Table of Contents
Origin and Rationale
Keywords: Personal characteristics, state of mental health treatment, mental health education, mental health program and system evaluation, civil rights movement
My training in measurement and psychotherapy at the University of Minnesota did not prepare me for my encounter with multi-cultural, multi-problem patients in a large downtown metropolitan general hospital. For a period of time I provided psychological services to the entire hospital, all departments. Psychoanalytic-based and dynamic psychology therapies were appropriate for only a very small number of patients. The available psychological measures were often useless and irrelevant, with the exception of intelligence and brain damage measures. The disconnect between professional training and post-graduate work environments was typical of that time.
It was assumed and believed that we (primarily the psychiatrists, but the other mental health professions as well) knew what we were doing and how well we were succeeding. There was no challenge to the accuracy of these beliefs from within the professions and from the ruling lay population. “If you want to know how I am doing, ask me. I am the authority.” This is an actual quote.
Treatment activity was not constrained or judged by funding agencies, notably the insurance industry, or consumer representatives.
In the 1960’s there was a powerful zeitgeist favoring minorities, women, and others having a relative disadvantage in economic and political power. There was a strong message emanating from the National Institutes of Mental Health and local state mental health leaders that required attention to and reform of mental health services, particularly local hospital and state hospital mental health patient care.
Evaluation of programs and systems of care were just being initiated and mandated. The topic of evaluation was the domain of prominent psychiatrists and sociologists. A professional society was established to provide a forum for the leading figures in this new movement. The topic of evaluation also drew its life’s blood from the funding and requirements set forth by federal mandates that insisted on active evaluation of mental health services. A newer set of individuals emerged from program directors and program innovators that presented their work in the form of evaluation presentations and publications.
Mental health programs and services were run by professionals (commonly psychiatrists at first and later other professions as well) that had no formal training in administration, management, financing, and measurement. The intrinsic model was the extension of office psychiatry treating mental pathology with little or no understanding of community, special populations, or the realities of true rehabilitation and reintegration into daily living within a context of multiple problems and constraints.
Modifications of treatment and treatment theory were a fluid process with few if any research-based rationales. For instance, our training and treatment supervision that placed emphasis on the reconstruction of homosexuals into normal heterosexuality suddenly disappeared, without notice. Stereotypes of minorities and women were fully integrated into treatment formulations and practice. These also disappeared without formal notice. Sexual abuse of patients had not yet achieved the attention and remedy of current day practice. The changes occurred because of social (including within-profession organizations) and political pressure, not research-based decision making.
The fluid, changing overall context and an associated lesser level of constraint (compared to today) permitted creative individuals to develop new programs and innovations often with far reaching consequences i.e., Day Treatment, Suicide Prevention, Crisis Intervention, Sexual Assault Services, Community Mental Health Programs, Psycho-social Rehabilitation Programs, and a variety of evaluation methods, including Goal Attainment Scaling.
One over-riding characteristic of that period was that, with very rare exceptions and notwithstanding all the diversity of training and background, everyone was doing their best to help their patients. While the concepts and tools were ill-suited to the tasks required of them, there probably were effective treatments mixed with powerful nonspecific and placebo effects. These treatments, delivered in settings that were safe and containing an ambience of healing, brought about many positive changes in the lives of patients. Many therapists found Goal Attainment Scaling to be self-evident and a useful tool in treatment. Typically, they did not write articles, they saw patients.
Keywords: Linkage of Clinical Psychology and Biometry
Although statistician Bob Sherman and I were well trained in our specialties of Biostatistics and Clinical Psychology, neither of us had credentials or publications in mental health evaluation. We were not typical members of our professions in academia or in service delivery. I kept trying to develop a measure that would be open to any form of content and still have respectable psychometric properties. Sherman provided the structure and linkage to statistical concepts that would be familiar to statisticians. We were greatly aided and encouraged by Dr. Byron W. Brown, then Head of Biometry at the University of Minnesota and later Head of the Department of Epidemiology at Stanford University. I felt secure that the method could withstand challenge and scrutiny and had the potential for wide application. We learned one week after manuscript submission that our article would be published in The Journal of Community Mental Health. Authoritative sources told me that with random assignment, the method was iron-clad. It turned out that even without random assignment, if the method were open to professional audit, the method would prove useful in a wide variety of settings.
Dissemination and Utilization
Keywords: National Institutes of Mental Health (NIMH), knowledge transfer and utilization (KTU)
The initial application of GAS was in a comprehensive mental health program containing inpatient, outpatient (group, individual, and medication treatments), day treatment, social rehabilitation, and community outreach. All forms of contemporary treatments were offered. The initial skepticism regarding GAS was derived from its novelty and the fact that it was implemented with a design of randomization to treatments, therapists, students and staff. Even while the method was being implemented, NIMH officials encouraged dissemination of the idea, probably to see how it survived scrutiny in many settings, and to promote the idea of individualized evaluation. NIMH was also interested in promoting the concepts of knowledge transfer and utilization as part of the process of bringing about desired change in mental health services. With our Federal funding we maintained a nation-wide newsletter, produced implementation aids, and held several national conferences. This process permitted early users to communicate with each other and to demonstrate their efforts. I have made periodic efforts to summarize utilization of GAS, and using standard library databases and Google, I estimate that there are about 2,000 or more references. I am unable to vouch for the quality of these references. Many are in foreign languages and chapters in books are not covered. The range of content is amazing to me. Perhaps I should just tabulate them. There continues to be about ten to twelve new references per year in the standard databases. There are several additional journals that take special effort to locate. Thus my estimates are probably conservative.
Keywords: Early controversy, statistical comparisons, multi-site comparisons, “either/or” dichotomy
GAS proved to be an interesting and useful method but required adaptation to particular settings. Standardized measures were easier to use, but included many items that were irrelevant to the particular setting or individuals, including the therapists. Smith and Cardillo demonstrated that by including only those items in standardized measures that were relevant to individual cases, the distinction between standardized and individualized measurement largely disappeared. Smith and Cardillo also stressed the idea that GAS was not a measure of current status but was a measure of change, thus linking the method to familiar statistical concepts. I had always thought of GAS as a measure of prognoses – a concept familiar in the clinical process.
Early criticism often involved modifications of the method that precluded comparison with our reliability and validity findings. Much of our early writings were in defense against challenges that have now largely evaporated. I have about 1,200 references in my Endnote database, but using summaries and abstracts, I have found little or no interest in the methodological topics. Instead, nearly all the articles and dissertations describe applications, their results, and judgments of usefulness.
One of my psychological colleagues privately confided to me that it was particularly galling to him that he had spent so many hours studying and mastering psychological measures only to be confronted with a method that anyone can make up!
One pervasive problem that exists today is how to compare different treatment settings. If the patients, therapists, conditions, and available resources are the same or very similar, then the comparisons using standard measures (medication errors, side effects, costs, quality of treatment measures) can be used. You would still have the problem of within-setting patient specific expected outcomes. As you might expect from me, I see this as only the development of Follow-up Guides for organizations.
An interesting straw man argument used here and abroad, tried to force the choice between standardized and individualized measures. It was as though I had stated that we should use only individualized measures for everything. Nonsense! Of course, even if you were measuring height you would have to use both types of measures, the established measure of distance and the expected or appropriate height for individuals. In reply, I used Kierkegaard’s titles “Either Or,” and “Both.” This would put off my challengers into a cloud of uncertainty and imply that the confounding complexities of Existentialism might lie before them.
I wish I were able to make a comprehensive, scholarly summary of the current status of GAS and its probable future. This is probably antithetical to the original intent of the method which was to make a universally useful tool (my father was a blacksmith and tool maker) that would be readily accessible to everyone. It was like releasing a bird without ever knowing where it would go. With the development of mass communication methods, there is no way to know of all the uses and adaptations of GAS.
One image comes to mind - after delivering my expert presentation somewhere in Canada, a nun came forward and asked me if there had been any applications to community interventions and to ethnic populations. Since I was the expert, I held forth at some length. Only later did I learn from her that she and her religious order had been using the method for three years in a Native American community. She was considerably more experienced than I on this topic. When I urged her to publish their efforts, she stated simply that it would not be compatible with their religious order for them to call attention to themselves. I was a very chastened and thoughtful passenger on my return flight.
So how many other individuals and groups are simply going ahead and competently and quietly using the method? When I asked a local Jungian psychotherapist if she used GAS, she said, “Of course. It only makes sense.” End of story.
I am still receiving inquiries from Europe, Australia, New Zealand, and even Minneapolis. What I particularly enjoy about what I see in Steve Marson’s application and in other demonstrations that I have been able to examine, is the maintenance of the essential heart of the matter: the full knowledge of the professional specialty, the effort to know and understand their clients/patients, and to seek the best fit between their professional efforts and the needs of their clientele.
There is some effort in carrying out this task. It is easier to simply hand the client a test and set up an appointment for next week. When you are on the receiving end of services delivered in this manner you know how you feel. “I could have been anybody.” “Do they have any idea who I am?” The extra effort involves establishing a relationship and mutual understanding. The risk is that it also makes you accountable - unlike the routine processing method that provides insulation against evaluation. In a psychiatric departmental presentation that I made some years ago, a staff psychiatrist asked the question, “Just who are you evaluating, the patient or us?” I didn’t answer.