Community Ment Health J (2010) 46:282288 DOI 10.

1007/s10597-010-9293-5

BRIEF REPORT

Parent and Adolescent Satisfaction with Mental Health Services: Does it Relate to Youth Diagnosis, Age, Gender, or Treatment Outcome?
Jessica A. Turchik Veronika Karpenko Benjamin M. Ogles Petya Demireva Danielle R. Probst

Received: 23 November 2008 / Accepted: 20 January 2010 / Published online: 5 February 2010 Springer Science+Business Media, LLC 2010

Abstract Consumer satisfaction with treatment is important information for providers of mental health services. The goal of the current study was to examine the relationship between youth and parent satisfaction ratings and the following youth variables: gender, age, primary diagnosis, and changes in functioning and symptomatology after 6 months of services. Results demonstrated that in a large sample of youth receiving community mental health services satisfaction with services differed as a function of the adolescents clinician-derived primary diagnosis, age, and reported changes in symptoms and functioning. Although signicant, these variables accounted for only a small portion of the variance in satisfaction. Additionally, the relationship between parent and youth ratings of satisfaction was low, but signicant. The implications of these ndings are discussed as well as future directions for clinicians and researchers. Keywords Client satisfaction Adolescents Parents Treatment outcome Diagnosis

The pressure on practitioners and mental health agencies to be accountable for their services is steadily increasing (Asay et al. 2002). A large number of practitioners and mental health agencies have in turn begun to utilize measures of consumer satisfaction as an indicator of the
J. A. Turchik (&) V. Karpenko B. M. Ogles P. Demireva D. R. Probst Ohio University, Athens, OH, USA e-mail: jt865504@ohio.edu J. A. Turchik 1227 Chelwood Park Blvd NE, Unit B, Albuquerque, NM 87112, USA

effectiveness and quality of services (Edlund et al. 2003; Ogles et al. 2002). There are a number of reasons for the popularity of satisfaction measures, including their face validity, brevity, and cost-effectiveness (Ogles et al. 2002). Additionally, the use of measures of satisfaction aligns with the movement in the eld of mental health, as well as with broader health care movements, to increase consumers voices and input into the nature of services, and service evaluation (Garland et al. 2007; Kessler and Mroczek 1995). The consistent ndings that satisfaction with mental health services is poorly related to symptomatic change (e.g., Garland et al. 2007; Lambert et al. 1998) indicate that satisfaction taps into a unique domain of consumers experiences in therapy and can, thus, be a valuable measure to use along with measures of symptomatology. In fact, if satisfaction were signicantly correlated with symptoms, they would be two overlapping constructs, and there would be no need to measure both as part of the quality assurance process. However, because years of research demonstrate that satisfaction is a distinct construct from symptoms, it behooves the mental health system to improve its understanding of the input consumers provide about their satisfaction with mental health services. Although there is relatively little research in the adolescent treatment outcome literature on the construct of satisfaction and its correlates (Garland et al. 2007), satisfaction data are frequently used to inform policy and funding decisions and are also included in health care accreditation reviews (Garland et al. 2007; Salzer 1999). Thus, there is a burning need to improve our understanding of this frequently misunderstood and misused construct. Garland et al. (2007) noted that there are three important clusters of variables that can inuence consumers satisfaction with mental health services: (1) characteristics present at service entry (e.g., age, gender, diagnostic

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presentation); (2) treatment/therapist characteristics (e.g., therapist experience); and (3) clinical outcomes (e.g., symptom and functional change). There is a lack of research examining satisfactions relationship to the above delineated clusters of variables in the adolescent treatment outcome literature (Garland et al. 2007; Lambert et al. 1998). It is particularly important to study satisfaction with mental health services in the adolescent population as the characteristics of this developmental stage, such as involuntary referral for services, striving for independence, and rebellion against authority gures, can create unique challenges for engagement in therapy (Adams 2000). In fact, research shows that 4060% of adolescents drop out of therapy prematurely (Wierzbicki and Pekarik 1993). There has been no empirical research in the child treatment outcome literature examining the relation between premature termination and satisfaction; however, studies in the adult treatment outcome literature (Lebow 1982) describe low to moderate correlations between these two constructs. Thus, future research will have to examine how rates of satisfaction with mental health services affect rates of noshows and drop-out from treatment in the adolescent population. Since parents are usually involved in the treatment plan, in addition to bringing their adolescent to therapy, it is necessary to study both adolescents and their parents satisfaction with services as it may relate to different outcomes. Surprisingly, there are only a handful of studies that have examined both parents and adolescents satisfaction with mental health services (Barber et al. 2006; Garland et al. 2000), nding low agreement between parents and adolescents on satisfaction (r = .16.29), despite high ratings of satisfaction (Garland et al. 2007; Lambert et al. 1998; Godley et al. 1998). There have been inconsistent ndings in the literature concerning the relationship between adolescents and their parents satisfaction with mental health services and such demographic variables as age, gender, and ethnicity. While at least two older studies nd that adolescent males are more satised than adolescent females with mental health services and that younger youth are more satised than older youth (Shapiro et al. 1997; Stuntzer-Gibson et al. 1995), more recent studies nd no relationship between satisfaction and these demographic variables using youth (Barber et al. 2006; Copeland et al. 2004; Garland et al. 2000, 2007) or parent ratings (Barber et al. 2006; Copeland et al. 2004; Garland et al. 2007). Although not consistent, overall, demographics have not been found to be strong predictors of client satisfaction. Adolescents diagnostic presentation is an important variable that can potentially inuence satisfaction with services. A few studies that have examined the effects of diagnosis on satisfaction with mental health services in adults found that clients diagnosed with more severe and

chronic mental illness (e.g., schizophrenia, bipolar disorder, personality disorders) are less satised with treatment than clients with less severe diagnoses (e.g., affective, anxiety, and adjustment disorders; Hasler et al. 2004; Kelstrup et al. 1993; Perreault et al. 1996). However, only one study has examined the nature of this relationship in adolescents. Garland et al. (2007) found no differences between diagnostic category (externalizing, mood, and anxiety) and youth and parent satisfaction with mental health services. A few studies have found that more severe symptomatology is related to poorer satisfaction in youths (Garland et al. 2000; Godley et al. 1998), as well as in their parents (Godley et al. 1998); however, the results have been somewhat inconsistent. With regards to traditional measures of clinical outcome, research nds only a minimal relationship between satisfaction and change in symptoms (Garland et al. 2007; Lambert et al. 1998; Pekarik and Guidry 1999), spanning from no relationship (r = -.06) to a modest relationship (r = .26) on parent-rated (Garland et al. 2007; Lambert et al. 1998) and youth-rated measures of satisfaction (Garland et al. 2007; Lambert et al. 1998; Shapiro et al. 1997). The relationship between functioning and satisfaction has received less attention in the literature; however, studies have found a modest relationship between functioning and satisfaction, as rated by youth (Garland et al. 2003) and parents (Garland et al. 2007). Some methodological limitations of past research of adolescent satisfaction include: small sample sizes (e.g., Barber et al. 2006; Garland et al. 2000); lack of cultural diversity (see Copeland et al. 2004); cross-sectional rather than prospective designs (Barber et al. 2006; Garland et al. 2000); utilization of solely parent ratings (e.g., Bradley and Clark 1993; Heinger et al. 2004); use of only youth ratings (e.g., Garland et al. 2003; Shapiro et al. 1997); and use of satisfaction measures with unacceptable or untested psychometric properties (e.g., Barber et al. 2006; Garland et al. 2000). The current study addresses limitations of previous research by utilizing a large, diverse sample of data collected in a real-world clinical setting, a prospective design, validated outcome measures, and both parent and youth paired ratings of satisfaction on the same measure. The current study also extends the previous literature by examining the relationship between clinical diagnoses and satisfaction. The aim of the present study was to examine the relationship between parent and adolescent satisfaction with community mental health services received by adolescents and: (1) adolescents primary diagnosis (2) ratings of symptomatic and functional change; and (3) adolescents age and gender. It was predicted that adolescents with more severe diagnoses (psychotic disorders, major depression, bipolar disorder) and their parents would report lower satisfaction

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than those diagnosed with less severe disorders (e.g., adjustment disorders). Drawing on previous research, it was hypothesized that the relationship between satisfaction and clinical outcomes (symptoms and functioning) would be signicant but small. No specic hypotheses were made for the relationships between age, gender, and satisfaction with mental health services.

(e.g., substance abuse, impulse control disorders, developmental disorders). Measures The Ohio Scales The Ohio Scales include a youth self-report form (for ages 1218), a parent report form, and an agency worker (clinician) report form, assessing four domains: severity of the problem behavior, functioning, hopefulness, and satisfaction with services (Ogles et al. 2001). Parents and agency workers complete the Ohio Scales for youth ages 518. The Satisfaction Scale is a 4-item measure which assesses satisfaction with and inclusion in behavioral health services on a 6-point scale; parent and youth versions utilize comparable items. The total Satisfaction score (range 424) is calculated by summing the items with higher scores indicating greater dissatisfaction with services. However, in the current study the scores were reverse coded so that higher scores indicated greater satisfaction. The Problem Severity Scale is comprised of 20 items that address typical problems of youth who utilize mental health services (Ogles et al. 2001); higher scores (range 0100) indicate greater severity and frequency. The Functioning Scale includes 20 items that assess youths functioning across various aspects of daily life, such as recreation, interpersonal relationships, and motivation; higher scores (range 080) indicate better functioning. The Ohio Scales have demonstrated good reliability and validity. The Problem Severity and Functioning scales showed adequate 1-week testretest reliabilities that ranged from .63 to .88 for parents and youth (Ogles et al. 2004). The Problem Severity Scale has shown good convergent validity, correlating signicantly (r = .63.66) with the Child Behavior Checklist (CBCL; Achenbach 1991; Texas Department of Mental Health and Mental Retardation 2004). The Ohio Functioning Scales have also shown appropriate convergent validity when correlated with the CBCL (ranging from r = -.52 to -.55; TDMHMR 2004). The Ohio Scales have also been shown to differentiate among broad diagnostic categories, providing further evidence of convergent and discriminant validity (Turchik et al. 2007). Evidence of convergent validity of the Ohio Scales Satisfaction Scale has been demonstrated by signicant correlations with the Client Satisfaction Questionnaire (CSQ-8; Attkisson and Zwick 1982) for parents (r = -.68) and youth (r = -.52) (Ogles et al. 2000). In the current study, the internal consistency reliabilities were adequate to excellent for the Functioning Scale (a = .94 and .91), Problem Severity Scale (a = .91 and .88), and Satisfaction Scale (a = .85 and .81) for parent and youth reports, respectively.

Method Participants An archival dataset from the Ohio Department of Mental Health (ODMH) containing information from adolescent clients who received outpatient mental health services in the state of Ohio was utilized in the current study. The statewide outcomes database contained data through December 2005 with a total of 59,601 youth ratings and 94,722 parent ratings at intake. Only individuals who had the following information were included in the current study: (1) youth with ages between 12 and 18, (2) presence of a primary diagnosis, (3) a satisfaction score at 6-month follow-up, and (4) presence of youth and parent satisfaction ratings for the same youth client. The current study utilized 3,860 paired youth and parent ratings after the criteria were applied. As a result, 6.5% of the original youth and 4.1% of the original parent ratings from the larger database were included in this study. The demographics (e.g., race, gender, primary diagnosis) of the sample used in this study are similar to those of the youth and parents who were part of the statewide outcomes database in 2005 (Ohio Department of Mental Health 2006). The authors did not have access to the full dataset so statistical comparisons between the current sample and the full database were not conducted. Sample Demographics Approximately 51.7% of the youth were male, 45.2% were female, and 3.1% of data regarding sex were missing. Youth ranged in age from 12 to 18 (M = 14.82) with 36.1% age 1214, 36.2% age [1416, and 27.7% age [ 1618. The ethnic backgrounds of the youth in the sample were identied as: 59.4% Caucasian, 23.5% African American, 2.6% Hispanic/Latino, 1% Native American/ Pacic Islander, .6% Asian, 1.7% other, and 1.4% unknown. About 21.1% of the youth were diagnosed with oppositional deant disorder (ODD) or conduct disorder (CD), 16.4% with attention-decit/hyperactivity disorder (ADHD), 14.8% with an adjustment disorder, 6.7% with major depression, 5.8% with a bipolar disorder, 11.9% with other mood disorders, 4.8% with an anxiety disorder, 1.2% with a psychotic disorder, and 16.8% with other diagnoses

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Procedure The current research was approved by the Institutional Review Board at Ohio University. An archival dataset from the Ohio Department of Mental Health was utilized. During the period in which the data were collected, it was required in the state of Ohio that all agencies receiving state funding for outcomes-qualifying services (excluding crisis, assessment, and other services) administer outcome measures at intake, at the 180-day follow-up, and yearly thereafter. Thus, youth (ages 1218), their parents and agency workers (e.g., case manager, psychologist) completed corresponding forms of the Ohio Scales. Parents and agency workers can complete their forms of Ohio Scales for children ages 518 years. Youth and parents were administered the Ohio Scales at intake. Diagnoses were made by licensed clinicians as a part of routine clinical practice and were based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text-Revision (DSM-IV-TR; American Psychiatric Association 2000). Clients responses and information were deidentied and entered into a database. For the purposes of the current study, only data from parent and youth ratings on the Problem Severity, Functioning, and Satisfaction Subscales of the Ohio Scales were analyzed. For the Satisfaction scale, if any items were missing for an individual, the scale score was not computed. For the Problem Severity scale, if more than 4 items were missing the total score was not computed; if 4 or less items were missing, mean substitution was used to replace the missing values. For the Functioning scale, if more than 4 items were missing the total score was not computed; if 4 or less items were missing a score of 3 was substituted for each missing value.

Satisfaction by Specic Diagnostic Categories To examine the relationship between Ohio Scales Satisfaction scores and adolescent diagnoses, a 8 9 3 9 2 9 2 univariate analysis of variance (ANOVA) was conducted for satisfaction ratings. Satisfaction scores were entered as the dependent variable and rater (1 = youth, 2 = parent), age group (1 = age 1214, 2 = age [1416; 3 = age [ 1618), gender, and diagnoses (recoded into the following eight categories: bipolar disorder, major depression, other mood disorder, adjustment disorder, psychotic disorder, anxiety disorder, ADHD, disruptive behavior disorder [ODD/CD]) were entered as the between-subjects independent variables. The ANOVA revealed signicant differences in rater, F(1, 6,218) = 135.66, p \ .01, g2 p = .021, age, F(2, 6,218) = 7.84, p \ .01, g2 p = .003, and diagnosis, F(7, 6,218) = 7.46, p \ .01, g2 p = .008. There was also a signicant interaction of rater by age, F(2, 6,218) = 10.04, p \ .01, g2 p = .003. Gender and all other interactions were not signicant. Specically, it was found that youth (M = 19.70, SD = 4.42) were generally less satised than parents (M = 21.42, SD = 3.47). Tukeys HSD post hoc tests also revealed that Satisfaction scores were lower when the youth were age 1416 (M = 20.32, SD = 4.20) compared to when the youth were 1618 (M = 20.83, SD = 3.93) as rated overall by both youth and parents. Post hoc tests also revealed that overall youth and parent Satisfaction ratings were lower with youth diagnosed with major depression disorder (M = 20.55, SD = 4.07) than those diagnosed with adjustment disorders (M = 20.97, SD = 3.66), and that Satisfaction was lower when youth were diagnosed with disruptive behavior disorders (M = 19.99, SD = 4.39) compared to those diagnosed with bipolar disorders (M = 20.55, SD = 4.15), major depression (M = 20.55, SD = 4.07), other mood disorders (M = 20.69, SD = 3.94), adjustment disorders (M = 20.97, SD = 3.66), psychotic disorders (M = 21.24, SD = 3.15), anxiety disorders (M = 21.01, SD = 3.88), and ADHD (M = 20.67, SD = 4.07). Two separate ANOVAs were run after splitting the data by rater to explore the age by diagnosis interaction effect. Among youth there were signicant differences among the three age groups, F(2, 3,857) = 10.69, p \ .01, g2 p = .006, with Tukeys HSD post hoc tests revealing that those age 1214 (M = 19.49, SD = 4.36) and age 1416 (M = 19.47, SD = 4.53) were less satised that those 1618 (M = 20.21, SD = 4.23). A signicant difference was also found among parent ratings in relation to youth age, F(2, 3,857) = 7.48, p \ .01, g2 p = .004, with Tukeys HSD post hoc tests revealing that parents of those with youth age 1214 (M = 21.69, SD = 3.26) were more satised than parents of youth age 1416 (M = 21.21, SD = 3.60) and 1618 (M = 21.29, SD = 3.52).

Results Descriptive Data Overall, Satisfaction scores were high for both parents (M = 21.40, SD = 3.46) and youth (M = 19.68, SD = 4.40). Parents Functioning scores (intake: M = 43.30, SD = 15.04; follow-up: M = 48.40, SD = 14.88) were generally lower than youth Functioning scores (intake: M = 55.32, SD = 13.30; follow-up: M = 59.10, SD = 12.43), and parent Problem Severity scores (intake: M = 28.41, SD = 16.24; follow-up: M = 21.18, SD = 14.57) were generally higher than youth Problem Severity scores (intake: M = 25.22, SD = 16.21; follow-up: M = 18.59, SD = 13.78) at both time points. The correlation between parent and youth satisfaction scores at the 6-month follow-up was r (3860) = .17, p \ .01.

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Prediction of Symptoms and Functioning Correlations between Satisfaction scores at 6 months and changes in Problem Severity (youth: r = .10; parent: r = .12) and Functioning scores (youth: r = -.13; parent: r = -.13) from intake to 6 months were small but significant. In two separate hierarchical regression analyses, youth and parent Satisfaction scores were regressed upon age, gender, change in problem scores, and change in functioning scores. Age and gender were entered in the rst block of the regression analyses; the remaining predictors were simultaneously entered in the second block. In the regression analysis predicting youth satisfaction, the overall model was signicant, R2 = .02, F(4, 3,532) = 17.10, p \ .001, accounting for 2% of the variance in Satisfaction scores. In the presence of the other three predictors, three variables, older age, b = .04, t(3,532) = 2.45, p \ .05, lower youth problem severity, b = -.06, t(3,532) = -2.84, p \ .001, and higher youth functioning, b = .10, t(3,532) = 4.93, p \ .001, signicantly contributed to the model. In the regression analysis predicting parent satisfaction, the overall model was signicant, R2 = .03, F(4, 3,531) = 22.72, p \ .001, accounting for 3% of the variance in Satisfaction scores. In the presence of the other three predictors, three variables, younger youth age, b = -.06, t(3,531) = -3.77, p \ .001, lower parentrated problem severity, b = -.07, t(3,531) = -3.13, p \ .01, and higher parent-rated functioning, b = .09, t(3,531) = 4.41, p \ .001, signicantly contributed to the model.

Discussion Measures of satisfaction with mental health services increase consumers voice and input into service evaluation, enhancing quality assurance for mental health agencies. Moreover, consistent ndings of low relationships between satisfaction and symptomatic change demonstrate the unique contribution of satisfaction to our understanding of consumers experiences with services. Thus, it is necessary to better understand factors related to satisfaction in order to help mental health providers improve quality of care and retention in therapy. The current study sought to examine the relationship between parent and adolescent satisfaction with community mental health services and adolescents primary diagnosis, age, gender, symptom reduction, and functional impairment. The present study addressed limitations of previous research on youth satisfaction (see Garland et al. 2007) by utilizing a large, diverse sample collected from a real-world clinical setting, a prospective design, validated outcome measures, and both parent and youth paired

ratings of satisfaction on corresponding forms of the same measure. The results of the current study support previous research, which nds that demographic (Copeland et al. 2004; Garland et al. 2000, 2007) and clinical outcome variables (Garland et al. 2007; Lambert et al. 1998; Shapiro et al. 1997) do not account for a large amount of variance in satisfaction scores. In the present study, parents reported greater satisfaction with services than youth, which is consistent with one previous study (Godley et al. 1998). The present study found only a minimal relationship between diagnostic type at intake and youth and parent satisfaction, consistent with the results of the only other study that has examined this relationship (Garland et al. 2007). Although the present study found statistically signicant differences in satisfaction scores across diagnoses, the importance of these ndings is tempered by the small effect sizes. Both parents of youth and youth with the primary diagnosis of a disruptive behavior disorders were less satised than those with all other of the seven categories of disorders examined in this study. Additionally, youth with adjustment disorders had higher satisfaction with treatment compared to those diagnosed with major depression. Current ndings were only partially consistent with the predictions that youth with more severe disorders would be more satised than those with less severe disorders. With regard to the demographic variables, parents of younger adolescents were more satised with services than parents of older adolescents. Conversely, older adolescents reported greater satisfaction with mental health services than younger adolescents. This nding related to age may be due to the amount of control that each party felt they had during the treatment. Consistent with most previous research, no effect of gender was found (Copeland et al. 2004; Garland et al. 2000, 2007). Finally, similar to previous studies, although reduction in symptoms and improvement in functioning were related to greater satisfaction for both youth and parents at the 6-month follow-up, these relationships were small in magnitude (Garland et al. 2003, 2007; Lambert et al. 1998). After controlling for age and gender of the youth, level of functioning and problem severity accounted for only 13% of the variance. Also, although satisfaction scores were consistently higher for parents compared to youth across demographic and diagnostic categories, parent-rated functioning scores were signicantly lower and problem severity scores signicantly higher than those reported by youth at both intake and at 6 months. This nding seems especially counterintuitive if one believes that treatment outcomes and satisfaction are related and seems to further indicate that satisfaction is not a good proxy for clinical treatment outcomes, at least in the case of symptom severity and functioning.

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Limitations Although this study has a number of strengths, it is not without its limitations. First, the specic treatment that was provided to the youth is unknown and could have affected the satisfaction ratings. Second, the large overall sample size and high degree of power led to signicant ndings that may have questionable applications due to the small effect sizes; it may be that these differences are too small to be practically important. However, it may be that the high external validity of this study and large variance in the sample may have contributed to the weak relationships and that a more controlled study with higher internal validity would have produced stronger results. Lastly, diagnoses were not derived through a structured interview process, so it is not possible to know the inter-rater reliability or accuracy of the diagnoses. However, the external validity of the study is strengthened by the fact that the outcome measures and diagnoses were given in an outpatient clinical setting and can thus be generalized to similar settings. Implications The current study has a number of implications for quality assurance and accountability work performed within mental health systems. First, the minimal effect sizes for the relationship between levels of satisfaction and treatment outcomes documented in the current study, as well as in past research (Garland et al. 2007; Godley et al. 1998), remind us that satisfaction should not be used as a proxy for symptomatic change. Instead, satisfaction provides additional information about consumers view of therapy; for example, consumers may be satised with treatment due to factors other than symptom change, such as relapse prevention, improvement in specic presenting problems, or a good therapeutic relationship. Second, the ndings of a weak relationship between satisfaction ratings and diagnostic categories, as well as demographic variables, inform mental health agencies of the relatively small impact such variables have on client satisfaction with mental health services. Thus, future research needs to focus on other variables that are related to satisfaction scores. Some variables that have been suggested include client personality characteristics, agreement between therapist and client expectations, therapeutic alliance, customer relations variables (e.g., parking, convenience of scheduling), and desire for social conformity (Garland et al. 2007). Also, some clients enter treatment for a problem that may not be directly related to symptoms or functioning, and thus the relationship between satisfaction and changes in the severity of client-reported presenting complaints (Battle et al. 1966) needs to be examined in future research. Moreover, there is a lack of research

examining how adolescents and their parents satisfaction with mental health services affects therapy retention variables (e.g., frequency of cancellations and no-shows, family participation in sessions, agreement with therapist on termination). Considering the high rates of drop-out of adolescents from therapy (Wierzbicki and Pekarik 1993), it is necessary to study the process that contributes to these high drop-out rates; consumers satisfaction with the services can be one of the important variables in that process. Finally, there are multiple ways that measures of satisfaction can be used to improve service delivery and outcome, as well as be used in research studies. For example, satisfaction measures are most commonly used at posttreatment in mental health systems and research, which does not allow ongoing feedback from the client to the agency and correction of the effects of clients dissatisfaction (Ogles et al. 2002). By incorporating satisfaction measures as part of the treatment process, agencies can increase consumers input into the quality of the services. Researchers can study this process of ongoing feedback from clients to the agency and the possible effect satisfaction has on therapy retention and cancellation rates. Also, satisfaction measures often have ceiling effects, as clients rate their satisfaction highly. Thus, future research could focus on creating a wider range of items and possible responses on measures of satisfaction to circumvent this problem. Finally, there is often a lack of consistency across research studies in adolescent treatment outcome literature with regard to which measure of satisfaction is utilized. It would be important to develop measures of satisfaction for adolescents and their parents in the format of focus groups, where direct input from consumers, as well as input from mental health agencies, can drive the items on the measures. Well-constructed measures can then be consistently utilized across studies. As behavioral healthcare organizations are experiencing an increasing pressure to measure client satisfaction due to the increasing need to provide accountability for services (Garland et al. 2007; Pekarik and Guidry 1999), it is of great value to researchers and practitioners alike to further understand consumer satisfaction with mental health services.
Acknowledgments This research was funded by the Ohio Department of Mental Health, Grant No. 07.1232.

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