tend to compromise confidentiality protection because the 12-digit code would be on a computer file with each client’s consecutive number. However, an intruder would have to unscramble the five-letter code and then identify the individual codes needed from all contained on the file. A further disadvantage of the coding procedure is that it is cumbersome, especially when it is used with a billing system. That seems a small price to pay, however, for the almost total confidentiality that the system provides. It meets the needs of the professional who wants to protect client identity and the department, which needs to track clients throughout the state-supported mental health system. It permits the information system to reflect client activity without jeopardizing his right to privacy.
IMPLEMENTING AN AUTOMATED GOAL ATTAINMENT SYSTEM FOR CMHC PROGRAM EVALUATION Alan
R.
Donald].
Fiester,
Fort,
Ph.D.
Ph.D.
a Community mental health centers are being mandated to evaluate programs and to provide data on effectiveness of services. The mandate has posed a dilemma for the CM HC administrator-how can he quickly and effectively implement evaluation components for all the center’s direct services? There are several essential requirements for conducting successful program evaluation: the approach to evaluation must be accepted by mental health professionals and by review agencies, the procedure must be standardized but also flexible and should not interfere unduly with clinic operations, and results must be meaningful for the individual therapist as well as for the program administrator. In addition, there must be a degree of objectivity in measuring program success, and consumers must provide input into the evaluation process. After considering these factors, officials at the Community Mental Health Center of Palm Beach County in West Palm Beach, Florida, decided to develop an automated and modified version of Kiresuk’s and Sherman’s goal attainment scaling.1 This method of program evaluation was chosen for several reasons. The goal attainment scaling system has been successfully modified and adopted at a variety of mental health facilities across the country; it is flexible enough to be used to evaluate Dr. Fiester is director of research and evaluation and Dr. Fort is director of consultation at the Community Mental Health Center of Palm Beach County, 1041 45th Street, West Palm Beach, Florida 33407. A series of more extensive reports describing the project may be obtained from Dr. Fiester. 1. J. Kiresuk and R. E. Sherman, Goal Attainment Scaling: A General Method for Evaluating Comprehensive Community Mental Health Programs,’ Community Mental Health Journal, Vol. 4, December 1968, pp. 443-453.
different types of intervention; it permits goals to be written in a relatively brief and efficient manner with little intrusion into ongoing clinic operations; it is objective in that both the therapist and the client are asked to report on the extent of treatment success; and it can be readily automated. The following procedure is used at our center to complete the goal attainment process. Shortly after treatment has begun, the therapist establishes from one to three goals for the client. For each goal, the therapist chooses one of 16 standardized problem areas that characterize the particular goal. After the goal is established, the therapist breaks it down into three levels of attainment: best possible outcome, realistic outcome (noticeable improvement), and most unfavorable outcome (no change or deterioration). Therapists also indicate whether each goal has been set by the therapist or by the client, or has been mutually agreed on by both. At the end of treatment, the therapist rates his perception of the client’s level of attainment of the goals that were initially established. After the therapist completes the level-of-attainment rating, a staff member from the research and evaluation department contacts the client to learn his perception of the extent to which goals have been attained. The staff member also asks the client 23 standardized questions related to general consumer satisfaction as well as to availability, accessibility, and appropriateness of services. The data obtained from the initial goal sheet, therapists’ and clients’ ratings of level of goal attainment, and clients’ responses to the consumer satisfaction questions are keypunched and are analyzed on the center’s IBM System S Model 10 computer. The software for the goal attainment computer analysis was written in Report Program Generator (RPG II) language. Forty separate error messages have been devised to assure that quality control of goal attainment documents is maintained. The following reports are produced bimonthly: Count of goal sheets received. This report presents a breakdown for the entire center of the number of clients for whom goals are written during each month of the year. It provides data relevant to utilization patterns of goal attainment on a centerwide basis. Goal attainment roster. This print-out consists of two separate reports. One is a centerwide, alphabetized roster of all clients for whom goals have been written; the other identifies all clients for each individual therapist. The latter report is distributed to the respective therapists to help them in tracking clients through the goal attainment process. Goal attainment ratings listing. This report provides each individual therapist with results for those clients who have completed the total goal attainment process. The clients’ names are listed, followed by a consumer satisfaction score for each and then by the therapist’s and client’s ratings of levels of goal attainment. Summary statistics for all clients assigned to the individual therapist appear at the bottom of this print-out. The
VOLUME
27
NUMBER
9 SEPTEMBER
1976
625
results are further broken down so therapists can cornpare results for the previous two-month period with their ratings to date. Goal attainment averaged by problem. This report provides information on individual therapist, separate program, and centerwide outcome results broken down by each of the 16 standardized problem areas. It provides, on a bimonthly and to-date basis, the relative frequency of goals chosen; the per cent of attained goals as reported by therapist and by client; and the average goal attainment score as rated by therapist and by client. Summary statistics in these areas are also presented. Consumer satisfaction report. This report includes the frequency distribution for each of the 23 consumer satisfaction questions the client is asked during the follow-up interview. The results are presented on a bimonthly and to-date basis for each treatment program as well as for the total sample of clients who have been followed up. To date, the automated goal attainment evaluation system has been implemented in five separate direct service treatment programs at the center: outpatient, day treatment, substance abuse, halfway house, and the geriatric-psychiatric inpatient unit. There have been 1284 goal sheets written, representing 1160 unduplicated clients. Therapists have identified 679 of the 1160 clients as eligible for follow-up. The research and evaluation department has been successful in contacting 438 of the 679 clients. Client ratings of goal attainment outcome have averaged 2.1 out of a possible 3.0. The results indicate that the typical client reports an expected level of treatment success in relation to his individual goals. Furthermore, the results of the consumer satisfaction portion of the follow-up show that the majority of these same clients were satisfied with the services they received at the center. Center administrators and officials from various review agencies have indicated their satisfaction with this evaluation system, and have supported us in our efforts to develop a comparable automated goal attainment system for evaluation of direct services for children.
tive deficits and who has reached an impasse in his therapy. Inability to mobilize such a patient is a formidable obstacle to the initiation of socialization, intimacy, and self-respect. Techniques as varied as psychoanalytically oriented psychotherapy and token economies share this common problem. Confronted by the patient who faithfully appears for therapy sessions each week but who seems to be making little progress, the therapist may resort to analyzing the patient’s resistance, or he may cajole, coax, implore, or even threaten the patient. From the behaviorist’s viewpoint, action precedes emotional change and not the converse. Recently we have begun using a new technique that is simple but effective for some patients. It relies on the presumed authority of the doctor and his stalwart ally, the prescription pad. Following are three examples of our use of this technique with three patients, who achieved new gains simply because the therapist wrote on a prescription form explicit directions intended to motivate their behavior. The first patient was a 27-year-old white organic chemist whose wife recently had left him. When first seen, he had vegetative symptoms of depression, cornplete with vague suicidal ideation and profound rurninative thoughts of worthlessness. He was in danger of losing and subsequently did lose his job because of his inability to concentrate. He was treated on an outpatient basis once a week; initially he was placed on a dosage of 200 mg. of amitriptyline at bedtime. After one month the symptoms of depression had abated. His obsessive ruminations were quickly eliminated with one office session of thought-stopping with instructions in how to use the technique at home. In the meantime he did look for a new job, but he lacked the motivation to renew socialization. Various techniques were used to motivate him to find new friends, to re-engage in heterosexual relationships, and to resume activities he had previously enjoyed such as weight-lifting and stock-car racing. The techniques included role-playing, systematic desensitization, assertive training, lists of written instructions, and insight therapy for his problems of intimacy and passivity. His typical response to each attempt was I don’t seem to have the will power.” During a session one of the authors (CKC) took out his prescription pad and removed three blanks. He had written the patient’s name and address on each, and had signed them. The instructions on the first read, Lift weights 15 minutes every day.” The other instructions were “Go to bar and pick up girl” and “Call up old friend and see him for lunch.” At the next session the patient had completed each of the assigned tasks. Since then he has shown increasing assertiveness and socialization. Therapy has also dealt with problems related to his future vocation and longterm life goals. The second patient was a 57-year-old white widow with a history of schizo-affective schizophrenia. Since (Continued on page 633) “
THE PRESCRIPTION PAD HELPS PSYCHIATRISTS TO MOTIVATE PATIENTS Neil
Cal
B. Edwards, M.D. K. Cohn, M.D.
#{149} One of the therapist’s vating the patient who anxieties, ennui, apathy, Dr. Edwards is director versity of Pennsylvania Dr. Cohn inpatient Edwards’ Pennsylvania
626
“
most difficult problems is motiis suffering from incapacitating unresolved conflicts, or asser-
of the psychiatric Hospital. At the
was a resident in psychiatry psychiatry at the University mailing address is 1054
inpatient time this
unit paper
at the Uniwas written
there; he is now director of of Texas in Houston, Dr. Gates Pavilion, Philadelphia,
19104.
HOSPITAL
& COMMUNITY
PSYCHIATRY
IMPLEMENTING AN AUTOMATED GOAL ATTAINMENT SYSTEM FOR CMHC PROGRAM EVALUATION Alan
R.
Donald].
Fiester,
Fort,
Ph.D.
Ph.D.
a Community mental health centers are being mandated to evaluate programs and to provide data on effectiveness of services. The mandate has posed a dilemma for the CM HC administrator-how can he quickly and effectively implement evaluation components for all the center’s direct services? There are several essential requirements for conducting successful program evaluation: the approach to evaluation must be accepted by mental health professionals and by review agencies, the procedure must be standardized but also flexible and should not interfere unduly with clinic operations, and results must be meaningful for the individual therapist as well as for the program administrator. In addition, there must be a degree of objectivity in measuring program success, and consumers must provide input into the evaluation process. After considering these factors, officials at the Community Mental Health Center of Palm Beach County in West Palm Beach, Florida, decided to develop an automated and modified version of Kiresuk’s and Sherman’s goal attainment scaling.1 This method of program evaluation was chosen for several reasons. The goal attainment scaling system has been successfully modified and adopted at a variety of mental health facilities across the country; it is flexible enough to be used to evaluate Dr. Fiester is director of research and evaluation and Dr. Fort is director of consultation at the Community Mental Health Center of Palm Beach County, 1041 45th Street, West Palm Beach, Florida 33407. A series of more extensive reports describing the project may be obtained from Dr. Fiester. 1. J. Kiresuk and R. E. Sherman, Goal Attainment Scaling: A General Method for Evaluating Comprehensive Community Mental Health Programs,’ Community Mental Health Journal, Vol. 4, December 1968, pp. 443-453.
different types of intervention; it permits goals to be written in a relatively brief and efficient manner with little intrusion into ongoing clinic operations; it is objective in that both the therapist and the client are asked to report on the extent of treatment success; and it can be readily automated. The following procedure is used at our center to complete the goal attainment process. Shortly after treatment has begun, the therapist establishes from one to three goals for the client. For each goal, the therapist chooses one of 16 standardized problem areas that characterize the particular goal. After the goal is established, the therapist breaks it down into three levels of attainment: best possible outcome, realistic outcome (noticeable improvement), and most unfavorable outcome (no change or deterioration). Therapists also indicate whether each goal has been set by the therapist or by the client, or has been mutually agreed on by both. At the end of treatment, the therapist rates his perception of the client’s level of attainment of the goals that were initially established. After the therapist completes the level-of-attainment rating, a staff member from the research and evaluation department contacts the client to learn his perception of the extent to which goals have been attained. The staff member also asks the client 23 standardized questions related to general consumer satisfaction as well as to availability, accessibility, and appropriateness of services. The data obtained from the initial goal sheet, therapists’ and clients’ ratings of level of goal attainment, and clients’ responses to the consumer satisfaction questions are keypunched and are analyzed on the center’s IBM System S Model 10 computer. The software for the goal attainment computer analysis was written in Report Program Generator (RPG II) language. Forty separate error messages have been devised to assure that quality control of goal attainment documents is maintained. The following reports are produced bimonthly: Count of goal sheets received. This report presents a breakdown for the entire center of the number of clients for whom goals are written during each month of the year. It provides data relevant to utilization patterns of goal attainment on a centerwide basis. Goal attainment roster. This print-out consists of two separate reports. One is a centerwide, alphabetized roster of all clients for whom goals have been written; the other identifies all clients for each individual therapist. The latter report is distributed to the respective therapists to help them in tracking clients through the goal attainment process. Goal attainment ratings listing. This report provides each individual therapist with results for those clients who have completed the total goal attainment process. The clients’ names are listed, followed by a consumer satisfaction score for each and then by the therapist’s and client’s ratings of levels of goal attainment. Summary statistics for all clients assigned to the individual therapist appear at the bottom of this print-out. The
VOLUME
27
NUMBER
9 SEPTEMBER
1976
625
results are further broken down so therapists can cornpare results for the previous two-month period with their ratings to date. Goal attainment averaged by problem. This report provides information on individual therapist, separate program, and centerwide outcome results broken down by each of the 16 standardized problem areas. It provides, on a bimonthly and to-date basis, the relative frequency of goals chosen; the per cent of attained goals as reported by therapist and by client; and the average goal attainment score as rated by therapist and by client. Summary statistics in these areas are also presented. Consumer satisfaction report. This report includes the frequency distribution for each of the 23 consumer satisfaction questions the client is asked during the follow-up interview. The results are presented on a bimonthly and to-date basis for each treatment program as well as for the total sample of clients who have been followed up. To date, the automated goal attainment evaluation system has been implemented in five separate direct service treatment programs at the center: outpatient, day treatment, substance abuse, halfway house, and the geriatric-psychiatric inpatient unit. There have been 1284 goal sheets written, representing 1160 unduplicated clients. Therapists have identified 679 of the 1160 clients as eligible for follow-up. The research and evaluation department has been successful in contacting 438 of the 679 clients. Client ratings of goal attainment outcome have averaged 2.1 out of a possible 3.0. The results indicate that the typical client reports an expected level of treatment success in relation to his individual goals. Furthermore, the results of the consumer satisfaction portion of the follow-up show that the majority of these same clients were satisfied with the services they received at the center. Center administrators and officials from various review agencies have indicated their satisfaction with this evaluation system, and have supported us in our efforts to develop a comparable automated goal attainment system for evaluation of direct services for children.
tive deficits and who has reached an impasse in his therapy. Inability to mobilize such a patient is a formidable obstacle to the initiation of socialization, intimacy, and self-respect. Techniques as varied as psychoanalytically oriented psychotherapy and token economies share this common problem. Confronted by the patient who faithfully appears for therapy sessions each week but who seems to be making little progress, the therapist may resort to analyzing the patient’s resistance, or he may cajole, coax, implore, or even threaten the patient. From the behaviorist’s viewpoint, action precedes emotional change and not the converse. Recently we have begun using a new technique that is simple but effective for some patients. It relies on the presumed authority of the doctor and his stalwart ally, the prescription pad. Following are three examples of our use of this technique with three patients, who achieved new gains simply because the therapist wrote on a prescription form explicit directions intended to motivate their behavior. The first patient was a 27-year-old white organic chemist whose wife recently had left him. When first seen, he had vegetative symptoms of depression, cornplete with vague suicidal ideation and profound rurninative thoughts of worthlessness. He was in danger of losing and subsequently did lose his job because of his inability to concentrate. He was treated on an outpatient basis once a week; initially he was placed on a dosage of 200 mg. of amitriptyline at bedtime. After one month the symptoms of depression had abated. His obsessive ruminations were quickly eliminated with one office session of thought-stopping with instructions in how to use the technique at home. In the meantime he did look for a new job, but he lacked the motivation to renew socialization. Various techniques were used to motivate him to find new friends, to re-engage in heterosexual relationships, and to resume activities he had previously enjoyed such as weight-lifting and stock-car racing. The techniques included role-playing, systematic desensitization, assertive training, lists of written instructions, and insight therapy for his problems of intimacy and passivity. His typical response to each attempt was I don’t seem to have the will power.” During a session one of the authors (CKC) took out his prescription pad and removed three blanks. He had written the patient’s name and address on each, and had signed them. The instructions on the first read, Lift weights 15 minutes every day.” The other instructions were “Go to bar and pick up girl” and “Call up old friend and see him for lunch.” At the next session the patient had completed each of the assigned tasks. Since then he has shown increasing assertiveness and socialization. Therapy has also dealt with problems related to his future vocation and longterm life goals. The second patient was a 57-year-old white widow with a history of schizo-affective schizophrenia. Since (Continued on page 633) “
THE PRESCRIPTION PAD HELPS PSYCHIATRISTS TO MOTIVATE PATIENTS Neil
Cal
B. Edwards, M.D. K. Cohn, M.D.
#{149} One of the therapist’s vating the patient who anxieties, ennui, apathy, Dr. Edwards is director versity of Pennsylvania Dr. Cohn inpatient Edwards’ Pennsylvania
626
“
most difficult problems is motiis suffering from incapacitating unresolved conflicts, or asser-
of the psychiatric Hospital. At the
was a resident in psychiatry psychiatry at the University mailing address is 1054
inpatient time this
unit paper
at the Uniwas written
there; he is now director of of Texas in Houston, Dr. Gates Pavilion, Philadelphia,
19104.
HOSPITAL
& COMMUNITY
PSYCHIATRY
