Abstract
Objective:
Goal advancement is critical to mental health clients’ reintegration into the community. This research considers factors likely to contribute to goal advancement among members of four consumer-run mental health self-help agencies (SHAs) who responded to questions about their goals at baseline and six-month follow-up.
Method:
Type of goals, demographics, psychiatric disability, agency characteristics, and members’ attitudes toward professionals were used to predict goal advancement.
Results/Discussion:
Surprisingly, faith in the psychiatrist as the source of responsibility for treatment decisions was associated with goal advancement. This is contrary to SHA ideology, which emphasizes peer-driven help. Other findings are also discussed.
We want to learn how to keep ourselves healthy, cope effectively with the demands that life makes on us, improve our mental health on our own, work with satisfaction and success, handle our conditions and any disabilities they create, make our organizations strong, advocate successfully for our peers, change society’s attitudes towards us, run businesses, provide services, and develop networks. We want to empower ourselves. “
(The mental health self-help agency philosophy, as described by Miller & Katz, 1992, pp. 162–163)
Mental health self-help agencies (SHAs) are consumer-run, consumer-governed, and formally incorporated organizations serving individuals with psychiatric disabilities. They include little or no professional involvement in their programs and offer services that range from peer counseling to assistance with housing and benefits. Service delivery is grounded in an egalitarian philosophy with a mission that focuses on decreasing the stigma associated with mental illness, restoring dignity and self-esteem to their members, and encouraging member empowerment and independent functioning (Chamberlin, 1990; Segal, Silverman, & Temkin, 1995a, 1995b, 1997). In order for SHA members to achieve this level of autonomy and independent living, it is necessary for them to set and advance realistic goals (Howell, 1986). This study investigates factors associated with goal advancement among members of mental health SHAs.
Factors Hypothesized To Foster Goal Advancement
Self-help philosophy is most accurately described as one of mutual support (Rappaport et al., 1985). Therefore, the central and distinctive characteristic of SHAs is reliance upon peer, rather than professional help. Self-helpers believe that a peer who has endured similar struggles to one’s own can understand and help in ways thought to be impossible for professionals without first-hand understanding of mental illness (Zinman, Harp, & Budd, 1987). By their very natures, SHAs are non-medically and non-professionally oriented (Zinman, Harp, & Budd, 1987). Faith in the helping process in the psychotherapeutic context has been shown to be a powerful predictor of positive outcomes (O’Connell, 1983; Senger, 1987). Thus, we would expect that faith in the self-help (peer-driven) model would lead to greater levels of goal advancement, given the peer-reliant ideology present at SHAs (Long & Van Tosh, 1988).
The SHA’s inclusive and supportive philosophy is reflected in its efforts to empower its members through involvement within the organization. Organizationally mediated empowerment is the mechanism by which an SHA includes members in its significant decision processes, enabling them to exercise control and influence within the organization (Segal, Silverman, & Temkin, 1995b). For this reason, organizationally mediated empowerment is a good index of the agency’s role in fostering the necessary independence and skills needed for goal advancement. If the agency trusts and empowers the individual to take control and responsibility within the organization, the member will likely feel more efficacious outside the agency as well, thus providing support for goal advancement. Further, it is hypothesized that attendance at the agency will increase the likelihood of goal attainment, via the greater likelihood of support (emotional, instrumental, etc.) received from the agency. There is evidence that, for those with psychiatric disabilities, peers who participated more at an agency were more likely to advance their goals (Murray & Baier, 1996).
Finally, in mental health settings, goals are typically formulated across six “life domains”: vocational/educational, social/recreation, independent living/housing, financial/legal, transportation, and health. Self-selected goals considered important to the person are more likely to be advanced (Hollenbeck & Wiliams, 1987). When clients determine their own goals, the two most common domains are independent living and socialization (Hierholzer & Liberman, 1986; Rapp & Wintersteen, 1989). In general, concrete goals are more likely to be accomplished than are intrapersonal/insight-oriented goals (Falloon & Talbot, 1982; Howell, 1986). Given this observation, obtaining a better job/better income, a better place to live, and education/training are goals most likely to be advanced—for example, the concrete and instrumental goals of successful community living. Advancement of mental health/health goals may be less likely, since they may require more insight and intra-personal work. Further, the anti-professional stance of some SHAs may provide less support for such efforts (Chamberlin, 1990), goals more likely to be fostered in traditional community mental health agencies (Wohlford, Myers, & Callan, 1993).
Factors Hypothesized To Inhibit Goal Advancement
Psychiatric disabilities, such as cognitive disorientation can impede the process of goal setting and advancement. Those with high levels of psychiatric disturbance will be less able to mobilize the cognitive resources necessary to set concrete and realistic goals, to remain committed to accomplishing such goals, and to provide the self-feedback necessary to measure steps toward advancement (Murray & Baier, 1996; Scott & Haggarty, 1984). Affect has been found to be strongly related to goal advancement, with a more positive affect related to higher levels of goal attainment (Klein, Wesson, Hollenbeck, & Alge, 1999). Depression inhibits one’s perceived ability, due to a sense of powerlessness to make changes in one’s own life, i.e. by setting and advancing goals (Leggett & Archer, 1979). Finally, anger and impulsiveness inhibit goal advancement. The steps necessary for accomplishing goals (such as continued commitment to goals) are undermined by high levels of impulsive behavior. Setting and achieving goals is a process requiring patience, commitment, and continual feedback to oneself about progress made and further steps necessary to achieve the goal (Osmond, Wambach, Harrison, & Byers, 1993; Scott & Haggarty, 1984).
Although there is only limited evidence in the goal attainment literature related to demographic differences, ethnicity, gender, and income differences are typically conceptualized as barriers to goal advancement (Diblasio & Belcher, 1993). African-Americans have been found to be less involved in formal agencies, thus putting them at risk for impeded goal advancement based on the idea that participation at the agency promotes goal advancement (Lieberman & Snowden, 1993; Neighbors, 1985). Women have been found to set less difficult goals and to fear social condemnation of their success (Stake, 1976). Low levels of income act as barriers to goal advancement, as they prevent access to necessary resources (Diblasio & Belcher, 1993). Further, “the multiple jeopardy hypothesis” would indicate that these negative effects are additive (Luthar, Cushing, Merikangas, & Rounsaville, 1998; Osmond, Wambach, Harrison, & Byers, 1993).
Goal advancement measures progression from the goal statement to continued work on (or interest in) accomplishing the goal, to goal achievement. While goal advancement is not the ultimate outcome of SHA involvement, it is a necessary precursor to other more distal outcomes such as successful community functioning. Goal advancement can be seen as a protective mechanism, helping individuals with mental illness to continue living independently in the community by preventing negative outcomes such as psychiatric hospitalization (Murray & Baier, 1996). We study this intermediate step of goal advancement, rather than the more distal outcomes of successful community living and reduced rates of psychiatric hospitalization. By doing so, we hope to understand goal advancement’s mediating effects upon community adjustment of SHA members. We examine member attitudes toward peer help, agency characteristics, the types of goals held, levels of psychiatric disability, and demographics, to enhance our understanding of the relative importance of these factors in promoting or detracting from goal advancement.
Method
Study Design
This project is a secondary analysis of an existing data set maintained by the Center for Self-Help Research (CSHR) in affiliation with the Public Health Institute and the University of California, Berkeley School of Social Welfare. The data were collected in 1992–93. The data set is a Time 1/Time 2 survey of 310 members of four mental health self-help agencies in the San Francisco Bay Area (246 respondents at follow-up). Each agency is peer-run, independently incorporated, has a governing board, and offers a wide range of services (Segal, Silverman, & Temkin, 1995a).
Our goal is to contribute to the advancement of empirically-based theory rather than to evaluate particular agencies. We are confirming the association of factors thought to be related to goal advancement rather than evaluating particular time-bound agency outcomes. Further, since the data came from model programs (funded by SAMHSA and private foundations), that have been the exemplars for the development of self-help agencies nationally, we believe empirical documentation of their practice is important for the field to see even if the data are 10 years old.
The independent variables were measured at baseline, while goal advancement outcomes were measured at the six-month follow-up. This research design provides a longitudinal perspective on factors associated with goal advancement. All measures are scales and questionnaires administered by in-person interviews. All interviewers were trained by the Center for Self-Help Research in Berkeley, California, and included mental health consumers as well as mental health professionals.
Participants and Sampling Procedures
Respondents were long-term users of the four member-run mental health self-help agencies, defined as having attended at least twelve times over the previous three months. Overall, 96% of those asked to participate in the study agreed to do so. At the six-month follow-up, 80% (n = 246) of respondents were re-interviewed. Demographically, the sample had a mean age of 38 years (SD = 8.4), 64% were African-American, 72% were men, 46% were homeless, 87% had DSMIII-R diagnoses, and 20% had a diagnosis of drug or alcohol abuse. Twenty-four percent of the sample was employed at the time of the baseline interview, working a mean of 23 hours per week (SD = 20), with mean monthly income of $996 (SD = $2339).
See Table 1 for a description of the participants across a range of demographic, clinical, and employment variables (largely from Segal, Silverman, & Temkin, 1995a).
Table 1—
Description of the Participants in the Sample at Baseline (N = 310)
| Characteristic | Percent of Sample |
|---|---|
| Gender: Women | 28% |
| Ethnicity: | |
| African-American | 64% |
| Caucasian | 17% |
| Other/Did not answer | 19% |
| Primary Diagnosis: | |
| None | 13% |
| Drug or alcohol abuse | 20% |
| Antisocial personality disorder | 12% |
| Panic disorder/PTSD/Anxiety disorder/dysthymia | 24% |
| Affective disorder | 19% |
| Schizophrenia | 13% |
| Homeless | 46% |
| Never married | 49% |
| Age (years): | |
| 18 to 24 | 5% |
| 25 to 44 | 76% |
| 45 to 64 | 19% |
| Over 65 | <1% |
| Education | |
| Bachelor’s degree or higher | 8% |
| Some college | 31% |
| High school | 30% |
| Less than high school | 27% |
| Employed in paying position | 24% |
| Mean hours worked per week | 23 hours |
| Mean monthly income | $996 |
| Source of Income: | |
| Employment | 24% |
| SSI or SSD | 36% |
| General assistance (GA) | 36% |
| AFDC | 5% |
| Food stamps | 33% |
| Money from family or friends | 16% |
Study Sites (Agencies)
All four SHAs were located in urban settings of the San Francisco Bay area. Three of the agencies are located in densely populated, low-income, ethnically diverse neighborhoods, and the fourth in a residential area of single-family dwellings, though this last agency was within walking distance of an urban downtown, from which it drew much of its clientele. Three of the agencies targeted services to homeless persons with mental disabilities, and one to all individuals with mental disabilities (Segal, Gomory, & Silverman, 1998).
Each SHA offers multiple services, including basic resources such as food, drop-in center services, and laundry, as well as advocacy, peer counseling services, and assistance in meeting goals. Other services offered at the four sites (varying between sites) include: financial advocacy/payee assistance, assistance locating housing, financial benefits counseling and advocacy, vocational counseling, substance abuse counseling and groups, case management, and resource referrals. Also, each of these agencies focuses upon community activism and social change-oriented activities such as lobbying for the rights of those with psychiatric disabilities (Segal, Silverman, & Temkin, 1995a).
Data Collection and Measures
The CSHR Interview Schedule, developed jointly by researchers and consumers, obtained information on goal setting and advancement, member attitudes toward self-help, agency characteristics, goal setting and advancement, demographics, and psychiatric disability (among other constructs).
With respect to goal setting, respondents were asked at baseline to list a number of goals they had for the next six months. The interview schedule listed fifteen goal categories, as well as an “other” category in which respondents could classify their goals. All data was self-report. Goals listed as “most important” were used as baseline measures against which to evaluate goal advancement. Goal advancement was measured at the six-month follow-up interview. Goal advancement was a three-item ordinal variable measuring progress from having a goal statement to continued interest in or achievement of the goal. A respondent could score 1 (did not accomplish goal, no longer interested in accomplishing), 2 (did not accomplish goal, but remains interested in accomplishing), or 3 (accomplished goal). A higher score indicates more progress toward goal achievement. Baseline goals, collapsed into five categories for analysis, included those related to issues of: Mental health/health, job and income, living situation, education/training, and “other.”
Attitudes toward peer/professional helping were measured by member agreement/disagreement with two statements: “The psychiatrist should have the ultimate responsibility for treatment decisions” and “the best help comes from a professional, not a peer.”
Organizational empowerment was measured via a scale created by CSHR staff in conjunction with SHA members, Alpha = .87 in this sample (Segal, Silverman, & Temkin, 1995b). This scale measures members’ participation and involvement at the agency via such questions as “have you helped set up a meeting?,” “have you taken part in deciding what activities will be held?,” and “have you taken part in deciding what rules people need to follow?.”
Attendance at the self-help agency was measured by number of days per week attended by the member (range 0–7 days).
Severity of psychiatric disability was measured by the Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1962). The BPRS is a 24-item scale measuring symptoms such as guilt, hostility; depression, anxiety, hallucinations, and conceptual disorganization. The Scale is a symptom-based index that has been frequently employed in drug trials (Rhoades & Overall, 1988) and used by Segal and colleagues (Segal & Aviram, 1978, Segal & Kotler, 1993) in their studies of former psychiatric patients in residential board and care settings. We used training films and dictionaries to standardize assessments on these symptom ratings. Staff members, both peers and mental health professionals, were trained with the aid of the Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation at UCLA. Interrater reliabilities during training were in the .9 range. In the current sample, the Scale’s internal consistency was α = .79.
Severity of psychiatric disability was also measured by the Center for Epidemiologic Studies Depressed Mood Scale (CES-D) (Radloff, 1977). Its internal consistency for this sample is alpha = .85. The CES-D is a self-report measure which asks questions regarding depressed mood, such as: “In the past week, I was bothered by things that don’t usually bother me,” “I did not feel like eating; my appetite was poor,” and “I felt that everything I did was an effort.”
Anger and impulsiveness were measured by the Novaco Impulsive Reaction Scale (Novaco, 1975). Its internal consistency among the sample is Alpha = .84. In this study, the Novaco was a 12-item scale, asking for agreement/disagreement with statements such as “my temper is quick and hot,” “if someone crosses me, I get back at them,” and “when I get angry, I fly off the handle before I know it.” Respondents are rated on a three-point scale (“never true,” “sometimes true,” and “always true”).
Analyses
Chi-square and ANOVA were used to examine associations between facilitating and hindering factors and goal advancement. Linear regression was used to assess the relative importance of factors significantly associated with goal advancement.
Results
Overwhelmingly, the respondents had goals. Ninety-one percent indicated they had a goal at baseline. At the six-month follow-up, 19% had accomplished their most important goal, 55% had not accomplished but were still interested in pursuing their goal, and 26% had not accomplished the goal and were no longer interested in accomplishing it. Table 2 provides an overview of the descriptive statistics for all factors thought to contribute to or detract from goal advancement.
Table 2—
Descriptive Statistics for Each Predictor Variable at Baseline (N = 310)
| Variable | Descriptive Statistics (n, %) |
|---|---|
| Most important goal: | |
| Mental health/health | 72 (25%) |
| Better job/better income | 100 (35%) |
| Better place to live | 58 (20%) |
| Education/training | 36 (13%) |
| Other | 19 (7%) |
| Gender: | |
| Women | 88 (28%) |
| Men | 222 (72%) |
| Ethnicity: | |
| African-American | 203 (68%) |
| All other ethnicities | 97 (32%) |
| Income (per month) | $996 (mean) $2340 sd |
| Depression (CES-D) | 46 (mean) 10.4 sd |
| Psychiatric symptom severity (BPRS) | 42 (mean) 11.6 sd |
| Anger/impulsive reaction scale | 20 (mean) 4.9 sd |
| Organizational empowerment | 4.5 (mean) 3.8 sd |
| Days per week attend agency | 4.1 (mean) 1.5 sd |
| “Psychiatrist should have ultimate responsibility for treatment decisions”: | |
| Yes | 134 (49%) |
| No | 142 (51%) |
| “The best help comes from a professional, not a peer”: | |
| Strongly agree | 11 (4%) |
| Agree | 70 (23%) |
| Equally agree/disagree | 29 (10%) |
| Disagree | 163 (53%) |
| Strongly disagree | 33 (11%) |
Bivariate analyses showed only two factors were significantly associated with goal advancement: 1) Agreement with the statement “the psychiatrist should have ultimate responsibility for treatment decisions” is associated with goal advancement (p = .035), as is having a goal of “education/training” (p = .050).
Our multiple regression model is, however, significant (R2 = .159, df = 14, f = 2.252, p = .008). It showed that in combination five factors are significantly associated with goal advancement. In order of their relative importance they are: (a) having goals of finding a better place to live (b = .245, p = .019); (b) improved mental health/health (b = .225, p = .038); and (c) obtaining additional education/training (b = .197, p = 041) are associated with goal advancement, as is agreement with the statement “the psychiatrist should have ultimate responsibility for treatment decisions” (b = .187, p = .015). Higher levels of anger/impulsiveness are negatively associated with goal advancement (b = −.160, p = .044) (See Table 3).
Table 3—
Linear Regression Model: Factors Associated with Goal Advancement (N = 246)
| Independent Variables | Standardized Regression Coefficient/b | T | P |
|---|---|---|---|
| Type of Goal (most important goal) | |||
| Mental health/health goal | .225 | 2.091 | .038* |
| Better job/better income goal | .059 | .526 | .600 |
| Better place to live goal | .245 | 2.364 | .019* |
| Education/training goal | .197 | 2.055 | .041* |
| Demographics | |||
| Gender | .032 | .440 | .661 |
| Ethnicity | −.021 | −.273 | .785 |
| Income | .016 | .221 | .825 |
| Psychiatric Disability Indicators | |||
| Psychiatric severity (BPRS) | −.168 | −1.766 | .079 |
| Depression (CESD) | .153 | 1.644 | .102 |
| Anger/impulsive reactions | −.160 | −2.029 | .044* |
| Agency Characteristics | |||
| Organizational empowerment | .018 | .235 | .814 |
| Attendance at agency | .086 | 1.157 | .249 |
| Professional vs. Peer Helping | |||
| Psychiatrist responsible for treatment decisions | .187 | 2.461 | .015* |
| The best help comes from a professional, not a peer | −.038 | −.510 | .610 |
Variable is significant at p is less than or equal to p = .05
Model Summary: R2 = .159, df = 14, f = 2.252, p = .008
Discussion and Conclusions
Kurtz (1990) predicted that self-help would become a major delivery method of mental health services in the 1990s and estimated that there would be over 10 million self-help members by the year 2000. Nearly a decade later, while it is unclear if these predictions were accurate, self-help is now a recognized service in the mental health spectrum. It is, therefore, critical to better understand the ways in which SHAs support their members’ goal advancement and their resulting steps toward independence and successful community integration.
Overwhelmingly, this sample has goals. Ninety-one percent reported they had a goal to work on at baseline. Further, at the six-month follow-up, only 26% reported that they had not accomplished a goal and were no longer interested in accomplishing a goal. Thus, this sample is likely to be motivated to continue their efforts toward accomplishing their goal (55%) or reports they have actually achieved it (19%). Although the 19% rate of accomplishment may seem low, it must be kept in mind that only six months separated the baseline and follow-up interviews. Goals such as education/training, better job/better income and mental health/health are all rather complex and likely to take much longer than six months to accomplish. While SHAs tend to support members in areas such as financial assistance, housing searches, and employment assistance (Segal, Silverman, & Temkin, 1995a), the achievement of these goals is often contingent on scarce resources. Mental health goals may be more personal and therefore more easily achieved or held on to. Further, this is a group with severe disabilities. Given that nearly half of the sample is homeless, a large proportion are severely mentally ill or substance dependent, mean income is only $996 per month, and approximately one-third of the sample has less than a high-school education, a 19% rate of goal attainment may be typical. The latter conjecture should be a focus of future research.
The findings pointing to a link between faith in professional helping and goal advancement in this population appear ironic, since the SHAs are very much peer-driven environments with some history of an anti-professional stance (Chamberlin, 1990). Perhaps the leaders of the self-help movement are more committed to the latter attitude than the members of the organizations. At least in our sample, the attitude toward professional mental health treatment is fairly positive. Rather than completely shunning contact with the formal mental health system, the four SHA member groups seem to acknowledge the need for professional psychiatric care in addition to the supportive services of self-help. This suggests a more integrated, rather than an either/or perspective on relations between SHAs and traditional providers of mental health services.
The combination of this positive attitude toward psychiatry and the tendency to choose mental health goals provides some explanation for the advancement of mental health goals. Since the literature emphasizes hope, expectancy, and optimism for successful goal attainment, this faith in the psychiatrist may be a key factor leading to greater advancement of mental health/health goals over other types of goals (O’Connell, 1983; Senger, 1987).
The finding that SHA members with higher anger/impulsive reaction scores were less likely to advance their goals is validating of the previous results. Impulsive reactions are the exact opposite of what is required for goal advancement.
There is no research that specifically addresses goals in mental health SHAs. In fact, there is very little goal setting research on persons with psychiatric disabilities. Thus, by necessity, this work has attempted to piece together the extant literatures on goal setting, self-help, and the relevant variables in this study. The variables included in the multivariate model were chosen because they were considered relevant in either the self-help literature, the goal setting literature, or the general mental health literature. There may be other variables that we neglected to include in the analysis that would be important to understanding goal advancement among this sample.
Further, this is self-report data, presenting some validity problems. Yet the nature of goals is subjective and individualized, so to some extent we must rely upon this collection method to ensure we are truly assessing goals considered important to respondents.
This sample was drawn from four urban SHAs in the Bay Area of Northern California. The sample may be unlike self-help members from more rural areas, or from other geographic locations. Segal, Silverman, and Temkin (1995a) found some specific differences between this sample and another national sample of self-help members. Compared to the other sample, clients in this study were more likely to be men, African-American and homeless.
Despite these potential weaknesses in external validity, there is some evidence that this sample is representative of the larger urban SHA community in California. Like most self-help organizations, this sample has multiple disabilities, has an extensive history of psychiatric hospitalization, and is quite likely to experience housing instability (Segal, Silverman, & Temkin, 1995a; 1995b). These are model agencies for the larger SHA community, as evidenced by funding from SAMSHA and private foundations.
Finally, research is needed on the degree to which goal advancement is related to concrete positive outcomes. This study looked at factors associated with goal advancement, but goal advancement is an intermediate step toward independence and community functioning. Future studies should investigate the link between goal advancement and outcomes for the members of these agencies.
Acknowledgments
THIS STUDY WAS SUPPORTED BY THE NATIONAL INSTITUTE OF MENTAL HEALTH GRANT ROI MH-37310 AND TRAINING GRANT HH-18828.
Contributor Information
John Q. Hodges, UNIVERSITY OF MISSOURI-COLUMBIA. SCHOOL OF SOCIAL WORK..
Steven P. Segal, MENTAL HEALTH AND SOCIAL WELFARE RESEARCH GROUP. SCHOOL OF SOCIAL WELFARE. UNIVERSITY OF CALIFORNIA. BERKELEY..
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