Common use of Setting Clause in Contracts

Setting. VRND is a public drug treatment facility affiliated with Yuschenko Regional Psychiatric Hospital, and the Department of Medical Psychology and Psychiatry of Vinnitsya Pirogov Medical University. Traditionally, treatment consists of three phases: N medical therapy (adrenergic blockers for withdrawal and detoxification, minor tranquilizers for anxiety and agitation, major tranquilizers for psychosis, antidepressants for depression, vitamins, general nursing and medical care, and referrals), and rarely used physiotherapy (trans-cranial impulse stimulation, electro sleep) and conditioned aversive reflex therapy; N psychotherapy (individual and group counseling, without strict adherence to any systematic evidence-based model); N rehabilitation and supportive therapy (surveillance, prophylactic treatment, medical services, employment assistance, family recovery). There are four inpatient departments and one outpatient department in the VRND. One of the inpatient departments provides acute medical care for intoxications and psychoses, and the other three serve all other patients, without evident specialization by nosology or other patient characteristics. There are three full-time physicians (narcologists) and 12 nurses in each department. There are four psychologists serving all departments in the VRND. In total there are 37 direct treatment providers and 118 support personnel in the VRND and its affiliated medical institutions. The VRND is a 160-bed facility, but these beds are rarely full due to inadequacy and cost of drug addiction treatment in Ukraine. On average, admissions over the past 5 years were 1500 patients per year or 125 per month. Median duration of in-patient stay was 21 days. Although the police brought many patients to the hospital for alcohol detoxification, treatment at the VRND is voluntary, and self- or family-referred. Alcohol-related disorders among registered patients were most common (89.8%), with 10.2% of patients diagnosed with opiate, marijuana, or other substance-related disorders. Depression and psychotic disorders were reported in approximately 30% of the patients. Males represented approximately 70% of the patient population and females 30% with an age range of 18– 65 years. Participants for this study were recruited through an announcement made to VRND patients and staff by the Director of the VRND. Participation was voluntary, and everybody who volunteered was eligible and participated. Staff participants constituted 22.6% of all service providers. Approximately 30% of patients present in the VRND at that time participated. ▇▇▇▇▇▇ informed consent was obtained before each interview and no personalized information was collected from the participants. The study protocol was approved by The University of Alabama at Birmingham Institutional Review Board. An original instrument, the Addiction Treatment Agreement Scale (ATAS), was designed to measure the degree of personal agreement with three common psychosocial drug and alcohol addiction treatment models. The models were chosen from those evaluated by the Project MATCH (Project MATCH Research Group, 1997a): Cognitive Behavioral Therapy (CBT), Motivational Enhancement Therapy (MET), and 12-step Facilitation (TSF). Instrument development began by identifying five experts in the field of drug addiction representing treatment (two), research (one), and theory (one) in addition to the second author, who is an expert in all three areas (JES). The second author facilitated the following scale development process. First, the experts discussed the aims of the nature and goals of the measurement process. They agreed that: N the instrument should have multiple constructs or dimensions common to each treatment model; N dimensions should be operationally defined; N expert decisions should be unanimous; N treatment agreement should be empirically compared with a standard; N the instrument should be suitable for systematic administration and scoring. Secondly, the experts agreed on six dimensions that were believed to affect treatment preferences, engagement, compliance, and outcomes. They were Etiology, The Problem, Recovery, Client Characteristics, Treatment Relationship, and Provider Characteristics. Thirdly, the experts identified and agreed on operational definitions for each dimension, keeping in mind three treatment models (TSF, MET, and CBT). The final number of definitions was limited to five per dimension that were agreed to fairly represent each treatment model. Finally, the experts ranked all definitions for each dimension from most important to least important (1–5) for each treatment model. Table I shows the final ATAS, consisting of six dimensions with five definitions per dimension for a total of 30 items. Table I. Expert and sample participant importance rankings of dimension definitions for three models of addiction treatment. Dimension, stem and definitions TSF CBT MET participant The personality 3 5 4 1 Coping with stress 4 1 3 2 Moral weakness 2 3 2 3 Personal choice 5 2 1 5 A disease 1 4 5 4 Excessive or over use 5 2 2 2 Negative consequences like illness, 4 1 1 1 loosing a job, or stealing Accepting that addiction is a life long problem 2 2 4 2 Will power and self determination 4 3 1 1 Defined by friends, family, and society 3 5 3 4 Culture or class 4 4 4 4 Understanding of the problem 5 3 3 1 Motivation or drive to change 3 2 1 3 [Dimension 5—Treatment Relationship]The drug/alcohol treatment relationship mostly related to recovery is … Being told ‘‘this is what you must do’’ 1 2 4 4 Participating in the treatment process 4 3 3 3 addiction Not being judged or labeled 5 4 2 5 [Dimension 6—Provider Characteristics]Characteristics of drug/alcohol treatment providers mostly related to recovery are … Formal education and specialized training 4 1 1 2 Friendship 2 4 4 3 Importance rankings by experts Example ranking by 1 Note: TSF (12-step), CBT (Cognitive Behavior Therapy), and MET (Motivational Enhancement Therapy). The ATAS was administered by presenting five items on laminated cards (in random order) for each dimension (in random order) to the participant, one dimension at a time. The participant was shown and read the ‘‘stem’’ (e.g. Domain 1, Etiology: The causes of drug/alcohol addiction are mostly related to …) for each dimension and then asked to rank order the defining items from that dimension in order of importance from 1 (most important) to 5 (least important). Table I shows unanimous expert rankings for each item, by dimension, for each of the three treatment models. It also shows rankings from a sample participant for illustrative purposes. To assure understanding of the procedure, a sample food dimension was administered first (i.e., My favorite foods are …), and the respondent was asked to arrange vegetables, meats, breads, juices, and cheeses in order of preference. It was emphasized that there is no right or wrong order, and only individual preferences are of interest. The ATAS was scored by correlating participant with expert item rankings for each treatment model using ▇▇▇▇▇▇▇▇ correlation coefficients (considering the fact that integers from 1 to 5 may not be equally spaced in terms of actual importance). Agreement correlations were calculated for the overall ATAS scale and by dimension for each TSF, MET, and CBT treatment model. A high/low correlation indicated high/low agreement with the standard (unanimous expert rankings).