A program to assist people with severe mental illness in formulating realistic life goals. (Formulating Realistic Life Goals).

The Journal of Rehabilitation October 1, 2002 | Ng, Bacon F.L.; Tsang, Hector W.H.

The literature reveals that spiritual and hope-inspiring issues have recently received more emphasis in the area of psychiatric rehabilitation (Kehoe, 1999; Landeen, Pawlick, Woodside, Kirkpatrick, & Byrne, 2000; Russinova, 1999). Fine (1991) believed that hope helps an individual face adversity and maintain a positive sense of direction in life. Hope also helps contribute insight into the nature and meaning of an individual’s life (American Occupational Therapy Association [AJOT], 1995). The mind-body-spirit reference of healing philosophies has been suggested since the time of Hippocrates (Christiansen, 1997). It is believed that man can bear great physical or spiritual hardship, but what cannot be beared is a sense of meaninglessness (Howard & Howard, 1997). The active, creative and reflective potential of a person is cut off when work becomes meaningless. Antonovsky’s (1993) phenomenological research on sense of coherence showed that understanding, managing, and deriving a sense of meaning from one’s life is a powerful factor to assist him/ her in coping with high levels of stress and adversity in life. It is a common belief among different cultures that instilling hope in life can restore the ability to cope with uncertainty and stress.

A review by Spencer, Davidson, & White (1997) indicated several clinical approaches for helping individuals develop hope for the future. These approaches include goal setting, goal attainment, examination of change in an individual’s occupational configurations over time, and qualitative interviews about life history. It was reported that rehabilitation professionals used purposeful activities to help individuals develop goals during the recovery process (Howard & Howard, 1997).

A longitudinal study (Harding & Zahniser, 1994) demonstrated that people with serious mental illness can recover as evidenced by their successful employment and meaningful lives. A case study by Stern and Drummond (1991) illustrated that individuals with persistent schizophrenia changed from being `unwilling to be discharged’ to `willing’ when appropriate strategy was used. Steams (1998) measured the change in hope of 13 individuals with mental illness after receiving a three-month Lowa rehabilitation program. Significant differences in pre and post measures of the Herth Hope Scale were noted.

To date, hospital-based treatment protocol to help individuals with mental illness in setting realistic life goals has been scant. Bauer & McBride (1996) developed a five-session psycho-educational program designed to help in-patients with affective disorder develop life goals, improve their social and occupational functioning and improve self-management skills. The program however, was not suitable for individuals with persistent schizophrenia as individuals with this disorder are usually detached from reality and have poorer prognosis than individuals with affective disorder. Structured protocol to assist the development of life goal for individuals with severe mental illness has rarely been documented. A clinical protocol (Goal Attainment Program, GAP) (Ng, 1999) was therefore designed and piloted to in-patients with severe mental illness in Hong Kong (a Special Administrative Region of China). This paper aims at describing the theoretical framework and reporting the findings of the pilot study regarding the effectiveness of the GAP.

Framework of the Four-stage Cyclic Model of Goal Attainment The framework for planning the Goal Attainment Program was based on the Mezirow (1981) learning cycle (adult learning theory) and a planning model for change (Rantz and Miller, 1987). Mezirow’s adult learning theory (1981) provides a framework to guide individual mentoring processes which was found useful in integrating Chinese scholars into Canadian culture (Morales-Mann & Higuchi, 1995). The adult learning theory was used as guideline for the program in this study because it emphasizes self-examination and relates one’s experience to others. It is consistent with the approach of life history review during counseling sessions. The adult learning theory also encourages building competence and confidence in new ways of acting, which is one of the objectives for the Goal Attainment Program. As in-patients with severe mental illness have often adopted a maladaptive passive life pattern, encouraging them to view life with a new perspective may facilitate change. Finally, the reintegration into society as the final step of adult learning theory matches the ultimate goal of the Goal Attainment Program.

The change theory of Rantz & Miller (1987) can be divided into six components which represent a logical flow of events in planning by nurses in long-term care settings. It is similar to the problem solving process that therapists and counselors adopt during daily practice, i.e. problem identification, developing alternatives, selecting solutions, implementation, and feedback (Hagedorn, 1992). The change theory starts with a realization stage, which is important to prepare individuals for treatment. The realization phase is also supported by Gale & Marsden (1982) as pre-diagnostic interpretation. The reformation stage of change theory also reminds the therapist to consciously develop strategies to help in-patients sustain their new goals and hopes for the future.

The Goal Attainment Program As both adult learning theory and change theory are cyclical models, they are in line with the need for continuous review in decision making and reassessment of the dynamic real-life situations faced in this type of program. A four-stage cyclical model for the Goal Attainment Program (Ng, 1999) was developed with the following stages:

1. Affirming Personal Worth 2. Imaging the Future 3. Establishing a Sense of Control 4. Setting Goals The first stage focuses on rapport development and identifying the strengths of the individuals. The second stage uses the individual’s imagination to instill hope and facilitate divergent thinking. The third stage allows the individuals to select the venue and activity to be performed so as to create a sense of control. The fourth stage focuses on non-threatening goal setting for the future. The developmental sequence of the four-stage cyclical model was supported by the results of a pilot study (Ng, 1999). go to web site adult learning theory

The four stages of the Goal Attainment Program were arranged in four different sessions with specific objectives based on the development process in this study. The success in achieving the objectives of each session became a stepping-stone contributing to the overall progress of the program. The Goal Attainment Program consisted of four individual sessions with each session lasting approximately 45 minutes. The four session program was completed within a three week duration.

The first session aimed to establish rapport with the inpatients and affirm personal worth. This session focused on ways to facilitate them in realizing their own strengths through self-examination and motivating them to make changes. Therapists attempted to uncover and record the aspects of each individual that were indicative of his/her personal worth (e.g., good working histories, specific skills to be proud of, optimistic and open minded attitude, willingness to change his/her present patterns, willingness to take up the family care-giving roles and willingness to learn new skills). The assets that were identified helped them to see their personal worth, and hence to improve their self-perceptions and self-esteem. Also, in the first session, patients were encouraged to revisit previous major life changes and life expectations using the role checklists (Barris, Oakley, & Keilhofner, 1988). They were encouraged to reconstruct past experiences, identify previous responsibilities, and share their own uplifting memories/experiences, and clarify future aspirations (Henry and Kielhofner, 1989; Canadian Association of Occupational Therapists [CAOT], 1995; Herth, 1990). Perceptions of relative importance and expectations of future roles were formulated using the role checklist with a focus on an occupational change.

Life histories were reviewed to develop hope (Neuhaus, 1997; Spencer et al., 1997). Positive and non-judgmental strategies were adopted to develop rapport with them. Rapport development was considered the key strategy of session one (Hampton, 1994; King, 1992; Sieloff et al. 1998). Mattingly & Fleming (1994) examined in depth the use of narrative thinking in life history review and collaborating with individuals in anticipating future through hope fostering during the process of clinical reasoning.

In the second session, a small wish was introduced as the concrete reward to motivate them during activity of goal setting (Katzell & Thompson, 1990). The hypothetical situation focused on the future and explored goals through their imagination (Amburg, 1997; Davis, Eshelman, and Mckay, 1995). Christmas and New Year had always been a symbolic time of hope for some individuals. The program adopted some of the cultural beliefs and feelings associated with these holidays to help them to express small wishes (e.g., to give a Christmas surprise to family members during their visits, to send a Christmas card to an old friend, or to make a New Year’s wish for him or herself to learn a new skill or to perform selected activities). This session explored realistic and challenging life goals. This acknowledged the difficulties the individual faced and helped him/her develop positive beliefs and feelings about the future (Farran, Herth, & Popovich, 1995). In brief, this session focused on meeting the cognitive, spiritual and emotional needs of the in-patients through allowing them to express themselves and elaborate on their small hopes. These small hopes were then acted upon in the third session.

The third session allowed them to make their own choices and establish a sense of control. This session helped them to reconfirm their sense of being active agents in designing their futures (Amburg, 1997). Increasing the individual’s sense of efficacy was associated with the tendency to seek for opportunities and to use feedback to change his/her performance (Keilhofner, 1995). They were allowed to select the venue of the program and the activity to be performed in this session (e.g., learning computer skills or English, performing domestic cooking or beauty care, drawing Christmas cards for family, sharing special snacks or enjoying favorite drinks outside their wards). These therapeutic activities were tailored to the individual’s needs as expressed in session two. These small achievements were used as a stepping stone to cultivate a sense of accomplishment and to encourage thinking about the long-term hope.

In the fourth session, life goals at home and work resettlement were set. Padesky & Greenberger (1995) provided a guide in planning this sort of the program. They recommended using questions to guide individuals setting and prioritizing specific goals. Patients were encouraged to build on success in achieving the small goals set in session three and to plan for the future. They were encouraged to set a non-threatening but realistic time frame for themselves in achieving the future residential and work resettlement plans (ranging from one-half to five years). Subsequently, non-threatening goal setting was carried out in a logical stepwise developmental sequence. The time frame and future goals were documented and communicated to other health care professionals to sustain the success of the intervention. A study was conducted to evaluate the effectiveness of these procedures.

Method Participants The study was conducted in the 1000-bed Castle Peak Hospital which is the largest mental hospital in Hong Kong. Potential participants were selected from three extended care wards. Out of the total of 183 patients (122 males and 61 females) in the three wards, 76 of them (42%; 23 females and 53 males) fulfilled the inclusion criteria. The selection criteria were those diagnosed with schizophrenia with no discharge plan and a score of 0 to -2 in the item of “Goal Formulation” in the validated 10-item version of the Goal Attainment Scale of Psychiatric Inpatients. To ensure participants would be able to benefit from the program, the Global Assessment of Functioning Scale (GAF) of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was adopted as the screening tool (American Psychiatric Association, 1994). Only patients with scores higher than 50 (i.e., with less than serious symptoms or no serious impairment in social, occupational or school functioning) were selected to participate in the study.

Simple random sampling was then used to select 38 participants (50%) out of the 76 eligible in-patients. Informed consent was obtained from 28 participants (74%). Three of them did not complete the intervention due to unexpected circumstances (such as relapse of mental state or fighting with co-patients that required detention in ward for observation). Finally, a total of 25 psychiatric in-patients (10 males and 15 females) took part in the study as participants and completed the four session Goal Attainment Program as described. The participants had an average length of stay in the hospital of 5.3 years with a range from 1.1 to 21.9 years. Their mean age was 39.0 ranging from 23 to 55. They had an average of six admissions to mental hospitals. Details of sociodemographic data are presented in Table 1.

Measures The 10-item version of Goal Attainment Scale for Psychiatric In-patients (GASPI-10). Guy & Moore (1982) derived a uniform Goal Attainment Scale for psychiatric in-patients to measure effectiveness of treatment modalities of the treatment team. This standardized scale helped to provide care monitoring as well as program evaluation for psychiatric in-patients. Guy & Moore (1982) suggested that rehabilitation professionals could extract relevant items from the original 37 item scale to suit individual needs in measuring treatment outcome. Ten items were found to be relevant for this study with percentage of agreement over 50% by a panel (five clinicians and two academic staff members) of content experts. Adjustment of the definition of the outcome behavior within the five-point scale from “Most unfavorable treatment outcome” (-2) to “Best anticipated treatment success” (+2) and the relative weighting of each item were conducted. The 10-item version of the Goal Attainment Scale for Psychiatric In-patients (GASPI-10) for use in this study was found to have good inter-rater reliability (.64 to .88) and internal consistency (.92).

An example of the validated item was listed in table 2. It is important to emphasize that all outcomes listed are potentially possible. It is designed to evaluate change across time. The scale can be transformed to a standardized T-score using an equation with input of correlation, goal weighting and level of attainment in response categories (Kiresuk and Sherman, 1968; Ottenbacher and Cusick, 1993). The conversion helps to transform the distribution with a mean of 50 and a standard deviation of 10 for comparison. Participants obtaining a T-score higher than 50 implies improvement after the GAP while a T-score lower than 50 implies deterioration after the GAP.

The Cultural-free Self-esteem Inventory–Hong Kong version (CFSEI-HK). The Cultural-free Self-esteem Inventory (CFSEI) was developed in English and is available in French and Spanish. Battle (1992) commented that the CFSEI is not a test of psycholinguistic abilities, and therefore minor differences in dialects are not assumed to skew results. It takes approximately 15 to 20 minutes for self-administration. The CFSEI was translated to Chinese as Culture Free Self-esteem Inventory–Hong Kong version (CFSEI-HK) for use in this study. Validation studies showed that it has good internal consistency (.88) and test-retest reliability (.83). The survey included 40 items, and can be re-grouped into four sub-scales of the CFSEI-HK: General self-esteem (16 items: e.g., “Are you happy most of the time?”); Social self-esteem (eight items: e.g., “Do you have only a few friends?”); Personal self-esteem (eight items: e.g., “Are you easily depressed?”), and Lie sub-test (eight items: “Do you always tell the truth?”). Response categories were “Yes” or “No” and scored 0 or 1 according to the rating guide.

Procedures A quasi-experimental one-group pre-treatment/post-treatment design was adopted in this pilot study (Portney and Watkins, 1993). Pre- and post-treatment assessments were conducted using the GASPI-10 and the CFSEI-HK to assess any change in performance.

After obtaining informed consent, the researcher acted as trainer for the counselors who were to implement the Goal Attainment Program to the participants. The counselors were final year students studying the Bachelor of Sciences Degree in Occupational Therapy at The Hong Kong Polytechnic University who scored “distinction” in fieldwork in mental health settings. Before implementation, the counselors went through a two-week training with focus on their communication skills, attitude, use of role checklist and relevant therapeutic activities provided by the researcher. In addition, the counselors needed to conduct a treatment session with trainer to ensure their capability in following the clinical protocol.

Assessors who were blind as to the research design were responsible for conducting the pre-intervention assessment one week before the program started and post-intervention assessment one week after the program completed. Relevant demographic data (e.g., age, educational level, previous admissions, length of stay) of the participants were also collected for analysis. A follow-up assessment of participants two months after the completion of the Goal Attainment Program was conducted to assess the generalization effect of the program. The questions included whether the participants were willing to leave the hospital and whether they had a concrete plan for competitive employment. website adult learning theory

The study used a short treatment intervention (four sessions in three weeks) and a stable group (chronic clients with psychiatric illness) to minimize the extraneous variables and the temporal effects of spontaneous recovery.

Statistical Analyses The Statistical Package for the Social Sciences for Personal Computer Version 8.0 was used for data analyses. Paired t tests were used to compare changes in scores of the two instruments. The Bonferroni’s correction of adjusting the [alpha] was utilized to avoid the inflation of Type I error.

Results Goal Attainment Differences between the GASPI-10 scores before and after the GAP are summarized in Table 3. As shown in Table 3, the item that had the greatest level of improvement was Goal Formulation. Paired t tests indicate that there were significant differences between nine pairs of pre- and post-treatment item scores; Goal formulation, Insight, Decisiveness, Self-confidence, Assertiveness, Direction-following, Attention-concentration, Dependence-independence, and Participation. However, no significant difference between the pre- and post-treatment item scores of the item Responsibility was found (p = .071). Type II error and effect size are also shown in Table 3. It was found that item 10 `Responsibility’ had a low effect of .22 and a type II error of .81. The type II error ([beta]) of the remaining nine items ranged from .005 to. 18 and effect size (d) ranged from .74 to 1.74.

The average post treatment T-score of participants was 66.07 with a range from 46.4 to 89.6. It was found that 23 clients (92%) had T-score greater than 50 after the completion of program. One Sample t test against the standardized mean (50) found that there was significant improvement in goal attainment (t = 6.422, df = 24, p = .0.00).

Self-esteem In addition to increased goal attainment, a significant increase in CFSEI-HK scores after program intervention was found. Relevant statistics regarding the CFSEI-HK scores before and after the GAP are shown in Table 4. The post-treatment mean score of the CFSEI-HK in General, Personal, Social, and Total were significantly higher than the pre-intervention scores. Conversely, the `Lie’ score decreased after treatment. Though the difference was not statistically significant (p = .053). Paired t tests indicated that there were significant differences between pre- and post-treatment in `Total’, `General’, `Personal’ and `Social’ scores (p < .003). Effect size and type II error are also shown in Table 4 as well. Effect size (d) ranged from .34 to .68. Type II error ([beta]) ranged from .23 to .67.

Comparison of Rehabilitation Stages Upon completion of the program, 92% of participants set the future residential goal of leaving the hospital, and 72% of participants planned to seek paid employment upon discharge. The effect of the treatment program on participant’s involvement in the rehabilitation progress was compared. It was found that 11 out of 25 participants showed improvement in rehabilitation status and attended the rehabilitation services on work and home resettlement program. The results reveal that after participating in the Goal Attainment Program, participants were more willing to receive rehabilitation services. Two female participants were discharged two months after completion of the GAP.

Discussion Traditional psychiatric rehabilitation programs focus on `problems’ and `negatives’ of individuals and tend to ignore strengths and assets (Hagedorn, 1992). Unlike the traditional approach, this program uses a holistic and client-centered approach (Rogers, 1984) which helps individuals establish future directions in home and work resettlement. The Goal Attainment Program focused on the participants’ future expected life roles and social functioning in relation to the environmental context (i.e. their `participation level’, according to the International Classification of Impairment, Disability and Handicap (ICIDH-2) of the World Health Organization). The program emphasized the needs and positive aspects of individuals (Rogers, 1984), as well as the attainment of self-esteem in the self-actualization hierarchy (Maslow, 1970). The program is based on the belief that each individual has the potential to control his/her life and to choose what he/she wishes to become. With this belief, change can only take place when the individual finds the meaning in himself/herself. Positive change can occur throughout life. The role of therapist is to facilitate the willingness to change (Hagedorn, 1992). This study also used Frankl’s (1946/1992) belief that the most basic human motivation is the will to meaning.

In this pilot implementation of the Goal Attainment Program, results indicate success. This is evidenced by the fact that the participants increased significantly in their goal formulation and self-esteem. In addition, most participants were willing to leave the hospital and planned to seek competitive employment upon discharge (Ng & Tsang, 2000).

During the pilot study, it was found that participants needed encouragement to admit that they needed help. Creek (1997) echoed that the experience of hospitalization could be very traumatic, particularly if frequent relapses and readmissions were unavoidable. It appeared difficult for them to admit that they needed help.

Hagedorn (1992) pointed out that the concept of an individual being able to control his/her life choices might be overstated and unrealistic. In the pilot implementation, the counselors acted as the participant’s advocate, putting forward his/her wishes and helping him/her to ascertain the realistic wishes from unrealistic ones. It was a difficult process that requires careful handling.

In Hong Kong, there exists a limited range of rehabilitation services available to in-patients with severe mental illness. Most patients are discharged without a discharge plan. This study aimed to tailor a program for this neglected group, working in line with the zero-exclusion and customer self-determination philosophies in rehabilitation (Bybee, Mowbray, and McCrohan, 1996). The Goal Attainment Scale for Psychiatric In-patients and the Culture Free Self-esteem Inventory were validated and used to reflect the change in life goals and self-esteem after attending the four-session individualized Goal Attainment Program (Ng, 1999, Ng & Tsang, 2000). This study provides more evidence for the usefulness of the Goal Attainment Scale (Kiresuk and Sherman, 1968) in monitoring and documenting the progress of in-patients.

Counselors however, should avoid the temptation to promise unachievable results (Tiffany, 1983). Facilitating the individual’s personal search for purpose, meaning, and self-actualization is important. A possible criticism of this type of counseling program is that the treatment outcome depends on the expertise of the therapist. A certain level of competency in communication and the appropriate attitude are definitely required to ensure the success of this program. Using the individual himself/herself as a therapeutic agent (Neistadt, 1998) is important and acts as a key to success in the Goal Attainment Program. Cohen, Farkas, Cohen, and Unger (1997) recently developed a training protocol for practitioners to learn how to set overall rehabilitation goals for individuals with mental illness in residential, educational, vocational and social environments. Further exploration is necessary to determine the appropriate level of counselor competency needed for this program.

A number of limitations should be considered when evaluating the results of this study. The confounding influences of selection interaction, history, testing and instrumentation cannot be ruled out. This quasi-experimental design posed serious threats to the internal validity because the lack of randomization and control groups for comparison. Furthermore, the group of participants (74%) who were willing to participate in the study may represent individuals who had more overall potential for improvement, thus creating a possible bias towards positive results. Furthermore, there was an attrition of 11% of the participants during the course of the study. Those who remained to complete the post-test may be different in some way. Therefore, cautions should be taken when interpreting the results. In order to make results more generalizable to other groups of individuals, alternative studies using larger sample size, a more probabilistic recruitment process, and with a control group should be carried out.

Conclusion This pilot study supports the conclusion that the Goal Attainment Program is a promising tool to help individuals with severe and persistent mental illness to formulate realistic life goals. It has potential for shortening length of stay in mental hospitals and motivating in-patients to join home and work rehabilitation programs.

Table 1 Social-demographic Characteristics of Clients

Male Female (n = 10) (n = 15) n n

Age 23-31 3 4 32-39 1 5 40-47 4 3 48-55 2 3

Marital Status Single 9 9 Married 1 3 Divorced 0 3

Educational level Primary school 1 6 Secondary school 9 9

Previous Admissions (No.) 0-2 1 3 3-5 4 8 7-9 3 1 10 or above 0 3

Length of Stay 1-5 years 6 9 6-10 years 0 3 > 10 years 4 3

Suicidal History Yes 2 7 No 8 8

Criminal Offence Yes 2 2 No 8 13

GAF Score 50-59 3 8 60-69 6 4 70-79 1 2

Table 2 One of the Validated Item (Goal Formulations) of the GASPI-10

Rating Description

-2 Client unable to formulate short-term goals: does not independently remember scheduled activities.

-1 Client may verbalize daily schedule when asked, but takes no initiative to attend activities.

0 Client is aware of scheduled activities and follows weekly schedule (may require reminders).

+1 Client verbalizes some problem areas and can, with assistance, outline possible solutions for situations in and:out of hospital.

+2 Client has formulated discharge plan with specific short-term and long-term goals (home passes, mental health center visits, job interviews, home and work resettlement plan, etc).

Table 3 Comparison of GASPI-10 Scores Before and After the GAP

Score [Treatment.sup.a]

Before After

[w.sub.i. M SD M SD sup.b]

Goal Formulations 4.57 -.88 .78 .72 1.06 Insight 3.71 -.88 .93 .32 1.07 Decisiveness 3.71 -.80 .76 .28 .61 Self-confidence 4.29 -.88 .67 .20 .82 Assertiveness 2.86 -.12 .97 1.04 .68 Direction Following 2.71 .20 .96 .96 1.10 Attention-Concentration 3.00 .24 1.09 1.04 1.02

Dependence-Independence 2.86 .36 .36 1.04 .98

Participation 2.71 .32 .32 .84 .55 Responsibility 2.71 -.08 .81 .28 .98

Score Type I Type II Error Error

Change df = 24

M SD t p d [beta]

Goal Formulations 1.60 1.12 -7.16 ** .000 1.74 < .005. one-tailed. *'12 < .001. one-tailed.

Table 4 Comparison of the Score of CFSEI-HK Before and After Treatment

Score Treatment

Before After Type I Type II Error Error

(N = 25) (N = 25) df = 24

M SD M SD t p d [beta]

General 8.36 3.78 10.12 3.71 -3.636 ** .000 .68 .29 Social 3.96 2.28 5.32 1.70 -4.461 ** .000 .47 .23 Personal 4.20 2.29 5.64 2.22 -3.218 ** .002 .64 .51 Lie 3.88 1.72 3.32 1.60 1.686 .053 .34 .29 Total 16.72 6.95 20.92 6.44 -4.905 ** .000 .63 .67

** p < .003. one-tailed. * p < .017. one-tailed.

Acknowledgement The authors wish to thank Dr. H.S. Ng, Consultant Psychiatrist, Dr. S.P. Leung, Consultant Psychiatrist, Ms. Amy Chan, Department Manager of the Occupational Therapy Department of Castle Peak Hospital, and all the members of the New Territories North Cluster Hospital Ethics Committee for their kind approval to carry out the study.

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Bacon F. L. Ng Castle Peak Hospital

Hector W. H. Tsang The Hong Kong Polytechnic University Ng, Bacon F.L.; Tsang, Hector W.H.