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The development and evaluation of the goal attainment scaling process Hover, Gerald Robert 1981

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THE DEVELOPMENT AND EVALUATION OF THE GOAL ATTAINMENT SCALING PROCESS b y GERALD ROBERT HOVER B . A M . A • r • r G o n z a g a U n i v e r s i t y , 1969 G o n z a g a U n i v e r s i t y , 1970 A T H E S I S S U B M I T T E D I N P A R T I A L F U L F I L L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F D O C T O R O F E D U C A T I O N T h e F a c u l t y o f G r a d u a t e S t u d i e s F a c u l t y o f E d u c a t i o n T h e D e p a r t m e n t o f C o u n s e l l i n g P s y c h o l o g y W e a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d : i n T H E U N V E R S I T Y O F B R I T I S H C O L U M B I A OeTOBERC' 1980 , ( C ) C o p y r i g h t : G e r a l d R o b e r t H o v e r , 1981 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o an a d v a n c e d d e g r e e at the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f c The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 Wesbrook Place Vancouver, Canada V6T 1W5 i ABSTRACT The purpose of t h i s study was to develop a group process to a s s i s t c l i e n t s i n a g o a l - o r i e n t e d p r o b l e m - s o l v i n g approach to b r i e f therapy. The Goal Attainment S c a l i n g Process (GASP) d e s c r i b e d i n t h i s paper was to become an important p a r t of the treatment program of a v o l u n t a r y i n p a t i e n t p s y c h i a t r i c u n i t . An e v a l u a t i o n was conducted, comparing h o s p i t a l i z a t i o n with and without the GASP. The t h e o r e t i c a l r a t i o n a l e u n d e r l y i n g the GASP i s based upon the assumption that as people work on minute steps of p r o g r e s s they w i l l r e c e i v e r e i n f o r c e m e n t at t h e i r lower l e v e l s of goal attainment. Such reinforcement w i l l serve as an impetus f o r a t t a i n i n g higher l e v e l s of goal a t t a i n m e n t . F u r t h e r , as c l i e n t s i d e n t i f y themselves as r e s p o n s i b l e f o r change, they g a i n more c o n t r o l over t h e i r f a t e . Thus as the c l i e n t s c l a r i f y t h e i r e x p e c t a t i o n s and g o a l s , they are l e s s l i k e l y to f e e l anxious about t h e i r l i v e s . As they e x e r c i s e d e c i s i o n s and c h o i c e s f o r c o n t r o l , there i s an expected i n c r e a s e i n a s s e r t i v e n e s s . With a c o n c r e t e l i f e - f o c u s , such as the GASP p r o v i d e s v i a small s e q u e n t i a l s t e p s , i t i s l o g i c a l to assume that c l i e n t s ' enthusiasm f o r both them-s e l v e s and l i f e i n general would r i s e as the g o a l s are a t t a i n e d . Concomitantly, as t h e i r g o a l s are a t t a i n e d , c l i e n t s become more s e l f - r e l i a n t , e n t h u s i a s t i c , and l e s s anxious. Then, l e s s time i s spent worrying about "where I went wrong" or the g u i l t of past mistakes. i i T h i s process i s c o n s i s t e n t with the n o t i o n s o f : time l i m i t e d q o a l s , t a l k i n g about p r e s e n t e v e n t s , f o s t e r i n q v e n t i l a t i o n , and r a p i d l y developing a f a c i l i t a t i v e i n t e r -p e r s o n a l r e l a t i o n s h i p . The t h e r a p i s t manaqed the problem-s o l v i n q s e s s i o n d i r e c t l y ; s u p p o r t i v e a d m i n i s t r a t i v e i n t e r -v e n t i o n s screened a p p r o p r i a t e c l i e n t s and f o s t e r e d t h e r a -p e u t i c f l e x i b i l i t y . The GASP tauqht c l i e n t s s e l f - c o n t r o l throuqh a d i r e c t assessment s t r a t e g y t h a t encouraqed c l i e n t s to r e q u l a t e t h e i r own behavior by examining the d e f i n i t i o n of the problem and coping s k i l l s . The c o n c l u s i o n was that the afore-mentioned f a c t o r s could be combined i n developing a needed therapy f o r a s h o r t - t e r m p s y c h i a t r i c h o s p i t a l i z a t i o n proqram. S p e c i -f i c a l l y , an instrument used to measure p s y c h o t h e r a p e u t i c outcome, the Goal Attainment S c a l e , could be m o d i f i e d i n t o a p r o c e d u r e t o a i d v o l u n t a r i l y h o s p i t a l i z e d p s y c h i a t r i c p a t i e n t s . The s u b j e c t s were 32 v o l u n t a r i l y h o s p i t a l i z e d p a t i e n t s of the p s y c h i a t r i c u n i t of V a l l e y General H o s p i t a l . An a d a p t a t i o n of the non-equivalent c o n t r o l qroup desiqn was chosen. They were administered the Rotter I n t e r n a l - E x t e r n a l Locus of C o n t r o l S c a l e , the Tarqet Outcome Assessment Sheet, and t h e S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e upon admission, and aqain e i q h t days a f t e r t h e i r i n i t i a l i n t e r -view. Eleven s u b j e c t s i n both treatment qroups and a p r e -experimental group were administered the Ward Atmosphere S c a l e . The purpose was to see i f the atmosphere during h o s p i t a l i z a t i o n w i t h the GASP was d i f f e r e n t t han the atmosphere of h o s p i t a l i z a t i o n without the GASP. It was hypothesized t h a t there would be no d i f f e r e n c e s i n the ward environment s i x months before t e s t i n g and d u r i n q the two e v a l u a t i o n p e r i o d s , that there would be no d i f f e r -ences between p r e t e s t s c o r e s , t h a t there would be a d i f -f erence i n a t t a i n i n g both the c l i e n t s ' "most important" g o a l , as w e l l as a l l t h e i r other g o a l s ; t h a t there would be a d i f f e r e n c e i n the s u b j e c t s ' subsequent sc o r e s o f s e l f -c o n t r o l ; t h a t the c l i e n t s would have more p e r s o n a l i t y i n t e g r a t i o n , be more a s s e r t i v e and e n t h u s i a s t i c , and l e s s q u i l t y and anxious; and that the length of h o s p i t a l i z a t i o n time would be shortened. A m u l t i v a r i a t e a n a l v s i s of v a r i a n c e d i d not r e v e a l any d i f f e r e n c e s i n ward atmosphere d u r i n g the two treatments and f o r the s i x months p r i o r to the e v a l u a t i o n . F u r t h e r , the p r e t e s t scores of both groups at admission were not found to be d i f f e r e n t . For the most p a r t the q o a l s i d e n t i f i e d at admission were i n the same c a t e g o r i e s as those i d e n t i f i e d d u r i n q the GASP. A l s o , c l i e n t s ' q o a l s at admission and d u r i n g the GASP were s t a t e d i n the same d i r e c t i o n . A n a l v s i s o f t h e p o s t t e s t r e v e a l e d t h e r e was no s i g n i f i c a n t d i f f e r e n c e between the groups r e l a t i v e to g o a l achievement, eqo s t r e n g t h , a s s e r t i v e n e s s , and q u i l t . The GASP c l i e n t s were s i g n i f i c a n t l y more i n t e r n a l , more e n t h u s i -a s t i c , and l e s s anxious. F i n a l l y , h o s p i t a l i z a t i o n with the i v GASP was s h o r t e r by 16.3 per cent, but t h i s was not s t a t i s -t i c a l l y s i g n i f i c a n t . V TABLE OF CONTENT I. INTRODUCTION 1 The H o s p i t a l A d m i n i s t r a t i o n ' s Need 3 Promising Components of Short-Term Psycho-therapy 3 P r o m i s i n g Developments of P r o b l e m - S o l v i n g Therapies Goal Attainment S c a l i n g 8 Statement of the Problem Development of the goal attainment s c a l e as therapy I n t e g r a t i o n 7 10 12 13 19 I I . SURVEY OF THE LITERATURE B r i e f Psychotherapy H i s t o r i c a l development of b r i e f p s y c h o -therapy C h a r a c t e r i s t i c s common to b r i e f p s y c h o -therapy Outcome research with b r i e f psychotherapy 4 3 Problem-Solving Therapy 46 Problems and short-comings of b r i e f and problem-solving research H i s t o r i c a l Development of the Goal Attainment Scale T h e o r e t i c a l u n d e r p i n n i n g s of the g o a l attainment s c a l e 55 52 54 59 60 I I I . DEVELOPMENT OF THE GASP The GASP procedure Implementation of the GASP Need f o r cohesive treatment approach Adoption of the goal attainment s c a l e and i t s a d a p t a t i o n to group therapy P s y c h i a t r i c U n i t , V a l l e y General H o s p i t a l I n t r o d u c t i o n of GASP 73 61 69 69 71 v i S t a b i l i t y of GASP Goals 7b Comparative E v a l u a t i o n 76 Hypotheses r e l a t e d to c o n t r o l i s s u e s 77 Ev a l u a t i o n hypotheses 80 S i g n i f i c a n c e l e v e l s 85 IV. EVALUATION METHODOLOGY Comparative e v a l u a t i o n of the GASP 88 Design 88 Instruments Ward Atmosphere Scale 91 The Target Outcome Assessment Sheet 95 The R o t t e r I n t e r n a l - E x t e r n a l Locus of Co n t r o l Scale 96 The Sixt e e n P e r s o n a l i t y Factor Question-n a i r e 97 Procedure Subjects 99 Test a d m i n i s t r a t i o n 100 T h e r a p i s t s 102 P s y c h i a t r i c u n i t 103 Treatments 103 S t a t i s t i c a l Analyses Data p r e p a r a t i o n 110 Co n t r o l hypotheses 110 E v a l u a t i o n hypotheses 111 V. RESULTS Comparative E v a l u a t i o n P r e l i m i n a r y a n a l y s i s of c o n t r o l i s s u e s 113 Pre-treatment c o m p a r a b i l i t y of samples 115 Summary 115 v i i V I . D I S C U S S I O N AND SUMMARY Summary o f R e s u l t s 125 T h e D e v e l o p m e n t o f t h e GASP 125 T h e P r e l i m i n a r y E v a l u a t i o n o f t h e GASP 126 L i m i t a t i o n s o f t h e S t u d y 131 R e c o m m e n d a t i o n s f o r F u r t h e r R e s e a r c h 133 C o n c l u s i o n 135 B I B L I O G R A P H Y 136 A P P E N D I C E S 169 v i i i L I S T OF FIGURES F i g u r e 1 Ward Atmosphere T e s t S c h e d u l e 78 F i g ure 2 A c t u a l D e s i g n 89 F i g ure 3 T e s t A d m i n i s t r a t i o n S c h e d u l e 95 F i g ure 4 A d m i s s i o n and D i s c h a r g e D a t e s GASP Group, May 1 - June 15 f o r t h e 104 F i g u r e 5 A d m i s s i o n and D i s c h a r g e D a t e s N o n - e q u i v a l e n t C o n t r o l Group, A u g u s t 15 f o r J u l y the 1 -105 i x LIST OF TABLES Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Table 13 Table 14 C l i e n t C h a r a c t e r i s t i c s GASP D a i l y Schedule Non-GASP D a i l y Schedule A c t i v i t i e s o f N o n - E q u i v a l e n t C o n t r o l Group Means and Standard D e v i a t i o n s o f the Three Test P e r i o d s o f the Ward Atmo-sphere Scale M u l t i v a r i a t e A n a l y s i s o f the Ward A t -mosphere Scale at January, June, and August U n i v a r i a t e A n a l y s i s o f Variance on the Ward Atmosphere Subscales Means and S t a n d a r d D e v i a t i o n s o f P r e t e s t Scores o f the F i v e Subscales o f the S i x t e e n P e r s o n a l i t y F a c t o r Ques-t i o n n a i r e M u l t i p l e A n a l y s i s of Variance of S i g -n i f i c a n t D i f f e r e n c e s Between P r e t e s t S c o r e s on the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e U n i v a r i a t e F-Ratios o f D i f f e r e n c e on the P r e t e s t Scores on the F i v e Sub-s c a l e s o f the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e Means and S t a n d a r d D e v i a t i o n s o f P r e t e s t Scores on the Locus of C o n t r o l S c a l e and the Number of Goals on the Target Outcome Assessment Sheet M u l t i v a r i a t e A n a l y s i s o f Va r i a n c e f o r S i g n i f i c a n t D i f f e r e n c e s Between P r e t e s t Score of the Locus of C o n t r o l S c a l e and the Number of Goals on the Target Out-come Assessment Sheet A n a l y s i s o f Variance and Means o f Post-t e s t S c o r e s f o r the T a r g e t Outcome Assessment Sheet A n a l y s i s of Variance and Means of Post-t e s t Scores f o r the Locus of C o n t r o l S c a l e 101 107 108 109 114 114 115 11 7 1 1 7 1 1 7 1 1 9 119 119 121 X Table 15 M u l t i p l e A n a l y s i s of V a r i a n c e f o r Post-t e s t Scores on the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e Table 16 Means and Standard D e v i a t i o n s f o r the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n -n a i r e P o s t t e s t T a b l e 17 A n a l y s i s of Variance f o r the S i x t e e n P e r s o n a l i t y F actor Q u e s t i o n n a i r e Post-t e s t Table 18 t-Test Results f o r Lenqth of Stay Table 19 Summary of P o s t t e s t R e s u l t s 1 22 123 123 124 124 x i ACKNOWLEDGEMENTS Like most of l i f e , t h i s e f f o r t was accomplished through the h e l p of many people. Although I am s o l e l y r e s p o n s i b l e f o r the content and the e r r o r s , I would l i k e to thank my committee, my f a m i l y , my f r i e n d s , and my c o l l e a g u e s f o r t h e i r h e lp and encouragement. I a p p r e c i a t e the time and e f f o r t e x t e n d e d by my committee members: Drs. S. Marks, T. Rogers, L. Greenberg, and D. McKie. T h e i r i n t e g r i t y and a t t e n t i o n to d e t a i l have enhanced t h i s work. I am ever g r a t e f u l to the l o v e , support, and encourage-ment, o f my p a r e n t s and b r o t h e r t h r o u g h o u t t h i s whole e x p e r i e n c e . I owe a debt of g r a t i t u d e to the Hovers, the Barons, the Knoxs, the Lynchs, and the P e n d e r g r a f t s . My f r i e n d s , P. P a t t y Sorenson, Dan Zanchi, Adam and Barb Horvath, C a r o l and Dennis O ' N e i l l , Janet Gubanc, Helen S t o l t e , and Dave and Beth B o l l e s are acknowledged as being c r u c i a l to my graduate school e f f o r t . I am a l s o g r a t e f u l f o r the sustenance of the f o l l o w i n g people: the s t a f f at V a l l e y General H o s p i t a l , Jon B e l l , V i r g i n i a Bzdek, Andy G e n t i l e , R e i n h a r d T a u s c h , Don Wise, Myles and Myrna Anderson, Ken Ames, Mel Jordan, Bud Hartlaub, Jack K e a t i n g , Hugh Armstrong, and Norma Komar. To a l l of you I warmly say "Thank you." 1 CHAPTER I INTRODUCTION Three of the more i n t e r e s t i n g r ecent developments i n psychotherapy have been the advancement o f b r i e f psycho-therapy, the growth of p r o b l e m - s o l v i n g / s e l f - c o n t r o l t h e r a -p i e s , and the development of Goal Attainment S c a l i n g . B r i e f psychotherapy i s a r e s u l t of a search f o r a more e f f i c i e n t means to meet c l i e n t needs. Problem-solving psychotherapy has developed from research i n c o g n i t i v e therapy w i t h i n the boundaries of behavior therapy. Goal Attainment S c a l i n q i s a response to the demands of measurement, p r e c i s i o n , and a c c o u n t a b i l i t y i n psychotherapy. L o r i o n (1974) r e p o r t e d t h a t the N a t i o n a l Center f o r H e a l t h S t a t i s t i c s found t h a t f o r 979,000 c l i e n t s , t h e average number o f c o n t a c t s w i t h a t h e r a p i s t was 4.7. Whether or not t h i s number of c o n t a c t s i s due to premature t e r m i n a t i o n , i t n e v e r t h e l e s s demonstrates a need f o r b r i e f t h e r a p i e s . Mahonev and Arknoff (1978) e x t e n s i v e l y reviewed completed r e s e a r c h and development i n the area o f s e l f -c o n t r o l t h e r a p i e s and concluded that these approaches showed gr e a t promise as a technology f o r t h e r a p e u t i c change. Goal Attainment S c a l i n g has been used as an instrument f o r 2 e v a l u a t i n g the outcome of psychotherapy and can a l s o be used as a treatment i t s e l f (Smith, 1974). Goal Attainment S c a l i n g lends i t s e l f to being used as a t h e r a p e u t i c method because i t i s a very concrete system f o r e s t a b l i s h i n g g o a l s . Taken together, these three developments i n psychotherapy have the p o t e n t i a l to be s y n t h e s i z e d i n t o a short-term treatment procedure. There are i n d i c a t i o n s that a s y n t h e s i s o f problem-s o l v i n g p s y c h o t h e r a p y , b r i e f p s y c h o t h e r a p y , and Goa l Attainment S c a l i n g could prove s u c c e s s f u l . The l i t e r a t u r e suggests the i n t e g r a t i o n should i n c l u d e many t h e r a p e u t i c a s p e c t s . The syn t h e s i z e d process should take i n t o account the importance o f : time l i m i t e d g o a l s , t a l k i n g about pres e n t events, f o s t e r i n g v e n t i l a t i o n , and r a p i d l y d e veloping an i n t e r p e r s o n a l r e l a t i o n s h i p . The t h e r a p i s t should manage the problem-solving s e s s i o n d i r e c t l y . S upportive a d m i n i s t r a t i v e i n t e r v e n t i o n s should p l a c e a p p r o p r i a t e c l i e n t s i n treatment q u i c k l y and should f o s t e r t h e r a p e u t i c f l e x i b i l i t y . The process should teach c l i e n t s s e l f - c o n t r o l through a d i r e c t assessment s t r a t e g y that encourages c l i e n t s to r e g u l a t e t h e i r own behavior. F i n a l l y , the therapy should emphasize problem d e f i n i t i o n and broad coping s k i l l s . In order to pursue t h i s s y n t h e s i s , four i s s u e s were addressed i n the present study. These were: (1) meeting the requirements o f the h o s p i t a l ; (2) e v a l u a t i n g the components o f short-term psychotherapy; (3) i d e n t i f y i n g the promising aspects o f 3 prob l e m - s o l v i n g psychotherapy; and (4) examining the Goal Attainment S c a l i n g procedure. The H o s p i t a l A d m i n i s t r a t i o n ' s Need The i n t e g r a t i o n o f the program components b r i e f l y d e s c r i b e d above, and the subsequent e v a l u a t i o n o f the e f f e c t i v e n e s s o f the r e s u l t i n g procedure was completed at V a l l e y General H o s p i t a l i n S e a t t l e , Washington. While a number o f other h o s p i t a l s were approached, t h i s s i t e was chosen f o r two reasons. F i r s t , the h o s p i t a l a d m i n i s t r a t o r s wanted a procedure t h a t could be conducted d a i l y w i t h i n s i x t y minutes, given that c l i e n t s would be h o s p i t a l i z e d f o r an average o f two weeks. The procedure was a l s o r e q u i r e d to f i t i n t o the a d m i n i s t r a t i o n ' s ideas of openness and ward m i l i e u . Second, as the process was to be based upon e x i s t i n g e m p i r i c a l l y v a l i d a t e d p r a c t i c e s , the h o s p i t a l a d m i n i s t r a t o r s c o n t r a c t e d to evaluate the e f f e c t i v e n e s s o f the procedure. Promising Components of Short-Term Psychotherapy As people were being seen f o r a r e l a t i v e l y small number of s e s s i o n s , t h e r a p i s t s had to develop a technology to meet t h i s need f o r b r i e f treatment. In t h e i r review of r e s e a r c h on b r i e f and c r i s i s - o r i e n t e d t h e r a p i e s , Butcher and Koss (1978) noted t h a t , i n s p i t e o f d i f f e r i n g t h e o r e t i c a l 4 assumptions and treatment s t r a t e g i e s , most b r i e f treatments have a number of c h a r a c t e r i s t i c s i n common. These a r e : 1. Therapy is- managed w i t h i n a s p e c i f i e d p e r i o d of time. Butcher and Koss (1978) suggested t h a t i n f o r m i n g the c l i e n t of the time l i m i t s accomplished two t h e r a p e u t i c g o a l s . I t encouraged c l i e n t optimism t h a t change was pos-s i b l e i n a s h o r t time and provided therapy with a s t r u c t u r e of a b e g i n n i n g , a middle, and an end. 2. T h e r a p e u t i c g o a l s are l i m i t e d . Both Malan (1963) and Wolberg (1965a) rep o r t e d that b r i e f psychotherapy aban-doned n o t i o n s of " t h e r a p e u t i c p e r f e c t i o n " and "the p r e j u -d i c e s of depth" t h a t are generated with ideas of e x t e n s i v e p e r s o n a l i t y r e c o n s t r u c t i o n . Goals e s t a b l i s h e d f o r b r i e f psychotherapy are l i m i t e d to e s t a b l i s h i n g emotional e q u i -l i b r i u m w i t h i n the time framework of therapy. 3. T h e r a p e u t i c content i s c e n t e r e d i n the p r e s e n t . Butcher and Koss (1978) suggested that the g o a l s of b r i e f psychotherapy c o u l d be accomplished most e f f e c t i v e l y i f t h e r a p e u t i c a t t e n t i o n i s focused on a thorough e x p l o r a t i o n of the primary problem area, which more o f t e n than not i s a c u r r e n t problem i n the c l i e n t ' s l i f e . C h i l d h o o d memories, dreams, and i n t e r p r e t a t i o n s of t r a n s f e r e n c e should be em-ployed o n l y as they come to bear on the present problem. 4. • The s e s s i o n i s managed d i r e c t l y by the t h e r a p i s t . Strupp (1973) demonstrated that a f t e r c l a r i f i c a t i o n , d i r e c t guidance was the second most f r e q u e n t t h e r a p e u t i c a c t i v i t y i n b r i e f psychotherapy. Short-term b e h a v i o r a l t h e r a p i s t s 5 are a l s o s i g n i f i c a n t l y more d i r e c t i v e than p s y c h o a n a l y t i c a l -l y o r i e n t e d t h e r a p i s t s (Sloane, S t a p l e s , C r i s t o l , Yorkston, & Whipple, 1975). Gelb and Oilman (1967) argued that work-ing i n a b r i e f psychotherapy framework, t h e r a p i s t s must guide the c l i e n t to methods of behavior and i n t e r a c t i o n t h at are d i f f e r e n t from the c l i e n t ' s customary mode of o p e r a t i n g . 5. The c l i e n t i s assessed r a p i d l y and e a r l y . B r i e f therapy makes i t imperative that the t h e r a p i s t s understand the p r e c i p i t a t i n g events ( H a r r i s , K a l i s , & Freeman, 1963; Jacobson, W i l n e r , Morley, Schneider, S t r i c k l e r , & Sommer, 1965; S i f n e o s , 1975). Small (1971) suggested t e n t a t i v e guides whereby the c l i e n t s i d e n t i f i e d the complaint, the p r e c i p i t a t i n g causes, the v a r i a t i o n s of the present behav-i o r , the meaning of the behavior, and t h e i r own s t r e n g t h s and weaknesses. 6. T h e r a p e u t i c i n t e r v e n t i o n s are adapted to meet the requirements of the i n d i v i d u a l . Alexander and French (1946) concluded that the primary t e c h n i c a l p r i n c i p l e i n short-term psychotherapy was adapting the treatment to the c l i e n t . Consequently, short-term psychotherapy r e q u i r e s a v a r i e t y of p s y c h o t h e r a p e u t i c techniques which come from p s y c h i a t r y , p s y c h o a n a l y s i s , psychology, and s o c i o l o g y (Wolberg, 1965b). 7. I n t e r v e n t i o n i s prompt. T h i s a c t i o n i s necessary as there may not be another s e s s i o n . Many r e s e a r c h e r s ( B e l l a k & S m a l l , 1965; C a p l a n , 1961; Lindemann, 1 944 ; Wolkon, 1972) suggest i t i s advantageous to t r e a t people as q u i c k l y as p o s s i b l e . Prompt i n t e r v e n t i o n p a r a l l e l s the 6 e a r l i e r i d e a t h a t the emphasis i n b r i e f p s y c h o t h e r a p y c e n t e r s on c u r r e n t l i f e problems and thus the p r a c t i t i o n e r s should o f f e r therapy when the c l i e n t has awareness o f the problem and i s ready to work on i t . 8. Emotional t e n s i o n i s v e n t i l a t e d . In reviewing a l l o f t h e major a p p r o a c h e s t o b r i e f and c r i s i s - o r i e n t e d therapy, v e n t i l a t i o n was found to be important (Alexander & French, 1946; Baker, 1947; Butcher & Koss, 1978; Butcher & Maudal, 1976; Frank, 1974b; Lindemann, 1944; Mann, 1973; Semrad, B i n s t o c k , & White, 1966; Wolberg, 1965b; Wolpe & Lazarus, 1966). Within a c a t h a r t i c environment, c l i e n t s can experience and express t h e i r f e e l i n g s spontaneously and n a t u r a l l y . 9. A f a c i l i t a t i v e i n t e r p e r s o n a l r e l a t i o n s h i p i s estab-l i s h e d q u i c k l y . T h i s r e l a t i o n s h i p i s seen as d e s i r a b l e by any school of therapy (Bergin & Suinn, 1975) and may be enhanced by many f a c t o r s . Two of these f a c t o r s are the c l i e n t ' s e x p e c t a t i o n of t h e r a p e u t i c g a i n ( L i c k & B o o t z i n , 1975) and the t h e r a p i s t ' s enthusiasm and involvement (Malan, 1963, 1976a). 10. A p p r o p r i a t e c l i e n t s are s e l e c t e d . According to the review by Butcher and Koss (1978), four types o f c l i e n t s were recognized as best s u i t e d f o r b r i e f psychotherapy: those i n whom the b e h a v i o r a l problem i s acute; those i n whom pre v i o u s adjustment has been good; those with good a b i l i t y to r e l a t e ; and those with high m o t i v a t i o n . C l i e n t s whom 7 Butcher and Koss thought were unsuited f o r short-term t h e r -apy were: those who d e s i r e p e r s o n a l i t y r e c o n s t r u c t i o n , are deeply dependent, p e r s i s t e n t l y a c t out, or are u n r e s t r a i n -a b l v a n x i o u s ; t h o s e who a r e o u t s p o k e n l y s e 1 f - c e n t e r e d , passively-dependent, m a s o c h i s t i c , or s e l f - d e s t r u c t i v e ; and those who are not educated beyond f i f t h qrade, p s y c h o t i c , m e n t a l l y d e f e c t i v e , or t o x i c due to i l l n e s s or o r g a n i c i t y . These ten components have g e n e r a l l y been i n t e g r a t e d i n t o most short-term psychotherapies (Butcher & Koss, 1978). The c h a l l e n g e i s to s y n t h e s i z e the contemporary p r a c t i c e of short-term psychotheraDy with problem-solving therapy and Goal Attainment S c a l i n q . Promising Developments of Problem-Solving T h e r a p i e s One way to enhance the g o a l d i r e c t e d n e s s of b r i e f psychotherapy i s to encourage c l i e n t s to change t h e i r behav-i o r (Frank, 1974a; Liberman, Imber, Stone, Hoehn-Saric, & Frank, 1974). " A v a i l a b l e r e s e a r c h evidence supports the widely h e l d view amonq b r i e f t h e r a p i s t s t h a t concrete imple-mentation of new r o l e s or behaviors i s an imDortant and e f f e c t i v e process i n b r i e f treatment approaches" (Butcher & Koss, 1978, p. 748). In t h i s reqard, Mahoney and A r n k o f f (1978) speculated that of a l l the c o q n i t i v e and s e l f - c o n t r o l t h e r a p i e s i d e n t i f i e d as b e h a v i o r a l , the p r o b l e m - s o l v i n q t h e r a p i e s , which view p s y c h o l o q i c a l problems as the r e s u l t of i n e f f e c t i v e behavior, miqht y i e l d the most encouraging 8 c l i n i c a l r e s u l t s . Problem-solving t h e r a p i s t s do not look upon problems as abnormal behavior or emotional d i s t u r b a n c e . The p r o b l e m - s o l v i n g t h e r a p i s t s e x p l o r e the s i t u a t i o n a l problems i n the c l i e n t ' s l i f e . Problem-solving t h e r a p i s t s a l s o examine the c l i e n t ' s inadequate attempts to solve these problems which may c r e a t e such u n d e s i r a b l e e f f e c t s as a n x i e t y , d e p r e s s i o n , or i n d e c i s i v e n e s s . Mahoney and A r n k o f f (1 978) suggested t h e r a p i e s of t h i s nature may i n p a r t be e f f e c t i v e due t o : 1. the teaching of coping s k i l l s , 2. the d i r e c t s t r a t e g i e s of assessment, 3. an emphasis on problem d e f i n i t i o n , 4. the s e l f - r e g u l a t o r y nature o f these approach-es, and/or 5. the a c t i v e and r e s p o n s i b l e p a r t i c i p a t i o n of c l i e n t and t h e r a p i s t . Goal Attainment S c a l i n g I ntended as a b e h a v i o r a l measure o f t h e r a p e u t i c outcome, the Goal Attainment Scale (Kiresuk & Sherman, 1968) i s used to i d e n t i f y t h e r a p e u t i c g o a l s and to break down, step-by-step, the behaviors a person engages i n to achieve each g o a l . The f i n a l behaviors are then c h a r t e d , and a judgment i s made as to whether or not the therapy a s s i s t e d or hindered that person's goal attainment. 9 Using Goal Attainment S c a l i n g , the f o l l o w i n g i s a l i s t o f some b e h a v i o r s c l i e n t s have i d e n t i f i e d f o r change (Garwick & Lampman, 1972): 1. a g g r e s s i o n , 2. a l c o h o l use, 3. a n x i e t y , 4. p s y c h o p a t h o l o g i c a l symptoms, 5. d e c i s i o n s , 6. d e p r e s s i o n , 7. drug use, 8. e d u c a t i o n , 9. f a m i l y or m a r i t a l concerns, 10. f i n a n c e s , 11. i n t e r p e r s o n a l problems, 12. l e g a l p r o b l e m s , 13. l i v i n g a r r a n g e m e n t s , 14. m e d i c a l problems, 15. s e l f r e f e r e n c e s , 16. s e x u a l i t y , 17. s u i c i d e , 18. treatment, and 19. work. Smith (1974, 1976) proposed that the Goal Attainment Scale i t s e l f possessed p s y c h o t h e r a p e u t i c p r o p e r t i e s . He e v a l u a t e d the d i f f e r e n c e between, i n d i v i d u a l s who had completed the Goal Attainment Scale i n therapy and those who had not. He concluded that by i d e n t i f y i n g g o a ls using the Goal Attainment S c a l e , c l i e n t s improved more than i f they had not used t h i s instrument. Smith's e f f o r t was laudable i n that he c r e a t i v e l y examined the n o t i o n t h a t the instrument (the Goal Attainment Scale) i t s e l f possessed p r o p e r t i e s conducive to f o s t e r i n g good mental h e a l t h . In a p r e l i m i n a r y way, Smith demon-s t r a t e d that the Goal Attainment Scale was a d j u n c t i v e to therapy. Kiresuk (1977) s t a t e d that Smith was the o n l y r e s e a r c h e r demonstrating the p s y c h o t h e r a p e u t i c p r o p e r t i e s of Goal Attainment S c a l i n g . F u r t h e r , Kiresuk was unaware o f any attempts to employ the Goal Attainment Scale i n groups. The g e n e r a l i z a b i l i t y of Smith's e f f o r t to i d e n t i f y the p s y c h o t h e r a p e u t i c p r o p e r t i e s of the Goal Attainment Scale i s 10 l i m i t e d to i n d i v i d u a l therapy and to suburban white adoles-cents i n guidance c e n t e r s . T h i s g e n e r a l i z a b i l i t y would be in c r e a s e d bv these o p e r a t i o n s : 1. Employing a d i f f e r e n t treatment s e t t i n g , 2. Examininq more s u b j e c t s , 3. Representing d i f f e r e n t aqe qroups, 4. D e l i n e a t i n q deqrees of p s y c h o l o q i c a l d i s t u r b a n c e s , 5. Examininq group psychotherapy i n s t e a d o f i n d i v i d u a l therapy, and 6. I n t e q r a t i n q r e l e v a n t r e s e a r c h i n t h i s area i n order t o a r t i c u l a t e the process s p e c i f i c a l l y . Statement of the Problem B r i e f psychotherapv, problem-solvinq therapy, and Goal Attainment S c a l i n q provide the b u i l d i n q b l o c k s f o r a s h o r t -term, q o a l - o r i e n t e d , problem-solvinq qroup treatment. I t was thouqht t h a t bv combininq these areas i t would be p o s s i b l e to develop a short-term t h e r a p e u t i c p r o c e s s with o p e r a t i o n a l i z e d o b j e c t i v e s f o r use with qroups of c l i e n t s . The purpose of the c u r r e n t study was t w o - f o l d : f i r s t , u s i n q the three developments d e s c r i b e d b r i e f l y above, to develop a short-term (two week) qroup treatment procedure t o be used i n a p s y c h i a t r i c u n i t ; and second, t o conduct an e x p l o r a t o r y e v a l u a t i o n o f t h i s procedure. The name of the t h e r a p e u t i c procedure developed i n t h i s studv i s the Goal Attainment S c a l i n q Process (GASP), a multicomponent therapy which qoes beyond Goal Attainment S c a l i n q . 11 O r g a n i z a t i o n of D i s s e r t a t i o n The c h a r a c t e r i s t i c s o f b r i e f and p r o b l e m - s o l v i n g t h e r a p i e s , and Goal Attainment S c a l i n g are reviewed and s y n t h e s i z e d i n Chapter I I . In Chapter I I I , the development of the GASP i s presented, followed by the hypotheses which were addressed i n the e x p l o r a t o r y e v a l u a t i o n of the Goal A t t a i n m e n t S c a l i n g P r o c e s s . C h a p t e r IV i n c l u d e s a d e s c r i p t i o n o f the design used f o r t h i s e v a l u a t i o n . The e v a l u a t i o n r e s u l t s are presented i n Chapter V and d i s c u s s e d i n Chapter VI. 12 CHAPTER II SURVEY OF THE LITERATURE I t i s necessary to have a thorough understanding of b r i e f p s y c h o t h e r a p y , p r o b l e m - s o l v i n g t h e r a p y , and Goal Attainment S c a l i n g i n order to have a c l e a r e r comprehension of the Goal Attainment S c a l i n g Process (GASP). Each o f these three areas i s examined i n b u i l d i n g the j u s t i f i c a t i o n f o r the GASP, and t h e i r i m p l i c a t i o n s t o the GASP are i d e n t i f i e d . B r i e f Psychotherapy Psychotherapy can be c l a s s i f i e d i n many ways. Some examples are: group versus i n d i v i d u a l ; c h i l d versus a d u l t v e r s u s f a m i l y ; b e h a v i o r a l v e r s u s a n a l y t i c ; l o n g v e r s u s s h o r t . The most p e r t i n e n t to the s u b j e c t at hand i s the l o n g - s h o r t d i s t i n c t i o n . Long-term t h e r a p y i s u s u a l l y d e f i n e d as treatment c o n s i s t i n g of more than 25 s e s s i o n s , and b r i e f psychotherapy i s d i s t i n g u i s h e d by l e s s than 25 s e s s i o n s (Butcher & Koss, 1978). 13 Whereas both b r i e f and long-term treatment are designed to change c l i e n t behavior, b r i e f psychotherapy i s neces-s a r i l y very s p e c i f i c i n regard to the goals of therapy. T h i s emphasis i s u n l i k e the broader a s p i r a t i o n s of long-term t h e r a p i e s which focus on " p e r s o n a l i t y r e c o n s t r u c t i o n " or a " t h o r o u g h u n d e r s t a n d i n g o f o n e s e l f " (Wolberg, 1965a). T h e r e f o r e , although i t may be a p p l i e d i n v a r i o u s s e t t i n g s , b r i e f psychotherapy i s more o f t e n concerned with l i m i t e d g o a l s . Thus b r i e f psychotherapy i s not simply abbreviated long-term therapy. While the processes may be s i m i l a r , the g o a l s are d i f f e r e n t . They are separate treatments a l t o -gether. T h i s d i s t i n c t i o n between t h e i r g o a ls does not mean that the r e s e a r c h i n one f i e l d could not or does not i n f l u e n c e the other f i e l d . I t c e r t a i n l y can and does. However, the c l i n i c a l a p p l i c a t i o n of any r e s e a r c h would look d i f f e r e n t , depending upon the l e n g t h of time therapy i s expected to l a s t . A f t e r the h i s t o r i c a l development of b r i e f psychotherapy i s presented, the c h a r a c t e r i s t i c s common to most b r i e f p s y c h o t h e r a p i e s are examined. F i n a l l y , evidence f o r the e f f i c a c y of b r i e f psychotherapy i s presented. H i s t o r i c a l development of b r i e f psychotherapy B r i e f psychotherapy i s not new (Kardiner, 1941; Malan, 1963; Wolberg, 1965a). F e r e n c z i (1920) t r i e d to keep a n a l y s i s b r i e f by i n s t r u c t i n g a n a l y s t s to be a c t i v e and 14 d i r e c t i v e i n therapy r a t h e r than p a s s i v e and n o n - d i r e c t i v e . The e f f e c t i v e n e s s of b r i e f psychotherapy was explored by Alexander and French (1946) when they shortened treatment time by i d e n t i f y i n g e a r l y s i g n s of maladjustment i n c l i e n t s . Malan (1963) pointed out i n a review o f b r i e f psychotherapy that i n i t i a l l y p s y c h o a n a l y s i s was s h o r t and became lo n g e r when the focus of therapy s h i f t e d from symptom r e l i e f to t r a n s f e r e n c e i n t e r p r e t a t i o n . Butcher and Koss (1978) pointed to three h i s t o r i c a l developments that l e d to the acceptance of b r i e f psycho-therapy i n t o the mainstream of psychology. The three events were: the Second World War and i t s r e l a t e d t r a n s i e n t emotional d i s t u r b a n c e s ; the beginning of f r e e c l i n i c s ; and the development of behavior m o d i f i c a t i o n techniques. They argued that i n World War I I , combatants s u f f e r e d severe s t r e s s e s and a n x i e t i e s that were u s u a l l y o f a s h o r t d u r a t i o n and s p e c i f i c to a p a r t i c u l a r s i t u a t i o n . I n d i v i d u a l s who worked with these s o l d i e r s attempted to provide therapy as soon as decompensation o c c u r r e d . T h e i r aim was to decrease s t r e s s , r e l i e v e symptoms, r e s t o r e s e l f - e s t e e m , and avoid f u r t h e r maladjustment (Grinker & S p i e g e l , 1944a, 1944b; 1945; Kardiner, 1941). J a n i s (1951) di d an e x t e n s i v e study of emotional s t r e s s r e s u l t i n g from World War I I . He reviewed the l i t e r a t u r e o f the Americans, the B r i t i s h , the Germans, and the Japanese and found the r e s u l t s s t r i k i n g l y s i m i l a r . In a l l f o u r 15 c o u n t r i e s a i r a t t a c k s d i d not i n c r e a s e c h r o n i c psychopatho-l o g i c a l d i s o r d e r s i n c i v i l i a n s . There was r e l a t i v e l y no d i f f e r e n c e i n the number o f a d m i s s i o n s to p s y c h i a t r i c h o s p i t a l s two weeks before an a t t a c k , and two weeks a f t e r (Weatherby, 1943). However, there was an i n c r e a s e i n acute d i s t u r b a n c e s . T r a n s i e n t emotional d i s t u r b a n c e s took the form o f a c u t e a n x i e t y , m i l d d e p r e s s i o n , and a p a t h y (Kardiner, 1941). Dunsdon (1941) claimed bombings f r e q u e n t -l y produced acute a n x i e t y i n the B r i t i s h c i v i l i a n s . C l i e n t s who absented themselves from work on the p r e t e x t of f a t i g u e were r e a l l y missing work because of a n x i e t y . In these i n s t a n c e s J a n i s (1951) d e s c r i b e d a treatment of " p s y c h i a t r i c f i r s t a i d : r e s t , sympathy, and suggestion" (p. 86). While J a n i s (1951) was unable to l o c a t e d e f i n i t e evidence of any i n c r e a s e i n d e p r e s s i o n , he obtained v e r b a l accounts o f increased apathy, pessimism and r e l a t e d d e p r e s s i v e mani-f e s t a t i o n s that followed a i r a t t a c k s / According to Denny-Brown (1943), Japanese and E n g l i s h m i l i t a r y personnel were a l s o s u b j e c t to v a r i o u s t r a n s i e n t c o n d i t i o n s of exhaustion, a n x i e t y , d e p r e s s i o n , and i r r i t a t i o n . B u t c h e r and Maudal (1976) noted t h a t the s t r e s s r e a c t i o n s t h a t are c h a r a c t e r i s t i c o f l i f e are not u n l i k e the s t r e s s of war. Personal t r o u b l e s are o f t e n a response to s o c i a l problems. The two s t r e s s e s are o f t e n a r e a c t i o n t o the s o c i e t y at l a r g e , and need not be considered abnormal (Grossack, 1965). In both cases the s t r e s s i s b r i e f and acute i n nature, r e s u l t s i n high a n x i e t y and the l o s s of 16 c o n t r o l , and i s o f t e n r e l a t e d to a s p e c i f i c s i t u a t i o n . For t h i s reason Butcher and Maudal (1976) argued that t h e r a p i s t s began to apply the techniques of the war-front p s y c h i a t r i c c e n t e r s to the homefront c l i n i c s . T h e r a p i s t s modified those techniques to f i t t h e i r own t h e o r i e s and t h e r a p i e s f o r working with acute c l i e n t s . S p e c i f i c a l l y , S t a n l e y Cobb at Massachusetts General H o s p i t a l i s c r e d i t e d with developing one o f these e a r l y programs f o r emergency p s y c h i a t r i c s e r v i c e i n 1934 (Malan, 1976a). L a t e r , E r i c h Lindemann, one o f Cobb's e a r l y r e c r u i t s , c r y s t a l i z e d h i s ideas on c r i s i s i n t e r v e n t i o n as a r e s u l t of h i s involvement with the d e v a s t a t i n g f i r e at the n i g h t c l u b c a l l e d "The Coconut Grove". A l a r g e number of people had l o s t t h e i r l i v e s i n t h i s f i r e . S u r v i v o r s were subsequently s t r e s s e d and traumatized with g r i e f (Lindemann, 1944). Lindemann organized emergency f a c i l i t i e s to a s s i s t them. Another example of t h i s a d a p t a t i o n from the Second World War i s the Community Mental Health Program at the Harvard School of P u b l i c Medicine (Parad, 1967). Advocates of the Program b e l i e v e d people must l e a r n to l i v e i n the world by meeting s t r e s s e s and s t r a i n s of l i v i n g and change. Fo l l o w i n g much data g a t h e r i n g , they i d e n t i f i e d f i v e c r i t i c a l t r a n s i t i o n p o i n t s i n the normal development of the f a m i l y l i f e c y c l e : g e t t i n g married, b i r t h o f the f i r s t c h i l d , c h i l d r e n going to s c h o o l , death of a spouse, and c h i l d r e n l e a v i n g home. The school set about developing progams i n 17 p r e v e n t i v e i n t e r v e n t i o n t o h e l p people respond to these p r e d i c t a b l e f a m i l y s t r e s s e s . The second h i s t o r i c a l development came i n the 1960's with the advent of f r e e c l i n i c s . Butcher and Koss (1978) po i n t e d out that t h i s movement was i n response to s o c i a l changes i n D o l i t i c s , drug a c c e s s i b i l i t y , and c h a n g i n g morals. They, and others ( G l a s s c o t e , Raybin, R e i f l e r , & Kane, 1975), mentioned t h a t d u r i n g t h i s p e r i o d , people sought h e l p from l e s s t r a d i t i o n a l mental h e a l t h sources such as d r o p - i n c e n t e r s , "rap" groups, and c r i s i s c e n t e r "hot-l i n e s " (Rappaport, 1977). From these i n f o r m a l s e t t i n g s , short-term mental h e a l t h programs have been developed to c o n f r o n t : o l d age ( S l o a t e , 1974); drug abuse ( K l e b l e r , 1974); a l c o h o l i s m (Chafetz, 1974); s u i c i d e p r e v e n t i o n , rape, o r o t h e r l i f e c r i s e s ( R a p p a p o r t , 1977); and d i v o r c e , s e p a r a t i o n , d e a t h , h o m o s e x u a l i t y , a d o l e s c e n t c r i s i s , d e p r e s s i o n , and s u i c i d a l , h o m i c i d a l , o r a s s a u l t i v e behavior (Slaby, L i e b , & Tahcred, 1975). The development of f r e e c l i n i c s was p a r t o f a v i q o r o u s movement i n the United States toward community mental h e a l t h ( B e l l a k & Small, 1965; Chu & T r o t t e r , 1974; Malan, 1976a; Rappaport, 1977). A l a r g e amount of monev was pr o v i d e d by the government t o e s t a b l i s h m e n t a l h e a l t h c e n t e r s f o r treatment. Located i n the community so t h a t people would not have to be taken away from t h e i r neighbourhoods, these c e n t e r s were s p e c i f i c a l l y r e q u i r e d t o i n c l u d e a p r o v i s i o n f o r e a r l y , easy access to psychotherapy l i k e the treatment 18 t h a t most emergency rooms i n h o s p i t a l s o f f e r to medical c l i e n t s . The t h i r d h i s t o r i c a l development that Butcher and Koss (1978) c i t e d was the use of b e h a v i o r a l techniques to modify behavior. They pointed out that even though Watson and Rayner (1920) demonstrated the phenomena of " u n l e a r n i n g " , the a p p l i c a t i o n of l e a r n i n g p r i n c i p l e s to psychotherapy was not i n the mainstream u n t i l Wolpe (1958) examined n e u r o s i s as a f u n c t i o n of learned behavior. T h i s was not to say th a t there had been no e a r l i e r a p p l i c a t i o n o f l e a r n i n g p r i n c i p l e s to therapy, f o r indeed other c l i n i c i a n s had employed these p r i n c i p l e s (Holmes, 1936; Jones, 1931; Terhune, 1949). What they were saying was that a f t e r Wolpe the technology o f behavior change blossomed. Malan (1976a) s a i d therapy i s a l e a r n i n g process and i t s o p e r a t i o n s are concerned with f a c i l i t a t i n g t h a t p r o c e s s . In t a l k i n g about a p a t i e n t ' s experience i n b r i e f therapy, Malan (1976a) s t a t e s , "Not onl y does he l e a r n about h i m s e l f , he l e a r n s new ways of s o l v i n g emotional problems, which, i t i s hoped, he w i l l be able to make use of i n the f u t u r e " (Malan, 1976a, p. 24). More d i r e c t l y , the b e h a v i o r i s t s have developed techniques which c l i n i c i a n s have used such as modeling and b e h a v i o r a l r e h e a r s a l (Bandura, 1971). T h i s technology brought with i t procedures, language, and data g a t h e r i n g techniques that were q u i c k l y amenable to s h o r t -term treatment. E s s e n t i a l l y no attempt was made to c r e a t e 19 any one s c h o o l o f b r i e f p s y c h o t h e r a p y , but c l i n i c i a n s adapted the phi l o s o p h y and the re s e a r c h where they c o u l d . C h a r a c t e r i s t i c s common to b r i e f psychotherapy An e f f i c i e n t way to review t h i s l i t e r a t u r e i s to use the format p r e s e n t e d i n C h a p t e r I f o r o r g a n i z i n g the d i s c u s s i o n o f b r i e f psychotherapy. In t h i s s e c t i o n the r e l e v a n t l i t e r a t u r e i n these areas i s summarized. Time By d e f i n i t i o n b r i e f therapy i s of short d u r a t i o n . Time then i s one of the primary v a r i a b l e s that d i s t i n g u i s h e s b r i e f psychotherapy from other approaches. Most t h e r a p i s t s i n b r i e f psychotherapy c a r e f u l l y d e f i n e the maximum number of s e s s i o n s therapy w i l l l a s t . In t h e i r summary of the res e a r c h on b r i e f and c r i s i s - o r i e n t e d therapy, Butcher and Koss ( 1 978 ) i d e n t i f i e d t h a t although the time l i m i t s f o r b r i e f therapy vary with c l i e n t and problem, c l i e n t s should be informed at the beginning of therapy of that time l i m i t . In the f o l l o w i n g s t u d i e s , change i s demonstrated i n one to t h i r t e e n s e s s i o n s w i t h a c r o s s - s e c t i o n o f c l i e n t s and problems. Many t h e r a p i s t s recommended t e l l i n g c l i e n t s i n the f i r s t s e s s i o n that the therapy they would r e c e i v e would be b r i e f ( B e l l a k & Small , 1965; F r a n k e l , 1973; Koegler & Cannon, 1 966; S p o e r l , 1975). T h i s was done f o r three reasons. F i r s t i t was to in c r e a s e c l i e n t optimism through 20 t h e r a p i s t confidence that change was p o s s i b l e i n a s h o r t time. Secondly, t h i s time d e f i n i t i o n was to keep therapy focused. T h i r d l y such a s t r u c t u r e was to g i v e therapy a beginning, a middle, and an end. As Malan (1976a) wrote re g a r d i n g time l i m i t s : ... A time l i m i t ... helps to concentrate both the p a t i e n t ' s m a t e r i a l and the t h e r a p i s t ' s work, and t o p r e v e n t t h e r a p y from becoming d i f f u s e and aimless and d r i f t i n g i n t o a long-term involvement. It enables the prospect of t e r m i n a t i o n to be brought i n q u i t e n a t u r a l l y as the time f o r t h i s approaches; and o f t e n t h i s enables a therapy that had been i n danger of becoming d i f f u s e to become c l e a r and f o c a l again. (Malan, 1976a, p. 257) In l i n e with Butcher and Koss's (1978) o b s e r v a t i o n t h a t as many b r i e f c l i n i c i a n s recommend "... courses of treatment l a s t i n g from one to s i x s e s s i o n s , as the longer 10-25 s e s s i o n treatment" (p. 730), t h i s review d i v i d e s a t t e n t i o n between those s t u d i e s that show change i n l e s s than s i x s e s s i o n s and more than s i x s e s s i o n s . The review i s organ-iz e d from the l e a s t to the g r e a t e s t number of s e s s i o n s , and w i l l deal with both i n d i v i d u a l and group treatments. A t k i n s (1976) demonstrated change i n homosexuals i n one to three i n d i v i d u a l s e s s i o n s . She t r e a t e d 16 male and 16 female homosexuals and c l i e n t s r e p o r t e d improvements i n areas of d e p r e s s i o n , a n x i e t y , f a m i l y r e l a t i o n s , and a b i l i t y to c o n f r o n t the community's r e a c t i o n s . In a case study by Brink (1977), a 64 year o l d widow was seen f o r four one-hour therapy s e s s i o n s over 15 days and r e p o r t e d an i n c r e a s e d a b i l i t y to i d e n t i f y problems and s o l u t i o n s . A two-year follow-up i n d i c a t e d the c l i e n t ' s progress had c o n t i n u e d . 21 Werman, Agle, McDaniel, and Schoof (1976) t r e a t e d 80 c l i e n t s between 17 and 62 years of age i n i n d i v i d u a l therapy. Treatment ranged from four to s i x s e s s i o n s . In a follow-up two months a f t e r treatment, 75 per cent r e p o r t e d they had improved and 2 5 per cent reported no improvement. Cabral and P a t t e r s o n (1975) showed improvement u s i n g a g r o u p therapy.format with 19 a d u l t c l i e n t s whose mean age was 24. C l i e n t s s t a t e d they f e l t more accepted by t h e i r peers a f t e r f i v e weekly s e s s i o n s of two hours i n l e n g t h . Newton and S t e i n (1974) a l s o employed group therapy with a l c o h o l i c s and r e p o r t e d p o s i t i v e changes a f t e r s i x s e s s i o n s . They compared t h r e e t y p e s o f t r e a t m e n t : g e n e r a l m i l i e u , an a n x i e t y r e d u c t i o n approach, and b r i e f psychotherapy that was l i m i t e d to o n l y s i x s e s s i o n s . In a l l three the c l i e n t s ' p e r c e i v e d l e v e l of d i s t r e s s was lowered and they f e l t they had been helped to overcome t h e i r sense of h e l p l e s s n e s s . Hayes, G r i f f i n , Mooney, and P a r i s e (1975) saw 21 c o l l e g e students i n i n d i v i d u a l therapy. The students were t r e a t e d f o r s i x s e s s i o n s that were 30 minutes i n l e n g t h . A l l c l i e n t s r eported a decrease i n headaches and an increased a b i l i t y to r e l a x . Thus, the c o n c l u s i o n may be drawn that there i s evidence f o r change i n therapy i n the range of one to s i x s e s s i o n s . For therapy l a s t i n g more than s i x s e s s i o n s , Turner and V e l k e r s (1975) were able to r e p o r t a decrease i n i n s e c u r i t y a f t e r seeing people i n group therapy f o r seven s e s s i o n s . Thomas (1976) demonstrated that a group therapy program of 22 e i g h t s e s s i o n s was a s u f f i c i e n t number f o r 30 f e m a l e undergraduates to r e p o r t an i n c r e a s e i n s e c u r i t y . K i l l e e n and Jacobs (1976) a l s o s t u d i e d women c o l l e g e students who were seen i n e i g h t one-hour group therapy s e s s i o n s . T h e i r s t u d e n t s r e p o r t e d a decrease i n a n x i e t y . F o r t y c o l l e g e students were seen i n e i g h t weekly s e s s i o n s by Foulds and Hannigan (1976). These s e s s i o n s were four hours i n l e n g t h . Pre-post t e s t i n g demonstrated c l i e n t s f e l t they were more s o c i a l l y d e s i r a b l e a f t e r the e x p e r i e n c e . Smith (1976) re p o r t e d a more i n t e r n a l l o c u s of c o n t r o l , a g r e a t e r symptom r e d u c t i o n , and a g r e a t e r attainment of treatment g o a l s over e i g h t i n d i v i d u a l s e s s i o n s with a d o l e s c e n t s . K a r l e (1976) and Woldenberg (1976) were able to demonstrate c l i e n t s made more p o s i t i v e s e l f - s t a t e m e n t s a f t e r 10 one-hour s e s s i o n s of group therapy. B o n e t t i (1975) worked with people who had an i d e n t i f i e d common problem (a c o n f l i c t s i t u a t i o n ) . A f t e r 10 one-hour s e s s i o n s of group p s y c h o t h e r a p y , h i s c l i e n t s r e p o r t e d e i t h e r a decrease or absence of t h e i r c o n f l i c t . Deutsch and Kramer (1977) were able to decrease r e p o r t e d p r o b l e m a t i c b e h a v i o r s , l i k e l o n e l i n e s s , i n the e l d e r l y by employing 12 ninety-minute s e s s i o n s of group psychotherapy. W i t h e r s t y , P o r t e r f i e l d , and S p r a d l i n (1975) were a b l e to reduce the frequency of f a m i l y problems over 13 c o n s e c u t i v e days when they were t r e a t i n g h o s p i t a l i z e d a d o l e s c e n t s . In summary, these r e s u l t s do not suggest t o t a l recuper-a t i o n , but they h i g h l i g h t that change i s p o s s i b l e w i t h i n a s h o r t p e r i o d of time. Although l i t e r a t u r e from c l i n i c i a n s 23 s u g g e s t e d t h a t i d e n t i f y i n g the e x p e c t e d time frame o f therapy i n the i n i t i a l s e s s i o n as w e l l as a d v i s i n g c l i e n t s o f the time l i m i t e a r l y on was an important p a r t o f the process of short-term therapy, there were no data to support t h i s c o n t e n t i o n . However there was an abundance of r e s e a r c h that demonstrates that v a r i o u s kinds of p s y c h o l o g i c a l change are p o s s i b l e w i t h i n a b r i e f p e r i o d of time. Consequently, i t i s not unreasonable to expect p s y c h o l o g i c a l changes i n two weeks. Li m i t e d g o a l s Due to the time l i m i t a t i o n , b r i e f therapy and long-term therapy e x p l o r e g o a l s o f a d i f f e r e n t nature. Long-term g o a l s such as e x t e n s i v e p e r s o n a l i t y r e s t r u c t u r i n g and dynamic i n s i g h t s about psychogenetic o r i g i n s o f behavior are impossible i n b r i e f psychotherapy. Ursano and D r e s s i e r (1974) found t h a t long-term therapy i s more e x p l o r a t i v e , while short-term therapy i s more s u p p o r t i v e i n nature. A c c o r d i n g to some' c l i n i c i a n s ( B e l l a k & S m a l l , 1965; Jacobson, 1965; K r i s , 1960; Parad, 1967; S i f n e o s , 1972; Wolberg, 1965b) short-term t h e r a p i s t s b e l i e v e t h a t such therapy could accomplish one or more of the f o l l o w i n g g o a l s : removal or a m e l i o r a t i o n of the most d i s a b l i n g symptoms as soon as p o s s i b l e , prompt r e e s t a b l i s h m e n t o f p r e v i o u s e q u i l i b r i u m , development of the c l i e n t s ' understanding o f t h e i r c u r r e n t d i s t u r b a n c e , and an increase i n f u t u r e coping a b i l i t y . 24 One must r e s t r i c t one's v i s i o n f o r change i n order to work i n b r i e f psychotherapy. The o b j e c t of b r i e f therapy i s to put people back to t h e i r normal l i f e as q u i c k l y as p o s s i b l e ; i t i s not a goal to stay i n therapy u n t i l a l l t h e i r problems are r e s o l v e d . So, while again there were no e m p i r i c a l data to support the p o s i t i o n o f l i m i t e d g o a l s , there appeared to be an overwhelming persuasiveness both from the c l i n i c i a n s and l o g i c that says the g o a l s o f b r i e f therapy must be l i m i t e d . Focused i n t e r v i e w i n g and present centeredness The goals of therapy could be reached i f t h e r a p e u t i c a t t e n t i o n was focused on a complete e x p l a n a t i o n o f the primary problem area, u s u a l l y a c u r r e n t problem i n the c l i e n t ' s l i f e . S m a l l (1971) w r o t e : "Achievement and maintenance of a focus can be regarded as the s i n g l e most important aspect o f b r i e f psychotherapy..." (p. 121). Malan (1976b) pointed out that s h o r t , s u c c e s s f u l therapy must present such a focus e a r l y i n treatment. Malan (1963) and Wolberg (1965b) have s t r e s s e d that t h i s focus on the primary problem should be done e a r l y i n the f i r s t i n t e r v i e w when d e s c r i b i n g to the c l i e n t the terms and the s t r u c t u r e of therapy. H a r r i s , K a l i s , and Freeman (1963) s a i d that one of the more important d i f f e r e n c e s between b r i e f and t r a d i t i o n a l forms of therapy was the systematic f o c u s i n g on the c u r r e n t s i t u a t i o n . Malan (1963, 1976b), Pumpian-Mindlin (1953), 25 Small (1971), and Wolberg (1965b) agreed that the g o a l s of therapy can be best accomplished i f the t h e r a p i s t e x p l o r e s o n l y a primary problem area and e i t h e r ignores or d i r e c t s the person away from such areas as c h i l d h o o d memories, dreams, o r b i r t h o r d e r . Malan (1976b) s a i d : "Those cases tend to be s u c c e s s f u l who present a focus e a r l y and have the m o t i v a t i o n to work through i t . T h i s w i l l lead to a s h o r t , s u c c e s s f u l therapy" (p. 203). Thus the b r i e f t h e r a p i s t keeps much of the c o n v e r s a t i o n i n the present and on the problem at hand. A c t i v i t y and d i r e c t i v e n e s s The q u e s t i o n then becomes: How does one maintain t h i s focus on the present problem? Butcher and Koss (1978) put forward the argument that b r i e f t h e r a p i s t s must be more a c t i v e than many long-term t h e r a p i s t s . A c t i v e means t a l k i n g more, d i r e c t i n g t o p i c s of c o n v e r s a t i o n , e x p l o r i n g areas of i n t e r e s t , g i v i n g support and guidance, and d e v e l o p i n g a course o f a c t i o n f o r the c l i e n t to f o l l o w . Thus b r i e f p s y c h o t h e r a p i s t s r e f e r r e d to the importance of teaching the c l i e n t p roblem-solving methods. The problem-solving methods are a v e h i c l e f o r t h e r a p i s t a c t i o n (Gelb & Ullman, 1967; McGuire & S i f n e o s , 1970; Sloane, S t a p l e s , C r i s t o l , Yorkston, & Whipple, 1975). In Malan's e x t e n s i v e review of b r i e f psychotherapy the p o i n t i s made: . . . that the area o f g r e a t e s t agreement i n the whole l i t e r a t u r e on b r i e f t h e r a p y was t h a t p a s s i v i t y must be r e p l a c e d by a c t i v i t y i n v a r i o u s forms. T h i s s t a r t s with the s t r a t e g i c p l a n n i n g of 26 a 1imited aim from the beginning. E a r l i e r authors who emphasized t h i s aspect were Alexander and French (1946), F i n e s i n g e r ( " g o a l - d i r e c t e d planning and management," 1948), and Deutsch ( " g o a l - l i m i t e d adjustment," " s e c t o r therapy," 1949). The l i m i t e d aim can be formulated i n terms o f a d e s i r e d t h e r a p e u t i c e f f e c t ... there a r i s e s the n e c e s s i t y f o r a more t a c t i c a l form o f " a c t i v i t y " , namely g u i d i n g the s e l e c t i v e a t t e n t i o n , and s e l e c t i v e  n e g l e c t . For t h i s I t " i s very n a t u r a l to use the metaphorical verb "focus"; the t h e r a p i s t "focuses" a t t e n t i o n , and t r i e s to cause the p a t i e n t to focus a t t e n t i o n , on the chosen area. T h i s area i t s e l f then becomes known by the metaphorical noun, the "focus" of the therapy ... Almost every author who s t u d i e s b r i e f therapy comes to r e a l i z e the need f o r p l a n n i n g and a c t i v i t y , and many of them come to use the word focus and i t s d e r i v a t i v e s to d e s c r i b e these elements i n t h e i r techniques. (Malan, 1976a, p. 32-33) Barten (1971), H a r r i s , K a l i s , and Freeman (1963), and Swartz (1969) are a l l adamant about the importance f o r b r i e f t h e r a p i s t s to be d i r e c t i v e and a c t i v e . Perhaps Wolberg i s the most s u c c i n c t , s t a t i n g : [An] anathema to s h o r t - t e r m t h e r a p y i s p a s s i v i t y i n the t h e r a p i s t . Where time i s no o b j e c t , the t h e r a p i s t can s e t t l e back and l e t the p a t i e n t p i c k h i s way through the l u s h j u n g l e s o f h i s psyche ... Treatment f a i l u r e s are o f t e n the product of l a c k of proper a c t i v i t y . (Wolberg, 1965b, p. 135) T h e r a p i s t a c t i v i t y and d i r e c t i o n , and the aforemen-t i o n e d development o f b e h a v i o r a l t e c h n o l o g y a r e a l s o important components of the GASP. E a r l y assessment E s t a b l i s h i n g the focus i n b r i e f psychotherapy r e q u i r e s an understanding of the person's p s y c h i a t r i c c l a s s i f i c a t i o n . C l i n i c i a n s need f u l l knowledge of the p r e c i p i t a t i n g events 27 of the c r i s e s and t h e i r meaning to c l i e n t s i n order to make a proper assessment o f t h e i r problems ( H a r r i s , K a l i s , & Freeman, 1963; J a c o b s o n , W i l n e r , M o r l e y , S c h n e i d e r , S t r i c k l e r & Sommer, 1965; S i f n e o s , 1972). Two authors provide d i f f e r i n g guides f o r t h i s type o f assessment. Small (1971) explored the t a r g e t complaint, the causes f o r the complaint, p r e v i o u s behavior, and the meaning of a l l t h i s to the c l i e n t , as w e l l as a l i s t i n g o f the c l i e n t ' s s t r e n g t h s and weaknesses. Wolberg (1965b) recom-mended an a l t e r n a t i v e s t y l e . He wanted to understand what the c l i e n t does and how the c l i e n t b e l i e v e s that behavior to be p r o b l e m a t i c . Thus Wolberg e x p l o r e d the deg r e e o f a n x i e t y , d e f e n s i v e n e s s , s e l f - e s t e e m , dependence-indepen-dence , i n t e r p e r s o n a l r e l a t i o n s h i p s , and t h e c l i e n t ' s p o t e n t i a l to decompensate. The remainder of t h i s s e c t i o n w i l l e xplore n o t i o n s r e l a t i v e to the is s u e o f dependence-independence. The idea o f dependence-independence r e f e r s to how people p e r c e i v e themselves i n r e l a t i o n s h i p to the world around them. T h i s p e r c e p t i o n o f the wo r l d i s an e x i s t e n t i a l v i e w p o i n t . E x t e n t i a l i s m w i l l be b r i e f l y d i s c u s s e d . F i n a l l y t he e x i s t e n t i a l concept o f s e l f - r e s p o n s i b i l i t y w i l l be r e l a t e d to R o t t e r ' s (1954) t h i n k i n g and re s e a r c h on the Locus o f C o n t r o l . R e l a t i v e to the issue of dependence-independence, a l a r g e number of t h e o r e t i c i a n s argued with v a r y i n g degrees o f f e r v o r that people are a c t o r s s u b j e c t to c e r t a i n e n v i r o n -28 mental c o n s t r a i n t s . E l l i s (1973b), F i e d l e r (1951), G l a s s e r (1965), P e r l s (1969), and Rogers (1961b) emphasized the importance of how i n d i v i d u a l s p e r c e i v e and evaluate t h e i r i n t e r n a l needs and e x t e r n a l events. According to t h i s view, persons act on the world r a t h e r than the world a c t i n g on them. In the extreme, a l l human behavior i s moderated by the s u b j e c t i v e p e r c e p t i o n . P e o p l e e v a l u a t e t h e i r own experience and act on that e v a l u a t i o n . In essence, the above c l i n i c i a n s s a i d that everyone was r e s p o n s i b l e f o r t h e i r a c t i o n s and the consequences o f those a c t i o n s . The c l i n i c i a n s b e l i e v e that people possess the power to c o n t r o l themselves. These same c l i n i c i a n s b e l i e v e t h a t behavior change, the g e n e r a l goal of therapy, i s achieved more r e a d i l y i f people are not c o n t r o l l e d by e x t e r n a l f o r c e s . I t was much l i k e the d i f f e r e n c e between an a c t o r and a marion-e t t e : one performed, while the other was caused to perform. The c l i e n t s f u n c t i o n e d b e t t e r i f they p e r c e i v e d themselves as having "no s t r i n g s a t t a c h e d " . The concern with understanding the c l i e n t ' s p e r c e p t i o n of the world i s the b a s i s of an " e x i s t e n t i a l " approach to psychotherapy ( P a t t e r s o n , 1966). However, there i s no one e x i s t e n t i a l therapy. Although these approaches have much i n common, they d i f f e r , so i t i s not p o s s i b l e to r e f e r to the e x i s t e n t i a l method. The fundamental c h a r a c t e r o f e x i s t e n -t i a l psychotherapy i s that i t i s concerned with the nature of being and the c l i e n t ' s e x i s t e n c e . The task o f the t h e r a p i s t i s to understand the c l i e n t as a being and as a 29 being i n h i s or her world. C l i e n t s should then come to understand themselves b e t t e r as a r e s u l t of t h i s inward r e f e r e n c e to and s t r u g g l e with t h e i r d i r e c t l y f e l t exper-i e n c i n g . Heine's (1962) resea r c h supports t h i s p h i l o s o p h y t h a t what i s important are the c l i e n t s ' p e r c e p t i o n of how they are understood by the t h e r a p i s t and whether they have i n d e p e n d e n c e i n making c h o i c e s and d e c i s i o n s . Heine e v a l u a t e d i n d i v i d u a l s who had gone f o r p s y c h o t h e r a p e u t i c h e l p t o p s y c h o a n a l y t i c , c l i e n t - c e n t e r e d , and A d l e r i a n t h e r a p i s t s . A l l c l i e n t s r e p o r t e d s i m i l a r changes i n a l l three t h e r a p i e s . However what i s of i n t e r e s t here i s t h e i r p e r c e p t i o n of the t h e r a p e u t i c r e l a t i o n s h i p . A l l c l i e n t s a g r e e d t h a t t r u s t , u n d e r s t a n d i n g , and the f e e l i n g o f independence they had experienced accounted f o r the changes i n themselves. When he w r i t e s of the importance of being f r e e from e x t e r n a l e v a l u a t i o n , Rogers (1961b) s t a t e d : ... In almost every phase of our l i v e s — at home, at work -- we f i n d o u r s e l v e s under the rewards and pu n i s h m e n t s of e x t e r n a l j u d g e m e n t s . " T h a t ' s good." "That's naughty." "That's worth an A." "That's a f a i l u r e . " "That's good c o u n s e l i n g . " "That's poor c o u n s e l i n g . " Such judgements are a p a r t of our l i v e s from i n f a n c y to o l d age. I b e l i e v e they have a c e r t a i n s o c i a l u s e f u l n e s s to i n s t i t u t i o n s and o r g a n i z a t i o n s such as s c h o o l s and p r o f e s s i o n s . Like everyone e l s e , I f i n d myself a l l too o f t e n making such e v a l u a t i o n s . But, i n my exp e r i e n c e , they do not make f o r p e r s o n a l growth and hence, I do not b e l i e v e they are p a r t of a h e l p i n g r e l a t i o n s h i p . C u r i o u s l y enough, a p o s i t i v e e v a l u a t i o n i s as t h r e a t e n i n g i n the long run as a negative one, s i n c e to inform someone he i s good i m p l i e s that one a l s o has the r i g h t to t e l l him he i s bad. So I have come to f e e l t h a t 30 t h e more I can keep a r e l a t i o n s h i p f r e e o f judgement and e v a l u a t i o n , the more t h i s w i l l permit the other person to reach the p o i n t where he r e c o g n i z e s the l o c u s of e v a l u a t i o n , the c e n t e r o f r e s p o n s i b i l i t y , l i e s w i t h i n h i m s e l f . The meaninq and value of h i s experience i s i n the l a s t a n a l y s i s something which i s up to him, and no amount of e x t e r n a l judgement can a l t e r t h i s . So I should l i k e to work toward a r e l a t i o n s h i p i n which I am not, even i n my own f e e l i n q , e v a l u a t i n g him. T h i s , T b e l i e v e , can s e t him f r e e to be a s e l f -r e s p o n s i b l e person. ... There does seem to be w i t h i n the b i o l o g i c a l organism feedback mechan-isms, e v a l u a t i o n a l systems -- whatever you might c a l l them -- which enable the orqanism to d i s -c r i m i n a t e , a l t h o u g h n o t always w i t h immediate accuracy, between experiences which are f a v o r a b l e to i t s own growth and development and those which are u n f a v o r a b l e . Although such n a t u r a l tendencies can c e r t a i n l y be deceived and thrown out of k i l t e r by v a r i o u s d i s t o r t i n g e x p e r iences, n e v e r t h e l e s s , t h e f u n d a m e n t a l a b i l i t y o f the o r g a n i s m t o d i s t i n g u i s h between experiences which fa v o r i t s own development and those which do not seem to be the c a p a c i t y on which not o n l y therapy but.a q r e a t many other processes depend. (p. 108-109) Rott e r ' s i d ea (1954) t h a t another p s y c h o t h e r a p e u t i c task i s to i n c r e a s e the c l i e n t ' s i n t e r n a l l o c u s of c o n t r o l p a r a l l e l s the n o t i o n of s e l f - r e s p o n s i b i l i t y . Rotter be-l i e v e s that as c l i e n t s attend more to what they want to do, the more s a t i s f i e d they w i l l be. The e x i s t e n t i a l n o t i o n o f s e l f - r e s p o n s i b i l i t y i s s t r e s s e d . C l i e n t s are tauqht to decide f o r themselves what they l i k e , r a t h e r than to have t h e i r l i k e s and d i s l i k e s determined bv o t h e r s . The degree to which people b e l i e v e d t h e i r b ehavior i s determined by themselves or by persons and events o u t s i d e themselves i s more than a t h e o r e t i c a l c o n s t r u c t . The c o n s t r u c t can be measured bv the R o t t e r I n t e r n a l - E x t e r n a l Locus of C o n t r o l Scale ( R o t t e r , 1966). I f people b e l i e v e 31 e x t e r n a l f a c t o r s c o n t r o l them, they are s a i d to have an e x t e r n a l l o c u s of c o n t r o l . Such people tend to b e l i e v e i n chance, l u c k , or f a t e , or may a l s o suppose they are t o t a l l y or p a r t i a l l y under the i n f l u e n c e of powerful o t h e r s . I f people b e l i e v e most events are determined by t h e i r own thoughts and f e e l i n g s , they are s a i d to have an i n t e r n a l l o c u s of c o n t r o l . Thus Rotter has provided an instrument to assess what some e x i s t e n t i a l c l i n i c i a n s c o n s i d e r a c r u c i a l component of p s y c h o l o g i c a l growth and change, the l o c u s of e v a l u a t i o n . R ecent r e s e a r c h has shown a p o s i t i v e r e l a t i o n s h i p between goal achievement and an i n t e r n a l l o c u s of c o n t r o l ( P r o c i u k , Breen, & L u s s i e r , 1976). A p o s i t i v e r e l a t i o n s h i p has a l s o been shown between s u c c e s s f u l therapy and an i n t e r n a l l o c u s of c o n t r o l (Henson, 1976). These areas of r e s e a r c h i n d i c a t e t h a t i n s t r u c t i n g people on how to take command of t h e i r l i v e s and become more i n t e r n a l should prove bene f i c i a 1 . T h e r e f o r e i t i s h e l p f u l i n making an e a r l y assessment i f the t h e r a p i s t understands the degree of dependence-independence a c l i e n t experiences and t r i e s t o i n c r e a s e c l i e n t s e l f - c o n t r o l . I f a method f o r i n c r e a s i n g s e l f -c o n t r o l were i n c o r p o r a t e d i n t o therapy, a p o s i t i v e r e l a t i o n -s h i p between an i n t e r n a l l o c u s of c o n t r o l and t h e r a p e u t i c success could be. expected. As c l i e n t s gained c o n t r o l over t h e i r l i v e s , t h i s experience of s e l f - d e t e r m i n a t i o n c o u l d be s e l f - r e i n f o r c i n g . 32 T h e r a p e u t i c f l e x i b i l i t y B r i e f and c r i s i s t h e r a p i s t s t r e a t a v a r i e t y of people who can b e n e f i t from a d i v e r s i t y of t h e r a p e u t i c techniques. No one t h e r a p e u t i c technique has been shown to have a c l e a r - c u t r e l a t i o n s h i p to a l l diagnoses (Smith & G l a s s , 1977) . In f a c t , the argument has been made that a t h e r a p i s t who adheres to o n l y one set of techniques would not perform w e l l in the b r i e f psychotherapy s e t t i n g (Butcher & Koss, 1978) . In Barten's review of b r i e f psychotherapy he d e s c r i b e d the importance of t h e r a p e u t i c f l e x i b i l i t y : Short-term t h e r a p i e s were i n e v i t a b l y r e d i s -c o v e r e d as p s y c h i a t r i s t s embraced a g r o w i n g e c l e c t i c i s m . . . T r a d i t i o n a l techniques have by no means been d i s c a r d e d , but they have come to be used more j u d i c i o u s l y . In some cases, they have worked b e t t e r . B r i e f techniques themselves have expanded to i n c l u d e b r i e f group and f a m i l y t h e r a -p i e s , behavior t h e r a p i e s , drug t h e r a p i e s , sug-g e s t i v e t h e r a p i e s such as hypnosis, r e - e d u c a t i v e t h e r a p i e s , and r o l e - i n d u c t i o n t h e r a p i e s . The t r a d i t i o n a l p s y c h o t h e r a p i s t may view t h i s as a r e g r e t t a b l e compromise, an ignoble surrender to the p r e s s u r e s of circumstances which produce t r a n s i e n t , s u p e r f i c i a l or token r e s u l t s . To the e c l e c t i c , b r i e f t h e r a p i e s are i n n o v a t i v e , prag-matic developing approaches which may change our conception of the nature, o b j e c t i v e s , p o s s i b i l i -t i e s and l i m i t a t i o n s of psychotherapy. We should n e i t h e r e x a g g e r a t e the r e s u l t s o f s h o r t - t e r m therapy nor deprecate the r a t i o n a l e and o b j e c t i v e s of long-term therapy. (Barten, 1971, p. 3-4) A given t h e r a p i s t would not be expected to be e x p e r i -enced in a l l t h e r a p e u t i c techniques. It does seem reason-able to expect a c l i n i c ' s s t a f f c o l l e c t i v e l y to o f f e r a 33 range of techniques a p p r o p r i a t e to the r e s p e c t i v e c l i e n t needs. Thus the personnel o f a short-term p s y c h i a t r i c h o s p i t a l should be b e t t e r than any s i n g l e c l i n i c i a n t o provide t h e r a p e u t i c f l e x i b i l i t y . Promptness of i n t e r v e n t i o n The emphasis i n b r i e f therapy has been on the c l i e n t ' s immediate p r o b l e m . The l i t e r a t u r e has emphasized the t i m e l i n e s s of p r o v i d i n g therapy when a c l i e n t who seeks therapy i s motivated to work on a s o l u t i o n . Butcher and Koss (1978) d i s c o u r a g e d m u l t i p l e i n t a k e i n t e r v i e w s o r lengthy psychometric assessment b a t t e r i e s . Since the c r i s e s are about a present l i f e problem, i t i s important to o f f e r therapy as q u i c k l y as p o s s i b l e (Caplan, 1961; Lindemann, 1944). B e l l a k and Small (1965) recognized t h i s urgency and developed mobile c o u n s e l i n g u n i t s to reach people immedi-a t e l y d u r i n g a d i s a s t e r . E m p i r i c a l s u p p o r t f o r t h i s recommendation was given by Wolkon (1972) who demonstrated f a s t e r symptom r e m i s s i o n when c l i e n t s are seen immediately than when the people were asked to wait s e v e r a l days f o r an appointment. T h i s evidence suggests that any p s y c h i a t r i c f a c i l i t y t h a t engages i n b r i e f psychotherapy should see c l i e n t s promptly, a v o i d i n g w a i t i n g l i s t s , and minimizing i n - t a k e t e s t i n g procedures. 34 V e n t i l a t i o n R e g a r d l e s s o f t r e a t m e n t a p p r o a c h , most t h e r a p i s t s attempt to c r e a t e an environment i n which the c l i e n t f e e l s secure. A secure atmosphere enhances the c l i e n t ' s exper-ience as w e l l as a b r i e f psychotherapy program. The Butcher and Koss (1 978) review acknowledged that "... a l l manor a p p r o a c h e s t o b r i e f and c r i s i s - o r i e n t e d p s y c h o t h e r a p y r e c o g n i z e s the value o f a l l o w i n g the c l i e n t to v e n t i l a t e emotional t e n s i o n " (p. 737). Now although there i s l i t t l e e m p i r i c a l support f o r t h i s p o s i t i o n i n b r i e f psychotherapy, the c l i n i c i a n s argue t h a t t o e x p e r i e n c e some s o r t o f c a t h a r s i s o r i d e n t i f i c a t i o n and e x p r e s s i o n o f f e e l i n g s enhances a short-term psychotherapy proqram. As S h a f f e r and Shoben (1956) wrote: It i s not s u r p r i s i n g , then, that t h e r a p e u t i c c o n v e r s a t i o n s a r e c e n t e r e d on the c l i e n t ' s a n x i e t y , g u i l t f e e l i n g s , and f e e l i n g s o f i n f e r i o r -i t y , or inadequacy, and on the occurrences that engender them. O b v i o u s l y , such t o p i c s a r e p r e c i s e l y the ones that are most d i f f i c u l t f o r the c l i e n t to t a l k ^about. One of the hiderances t o s u c c e s s f u l c o u n s e l i n g i s t h a t i t depends on d i s c u s s i n g the very t h i n g s t h a t the c l i e n t i s l e a s t i n c l i n e d to d i s c u s s and which are most s u s c e p t i b l e to r e p r e s s i o n . (p. 529) Moreover, some t h e r a p i s t s p u r p o s e l y attempted t o e l i c i t s t rong emotions to f a c i l i t a t e t e n s i o n r e l e a s e ( N i c h o l s , 1974; N i c h o l s & R e i f l e r , 1973; Stampfl & L e v i s , 1967). Among these, N i c h o l s (1974) noted t h a t Janov's (1970) p r i m a l therapy had r e c e i v e d much a t t e n t i o n , but t h a t o t h e r ap-p r o a c h e s i n c l u d i n g g e s t a l t t h e r a p y ( P e r l s , 1969), new 35 i d e n t i t y groups ( C a s r i e l , 1972), r e e v a l u a t i o n c o u n s e l i n g ( J a c k i n s , 1965), and b i o e n e r g e t i c s (Lowen, 1967) emphasized the r e l e a s e of emotion. These new approaches are not a d i s c o v e r y but a r e v i v a l of i n t e r e s t i n the t h e r a p e u t i c p r o p e r t i e s of v e n t i l a t i o n . C a t h a r t i c techniques have played a c e n t r a l r o l e i n h e a l i n g i n r i t u a l s (Frank, 1961; LaBarre, 1964; Z i l b o o r g , 1941), r e l i g i o u s r e v i v a l i s m (Davenport, 1917), A l c o h o l i c s Anonymous and Synanon (Zax & Cowen, 1972), hypnotherapy (Brenman & G i l l , 1947), and d r u g - a s s i s t e d a b r e a c t i v e therapy ( G r i n k e r & S p i e g e l , 1945). Although Freud (Freud & Breuer, 1966) used c a t h a r s i s t o r e s o l v e h y s t e r i a , he l a t e r abandoned h i s dependence on t h i s technique. However, modern psycho-a n a l y s i s s t i l l employs c a t h a r s i s as a t o o l to reduce t e n s i o n and to a i d the remembering of memories (Greenson, 1967). C a t h a r s i s i s a l s o a major technique i n play therapy (Levy, 1943), psychodrama (Moreno, 1958), and t r a d i t i o n a l group psychotherapy (Yalom, 1970). There has been l i t t l e e m p i r i c a l r e s e a r c h on the c a t h a r t i c approaches (Butcher & Koss, 1978). In a review o f v e n t i l a t i o n up to 1974, N i c h o l s (1974) wrote: As yet, l i t t l e has been done to base the v a r i o u s c a t h a r t i c approaches on e m p i r i c a l evidence or even w e l l rounded t h e o r i e s . In f a c t , there does not e x i s t a body o f c o n t r o l l e d s t u d i e s i n therapy i n which c a t h a r s i s i s the independent v a r i a b l e . T h e o r e t i c a l r e p o r t s have o f t e n s i n g l e d out c a t h a r s i s as one o f the key elements i n s u c c e s s f u l therapy (e.g., Frank, 1971; Rosenzweig, 1936), but on l y a few s t u d i e s have shown c a t h a r s i s to be e f f e c t i v e i n l e a d i n g to improvement i n p s y c h o t h e r a p y (Janov, 1971; L i f s h i t z & B l a i r , 36 1 960; Symonds, 1951). ... In h i s work on "focus-i n g " , Gendlin and h i s c o l l e a g u e s have r e p e a t e d l y found that c l i e n t s who express t h e i r f e e l i n g s d i r e c t l y improve more than those who merely r e p o r t them ( G e n d l i n , Beebe, C a s s e n s , K l e i n , & Oberlander, 1968; Gendlin, Jenny, & S c h l i e n , 1960; Gendlin & Olsen, 1970). (p. 403-404) As was noted e a r l i e r many of the b r i e f c l i n i c i a n s mention v e n t i l a t i o n of emotion as important. Here two examples of i t s e f f e c t i v e n e s s are d e t a i l e d . In N i c h o l s 1 (1974) a r t i c l e he explored the n o t i o n that c a t h a r s i s leads to improvement i n short-term therapy. He compared an emotive treatment a g a i n s t a non-emotive treatment. C l i e n t s were 22 u n i v e r s i t y students, 17-28 years o l d , with a median age of 20. They were seen i n d i v i d u a l l y from four to twenty-f i v e s e s s i o n s , with the mean number of s e s s i o n s being n i n e . The non-emotive t r e a t m e n t c o n d i t i o n was a t r a d i t i o n a l i n s i g h t therapy. In the emotive treatment c o n d i t i o n c l i e n t s r o l e - p l a y e d , repeated a f f e c t laden phrases, and/or engaged i n e x p r e s s i v e movement l i k e s t r i k i n g a couch. The non-emotive group s i g n i f i c a n t l y changed t h e i r pre-post MMPI s c o r e s , w h i l e the emotive group a t t a i n e d s i g n i f i c a n t l y g r e a t e r r e m i s s i o n of t h e i r b e h a v i o r a l t a r g e t complaints and reported s i g n i f i c a n t l y more s a t i s f a c t i o n with t h e i r t r e a t -ment. These r e s u l t s lead to p a r t i a l support f o r c a t h a r s i s . The study by Bierenbaum, N i c h o l s , and Schwartz (1976) found s i m i l a r r e s u l t s . They saw 41 c l i e n t s under three v a r i o u s c a t h a r t i c therapy c o n d i t i o n s . The c o n d i t i o n s were one h a l f hour two times per week, one hour once per week, 37 and two hours every other week. C l i e n t s never switched c o n d i t i o n s and were p r e t e s t e d on the MMPI and t h e i r t a r q e t complaints. P o s t t e s t i n q i n c l u d e d these instruments and a c l i e n t r a t i n q of s a t i s f a c t i o n . Under the one hour per week c o n d i t i o n c l i e n t s who expressed the most a f f e c t i v e expres-s i o n were the most s a t i s f i e d and had met most o f t h e i r t a r q e t e d o b j e c t i v e s . Under the c o n d i t i o n o f one h a l f hour two times per week, c l i e n t s ' MMPI scores were the most improved. When c l i e n t s were seen two hours every other week, they demonstrated the l e a s t amount of chanqe. Evidence i s a v a i l a b l e that a b r e a c t i o n i s b e n e f i c i a l to psychotherapy o n l y f o r some people. Perhaps i n some people e m o t i v e t h e r a p y i n c r e a s e s t h e i r a n x i e t y and t h e r e f o r e i n h i b i t s t h e i r p r o q r e s s . However, f u r t h e r s t u d i e s are r e q u i r e d to r e - e v a l u a t e t h i s p o s i t i o n . U n t i l t h a t r e s e a r c h i s forthcominq, i t i s prudent t o i n c l u d e an aspect o f v e n t i l a t i o n i n the development of the GASP. A f a c i l i t a t i v e t h e r a p e u t i c r e l a t i o n s h i p A f a c i l i t a t i v e t h e r a p e u t i c r e l a t i o n s h i p i s fundamental to any t h e o r e t i c a l p e r s p e c t i v e (Berqin & Suinn, 1975). B r i e f p s y c h o t h e r a p y i s c h a r a c t e r i z e d by a t h e r a p e u t i c r e l a t i o n s h i p of a r e l a t i v e l y s h o r t d u r a t i o n . However views o f the i m p o r t a n c e o f the f a c i l i t a t i v e c o n d i t i o n s have chanqed. Two e x t e n s i v e reviews o f the r e s e a r c h on t h e r a p i s t v a r i a b l e s i n r e l a t i o n to process and outcome have been w r i t t e n by Truax and M i t c h e l l (1971) and P a r l o f f , Waskow, 38 and Wolfe (1978). In t h i s s e c t i o n the r e l e v a n t r e s e a r c h r e l a t e d o n l y to s t u d i e s o f t h e r a p i s t s independent of the c l i e n t are h i q h l i g h t e d . Rogers (1951, 1961b, 1975) s t a t e d t h a t there were s i x n e c e s s a r y and s u f f i c i e n t c o n d i t i o n s f o r c o n s t r u c t i v e p e r s o n a l i t y change. Three of these c o n d i t i o n s were " a t t i -t u d i n a l c h a r a c t e r i s t i c s " o f the t h e r a p i s t : genuineness, u n c o n d i t i o n a l p o s i t i v e reqard, and empathy. The f o u r t h c o n d i t i o n r e q u i r e d the c l i e n t to p e r c e i v e these a t t i t u d i n a l c h a r a c t e r i s t i c s . The remaining two have been dropped from any s e r i o u s d i s c u s s i o n as beinq too s e l f - e v i d e n t : the c l i e n t and t h e r a p i s t must be aware of each ot h e r , and the c l i e n t should be inconqruent, v u l n e r a b l e , or anxious. The l i s t of necessary and s u f f i c i e n t c o n d i t i o n s was pared to the f i r s t t h r e e . The i n i t i a l r e s e a r c h r e s u l t s of Roqers 1 hypothesis were very e n t h u s i a s t i c a l l y r e c e i v e d ( B a r r e t t - L e n n a r d , 1962; Truax & Carkhuff, 1967). S c a l e s had been developed to measure t h e s e b a s i c c o n d i t i o n s and i n i t i a l r e s e a r c h c o n f i r m e d Roqers' p o s i t i o n . Based on t h e i r e x t e n s i v e review of the p e r t i n e n t l i t e r a t u r e up to 1970, Truax and M i t c h e l l (1971) concluded: These s t u d i e s taken toqether suqqest t h a t t h e r a p i s t s o r c o u n s e l o r s who a r e a c c u r a t e l y empathic, n o n p o s s e s s i v e l y warm i n a t t i t u d e , and genuine are indeed e f f e c t i v e . A l s o , these f i n d -mqs seem to hold with a wide v a r i e t y of t h e r a -p i s t s and c o u n s e l o r s , r e q a r d l e s s of t h e i r t r a i n i n q or t h e o r e t i c o r i e n t a t i o n , with a wide v a r i e t y o f c l i e n t s o r p a t i e n t s , i n c l u d i n q c o l l e q e u n d e r -a c h i e v e r s , j u v e n i l e d e l i n q u e n t s , h o s p i t a l i z e d s c h i z o p h r e n i c s , c o l l e q e c o u n s e l o r s , m i l d to severe 39 o u t p a t i e n t n e u r o t i c s , and the mixed v a r i e t y of h o s p i t a l i z e d p a t i e n t s . F u r t h e r , the e v i d e n c e suggests that these f i n d i n g s h o l d i n a v a r i e t y of t h e r a p e u t i c contexts and i n both i n d i v i d u a l and group psychotherapy or c o u n s e l i n g . (P. 310) Not o n l y d i d Truax and M i t c h e l l b e l i e v e that there was o v e r w h e l m i n g e v i d e n c e f o r the n e c e s s a r y and s u f f i c i e n t c o n d i t i o n s of a c c u r a t e empathy, warmth, and genuineness. They a l s o b e l i e v e d that these were necessary and s u f f i c i e n t r e g a r d l e s s of the type of problem or s c h o o l of therapy. F u r t h e r , they went on to conclude that low l e v e l s of any of these f a c t o r s c o n t r i b u t e d to c l i e n t d e t e r i o r a t i o n . There are a number of s t u d i e s to support the n o t i o n t h a t p o s i t i v e t h e r a p e u t i c outcome i s r e l a t e d to one or more of these i n t e r p e r s o n a l dimensions ( C a i r n s , 1972; M i n s e l , Bommert, B a s t i n e , Langer, N i c k e l , & Tausch,, 1971; Truax & Wittmer, 1971; Truax, Wittmer, & Wargo, 1971). However, doubt began to grow as other r e s e a r c h e r s o f f e r e d r e s u l t s t h a t were i n c o n f l i c t with the c o n c l u s i o n of Truax and M i t c h e l l (1971) . Other i n v e s t i g a t o r s r e p o r t e d there was l i t t l e or no evidence of an a s s o c i a t i o n ( B e u t l e r , Johnson, N e v i l l e , & Workman, 1972; B e u t l e r , J o h n s o n , N e v i l l e , Workman, & E l k i n s , 1973; G a r f i e l d & B e r g i n , 1971; Kurtz & Grummon, 1972; Mintz, Luborsky, & Auerbach, 1971; Mullen & Abe l e s , 1971; Sloane, S t a p l e s , C r i s t o l , Y o r k s t o n , & Whipple, 1975). 40 Two l a t e r reviews ( M i t c h e l l , B o z a r t h , Truax, & K r a u f t , 1973; P a r l o f f , Waskow, & Wolfe, 1978) reach s i m i l a r c o n c l u -s i o n s i n th a t empathy, warmth, and genuineness are seen as r e l a t e d to c l i e n t change but t h e i r potency and g e n e r a l i z a -b i l i t y i s l e s s than i n i t i a l l y expected. P a r l o f f , Waskow, and Wolfe (1978) wrote: In response to the f a c t t h at more re c e n t s t u d i e s have f a i l e d t o s u p p o r t the i n i t i a l e n t h u s i a s t i c c l a i m s f o r v a l i d i t y of the b a s i c h y p o t h e s i s concerning the necessary and s u f f i c i e n t c o n d i t i o n s , i n c r e a s e d e f f o r t has been devoted to t r y i n g to r e c o n c i l e the apparent d i s c r e p a n c i e s . Prominent among such a n a l y s e s have been attempts to i d e n t i f y flaws and l i m i t a t i o n s i n the non-conforming s t u d i e s . ... Two of the most f r e q u e n t l y c i t e d o b j e c t i o n s [were]: (a) f a i l u r e to p r o v i d e the p r e r e q u i s i t e minimal l e v e l s of t h e r a p e u t i c c o n d i t i o n s , and (b) the use of d i f f e r e n t sources of r a t i n g s . (p. 248) The time c o n s t r a i n t s o f s h o r t - t e r m p s y c h o t h e r a p y r e q u i r e t h a t a f a c i l i t a t i v e r e l a t i o n s h i p be d e v e l o p e d q u i c k l y . Although a complex i s s u e , i t i s apparent t h a t the f a c i l i t a t i v e t h e r a p e u t i c r e l a t i o n s h i p i s v e r y important. I t i s the c h a l l e n g e of b r i e f psychotherapy to e s t a b l i s h a f a c i l i t a t i v e r e l a t i o n s h i p w i t h i n the time c o n s t r a i n t s o f t h i s kind of therapy. C l i e n t s e l e c t i o n Psychotherapy r e s e a r c h e r s have attempted to d e f i n e what treatment works f o r which people and under what c o n d i t i o n s . B r i e f psychotherapy i s no d i f f e r e n t . Researchers have undertaken p r o j e c t s to s p e c i f y who i s and who i s not s u i t e d f o r b r i e f psychotherapy. 41 R e l a t i v e to s e l e c t i o n , Butcher and Koss (1978) summar-i z e d : S e l e c t i n g the a p p r o p r i a t e p a t i e n t s f o r b r i e f treatment i s an important c o n s i d e r a t i o n . P a t i e n t s who have had a good premorbid adjustment and an acute onset of symptoms are considered by many to be b e t t e r candidates f o r short-term therapy than the more s e v e r e l y d i s t u r b e d p a t i e n t s . However, r e c e n t e v i d e n c e , b o t h c l i n i c a l and r e s e a r c h , suggests that some short-term t h e r a p e u t i c i n t e r -v e n t i o n s might be h i g h l y s u c c e s s f u l with more s e v e r l y d i s t u r b e d p a t i e n t s . P a t i e n t s who have a good a b i l i t y to r e l a t e are a l s o considered to be b e t t e r candidates f o r b r i e f therapy than those who have d i f f i c u l t y forming r e l a t i o n s h i p s . (p. 740) The remarks of S i f n e o s (1972) may be summarized by saying that i t i s a necessary, but not a s u f f i c i e n t c o n d i -t i o n , that the c l i e n t have the a b i l i t y to see a circum-s c r i b e d problem. A d d i t i o n a l l y , he b e l i e v e d that at l e a s t three of the f o l l o w i n g c o n d i t i o n s must be met i f the c l i e n t i s to be accepted f o r treatment: 1. above average i n t e l l i g e n c e , 2. at l e a s t one meaningful r e l a t i o n s h i p d u r i n g the c l i e n t ' s l i f e t i m e , 3. an emotional c r i s i s , 4. an a b i l i t y to i n t e r a c t w e l l with the t h e r a -p i s t and to express f e e l i n g s , 5. m o t i v a t i o n to change, and 6. a s p e c i f i c c h i e f complaint. In order to assess m o t i v a t i o n , S i f n e o s examined the person's w i l l i n g n e s s to be an honest, r e a l i s t i c , c u r i o u s , 42 eager, a c t i v e p a r t i c i p a n t who recognizes that the symptoms are p s y c h o l o g i c a l i n nature. Malan (1976a) i s more t e r s e i n h i s summary of s e l e c t i o n procedures. He says, "Although the process of assessment i s thus very complex, the process of s e l e c t i o n can r e a l l y be formulated very b r i e f l y : A focus can be found, the c l i e n t has a l r e a d y r e s p o n d e d t o i t p o s i t i v e l y , m o t i v a t i o n i s s u f f i c i e n t , and c e r t a i n s p e c i f i c dangers [such as a c t i v e p s y c h o s i s ] do not seem i n e v i t a b l e " (p. 256). Butcher and Koss (1978) suggested that the f o l l o w i n g people are best s u i t e d f o r short-term therapy: 1. those i n whom the b e h a v i o r a l problem i s acute at the onset of therapy, 2. t h o s e whose p r e v i o u s a d j u s t m e n t has been good , 3. those with a good a b i l i t y to r e l a t e p o s i -t i v e l y , and 4. those with high m o t i v a t i o n s . C r i t e r i a f o r e x c l u s i o n from b r i e f psychotherapy have a l s o been generated. Malan (1976a) excluded anyone who: had made s e r i o u s s u i c i d e attempts; was a drug a d d i c t ; was a convinced homosexual; r e q u i r e d long-term h o s p i t a l i z a t i o n ; had experienced more than one course of e l e c t r o - c o n v u l s i v e therapy; was c h r o n i c a l l y a l c o h o l i c ; endured c h r o n i c obses-s i o n a l or phobic symptoms; or who r u i n o u s l y acted out. Three other r e s e a r c h e r s have i d e n t i f i e d the c h a r a c t e r -i s t i c s of people who are i l l - s u i t e d f o r short-term therapy. 43 T h i s would i n c l u d e the c l i e n t who wants p e r s o n a l i t y recon-s t r u c t i o n , i s h i q h l y anxious, or p e r s i s t e n t l y anxious or a c t s out (Wolbert, 1965a); i s outspoken and s e l f - c e n t e r e d , p a s s i v e - d e p e n d e n t , m a s o c h i s t i c , o r s e l f - d e s t r u c t i v e (Castelnuovo-Tedesco, 1966); or the c l i e n t with l e s s than f i f t h - q r a d e e d u c a t i o n , i l l f o r t o x i c or o r q a n i c reasons, m e n t a l l y d e f i c i e n t , or p s y c h o t i c (Frank, 1974b). In summary, Dumont's (1968) c a u t i o n about c l i e n t s e l e c t i o n i s important. "Psychotherapy as i t i s q e n e r a l l y p r a c t i c e d , r e q u i r e s a person who i s v e r b a l , i n s i g h t f u l , and motivated, one who can delay g r a t i f i c a t i o n , and who, more or l e s s , shares the v a l u e s of the t h e r a p i s t , thereby v i r t u a l l y e x c l u d i n q the l o w e r - c l a s s person from treatment" (p. 25). The p o s s i b i l i t y e x i s t s t h a t t h o s e who use t h e p u b l i c community mental h e a l t h c e n t e r s are homely, o l d , u q l y , non-v e r b a l , and of lower i n t e l l i g e n c e . Obviously a mental h e a l t h proqram can not exclude everyone from treatment. However, a short-term therapy proqram miqht succeed i f the a d m i n i s t r a t i o n were to d e f i n e who i t would and would not accept. Outcome r e s e a r c h with b r i e f psychotherapy Although comparative s t u d i e s between b r i e f b e h a v i o r a l t h e r a p y and u n l i m i t e d t h e r a p i e s showed e s s e n t i a l l y no d i f f e r e n c e s i n outcome e f f e c t i v e n e s s (Levene, Breqer, & P a t t e r s o n , 1972; M o l e s k i & T o s i , 1976; N i c h o l s , 1974; N i c h o l s & R e i f l e r , 1973; P a t t e r s o n , Levene, & Breqer, 1971; 44 P a u l , 1966, 1967; Sloan, S t a p l e s , C r i s t o n , Yorkston, & Whiople, 1975, 1976), i t i s c l e a r t h a t b r i e f psychotherapy and lonq term psychotherapy are d i f f e r e n t . B r i e f psycho-therapy can reach more people on a p e r - c l i e n t b a s i s ; i f the average number of v i s i t s i s f i v e , one short-term t h e r a p i s t can s u c c e s s f u l l y t r e a t s i x people, while the lonq-term t h e r a p i s t can see onl y one i n the same time p e r i o d . Yet, the sequencing of events d u r i n g b r i e f psychother-apy has not been e s t a b l i s h e d . Althouqh the content f o r any two c l i e n t s may d i f f e r , a c o n s i s t e n t procedure could be e s t a b l i s h e d . T h i s l a c k of a d e f i n e d process i s c u r i o u s f o r two r e a s o n s . F i r s t , s h o r t - t e r m p s y c h o t h e r a p y i s v e r y amenable to r e s e a r c h . I t p r o v i d e s more o p p o r t u n i t y to c o n t r o l the r e s e a r c h design than does long-term therapy. L o q i s t i c a l l y monitoring r e s e a r c h f o r a s h o r t p e r i o d o f time i s e a s i e r than f o r a long p e r i o d of time. The c r i t e r i o n f o r outcome i s q e n e r a l l y q o a l - o r i e n t e d . I t i s s u b s t a n t i a l l y e a s i e r to a r t i c u l a t e short-term q o a l s . Because short-term therapy techniques have u s u a l l y been developed to d e a l with e i t h e r s p e c i f i c p o p u l a t i o n s o r p r o b l e m s , the f o l l o w - u o c r i t e r i a are e a s i e r to i d e n t i f y . For these reasons i t could be assumed t h a t a c l e a r l y d e f i n e d p r o c e d u r e c o u l d be i d e n t i f i e d to h e l p achieve the t h e r a p e u t i c q o a l s . S i n c e the process of short-term therapy i s s i m i l a r to the process of l o n q - t e r m t h e r a p y , n o t i o n s q l e a n e d from t h e s h o r t - t e r m approach miqht be a p p l i e d t o lonq-term therapy. While 45 r e s e a r c h on short-term therapy may be e a s i e r than on lonq-term, i t does not mean there are no problems with short-term therapy. There are, and they w i l l be addressed l a t e r . The second reason why i t i s odd that short-term psycho-therapy l a c k s s p e c i f i c i t y i s t hat behavior m o d i f i c a t i o n p r o v i d e s an e x c e l l e n t model. The behavior m o d i f i c a t i o n t h e r a p i s t s have been qood at s p e c i f y i n q the process of t h e i r t echniques. Beqinninq with Wolpe and Lazarus (1966) the b e h a v i o r i s t s have continued to s p e c i f y the "how t o " aspects of t h e i r approaches. These d e l i n e a t i o n s are then h e l p f u l both i n the conduct of followup research as w e l l as e x p l o r -inq the p a r t i c u l a r s of the process i t s e l f . I t appears e n t i r e l y p o s s i b l e to develop a s p e c i f i c b e h a v i o r a l process to be employed i n the context of short-term therapy. Aqain the n e c e s s i t y f o r a w e l l d e f i n e d process i s mentioned. Do we not a l r e a d y have such p r o c e s s e s , e s p e c i a l -l y from behavior m o d i f i c a t i o n ? The answer i s "no". What has qone before q i v e s the t h e r a p e u t i c process form. What i s beinq developed here i s the content -- a very d e t a i l e d content such t h a t should someone d e s i r e to r e p l i c a t e the technique, he could do so e x a c t l y . I t would be analoqous to f o l l o w i n q a cookinq r e c i p e , where the d i r e c t i o n s are p r e -c i s e l y and e x p l i c i t l y d e t a i l e d . Now t h a t b r i e f psychotherapy has been d e s c r i b e d , the elements of problem-solvinq therapy w i l l be examined. 46 Problem-Solving Therapy A c c o r d i n g to Mahoney and A r n k o f f (1978) , there are three major d i v i s i o n s w i t h i n the area of the c o g n i t i v e l e a r n i n g t h e r a p i e s : 1. p r o b l e m - s o l v i n g t h e r a p i e s , 2. coping s k i l l s t h e r a p i e s , 3. c o g n i t i v e r e s t r u c t u r i n g . Of the three c o g n i t i v e l e a r n i n g t h e r a p i e s , the problem-s o l v i n g t h e r a p i e s have been the most supported by c l i n i c a l outcome r e s e a r c h (Mahoney & A r n k o f f , 1978) . I t i s of i n t e r e s t here because of the emphasis on s e t t i n g g o a l s and developing a s t r a t e g y to achieve these g o a l s . An attempt i s being made to l i n k a process f o r e s t a b l i s h i n g g o a l s (the GASP) to the broad n o t i o n s of p r o b l e m - s o l v i n g . D ' Z u r i l l a and G o l d f r i e d (1971) were the f i r s t to note the need, to e x p l o r e p r o b l e m - s o l v i n g s t r a t e g i e s from a b e h a v i o r a l v i e w p o i n t . A f t e r noting that the phenomenon of p r o b l e m - s o l v i n g had long been of i n t e r e s t to e x p e r i m e n t a l and c o g n i t i v e p s y c h o l o g i s t s , they concluded: Much of what we view c l i n i c a l l y as abnormal behavior or 'emotional d i s t u r b a n c e ' may be viewed as i n e f f e c t i v e behavior and i t s consequences, i n which the i n d i v i d u a l i s unable to r e s o l v e c e r t a i n s i t u a t i o n a l problems i n h i s l i f e and h i s inade-quate attempts to do so are having u n d e s i r a b l e e f f e c t s , such as a n x i e t y , d e p r e s s i o n , and the c r e a t i o n of a d d i t i o n a l problems. (p. 107) Spivack and h i s c o l l e a g u e s deserve much of the c r e d i t f o r the growth i n problem-solving t h e r a p i e s f o r t h e i r work 47 w i t h p r e - s c h o o l e r s , e m o t i o n a l l y d i s t u r b e d c h i l d r e n , a d o l e s -c e n t s , and i n s t i t u t i o n a l i z e d p s y c h i a t r i c c l i e n t s ( P i a t t , S c u r a , & Hannon, 1973; P i a t t & Spivack, 1972a, 1972b, 1973, 1974; Shure & Spivack, 1972; Shure, Spivack, & Jaeger, 1971; S i e g e l & Spivack, 1976; Spivack, P i a t t , & Shure, 1976; Spivack & Shure, 1974). E s s e n t i a l l y the two important c o n c l u s i o n s were: f i r s t , there were d i f f e r e n c e s i n problem-s o l v i n g s k i l l s between the "normal" and " d e v i a n t " p o p u l a -t i o n s ; and second, there was p r e l i m i n a r y success i n s e v e r a l p r o j e c t s i n which " d e v i a n t " s u b j e c t s were g i v e n s y s t e m a t i c t r a i n i n g i n p e r s o n a l p r o b l e m - s o l v i n g . A number of promising s t u d i e s have supplemented the r e s e a r c h of Spivack and o t h e r s . I n s t r u c t i o n i n and p r a c t i c e of p r o b l e m - s o l v i n g s k i l l s were b e n e f i c i a l i n d e c r e a s i n g c o n f l i c t s i t u a t i o n s with p r e d e l i n q u e n t youths ( K i f e r , Lewis, Green, & P h i l l i p s , 1974). MacPherson, Candee, and Hohman (1974) e v a l u a t e d an experiment where aide s were i n s t r u c t e d to manage the lunchroom behavior of c h i l d r e n aged s i x to t h i r t e e n . The c h i l d r e n were evenly d i v i d e d i n t o three lunch p e r i o d s with d i f f e r i n g treatments. The f i r s t was behavior m o d i f i c a t i o n , f o r example p o s i t i v e r e i n f o r c e m e n t , p r a i s e , and a t t e n t i o n c o n t i n g e n t upon behavior. In the second c o n d i t i o n behavior m o d i f i c a t i o n plus a punishment essay were used. I f c h i l d r e n disobeyed they were g i v e n an essay [ s i c ] to w r i t e ("Write 'I w i l l not chew gum' 50 t i m e s " ) . In the t h i r d c o n d i t i o n c h i l d r e n were exposed to behavior m o d i f i c a -t i o n p l u s a m e d i t a t i o n essay. If they disobeyed they were 48 t o l d to copy an essay the experimenters had devised on "What d i d I do wrong." T h i s t h i r d c o g n i t i v e c o n d i t i o n was s i g n i f i c a n t l y more e f f e c t i v e i n reducing i n t e r r u p t i o n s o f the a i d e s , q u a r r e l i n g , and out of seat behavior. Coche and F l i c k (1975) examined s m a l l group t h e r a p y o v e r e i g h t s e s s i o n s with h o s p i t a l i z e d p s y c h i a t r i c c l i e n t s . There were three treatment c o n d i t i o n s : the teaching of problem-solving s k i l l s , a placebo c o n t r o l , and a w a i t - l i s t c o n t r o l . A l l three groups were administered the Means End Problem-Solving Procedure as a pre and p o s t t e s t measure. The treatment group had the hig h e s t p o s t - s c o r e on the Means End Problem-S o l v i n g P r o c e d u r e . Not o n l y d i d the t r e a t m e n t group i n c r e a s e i t s score on the Means End Problem-Solving Pro-cedure, both that group and the placebo c o n t r o l had s i g n i f i -c a n t l y s h o r t e r stays i n the h o s p i t a l than d i d the w a i t - l i s t c o n t r o l group. Stone, Hinds, and Schmidt (1975) were s u c c e s s f u l i n teaching i n f o r m a t i o n seeking s k i l l s to t h i r d , f o u r t h , and f i f t h graders i n two elementary s c h o o l s . The 144 c h i l d r e n were randomly assigned to e i t h e r a treatment or c o n t r o l group. In three s e s s i o n s the treatment group was taught three t a s k s : i n f o r m a t i o n seeking, g e n e r a t i o n o f a l t e r n a t i v e s , and the s e t t i n g o f p e r s o n a l g o a l s . Both groups were pre and p o s t t e s t e d on t h e i r responses to video -taped s i t u a t i o n s . An example o f the quest i o n s asked i s : a. How can Tommy qet more i n f o r m a t i o n about h i s problem? Name the ways you can. (Facts) b. How many ways could Tommy s o l v e h i s problem? Name the ways you can. (Choices) 49 c. What could Tommy do? ( S o l u t i o n ) (Stone, Hinds, & Schmidt, 1975, p. 37) The r e s u l t s show t h a t the t r e a t m e n t group had h i g h e r f r e q u e n c i e s i n a l l three c a t e g o r i e s . Mendonca and S i e s s (1976) d i s c o v e r e d that a combination of both anxiety-management and problem-solving s k i l l s had a g r e a t e r e f f e c t than e i t h e r anxiety-management or problem-s o l v i n g alone i n t r e a t i n g anxious v o c a t i o n a l i n d e c i s i o n . T h i r t y - t w o u n i v e r s i t y undergraduates (18-25 years old) were randomly assigned to one o f f i v e c o n d i t i o n s f o r seven s e s s i o n s . The three treatment groups were: anxiety-manage-ment, pro b l e m - s o l v i n g , and a combination of both. The two c o n t r o l groups were d i s c u s s i o n placebo and no treatment. The anxiety-management group was t r e a t e d with d e s e n s i t i z a -t i o n . The p r o b l e m - s o l v i n g group was t a u g h t d e f i n i n g problems'and g o a l s , g e n e r a t i n g a l t e r n a t i v e s , e x p l o r i n g the consequences of the a l t e r n a t i v e s , and s e l e c t i n g a p l a n . The d i s c u s s i o n c o n t r o l examined how c a r e e r b i a s e s e f f e c t employment d e c i s i o n s . The r e s u l t s were that the a n x i e t y management group and the combination group demonstrated g r e a t e r pre-post d i f f e r e n c e s on a paper and p e n c i l t e s t of v o c a t i o n a l e x p l o r a t o r y b e h a v i o r s . There was no d i f f e r e n c e between groups on a pre-post a n x i e t y measure, with the exception of the wait l i s t c o n t r o l group where a n x i e t y l e v e l r e mained unchanged. A l l t h r e e t r e a t m e n t g r o u p s s e l f -r eported e q u i v a l e n t s a t i s f a c t i o n with t h e i r p r o b l e m - s o l v i n g s k i l l s . 50 Jacobson (1977) t r e a t e d ten married couples under a w a i t - l i s t versus treatment d e s i g n . A l l couples r e p o r t e d m a r i t a l d i s s a t i s f a c t i o n . The treatment group was seen f o r e i g h t s e s s i o n s . During treatment they were taught t o i n t e r a c t p o s i t i v e l y , problem-solve, and to develop w r i t t e n contingency c o n t r a c t s . Nine weeks f o l l o w i n g treatment, the treatment group behaved more p o s i t i v e l y toward each other and were more s a t i s f i e d with t h e i r r e s p e c t i v e spouses. F i n a l l y , Blechman (1974) has devised a f a m i l y problem-s o l v i n g game. Blechman, Olson, Schornagel, H a l s d o r f , and Turner (1976) examined the e f f e c t i v e n e s s of t h i s Family Contract Game. The game i s a board game f o r f a m i l y members and i s designed to r e s o l v e s p e c i f i c i n t r a - f a m i l y problems by r e d u c i n g c o n f l i c t and i d e n t i f y i n g m u t u a l l y a c c e p t a b l e p r o b l e m s o l u t i o n s . The game prompts and c o n t i n g e n t l y r e i n f o r c e s a chain of f a m i l y i n t e r a c t i o n beginning with the s e l e c t i o n of a problem to be s o l v e d . The game i s to end with an agreement signed by a l l p l a y e r s . T h i s i s a l l done without the a s s i s t a n c e of a t h e r a p i s t . Using the N=1 r e v e r s a l d e s i g n the r e s e a r c h e r s d e m o n s t r a t e d t h a t t h e f r e q u e n c y o f arguments, i n s u l t s , and i n t e r r u p t i o n s had decreased with the demands o f the game, but were i n c r e a s e d when the game was not i n e f f e c t . L a t e r , Blechman, Olson, and Hellman (1976) were able to r e p l i c a t e these r e s u l t s with e i g h t s u b j e c t s , using the same N=1 r e v e r s a l d e s i g n . C l i n i c a l p r a c t i t i o n e r s have a l s o i n c l u d e d p r o b l e m -s o l v i n g t r a i n i n g i n t h e i r treatment packages (Haley, 1976; 51 Weiss, Hops, & P a t t e r s o n , 1973). For example, an e f f e c t i v e s t r a t e g y f o r the treatment o f o b e s i t y has been developed u s i n g the mnemonic SCIENCE (Mahoney, 1977b; Mahoney & Mahoney, 1976a, 1976b): S S p e c i f y general problem C C o l l e c t i n f o r m a t i o n I I d e n t i f y causes or p a t t e r n s E Examine o p t i o n s N Narrow o p t i o n s and experiment C Compare data E Extend, r e v i s e , or r e p l a c e In the v a r i o u s s t a g e s o f p r o b l e m - s o l v i n g , t h e c l i e n t develops a d d i t i o n a l s k i l l s l i k e s e l f - m o n i t o r i n g , means-ends t h i n k i n g , e v a l u a t i o n of probable consequences, and r e h e a r s a l of o p t i o n s . Mahoney and Arnkoff (1978) are of the o p i n i o n that p r o b l e m - s o l v i n g p e r s p e c t i v e s y i e l d e n c o u r a g i n g r e s u l t s because they a l s o encompass aspects from both the c o g n i t i v e r e s t r u c t u r i n g and coping s k i l l s t h e r a p i e s . In f a c t , with the problem-solving approaches, Mahoney and A r n k o f f (1978) reported t hat c l i e n t s are taught not o n l y broad coping s k i l l s , but a l s o the more general s t r a t e g i e s from c o g n i t i v e r e s t r u c t u r i n g such as assessment and problem d e f i n i t i o n . They argue that with the problem-solving type of approach the t h e r a p i s t teaches the c l i e n t to be a student of e f f e c -t i v e s e l f - r e g u l a t i o n . As with b r i e f psychotherapy, the r e s e a r c h on problem-s o l v i n g approaches allows s u b s t a n t i a l room f o r the c l i e n t ' s uniqueness. The focus i n problem-solving therapy i s on h e l p i n g the i n d i v i d u a l d i s c o v e r and implement whatever 52 adjustment s t r a t e g i e s are necessary. Thus t h i s type of approach i s geared toward p e r s o n a l e f f e c t i v e n e s s . Mahoney and Ar n k o f f (1978) noted that because the problem-solving t h e r a p i e s s t r e s s broad coping s k i l l s , they may f a r e b e t t e r than others i n terms o f g e n e r a l i z a b i l i t y . That i s , to the extent that c l i e n t s l e a r n p e r s o n a l adjustment s k i l l s , they would "... enhance t h e i r independent a b i l i t y to cope and grow with a changing environment" (p. 710). The c l i e n t s can g e n e r a l i z e t h i s l e a r n i n g to other problems at other times i n t h e i r l i v e s . In summary i t a p p e a r s the d a t a s u p p o r t t h a t the p r o b l e m - s o l v i n g t h e r a p i e s have the f o l l o w i n g p o s i t i v e components: (1) the teaching of broad coping s k i l l s ; (2) d i r e c t assessment; (3) emphasis on problem d e f i n i t i o n ; (4) eng a g i n g c l i e n t s t o r e g u l a t e t h e i r own b e h a v i o r ; (5) i d e n t i f y i n g g o a l s ; (6) developing a treatment p l a n . Problems and s h o r t - c o m i n g s o f b r i e f and p r o b l e m - s o l v i n g r e s e a r c h Below i s a l i s t i n g of problems and short-comings from b o t h the b r i e f and the p r o b l e m - s o l v i n g t h e r a p i e s t h a t suggest the need to a r t i c u l a t e the sequencing of events i n therapy. As mentioned e a r l i e r , b r i e f psychotherapy r e s e a r c h has i t s problems. F i r s t o f a l l , Butcher and Koss ( 1 978) cautioned t h a t r e s e a r c h on b r i e f psychotherapy i s d i f f i c u l t to do not o n l y because of c l i e n t m o b i l i t y but a l s o because o f the h e t e r o g e n e o u s p o p u l a t i o n s t h a t f r e q u e n t b r i e f 53 treatment c e n t e r s . A mobile c l i e n t p o p u l a t i o n does not e a s i l y permit f o l l o w - u p . A heterogeneous p o p u l a t i o n i s d i f f i c u l t to research because sample s p e c i f i c a t i o n s do not f i t n e a t l y i n t o r e s e a r c h designs concerned with the type of c l i e n t seen. Second, the reviewers c a u t i o n e d t h a t most of the r e s e a r c h on outcomes of psychotherapy. has been plagued with the problems a s s o c i a t e d with c o n t r o l groups. In t h e i r review the authors p o i n t e d out t h a t c o n t r o l groups were e i t h e r not employed or the procedures f o r the c o n t r o l group were not s p e c i f i e d . T h i r d , and perhaps most important, the e x i s t i n g outcome s t u d i e s f a i l to d e l i n e a t e the o p e r a t i o n s of the p r o c e s s , making f o l l o w - u p and f u r t h e r e x a m i n a t i o n extremely d i f f i c u l t , i f not i m p o s s i b l e . In t h e i r e x t e n s i v e r e v i e w of the p r o b i em-so 1 v i n g l i t e r a t u r e , Mahoney and A r n k o f f (1978) c r i t i c i z e d t h e p r o b l e m - s o l v i n g research f o r two reasons. F i r s t , problem-s o l v i n g t h e r a p i e s l a c k a s p e c i f i c and sound t h e o r e t i c a l model; i t i s o f t e n d i f f i c u l t to examine what the domain of p r o b l e m - s o l v i n g therapy i s . Consequently, the s t u d i e s which r e s u l t have poor i n t e r n a l and/or e x t e r n a l v a l i d i t y (Mahoney & A r n k o f f , 1978). Second, the r e s e a r c h e r s have not s p e c i -f i e d the t h e r a p e u t i c procedures. T h i s u l t i m a t e l y must be done to permit r e p l i c a t i o n . There seems to be a n a t u r a l c o m p a t i b i l i t y between the b r i e f and p r o b l e m - s o l v i n g p s y c h o t h e r a p i e s . I t should be 54 p o s s i b l e to combine the s t r e n g t h s from each approach i n t o a s p e c i f i c a l l y d e f i n e d s e t o f p r o c e d u r e s which c o u l d be s t a n d a r d i z e d f o r use i n an " i n v i v o " c l i n i c a l s e t t i n g . T h i s process should i n c l u d e : 1. a time l i m i t f o r therapy, 2. l i m i t e d g o a l s , 3. c o n v e r s a t i o n centered i n the present, 4. d i r e c t t h e r a p i s t management, 5. r a p i d e a r l y assessment, , 6. t h e r a p e u t i c f l e x i b i l i t y , 7. prompt i n t e r v e n t i o n , 8. v e n t i l a t i o n of emotion, 9. a f a c i l i t a t i v e i n t e r p e r s o n a l r e l a t i o n s h i p , 10. a p p r o p r i a t e c l i e n t s e l e c t i o n , 11. emphasis on problem d e f i n i t i o n , g o a l s , and plans to achieve the g o a l s , 12. an a c t i v e t h e r a p i s t using d i r e c t assessment s t r a t e g i e s . H i s t o r i c a l Development of the Goal Attainment S c a l e Mention has been made e a r l i e r i n t h i s chapter of how important the i d e n t i f i c a t i o n of g o a l s are to both b r i e f and problem-solving t h e r a p i e s . The l i t e r a t u r e suggests i t i s h e l p f u l to i n s t r u c t people as to how they can r e g u l a t e t h e i r l i v e s , or exert s e l f c o n t r o l . However, as yet there has been no e x p l i c i t l y d e t a i l e d process to accomplish t h i s . 55 An instrument to measure t h e r a p e u t i c outcome, the Goal Attainment S c a l e , has been developed, and that instrument has been shown to p o s s e s s some t h e r a p e u t i c p r o p e r t i e s i t s e l f . Since the Goal Attainment Scale attempts to measure the success of therapy and does, i n a p r e l i m i n a r y way, have ps y c h o t h e r a p e u t i c p r o p e r t i e s , i t might prove h e l p f u l t o a r t i c u l a t e a process that i s i n p a r t developed from the Goal Attainment S c a l e . T h e o r e t i c a l underpinnings of the goal attainment s c a l e Kiresuk and Sherman (1968) were charged with measuring the outcome of the mental h e a l t h e n t e r p r i s e at the Hennepin County Mental Health S e r v i c e . T h e i r s o l u t i o n i s c a l l e d the Goal Attainment S c a l e . It was developed from the f o l l o w i n g sources: 1. They drew upon the schools of m o t i v a t i o n and dynamic psychology which i n d i c a t e t hat people s t r i v e to reach some end. They r e l i e d upon the l e v e l o f a s p i r a t i o n s t u d i e s o f Lewin, Dembo, F e s t i n g e r , and Sears (1965) which compared the a c t u a l performance o f a s u b j e c t to h i s hoped-for e x p e c t a t i o n s . K i r e s u k and Sherman were a l s o i n f l u e n c e d by the s t u d i e s of M c C l e l l a n d and Winter (1969) who developed a goal attainment measure to determine progress towards a set o f g o a l s that was unique f o r each s u b j e c t i n the area of economic achievement. 2. Kiresuk and Sherman were i n f l u e n c e d by Cowle (1971, 1972) who employed a management-by-o b j e c t i v e s a p p r o a c h to p e r s o n a l management. E s s e n t i a l l y mangement-by-objectives p r e s s e s f o r i d e n t i f i e d g o a l s , and a measurement of t h e i r ach i evernent. 3. Kiresuk and Sherman b e l i e v e d the work of Ullman and Krasner (1965) was important. Ullman and Krasner r e q u i r e d c a r e f u l documentation of the c u r r e n t problem and s p e c i f i c a t i o n of the behav-i o r a l change to be achieved. K i r e s u k and Sherman f e l t t h a t a n a t u r a l e x t e n s i o n of t h i s procedure would be to l i s t these b e h a v i o r a l g o a l s i n a g o a l attainment format. 4. Kiresuk and Sherman drew upon the work of P o l l a r d and M i t c h e l l (1972) which s t a t e d t h a t behavior i s a f u n c t i o n of the p r o b a b i l i t y outcomes or c o n s e q u e n c e s and the i m p o r t a n c e o f t h e s e consequences. Thus the Goal Attainment S c a l e r e q u i r e s d e f i n i n g expected l e v e l s of t h e r a p e u t i c outcome. 5. Kiresuk and Sherman r e l i e d on K i e s l e r (1966) who s t a t e d that any assumptions of c l i e n t or t h e r a p i s t u n i f o r m i t y were f a l l a c i e s i n the f i e l d of therapy r e s e a r c h . While a l s o b e l i e v i n g t h a t g e n e r a l p r i n c i p l e s of behavior are important, Kir e s u k and Sherman (1968) attempted to honor both 57 the i d i o s y n c r a t i c and nomothetic t r a d i t i o n s i n t h e i r e v a l u a t i o n system. The goal attainment s c a l e The Goal Attainment S c a l e may be o u t l i n e d i n the f o l l o w i n g manner. A f t e r an i n i t i a l s c reening p r o c e s s , and before assignment to treatment, the goal s e l e c t o r d e c i d e s upon a r e a l i s t i c s et o f mental h e a l t h g o a l s f o r the c l i e n t . For each s p e c i f i e d g o a l , a s c a l e of probable outcomes ranging from the l e a s t to most f a v o r a b l e i s a l s o decided upon by e i t h e r a s t a f f member or the c l i e n t , whichever i s customary i n t h a t i n s t i t u t i o n . The s c a l e s are to be p r e c i s e and o b j e c t i v e l y d e s c r i b e d so that an observer u n f a m i l i a r with the treatment and the c l i e n t can determine to which l e v e l the c l i e n t has progressed with r e s p e c t to each g o a l . Each i n d i v i d u a l s c a l e i s to be "a judgmental t r a n s f o r m a t i o n of t h e r a p e u t i c outcome, i n t o approximately a random v a r i a b l e with zero mean and v a r i a n c e once [ s i c ] " (Kiresuk & Sherman, 1968, p. 477 ). These s c a l e s are to be s p e c i f i c to an i n d i v i d u a l c l i e n t , with a d e f i n e d p o s s i b l e outcome, poten-t i a l l y d i r e c t l y r e l a t e d to the g o a l . For example, a c l i e n t ' s goal may be " l e s s dependency on mother", with a p o s s i b l e outcome being "a r e t u r n to s c h o o l " . W r i t i n g the p o s s i b l e outcomes i n terms of events i s important so t h a t a follow-up worker who has had no contact with the c l i e n t can determine to which l e v e l the c l i e n t has advanced i n r e l a -t i o n s h i p to t h i s g o a l . 58 K i r e s u k and Sherman (1968) recommended at l e a s t one goal but no maximum number. T h e i r r a t i o n a l e i s th a t one goal might be s u f f i c i e n t with c l i e n t s who have e x p l i c i t problems l i k e an environmental dilemma, or v o c a t i o n a l o r f i n a n c i a l concerns. By not l i m i t i n g the number of g o a l s , Kiresuk and Sherman hoped to have t h e i r s c a l i n g process r e f l e c t the c l i n i c a l r e a l i t i e s of the treatment u n i t . T h e r a p e u t i c treatment i s then to be administered, and a f t e r a predetermined i n t e r v a l , the case i s c a l l e d to the a t t e n t i o n o f the follow-up u n i t p e r s o n n e l , who can then assess p r o g r e s s . A st a n d a r d i z e d composite Goal Attainment Score i s d e r i v e d so that outcome can be assessed i r r e s p e c -t i v e of the type o f treatment o f f e r e d . E s s e n t i a l l y , then, the Goal Attainment Scale has the f o l l o w i n g c h a r a c t e r i s t i c s : (1) a s e t o f g o a l s f o r an i n d i v i d u a l ; (2) ,a system of weights f o r these g o a l s ; (3) a set of expected outcomes f o r these goals ranging from "most unfavorable" to "most f a v o r a b l e " ; (4) a follow-up s c o r i n g o f these outcomes; and (5) a score summarizing the outcome across a l l g o a l s (Kiresuk, 1973). Mauger, Audette, S i m o n i n i , and S t o l b e r g (1974) analyzed the Goal Attainment Scale a g a i n s t the MMPI f o r v a l i d i t y . They found a c o r r e l a t i o n of .30 between MMPI sco r e s and the Goal Attainment Scale r a t i n g s . R e l i a b i l i t y was found to be .71 f o r d i f f e r e n t follow-up r a t e r s i n i n i t i a l g o al s e t t i n g , .70 a f t e r two months, and .47 a f t e r s i x months (Garwick, 59 1974a). The two week t e s t - r e t e s t r e l i a b i l i t y has been r e p o r t e d as .57 (Sherman, Baxter, & Audette, 1974). Development of the goal attainment s c a l e as therapy In 1974, Smith a l l e g e d that the Goal Attainment Scale i t s e l f possessed p s y c h o t h e r a p e u t i c p r o p e r t i e s . T h i s n o t i o n t h a t Goal Attainment S c a l i n g had a t h e r a p e u t i c impact was a l s o l a t e r r eported by Calsyn and Davidson (1978). Smith (1974, 1976) evaluated the d i f f e r e n c e between i n d i v i d u a l s who had completed the Goal Attainment Scale i n therapy and those who had not. His comparison was between t e s t s c o r e s of a treatment qroup using the Goal Attainment S c a l e , and a treatment group not using the Goal Attainment S c a l e . The i n s t r u m e n t s he employed were the P e r s o n a l O r i e n t a t i o n Inventorv, the N o r w i c k i - S t r i c k l a n d Locus o f C o n t r o l S c a l e , a Consumer S a t i s f a c t i o n S c a l e , and the l e v e l of f u n c t i o n i n g on the Outcome Assessment Sheet. He concluded t h a t when employinq the Goal Attainment Scale i n i n d i v i d u a l psycho-therapy, the Goal Attainment Scale was i t s e l f t h e r a p e u t i c . When used i n t h i s way with suburban white a d o l e s c e n t s (13-17 years o l d ) , Smith showed t h a t Goal Attainment S c a l i n q had p s y c h o t h e r a p e u t i c p r o p e r t i e s beyond the measurement o f q o a l s . 60 I n t e g r a t i o n A review o f the l i m i t e d Goal Attainment Scale l i t e r a -t u r e showed that Smith (1974, 1976) has been able to explore the p s y c h o t h e r a p e u t i c p r o p e r t i e s o f the instrument. Smith's r e s e a r c h touched on the idea of the measuring instrument as t h e r a p e u t i c (Greenberg S> C l a r k e , 1979 ). T h i s l e d to the qu e s t i o n as to whether the Goal Attainment Scale could be expanded i n t o ah a c t u a l t h e r a p e u t i c p r o c e s s . From a r e v i e w o f the l i t e r a t u r e d i s c u s s i n g b r i e f p s y c h o t h e r a p y , p r o b l e m - s o l v i n g t h e r a p y , and the Goal Attainment S c a l e , i n t e g r a t i n g the b e n e f i c i a l aspects of these three areas i n t o a c l e a r l y s p e c i f i e d procedure o f psychotherapy seemed e n t i r e l y p o s s i b l e . I t would be an e x p l i c i t treatment process that would be aimed at c l i e n t s o f b r i e f psychotherapy. It would be of a broad problem-solving nature, using Goal Attainment S c a l i n g as a model. 61 CHAPTER I I I DEVELOPMENT OF THE GASP The GASP procedure The GASP i s a procedure whereby c l i e n t and t h e r a p i s t j o i n t l y i d e n t i f y the e x p e c t e d outcome of t h e r a p y . The procedure i n v o l v e s 14 s t e p s , l i s t e d below i n the form of i n s t r u c t i o n s to be given to p a r t i c i p a t i n g t h e r a p i s t s : 1. Obtain a room with c h a i r s f o r everyone, a b l a c k -board, and c h a l k . 2. Introduce new members, s t a f f , and c l i e n t s , to the commun i t y . 3. Inform new members of the purpose of the GASP, e i t h e r by t e l l i n g them d i r e c t l y or by having a c l i e n t t e l l them. The purpose i s t h r e e f o l d : a. To i d e n t i f y goals f o r t h i s h o s p i t a l i z a t i o n to be accomplished w i t h i n two weeks. I t i s not an attempt to s o l v e a l l the c l i e n t ' s d i f f i c u l t i e s . b. To l e t the group know what b r i n g s the person to the h o s p i t a l . c. To i n f o r m the community of what g o a l s and behaviors the person i s working on so t h a t the community can support the c l i e n t . 4. Complete any t o p i c s remaining from the p r e v i o u s day before s t a r t i n g with a new c l i e n t . T h i s i s a s t a n d a r d i z e d 62 process to be completed w i t h i n 60 minutes. I t i s expected most c l i e n t s w i l l complete t h i s process w i t h i n t h i s time frame. However, due to c l i e n t and t h e r a p i s t i d i o s y n c r a c i e s , some c l i e n t s may r e q u i r e more time. I t i s proper to f i n i s h a l l t o p i c s before s t a r t i n q with a new c l i e n t . 5. Ask i f there are c l i e n t s who would l i k e to work on t h e i r other q o a l s ; i f no one v o l u n t e e r s , i d e n t i f y a person to be the focus f o r the procedure. 6. Write the word "events" at the top l e f t corner of the blackboard. The i n d i v i d u a l i s to enumerate the p r e -c i p i t a t i n g events l e a d i n g up to t h i s h o s p i t a l i z a t i o n . These events are to be w r i t t e n on the board by the s t a f f person. To a s s i s t the c l i e n t i n developing t h i s l i s t , the f o l l o w i n g probes may be h e l p f u l : a. What b r i n g s you to the h o s p i t a l at t h i s time? b. What has been happening i n your l i f e d u r i n g the past s i x months? c. Why are you here now? The purpose of t h i s l i s t i s f o r the c l i e n t s and s t a f f to understand why the c l i e n t i s seeking treatment at t h i s time. F u r t h e r , i t i s hoped that c l i e n t s w i l l see why they are i n t h e i r present s i t u a t i o n . The r a t i o n a l e i n l i s t i n g these events on the blackboard has been best a r t i c u l a t e d by Meichenbaum (1975). He suggested that i t i s important to understand the nature of the c l i e n t ' s p r e s e n t i n g problems 63 and to formulate an i n i t i a l treatment p l a n . In t h i s way the c l i e n t ' s a n x i e t y about h i s or her s i t u a t i o n i s l e s s e n e d . L a t e r i n the process, community members a s s i s t the c l i e n t along with the t h e r a p i s t i n the f o r m u l a t i o n o f g o a l s . To make t h i s f o r m u l a t i o n the group members, i n c l u d i n g the c l i e n t and the t h e r a p i s t , must be able to make some sense o f the behavior, that i s , to understand what happened. 7. Write the word " f e e l i n g s " at the head of the next column on the board. The i n d i v i d u a l i s now to recount the f e e l i n g s s/he had as the pre v i o u s event o c c u r r e d . The f o l l o w i n g probes may be used: a. What were your d i f f e r e n t f e e l i n g s 'as these t h i n g s happened? b. What d i d you f e e l l i k e when "such and such" happened? A l l of the f e e l i n g s the c l i e n t expresses are to be w r i t t e n on the board. When the c l i e n t b e l i e v e s the l i s t i s complete, i t i s proper to ask the group members what they might have f e l t i f these events had happened to them. The c l i e n t i s f r e e to accept or r e j e c t these s u g g e s t i o n s . Suggestions which are accepted are to be w r i t t e n on the black b o a r d . The purpose of t h i s step i s twofold. F i r s t , the e x e r c i s e a s s i s t s both the c l i e n t and the group i n under-standing the c l i e n t . Second, having others suggest f e e l i n g s helps the c l i e n t explore and c o n s o l i d a t e h i s or her con-c e p t u a l i z a t i o n of the problem (Meichenbaum, 1975). 64 h e l p s the c l i e n t e x p l o r e and c o n s o l i d a t e h i s or her con-c e p t u a l i z a t i o n of the problem (Meichenbaum, 1975). 8. Write the word " s t r e n q t h s " i n the next column. T h i s e x e r c i s e , as the c a p t i o n i n d i c a t e s , focuses on the i n d i v i d u a l ' s s t r e n q t h s . The c l i e n t may be asked the f o l l o w i n q q u e s t i o n s : a. What do you l i k e about y o u r s e l f ? b. What do others say they l i k e about you? c. You have l i v e d "x" years; how have you l i v e d so long? d. What do you thin k w i l l qet you through t h i s c r i s i s ? The r a t i o n a l e f o r t h i s c o n c e n t r a t i o n i s t o permit the c l i e n t t o see therapy as addinq t o what he or she a l r e a d y i s . The c l i e n t should r e a l i z e t h a t he or she does possess p o s i t i v e a t t r i b u t e s and q u a l i t i e s and t h a t he o r she i s not merely an empty c o n t a i n e r to be f i l l e d by whatever the h o s p i t a l i z a t i o n can o f f e r . 9. Next, the community members are asked t o say what thev p e r c e i v e the c l i e n t ' s s t r e n q t h s to be. These comments are to be t r a n s c r i b e d on the board without the c l i e n t ' s e x e r c i s i n q an e d i t o r i a l p r e r o g a t i v e . The reason here i s t h r e e f o l d : a. To d i r e c t the members of the group t o see themselves i n some way s i m i l a r t o and to be empathic with another human being; t o 65 c. To induce group cohesion. 10. Write the word "problem" on the board at the head of the next column. At t h i s p o i n t the c l i e n t i s to l i s t what he or she assumes h i s or her problems to be. The c l i e n t may be a s s i s t e d by the f o l l o w i n g q u e s t i o n s : a. What are the areas you would say you have problems with? b. Looking at what you have d e s c r i b e d , do you see any p a t t e r n as having developed? 11. Next, the others i n the community are asked i f they see problem areas the c l i e n t does not r e c o g n i z e . Here, again, everyone i s to p a r t i c i p a t e as f u l l y as p o s s i b l e by c r e a t i n g a comprehensive l i s t o f problems. By i d e n t i f y i n g problem areas, i t i s hoped that c l i e n t s w i l l g a in g r e a t e r cognizance of t h e i r d i f f i c u l t i e s , perhaps even some problems they had not thought about. With such a complete l i s t , the c l i e n t w i l l then be i n a p o s i t i o n to make a more informed choice regarding goals on which to focus. 12. Write the word "goals" on the board. The c l i e n t i s to l i s t no more than four g o a l s s/he w i l l work on f o r the next two weeks. As the goals are i d e n t i f i e d , i t i s h e l p f u l to check o f f the problems that the c l i e n t p e r c e i v e s each goal to be a l l e v i a t i n g . The more b e h a v i o r a l l y s p e c i f i c a goal i s , the e a s i e r i t w i l l be to write l e v e l s f o r that g o a l . For example, the goal "to get i n touch with my f e e l i n g s " i s l e s s d e s i r a b l e than "to express my anger." 66 13. Write the l e v e l s of success, n-^2_, 0, +1_, +2", on the board. C l i e n t s w i l l r e q u i r e the a s s i s t a n c e of the s t a f f member i n s p e c i f y i n g what behaviors they w i l l engage i n at each l e v e l . L e v el 2_ i s t n e l e a s t expected outcome. The l e s s - t h a n -expected l e v e l o f success i s ^J_; what the c l i e n t can reasonably hope to a t t a i n w i t h i n the h o s p i t a l i z a t i o n i s _0. The more than expected l e v e l of success i s +J_, and +_2 i s the most d e s i r e d outcome. In order f o r c l i e n t s to understand more c l e a r l y t h e i r range and c o n t r o l of behavior, the t h e r a p i s t w i l l s t a r t with l e v e l ^ J _ , the less-than-expected l e v e l of success. The goal "express my anger" i s used throughout the remainder of t h i s s e c t i o n as an example. The t h e r a p i s t begins by asking the c l i e n t , "What are you doing now i n r e l a t i o n to t h i s g o a l ? " If the c l i e n t says s/he now l e t s h i s or her anger - b u i l d up then "explodes" over minor i s s u e s , the t h e r a p i s t should complete the 2I. c e l l with "never express my anger except to explode." It may occur that the c l i e n t t h i n k s the i n i t i a l l e v e l o f success should be i n the ^_ c e l l . T h i s i s never to be the case; the c l i e n t can always become worse. By beginning with the ^ J . l e v e l , i t i s hoped that the c l i e n t w i l l see how much more f l e x i b l e than r i g i d he or she i s . F u r t h e r , i t i s a n t i c i p a t e d c l i e n t s w i l l experience t h e i r c o n d i t i o n as being not as unfavorable as they had thought. The next movement i s to i d e n t i f y the ^_ l e v e l . "What would you be doing i f 6 7 you became worse?" i s an a p p r o p r i a t e q u e s t i o n . With the goal of expressing angry f e e l i n g s , two p o s s i b i l i t i e s f o r t h i s l e v e l might be "never express angry f e e l i n g s " , or "attempt s u i c i d e . " Now the c l i e n t and the t h e r a p i s t i d e n t i f y what the c l i e n t would be doing i n order to reach the expected l e v e l o f success, 0^ . F i n a l l y , the two w i l l a s c e r t a i n the +1_ and +2 l e v e l s , the more-than-expected and the most f a v o r a b l e outcome expected. For example, the c l i e n t who has the goal o f e x p r e s s i n g anger may have the f o l l o w i n g l e v e l s o f s u c c e s s : -2 Attempt s u i c i d e . -1 Express anger only i n e x p l o s i v e manner. 0 L i s t each time I f e e l angry, the s i t u a t i o n , and the reason. +1 Share the l i s t with h o s p i t a l community. + 2 Have a meeting to share the l i s t with my f a m i l y . 14. Once a week ask community members to read t h e i r g o a l s and t h e i r goal l e v e l s and to i d e n t i f y the l e v e l on which they t h i n k they are. The other community members are to g i v e feedback as to whether they agree or d i s a g r e e with the c l i e n t ' s p e r c e p t i o n and why. In t h i s way c l i e n t s r e c e i v e i n f o r m a t i o n about t h e i r behavior and have a r e f e r -ence group to say whether they are i n agreement with the c l i e n t ' s s e l f p e r c e p t i o n . (See Appendix A f o r an example o f 68 the p r o c e s s . For an example of completed s c a l e s , see Appendix B.) The GASP i n c l u d e s a l l the important components i d e n t i -f i e d e a r l i e r i n Chapter I I . The h o s p i t a l a d m i n i s t r a t i o n has taken care to see that a broad group of treatment s k i l l s are represented i n t h e i r p s y c h i a t r i c s t a f f , thus i n c r e a s i n g the p o t e n t i a l f o r t h e r a p e u t i c f l e x i b i l i t y . A f t e r an e a r l y assessment by the admitting p s y c h i a t r i s t , the c l i e n t i s r e f e r r e d t o the most a p p r o p r i a t e t r e a t m e n t f a c i l i t y . C l i n i c a l i n t e r v e n t i o n i s begun promptly w i t h i n 24 hours of admittance. At the f i r s t GASP s e s s i o n c l i e n t s are t o l d that the purpose of the GASP i s : (1) an emphasis on problem d e f i n i t i o n , g o a l s , and p l a n s , and (2) an estimate of what can be accomplished i n two weeks, s i n c e that i s the average l e n g t h o f stay at the h o s p i t a l . In order to use the GASP, the t h e r a p i s t must be a c t i v e l y asking questions and s o l i c i t -ing i n f o r m a t i o n . There i s no room, nor time, f o r p a s s i v e , r e f l e c t i v e l i s t e n i n g . In order to keep the c o n v e r s a t i o n i n the p r e s e n t , the c l i e n t i s informed that the process w i l l be concerned with the events l e a d i n g up to the h o s p i t a l i z a t i o n . T h i s may n e c e s s i t a t e the l i s t i n g of an event s i x months e a r l i e r , but f o r the most part no a t t e n t i o n w i l l be giv e n to b i r t h o r d e r , e a r l y memories, or dreams. T h i s i s a process engineered to assess what has happened now and what d i r e c -t i o n c l i e n t s are going to take to r e c t i f y the problem. In order to begin to g i v e v e n t i l a t i o n to emotions, the is s u e o f 69 the c l i e n t ' s f e e l i n g s i s addressed d i r e c t l y . F i n a l l y , i t i s b e l i e v e d t h a t by a s s i s t i n g c l i e n t s to a r t i c u l a t e t h e i r p l a n s , the c l i e n t s would f i n d t h i s r e l a t i o n s h i p h e l p f u l . Implementation of the GASP Need f o r cohesive treatment approach In A p r i l o f 1974, the author was employed by V a l l e y General H o s p i t a l as a p s y c h o t h e r a p i s t . A month l a t e r he met with the p s y c h i a t r i c u n i t ' s medical d i r e c t o r , head nurse, and s t a f f p s y c h o l o g i s t to explore a d d i t i o n a l treatment the u n i t could o f f e r c l i e n t s . He pointed to the need f o r cohesion w i t h i n each c l i e n t ' s t h e r a p e u t i c treatment and suggested such cohesion could be gained from employing Kiresuk and Sherman's (1968) Goal Attainment S c a l e . That suggestion was adopted and the author was g i v e n the respon-s i b i l i t y o f t r a i n i n g other s t a f f i n i t s implementation f o r i n d i v i d u a l c l i e n t s . Adoption of the goal attainment s c a l e and i t s a d a p t a t i o n t o  group therapy Over the next twelve months the s t a f f became s k i l l e d at developing the goals with c l i e n t s i n one-to-one s e t t i n g s . The i n f o r m a t i o n gained from the t h e r a p i s t s ' o b s e r v a t i o n s and recommendations about the one-to-one process was shared with the author. The author sought o p i n i o n s and comments about the Goal Attainment Scale from every s t a f f member. Then, i n the Spring of 1975, the author again met with the medical 70 d i r e c t o r , the head nurse, and the s t a f f p s y c h o l o g i s t to request that the i d e n t i f i c a t i o n of g o a l s be m o d i f i e d . I t was noted that while the i d e n t i f i c a t i o n and s c a l i n g of g o a l s was being done e f f e c t i v e l y , the procedure was not e f f i c i e n t . Other s t a f f members resented the time i t took to i n s t r u c t c l i e n t s . Moreover, the u n i t had expressed b e l i e f i n the p h i l o s o p h y of a t h e r a p e u t i c community, with openness of communication. It seemed to the author t h a t the Goal Attainment Scale (Kiresuk & Sherman, 1968) could be bene-f i c i a l f o r the c l i e n t s and the u n i t i f i t were done i n the context of group therapy. T h i s change was opted f o r i n the b e l i e f t h a t a group: (a) was more economical, (b) o f f e r e d a v i c a r i o u s l e a r n i n g experience s i m i l a r to other forms of group therapy, and (c) had the advantage o f e n a b l i n g the c l i e n t s to know about each ot h e r ' s g o a l s and comment on them. This l a s t purpose was a l s o congruent with the h o s p i t a l ' s philosophy of openness. Again the author monitored t h i s formation of goals i n groups by d a i l y s i t t i n g i n on the group. The a n a l y s i s of i n f o r m a t i o n was shared i n monthly s t a f f meetings where the s t a f f expressed t h e i r o p i n i o n s of the group g o a l s p r o c e s s , and how i t c o u l d be improved. By the Spring of 1 976, the end r e s u l t o f t h i s development was i d e n t i f i e d as the GASP. The h o s p i t a l requested the author to s t a n d a r d i z e and conduct the p r e l i m -i n a r y e v a l u a t i o n of the GASP as developed over the p r e v i o u s three years. The process was s t a n d a r d i z e d i n October of 71 1976. In A p r i l of 1977 the h o s p i t a l a d m i n i s t r a t i o n con-t r a c t e d with the author f o r a s i x month e v a l u a t i o n as to whether h o s p i t a l i z a t i o n i n V a l l e y G e n e r a l H o s p i t a l ' s p s y c h i a t r i c u n i t was more b e n e f i c i a l with or without the GASP. P s y c h i a t r i c U n i t , V a l l e y General H o s p i t a l Purpose The p s y c h i a t r i c u n i t at V a l l e y General H o s p i t a l was opened i n 1974. I t was to serve as a short-term treatment f a c i l i t y f o r the s o u t h e r n p o r t i o n o f K i n g C o u n t y , Washington. Other p u b l i c and p r i v a t e f a c i l i t i e s s p e c i a l i z e d i n treatment of p a r t i c u l a r problems such as a l c o h o l abuse, drug abuse, v i o l e n t behavior ( a s s a u l t , a r s o n ) , and long-term c a r e . The p s y c h i a t r i c u n i t of V a l l e y General H o s p i t a l was designed not to d u p l i c a t e or o v e r l a p with these o t h e r f a c i l i t i e s . The p s y c h i a t r i c u n i t i d e n t i f i e d i t s t a r g e t p o p u l a t i o n as anyone who v olunteered f o r treatment and was not s u i t a b l e f o r the other treatment programs. By the end of i t s f i r s t twelve months o f o p e r a t i o n , i t was an e s t a b l i s h e d mental h e a l t h resource i n the community to which other mental h e a l t h p r o f e s s i o n a l s t u rned. By the end of the second year of o p e r a t i o n , the u n i t was o f f e r i n g a s t a b l e and s t a n d a r d i z e d treatment program, an i n t e g r a l p a r t of which was the GASP. 72 C I i e n t e l e The u n i t t r e a t s people who are f o r the most p a r t , i n c r i s i s and b e l i e v e they need he l p . They could see someone o u t s i d e the h o s p i t a l f o r therapy once a week, but they have chosen, a f t e r c o n s u l t i n g a mental h e a l t h p r a c t i t i o n e r , to admit themselves to the h o s p i t a l f o r a s h o r t , s e l f - d e f i n e d p e r i o d of time. They are t o l d that i n order to leave they must have the approval of the t h e r a p e u t i c community as w e l l as t h e i r admitting p s y c h i a t r i s t . However, they may leave any time they d e s i r e , r e g a r d l e s s of the medical a d v i c e , provided they are not dangerous to themselves or o t h e r s . The mean length o f stay at V a l l e y General H o s p i t a l during 1974 t o 1976 was 12.4 days, but persons d i d leave on oc c a s i o n a f t e r only a few days. Whatever the length of stay in the p s y c h i a t r i c u n i t , f o r many people i t may be the o n l y c o n t a c t with therapy they are ever l i k e l y to have. For that reason the therapy provided must be s p e c i f i c a l l y geared to short-term treatment. Treatment philosophy V a l l e y G e n e r a l H o s p i t a l does not have a p r i m a r y -t h e r a p i s t o r i e n t a t i o n . No one t h e r a p i s t works e x c l u s i v e l y with one c l i e n t . Rather, each c l i e n t i s the r e s p o n s i b i l i t y o f every t h e r a p i s t . Treatment i s very open. The s t a f f share i n f o r m a t i o n regarding the c l i e n t s , and each c l i e n t has access to i n f o r m a t i o n about h i s or her own case d u r i n g 73 "c h a r t group", the time s e t as i d e each day f o r reading the s t a f f ' s remarks i n one's own c h a r t . I n t r o d u c t i o n of GASP Between October and November, 1976, the author t r a i n e d the p s y c h o t h e r a p i s t s and p s y c h i a t r i c nurses a t the h o s p i t a l to a d m i n i s t e r the GASP to the c l i e n t s h o s p i t a l i z e d then. There were 10 p s y c h i a t r i c nurses and 10 p s y c h o t h e r a p i s t s on the s t a f f . Due to s t a f f r o t a t i o n , not every s t a f f member was pr e s e n t a t a l l 40 ( f i v e times per week f o r e i g h t weeks) of these t r i a l runs. However every s t a f f member was presen t at at l e a s t two of these t r i a l s per week. The author conducted e i g h t weekly meetings to s t a n d a r d i z e the GASP pr o c e s s . These meetings were 50 minutes each. At the f i r s t meeting the s t a f f was informed of how important t h i s element of u n i f o r m i t y was to r e s e a r c h . They were then g i v e n the 14-p o i n t o u t l i n e presented at the beginning of t h i s c h a p t e r . The s e s s i o n concluded by mentioning t h a t the author would be s i t t i n g i n on t h e i r s e s s i o n s as they employed the GASP and tha t h i s o b s e r v a t i o n s and the s t a f f ' s problems would be d i s c u s s e d over the next seven weekly t r a i n i n g s e s s i o n s . At s e s s i o n s 2 through 8, the s t a f f r e c e i v e d feedback on t h e i r i n d i v i d u a l p rogress (See Appendix C f o r T r a i n i n g Agenda) . At these times, too, the importance of u n i f o r m i t y was r e i t e r a t e d . The s t a f f ' s p e r c e p t i o n of o t h e r s ' a t t e n t i o n to d e t a i l was a l s o d i s c u s s e d as w e l l as the r a t i o n a l e f o r each s t e p . By the end of the seventh s e s s i o n a l l s t a f f c o u l d 74 conduct the GASP from memory. At the e i g h t h s e s s i o n , the s t a f f d i s c u s s e d cues they had developed to remember the pr o c e s s , and shared t h e i r f e e l i n g s about t h i s experience. Problems presented when s t a n d a r d i z i n g I n t e r e s t i n g problems developed when the GASP was being s t a n d a r d i z e d . As the GASP took shape, there were i n i t i a l d i s c r e p a n c i e s concerning the time frame i n which the go a l s should be accomplished. It was necessary to d i r e c t the t h e r a p i s t s away from g l o b a l , all-encompassing l i f e changes. T h i s experience was not going to be an attempt to s o l v e a l l the c l i e n t ' s problems. Rather the process was to focus upon what could be accomplished i n two weeks. The i s s u e o f b r e v i t y had other r a m i f i c a t i o n s which w i l l be addressed l a t e r . Another problematic area was to d i r e c t the s t a f f to focus upon behavior. As t h e i r t h e r a p e u t i c o r i e n t a t i o n s were d i v e r s e , i t was important to avoid opening a forum f o r the "best" or " r i g h t " school o f therapy. The is s u e of behavior was accepted by the s t a f f when they experienced the d i f -f i c u l t y of w r i t i n g g o a l s and l e v e l s t h a t were not focused on beha v i o r . The s t a f f a l s o d i s c o v e r e d how much e a s i e r i t was to observe changes i n behavior, and what d i f f i c u l t y c l i e n t s had changing t h e i r behavior. T h i s i n pa r t might have been because i t i s e a s i e r to observe and agree someone i s doing something l i k e " t a l k i n g with people" than i t i s to have consensus that someone i s "not g e t t i n g angry". As mentioned 75 above i t was necessary to remind the s t a f f that t h i s process was to focus on what c l i e n t s could accomplish i n two weeks. The importance of c o n s o l i d a t i n g the group l e a d e r s ' time w i t h i n the process a l s o became apparent. The GASP i s open-ended with regard to membership but not i n terms o f content. I t does not have a v a r i e d agenda. I t r e q u i r e s a more a c t i v e r o l e on the pa r t of the t h e r a p i s t . The t h e r a p i s t must t h e r e f o r e s t r u c t u r e the s e s s i o n t i g h t l y . One way to do t h i s was to make the l i s t i n g of "Events" b r i e f . Rather than examine the c l i e n t ' s whole l i f e , the purpose i s to create a rough o u t l i n e of the s i g n i f i c a n t events o f the previous s i x months. The process could a l s o be speeded up by l i s t i n g the c l i e n t ' s f e e l i n g s as they are mentioned. Again, i t was important to remind the t h e r a p i s t s that these l i s t s were not to be exhaustive, but overviews. F i n a l l y , the s t a f f n o t i c e d an o c c a s i o n a l problem when a c l i e n t would not or could not a r t i c u l a t e "Goals". There was a f e e l i n g o f f o r c i n g the c l i e n t to accept what the s t a f f wanted r a t h e r than what the c l i e n t wanted. In an ins t a n c e l i k e t h i s the t h e r a p i s t was encouraged to c o n s u l t o t h e r s t a f f with the concern and then decide how to proceed. S t a b i l i t y and I n t e g r i t y of GASP Goals A f t e r the GASP had been adopted, a q u a l i t a t i v e evalua-t i o n was conducted. It was important to know whether or not c l i e n t s switched t h e i r g o a ls as a r e s u l t o f t h i s p r o c e s s . 76 I f c l i e n t s d i d not change t h e i r g o a l s , i t was important to know i f the go a l d i r e c t i o n s had been a l t e r e d . I f the g o a l s changed i n e i t h e r kind or d i r e c t i o n , the subsequent r e s u l t s would be meaningless. An examination of the go a l s i d e n t i f i e d upon admission and those i d e n t i f i e d d u r i n g the GASP was undertaken. Three i n d e p e n d e n t t h e r a p i s t s c l a s s i f i e d the g o a l s i n t o the f o l l o w i n g four c a t e g o r i e s : s e l f , f a m i l y , f r i e n d s , and work. R e l i a b i l i t y among r a t e r s was e s t a b l i s h e d through use of S c o t t ' s (1955) c o e f f i c i e n t . There was a .995 agreement among the t h e r a p i s t s with regard to assignment to goal category. It was a s c e r t a i n e d t h a t , of the goals i d e n t i f i e d upon admission, 90 per cent were i n the same category d u r i n g the GASP. A l l of these goals i d e n t i f i e d during the GASP were i n the same d i r e c t i o n as those i d e n t i f i e d by the c l i e n t s at admission. The goals had s t a b i l i t y . Comparative E v a l u a t i o n Two purposes were addressed in the present study. The f i r s t was the development of the GASP as d e s c r i b e d i n the preceding s e c t i o n . The second was to conduct an e x p l o r a t o r y comparative e v a l u a t i o n of the e f f e c t i v e n e s s of h o s p i t a l i z a -t i o n with the GASP as compared to h o s p i t a l i z a t i o n without the GASP. In the f o l l o w i n g d i s c u s s i o n , h o s p i t a l i z a t i o n without the GASP i s r e f e r r e d to as the non-equivalent 77 c o n t r o l g r o u p . T h i s e v a l u a t i o n was d i v i d e d i n t o two s e c t i o n s corresponding to two c o n t r o l hypotheses, and f i v e e v a l u a t i o n hypotheses. Hypotheses r e l a t e d to c o n t r o l i s s u e s I n i t i a l a n a l y s i s of the ward atmosphere was performed to c o n t r o l f o r environmental p r e s s . This was done f o r two reasons. F i r s t , there was a l a c k of random assignment to treatment c o n d i t i o n ; and second, h o s p i t a l s i z e was l i m i t e d to only one ward. These two reasons meant that the GASP and the non-equivalent c o n t r o l groups could not run c o n c u r r e n t -l y . Normal monitoring of the behaviors the c l i e n t s engaged i n d u r i n g the GASP was performed but i t was decided t h a t simple monitoring of o v e r t behaviors was not enough to counter the e f f e c t of any c o v e r t behaviors and a t t i t u d e s on the part of the s t a f f . For that reason, the environmental press as p e r c e i v e d by the c l i e n t s was monitored, to a s c e r -t a i n whether the c l i e n t p e r c e i v e d the environment d i f f e r -e n t l y between the times when resea r c h was and was not being conducted. The environmental press was measured on the ten subscales of the Ward Atmosphere S c a l e : a. Involvement b. Support c. Spontaneity d. Autonomy e. P r a c t i c a l O r i e n t a t i o n 78 f . P e r s o n a l Problem O r i e n t a t i o n g. Anger and Agg r e s s i o n h. Order and O r g a n i z a t i o n i . Program C l a r i t y j . S t a f f C o n t r o l Moos (1974) demonstrated that h i s Ward Atmosphere S c a l e measured aspects of the treatment environment t h a t may remain s t a b l e even though there has been a complete t u r n o v e r i n the c l i e n t p o p u l a t i o n ; t h a t i s d i f f e r e n t p o p u l a t i o n s p e r c e i v e d the same environment i n the same way. F u r t h e r , P i e r c e , T r i c k e t t , and Moos (1972) demonstrated the Ward Atmosphere Scale to be s e n s i t i v e to changes i n ward t r e a t -ment programs. The instrument i s d i s c u s s e d i n more d e t a i l in Chapter IV. F i g u r e 1 p r e s e n t s the time sequence f o r the three a d m i n i s t r a t i o n s of the Ward Atmosphere S c a l e . In January 1977, the c l i e n t p o p u l a t i o n was sampled with the FIGURE 1 Ward Atmosphere Test Schedule January 1977 Pre-Experimental C o n d i t i o n Test 1 with Ward Atmosphere Scale June 1977 GASP C o n d i t i o n Test 2 with Ward Atmosphere Scale August 1977 N o n - e q u i v a l e n t C o n t r o l C o n d i t i o n Test 3 with Ward Atmosphere S c a l e Ward Atmosphere S c a l e t o p r o v i d e a p e r c e p t i o n o f the pre-ex p e r i m e n t a l environment. A second t e s t was made i n June of 1977, a f t e r the GASP had been i n o p e r a t i o n f o r s i x 79 weeks. A t h i r d t e s t i n g was taken i n August of 1977, d u r i n g the Non-Equivalent c o n t r o l c o n d i t i o n , (when the GASP had been absent f o r six weeks). Since there was no p r i o r r e s e a r c h of the GASP, there was no reason to p o s t u l a t e d i r e c t i o n a l i t y i n the hypotheses. The hypotheses were t h e r e f o r e w r i t t e n i n the n u l l form. Hypothesis 1 There i s no d i f f e r e n c e i n the environmental press measured by the Ward Atmosphere Scale i n January, June, and August. N o n - s i g n i f i c a n t r e s u l t s would i n d i c a t e t h a t the i n t e r n a l v a l i d i t y o f the e v a l u a t i o n was not contaminated by h i s t o r y , person, or Hawthorne e f f e c t , and i n t e r a c t i o n of t h e r a p i s t s and treatment (Campbell & Stanley, 1963). T h i s more r i g o r o u s c r i t e r i o n f o r c o n t r o l l i n g these extraneous t h r e a t s to v a l i d i t y i n c r e a s e s the potency of the study. Hypothesis 2 There i s no d i f f e r e n c e between the p r e t e s t scores of the GASP group and the non-equivalent c o n t r o l group on the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e , and the Rotter I n t e r n a l - E x t e r n a l Locus of C o n t r o l S c a l e , and the number o f g o a l s on the Target Outcome Assessment Sheet. Since both groups had the same composition of n e u r o t i c s and p s y c h o t i c s , t h e i r scores were a n t i c i p a t e d to be the same. N o n - s i g n i f i c a n t r e s u l t s would i n d i c a t e t hat the two 80 groups began at e s s e n t i a l l y the same p l a c e on t h e i r pre-t e s t s . E v a l u a t i o n hypotheses In order to t e s t the v i a b i l i t y of the GASP as an e f f e c t i v e p s y c h i a t r i c treatment method, the e f f e c t i v e n e s s of p s y c h i -a t r i c h o s p i t a l i z a t i o n with the GASP and p s y c h i a t r i c hos-p i t a l i z a t i o n without the GASP were compared. The mean performances of each group were compared on three dependent measures (The S i x t e e n . P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e , R o t t e r ' s Locus of C o n t r o l S c a l e , and the Target Outcome Assessment Sheet) together with the l e n g t h of time c l i e n t s stayed i n the h o s p i t a l under each c o n d i t i o n . Hypothesis 3 There i s no d i f f e r e n c e between the GASP group and the non-equivalent c o n t r o l group mean p o s t t e s t s c o r e s on the Target Outcome Assessment Sheet. The GASP i d e n t i f i e s minute i n c r e m e n t s of p r o g r e s s toward a go a l with c l e a r and concre t e d i r e c t i o n s . A t t a i n -ment at the lower l e v e l s of the goal should r e i n f o r c e the type of behavior necessary to a t t a i n the higher l e v e l s of the goal h i e r a r c h y . The present h y p o t h e s i s focuses upon which treatment procedure produces the g r e a t e r r e p o r t e d 81 b e h a v i o r a l changes. C l i e n t s a c h i e v e t h e i r g o a l s by a t t a i n i n g higher l e v e l s of s u c c e s s . Hypothesis 4 There i s no d i f f e r e n c e between the GASP group and the non-equivalent c o n t r o l group mean p o s t t e s t scores on the "most important g o a l " of the Target Outcome Assessment Sheet. With some c l i e n t s a l l other goals may take a permanent second place to a p a r t i c u l a r g o a l . Thus i t i s p o s s i b l e to lower the grand mean of the Target Outcome Assessment Sheet by c o n c e n t r a t i n g on the achievement o f one goal to the r e l a t i v e e x c l u s i o n of the r e s t . In such an instance c l i e n t s might make progress on t h e i r "most important g o a l " and l i t t l e or no progress on the other g o a l s . T h e r e f o r e , c o n s i d e r a t i o n was g i v e n t o h a v i n g the c l i e n t s rank-order t h e i r g o a l s or to have them weighted r e l a t i v e t o each o t h e r as K i r e s u k and Sherman (1978) suggested. Rank-ordering i m p l i e s a weighting procedure of which the c l i e n t and/or t h e r a p i s t may not be aware. To the degree that both c l i e n t and t h e r a p i s t become aware of the inherent weighing and meaning, they s e r i o u s l y d i s r u p t the t h e r a p e u t i c p r o c e s s . For t h i s reason r a n k - o r d e r i n g was excluded. In t h e i r e a r l y work, K i r e s u k and Sherman (1968) r e f e r r e d to weighting the c l i e n t ' s g o a l s i n such a way t h a t t h i s problem might be s o l v e d . O r i g i n a l l y they were employed 82 as e v a l u a t o r s , and had a cadre of employees whose s o l e r e s p o n s i b i l i t y was to c o l l e c t d a t a . T h i s team of e v a l u a t o r s asked c l i e n t s what t h e i r p r i o r i t i e s were. The team employed a v e r b a l / c o n v e r s a t i o n a l manner. V a l l e y General H o s p i t a l d i d not have such a research team a v a i l a b l e to o b t a i n t h i s i n f o r m a t i o n . I f the technique had been used, the r e s p o n s i -b i l i t y would have been l e f t with s t a f f members whose primary i n t e r e s t was psychotherapy, not r e s e a r c h . Moreover, the c o n v e r s a t i o n a l approach to t h i s i s s u e i s d i s r u p t i v e to the course of therapy. The w r i t t e n approach was too cumbersome and i n a c c u r a t e s i n c e there was no way of knowing whether the respondent understood the d i r e c t i o n s . A compromise was a r r i v e d at by asking the c l i e n t s to mark which of t h e i r g o a ls was "most important" to them and proceeding with the e v a l u a t i o n from t h e r e . Thus, at both pre and p o s t t e s t i n g times c l i e n t s were asked which one of t h e i r g o a l s was "most important" to them and the mean achievement on t h i s g oal was assessed and compared between the GASP and non-equivalent c o n t r o l group. The r a t i o n a l e f o r t h i s h y p o t h e s i s i s the same as i n Hypotheses 3. I t i s more f i n e l y focused to be concerned with j u s t one g o a l . I f c l i e n t s i d e n t i f y a g o a l as "most important", i t i s c o n c e i v a b l e that they w i l l work harder on that one than on o t h e r s . The present h y p o t h e s i s focuses on which treatment produces the most change with regard to the goal the c l i e n t determines as "most important". 83 Hypothesis 5 There i s no d i f f e r e n c e between the GASP qroup and the non-equivalent c o n t r o l qroup on the mean p o s t t e s t scores o f the Rotter I n t e r n a l - E x t e r n a l Locus of C o n t r o l S c a l e . As was s t a t e d e a r l i e r , the GASP i d e n t i f i e s s m a l l , c l e a r , and concrete steps of proqress toward a g o a l . As c l i e n t s move both throuqh the GASP i t s e l f and toward t h e i r d e s i r e d q o a l s , as i d e n t i f i e d on the T a r q e t Outcome Assessment Sheet, i t i s reasonable to assume t h a t they w i l l experience more r e s p o n s i b i l i t y f o r t h e i r l i f e s i t u a t i o n s . One could expect that people would see t h e i r behavior as more determined by t h e i r own thouqhts and f e e l i n q s , r a t h e r than by f a t e or "bad karma," or some o u t s i d e i n f l u e n c e . In t h i s e v a l u a t i o n i t i s a p p r o p r i a t e to determine i f one p a r t i c u l a r treatment q i v e s the c l i e n t a q r e a t e r i n t e r n a l l o c u s of c o n t r o l . The present hypothesis focuses on which treatment produces more i n t e r n a l i t y i n c l i e n t s . Hypothesis 6 There are no d i f f e r e n c e s between the GASP qroup and the non-equivalent c o n t r o l qroup mean p o s t t e s t s c o r e s on the f o l l o w i n q f i v e s u b s c ales o f the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e : a. Factor C, eqo s t r e n q t h b. F a c t o r E, a s s e r t i v e n e s s c. Factor F, surqency 84 d . Factor 0, g u i l t e. F a c t o r Q^, a n x i e t y . C a t t e l l (1966) and C a t t e l l , Eber and Tatsuoka (1970) pointed out that people showed improvement on f i v e o f the sub s c a l e s of the Sixteen P e r s o n a l i t y Factor Q u e s t i o n n a i r e when therapy was s u c c e s s f u l . Therefore the same f i v e s u b s c a l e s o f the Sixte e n P e r s o n a l i t y Factor Q u e s t i o n n a i r e were chosen i n t h i s r e s e a r c h because they seemed to i n d i c a t e what occurred i n the GASP. I t was thought that the GASP would decrease a n x i e t y and g u i l t and at the same time i n c r e a s e e n t h u s i a s m , s e l f - d i r e c t i o n , and a s s e r t i v e n e s s . While t h i s t h i n k i n g was the main c o n s i d e r a t i o n f o r s e l e c t i n g the Sixteen P e r s o n a l i t y Factor Q u e s t i o n n a i r e , i t was a l s o important that the instrument be r e l i a b l e , and quick and easy f o r c l i e n t s to mark. The Sixte e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e met these c r i t e r i a . The assumptions f o r the d e s i r e d change on the f i v e sub-s c a l e s l i s t e d above are as f o l l o w s : As the c l i e n t s c l a r i f y t h e i r e x p e c t a t i o n s and go a l s f o r the f u t u r e , they l i k e l y w i l l f e e l l e s s anxious about t h e i r l i f e s i t u a t i o n . As c l i e n t s e x e r c i s e t h e i r d e c i s i o n s and choices f o r c o n t r o l of t h e i r s i t u a t i o n s , i n c r e a s e s i n a s s e r t i v e n e s s are a n t i c i -pated. With a concrete l i f e focus such as the GASP p r o v i d e s v i a small s e q u e n t i a l steps, i t i s l o g i c a l to expect t h a t c l i e n t s ' enthusiasm f o r both themselves and l i f e i n general should r i s e as each step i s a t t a i n e d . Concomitantly, as 85 c l i e n t s becomes more s e l f - c o n f i d e n t , r e s i l i e n t , and e n t h u s i -a s t i c , and l e s s anxious as t h e i r g o a l s are a t t a i n e d , l e s s time should be spent worrying about "where I went wrong" or the g u i l t of past mistakes. Hypothesis 7 There i s no d i f f e r e n c e between the experimental (GASP) group and the non-equivalent c o n t r o l group mean l e n g t h s o f stay i n the h o s p i t a l . In a d d i t i o n to the t h e o r e t i c a l and b e h a v i o r a l reasons f o r choosing the GASP, the r e l a t i v e expense o f the two procedures i s a l s o important. bo the treatments cost the same i n terms o f e f f e c t i v e n e s s and e f f i c i e n c y ? On t h i s i s s u e of a c c o u n t a b i l i t y , length of h o s p i t a l i z a t i o n speaks to e f f i c i e n c y of treatment. As people i d e n t i f y a p p r o p r i a t e l i f e g o a l s and a t t a i n those goals v i a a concrete l i f e f o c us, i t i s expected that they w i l l move through treatment f a s t e r . An attempt was made to a s c e r t a i n under which treatment c l i e n t s were d i s c h a r g e d more q u i c k l y . S i g n i f i c a n c e l e v e l s There are two kinds of e r r o r s that have to be guarded against when t e s t i n g any h y p o t h e s i s : Type I and Type I I . The former e r r o r suggests a d i f f e r e n c e when none e x i s t s . The l a t t e r e r r o r suggests there i s no d i f f e r e n c e when i n f a c t a d i f f e r e n c e does e x i s t . 86 Every r e s e a r c h e r must comprehend the degree of r i s k i m p l i c i t i n these e r r o r s . For example, i n a study i n v o l v i n g an e v a l u a t i o n of the s t r e s s on metal under f l i g h t c o n d i -t i o n s , i t would be wise to maintain the c o n s e r v a t i v e l e v e l s of s i g n i f i c a n c e . A Type I e r r o r could be very expensive, i f not c a t a s t r o p h i c ; the a c t u a l use of a metal t h a t cannot withstand s t r e s s i n an a i r c r a f t could r e s u l t i n a c r a s h and l o s s of human l i f e . However, i n s e t t i n g a c o n s e r v a t i v e alpha l e v e l , .001, the p r o b a b i l i t y of a Type I I e r r o r i n c r e a s e s . That i s the r e s e a r c h e r i s more l i k e l y to r e j e c t metal that would a c t u a l l y do the job p r o p e r l y . The present e v a l u a t i o n , however, does not i n v o l v e the same k i n d s of r i s k s as the above example, because the q u e s t i o n beinq asked i s : "Is h o s p i t a l i z a t i o n with the GASP e f f e c t i v e ? " Since t h i s i s an e x p l o r a t o r y e v a l u a t i o n of the GASP, i t i s suqqested that the e v a l u a t i o n should be as broad as p o s s i b l e i n order to determine p o t e n t i a l areas f o r f u t u r e r e s e a r c h . C o n s i d e r i n q the c o s t of the Type I and Type I I e r r o r s , the alpha l e v e l was s e t at the c o n v e n t i o n a l .05 f o r the f i n a l comparative e v a l u a t i o n s , and at .25 f o r the c o n t r o l e v a l u a t i o n s . By lowerinq the p r o b a b i l i t y of a Type I I e r r o r with t h i s l a r q e r (.25) alpha l e v e l , one i s reasonably sure i f no d i f f e r e n c e s are found, no d i f f e r e n c e s e x i s t ; the qroups are e q u i v a l e n t at the p r e t e s t . 87 A f t e r the GASP had been s t a n d a r d i z e d , the e v a l u a t i o n was conducted. The formal t e s t i n g and i t s r e s u l t s are the s u b j e c t of the f o l l o w i n g c h a p t e r s . 88 CHAPTER IV EVALUATION METHOD Comparative e v a l u a t i o n of the GASP As a p r e l i m i n a r y e v a l u a t i o n of the v i a b i l i t y o f the GASP as a p s y c h i a t r i c treatment method, the e f f e c t i v e n e s s o f p s y c h i a t r i c h o s p i t a l i z a t i o n with the GASP and p s y c h i a t r i c h o s p i t a l i z a t i o n without the GASP were compared. The mean performances of each qroup were compared on three dependent measures (The S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e , R o t t e r ' s Locus of C o n t r o l S c a l e , and the Target Outcome Assessment Sheet), toqether with the lenqth of time c l i e n t s stayed i n h o s p i t a l under each treatment procedure. The f o l l o w i n q i s a d i s c u s s i o n of the method used i n makinq these comparisons. Design An a d a p t a t i o n o f t h e n o n - e q u i v a l e n t c o n t r o l group qu a s i - e x p e r i m e n t a l design (Campbell & S t a n l e y , 1963, p. 42) was employed i n the e v a l u a t i o n . T h i s d e s i g n was chosen because random assignment of s u b j e c t s to treatment was not 89 p o s s i b l e . F u r t h e r , a second comparable h o s p i t a l was• not a v a i l a b l e . Both groups had to use the same f a c i l i t y . The p h y s i c a l s t r u c t u r e of the u n i t l i m i t e d the number of people t h a t could be t r e a t e d at any one time. Even i f there had been a d d i t i o n a l bed space, i t would not have been p o s s i b l e to i s o l a t e both groups t o t a l l y . The contact with each o t h e r would have r e s u l t e d i n contamination. Therefore one group was seen dur i n g one t r i a l p e r i o d , the second was seen d u r i n g the second t r i a l p e r i o d , as shown i n Fig u r e 2. F i g u r e 2 A c t u a l design GASP group n=16 01 X 1 02 Non-equivalent c o n t r o l group n = 16 01 X 2 02 n = Sample s i z e 01 = p r e t e s t 02 = p o s t t e s t X 1 = GASP i n t e r v e n t i o n of 8 days (May 1 to June 15) X 2 = normal ward a c t i v i t y ( J u l y 1 to August 15) 90 Group one, the GASP group, c o n s i s t e d of the f i r s t 16 p e o p l e who v o l u n t a r i l y sought treatment i n May and June of 1977. Group two, the non-equivalent c o n t r o l group, was composed of the f i r s t 16 people who v o l u n t a r i l y sought treatment i n J u l y and August of 1977. The GASP was made a v a i l a b l e to the May and June group o n l y . In a l l other r e s p e c t s the groups were t r e a t e d the same. The groups were s i m i l a r i n the r e c r u i t -ment procedure ( v o l u n t a r y ) and i n p s y c h o l o g i c a l c o m p o s i t i o n (twice as many n e u r o t i c s as p s y c h o t i c s ) . T h i s design attempts to c o n t r o l f o r the i n f l u e n c e s of h i s t o r y , m a t u r a t i o n , t e s t i n g , and i n s t r u m e n t a t i o n (Campbell & S t a n l e y , 1963). Thus, i f any d i f f e r e n c e s are noted at the p o s t t e s t , t h e y a r e not u s u a l l y a t t r i b u t e d t o s p e c i f i c e x t e r n a l events between the p r e t e s t and p o s t t e s t s . However, the design employed was an a d a p t a t i o n of the n o n - e q u i v a l e n t c o n t r o l group d e s i g n . The treatment and the c o n t r o l group c o u l d not run c o n c u r r e n t l y . T h i s a d a p t a t i o n c o u l d be c r i t i c i z e d with r e s p e c t to h i s t o r y , Hawthorne e f f e c t , and the i n t e r a c t i o n of treatment and t h e r a p i s t b i a s . In order to i n s u r e the pre-treatment e q u i v a l e n c e s of t h e two g r o u p s f u r t h e r , t h e c o m p a r a b i l i t y o f p r e t e s t measures of both groups was e v a l u a t e d . The p r e t e s t s were f i v e s c a l e s of the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e , the Rotter Locus of C o n t r o l S c a l e , and the Target Outcome Assessment Sheet. Due to the s h i f t i n the m o d i f i e d n o n - e q u i v a l e n t c o n t r o l group d e s i g n , an a d d i t i o n a l check on f a c t o r s t h a t might 91 i n f l u e n c e the v a l i d i t y o f the r e s u l t s was gained by using the Ward Atmosphere S c a l e . Although both the experimental group and the non-equivalent c o n t r o l group were conducted r e l a t i v e l y c l o s e to each o t h e r , they were not conducted at p r e c i s e l y the same time. The Ward Atmosphere Scale was employed to d e t e c t any s u b t l e i n f l u e n c e s of h i s t o r y and to assess whether or not both environments were comparable. Instruments Ward Atmosphere S c a l e The Ward Atmosphere S c a l e , which i n c o r p o r a t e d Murray's need-press model o f the i n d i v i d u a l and environment, was s e l e c t e d because i t i s the most widely used and researched environmental instrument a v a i l a b l e . Designed to measure the shared environmental p e r c e p t i o n s of p s y c h i a t r i c treatment s e t t i n g s , the s c a l e c o n s i s t s of ten s u b s c a l e s from nine to twelve items each. The items d e s c r i b e t y p i c a l behaviors on p s y c h i a t r i c wards. C l i e n t s are asked to i n d i c a t e whether the items are true or f a l s e f o r t h e i r ward. (See Appendix D.) There are t h r e e s c a l e s ( s u p p o r t , i n v o l v e m e n t , and s p o n t a n e i t y ) t o measure r e l a t i o n s h i p v a r i a b l e s . Four s c a l e s , (autonomy, p r a c t i c a l o r i e n t a t i o n , p e r s o n a l problem o r i e n t a t i o n , and anger) assess aspects of the treatment program. The f i n a l three s c a l e s ( o r d e r , c l a r i t y , and s t a f f c o n t r o l ) measure v a r i a b l e s i n a d m i n i s t r a t i o n s t r u c t u r e . 92 The scores of a l l c l i e n t s on the ward are averaged and the mean used as an index of environmental p r e s s . Moos (1974) assumed that a measure of consensual p e r c e p t i o n i s more accurate than s u b j e c t i v e i n d i v i d u a l p e r c e p t i o n s . The Ward Atmosphere S c a l e S u b s c a l e s have adequate i n t e r n a l c o n s i s t e n c y and t e s t - r e t e s t r e l i a b i l i t y . S t e r n (1970) c a l c u l a t e d i n t e r n a l c o n s i s t e n c i e s by u s i n q the a v e r a q e w i t h i n proqram v a r i a n c e s f o r the items. He i n d i c a t e d t h a t the i n t e r n a l c o n s i s t e n c i e s are a l l w i t h i n an a c c e p t a b l e r a n q e , v a r y i n q from moderate ( S p o n t a n e i t y a t .55) t o moderately stronq (Involvement at .78). Stern's (1970) t e s t - r e t e s t r e l i a b i l i t i e s of 42 c l i e n t s a f t e r one week of therapy ranqed from .68 f o r P r a c t i c a l O r i e n t a t i o n to .83 f o r Personal Problem O r i e n t a t i o n . A t e s t - r e t e s t p r o f i l e of s t a b i l i t y , obtained by c a l c u l a t i n g i n t e r c l a s s c o r r e l a t i o n s on standard scores of the d i f f e r e n t a d m i n i s t r a t i o n s on each proqram, ranqe from .92 a f t e r one week throuqh .76 a f t e r one to two months to .77 at four to seven months ( S t e r n , 1970). Very few i f any of the same c l i e n t s were t e s t e d on both occasions when the t e s t - r e t e s t i n t e r v a l s were s i x months or more. T h i s would i n d i c a t e that the Ward Atmosphere S c a l e measures aspects of the treatment environment t h a t may remain s t a b l e even with a complete turnover i n c l i e n t p o p u l a t i o n . P i e r c e , T r i c k e t t , and Moos (1972) demonstrated that the Ward Atmosphere Scale i s s e n s i t i v e t o chanqes i n ward treatment proqrams. In t h e i r study, the Ward Atmosphere 93 S c a l e was f i r s t used as a d i a g n o s t i c p r e t e s t . Subsequently, the environment was manipulated to r a i s e some s c o r e s and lower o t h e r s . P o s t t e s t i n g with the Ward Atmosphere S c a l e demonstrated t h a t s i g n i f i c a n t changes had o c c u r r e d i n the a p p r o p r i a t e d i r e c t i o n s . In the present e v a l u a t i o n , the Ward Atmosphere S c a l e was a d m i n i s t e r e d three times at V a l l e y General H o s p i t a l i n an e f f o r t to assess p o s s i b l e t h r e a t s to i n t e r n a l v a l i d i t y from three s o u r c e s : h i s t o r y , the Hawthorne e f f e c t , and the i n t e r a c t i o n of treatment and t h e r a p i s t s . The s c a l e was a d m i n i s t e r e d i n January before the r e s e a r c h began; i n June, when the f i r s t phase of the research c o r r e s p o n d i n g to the use of the GASP had been i n o p e r a t i o n f o r one month; and again i n August, when the second phase of the r e s e a r c h had been in o p e r a t i o n f o r one month. (See F i g u r e 1, p. 78) H i s t o r y i n c l u d e d the s p e c i f i c events t h a t o c c u r r e d between the f i r s t and second treatment c o n d i t i o n s (Campbell & S t a n l e y , 1963). H i s t o r y was an important c o n s i d e r a t i o n s i n c e both treatment groups were not being o f f e r e d at the same time. I f there were no s i g n i f i c a n t d i f f e r e n c e s d u r i n g the i n t e r v a l s among January, June, and August as measured by the Ward Atmosphere S c a l e , the events of h i s t o r y d i d not s i g n i f i c a n t l y a f f e c t the environmental p r e s s . O c c a s i o n a l l y the e f f e c t s t h a t are shown i n r e s e a r c h stem from the e v a l u a t i o n process i t s e l f (Campbell & S t a n l e y , 1963). That i s , the environment may exert a s u b t l e d i f f e r -ence by v i r t u e of the way i n which the experiment i s 94 designed. The e v a l u a t i o n may be o b t r u s i v e . N o n - s i g n i f i c a n t d i f f e r e n c e s between the three t e s t p e r i o d s using the Ward Atmosphere S c a l e would demonstrate t h a t the environmental press was about the same whether or not the p s y c h i a t r i c u n i t was i n v o l v e d with an e v a l u a t i o n e f f o r t . Psychotherapy r e s e a r c h may be c r i t i c i z e d because the t h e r a p i s t and treatment combine i n a unique way. T h i s unique combination may be what accounts f o r the chanqes. A d i f f e r e n t t h e r a p i s t would not produce the same r e s u l t s . T h i s e v a l u a t i o n was not l i k e l y t o have a t h e r a p i s t b i a s because of the t h e r a p i s t s ' r o t a t i n q work hours. However i t could be p o s s i b l e that t h i s therapy team could be under p a r t i c u l a r p r e s s u r e s to a s s i s t or to undermine a r e s e a r c h e f f o r t . I t was expected t h a t i f the therapy team d i d experience such pressure around the r e s e a r c h i s s u e s , the p r e s s u r e would be d e m o n s t r a t e d i n the e n v i r o n m e n t and measured by the Ward Atmosphere S c a l e . N o n - s i q n i f i c a n t d i f f e r e n c e s amonq the three t e s t p e r i o d s using the Ward Atmosphere S c a l e d e m o n s t r a t e t h a t whatever th e team's f e e l i n g s about th e t h e r a p y , t h i s i n t e r a c t i o n d i d not s i g n i f i c a n t l y a l t e r the c l i e n t s ' p e r c e p t i o n of the e n v i r o n -ment. 95 The Target Outcome Assessment Sheet The Target Outcome Assessment Sheet (TOAS) was d e v e l -oped f o r the purpose of t h i s study to provide b e h a v i o r a l c r i t e r i a f o r d e t e r m i n i n g change r e s u l t i n g i n t h e r a p y . Derived from Smith's (1974) Outcome Assessment Sheet, i t i s i n essence the "expected outcome" p o r t i o n o f the Goal Attainment Scale followup guide (Kiresuk & Sherman, 1968). A s t a f f member asks the c l i e n t what the problems are th a t brought him/her to the h o s p i t a l , and what s/he expects to be d i f f e r e n t i n each area at the end of t h i s h o s p i t a l i z a -t i o n . The c l i e n t ' s present l e v e l of f u n c t i o n i n g i s a l s o recorded. This was the so l e agenda of what was c a l l e d an I n i t i a l Treatment Conference. T h i s meeting took p l a c e w i t h i n 24 hours of admission (See Fig u r e 3 ) . FIGURE 3 Test s A d m i n i s t r a t i o n Schedule I n i t i a l Treatment Conference Within E i g h t Days A f t e r Upon Admission 24 Hours of Admission Goal I d e n t i f i c a t i o n 16 PF TOAS 16 PF Locus of C o n t r o l Locus of C o n t r o l TOAS At p o s t - t r e a t m e n t , the c l i e n t i s asked t o r e p o r t h i s / h e r behavior i n each of the o r i g i n a l concern areas. I f h i s / h e r behavior has not reached the expected l e v e l , the c l i e n t i s asked to c l a s s i f y the behavior i n one of the fou r 96 remaining c a t e g o r i e s : worse, much worse, b e t t e r , or much b e t t e r . T h i s f i v e - p o i n t s c a l e i s scored i n the same manner as the Goal Attainment Scale follow-up guide. Since a l l the c l i e n t s began at the same l e v e l (-1, l e s s than expected l e v e l of s u c c e s s ) , any prescore a n a l y s i s would have y i e l d e d the same means, with zero v a r i a n c e . Therefore the number o f g o a l s was analyzed to see i f there was any d i f f e r e n c e based on the number of g o a l s i n d i v i d u a l s i d e n t i f i e d . The p o s t -scores were analyzed to determine i f , there had been any d i f f e r e n t i a l attainment of g o a l s . The R o t t e r I n t e r n a l - E x t e r n a l Locus of C o n t r o l S c a l e In Smith's (1974, 1976) work, one o f the measures employed f o r outcome was the N o w i c k i - S t r i c k l a n d Locus of C o n t r o l Scale f o r C h i l d r e n . In t h i s r e s e a r c h an outcome measure that was more a p p l i c a b l e to a d u l t s was needed. The Rotter I n t e r n a l - E x t e r n a l Locus of C o n t r o l Scale ( R o t t e r , 1966) was s e l e c t e d . The Rotter Locus of C o n t r o l Scale was used to measure the degree to which people b e l i e v e d t h e i r behavior was determined by other people and e x t e r n a l events. As mention-ed e a r l i e r , i f most d e c i s i o n s were seen as being determined by e x t e r n a l events, i t was s a i d that that person had an e x t e r n a l l o c u s of c o n t r o l . People were s a i d to have an i n t e r n a l l o c u s of c o n t r o l i f t h e i r behavior was determined by t h e i r own thoughts and f e e l i n g s (Rotter, 1966). 97 The R o t t e r I n t e r n a l - E x t e r n a l Locus of C o n t r o l Scale (See Appendix F) i s composed of 23 i n t e r n a l - e x t e r n a l items and s i x f i l l e r items. Researchers (Scheek, 1973; Stephens, 1972) have used the I n t e r n a l - E x t e r n a l Locus of C o n t r o l Scale with a d u l t p o p u l a t i o n s ranging from s c h i z o p h r e n i c through normal. The t e s t has i n d i c a t e d a r e l a t i o n s h i p between the concept of i n t e r n a l i t y / e x t e r n a l i t y and a v a r i e t y of behav-i o r s , i n c l u d i n g l e a r n i n g s i t u a t i o n s , conformity s i t u a t i o n s , r i s k t a k i n g , d i f f e r e n c e among known groups, changes i n a t t i t u d e s , s k i l l and chance rewards, r e s i s t a n c e t o sug-g e s t i o n , and attempts to c o n t r o l the environment. T e s t -r e t e s t r e l i a b i l i t y was .79 a t 14 days ( R o t t e r , 1966). O p e r a t i o n a l l y , the locus o f c o n t r o l i s d e f i n e d as the score on the Locus o f C o n t r o l Scale ( R o t t e r , 1966). A lower score means more i n t e r n a l ; a higher score means more e x t e r n a l . The S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e The S i x t e e n P e r s o n a l i t y F a c t o r y Q u e s t i o n n a i r e was used t o t e s t v a r i o u s a s p e c t s o f a c t u a l p e r s o n a l i t y change. C a t t e l l , Eber, and Tatsuoka (1970) have demonstrated t h a t f i v e of the 16 f a c t o r s are a p p l i c a b l e f o r o s y c h a i t r i c i n -p a t i e n t s . In other words, f i v e o f these f a c t o r s u s u a l l y change as a r e s u l t of psychotherapy. The f i v e f a c t o r s a r e : Ego s t r e n g t h ( F a c t o r C), A s s e r t i v e n e s s ( F a c t o r E ) , Surgency (Factor F) , G u i l t proneness (Fa c t o r 0 ) , and Anxie t y ( F a c t o r Q 4) . Ego s t r e n g t h r e f e r s to p e r s o n a l i t y i n t e g r a t i o n or m a t u r i t y and i s o p e r a t i o n a l l y d e f i n e d as the t o t a l F a c t o r C 98 s c o r e . A s s e r t i v e n e s s i s the expression of what one wants and i s o p e r a t i o n a l l y d e f i n e d as the t o t a l F a c t o r E s c o r e . Surgency means enthusiasm and i s o p e r a t i o n a l l y d e f i n e d as the t o t a l F a c t o r F s c o r e . G u i l t proneness i s the f e e l i n g one has a f t e r doing wrong and i s o p e r a t i o n a l l y d e f i n e d as the t o t a l F a c t o r 0 s c o r e . Anxiety i s the a f f e c t i v e s t a t e o f f e e l i n g uneasy, apprehensive, and worried. O p e r a t i o n a l l y i t i s d e f i n e d as the t o t a l F a c t o r Q 4 s c o r e . (See Appendices F and G f o r t e s t . ) The S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e was o r i g i n a l l y developed by C a t t e l l (1950a) and r e v i s e d to i t s f i n a l form by C a t t e l l , Eber, and Tatsuoka (1970). Norms f o r the S i x t e e n P e r s o n a l i t y F a c t o r Questionnaire were drawn from 3,600 people who represented the American census p o p u l a t i o n at l a r g e almost e x a c t l y according to area r e p r e s e n t a t i o n , p o p u l a t i o n d e n s i t y , age group, and f a m i l y income groups. The t e s t - r e t e s t r e l i a b i l i t i e s at seven days were 0.74 f o r C, 0.85 f o r E, 0.87 f o r F, 0.79 f o r 0, and 0.91 f o r Q 4. At two months the t e s t - r e t e s t scores were: 0.75, 0.84, 0.78, 0.77, 0.78, r e s p e c t i v e l y . Evidence of i t s c o n s t r u c t v a l i d i t y was provided i n terms o f c o r r e l a t i o n s with the MMPI s c a l e s : between C and m a s c u l i n e - f e m i n i n e , 0.95; between E and i n t r o v e r s i o n - e x t r o v e r s i o n , 0.93; between F and hypomania, 0.91; between 0 and p a r a n o i a , 0.84; and between Q^ and a n x i e t y , 0.93. 99 Procedure S u b j e c t s Of the 80 c l i e n t s admitted during the d u r a t i o n of the e v a l u a t i o n (May-August), 55 c l i e n t s agreed to p a r t i c i p a t e i n the e v a l u a t i o n . The a t t r i t i o n was a t t r i b u t e d to e i t h e r the c l i e n t ' s r e f u s a l o r , f o r those who wanted to remain i n the study, f a i l u r e to meet t h i s e v a l u a t i o n ' s requirement of e i g h t days h o s p i t a l i z a t i o n a f t e r i d e n t i f y i n g g o a l s . A l l a c c e p t e d s u b j e c t s had the a p p r o v a l o f t h e i r a d m i t t i n g p s y c h i a t r i s t s and a l l signed an informed consent l e t t e r . (See Append ix H.) The f i n a l sample included two n e u r o t i c c l i e n t s f o r every p s y c h o t i c c l i e n t , a r a t i o which r e f l e c t e d the composi-t i o n of the 1200 c l i e n t s the h o s p i t a l had t r e a t e d over the p r e v i o u s 24 months. Of these 1200, 395 were p s y c h o t i c and 805 were n e u r o t i c . The a s s i g n i n g of a " p s y c h o t i c " designa-t i o n to a c l i e n t upon admission was based on the d i a g n o s t i c c r i t e r i a o f the World H e a l t h O r g a n i z a t i o n . The term p s y c h o t i c : ... i n c l u d e s those c o n d i t i o n s i n which impairment of mental f u n c t i o n s has developed to the degree t h a t i t i n t e r f e r e s g r o s s l y with i n s i g h t , a b i l i t y to meet some o r d i n a r y demands of l i f e . o r adequate co n t a c t with r e a l i t y . It i s not an exact or w e l l d e f i n e d term. Mental r e t a r d a t i o n excluded. (World Health O r g a n i z a t i o n , 1974, p. 19) 100 The a s s i g n i n g of a " n e u r o t i c " d e s i g n a t i o n to a c l i e n t upon admission was a l s o based on the d i a g n o s t i c c r i t e r i a o f the World Health O r g a n i z a t i o n . The term n e u r o t i c : ... i n c l u d e s mental d i s o r d e r s without any demon-s t r a b l e o r g a n i c b a s i s i n which the c l i e n t may have c o n s i d e r a b l e i n s i g h t and u n i m p a i r e d r e a l i t y t e s t i n g , i n that he u s u a l l y does not confuse h i s morbid s u b j e c t i v e experiences and f a n t a s i e s with e x t e r n a l r e a l i t y . B e h a v i o r may be g r e a t l y a f f e c t e d , a l t h o u g h r e m a i n i n g w i t h i n s o c i a l l y a c c e p t a b l e l i m i t s , but p e r s o n a l i t y i s not d i s -o r g a n i z e d . The p r i n c i p a l m a n i f e s t a t i o n s i n c l u d e e x c e s s i v e a n x i e t y , h y s t e r i c a l symptoms, phobias, o b s e s s i o n a l and compulsive symptoms, and depres-s i o n . Neuroses e x c l u d e p h y s i c a l d i s o r d e r s presumably psychogenic; and non-psychotic mental d i s o r d e r s a s s o c i a t e d with p h y s i c a l c o n d i t i o n s . (World Health O r g a n i z a t i o n , 1974, p. 37). As shown i n Table 1, there were four males and 12 females i n the GASP group, and two males and 14 females i n the non-equivalent c o n t r o l group. The mean age was 35.9 years f o r the GASP group and 36.8 years f o r the non-equiva-l e n t c o n t r o l group. Of the 1200 c l i e n t s seen over the p r e v i o u s two years, 238 were male and 962 were female, with a mean age of 36.5 y e a r s . T h i s 1:4 male/female r a t i o i s c l o s e to the 6:26 r a t i o here. In terms of age, sex, and d i a g n o s i s , the sample of c l i e n t s i n t h i s e v a l u a t i o n was r e p r e s e n t a t i v e of the c l i e n t s who had come to the h o s p i t a l over the previous 24 months. Te s t a d m i n i s t r a t i o n Each c l i e n t was administered the S i x t e e n P e r s o n a l i t y F a c t o r Questionnaire and the Locus of C o n t r o l Scale upon 101 Tabl e 1 C l i e n t C h a r a c t e r i s t i c s GASP Sex Mean Age Age Range Diagnosis Male 4 43.0 28-69 Non-eguivalent C o n t r o l Group Male Sex Mean Age Age Range Diagnosis 2 67. 5 51-84 Female 12 33.6 19- 57 P s y c h o t i c N e u r o t i c Female 14 32.4 20- 52 P s y c h o t i c N e u r o t i c Combined 35.9 1 9-69 6 10 Combined 36. 8 20-84 6 10 admission. These t e s t s were i n d i v i d u a l l y administered to the c l i e n t s i n t h e i r rooms. Wi t h i n 24 hours o f admission a l l c l i e n t s were seen i n an i n i t i a l i n t e r v i e w to determine t h e i r p s y c h o l o g i c a l h i s t o r i e s and goals f o r h o s p i t a l i z a t i o n . T h i s i n t e r v i e w was conducted i n a p r i v a t e c o n s u l t a t i o n room on the u n i t . At t h i s time the Target Outcome Assessment Sheet was completed j o i n t l y by the c l i e n t s and the s t a f f . E i g h t days a f t e r the i n i t i a l i n t e r v i e w the S i x t e e n Person-a l i t y F a ctor Q u e s t i o n n a i r e , the Target Outcome Assessment Sheet, and the Locus of C o n t r o l were r e - a d m i n i s t e r e d as a p o s t t e s t (See Figure 3, p. 95). Subjec t s who withdrew from 102 treatment p r i o r to the p o s t t e s t e i g h t days l a t e r were dropped from the study. (See Appendices I and J.) T-herapists The p s y c h i a t r i c u n i t employed 20 t h e r a p i s t s (13 male, 7 female). The s t a f f was composed of 10 p s y c h o t h e r a p i s t s and 10 p s y c h i a t r i c nurses. A d d i t i o n a l l y , there was an occupa-t i o n a l t h e r a p i s t , a s o c i a l worker, and s i x a d m i t t i n g p s y c h i a t r i s t s . These t h e r a p i s t s had been together as a team f o r three years, and had experience ranging from four to ten yea r s . A l l were t r a i n e d by the re s e a r c h e r i n how to conduct the GASP as d e s c r i b e d i n Chapter I I I . However, the members of the s t a f f had been t r a i n e d i n many approaches to therapy -- p s y c h o a n a l y t i c , g e s t a l t , t r a d i t i o n a l a n a l y s i s , c l i e n t -c e n t e r e d , and e x i s t e n t i a l . The d i v e r s i t y o f t r a i n i n g allowed the t h e r a p i s t s to employ a number of a l t e r n a t i v e s as t h e i r judgment d i c t a t e d , but none used behavior m o d i f i c a t i o n as t h e i r p r i m a r y t h e r a p e u t i c t o o l . I f a n y t h i n g , t h e p h i l o s o p h i c a l o r i e n t a t i o n o f V a l l e y G e n e r a l H o s p i t a l ' s t h e r a p i s t s was away from, not toward, behaviorism. Thus, the chances of the t h e r a p i s t s b i a s i n g i n favor o f the GASP procedure were minimal, and the p o s s i b i l i t y o f the GASP procedures i n f l u e n c i n g other procedures was e q u a l l y u n l i k e -l y . 103 P s y c h i a t r i c u n i t The p s y c h i a t r i c u n i t had a maximum c a p a c i t y f o r 14 c l i e n t s . These c l i e n t s were assigned to p r i v a t e rooms on the u n i t . The c l i e n t ' s room c o n s i s t e d o f a bed, p r i v a t e t o i l e t , and c l o s e t f o r c l o t h e s . No p r i v a t e room had a t e l e v i s i o n , although there was a t e l e v i s i o n room on the u n i t which was a c c e s s i b l e to a l l c l i e n t s . The average number o f s t a f f members a v a i l a b l e per eight-hour s h i f t was f o u r , depending on the number of c l i e n t s . Treatments As mentioned above, two groups were used i n the course of t h i s e v a l u a t i o n , the GASP group and the non-equivalent c o n t r o l group. Both o f these groups were open e n t r y groups. F i g u r e s 4 and 5 show the admission and d i s c h a r g e dates of i n d i v i d u a l s w i t h i n each group. Between June 16 and June 30 no c l i e n t s were e n l i s t e d as e v a l u a t i o n s u b j e c t s . The GASP was terminated when the f i n a l e v a l u a t i o n s u b j e c t was d i s c h a r g e d . To avoid contamination, the non-equivalent c o n t r o l group began o n l y a f t e r c l i e n t s who had had cont a c t with the GASP were discharged from the h o s p i t a l . GASP c o n d i t i o n Every person admitted to the h o s p i t a l during the GASP p a r t i c i p a t e d i n the procedure d e s c r i b e d i n Table 2. Every person admitted f o r treatment during t h i s time took p a r t i n a l l o f the r e q u i r e d a c t i v i t i e s . (Required a c t i v i t i e s are 104 FIGURE 4 Admission and Discharge Dates f o r the GASP Group, May 1 - June 15 June DATES 14 12 10 8 6 4 2 31 29 27 25 23 21 19 17 15 13 11 9 May 7 5 3 1 f — » — i — \ — \ — I — i — I — * — \ r — r 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 C l i e n t Number 105 FIGURE 5 Admission and Discharge Dates f o r the Non-equivalent C o n t r o l Group, J u l y 1 - August 15 DATES 14 1 2 10 8 6 4 August 2 31 29 27 25 23 21 19 1 7 15 13 1 1 9 7 5 3 J u l y 1 -I ' . 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 13 14 1 5 1 6 C l i e n t Number 106 c a p i t a l i z e d and un d e r l i n e d ; i f no time i s l i s t e d i t means t h i s was " f r e e time". On the schedule, "Goals Group" i s w r i t t e n i n place of GASP). S t a f f were t o l d to conduct a l l f a c e t s o f h o s p i t a l i z a t i o n as they u s u a l l y do. The author met with the s t a f f d a i l y to observe t h e i r performance with the GASP and to answer any ques t i o n s they might have had. There were 16 s u b j e c t s . A GASP group c o n s i s t e d of a minimum of four c l i e n t s and two s t a f f members. Non-equivalent c o n t r o l group treatment The n o n - e q u i v a l e n t c o n t r o l c o n d i t i o n c o n s i s t e d o f h o s p i t a l i z a t i o n as o u t l i n e d i n the schedule presented i n Table 3. Every person admitted f o r treatment d u r i n g t h i s time took p a r t i n a l l o f the r e q u i r e d a c t i v i t i e s . (Required a c t i v i t i e s are c a p i t a l i z e d and u n d e r l i n e d ; " f r e e time" was any time p e r i o d not l i s t e d on the Schedule.) S i x t e e n s u b j e c t s were seen. The s i n g l e d i f f e r e n c e between the schedule f o r the GASP group and the non-equivalent c o n t r o l qroup was the presence of the "Goals Group". T h e r a p e u t i c g o a l s were not d i s c u s s e d i n any syst e m a t i c f a s h i o n during the course o f treatment o f the non-equivalent c o n t r o l qroup. (See Table 2.) Within both treatment schedules, c l i e n t s could f i n d f r e e - t i m e . T h i s was true because, with the ex c e p t i o n of the r e q u i r e d a c t i v i t i e s , not a l l c l i e n t s p a r t i c i p a t e d i n the o p p o r t u n i t i e s . During these f r e e - t i m e p e r i o d s , c l i e n t s MONDAY TABLE 2 - GASP DAILY SCHEDULE TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 107 SUNDAY 6:45 Med icat ions 6:45 Med ica t ions 6:45 Med ica t i on s 6:45 Med ica t i on s 6:45 Med ica t i on s 6:45 Med ica t i on s 6:45 Medicat ions 7:30 B reak fas t 7:30 Breakfas t 7:30 B reak fa s t 7:30 B reak fa s t 7:30 B reak fa s t 7:30 B reak fa s t 7:30 Breakfast 8:00-9:00 00MMUN ITY MEET ING 8:00-9:00 00MMUN ITY MEET ING 8:00-9:00 OOMMUN ITY MEET ING 8:00-9:00 OOMMUN ITY MEET ING 8:00-9:00 OOMMUN ITY MEET ING 8:00-9:00 OOMMUN ITY MEET ING 8:00-9:00 OOMMUN ITY MEET ING 9:00-11:30 9:00-11:30 9:00-11:30 9:00-11:30 9:00-11:30 9:00-11:30 9:00-11:30 DDoc to r s Rounds DDoc to r s Rounds DDo c t o r s Rounds DDoc to r s Rounds DDo c t o r s Rounds DDoc to r s Rounds DDoc t o r s Round; 2)Fami ly 4 2) Fam i I y 4 Couples Conf. Couples Conf. w i th Dr. wi th Dr. 2) Fam i I y 4 Couples Conf. with Dr. 2) Fam i Iy 4 Couples Conf. w i th Dr. 2) Fam i I y 4 Couples Conf. w i th Dr. 2) Family 4 2) Fam i I y 4 Couples Conf. Couples Conf. wi th Dr . 11:00-12:00 GOALS GROUP wi th Dr. 11:00-12:00 GOALS GROUP 12:00 Med icat ions 12:15 Lunch 1:00-2:00 12:00 Med i ca t ions 12:15 Lunch 12:45-1:45 Doctors Rounds GOALS GROUP 2:00-2: 50 0CCUPAT ION AL 12:00 Med i c a t i o n s 12:15 Lunch 12:45-1:45 GOALS GROUP 12:00 Med i c a t i o n s 12:15 Lunch 12:45-1:45 GOALS GROUP THERAPY 12:00 Med i ca t ions 12:15 Lunch 12:45-1:45 GOALS GROUP 2:00-2:50 OCCUPAT ION AL THERAPY 12:00 Med i ca t ions 12: 15 Lunch 2:00-2:50 Fam i I y 4 Couples Conference 12: 0C Med icat ions 12:15 Lunch 1:00-1:50 B IBL IQTHERAPY 2:00-2:50 Fam i I y 4 Coup Ies Conference 3:00-4:00 3: 00-4 : 00 3:00-4:00 3:00-4:00 3:00-4:00 2:00-6:00 2:00-8:00 V i s i t i n g Hours* V i s i t i n g Hours* V i s i t i n g Hours* V i s i t i n g Hours* V i s i t i n g Hours* V i s i t i n g Hours* V i s i t i n g Hours* 4:00-4:50 B IBL lOTHERAPY 4:00-4:50 OCCUPAT ION AL THERAPY 4:00-4:50 BIBL 10 . 4 O.T. COMBINED 4:00-4: 50 Fam i Iy 4 Coup Ies Conference 5:00 Med ica t i on s 5:00 Med i ca t i on s 5:00 Med ica t i on s 5:00 Med ica t i on s 5:00 Med ica t i on s 5:00 Med i ca t i on s 5:00 Med ica t i on s .5:00-5:15 CHART REVIEW 5:15 D inner 6:00-8:00 V i s i t i n g Hours* 6:00-8:00 Conferences 4 Scheduled Rounds 8: 15-9: 15 EVEN ING GROUP 10:00 Med i c a t i o n s 5:00-5: 15 CHART REVIEW 5: 1 5 D inner 6:00-8:00 V i s i t i n g Hours* 6:00-8:00 Conferences 4 Scheduled Rounds 8: 15-9: 15 EVEN ING GROUP 10:00 Med i c a t i o n s 5: 00 -5 : ' 5 CHART REV IEW 5: 15 D i nner 6:00-8:00 V i s i t i n g Hours* 6:00-8: 00 Conferences 4 Scheduled Round s 8: 15-9:15 EVEN ING GROUP 10:00 Med i ca t ions 5:00-5:15 CHART REVIEW 5:15 D i nner 6:00-8:00 V i s i t i n g Hours* 6:00-8:00 Conferences 4 Scheduled Rounds 8:15-9:15 EVEN ING GROUP 10:00 Med i c a t i o n s 5:00-5:15 CHART REVIEW 5: 1 5 D inner 6:00-8:00 V i s i t i n g Hours* 6:00-8:00 Conferences 4 Scheduled Rounds 8:15-9:15 EVEN ING GROUP 10:00 Med i ca t ions 5:00-5: 15 CHART REVIEW 5:1 5 D inner 6:00-8:00 Conferences 4 Scheduled Rounds O 8:15-9:15 EVEN ING GROUP 10:00 Med i c a t ions 5:00-5:15 CHART REVIEW 5:1 5 D inner 6:00-8:00 Conferences 4 Scheduled Rounds 8: 15-9: 15 EVEN ING GROUP 10:00 Med i ca t ions 5 TABLE 3 - NON-GASP DAILY SCHEDULE 108 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY 6:45 Med icat ions 6:45 Med ica t i on s 7:30 B reak fa s t 7:30 B reak fa s t 6:45 Med ica t i on s 6:45 Med ica t i on s 6:45 Med ica t ions 6:45 Med ica t i on s 6:45 Med icat ions 7:30 B reak fa s t 7:30 B reak fa s t 7:30 Break fas t 7:30 B reak fa s t 7:30 Breakfas t 8:00-9:00 COMMUN ITY MEET ING 8:00-9:00 COMMUN ITY MEET ING 8:00-9:00 COMMUN ITY MEET ING 8:00-9:00 COMMUN ITY MEET ING 8:00-9:00 COMMUN ITY MEET ING 8:00-9:00 COMMUN ITY MEET ING 8:00-9:00 COMMUN ITY MEET ING 9:00-11:30 9:00-11:30 D D o c t o r s Rounds DDoc to r s Rounds 2) Fam TI y & 2) Fam i I y & 9:00-11:30 9:00-11:30 9:00-11:30 9:00-11:30 9:00-11:30 DDoc t o r s Rounds DDoc to r s Rounds D D o c t o r s Rounds DDoc to r s Rounds D D o c t o r s Rounds Couples Conf. wi th Dr. Couples Conf. w i th Dr. 2) Fam i I y & Couples Conf. w i th Dr. 2) Fam i I y & Couples Conf. w i th Dr. 2) Fam i I y 4 Couples Conf. wi th Dr. 2)Fami ly & Couples Conf. w i t h Dr. 2) Fam i I y 4 Couples Conf. wi th Dr. 12:00 Med i ca t ions 12:00 Med i ca t ions 12:00 Med i c a t i o n s 12:00 Med i c a t i o n s 12:00 Med icat ions 12:00 Med i ca t ions 12:00 Med i ca t ions 12:15 Lunch 12:15 Lunch 12:15 Lunch 12:15 Lunch 12:15 Lunch 12:15 Lunch 12:15 Lunch 1:00-2:00 2:00-2 : 50 Doctors Rounds OCCUPAT IQNAL THERAPY 2:00-2:50 " OCCUPAT IQNAL THERAPY 2:00-2: 50 Fam i Iy & Coup Ies Con ference 1:00-1:50 B IBL IQTHERAPY 2:00-2:50 Fam i I y 4 Coup Ies Conference 3:00-4:00 3:00-4:00 V i s i t i n g Hours* V i s i t i n g Hours* 3:00-4:00 3:00-4:00 3:00-4:00 2:00-8:00 2:00-8:00 V i s i t i n g Hours* V i s i t i n g Hours* V i s i t i n g Hours* V i s i t i n g Hours* V i s i t i n g Hours* 4:00-4:50 B IBL lOTHERAPY 4:00-4:50 OCCUPAT IQNAL THERAPY 4:00-4:50 B IBL 10 . & O.T. 'COMB IN ED 4:00-4: 50 Fam i I y 4 Coup I es Conference o 00 5: 00 Med icat ions 5: 00 Med icat ions 5: 00 Med i ca t ions 5: 00 Med i ca t ions 5: 00 Med icat ions 5: 00 Med i ca t ions 5: 00 Med i ca t ions 5:00-5:15 CHART REVIEW 5:00-5:15 CHART REVIEW 5:00-5:15 CHART REVIEW 5:00-5:15 CHART REVIEW 5:00-5: 15 CHART REVIEW 5:00-5: 15 CHART REVIEW 5:00-5:15 CHART REVIEW 5: 15 D inner 5: 15 D i nner 5: 1 5 D inner 5: 1 5 D inner 5:1 5 D inner 5:1 5 D inner 5:1 5 D inner 6:00-6:00 V i s i t i n g Hours* 6:00-8:00 Conferences 4 Scheduled Rounds 6:00-8:00 V i s i t i n g Hours* 6:00-8:00 Conferences 4 Scheduled Rounds 6:00-8:00 V i s i t i n g Hours* 6:00-8:00 Conferences 4 Scheduled Round s 6:00-8:00 V i s i t i n g Hours* 6:00-8:00 Conferences 4 Scheduled Round s 6:00-8:00 V i s i t i n g Hours* 6:00-8:00 Conferences 4 Sched uIed Round s 6:00-8:00 Conferences 4 Schedu led Rounds 6:00-8:00 Conferences 4 Scheduled Rounds 8: 15-9: 15 EVEN ING GROUP 8:15-9:15 EVEN ING GROUP 8:15-9:15 EVEN ING GROUP 8: 15-9: 15 EVEN ING GROUP 8:15-9:15 EVEN ING GROUP 8: 15-9: 15 EVEN ING GROUP 8: 15-9: 15 EVEN ING GROUP 10:00 Med i c a t i o n s 10:00 Med i ca t ions 10:00 Med icat ions 10:00 Med icat ions 10:00 Med i ca t ions 10: 00 Med i ca t ions 10:00 Med i ca t ions 109 Table 4 A c t i v i t i e s of Non-Equivalent C o n t r o l Group Per cent o f c l i e n t s i n v o l v e d A c t i v i t y i n a c t i v i t y S o c i a l i z e d with o t h e r s 61.5 Alone (watchinq t e l e v i s i o n , r e a d i n q , or s i t t i n q ) 19.2 In conference with e i t h e r p s y c h i a t r i s t or s t a f f member 7.7 On Pass 7.7 Slee p i n q 3.8 Uns u c c e s s f u l s u i c i d e attempt by w r i s t - s l a s h i n q (one person) .1 could be found v i s i t i n q with f a m i l y and f r i e n d s , t a l k i n q with s t a f f or other c l i e n t s , meetinq with p s y c h i a t r i s t s , walkinq on the h o s p i t a l qrounds, beinq on a pass t o conduct p e r s o n a l b u s i n e s s , or s l e e p i n g . For the non-equivalent c o n t r o l qroup, the author monitored the c l i e n t s ' a c t i v i t i e s by s t a t i o n i n q h i m s e l f i n the c e n t r a l area of the u n i t d u r i n g the usual hour of the GASP. These a c t i v i t i e s are l i s t e d i n Table 4. S t a f f members were a v a i l a b l e f o r c o n s u l t a t i o n whenever a c l i e n t asked. T h i s procedure was f o l l o w e d f o r two reasons. F i r s t , there i s an e t h i c a l / t h e r a p e u t i c concern t h a t c l i e n t s r e c e i v e as much c o n t a c t with s t a f f as they r e q u i r e d and d e s i r e d . To do otherwise, V a l l e y General 110 H o s p i t a l would have been g u i l t y o f d e n y i n g n e c e s s a r y t r e a t m e n t to t h o s e when t r e a t m e n t c o u l d r e a s o n a b l y be forthcoming. Second, there was a d e s i r e to keep the t h e r a -p e u t i c c o n t a c t time f o r both groups constant. S t a t i s t i c a l A nalyses Data p r e p a r a t i o n A l l t e s t s were hand scored and v e r i f i e d by an a s s i s -t a n t . These scores were then keypunched and 100 per cent v e r i f i e d . F i l e s were c o n s t r u c t e d . C o n t r o l hypotheses A one-way m u l t i v a r i a t e a n a l y s i s of v a r i a n c e was used to examine the environmental press f o r January, June, and August. The 10^dependent v a r i a b l e s corresponded to the 10 subscales of the Ward Atmosphere S c a l e . I n i t i a l d i f f e r e n c e s between the two groups were analyzed using one-way analyses o f v a r i a n c e . A m u l t i v a r i a t e a n a l y s i s , employing Wilk's l i k e l i h o o d r a t i o c r i t e r i o n , was used f o r the f i v e s u b s c a l e s o f the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e . U n i v a r i a t e analyses were conducted f o r the Target Outcome Assessment Sheet and the Locus o f C o n t r o l S c a l e . 111 E v a l u a t i o n hypotheses The r e s u l t s o f the above analyses, presented i n d e t a i l i n the next chapter, r e v e a l e d that at the .25 l e v e l o f s i g n i f i c a n c e t h e r e were no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s among the p r e t e s t p e r i o d i n January and e x p e r i -mental p e r i o d s i n June and August. T h e r e f o r e , i t was decided to analyze the p o s t t e s t r e s u l t s using a one-way a n a l y s i s of v a r i a n c e . Again, a m u l t i v a r i a t e a n a l y s i s was run f o r the f i v e s u b s c ales o f the Si x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e , and u n i v a r i a t e a n a l y s e s f o r the T a r g e t Outcome Assessment Sheet and the Locus of C o n t r o l S c a l e . A l l a n a l y s e s were p e r f o r m e d u s i n g M u l t i v a r i a n c e :  U n i v a r i a t e and M u l t i v a r i a t e A n a l y s e s of V a r i a n c e , C o v a r i - ance, R e g r e s s i o n , and Repeated Measures ( V e r s i o n VI) ( F i n n , 1978). A l l computer analyses were completed on the Amdahl computer at the U n i v e r s i t y of B r i t i s h Columbia. 112 CHAPTER V RESULTS F i r s t , c o n t r o l i s s u e s are examined through an a n a l y s i s of the Ward Atmosphere Scale and of the p r e t e s t scores o f the two groups. The f i v e e v a l u a t i o n q u e s t i o n s are then analyzed. The q u a l i t a t i v e analyses o f the qoals are pre -sented l a s t . In order t o t e s t the v i a b i l i t y o f the GASP, the e f f e c t i v e n e s s of h o s p i t a l i z a t i o n with the GASP was compared t o h o s p i t a l i z a t i o n w i t h o u t the GASP. Th r o u q h o u t the remainder o f t h i s paper, these two qroups w i l l be r e f e r r e d to as the GASP qroup and the non-equivalent c o n t r o l qroup r e s p e c t i v e l y . F u r t h e r , as was mentioned e a r l i e r , a l l hypotheses are i n the n u l l form owninq to a l a c k of research r e s u l t s t h a t would suqqest d i r e c t i o n a l i t y . 113 Comparative E v a l u a t i o n  P r e l i m i n a r y a n a l y s i s of c o n t r o l i s s u e s Hypothesis 1 There i s no d i f f e r e n c e i n the environmental press as measured by the Ward Atmosphere S c a l e i n January, June, and August. The January scores r e p r e s e n t the atmosphere f i v e months before the e v a l u a t i o n began. The June scores are measures on the atmosphere i n the middle of the f i r s t phase of the e v a l u a t i o n when the GASP was employed. The August scores r e f l e c t the atmosphere i n the middle of the second phase, when the GASP was not o f f e r e d . For each of the three t e s t a d m i n i s t r a t i o n s of the Ward Atmosphere S c a l e , n=11. The r e s u l t s of the m u l t i v a r i a t e a n a l y s i s r e v e a l e d that f o r the 10 subscales there were no s i g n i f i c a n t d i f f e r e n c e s among January, June, and August as shown i n Tables 5, 6, and 7. The F - s t a t i s t i c f o r the m u l t i v a r i a t e t e s t of e q u a l i t y was 0.5975, (p < 0.8923). Separate analyses o f v a r i a n c e f o r each v a r i a b l e r e v e a l e d that with the e x c e p t i o n of subscale 2 (support) (F = 2.21; p < .13), a l l other s u b s c a l e s were non-s i g n i f i c a n t at the .25 l e v e l of s i g n i f i c a n c e . Consequently, i t was concluded that there were no s i g n i f i c a n t d i f f e r e n c e s 114 Table 5 Means and Standard D e v i a t i o n s of the Three Test P e r i o d s of the Ward Atmosphere Scale WAS C e l l (Standard C e l l (Standard C e l l (Standard sub- Means Devia t i o n ) Means De v i a t i o n ) Means D e v i a t i o n ) s c a l e s January June August 1 9. 0000 (1 .6733) 8. 4545 (3. 2669 ) 8. 2727 (1. 6788 ) 2 6. 6363 (1 .6293) 7. 1818 (0. 9817 ) 6. 0000 (1. 2650 ) 3 5. 8181 (1 .4709) 5. 0909 (1 . 6404 ) 5. 7272 (1 . 7373 ) 4 5. 4545 (1 .0357) 6. 1818 ( 1. 9909 ) 6. 1818 (0. 6030 ) 5 7. 3636 (1 .1201 ) 7. 3636 (1 . 1201 ) 8. 0000 (0. 7746 ) 6 7. 6363 (0 .8090 ) 7. 0909 ( 1 • 3751 ) 7. 3636 (1. 5015 ) 7 6. 4545 (2 .0181 ) 7. 0000 (1 . 5491 ) 7. 5454 (0. 6876 ) 8 5. 7272 (1 .4894 ) 5. 2727 ( 1. 6181 ) 5. 0000 (2. 2361 ) 9 6. 6363 (1 . 7477 ) 6. 7272 (1 . 5551 ) 5. 7272 (1 • 4206) 10 1 . 7272 ( 1 .0091 ) 1. 0000 (0. 8944 ) 1. 6363 (1. 9633 ) Table 6 M u l t i v a r i a t e A n a l y s i s o f the Ward Atmosphere S c a l e a t January, June, and August Source M u l t i v a r i a t e of F - t e s t V a r i a b i l i t y F df P r o b a b i l i t y Occasion .5975 20 0.8923 Within 42 F _ K(20,42)=1.28 115 Table 7 U n i v a r i a t e A n a l y s i s of Variance of the Ward Atmosphere Subscales V a r i a b l e Mean Square U n i v a r i a t e P r o b a b i l i t y wi t h i n F 1 5.4303 0.2902 0.7503 2 1.7393 2.2125 0.1270 3 2.6242 0.3460 0.9660 4 1.8000 1.0774 0.3533 5 1.0363 1.0819 0.3519 6 1.6000 0.5114 0.6049 7 2.3151 1.4136 0.2591 8 3.2788 0.4529 0.6401 9 2.4970 1.3471 0.2753 10 1.8909 0.9135 0.4121 F (2,30)=1.45 i n the environment among January, June, and August time p e r i o d s . Pre-treatment c o m p a r a b i l i t y of samples Hypothesis 2 There i s no d i f f e r e n c e between the p r e t e s t s c o r e s of the GASP group and the non- e q u i v a l e n t c o n t r o l group on the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n -n a i r e , the R o t t e r I n t e r n a l - E x t e r n a l Locus o f C o n t r o l s c a l e , and the number of g o a l s on the Target Outcome Assessment Sheet. In order to examine whether the two groups of c l i e n t s were compa r a b l e a t the b e g i n n i n g of t h e i r r e s p e c t i v e 116 treatments, t h e i r p r e t e s t scores on both the f i v e subscales of the S i x t e e n P e r s o n a l i t y Factor Q u e s t i o n n a i r e , and the Locus of C o n t r o l Scale were compared. In a d d i t i o n , the number of q o a l s on the Tarqet Outcome Assessment Sheet was examined. "Number o f q o a l s " on the T a r q e t Outcome Assessment Sheet was s e l e c t e d s i n c e a l l c l i e n t s beqan at the -1 l e v e l of success, the l e s s than expected outcome. Conse-quent l y there are no d i f f e r e n c e s i n the Tarqet Outcome Assessment Sheet s i n c e a l l c l i e n t s s t a r t at the same p o i n t . However, i f c l i e n t s had d i f f e r e n t numbers of q o a l s , t h i s d i f f e r e n c e c o u l d be i n f l u e n t i a l . I t c o u l d have been s i g n i f i c a n t t h a t one c l i e n t had one goal f o r therapy, while another had f o u r . For t h i s reason, i t was decided to compare the number of goals each c l i e n t had before t r e a t -ment. For the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e , the F - s t a t i s t i c f o r the m u l t i v a r i a t e t e s t o f e q u a l i t y was 0.6586, with a computed p r o b a b i l i t y of 0.6579 (See Table 9 ) . Aqain, to avoid a Type I I e r r o r , a p r o b a b i l i t y o f .25 was s e l e c t e d . The correspondinq u n i v a r i a t e F's were never g r e a t e r than 1.38 (p < .25) (See Table 10. The h y p o t h e s i s of no s i g n i f i c a n t d i f f e r e n c e s on p r e t e s t s was not r e j e c t e d (See Tables 8, 9, and 10). The groups could be c o n s i d e r e d equal on the subscales of the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e p r e t e s t because o f the n o n - s i g n i f i c a n t d i f f e r e n c e s . 117 Tabl e 8 Means and Standard D e v i a t i o n s of P r e t e s t Scores on the F i v e Subscales of the Sixte e n P e r s o n a l i t y Factor Q u e s t i o n n a i r e C E F 0 GASP C e l l Means 4.1 8 3. 68 6.87 7. 18 6.00 GASP Standard D e v i a t i o n 2.55 1.89 2.30 2.15 2.1 9 Non-E q u i v a l e n t C o n t r o l Group C e l l Means 3.93 4.00 6.12 7. 18 6.56 Non-E q u i v a l e n t C o n t r o l Group Standard D e v i a t i o n 2.03 1.73 2.33 1 .91 1.86 Table 9 M u l t i p l e A n a l y s i s of Variance f o r S i g n i f i c a n t D i f f e r e n c e s Between P r e t e s t Scores on the Si x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e Source M u l t i v a r i a t e of F - t e s t V a r i a b i l i t y F df P r o b a b i l i t y Occasion 0.6586 5 0.6579 Within 26 F ? 5 ( 5 , 2 6 ) = 1.42 Table 10 U n i v a r i a t e F-Ratios of D i f f e r e n c e on the P r e t e s t Scores on the F i v e S u b s c a l e s o f the S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e Hypothesis U n i v a r i a t e Mean Sq. F P r o b a b i l i t y C 0. 50 0. 07 0. 78 E 0.78 0.21 0.64 F 4.50 0.84 0.36 O 3.12 0.67 0.41 Q 4 2.53 0.52 0.47 F > 7 5 ( 1 , 3 0 ) =1.38 118 The two analyses of v a r i a n c e f o r the Target Outcome Assess-ment Sheet and the Locus of C o n t r o l Scale y i e l d e d F-values of .29 and 1.10 r e s p e c t i v e l y . These were not s i g n i f i c a n t when compared to a tabled F 7 5 ( 1 , 3 0 ) = 1 .38 (See Tables 11 and 12). Therefore the two groups were considered to be e q u i v a l e n t on the Target Outcome Assessment Sheet and Locus o f C o n t r o l S c a l e . E v a l u a t i o n Hypotheses Hypothesis 3 There i s no s i g n i f i c a n t d i f f e r e n c e between the GASP and the non-equivalent c o n t r o l group mean p o s t t e s t scores of the Target Outcome Assessment Sheet. The value of the F - s t a t i s t i c corresponding to t h i s h y pothesis was 3.59 (p < 0.067). Thus, the h y p o t h e s i s of no s i g n i f i c a n t d i f f e r e n c e between treatment group and c o n t r o l was not r e j e c t e d (See Table 13). D e l e t i n g Hypothesis 4 I t was hypothesized that there would be a d i f f e r e n c e i n achievement with regard to g o a l s the c l i e n t d e f i n e d upon admission. I t was thought that the c l i e n t might expend more energy on accomplishing what s/he i d e n t i f i e d as the "most important" g o a l , and l e s s on the remaining g o a l s . 11 9 Table 11 Means and Standard D e v i a t i o n s of P r e t e s t Scores on the Locus o f C o n t r o l Scale and the Number of Goals on the Target Outcome Assessment Sheet GASP C e l l Means GASP Standard D e v i a t i o n Non-E q u i v a l e n t C o n t r o l Group C e l l Means Non-E q u i v a l e n t C o n t r o l Group Standard D e v i a t i o n TOAS 3.62 LOC 12.06 0. 72 3.40 3. 75 1 3.56 0. 58 4.59 Table 12 M u l t i v a r i a t e A n a l y s i s o f V a r i a n c e f o r S i g n i f i c a n t D i f f e r e n c e s Between P r e t e s t Score o f the Locus of C o n t r o l S c a l e and the Number o f G o a l s on the T a r g e t Outcome Assessment Sheet TOAS LOC Hypothesis Mean Sq. 0.12 18. 00 U n i v a r i a t e F 0.29 1.10 P r o b a b i l i t y 0.59 0. 30 Table 13 F ? 5(1,30)=1.38 A n a l y s i s of Variance and Means of P o s t t e s t Scores f o r the Target Outcome Assessment Sheet Degrees of Freedom F-Value P r o b a b i l i t y (1,30) 3. 59 0. 067 F > 9 5(1,30)=4.17 Mean P o s t t e s t Score GASP Non-Equivalent C o n t r o l Group 3.05 2.65 120 However, o n l y one person i n both groups i d e n t i f i e d a s i n g l e goal as the "most important". A l l other s u b j e c t s r a t e d every goal as the "most important". Given t h i s f a i l u r e to d i f f e r e n t i a t e among the g o a l s chosen, the hypothesis r e l a t e d to the "most important" goal could not be t e s t e d . Hypothesis 5 There i s no s i g n i f i c a n t d i f f e r e n c e between the GASP group and the non-equivalent c o n t r o l group as measured on the mean p o s t t e s t scores o f the Rotter I n t e r n a l - E x t e r n a l Locus of C o n t r o l S c a l e . The F - s t a t i s t i c r e v e a l e d that there was a s i g n i f i c a n t d i f f e r e n c e i n Locus of C o n t r o l between the group r e c e i v i n g the GASP and the group t h a t d i d not (F = 6.70; p < .01). The GASP group a t t a i n e d a s i g n i f i c a n t l y more i n t e r n a l score on the Rotter I n t e r n a l - E x t e r n a l Locus of C o n t r o l S c a l e than d i d the non-GASP group. (See Table 14). Hypothesis 6 There are no d i f f e r e n c e s between the GASP group and non-equivalent c o n t r o l group mean p o s t t e s t score o f the f o l l o w i n g f i v e s u b s c ales o f the Six t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e : a. F a c t o r C, ego s t r e n g t h . b. Factor E, a s s e r t i v e n e s s ; c. F a c t o r F, surgency or enthusiasm. 121 T able 14 A n a l y s i s of Variance and Means of P o s t t e s t Scores f o r the Locus of C o n t r o l Scale Degrees o f Freedom F-Value P r o b a b i l i t y (1,30) 6.70 0.01 Mean P o s t t e s t Scores Non-Equivalent GASP C o n t r o l Group 6.90 11.00 F > 9 5 ( 1 ,30)=4. 17 d. F a c t o r 0, g u i l t . e. F a c t o r Q^, a n x i e t y . The m u l t i v a r i a t e a n a l y s i s f o r the two groups r e s u l t e d i n an F - s t a t i s t i c of 4.81, which was s i g n i f i c a n t at the .05 l e v e l of s i g n i f i c a n c e . The hypothesis of no s i g n i f i c a n t d i f f e r e n c e s between the GASP and the non-GASP group was r e j e c t e d . T h e r e f o r e , i t was p o s s i b l e to explore f u r t h e r which f a c t o r s were c o n t r i b u t i n g to the s i g n i f i c a n c e (See Table 15). Examination of the u n i v a r i a t e F - r a t i o (Hummel & S l i g o , 1971) corresponding to the f i v e s u b s c a l e s o f the S i x t e e n 122 Table 15 M u l t i p l e A n a l y s i s of Variance f o r P o s t t e s t Scores on the S i x t e e n P e r s o n a l i t y F actor Q u e s t i o n n a i r e . Source M u l t i v a r i a t e o f F - t e s t V a r i a b i l i t y F df P r o b a b i l i t y Occasion 4.8143 5 0.0031 Within 26 F. Q,(5,26) = 1.42 P e r s o n a l i t y F actor Q u e s t i o n n a i r e r e p o r t e d i n Tables 16 and 17 r e v e a l d i f f e r e n c e s i n favor of the GASP on Surgency (F) (F = 5.14; p < .03), and A n x i e t y (Q 4) (F = 8.11; p < .008). F o r the r e m a i n i n g t h r e e t e s t s , the F - v a l u e s were not s i g n i f i c a n t . Hypothesis 7 There i s no s i g n i f i c a n t d i f f e r e n c e between the GASP group and the non-equivalent c o n t r o l group on the mean length of stay i n the h o s p i t a l . The average time i n the h o s p i t a l . f o r the GASP group was 13. 375 days, and the average time i n the h o s p i t a l f o r the non-equivalent c o n t r o l group was 15.5625 days. The d i f f e r -ence between the two groups was 2. 1875 days. T h i s was a 16.3 per cent d i f f e r e n c e . A comparison o f these groups y i e l d e d a t-value of 1.338 with 30 degrees of freedom, (p < .08). The hypothesis of no s i g n i f i c a n t d i f f e r e n c e s between treatment and c o n t r o l group was not r e j e c t e d (See Table 18). 123 Table 16 Means and Standard D e v i a t i o n s f o r Si x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e P o s t t e s t C E F 0 GASP C e l l Means 6.81 5.19 7.75 6.63 5.44 Non-E q u i v a l e n t C o n t r o l Group C e l l Means 5.06 4.75 6. 50 6.63 7. 50 GASP Standard D e v i a t i o n 2. 88 2.07 1. 57 2.55 2.28 Non-E q u i v a l e n t C o n t r o l Group Standard D e v i a t i o n 2.76 1.76 1 . 56 2.00 2.04 F > 9 5(1,30)=4.17 Table 17 A n a l y s i s o f V a r i a n c e f o r S i x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e P o s t t e s t Hypothesis Mean Sq. U n i v a r i a t e F P r o b a b i l i t y C 24.50 3.20 0.08 E 1. 53 0. 05 0.49 F 12.50 5.14 0.03 0 0. 00 0. 00 1.00 °4 34.03 8.1 1 0.008 124 Source GASP Table 18 t-Test R e s u l t s f o r Length of Stay Mean Standard t-Value D e v i a t i o n 13.3750 Non-equivalent C o n t r o l Group 15.5625 4.52953 -1.338 4.71832 t > 9 7 5 ( 3 0 ) = ±2, 04 Table 19 Summary of P o s t t e s t R e s u l t s TOAS LOC Ego A s s e r t . Surg. G u i l t Anxiety Len. S i g n i f i c a n t l y D i f f e r e n t NO YES NO NO YES NO YES NO P r o b a b i l i t y .06 .01 .08 .49 .03 1.00 .008 .08 Summary The r e s u l t s of the p o s t t e s t hypotheses r e v e a l that the GASP group was s i g n i f i c a n t l y more i n t e r n a l on the Locus o f C o n t r o l , higher on the Surgency, and lower on the An x i e t y subscales o f the Si x t e e n P e r s o n a l i t y F a c t o r Q u e s t i o n n a i r e . (See Table 19). 125 CHAPTER VI DISCUSSION AND SUMMARY Summary of R e s u l t s T h i s study has two p a r t s . The f i r s t p a r t was the development of the GASP and the second was the p r e l i m i n a r y e v a l u a t i o n of the GASP. The Development of the GASP The o b j e c t i v e was to develop a s t a n d a r d i z e d , group p r o c e d u r e f o r p a t i e n t s h o s p i t a l i z e d f o r a s h o r t t e r m . L i t e r a t u r e r e l e v a n t to t h i s task came from three a r e a s : b r i e f p s y c h o t h e r a p y , p r o b l e m - s o l v i n g t h e r a p y , and G o a l Attainment S c a l i n g . The a n a l y s i s and s y n t h e s i s of these areas showed that i t was p o s s i b l e to develop a s h o r t - t e r m group procedure. T h i s p r o c e s s , the GASP, c o n s i s t s of the f o l l o w i n g g e n e r a l s t e p s : communicating to the c l i e n t t h a t the task i s to a r t i c u l a t e g o a l s that can be accomplished w i t h i n two weeks; developing a l i s t of events t h a t preceded h o s p i t a l i z a t i o n ; w r i t i n g a l i s t of the f e e l i n g s the c l i e n t e x p e r i e n c e d when the events happened; c o n s t r u c t i n g a l i s t of 126 the c l i e n t ' s s t r e n q t h s that permit them to s u r v i v e t h e i r e m o t i o n a l trauma; l i s t i n g the problems the e v e n t s and f e e l i n g s c r e a t e ; l i s t i n g g o a ls that would so l v e the prob-lems; l i s t i n g what the person can do to make the problem worse and what can be done to a l l e v i a t e the problem; review-ing the c l i e n t ' s progress weekly. The f i r s t o b j e c t i v e , the development of the GASP was achieved. I t was p o s s i b l e to develop a s t a n d a r d i z e d short-term multi-component t h e r a -p e u t i c process f o r groups of c l i e n t s . The P r e l i m i n a r y E v a l u a t i o n of the GASP The s u b j e c t s f o r the p r e l i m i n a r y e v a l u a t i o n were 32 v o l u n t a r i l y h o s p i t a l i z e d p a t i e n t s of the p s y c h i a t r i c u n i t of V a l l e y General H o s p i t a l . They were d i v i d e d i n t o a non-e q u i v a l e n t c o n t r o l group and the GASP qroup. They were administered the Rotter I n t e r n a l - E x t e r n a l Locus of C o n t r o l S c a l e , the Target Outcome Assessment Sheet, and the S i x t e e n P e r s o n a l i t y Factor Q u e s t i o n n a i r e upon admission, and again e i q h t days a f t e r t h e i r i n i t i a l i n t e r v i e w . The r e s u l t s of the p r e l i m i n a r y e v a l u a t i o n were: 1. The environmetal press was found not to be d i f f e r e n t s i x months before the study or durinq both phases of the e v a l u a t i o n . The e m p i r i c a l support f o r e q u i v a l e n t ward atmospheres (Hypothesis 1) meant that the e n v i r o n -ment of the p s y c h i a t r i c u n i t was e s s e n t i a l l y the same s i x months before the r e s e a r c h beqan, and throuqhout the e v a l u a t i o n p e r i o d . The three d i f f e r e n t qroups of 127 c l i e n t s saw the environment as having the same psycho-l o g i c a l p r e s s , whether or not the e v a l u a t i o n was p r e s e n t . A l t h o u g h d i f f e r e n t e v e n t s o c c u r r e d i n January, June, and August, they were not s u f f i c i e n t l y d i f f e r e n t to cause the environments i n the h o s p i t a l at those times to be seen as d i f f e r e n t . Both groups were found not to be s i g n i f i c a n t l y d i f f e r -ent on t h e i r p r e t e s t s c o r e s . Both groups could be considered to have s t a r t e d at e s s e n t i a l l y the same point on t h e i r p r e t e s t s . Three independent r a t e r s rated the c a t e g o r i e s and the d i r e c t i o n of the c l i e n t s ' goals'. There was a 99.5 per cent i n t e r - r a t e r agreement. Ninety per cent of the c l i e n t s ' goals i d e n t i f i e d at admission stayed i n the same c a t e g o r i e s during the GASP. Of t h i s 90 per cent, goals were a l l i n the same d i r e c t i o n 100 per cent of the time. The c o n c l u s i o n here i s that most people know what they have to work on, and never s h i f t d i r e c t i o n . The goals i d e n t i f i e d upon admission are the same as those i d e n t i f i e d d u r i n g the G A S P . The GASP does not a s s i s t the c l i e n t s i n s e l e c t i n g g o a l s , but more f i n e l y d e f i n e s l e v e l s of attainment. Although both groups achieved higher p o s t t e s t scores on t h e i r l e v e l of goal attainment, n e i t h e r was s u p e r i o r i n h e l p i n g c l i e n t s to achieve a l l t h e i r g o a l s f o r h o s p i t a l i z a t i o n . The r e s u l t s f o r Hypothesis 3 showed that there was no d i f f e r e n c e between the two groups i n h e l p i n g c l i e n t s achieve t h e i r goals f o r h o s p i t a l i z a t i o n . Perhaps i f 128 another step were added to the GASP to improve the s p e c i f i c a t i o n of the l e v e l s of success during the GASP, goal attainment would be s i g n i f i c a n t l y h i g h e r . (Since s u b j e c t s f a i l e d to d i f f e r e n t i a t e t h e i r "most important g o a l " , the "most i m p o r t a n t g o a l " h y p o t h e s i s was dropped.) At the p o s t t e s t , the GASP group was s i g n i f i c a n t l y d i f f e r e n t on the i n t e r n a l l o c u s of c o n t r o l when compared to the non-equivalent c o n t r o l group. The s t a t i s t i c a l support f o r Hypothesis 5 i n d i c a t e d that the GASP i s b e t t e r than the non-equivalent c o n t r o l group in inducing a more i n t e r n a l locus of c o n t r o l f o r t h i s sample of c l i e n t s . T h i s increased sense of s e l f c o n t r o l i s in response both to the l e a r n i n g that takes plac e during the GASP, and the l e a r n i n g that the c l i e n t s undergo as the y a c t u a l l y put t h e i r g o a l attainment behaviors i n t o p r a c t i c e . In other words, h o s p i t a l i z a t i o n with the GASP i n f l u e n c e s people to b e l i e v e that they are r e s p o n s i b l e f o r what happens to themselves. The p o t e n t i a l to l e a r n how to understand the use of goals i n t e l l e c t u a l l y and to implement the procedure f o r t h e i r own goals may convince c l i e n t s t h a t they are more r e s p o n s i b l e f o r themselves and t h e i r c o n d i t i o n . At the p o s t t e s t , both groups were not s t a t i s t i c a l l y d i f f e r e n t i n i n c r e a s i n g ego s t r e n g t h . There was no s t a t i s t i c a l support f o r s t a t i n g that the GASP group was d i f f e r e n t than the non-equivalent c o n t r o l group on 129 Factor C, Ego Strength. The above f i n d i n g i s i n t e r -e s t i n g . One would expect that p s y c h i a t r i c h o s p i t a l i z a -t i o n should reduce the c l i e n t ' s s t a t e of c o n f u s i o n . It was i n i t a l l y b e l i e v e d that an a c t u a l l i s t i n g of events, f e e l i n g s , s t r e n g t h s , p r oblems, and g o a l s e n a b l e d c l i e n t s to have an even g r e a t e r u n d e r s t a n d i n g of themselves, but h o s p i t a l i z a t i o n without the GASP a l s o i n v o l v e s c l i e n t s in a f f e c t i v e and b e h a v i o r a l s e l f -examination. The GASP could p o s s i b l y be conducive to p e r m i t t i n g greater p e r s o n a l i t y i n t e g r a t i o n i f i t were expanded. For example, the stren g t h s l i s t could be designed to in c l u d e an e x e r c i s e on p o s i t i v e s e l f -statements. At the p o s t t e s t , both groups, were not s t a t i s t i c a l l y d i f f e r e n t in i n c r e a s i n g a s s e r t i v e n e s s . The data on A s s e r t i v e n e s s , Factor E, pointed out that n e i t h e r group was more a s s e r t i v e than the other. There are s e v e r a l p o s s i b l e e x p l a n a t i o n s f o r t h i s : a s s e r t i v e n e s s i s more complex than merely e x e r c i s i n g d e c i s i o n s and having s e l f - c o n t r o l i n a s i t u a t i o n , and the inc r e a s e d a s s e r -t i v e n e s s may have been a r e s u l t of the c l i e n t s ' p a r t i c i p a t i o n i n other p a r t s of the treatment program. At the p o s t t e s t , the GASP group was s i g n i f i c a n t l y d i f f e r e n t i n Surgency when compared with the non-eq u i v a l e n t c o n t r o l group. For Surgency, Factor F, the data demonstrated that the members of the GASP were s i g n i f i c a n t l y more e n t h u s i a s t i c about themselves than were t h e i r c o u n t e r p a r t s . I t i s suggested that t h i s 130 outcome i s the r e s u l t of the concrete focus the GASP p r o v i d e s . By proceeding i n small s e q u e n t i a l steps, the people's enthusiasm f o r both themselves and l i f e i n general r i s e s as each step i s a t t a i n e d . Psychotherapy should reverse the downward s p i r a l that causes a person to seek therapy in the f i r s t p l a c e . It i s speculated the even gr e a t e r enthusiasm demonstrated with the GASP i s a r e s u l t of the s e q u e n t i a l steps taken toward g o a l s , and of p o s i t i v e f e e l i n g s of s e l f - w o r t h that come from hearing others say what they l i k e about a person. At the p o s t t e s t f o r G u i l t , Factor 0, there was no d i f f e r e n c e between the GASP and the non-equivalent c o n t r o l group. Since both groups t e s t e d lower i n the p o s t t e s t , i t , appears that the other p a r t s of the program worked to lower g u i l t . At the p o s t t e s t f o r A n x i e t y , F a c t o r Q^, there was a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the GASP and the non-equiva1 ent c o n t r o l group. The GASP s u b j e c t s ' p o s t t e s t mean f o r a n x i e t y was lower than t h e i r p r e t e s t mean, while the non-equivalent c o n t r o l group s u b j e c t s p o s t t e s t mean f o r a n x i e t y was a c t u a l l y higher than t h e i r p r e t e s t mean. T h i s outcome appears to be a r e s u l t of GASP s u b j e c t s having a s p e c i f i c framework f o r how they came to seek treatment, what t h e i r problems a r e , and what they are s p e c i f i c a l l y going to do to remedy the s i t u a t i o n . As the c l i e n t s engage t h e i r s p e c i f i c steps and progress toward g o a l s , worry about "what to do" decreases. I t i s apparent 131 t h a t w i t h o u t t h i s type o f c o n c r e t e n e s s , p e o p l e ' s s i t u a t i o n s and problem-solving methods remain vague, and t h i s vagueness may inc r e a s e a n x i e t y , i n s t e a d o f lowerinq i t . 10. T h e re was no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the GASP and the non-equivalent c o n t r o l qroup f o r lenqth o f st a y . The lenqth of GASP h o s p i t a l i z a t i o n was reduced by 16.3 per cent. T h i s d i f f e r e n c e , thouqh not s i q n i f i c a n t , could have f i s c a l i m p l i c a t i o n s f o r p r o v i d i n q t r e a t m e n t . I t would be i n t e r e s t i n q t o examine t h i s hypothesis f o r treatment p e r i o d s d i f f e r e n t than e i q h t days, and/or f o r a time o f study lonqer than s i x weeks. These p r e l i m i n a r y r e s u l t s from the Locus of C o n t r o l S c a l e , and some sub s c a l e s of the Si x t e e n P e r s o n a l i t y Factor Q u e s t i o n n a i r e suqqest t h a t h o s p i t a l i z a t i o n with the GASP showed promise as a t h e r a p e u t i c procedure. The Goal A t t a i n -ment Scale could be modified and i n c o r p o r a t e d i n t o a psycho-t h e r a p e u t i c procedure and i n t e q r a t e d s u c c e s s f u l l y i n t o the t r e a t m e n t m i l i e u o f a s h o r t - t e r m p s y c h i a t r i c u n i t f o r v o l u n t a r i l y h o s p i t a l i z e d people. L i m i t a t i o n s of the Study The d i s c u s s i o n o f l i m i t a t i o n s o f t h i s study i s d i v i d e d i n t o two p a r t s : the l i m i t a t i o n s of the development of the GASP, and l i m i t a t i o n s o f the p r e l i m i n a r y e v a l u a t i o n . 132 The development of the GASP has an i n h e r e n t s h o r t -coming, the myth of o b j e c t i v i t y . The developer was r e q u i r e d to make d e c i s i o n s and c h o i c e s about which l i t e r a t u r e to i n c l u d e , and which to exclude. These judgments were based on e m p i r i c a l data whenever p o s s i b l e . However, p e r s o n a l b i a s e s c o u l d not be avoided. For example, the b e n e f i t s of the p s y c h o a n a l y t i c approach to psychotherapy might have been more f u l l y e x p l o r e d and i n c o r p o r a t e d i n t o the GASP. Although such psychotherapy may be e f f e c t i v e , the process i s t i m e - c o n s u m i n g and c o n s e q u e n t l y i s a c c e s s i b l e t o fewer c l i e n t s . The GASP c o u l d be enhanced by the c r i t i c a l a p p r a i s a l and use by c l i n i c i a n s with d i f f e r e n t t h e o r e t i c a l o r i e n t a t i o n s . With res p e c t to the p r e l i m i n a r y e v a l u a t i o n , there are l i m i t a t i o n s which should be recognized i n e v a l u a t i n g the r e s u l t s . F i r s t , t r ue random sampling was not p o s s i b l e i n s e l e c t i n g the p s y c h i a t r i c c l i e n t s . C o n s e q u e n t l y , t h e c o n c l u s i o n s may be g e n e r a l i z e d o n l y to c l i e n t s of S e a t t l e who would d e s i r e p s y c h i a t r i c treatment at V a l l e y General H o s p i t a l . S e c o n d, the r e a d e r s h o u l d be reminded t h a t t h i s e v a l u a t i o n was c o n d u c t e d w i t h v o l u n t a r i l y h o s p i t a l i z e d c l i e n t s , and that there were twice as many n e u r o t i c s as p s y c h o t i c s i n the p o p u l a t i o n . I t i s c o n c e i v a b l e t h a t the r e s u l t s of t h i s e v a l u a t i o n could o n l y be reconfirmed i f a s i m i l a r p o p u l a t i o n were used i n f u t u r e s t u d i e s . Perhaps the con c r e t e nature of the GASP i s a p p l i c a b l e o n l y f o r those who 133 a r e s u f f i c i e n t l y d i s t u r b e d or c o n f u s e d as to r e q u e s t h o s p i t a l i z a t i o n . T h i r d , although there i s research to i n d i c a t e that b r i e f psychotherapy i s important, follow-up research would have enabled the researcher to assess how l o n g - l a s t i n g the r e s u l t s were. Research could p o s s i b l y be b o l s t e r e d by data on r e c i d i v i s m or rate of r e t u r n to therapy. Both of these questions were i n i t i a l l y addressed; lack of c l i e n t p a r t i c i -p a t i o n l e d to i n c o n c l u s i v e r e s u l t s . Fourth, there i s no input from c l i e n t s as to how they d i f f e r e n t i a l l y p e r c e i v e d the e f f e c t s of t h e i r h o s p i t a l i z a -t i o n (See Appendices K and L f o r p o t e n t i a l c l i e n t s a t i s f a c -t i o n q u e s t i o n n a i r e s ) . F i f t h , the group was conducted as an open e n t r y , open e x i t group where membership was not r e s t r i c t e d . The r e s u l t s might be d i f f e r e n t with a contained, t i m e - l i m i t e d group. S i x t h , the sample s i z e was s m a l l . D i f f e r e n t r e s u l t s might be a c h i e v e d w i t h a l a r g e r sample of comparable p s y c h i a t r i c h o s p i t a l s . Recommendations f o r Fu r t h e r Research 1. As mentioned above, the present r e s u l t s do not address the long-term e f f e c t i v e n e s s of treatment employing the GASP. By g a i n i n g the co o p e r a t i o n of the c l i e n t s over some time, i t would be of i n t e r e s t to assess the long-term e f f e c t i v e n e s s of the GASP. F u r t h e r , i t would a l s o 134 be i n t e r e s t i n g to know under which c o n d i t i o n s c l i e n t s are more s a t i s f i e d with t h e i r h o s p i t a l i z a t i o n . The p r e l i m i n a r y f i n d i n g s suggest h o s p i t a l i z a t i o n with the GASP does have an impact on people i n c r i s i s . I t o f f e r s them a plan to help them problem-solve. As such, the a p p l i c a t i o n of the GASP to other areas of psychology seems to be a p o t e n t i a l l y f r u i t f u l venture. It i s e n t i r e l y p o s s i b l e that the GASP could be o f f e r e d as part of l i f e - p l a n n i n g workshops, c a r e e r - p l a n n i n g workshops, m a r i t a l i n t e r v e n t i o n procedures, and f a m i l y therapy, to name but a few areas of a p p l i c a t i o n . In l i g h t of the previous recommendation i t would be h e l p f u l to conduct e v a l u a t i o n s with l a r g e r samples and d i f f e r e n t p o p u l a t i o n s such as n o n - h o s p i t a l i z e d popula-t i o n s , more p s y c h o t i c p o p u l a t i o n s , or i n v o l u n t a r i l y h o s p i t a l i z e d p o p u l a t i o n s . While the area of a s s e s s i n g p s y c h o t h e r a p e u t i c proper-t i e s of a process i s not new, such research does ch a l l e n g e researchers to look at b e t t e r a r t i c u l a t i o n of the content of the process. Further e v a l u a t i o n s could be conducted to see i f there i s any merit i n such refinement. Along t h i s l i n e of refinement, i t might be b e n e f i c i a l to i d e n t i f y the more potent p a r t s of the GASP, as w e l l as those steps that are impotent by s e q u e n t i a l l y d e l e t i n g steps i n the GASP. Thus one could employ the v a r i o u s steps of the GASP, e x c l u d i n g some, and see i f the r e s u l t s are s i m i l a r . 135 5. In t h i s e v a l u a t i o n the GASP was an i n t e g r a l p a r t o f a t o t a l treatment program. I t would be i n t e r e s t i n g t o examine the GASP on i t s own, independent o f any program and see i f i t has the same p s y c h i a t r i c impact. C o n c l u s i o n I t may be concluded t h a t the Goal Attainment Scale can be adapted and i n c o r p o r a t e d i n t o a group process t h a t a s s i s t s c l i e n t s i n a g o a l - o r i e n t e d problem-solving approach to b r i e f therapv. T h i s process i n t e g r a t e d a l l the important components from the b r i e f psychotherapy, problem-solving therapy, and the Goal Attainment S c a l i n g l i t e r a t u r e such as: l i m i t e d g o a l s , s h o r t time d u r a t i o n , focused i n t e r v i e w i n g , p r e s e n t centeredness, t h e r a p e u t i c f l e x i b i l i t y , v e n t i l a t i o n , and the teaching of broad coping s k i l l s . The r e s u l t s o f the e x p l o r a t o r y e v a l u a t i o n suqgest t h i s i n t e g r a t i o n , the GASP, does d i f f e r e n t i a l l y a f f e c t some aspects o f the c l i e n t ' s h o s p i t a l i z a t i o n . H o s p i t a l i z a t i o n w i t h the GASP h o l d s promise as an e f f e c t i v e qroup process f o r h o s p i t a l i z e d p s y c h i a t r i c c l i e n t s . 136 BIBLIOGRAPHY Alexander, F. & French, T.M. P s y c h o a n a l y t i c therapy: P r i n - c i p l e s and a p p l i c a t i o n s . 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New York: Norton, 1 94~TT Zuckerman, M. , S o l a , S., Masterson, J . , & Angelone, J.V. MMPI p a t t e r n s i n drug abusers before and a f t e r treatment i n t h e r a p e u t i c communities. J o u r n a l of C o n s u l t i n g and  C l i n i c a l Psychology, 1975, 4_3, 3, 286-296. Zusman, J . Some ex p l a n a t i o n s of the changing appearance of p s y c h o t i c p a t i e n t s . In G.M. Bruenberg (Ed.), E v a l u a t i n g  the e f f e c t i v e n e s s of community mental h e a l t h s e r v i c e s . New York: Mibank, 1966. 169 APPENDIX A EXAMPLE OF ONE CLIENT'S COMPLETED GASP 170 EVENTS Married a f t e r she a f t e r entered completion to f i n d save me s h o r t l y n u r s i n g s c h o o l . She s t a r t e d work of s c h o o l i n g . Separated. Counseling to save marriage. Saw each other one/twice per week S l e p t t o g e t h e r . She s a i d she wanted me someone e l s e . She f i l e d f o r d i v o r c e to the pain of goodbye. I had a date with a g i r l . Thought of w i f e . Got nervous/tense. C a l l e d f r i e n d s — no answer. C a l l e d wife -- she refused to me. Talked on f r o n t lawn with w i f e . Said I wanted one more chance she said no. I turned by back and slashed w r i s t . Wife stopped my b l e e d i n g . Ambulance came. I came to p s y c h i a t r i c u n i t . I decided to stay f o r h e l p . see my STRENGTHS Gentle, empathic. *Determined. A f f e c t i o n a t e . *Plan ahead. Cu r i o u s . I n s i g h t . I n t e l l i g e n t . I n d u s t r i o u s . * C o n t r o l l e d . Good l i s t e n e r . Handsome. T r u s t i n g . H e l p f u l . Dependable. C a r i n g . S t r a i g h t f o r w a r d . Sexy. • P h y s i c a l l y power-f u l . * H i g h m o r a l s t a n d -ard . L i k e to help o t h e r s . * = a l s o problems. c a u s e s FEELINGS Hate myself, alone. Insecure, a f r a i d . L o s t , g u i l t y , d i r t y . Empty, angry, t i r e d . C o l d , l o n e l y , used. J e a l o u s , set-up, trapped Desparate, confused, sad H e l p l e s s , d i s a p p o i n t e d . GOALS I. I I . I I I . IV. V. PROBLEMS Hard to make f r i e n d s . IV S t i f l e anger - back p a i n . Hate myself. II S t i l l love w i f e . I I I / I V D i v i s i o n of p r o p e r t y . I I / I I I / I V E a s i l y d i s t r a c t e d . I Job d i s s a t i s f a c t i o n . Bad temper. (Number a f t e r Problem r e f e r s to Goal # that addresses t h i s problem) F i n i s h p r o j e c t s I s t a r t . F e e l good about myself. Face d i v o r c e . Communication s k i l l s . E s t a b l i s h a new home f o r myself. 171 A P P E N D I X B EXAMPLE OF C O M P L E T E D T A R G E T OUTCOME A S S E S S M E N T S H E E T GOAL LEVELS CN (-2) L e s s t h a n Ex-p e c t e d (-1) E x p e c t e d l e v e l o f S u c c e s s (0) More t h a n Ex-p e c t e d ( + 1) Most F a v o r -a b l e ( + 2) I n c r e a s e V e r b a l Communication D e c r e a s e S u i c i d e B e h a v i o r I n c r e a s e i n t e r -p e r s o n a l R e l a t i o n s E x p r e s s A n g r y F e e l i n g s z S p o n t a n e o u s l y speak to. no more t h a n one p e r s o n p e r day E f f e c t S u i c i d e Can name no one e x c e p t w i f e Never e x p r e s s a n g e r S p o n t a n e o u s l y speak t o no more t h a n 2 t o 4 p e o p l e p e r day H o s p i t a l i z e d f o r s u i c i d e a t t e m p t Can name 1 t o 3 p e o p l e he knows p e r s o n a l l y ( e x c l u d i n g w i f e ) E x p r e s s e s anger o n l y when en-r a g e d S p o n t a n e o u s l y speak t o 5 t o 6 p e o p l e p e r day C o n t a c t s t a f f when f e e l i n g s u i c i d a l ; no s u i c i d e a t t e m p t s Can name 4 t o 5 p e o p l e he knows p e r s o n a l l y When I f e e l a n g r y , l i s t e v e n t , c i r -c u m s t a n c e s , and a c t i o n . t a k e n S h a r e l i s t w i t h community Spontaneou s l y speak t o 7 to 9 p e o p l e p e r day No s u i c i d e f e e l -i n g s r e p o r t e d f o r 10 d a y s ; no a t t e m p t s Can name 6 t o 8 p e o p l e he knows p e r s o n a l l y S p o n t a n e o u s l y speak t o more t h a n 9 p e o p l e p e r day ti • — • I n d i c a t e s no s u i c i d e f e e l i n g s f o r 60 d a y s ; no a t t e m p t s Can name 9 o r more p e o p l e he knows p e r s o n a l l y Have a m e e t i n g t o s h a r e l i s t w i t h my f a m i l y APPENDIX C TRAINING AGENDA S e s s i o n 1: I n t r o d u c t i o n of u n i f o r m i t y In t h i s s e s s i o n the 14 p o i n t s were presented. The focus of the s e s s i o n was to u n d e r l i n e the n e c e s s i t y f o r c o n s i s t e n c y and u n i f o r m i t y of p r e s e n t a t i o n . Althouqh each c l i e n t ' s content would be d i f f e r e n t , the form of the process must stay the same. The s e s s i o n was spent d e f i n i n g what the GASP process must i n c l u d e . S e s s i o n 2: Timing -- b r e v i t y of goals As the n o t i o n of GASP u n i f o r m i t y had been emphasized i n i t i a l l y , the group was now ready to i d e n t i f y a means o f c o n t r o l l i n g the time f a c t o r of the p r o c e s s . T h i s was to be accom-p l i s h e d by e m p h a s i z i n g t h a t c l i e n t g o a l s should be such as to be achieved w i t h i n two weeks. The content o f the group was con-cerned with emphasizing t h i s p o i n t to c l i -e n t s . T h e i r g o a l s should be able to be achieved w i t h i n two weeks, not two months or one year. The s t a f f r o l e - p l a y e d examples of c l i e n t s with too expansive g o a l s . S e s s i o n 3: Timing -- b r e v i t y of process The group was i n s t r u c t e d how to keep the GASP under s i x t y minutes. Thus i f a c l i e n t i d e n t -i f i e d " f e e l i n g s " they should be i n s t a n t l y noted on the board r a t h e r than w a i t i n g f o r the " F e e l i n g " aspect of the p r o c e s s . T h i s i s a process that develops the l i s t s , r a t h e r than a process that needs to have every aspect of the c l i e n t emphasized. The s t a f f was i n s t r u c t e d to have c l i e n t s keep t h e i r comments b r i e f and then to move to the next p o i n t . Session 4: How to e l i c i t answers The group's task was to brainstorm q u e s t i o n s that would a s s i s t the c l i e n t i n the p r o c e s s . The group developed, and agreed upon, ques-t i o n s that were i n c o r p o r a t e d i n t o the process as suggested q u e s t i o n s . S e s s i o n 5: I d e n t i f y i n g b e h a v i o r a l g o a l s Session 6: I d e n t i f y i n g b e h a v i o r a l g o a l s Behavior c r i t e r i a f o r g o a l s was emphasized. It was e x p l a i n e d to the qroup how to t u r n any goal i n t o observable behavior. For example, i f the goal was "to f e e l b e t t e r " the s t a f f 175 was i n s t r u c t e d t o ask the c l i e n t what s/he would be doing i f s/he f e l t b e t t e r . Within both s e s s i o n s , the s t a f f was to i d e n t i f y any goa l and r e - d e f i n e that q o a l i n t o observable behavior. The qroup's taks was to i d e n t i f y t y p i c a l c l i e n t g o als and to come to an agree-ment as t o whether or not they r e f e r r e d t o observable behavior. S e s s i o n 7: F o r c i n g goals As some c l i e n t s are r e s i s t a n t or f i n d i t d i f f i c u l t t o a r t i c u l a t e q o a l s , the s t a f f e x p l a i n e d the problem of a r t i c u l a t i n g g o a l s f o r them — or f o r c i n g g o a l s upon the c l i e n t . I f , a f t e r e x p l o r i n g a l l p o t e n t i a l a l t e r n a -t i v e s , the c l i e n t has not d e f i n e d a qoal the t h e r a p i s t i d e n t i f i e d , i t was agreed to l e t the c l i e n t have h i s / h e r way. Sessi o n 8: Memory cues, f e e l i n g s , and c o n c l u s i o n The s t a f f shared methods they had developed to remember the GASP. I t appears that i n -d i v i d u a l s use unique methods t h a t o n l y they or l i k e t h i n k i n g people employ. Secondly, the s t a f f ' s f e e l i n g s about the GASP were explored as w e l l as t h e i r f e e l i n g s about t h i s r e s e a r c h . F i n a l l y , the GASP procedure was r e - a r t i c u l a t e d i n the 14 steps to ensure u n i f o r m i t y . The 8 one-hour weekly s e s s i o n s were a p a r t o f the r e g u l a r work day. S t a f f t h a t worked afternoon and evening s h i f t s were paid over-time to attend. In a d d i t i o n t o having a f o c u s i n g theme these were problem-solving s e s s i o n s where s t a f f was c r i t i q u e d on t h e i r performances of the past week. These s e s s i o n s were used to generate s o l u t i o n s t o p e r c e i v e d problems. The t y p i c a l problems are l i s t e d i n the themes of the weekly s e s s i o n s . The g e n e r a l tone of the meetings was one of excitement and c u r i o s i t y , generated by the s t a f f ' s n o t i o n t h a t they were i n v o l v e d i n a l e a r n i n g experience that was of value to them and the p a t i e n t s . 176 APPENDIX D THE WARD ATMOSPHERE SCALE 177 WAS Subscale D e f i n i t i o n s INVOLVEMENT measures how a c t i v e and e n e r g e t i c p a t i e n t s are i n the day-to-day s o c i a l f u n c t i o n i n g o f the ward, both as members of the ward as a u n i t and as i n d i v i d u a l s i n t e r a c t i n g w i t h other p a t i e n t s . P a t i e n t a t t i t u d e s such as p r i d e i n the ward, f e e l i n g s o f group s p i r i t , and general enthusiasm are a l s o assessed. SUPPORT measures how h e l p f u l and s u p p o r t i v e p a t i e n t s are towards other p a t i e n t s , how w e l l the s t a f f u n d e r s t a n d p a t i e n t needs and a r e w i l l i n g to help and encourage p a t i e n t s , and how encouraging and c o n s i d e r a t e d o c t o r s are towards p a t i e n t s . SPONTANEITY AUTONOMY measures the extent to which the environment encourages p a t i e n t s to act openly and to f r e e l y express t h e i r f e e l i n g s towards other p a t i e n t s and the s t a f f . assesses how s e l f - s u f f i c i e n t and independent p a t i e n t s are e n c o uraged t o be i n t h e i r p e r s o n a l a f f a i r s and i n t h e i r r e l a t i o n s h i p s with s t a f f ; how much r e s p o n s i b i l i t y and s e l f -d i r e c t i o n p a t i e n t s a r e e n c o uraged to e x e r c i s e ; and to what extent the s t a f f i s i n f l u e n c e d by p a t i e n t suggestions, c r i t i c i s m and other i n i t i a t i v e s . PRACTICAL ORIENTATION assesses the extent to which the p a t i e n t ' s environment o r i e n t s him/her towards p r e p a r i n g h i m s e l f f o r r e l e a s e from the h o s p i t a l and f o r the f u t u r e . Such t h i n g s as kinds of j o b s , l o o k i n g to s e t t i n g and working toward are c o n s i d e r e d . t r a i n i n g f o r new the f u t u r e and p r a c t i c a l g o a l s PERSONAL PROBLEM ORIENTATION measures the extent to which p a t i e n t s are e ncouraged t o be c o n c e r n e d w i t h t h e i r f e e l i n g s and p r o b l e m s , and t o seek t o understand them through openly t a l k i n g to other p a t i e n t s and s t a f f about themselves and t h e i r p a s t . ANGER AND AGGRESSION measures the extent to which a p a t i e n t i s allowed and encouraged to argue with p a t i e n t s and s t a f f , to become openly angry and to d i s p l a y other e x p r e s s i o n s of anger. 1 78 8. ORDER AND ORGANIZATION measures how important order i s on the ward, i n terms o f p a t i e n t s (how they l o o k ) , s t a f f (what they do to encourage order) and the ward i t s e l f (how w e l l i t i s k e p t ) ; a l s o measures o r g a n i z a t i o n , a g a i n i n terms o f p a t i e n t s (do they f o l l o w a r e g u l a r schedule, do they have c a r e f u l l y planned a c t i v i t i e s ) and s t a f f (do they keep appointments, do they h e l p p a t i e n t s f o l l o w s c h e d u l e s ) . 9. PROGRAM CLARITY 10. STAFF CONTROL measures the extent to which the p a t i e n t knows what t o e x p e c t i n t h e d a y - t o - d a y r o u t i n e of h i s ward and how e x p l i c i t the ward r u l e s and procedures a re. measures the extent to which i t i s necessary f o r the s t a f f to r e s t r i c t p a t i e n t , i . e . , i n the s t r i c t n e s s of r u l e s and schedules, i n the r e l a t i o n s h i p s between p a t i e n t and s t a f f , and in measures taken to keep p a t i e n t s under e f f e c t i v e c o n t r o l s . \ 179 The Ward Atmosphere S c a l e s Scale 1. Involvement 2. Support 3. Spontaneity 5. P r a c t i c a l o r i e n t a t i o n 6. Personal problem o r i e n t a t ion 7. Anger 8. Order 9. Program c l a r i t y 10. S t a f f c o n t r o l R e p r e s e n t a t i v e Item T h i s i s a l i v e l y ward. S t a f f go out of t h e i r way to help p a t i e n t s . P a t i e n t s a r e encouraged t o show t h e i r f e e l i n g s . P a t i e n t s are encouraged to l e a r n new ways of doing t h i n g s . Personal problems are openly t a l k e d about. P a t i e n t s o f t e n g r i p e . Most p a t i e n t s f o l l o w a r e g u l a r schedule each day. Ward r u l e s are c l e a r l y understood by the p a t i e n t s . P a t i e n t s who break r u l e s are punished f o r i t . 180 WARD ATMOSPHERE SCALE QUESTIONS D i r e c t i o n s : T h i s i s an i n v e n t o r y . There are no r i g h t or wrong answers. Please answer True or F a l s e to each q u e s t i o n as i t a p p l i e s to you. 1. P a t i e n t s can leave the ward whenever they want t o . 2. Doctors spend more time with some p a t i e n t s than with o t h e r s . 3. There i s very l i t t l e emphasis on making plans f o r g e t t i n g out of the h o s p i t a l . 4. S t a f f don't order the p a t i e n t s around. 5. I t ' s hard to get a group together f o r card games or other a c t i v i t i e s . 6. Most p a t i e n t s f o l l o w a r e g u l a r schedule each day. 7. P a t i e n t s t a l k very l i t t l e about t h e i r p a s t s . 8. P a t i e n t s put a l o t of energy i n t o what they do around here. 9. P a t i e n t s sometimes play p r a c t i c a l jokes on each o t h e r . 10. This i s a l i v e l y ward. 11. P a t i e n t s never know when a doct o r w i l l ask to see them. 12. P a t i e n t s can wear what they want. 13. P a t i e n t s tend to hide t h e i r f e e l i n g s from one another. 14. The h e a l t h i e r p a t i e n t s on t h i s ward help take care o f the l e s s h e althy ones. 15. T h i s ward emphasizes t r a i n i n g f o r new kinds of j o b s . 16. Once a schedule i s arranged f o r a p a t i e n t , the p a t i e n t must f o l l o w i t . 17. Many p a t i e n t s look messy. 18. P a t i e n t s t e l l each other about t h e i r p e r s o n a l problems. 19. A l o t of p a t i e n t s j u s t seem to be passing time on the ward. 181 20. I t ' s hard to get people to argue around here. 21. The p a t i e n t s know when doctors w i l l be on the ward. 22. There i s no p a t i e n t government on t h i s ward. -23. P a t i e n t s s et up t h e i r own a c t i v i t i e s without being prodded by the s t a f f . 24. Doctors have very l i t t l e time to encourage p a t i e n t s . 25. Most p a t i e n t s are more concerned with the pas t than with the f u t u r e . 26. The s t a f f very r a r e l y punishes p a t i e n t s by r e s t r i c t i n g them. 27. The ward has very few s o c i a l a c t i v i t i e s . 28. P a t i e n t s ' a c t i v i t i e s are c a r e f u l l y planned. 29. P a t i e n t s h a r d l y every d i s c u s s t h e i r sexual l i v e s . 30. The p a t i e n t s are proud o f t h i s ward. 31. P a t i e n t s o f t e n g r i p e . 32. New treatment approaches are o f t e n t r i e d on t h i s ward. 33. Things are sometimes very d i s o r g a n i z e d around here. 34. The s t a f f act on p a t i e n t s u g g e s t i o n s . 35. When p a t i e n t s d i s a g r e e with each other, they keep i t to themselves. 36. The s t a f f know what the p a t i e n t s want. 3 7. On t h i s ward everyone knows who's i n charge. 38. Personal problems are openly t a l k e d about. 39. Very few th i n g s around here ever get people e x c i t e d . 40. S t a f f never s t a r t arguments i n group meetings. 41. I f a p a t i e n t breaks a r u l e , he knows what w i l l happen to him. 42. Very few p a t i e n t s have any r e s p o n s i b i l i t y on the ward. 43. P a t i e n t s say anything they want to the d o c t o r s . 1 82 44. P a t i e n t s r a r e l y help each o t h e r . 45. There i s very l i t t l e emphasis on making p a t i e n t s more p r a c t i c a l . 46. P a t i e n t s can c a l l nursing s t a f f by t h e i r f i r s t names. 47. This i s a very w e l l organized ward. 48. P a t i e n t s are r a r e l y asked personal q u e s t i o n s by the s t a f f . 49. D i s c u s s i o n s are p r e t t y i n t e r e s t i n g on t h i s ward. 50. P a t i e n t s o f t e n c r i t i c i z e or joke about the ward s t a f f . 51. People are always changing t h e i r minds here. 52. P a t i e n t s can leave the ward without saying where they are going. 53. It i s . hard to t e l l how p a t i e n t s are f e e l i n g on t h i s ward. 54. S t a f f are i n t e r e s t e d i n f o l l o w i n g up p a t i e n t s once they leave the h o s p i t a l . 55. P a t i e n t s are encouraged to plan f o r the f u t u r e . 56. P a t i e n t s who break the ward r u l e s are punished f o r i t . 57. P a t i e n t s o f t e n do things together on the week-ends. 58. The ward sometimes gets very messy. 59. S t a f f are mainly i n t e r e s t e d i n l e a r n i n g about p a t i e n t s ' f e e l i n g s . 60. Nobody ever v o l u n t e e r s around here. 61. P a t i e n t s on t h i s ward r a r e l y argue. 62. If a p a t i e n t ' s medicine i s changed, a nurse or d o c t o r always t e l l s him why. 63. S t a f f r a r e l y g i v e i n to p a t i e n t p r e s s u r e . 64. I t ' s OK to act crazy around here. 65. Doctors sometimes don't show up f o r t h e i r appointments. 66. There i s very l i t t l e emphasis on what p a t i e n t s w i l l be doing a f t e r they l e a v e . 183 67. P a t i e n t s may i n t e r r u p t a doctor when he i s t a l k i n g . 68. The s t a f f make sure that the ward i s always neat. 69. The p a t i e n t s r a r e l y t a l k about t h e i r personal problems with other p a t i e n t s . 70. P a t i e n t s are p r e t t y busy a l l of the time. 71. On t h i s ward s t a f f t h i n k i t i s a he a l t h y t h i n g to argue. 72. P a t i e n t s never know when they w i l l be t r a n s f e r r e d from t h i s ward. 73. P a t i e n t s are expect to take l e a d e r s h i p on the ward. 74. P a t i e n t s tend to hide t h e i r f e e l i n g s from the s t a f f . 75. P a t i e n t s are encouraged to l e a r n 'new ways o f doing t h i n g s . 76. P a t i e n t s w i l l be t r a n s f e r r e d from t h i s ward i f they don't obey the r u l e s . 77. The ward s t a f f h elp new p a t i e n t s get acquainted on the ward. 78. The day room i s o f t e n messy. 79. P a t i e n t s are expected to share t h e i r p e r s o n a l problems with each o t h e r . 80. P a t i e n t s here r a r e l y become angry. 81. S t a f f t e l l p a t i e n t s when they are g e t t i n g b e t t e r . 82. P a t i e n t s are encouraged to show t h e i r f e e l i n g s . 83. Nurses have very l i t t l e time to encourage p a t i e n t s . 84. S t a f f care more about how p a t i e n t s f e e l than about t h e i r p r a c t i c a l problems. 85. P a t i e n t s a re r a r e l y kept w a i t i n g when t h e y have appointments with s t a f f . 86. The s t a f f set an example f o r neatness and o r d e r l i n e s s . 87. I t ' s not safe f o r p a t i e n t s to d i s c u s s t h e i r personal problems around here. 88. S t a f f sometimes argue with each o t h e r . 1 84 89. D o c t o r s don't e x p l a i n what t r e a t m e n t i s about t o p a t i e n t s . 90. P a t i e n t s here are encouraged to be independent. 91. P a t i e n t s are c a r e f u l about what they say when s t a f f are around. 92. S t a f f go out of t h e i r way to help p a t i e n t s . 93. P a t i e n t s must make plans before l e a v i n g the h o s p i t a l . 94. I t ' s a good idea to l e t the doctor know that he i s boss. 95. S t a f f s t r o n g l y encourage p a t i e n t s to t a l k about t h e i r p a s t s . 96. There i s very l i t t l e group s p i r i t on t h i s ward. 97. I f a p a t i e n t argues with another p a t i e n t , he w i l l get i n t o t r o u b l e with the s t a f f . 98. Ward r u l e s are c l e a r l y understood by the p a t i e n t s . 99. The s t a f f d iscourages c r i t i c i s m . 185 APPENDIX E THE TARGET OUTCOME ASSESSMENT SHEET 186 TARGET OUTCOME ASSESSMENT SHEET PROGRAM EVALUATION PROJECT LEVELS-WHERE ARE YOU ON THE SCALE? MUCH WORSE THAN EXPECTED SOMEWHAT LESS THAN EXPECTED EXPECTED OR MOST LIKELY RESULT SOMEWHAT BETTER THAN EXPECTED MUCH BETTER THAN EXPECTED GOAL 1 GOAL 2 GOAL 3 GOAL 4 1 87 A P P E N D I X F THE ROTTER I N T E R N A L - E X T E R N A L LOCUS OF CONTROL S C A L E ( S o c i a l R e a c t i o n I n v e n t o r y ) Name SOCIAL REACTION INVENTORY T h i s i s a q u e s t i o n n a i r e to f i n d out the way i n which c e r t a i n important events i n our s o c i e t y a f f e c t d i f f e r e n t people. Each item c o n s i s t s o f a p a i r of a l t e r n a t i v e s l e t t e r e d a or b. Please s e l e c t the one statement of each p a i r (and o n l y one) which you more s t r o n g l y b e l i e v e to be the case as f a r as you're concerned. Be sure to s e l e c t the one you a c t u a l l y b e l i e v e to be more true r a t h e r than the one you t h i n k you should choose or the one you would l i k e to be t r u e . T h i s a measure of personal b e l i e f ; o b v i o u s l y there are no r i g h t or wrong answers. Please answer those items c a r e f u l l y but do not spend too much time on any one item. Be sure to f i n d an answer f o r every c h o i c e . For each numbered qu e s t i o n make an X on the l i n e beside e i t h e r the a^  or the b, whichever you choose as the statement most t r u e . In some ins t a n c e s you may d i s c o v e r that you b e l i e v e both statements or n e i t h e r one. In such cases, be sure to s e l e c t the one you more s t r o n g l y b e l i e v e to be the case as f a r as you're concerned. Als o t r y to respond to each item independently when making your c h o i c e : do not be i n f l u e n c e d by your previous c h o i c e . REMEMBER S e l e c t that a l t e r n a t i v e which you p e r s o n a l l y b e l i e v e to be more t r u e . 189 C h i l d r e n get i n t o t r o u b l e because t h e i r parents punish them too much. The t r o u b l e with most c h i l d r e n nowadays i s that t h e i r parents are too easy with them. Many of the unhappy t h i n g s i n people's l i v e s are p a r t l y due to bad l u c k . People's misfortunes r e s u l t from the mistakes they make. One of the major reasons why we have wars i s because p e o p l e d o n ' t take enough i n t e r e s t i n p o l i t i c s . There w i l l always be wars, no matter how hard people t r y to prevent them. In the long run, people get the r e s p e c t they deserve i n t h i s world. U n f o r t u n a t e l y , an i n d i v i d u a l ' s worth o f t e n passes unrecognized no matter how hard he t r i e s . The idea that teachers are u n f a i r to students i s nonsense. Most students don't r e a l i z e the extent to which t h e i r grades are i n f l u e n c e d by a c c i d e n t a l happen-ing s. Without the r i g h t breaks one cannot be an e f f e c t i v e l e a d e r . Capable people who f a i l to become l e a d e r s have not taken advantage o f t h e i r o p p o r t u n i t i e s . No matter how hard you t r y , some people j u s t don't l i k e you. People who can't get others to l i k e them don't understand how to get along with o t h e r s . Heredity p l a y s the major r o l e i n determining one's p e r s o n a l i t y . It i s one's experiences i n l i f e which determine what they're l i k e . 190 I have o f t e n found that what i s going to happen w i l l happen. T r u s t i n g to f a t e has never turned out as w e l l f o r me as making a d e c i s i o n to take a d e f i n i t e course of a c t i o n . In the case of the w e l l prepared student there i s r a r e l y , i f ever, such a th i n g as an u n f a i r t e s t . Many times exam qu e s t i o n s tend to be so u n r e l a t e d to course work, that studying i s r e a l l y u s e l e s s . Becoming a success i s a matter of hard work; l u c k has l i t t l e o r nothing to do with i t . G e t t i n g a good job depends mainly on being i n the r i g h t p l a c e at the r i g h t time. The average c i t i z e n can have an i n f l u e n c e i n government d e c i s i o n s . T h i s world i s run by the few people i n power, and there i s not much the l i t t l e guy can do about i t . When I make p l a n s , I am almost c e r t a i n that I can make them work. It i s not always wise to plan too f a r ahead because many times t h i n g s turn out to be a matter of good or bad fortune anyhow. There are c e r t a i n people who are j u s t no good. There i s some good in everybody. In my case g e t t i n g what I want has l i t t l e or nothing to do with l u c k . Many times we might j u s t as w e l l decide what to do by f l i p p i n g a c o i n . Who gets to be the boss o f t e n depends on who was l u c k y enough to be i n the r i g h t p l a c e f i r s t . G e t t i n g people to do the r i g h t t h i n g depends upon a b i l i t y ; l u c k as l i t t l e or nothing to do with i t . As f a r as world a f f a i r s are concerned, most of us are the v i c t i m s of f o r c e s we can n e i t h e r under-stand, nor c o n t r o l . By taking an a c t i v e p a r t i n p o l i t i c a l and s o c i a l a f f a i r s , the people can c o n t r o l world events. 191 Most people can't r e a l i z e the extent to which t h e i r l i v e s are c o n t r o l l e d by a c c i d e n t a l happenings. There r e a l l y i s no such thing as " l u c k " . One should always be w i l l i n g to admit h i s mistakes. It i s u s u a l l y best to cover up one's mistakes. It i s hard to know whether or not a person r e a l l y l i k e s you. How many f r i e n d s you have depends upon how n i c e a person you are. In the long run, the bad t h i n g s t h a t happen t o us are balanced by the good ones. Most misfortunes are the r e s u l t of l a c k o f a b i l i t y , ignorance, l a z i n e s s , or a l l t h r e e . With enough e f f o r t we can wipe out p o l i t i c a l c o r r u p t i o n . It i s d i f f i c u l t f o r people to have much c o n t r o l over the things p o l i t i c i a n s do i n o f f i c e . Sometimes I can't understand how teachers a r r i v e at the grades they g i v e . There i s a d i r e c t connection between how hard I. study and the grades I get. A good leader expects people to decide f o r them-s e l v e s what they should do. A good leader makes i t c l e a r to everybody what t h e i r jobs are. Many times I f e e l that I have l i t t l e i n f l u e n c e over the t h i n g s that happen to me. It i s impossible f o r me to b e l i e v e that chance or luc k p l a y s an important r o l e i n my l i f e . People are l o n e l y because they don't t r y to be f r i e n d l y . There's not much use t r y i n g too hard to please people; i f they l i k e you, they l i k e you. 192 There i s too much emphasis on a t h l e t i c s i n high s c h o o l . Team s p o r t s are an e x c e l l e n t way to b u i l d char-a c t e r . What happens to me i s my own doing. Sometimes I f e e l t h a t I don't have much c o n t r o l over the d i r e c t i o n my l i f e i s t a k i n g . Most of the time I can't understand why p o l i t i c i a n s behave the way they do. In the long run the people are r e s p o n s i b l e f o r bad government on a n a t i o n a l as w e l l as on a l o c a l l e v e l . 193 A P P E N D I X G THE S I X T E E N P E R S O N A L I T Y FACTOR Q U E S T I O N N A I R E (16 P F ) 1 94 D i r e c t i o n s : T h i s i s an in v e n t o r y . There are no c o r r e c t or i n c o r r e c t answers. P l e a s e c i r c l e t he answer t o each q u e s t i o n as they apply to you. Answer each q u e s t i o n with your f i r s t impression. 1. I t h i n k my memory i s b e t t e r than i t ever was. a. yes, b. i n between, c. no. 2. I can e a s i l y go a whole morning without wanting to speak to anyone. a. o f t e n , b. sometimes, c. never. 3. If I say that water i s "dry" and the sun i s " c o l d " , I would say that "found" means the same as: a. gone, b. l o s t , c. unknown. 4. I g e n e r a l l y go to bed at n i g h t f e e l i n g that I've had a s a t i s f y i n g day. a. t r u e , b. i n between, c. f a l s e . 5. If I had p l e n t y o f money, I would: a. be c a r e f u l not to make other people envious, b. u n c e r t a i n c. show people how to l i v e w e l l . 6. The worst punishment f o r me would be: a. hard l a b o u r , b. u n c e r t a i n , c. to be shut up alone. 7. I f my income were more than enough f o r o r d i n a r y d a i l y needs, I would f e e l I should g i v e the r e s t to a church or other worthwhile cause. a. yes, b. u n c e r t a i n , c. no. 8. I'm the one who takes the f i r s t step i n making new f r i e n d s h i p s . a. u s u a l l y , b. sometimes, c. never. 9. On a f r e e evening, I would p r e f e r to read about: a. b. c. how to t a l k to people from abroad, u n c e r t a i n , m i l i t a r y defense a g a i n s t the enemy. 195 10. Most people "go l a z y " on a job i f they can get away with i t . a. yes. b. u n c e r t a i n , c. no. 11. When I was a c h i l d , I more o f t e n spent f r e e time: a. b u i l d i n g something, b. i n between, c. r e a d i n g . 12. I am much more f o r t u n a t e than most people i n being able to do the t h i n g s I l i k e . a. yes, b. u n c e r t a i n , c. no. 13. I can always f o r g e t t r i v i a l , unimportant t h i n g s that I have done wrong. a. yes, b. i n between, c. no. 14. If I had a l o t of money to g i v e to c h a r i t y , I would g i v e i t : a. a l l to s c i e n t i f i c r e s e a r c h , b. h a l f to each, c. a l l to churches. 15. A seaside beach would be more appealing to me i f there were: a. no people around, b. i n between, c. l o t s of f a m i l i e s at p l a y . 16. If I were to mix a l c o h o l i c d r i n k s at a p a r t y , I'd p r o b a b l y : a. t r y to make them e x a c t l y as people want them, b. u n c e r t a i n , c. s u r p r i s e people by making them s t r o n g . 17. I o f t e n jump to c o n c l u s i o n s . a. yes, b. i n between, c. no. 18. I have sometimes, even i f b r i e f l y , had h a t e f u l f e e l i n g s toward my p a r e n t s . a. yes, b. i n between, c. no. 196 19. I would p r e f e r to be: a. a business e x e c u t i v e who attends one meeting a f t e r another, b. u n c e r t a i n , c. a r e s e a r c h s c i e n t i s t . -20. I t h i n k the opposite of " r i g h t " i s the opposite o f : a. l e f t , b. wrong, c. c o r r e c t . 21. I f e e l that my emotions are: a. w e l l s a t i s f i e d , b. o n l y p a r t l y s a t i s f i e d , c. very l i t t l e s a t i s f i e d . 22. I admire more the person, who, when asked h i s o p i n i o n : a. wants to be sure of the d e t a i l s before d e c i d i n g , b. i n between, c. speaks r i g h t up, and shows where he stands. 23. I love to make people laugh with funny s t o r i e s , a. yes, b. i n between, c. no. 24. I thi n k most people take l i f e : a. too s e r i o u s l y , b. i n between, c. not s e r i o u s l y enough. 25. During an i n t e r v i e w , whether i t ' s important or not, I: a. f e e l "on edge" and i l l at ease, b. i n between, c. f e e l c o n f i d e n t and composed. 26. My f r i e n d s are more l i k e l y : a. to ask me f o r a d v i c e , b. i n between, c. to g i v e me a d v i s e . 27. I t h i n k most people take t h e i r d u t i e s to the community s e r i o u s l y enough. a. t r u e , b. i n between, c. f a l s e . 197 There are some areas o f knowledge that are b e t t e r l e f t alone. a. t r u e , b. i n between, c. f a l s e . If I f e e l l i k e t e l l i n g someone j u s t what I t h i n k o f him, I: a. go r i g h t ahead and speak the t r u t h , b. i n between, c. f i r s t c o n s i d e r the consequences of my doing so. I have more ups and downs i n mood than most people I know. a. yes, b. i n between, c. no. Today we need more l o g i c a l , c o o l t h i n k i n g i n s o c i a l matters and l e s s attachment to o l d e r ideas and l o y a l t i e s . a. yes, b. i n between, c. no. I p r e f e r to eat l u n c h : a. with l o t s of o t h e r people, b. i n between, c. by myself. I'm c a r e f u l and p r a c t i c a l about t h i n g s so that I have fewer a c c i d e n t s than most people. a. yes, b. i n between, c. no. When something unexpected happens, I: a. remain very composed or calm, b. i n between, c. become extremely nervous or tense. I t ' s hard f o r me to admit i t when I'm wrong. a. yes, b. sometimes, c. no. Which word does not belong with the other two? a. by, b. a f t e r , c. near. I have some s p e c i a l f e a r s , f o r example, o f c e r t a i n a n i m a l s , o r b e i n g shut i n , o r c r o s s i n g wide s t r e e t s , or being alone i n the dark, and so on. a. yes, b. i n between, c. no. 198 I r e a l l y can't blame people f o r t r y i n g to grab what they can. a. t r u e , b. i n between, c. f a l s e . If I had to choose one, I'd p r e f e r a v a c a t i o n which was: a. r e l a x i n g , b. i n between, c. f i l l e d with a c t i v i t i e s . I v a lue good manners and r e s p e c t f o r r u l e s , more than easy l i v i n g . a. t r u e , b. i n between, c. f a l s e . When I'm i n a group o f s t r a n g e r s , I'm u s u a l l y one of the l a s t to express my o p i n i o n p u b l i c l y . a. yes, b. i n between, c. no. I enjoy l e a r n i n g to work new gadgets i n everyday t h i n g s , from can openers to c a r s . a. yes, b. i n between, c. no. When people s e c r e t l y say bad t h i n g s about me, I : a. f o r g e t i t , b. i n between, c. t r y t o catch them at i t . In i n t e l l e c t u a l i n t e r e s t s , my parents are (were): a. above average, b. average, c. a b i t below average. Many popular magazines are concerned with w r i t i n g what most people want to read r a t h e r than with the t r u t h . a. yes, b. i n between, c. no. I never l e t myself get depressed over t r i f l e s . a. t r u e , b. i n between, c. f a l s e . There are times, every day, when I want to enjoy my own thoughts, u n i n t e r r r u p t e d by other people. a. yes, b. i n between, c. no. 199 50. .When I'm t a l k i n g t o p e o p l e , o u t s i d e n o i s e s , passersby, e t c . , don't draw my a t t e n t i o n away from what I'm doing. a. t r u e , b. i n between, c. f a l s e . 52. When I know I'm doing the r i g h t t h i n g , I f i n d my task easy. a. always, b. sometimes, c. seldom. 53. I'd p r e f e r a job which r e q u i r e s l o t s o f d e c i s i o n s i n d e a l i n g with people. a. t r u e , b. u n c e r t a i n , c. f a l s e . 54. "Hot" i s to "warm" as "mountain" i s t o : a. s l o p e , b. p l a i n , c. h i l l . 55. I get over disappointments: a. q u i c k l y , b. i n between, c. s l o w l y . 56. If I don't get my way with a c l e r k i n a l a r g e company, I don't h e s i t a t e to go to her s u p e r i o r . a. t r u e , b. i n between, c. f a l s e . 57. I take i t on myself to l i v e n up a d u l l p a r t y , a. o f t e n , b. sometimes, c. never. 58. When I need i m m e d i a t e l y the use o f s omething belonging to a f r i e n d but he's out, I t h i n k i t ' s a l l r i g h t to borrow i t without h i s p e r m i s s i o n . a. yes, b. i n between, c. no. 59. I can e a s i l y s t a r t to t a l k with a group of s t r a n -gers i n a bus or w a i t i n g room. a. yes, b. i n between, c: no. 60. As a job, I would p r e f e r : a. w r i t i n g or e d i t i n g c h i l d r e n ' s books, b. u n c e r t a i n , c. r e p a i r i n g e l e c t r i c a l machines. 61. Even i n an important game, I am more concerned with enjoying i t than with who wins. a. always, b. g e n e r a l l y , c. o c c a s i o n a l l y . 200 62. I would r a t h e r t h i n k about my ideas than take p a r t i n a t h l e t i c games. a. yes, b. i n between, c. no. 63. I thi n k i t i s wiser to keep the n a t i o n ' s m i l i t a r y f o r c e s strong than j u s t to depend on i n t e r n a t i o n a l g o o d w i l l . a. yes, b. i n between, c. no. 64. I'm more e a s i l y upset by bad news than most people I know. a. t r u e , b. u n c e r t a i n , c. f a l s e . 65. When I'm with a group of people, I agree with t h e i r ideas so that no arguments w i l l a r i s e . a. u s u a l l y , b. i n between, c. I o f t e n d i s a g r e e . 66. I would r a t h e r spend a f r e e evening: a. with a good book, b. u n c e r t a i n , c. working on a hobby with f r i e n d s . 67. I l i k e to f i n d excuses to put o f f work and have fun i n s t e a d . a. o f t e n , b. sometimes, c. r a r e l y . 68. When I'm c r i t i c i z e d , i t d i s t u r b s me badly, a. yes, b. i n between, c. no. 69. My mind doesn't work so c l e a r l y at some times as i t does at o t h e r s . a. t r u e , b. i n between, c. f a l s e . 70. I t a l k to people: a. to make them f e e l c o mfortable, b. i n between, c. o n l y when I have something to say. 71. I thi n k the proper number to c a r r y on the s e r i e s 1, 3, 2, 4, 3, 5, i s : a. 4, b. 6, c. 8. 201 I have the f e e l i n g that my blood pressure goes up very q u i c k l y when someone annoys me. a. yes, b. i n between, c. no. If I had to t e l l a person a d e l i b e r a t e l i e , I'd have to look away, being ashamed to look him i n the eye. a. t r u e , b. u n c e r t a i n , c. f a l s e . I would r a t e myself as a r e l a t i v e l y c a s u a l and l i g h t h e a r t e d person. a. yes, b. i n between, c. no. The s i g h t of l i t t e r e d , u n t i d y s t r e e t s makes me c r o s s . a. t r u e , b. i n between, c. f a l s e . I would l i k e a job where I: a. have a l o t of r e s p o n s i b i l i t y and can show my competence. b. i n between, c. would be gi v e n d e f i n i t e tasks so t h a t I always know what I'm supposed to do. I would p r e f e r to have: a. more money, b. u n c e r t a i n , c. more time f o r t h i n k i n g about l i f e . If anyone betrays my t r u s t , I: a. get very angry with him, b. i n between, c. soon f o r g i v e him. Newspaper accounts of everyday dangers and a c c i -dents : a. make r a t h e r d u l l , t r i v i a l r e a d i n g , b. i n between, c. h o l d my a t t e n t i o n . I can do hard p h y s i c a l work without f e e l i n g worn out as q u i c k l y as most people do. a. yes, b. sometimes, c. no. I don't f e e l g u i l t y i f I'm scolded f o r something I d i d n ' t do. a. t r u e , b. u n c e r t a i n , c. f a l s e . I would r a t h e r be known f o r : a. r e l y i n g or depending on w e l l - t r i e d methods, b. i n between, c. always t r i n g new i d e a s . I l i k e to keep t r a c k , at l e a s t roughly, of where money i s spent. a. yes, b. sometimes, c. no. When I have to face a hard day of work, I: a. wish i t would never come, b. i n between, c. look on i t as a c h a l l e n g e . If I can't seem to solve a problem, I: a. t r y harder, b. i n between, c. f e e l the problem i s too hard f o r me. I may be l e s s c o n s i d e r a t e of other people than they are of me. a. t r u e , b. sometimes, c. f a l s e . In my spare time I would r a t h e r j o i n : a. a h i k i n g and e x p l o r i n g c l u b , b. u n c e r t a i n , c. a community s e r v i c e o r g a n i z a t i o n . I have pots numbered 1, 2, 3, and 4. Each holds twice as much as the next lower number. A f t e r I pour from a f u l l 4 i n t o an empty 3, how many h a l f - f u l l 1's can I s t i l l f i l l from 4? a . 2 , b . 4 , c . 8 . When I get up i n the morning, I f e e l I can h a r d l y face the day. a. o f t e n . b. sometimes, c. never. 203 If we are l o s t i n a c i t y and my companions d i s a g r e e with me on the best way, I: a. h a p p i l y go my own way, b. i n between, c. make a f u s s , and f o l l o w them. I would r a t h e r l i s t e n to music: a. alone at home, b. u n c e r t a i n , c. with an audience i n a l a r g e auditorium. When I'm i n bed with the f l u or a bad c o l d : a. I enjoy i t as a s o r t of v a c a t i o n , b. u n c e r t a i n , c. I f e e l worried and concerned about not working. I f e e l I would have a great d e a l o f d i f f i c u l t y g i v i n g a speech before an audience of s t r a n g e r s . a. t r u e , b. u n c e r t a i n , b. f a l s e . Some of the th i n g s I enjoy i n v o l v e the the t h r i l l of danger. a. yes, b. i n between, c. no. Most p e o p l e g e t too up s e t o v e r t h i n g s o f no importance. a. t r u e , b. u n c e r t a i n , c. f a l s e . I'd p r e f e r : a. to go camping, b. i n between, c. to attend an outdoor musical performance. When I have to t e l l a f r i e n d something he won't 1 ike , I: a. get i t done at the f i r s t o p p o r t u n i t y , b. i n between, c. put i t o f f as long as p o s s i b l e . I sometimes f e e l s o r r y f o r a l l the people i n the world. a. yes, b. i n between, c. no. 204 99. I most enjoy a meal i f i t c o n s i s t s o f : a. unusual, e x o t i c foods, b. u n c e r t a i n , c. standard, r e g u l a r foods. 100. I enjoy being considered p a r t of the goup when my neighbours do anything. a. t r u e , b. i n between, c. f a l s e . 101. At times I f e e l l i k e smashing t h i n g s . a. t r u e , b. i n between, c. f a l s e . 102. Before a t e s t or examination, I: a. get tense and wrapped up i n what's coining, b. i n between, c. keep q u i t e calm. 103. I may deceive people by being f r i e n d l y when I r e a l l y d i s l i k e them. a. yes, b. sometimes, c. no. 104. Which word does not belong with the other two? a. l e a d , b. win, c. succeed. 105. I f Susan's mother's s i s t e r i s Judy's great aunt, what r e l a t i o n i s Judy's great aunt to Susan? a. grandma, b. aunt, c. mother. 205 L i s t o f Questions f o r Fa c t o r s C, E, F, 0, Q 4 C 1.1 g e n e r a l l y go to bed at n i g h t f e e l i n g that I've had a s a t i s f y i n g day. a. t r u e , b. i n between, c. f a l s e . E 2. If I had p l e n t y o f money, I would: a. be c a r e f u l not to make other people envious, b. u n c e r t a i n c. show people how to l i v e w e l l . F 3. The worst punishment f o r me would be: a. hard l a b o u r , b. u n c e r t a i n , c. to be shut up alone. 0 4. I can always f o r g e t t r i v i a l , unimportant t h i n g s t h a t I have done wrong. a. yes, b. i n between, c. no. Q 4 5. I o f t e n jump to c o n c l u s i o n s . a. yes, b. i n between, c. no. C 6. I f e e l that my emotions are: a. w e l l s a t i s f i e d , b. o n l y p a r t l y s a t i s f i e d , c. very l i t t l e s a t i s f i e d . E 7. I admire more the person, who, when asked h i s o p i n i o n : a. wants to be sure of the d e t a i l s before d e c i d i n g , b. i n between, c. speaks r i g h t up, and shows where he stands. F 8. I love to make people laugh with funny s t o r i e s . a. yes, b. i n between, c. no. O 9. I have more ups and downs i n mood than most people I know. a. yes, b. i n between. c. no. 206 When something unexpected happens, I: a. remain very composed or calm, b. i n between, c. become extremely nervous or tense. I have some s p e c i a l f e a r s , a n i m a l s , o r b e i n g shut s t r e e t s , or being alone i n a. yes, f o r example, of c e r t a i n i n , o r c r o s s i n g wide the dark, and so on. b. i n between, c. no. E 12. I r e a l l y can't blame people f o r t r y i n g to grab what they can. a. t r u e , b. i n between, c. f a l s e . F 13. If I had to choose one, I'd p r e f e r a v a c a t i o n which was: a. r e l a x i n g , b. i n between, c. f i l l e d with a c t i v i t i e s . 0 14. I never l e t myself get depressed over t r i f l e s . a. t r u e , b. i n between, c. f a l s e . 15. When I'm t a l k i n g t o p e o p l e , o u t s i d e n o i s e s , passersby, e t c . , don't draw my a t t e n t i o n away from what I'm doing. a. t r u e , b. i n between, c. f a l s e . C 16. I get over disappointments: a. q u i c k l y , b. i n between, c. s l o w l y . E 17. I f I don't get my way with a c l e r k i n a l a r g e company, I don't h e s i t a t e to go to her s u p e r i o r . a. t r u e , b. i n between, c. f a l s e . F 18. I take i t on myself to l i v e n up a d u l l p a r t y . a. o f t e n , b. sometimes, c. never. 0 19. I'm more e a s i l y upset by bad news than most people I know. a. t r u e , b. u n c e r t a i n , c. f a l s e . 207 When I'm c r i t i c i z e d , i t d i s t u r b s me badly. a. yes, b. i n between, c. no. I have the f e e l i n g that my blood pressure goes up very q u i c k l y when someone annoys me. a. yes, b. i n between, c. no. If I had to t e l l a person a d e l i b e r a t e l i e , I'd have to look away, being ashamed to look him i n the eye. a. t r u e , b. u n c e r t a i n , c. f a l s e . I would r a t e myself as a r e l a t i v e l y c a s u a l and l i g h t h e a r t e d person. a. yes, b. i n between, c. no. I don't f e e l g u i l t y i f I'm scolded f o r something I d i d n ' t do. a. t r u e , b. u n c e r t a i n , c. f a l s e . If I can't seem to solve a problem, I: a. t r y harder, b. i n between, c. f e e l the problem i s too hard f o r me. When I get up i n the morning, I f e e l I can h a r d l y f a c e the day. a. o f t e n , b. sometimes, c. never. If we are l o s t i n a c i t y and my companions d i s a g r e e with me on the best way, I: a. h a p p i l y go my own way, b. i n between, c. make a f u s s , and f o l l o w them. I would r a t h e r l i s t e n to music: a. alone at home, b. u n c e r t a i n , c. with an audience i n a l a r g e a u d i t o r i u m . I sometimes f e e l s o r r y f o r a l l the people i n the world. a. yes, b. i n between, c. no. 208 Q 4 30. Before a t e s t or examination, I: a. get tense and wrapped up i n what's coming, b. i n between, c. keep q u i t e calm. 209 APPENDIX H INFORMED CONSENT LETTER 210 LETTER OF INFORMED CONSENT C u r r e n t l y we are e v a l u a t i n g the e f f e c t i v e n e s s o f the treatment on our u n i t i n an e f f o r t to up-grade our s e r v i c e s . We are asking that you help us with t h i s e f f o r t by complet-ing three b r i e f groups of in f o r m a t i o n surveys. We wish to c o l l e c t i n f o r m a t i o n at the beginning o f treatment, l a t e r d u r i n g your treatment, and once a f t e r you l e a v e . The in f o r m a t i o n gathered i s c o n f i d e n t i a l and your i d e n t i t y w i l l r e main anonymous. P a r t i c i p a t i o n i n t h e s e s u r v e y s i s v o l u n t a r y . If you want to r e f u s e to p a r t i c i p a t e , you need o n l y say so. You may stop completing the requested informa-t i o n whenever you choose, and there w i l l be no r e p e r c u s -s i o n s . Such i n f o r m a t i o n w i l l h e lp us to o f f e r a more e f f e c t i v e and e f f i c i e n t s e r v i c e to our c l i e n t s . Your s i g n a t u r e below i n d i c a t e s that you have read t h i s l e t t e r , understand i t s contents, and agree to p a r t i c i p a t e i n t h i s e f f o r t . p a t i e n t ' s s i g n a t u r e 21 1 APPENDIX I CHRONOLOGY OF EVENTS FOR THE GASP 212 An Estimate of Chronology of Events f o r One P a t i e n t i n the GASP Event Date 1 ) Enter h o s p i t a l , s i g n informed consent l e t t e r to p a r t i c i p a t e i n r e s e a r c h . 4/15 2) Intake i n t e r v i e w . 4/15 3) P r e - t e s t 16 PF and I-E S c a l e ( S o c i a l Reaction Inventory) 4/15 4) I n i t i a l Treatment Conference. 4/16 5) Problems and l e v e l s determined on Target Outcome Assessment Sheets 4/18 6) Problems c a t e g o r i z e d according t o : S e l f , f a m i l y , peer, and work. 4/18 7) E i g h t days f o l l o w i n g i d e n t i f i c a t i o n o f c l i e n t ' s problems and l e v e l s : (a) c l i e n t completes Target Outcome Assessment Sheet, 16 PF and I-E Scale ( S o c i a l Reaction I n v e n t o r y ) ; (b) check made on percentage of agreement between c l i e n t problems upon admission and g o a l s i d e n t i f i e d v i a GASP; (c) d e t e r m i n a t i o n made of percentage of agree-ment i n d i r e c t i o n of goal/problem. 4/26 A P P E N D I X J CHRONOLOGY OF E V E N T S FOR T H E N O N - E Q U I V A L E N T CONTROL GROUP 214 An Estimate of Chonology of Events f o r One P a t i e n t In The Non-Equivalent C o n t r o l Group Event Date 1) Enter h o s p i t a l , s i g n informed consent l e t t e r to p a r t i c i p a t e i n r e s e a r c h . 5/1 2) Intake i n t e r v i e w . 5/1 3) P r e - t e s t 16 PF and I-E S c a l e . 5/1 4) I n i t i a l Treatment Conference 5/2 5) Problems and l e v e l s determined on Target Outcome Assessment Sheet 5/3 6) E i g h t days f o l l o w i n g i d e n t i f i c a t i o n of c l i e n t ' s problems and l e v e l s : (a) c l i e n t completes Target Outcome Assessment Sheet, 16 "PF and I-E S c a l e 5/11 A P P E N D I X K THE C L I E N T S A T I S F A C T I O N Q U E S T I O N N A I R E FOR THE GASP C l i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e 216 1. Now that you have l e f t the h o s p i t a l , how do you f e e l i n r e l a t i o n to your problem(s)? 1 . Much b e t t e r 2. Somewhat b e t t e r 3. No improvement 4. S l i g h t l y worse 5. Much worse 2. If f a m i l y or f r i e n d s were involved i n your treatment, how h e l p f u l d i d you f i n d t h i s experience? 1. Very h e l p f u l 2. Somewhat h e l p f u l 3. Not h e l p f u l at a l l 4. Made things worse Comments 3. During your h o s p i t a l s t a y , d i d you g e n e r a l l y r e c e i v e the hopeful f e e l i n g , from people you were i n v o l v e d with, that your problem(s) could be r e s o l v e d ? 1. Yes 2. C o n f l i c t i n g , yes and no 3. No 217 4. During your h o s p i t a l stay, how d i d you f e e l i n r e s p e c t to the amount of time that was spent with you by your t h e r a p i s t and other s t a f f members? 1. More than enough time was spent with me 2. S u f f i c i e n t time was spent with me 3. Not enough time was spent with me Please evaluate the f o l l o w i n g ward program a c t i v i t i e s by p l a c i n g an "X" beside the a p p r o p r i a t e response: 5* Morning Community M e e t i n g ( L a r g e meeting where a l l p a t i e n t s and s t a f f t a l k about concerns on the ward) 1. Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made things worse 5. Did not p a r t i c i p a t e Comments or suggestions 6. Goals Group ( P a t i e n t s meet with t h e r a p i s t s and other s t a f f to d i s c u s s only goals) 1. Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made things worse 5. Did no,t p a r t i c i p a t e Comments or suggestions 218 Evening Group 1 . Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made things worse 5. Did not p a r t i c i p a t e Comments or suggestions Chart Group 1. Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made things worse 5. Did not p a r t i c i p a t e Comments or suggestions Did you p a r t i c i p a t e i n f a m i l y conferences? 1 . Yes 2. No If yes, how were f a m i l y conferences? 1 . Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made th i n g s worse 5. Did not p a r t i c i p a t e Comments or suggestions 219 10. Occup a t i o n a l Therapy 1 . Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made th i n g s worse 5. Did not p a r t i c i p a t e Comments or suggestions 11. I n d i v i d u a l t a l k s with your p s y c h i a t r i s t and other s t a f f  members 1 . Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l . 4. Made things worse 5. Did not p a r t i c i p a t e Comments or suggestions 12. Informal d i s c u s s i o n s with other p a t i e n t s 1 . Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made th i n g s worse 5. Did not p a r t i c i p a t e Comments 220 Free L e i s u r e Time 1« Very h e l p f u l 2« Moderately h e l p f u l 3. Not h e l f u l 4 * Made th i n g s worse 5 - Did not p a r t i c i p a t e Comments or suggestions Other (Please s p e c i f y ) 1 • Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made th i n g s worse 5- Did not p a r t i c i p a t e T hinking back over your h o s p i t a l s t a y , what do you t h i n k were the t h r e e most h e l p f u l a c t i v i t i e s you p a r t i c i p a t e d in? Do you have any general comments or suggestions as to how we could have helped you more? 221 A P P E N D I X L THE C L I E N T S A T I S F A C T I O N Q U E S T I O N N A I R E FOR THE NON-EQUIVALENT CONTROL GROUP C l i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e 222 1. Now that you have l e f t the h o s p i t a l , how do you f e e l i n r e l a t i o n to your problem(s)? 1 . Much b e t t e r 2. Somewhat b e t t e r 3. No improvement 4. S l i g h t l y worse 5. Much worse 2. If f a m i l y or f r i e n d s were in v o l v e d i n your treatment, how h e l p f u l d i d you f i n d t h i s experience? 1. Very h e l p f u l 2. Somewhat h e l p f u l 3. Not h e l p f u l at a l l 4. Made things worse Comments 3. During your h o s p i t a l stay, d i d you g e n e r a l l y r e c e i v e the hopeful f e e l i n g , from people you were i n v o l v e d with, that your problem(s) could be r e s o l v e d ? 1. Yes 2. C o n f l i c t i n g , yes and no 3. No 223 4. During your h o s p i t a l stay, how d i d you f e e l i n r e s p e c t to the amount of time that was spent with you by your t h e r a p i s t and other s t a f f members? 1. More than enough time was spent with me 2. S u f f i c i e n t time was spent with me 3. Not enough time was spent with me Please evaluate the f o l l o w i n g ward program a c t i v i t i e s by p l a c i n g an "X" beside the a p p r o p r i a t e response: 5. Morning Community M e e t i n g ( L a r g e meeting where a l l p a t i e n t s and s t a f f t a l k about concerns on the ward) 1. Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made things worse 5. Did not p a r t i c i p a t e Comments or suggestions 6. Did you meet with p a t i e n t s and s t a f f to d i s c u s s o n l y goals? 1 . Yes 2. No 7. Evening Group 1 . Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made t h i n g s worse 5. Did not p a r t i c i p a t e Comments or suggestions 224 8. Chart Group 1. Very h e l p f u l 2. _____ Moderately h e l p f u l 3. Not h e l p f u l 4. Made things worse 5. Did not p a r t i c i p a t e Comments or suggestions 9. Did you p a r t i c i p a t e i n f a m i l y conferences? 1 . Yes 2. No If yes, how were f a m i l y conferences? 1 . Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made th i n g s worse 5. Did not p a r t i c i p a t e Comments or suggestions 10. O c c u p a t i o n a l Therapy 1. Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made things worse 5. Did not p a r t i c i p a t e Comments or sugg e s t i o n s 225 11. I n d i v i d u a l t a l k s with your p s y c h i a t r i s t and other s t a f f  members 1 . Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made things worse 5. Did not p a r t i c i p a t e Comments or suggestions 12. Informal d i s c u s s i o n s with other p a t i e n t s 1. Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made th i n g s worse 5. Did not p a r t i c i p a t e Comments 13. Free L e i s u r e Time 1. Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made things worse 5. Did not p a r t i c i p a t e Comments or suggestions 226 14. Other (Please s p e c i f y ) 1 . Very h e l p f u l 2. Moderately h e l p f u l 3. Not h e l p f u l 4. Made t h i n q s worse 5. Did not p a r t i c i p a t e 15. Thinking back over your h o s p i t a l s t a y , what do you t h i n k were the t h r e e most h e l p f u l a c t i v i t i e s you p a r t i c i p a t e d i n ? 16. Do you have any general comments or suggestions as to how we could have helped you more? 

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