: All three RCTs were discovered using PubMed. The articles were published in English in peer-reviewed journals and selected based on applicability to the clinical question.

Outcome Measured: A reduction in depressive symptoms was the outcome measured in all three studies using the Montgomery-Asbery Depression Rating Scale (MADRS). The mean change in baseline was calculated once intervention was received. …


Is Botulinum Toxin Effective At Reducing Sensory Symptoms In The Hands Of Patients With Raynaud’S Phenomenon?, Maria C. Dicioccio Jan 2022

Is Botulinum Toxin Effective At Reducing Sensory Symptoms In The Hands Of Patients With Raynaud’S Phenomenon?, Maria C. Dicioccio

PCOM Physician Assistant Studies Student Scholarship

Objective: The objective of this systematic review is to determine, “Is Botulinum Toxin Effective at Reducing Sensory Symptoms in the Hands of Patients with Raynaud’s Phenomenon?”

Study Design: A systematic review of two randomized controlled trials (RCTs) and one prospective case series published between 2017 and 2019.

Data Sources: The articles were discovered using PubMed or Academic Search Premier. The articles were published in English in peer-reviewed journals and selected based on pertinence to the clinical question.

Outcome Measured: A reduction in sensory symptoms was the outcome measured in all three studies using the VAS pain score (0-10/100) or McCabe …


Does Hippotherapy Improve Gross Motor Function In Children With Cerebral Palsy?, Victoria I. Bockius Jan 2022

Does Hippotherapy Improve Gross Motor Function In Children With Cerebral Palsy?, Victoria I. Bockius

PCOM Physician Assistant Studies Student Scholarship

OBJECTIVE: The objective of this selective EBM review is to determine whether or not “Does hippotherapy improve gross motor function in children with cerebral palsy?”.

STUDY DESIGN: A systematic review of three randomized controlled trials (RCTs), with one being a randomized crossover trial. All three were published between 2015 and 2018.

DATA SOURCES: Three RCTs published in peer-reviewed journals were chosen from PubMed. The studies were selected based on their relevance to the clinical question.

OUTCOMES MEASURED: The outcome measured was improvement in gross motor function. Either hip adductor spasticity using Modified Ashworth Scale (MAS) or the Gross Motor Function …


Meaningful Work And Remote Employee Engagement During The Covid-19 Pandemic, Monique Foster Jan 2022

Meaningful Work And Remote Employee Engagement During The Covid-19 Pandemic, Monique Foster

Walden Dissertations and Doctoral Studies

The COVID-19 pandemic accelerated the remote working trend, causing workplace leaders to be challenged and remote employees to feel meaninglessness and lose interest in their work. The subjective nature of meaningful work and enforced remote work is a relatively recent socioeconomic phenomenon, creating a gap in the literature regarding how middle managers foster meaningful work for employees in a remote work environment. The purpose of this qualitative narrative inquiry study was to understand how middle managers fostered meaningful work for employees in a remote work environment during the COVID-19 pandemic. Data were collected from semistructured interviews with 10 middle managers …


Self-Care: An Occupational Therapy Student Perspective, Isabelle Laposha, Stacy Smallfield Jan 2022

Self-Care: An Occupational Therapy Student Perspective, Isabelle Laposha, Stacy Smallfield

Journal of Occupational Therapy Education

Health professional students, including occupational therapy students, report increasing rates of stress, anxiety, depression, and burnout while completing their academic programs of study. Self-care is one potential solution to this crisis, as engagement in evidence-based self-care practices has been found to improve the health and well-being of various student populations; however, the self-care practices of occupational therapy students have not been well studied. Therefore, this study explored how occupational therapy students understand and practice self-care, and how self-care correlates to perceived stress. Twenty participants engaged in a focus group and completed a 72-hour time diary. Focus group results indicated that …


Impact Of An Interprofessional Student-Led Concussion Clinic, Anne W. Hunt, Kathryn Parker, Nick Reed Jan 2022

Impact Of An Interprofessional Student-Led Concussion Clinic, Anne W. Hunt, Kathryn Parker, Nick Reed

Journal of Occupational Therapy Education

This article describes the impact on the learners and health care institution of the OnTRACK-Concussion program, an innovative student-led clinic at a children’s rehabilitation hospital. The clinic, developed and operated by occupational therapists, serves the community full-time year-round. Interprofessional health care learners work together to provide education and intervention for youth with concussion and their families and to support research and community outreach initiatives. To determine the program’s impact on student learning, a post-placement questionnaire was used to capture feedback about their clinical education experience. To determine the program impact more broadly, the most significant change method was used to …


Cross-Cultural Adaptation And Psychometric Evaluation Of The Myanmar Version Of Oswestry Disability Questionnaire And Roland-Morris Disability Questionnaire For Individuals With Low Back Pain, Phyu Sin Oo Jan 2022

Cross-Cultural Adaptation And Psychometric Evaluation Of The Myanmar Version Of Oswestry Disability Questionnaire And Roland-Morris Disability Questionnaire For Individuals With Low Back Pain, Phyu Sin Oo

Chulalongkorn University Theses and Dissertations (Chula ETD)

This study aimed to develop cross-culturally adapted Myanmar versions of the Oswestry Disability Questionnaire (M-ODQ) and Roland-Morris Disability Questionnaire (M-RMDQ), and determine their psychometric properties in individuals with low back pain (LBP). In accordance with the previous guidelines, the original ODQ and RMDQ were translated and cross-culturally adapted into a Myanmar language. The psychometric evaluation of the adapted M-ODQ and M-RMDQ were conducted on 102 individuals with LBP for assessing reliability, validity, and responsiveness. Reliability was assessed using the intraclass correlation coefficient (ICC 2,1) while concurrent and construct validity were examined using the Spearman rank correlation coefficient and correlations with …


Neurophysiological And Psychological Characteristics Of Individuals With History Of Lateral Ankle Sprain, Katherine Bain Jan 2022

Neurophysiological And Psychological Characteristics Of Individuals With History Of Lateral Ankle Sprain, Katherine Bain

Theses and Dissertations--Rehabilitation Sciences

Lateral ankle sprain (LAS) is among the most common lower limb musculoskeletal injuries impacting both the general and sport populations. Even more problematic is that approximately 70% of individuals who sustain an LAS develop residual deficits. Of that subgroup, roughly 40% develop chronic ankle instability (CAI). Chronic ankle instability is a clinical diagnosis defined by the presence of ongoing impairments following the initial LAS which may include perceived instability, pain, mechanical instability, and episodes of giving way during physical activity. Not all who sustain multiple ankle sprains or experience residual deficits fit the clinical diagnosis criteria for CAI; yet may …


Content Validation Of A Patient-Reported Outcome Measure For Pediatric Clients With Hand And Upper Extremity Impairment, Jenny M. Dorich Jan 2022

Content Validation Of A Patient-Reported Outcome Measure For Pediatric Clients With Hand And Upper Extremity Impairment, Jenny M. Dorich

Theses and Dissertations--Rehabilitation Sciences

Occupational therapists and physical therapists practicing in hand therapy have adopted routine use of patient reported outcome measures (PROMs) for evaluating treatment outcomes. However, the PROMs currently used in pediatric hand care are limited in clinical utility for the pediatric population. Thus, a need exists for developing a PROM that is tailored to the pediatric hand therapy population. The overarching purpose of this dissertation is to establish the content validity of a novel PROM for children with hand and upper extremity impairment – the Upper Extremity Life Impact Measure-Youth (UE LIM-Y).

This three-part dissertation applies published standards for PROM development …


The Experience Of Meditation, And Its Effects On Attention, For Adults With Stroke Or Attention Deficit Hyperactivity Disorder: A Three-Part Dissertation With Qualitative And Quantitative Evidence, Cheryl Carrico Jan 2022

The Experience Of Meditation, And Its Effects On Attention, For Adults With Stroke Or Attention Deficit Hyperactivity Disorder: A Three-Part Dissertation With Qualitative And Quantitative Evidence, Cheryl Carrico

Theses and Dissertations--Rehabilitation Sciences

Impairment of attention is common after stroke; is a defining characteristic of attention deficit hyperactivity disorder (ADHD); and has been shown to correlate significantly with difficulties in daily life for individuals with these conditions. More research is needed to establish effective interventions addressing impaired attention in such cases. Meditation is not a standard-of-care intervention for this purpose but may have therapeutic potential. Meditation has been broadly defined as an activity which has self-regulation of attention as its main aim. In other words, it can be considered a training of attention. To shed light on the therapeutic potential of meditation, including …


Increasing Social Inclusion For Children With Disabilities In Faith-Based Settings: A Four-Part Dissertation, Valerie Miller Jan 2022

Increasing Social Inclusion For Children With Disabilities In Faith-Based Settings: A Four-Part Dissertation, Valerie Miller

Theses and Dissertations--Rehabilitation Sciences

The aim of this dissertation is to increase the body of research in occupational therapy about how to increase the social inclusion of children with disabilities in faith-based settings. Even since the advent of important legislation like the Americans with Disabilities Act, which paved the way for community participation for individuals with disabilities, individuals with disabilities continue to face barriers to participating in society. Decreased inclusion for individuals with disabilities is seen throughout all sectors of society. One area of regular societal participation for many Americans is in faith-based settings such as churches, synagogues and temples. It has been reported …


Occupation, Dissociation, And Queer Identity, Katie Christopherson Jan 2022

Occupation, Dissociation, And Queer Identity, Katie Christopherson

Occupational Therapy Capstones

Queer youth and young adults are more likely to experience trauma and are at a higher risk of developing mental health conditions and experiencing dissociation that negatively impacts occupational engagement (Keating & Muller, 2020; Tankersley et al., 2021). This disparity is attributed to environmental factors, such as discrimination (Keating & Muller, 2020). The goal of this project is to advocate for queer youth and young adults through educational resources. The resources were designed for an audience of healthcare professionals who work with queer youth in mental health settings in order to have a broader impact on the target population. The …


Programming To Help At-Risk Youth Find Success In And Outside Of The Classroom, Nora Carlson Jan 2022

Programming To Help At-Risk Youth Find Success In And Outside Of The Classroom, Nora Carlson

Occupational Therapy Capstones

Title: Senior Portfolios: A guide to Help Students Plan for the Transition to Adulthood Nora Carlson, OTDS, Dr. Andrea Young, OTD, OTR/L, Faculty Advisor, Department of Occupational Therapy, University of North Dakota School of Medicine Health Sciences, 501 North Columbia Rd, Grand Forks, ND 58202

Purpose: The purpose of the project was to assist at-risk students attending an alternative learning center (ALC) with secondary transition planning into adulthood to promote a successful first year out of high school. Planning is essential to ensure a smooth transition (Mankey, 2011). This project also aimed to showcase occupational therapy’s role in transition services, …


Protecting Against Pain And Stress In The Nicu: An Evidence-Based Eye Examination Guideline, Heather Jo Bowman Jan 2022

Protecting Against Pain And Stress In The Nicu: An Evidence-Based Eye Examination Guideline, Heather Jo Bowman

Occupational Therapy Capstones

Purpose: The purpose of this project was to create an evidence-based Neonatal Intensive Care Unit (NICU) eye examination guideline and associated resources that supported use of non-pharmacological interventions and emphasized the importance of parent education and involvement from both an interdisciplinary and occupational therapy perspective.

Literature Review: Although medically necessary, researchers and practitioners in the NICU interdisciplinary field have discussed pain and stress associated with preterm infant eye examinations (American Academy of Pediatrics [AAP], 2016; Fierson, 2018; Francis, 2016; Pollaci et al., 2020; Samra & McGrath, 2009). Pain and stress likely impact sensory and overall brain development (AAP, 2016; Brummelte …


An Occupational Therapy Practitioner’S Intervention Guide To Increasing Occupational Engagement In The Virtual Setting With Individuals Diagnosed With Serious Mental Illness, Oluwafeyikemi Deborah Adewoye Jan 2022

An Occupational Therapy Practitioner’S Intervention Guide To Increasing Occupational Engagement In The Virtual Setting With Individuals Diagnosed With Serious Mental Illness, Oluwafeyikemi Deborah Adewoye

Occupational Therapy Capstones

Purpose: The purpose of this scholarly project was to ultimately reduce psychiatric readmissions by enhancing tele-health services to those diagnosed with a serious mental illness (SMI). Coronavirus disease 2019 (COVID-19) brought attention to the barriers regarding public health policies and lack of a national pandemic response approach as care was moved to the virtual context (Robinson et al., 2021). Due to the restrictions set in place, many individuals lost their ability to engage in meaningful occupations (Hoel et al., 2021).

Methods: An in-depth literature review was conducted to better understand the supports and barriers that are affecting effective service care …


Addressing Autism Spectrum Disorder In A School Based Setting, Grant Baker Jan 2022

Addressing Autism Spectrum Disorder In A School Based Setting, Grant Baker

Occupational Therapy Capstones

Autism spectrum disorder (ASD) is a developmental disability that is currently estimated to be diagnosed in 1 in every 59 children (Baio et al., 2018). It has been established that it is important for individuals with a diagnosis of ASD to receive occupational therapy services (McGuire et al., 2015). Due to the high prevalence of an ASD diagnosis and the importance of occupational therapy services for children with this diagnosis there is a need for occupational therapy practitioners in all settings that work with these children to be competent in evidencebased approaches. Currently, students with ASD are receiving occupational therapy …


Referral And Outcomes In An Equine Facilitated Occupational Therapy Program, Julie A. Juracich Jan 2022

Referral And Outcomes In An Equine Facilitated Occupational Therapy Program, Julie A. Juracich

Occupational Therapy Capstones

A miscommunication between referral sources and therapists can lead to difficulties for both parties, as such the purpose of this study is to better understand the perspectives of primary care providers regarding the referral and communication process to equine facilitated occupational therapy. A phenomenological qualitative design was used, seven physicians were recruited through purposive sampling. Each physician participated in a 15-minute interview consisting of 10 open ended questions designed to explore their experiences and perspectives regarding referrals to an occupational therapy program utilizing equine movement. Themes identified in 4 categories were referrals, payment, education and marketing, and communication and updates. …


A Sensory-Based Toolkit For Health Management Of Patients With Aggressive Behaviors In Acute Care, Meghan Janssen Jan 2022

A Sensory-Based Toolkit For Health Management Of Patients With Aggressive Behaviors In Acute Care, Meghan Janssen

Occupational Therapy Capstones

Title: A Sensory-Based Toolkit for Health Management of Patients with Aggressive Behaviors in Acute Care

Introduction: Patients who have aggressive behaviors in acute care have limited engagement in health management and social participation (Beattie, Griffiths, Innes, & Morphet, 2018; Harwood, 2017). There is current evidence stating aggression and difficult behaviors can be caused by a dysregulated sensory system, a specific condition or an internal/external stressor (Bowman & Jones, 2016; Harwood, 2017; Scheydt et al., 2017). The purpose of this scholarly project is to promote patient engagement in health management and social participation through the implementation of a sensory-based toolkit that …


The Effects Of Retained Primitive Reflexes On Students’ Occupational And Academic Performance In The School Setting, Molly Banks Jan 2022

The Effects Of Retained Primitive Reflexes On Students’ Occupational And Academic Performance In The School Setting, Molly Banks

Occupational Therapy Capstones

Primitive reflexes (PR) are survival responses necessary for infants’ health and safety and are the foundation for higher motor skills (Desorbay, 2013). While they usually integrate a year after birth, there are instances when these reflexes stay retained. The retention of PRs often indicates a higher probability of a disruption/delay in motor and cognitive-emotional development. This disruption/delay can be observed in a school setting and can negatively impact a student’s academic performance and behavior in school. There is significant research on the impact of retained primitive reflexes (RPR), but there is a gap in research about effectively implementing reflex integration …


Pathway Through Nature: A Nature-Based Occupational Therapy Program To Support Adolescent Mental Health, Danielle Grace Halstead Jan 2022

Pathway Through Nature: A Nature-Based Occupational Therapy Program To Support Adolescent Mental Health, Danielle Grace Halstead

Occupational Therapy Capstones

Title: Pathway Through Nature: A Nature-Based Occupational Therapy Program to Support Adolescent Mental Health

Background: Adolescent mental health conditions have risen 13% between 2007-2017, with increased rates of untreated and unrecognized mental health challenges (World Health Organization [WHO], 2021; WHO, n.d.). Primary challenges include anxiety, depression, suicidal ideation, stress, coping skills, and self-identity (Kim, 2021; Magson et al., 2021; Rapee et al., 2019). Decreased access to professionals within the mental health field have presented as a barrier to combat the rise of the challenges listed above (Asher & De Silva, 2017). Nature-based therapy provides services within the most natural context …


The Development Of A Transition To Motherhood Education And Support Program: Elevate Motherhood, Chloe R. Haas Jan 2022

The Development Of A Transition To Motherhood Education And Support Program: Elevate Motherhood, Chloe R. Haas

Occupational Therapy Capstones

Background The transition to motherhood is a transformative event. The postpartum period is a significant timeframe that challenges a mother in all areas of her life through occupational, physical, hormonal, emotional, and cognitive changes. Although most mothers receive routine care throughout their pregnancy, it is known that standard education and support are typically inadequate, placing mothers at a greater risk for postpartum depression, postpartum anxiety, and other challenges of the postpartum period (Howell, Mora, Chassin, & Leventhal, 2010; Martin, Horowitz, Balbierz, & Howell, 2014). Research findings indicate that sufficient education and support prior to birth and through the postpartum period …


Wellness Education For The Food Insecure Population, Erin M. Grensteiner Jan 2022

Wellness Education For The Food Insecure Population, Erin M. Grensteiner

Occupational Therapy Capstones

Food insecurity is a problem facing the United States that often has few solutions. Those who face the challenges of food insecurity are known as the food-insecure population. Since the persistence of food insecurity, poorer health outcomes have become positively associated with the food-insecure population. After reviewing the literature, it was found that difficulties with the occupations of maintaining personal and home hygiene and resource seeking were prevalent and found to lead to poorer health outcomes. Difficulties with maintaining personal and home hygiene were found to stem from a lack of access or money to spend on personal and home …


Care For The Caregiver: A Rural Perspective, Michaela Claire Gerving Jan 2022

Care For The Caregiver: A Rural Perspective, Michaela Claire Gerving

Occupational Therapy Capstones

Title: Care for the Caregiver: A Rural Perspective

Background: Informal caregivers in rural communities have multiple challenges. First, they have limited access to caregiving training yet are expected to perform tasks at skilled levels (Morelli, Barello, Mayan, & Graffigna, 2019). Second, they have limited access to supportive services, such as respite, which keeps them on-call 24 hours a day (Pfankuch, 2018). Finally, this continual status of caregiving around the clock encroaches on their own engagement in personal health management (Hewitt & McNiesh, 2019).

Purpose: The product of this scholarly project is an interprofessional (IP) telehealth wellness program for informal caregivers …


Supporting Participation In Daily Tasks, Quality Of Life, And Well-Being For Individuals With Parkinson’S Disease Dementia, Miranda Kay Evanson Jan 2022

Supporting Participation In Daily Tasks, Quality Of Life, And Well-Being For Individuals With Parkinson’S Disease Dementia, Miranda Kay Evanson

Occupational Therapy Capstones

Introduction Parkinson’s disease dementia (PDD) is a progressive neurological disorder characterized by a decline in cognitive functioning severe enough to impact participation in daily life which can occur for individuals living with Parkinson’s disease (PD) at least one year or more following their PD diagnosis (Alzheimer’s Association, 2022b). There are currently almost one million people living with PD in the United States with about two thousand of those individuals living in North Dakota (Alzheimer’s Association, 2022b; Parkinson’s Foundation, 2022b). Studies show that 50-80% of those individuals will develop PDD throughout the course of the illness (Alzheimer’s Association, 2022b). The treatment …


Strategies For Campers With Sensory Challenges, Rachel Jessica Lindemann Jan 2022

Strategies For Campers With Sensory Challenges, Rachel Jessica Lindemann

Occupational Therapy Capstones

The OTS partnered with a summer camp agency to understand their needs for camp programming. The executive director informed the OTS that this camp would benefit from programming recommendations as they would like to be more inclusive toward campers of all abilities. Pfeiffer, Clark, and Arbesman (2018) explain that sensory challenges can exist in children/adolescents with or without an existing diagnosis. Children and adolescents who have difficulty regulating and responding to sensory input impedes their ability to participate in meaningful occupations. The OTS decided to provide the agency with programming recommendations to serve campers with sensory challenges in order to …


How To Support Adolescents Affected By Aces: An Advocacy Guide, Hallie Longtin Jan 2022

How To Support Adolescents Affected By Aces: An Advocacy Guide, Hallie Longtin

Occupational Therapy Capstones

The purpose of this scholarly project was to create a trauma-informed guide for educators within a school setting to be used to support adolescents effected by adverse childhood experiences (ACEs). 1 in 6 adults reported experiencing four or more types of ACEs, and 5 of 10 leading causes of death are associated with ACEs (CDC, 2022). ACEs can negatively impact adolescents in various ways, including cognitively, physically, and socially. These negative impacts affect adolescent’s overall well-being and leads to difficulty with engagement in several occupations. Due to their traumatic experiences and the various impacts, adolescents within a school setting are …


Bridging The Gap Between Ancillary Health Professions And Rural Community Health Needs, Mckenzie Rae Peterson Jan 2022

Bridging The Gap Between Ancillary Health Professions And Rural Community Health Needs, Mckenzie Rae Peterson

Occupational Therapy Capstones

Introduction Rural communities are home to nearly one-fifth of the American population, and they face unique challenges when working to access healthcare (Health Resources & Services Administration, 2021; Slagle et al., 2012). Ancillary health professionals (AHPs) are healthcare professionals, excluding physicians, nurses, and dentists (Ancillary Care Services, 2015). The scholarly project aimed to find what evidence existed in regard to bridging the gap between the healthcare needs of rural communities, and the availability of AHPs.

Methods The scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines (Tricco et al., 2018). Based …


Enhancing The Leisure, Social Participation, And Quality Of Life Of Older Adults Isolated During The Covid-19 Pandemic, Mariah Leroux Jan 2022

Enhancing The Leisure, Social Participation, And Quality Of Life Of Older Adults Isolated During The Covid-19 Pandemic, Mariah Leroux

Occupational Therapy Capstones

Title: Enhancing the Leisure, Social Participation and Quality of Life of Older Adults Isolated during the COVID-19 Pandemic

APA Citation Mariah LeRoux, OTDS. Enhancing the Leisure, Social Participation and Quality of Life of Older Adults Isolated during the COVID-19 Pandemic. Department of Occupational Therapy, University of North Dakota School of Medicine and Health Sciences, 1301 N Columbia Rd, Grand Forks, ND 58203.

Purpose The purpose of this scholarly project was to enhance the performance range of older adults in assisted living by equipping them with the skills to engage in meaningful occupations throughout a pandemic. The meaningful occupations outlined in …


Accessibility In Rural America, Ashley Osbjornson Jan 2022

Accessibility In Rural America, Ashley Osbjornson

Occupational Therapy Capstones

Introduction: Individuals with disabilities are often faced with barriers when trying to access public spaces out in the community, which results in lack of inclusion (Chibaya et al., 2021; Sandwood, 2019). This is an ongoing barrier that if addressed, may expand inclusion for those with disabilities (CDC, 2020a). The purpose of this scholarly project was to increase accessibility and usability for rural shoppers. Thus, a manual was created for Minnesota stores to use as a guide when assessing accessibility and usability. In addition, this manual was created to help store owners understand disability and its impact and identify strategies store …


Bridging The Gap: A Comprehensive Discharge Guide, Ashley Marie Mutziger Jan 2022

Bridging The Gap: A Comprehensive Discharge Guide, Ashley Marie Mutziger

Occupational Therapy Capstones

Much attention is paid to clients while they receive services, but after they have met their goals and are ready for their next steps, they can perceive a lack of support and feelings of uncertainty. Returning home from any healthcare setting can be a time of uncertainty for clients. There are many questions to be answered and potential unknowns surrounding the discharge processes. Literature shows there is a need for improving discharge practices to promote client understanding and follow-through to end the treatment experience with the confidence that the client has the tools and resources necessary to be successful in …