Stage of change in chinese patient with mental illness
Rehabilitation Psychology Copyright 2004 by the Educational Publishing Foundation2004, Vol. 49, No. 1, 39 – 47 0090-5550/04/$12.00 DOI: 10.1037/0090-5522.214.171.124 Stages of Change Among Chinese People With Mental Illness: A Preliminary Study Chih Chin Chou and Fong Chan Hector W. H. Tsang University of Wisconsin—Madison The Hong Kong Polytechnic University Objective: To determine the effect of self-efﬁcacy and outcome expectancy on the readiness for rehabilitation among Chinese people with mental illness. Participants: Fifty-eight men and 62 women with chronic mental illness. Outcome Measures: Change Assessment Questionnaire for People With Severe and Persistent Mental Illness, Task-Speciﬁc Self-Efﬁcacy Scale for People With Mental Illness, and Outcome-Expectancy Scale for People With Mental Illness. Results: Chinese people with mental illness can be meaningfully classiﬁed into 4 stages of change (SOC) groups: precontemplation, contem- plation, ambivalent– conforming, and action–maintenance. SOCs are related to self-efﬁcacy in interper- sonal, symptoms management, and help-seeking skills as well as expectations about the beneﬁt of social and coping skills. Conclusion: The SOC concept is useful for tailoring culturally sensitive psychiatric rehabilitation interventions for Chinese people with mental illness. Although deinstitutionalization is considered the norm in devel- community-based rehabilitation programming is beginning to re-oped countries, long-term psychiatric hospitalization coupled with ceive considerable attention. Similarly, in the vocational rehabili-pharmacological therapy is still the dominant model of treatment tation arena, sheltered workshops are still considered the mostfor individuals with mental illness in most Chinese societies, viable option for employment of people with psychiatric disabili-including Hong Kong and Taiwan (Cheng, 1985; Draguns, 1996; ties, but supported employment (primarily the use of enclave andSong & Singer, 2001; Tsang, Chan, & Bond, in press; Tsang, Tam, mobile crew) has been implemented successfully in the commu-Chan, & Cheung, 2003). This practice of routinely hospitalizing nity (Wong, Chiu, Chiu, & Tang, 2001; Wong et al., 2000). Theclients, especially those who are judged to be less responsive to major challenge for Chinese professionals, therefore, is to improvemedication, has led to signiﬁcant overcrowding of mental hospitals psychiatric rehabilitation services to a level equal to the quality(Cheung, 2001; Tsang, Chan, & Bond, in press). The average standards of those in developed countries without being insensitivelength of hospitalization for people with psychiatric disabilities in to the socioecological context of their own culture (Tsang, Chan,Hong Kong is estimated at 181 days (Hong Kong Government, & Bond, in press).1997). This practice of hospitalization and institutionalization also In Chinese societies, there is a strong social stigma againstruns counter to the community integration philosophy advocated individuals with mental illness (Chan, Hedl, et al., 1988; Tsang,by rehabilitation professionals and people with mental illness in Chan, & Chan, in press; Wang, Thomas, Chan, & Cheing, 2003)developed countries (Anthony, Cohen, & Farkas, 1990; Corrigan, that extends to their close family members because Chinese cultureRao, & Lam, 1999). attaches great importance to the collective representation of fam- As a result, rehabilitation professionals in both Hong Kong and ilies (Tam, Tsang, Chan, & Cheung, 2003; Tsang et al., 2003).Taiwan have begun to adopt contemporary psychiatric rehabilita- Having a close family member with mental illness is frequentlytion service approaches (e.g., supported employment) to help fa- viewed as shameful because it implies an inferior origin of thecilitate community integration of people with mental illness in family, failure of the parents, or even sin committed by the parentsthese two Westernized Chinese societies (Tsang, Chan, & Bond, in or their ancestors (Tsang et al., 2003). Hence, many Chinesepress). Currently, the conﬁguration of psychiatric rehabilitation families expend considerable efforts to conceal their relatives’services in Hong Kong and Taiwan reﬂects a high tolerance for the mental illness, resulting in social isolation and limitation of emo-coexistence of services that are sharply different from each other in tional and practical resources for dealing with the illness (Tam etideology and rehabilitation philosophy. For example, institution- al., 2003). The stigmatization of mental illness in Chinese societiesalization is still considered to be a valid approach to the rehabil- is so severe that it might also deter individuals with mental illnessitation and care of people with psychiatric disabilities, whereas and their families from embracing the community integration philosophy of rehabilitation. It is reasonable to assume that there are varying degrees of readiness for rehabilitation (especially in Chih Chin Chou and Fong Chan, Department of Rehabilitation Psychol- terms of working and living independently and assertively in theogy and Special Education, University of Wisconsin—Madison; Hector community) among Chinese people with mental illness, even inW. H. Tsang, Department of Rehabilitation Sciences, The Hong Kong those Westernized Chinese societies such as Hong Kong andPolytechnic University, Hong Kong, China. Correspondence concerning this article should be addressed to Fong Taiwan.Chan, PhD, Department of Rehabilitation Psychology and Special Educa- Interestingly, research in the United States also indicates that, intion, University of Wisconsin, 432 North Murray Street, Madison, WI the recovery process, people with severe mental illness may vary53706. E-mail: firstname.lastname@example.org in the degree to which they are ready to adapt to a psychosocial or 39
40 CHOU, CHAN, AND TSANGrehabilitation approach, and this variable may inﬂuence the en- & Ockene, 1994), brain injuries (Lam, Chan, & McMahon, 1991;gagement process as well as dropout and remission rates (Cohen, Lam, McMahon, Priddy, & Gehered-Schultz, 1988), and severeAnthony, & Farkas, 1997). Several rehabilitation researchers have and persistent mental illness (Hilburger & Lam, 1999; Rogers etadopted an empirically and theoretically based model, the stages of al., 2001). Prochaska et al. (DiClemente & Prochaska, 1998;change (SOC) model, to investigate the readiness for change Prochaska & DiClemente, 1992) have further developed a trans-among people with severe and persistent mental illness in the theoretical framework, integrating stages, processes, and levels ofUnited States (Hilburger & Lam, 1999; Rogers et al., 2001). This change, to provide understanding and intervention in facilitatingline of inquiry is particularly relevant for psychiatric rehabilitation behavior change.researchers and professionals in Hong Kong and Taiwan because In psychiatric rehabilitation, Hilburger and Lam (1999) andChinese people with mental illness and their family members Rogers et al. (2001) reported preliminary support for the applica-might resist the concept of community integration as a result of the bility of the SOC model to psychiatric rehabilitation. Both studieshigh cost of social stigma. The fear of social stigma and the lack indicated that people with severe mental illness exhibit similarof skills and experience to live in the community because of the patterns regarding the stages for change as presented in the SOClong concealment efforts of the family could result in different model. They found that people with severe mental illness could belevels of readiness to engage in rehabilitation by Chinese people classiﬁed into precontemplation, contemplation, action, and main-with mental illness. tenance stages based on their readiness for change. Although SOCs were initially identiﬁed in studying individuals who were several studies on various problem behaviors indicated that theattempting to quit smoking, both those participating in professional levels of self-efﬁcacy are strongly associated with the SOCs (e.g.,treatment and those attempting to quit on their own (DiClemente et Marcus, Rossi, Selby, Niaura, & Abrams, 1992), both Hilburgeral., 1991; DiClemente & Prochaska, 1982; Prochaska & Di- and Lam (1999) and Rogers et al. (2001) found little or noClemente, 1983). Prochaska, DiClemente, and Norcross (1992) correlation between SOCs and self-efﬁcacy. However, Leganer,have described the SOCs documented in their continuing program Kraft, and Roysamb (2000) suggested that task-speciﬁc self-efﬁ-of research. In the precontemplation stage, an individual shows no cacy measures might be more effective than generic measures inintention to change behavior, typically indicating no awareness predicting the intention of behavioral change. In addition, Hil-that any problem exists, even when external pressure is substantial. burger and Lam and Roger et al. did not study the effect ofIn the contemplation stage, the individual has become aware of the outcome expectancies on SOCs in their studies. Investigating theseexistence of a problem and has begun to think about making two variables in terms of their relationships to SOCs can providechanges but has not yet made a commitment to action in accom- further information on the applicability of the SOC model toplishing change. In the preparation stage, the individual intends to psychiatric rehabilitation.take action soon, with some minimal and largely unsuccessful To reiterate, the SOC model appears to be potentially useful forattempts at change in the recent past (e.g., short-term reduction in working with Chinese people with mental illness in psychiatricaddictive behavior without achieving abstinence). In the action rehabilitation. Because of the concealment efforts of the family,stage, the individual has committed substantial time and energy to Chinese people with mental illness might be more ambivalentchanging behavior and overcoming the problem and has success- about rehabilitation and might lack the necessary requisite skills tofully changed the behavior for some period of time. In the main- change than their American counterparts. Therefore, it is importanttenance stage, the individual commits substantial time and effort to for rehabilitation professionals to carefully gauge the readiness ofconsolidate changes that have occurred and to prevent resumption their Chinese clients for rehabilitation services and to provideof the problem behaviors. Prochaska and DiClemente (1983) con- interventions that are best suited to their level of readiness forceptualize the process of change according to a spiral rather than change within the socioecological context of the Chinese culture.linear model, with relapse, regression to earlier stages, and recy- The purpose of the current study is twofold: (a) to determine thecling through the stages as change progresses. The model also applicability of the SOCs model to Chinese people with mentalincorporates self-efﬁcacy and decisional balance– outcome expect- illness and (b) to determine the effects of task-speciﬁc self-efﬁcacyancy as outcome variables, which have been found to be indicators and outcome expectancy on their motivation to change. The ﬁnd-of stage movement, to study which individual factors can promote ings of this study could provide better understanding of the recov-behavioral change. ery process that Chinese people with mental illness experience and Much of the research on SOCs has focused on smoking and the services they need in order to move between different readinessother addictive behaviors, such as alcoholism (DiClemente & stages in the process of coping with their mental illness.Hughes, 1990; Miller & Tonigan, 1996), polydrug use (Belding,Iguchi, & Lamb, 1997), and obesity and weight control (Jeffery,French, & Rothman, 1999; Prochaska, Norcross, Fowler, Follick, Method& Abrams, 1992). However, the model has also been applied toother health risk behaviors, such as lack of exercise, poor nutrition, Participantsfailure to use sunscreen, and failure to use seatbelts in automobiles(Campbell et al., 2000; Nigg et al., 1999). In addition, it has been One hundred twenty mental health patients were recruited from three psychiatric rehabilitation centers in Hong Kong and Taiwan using theapplied to understanding change in general psychotherapy and following criteria: (a) a diagnosis of a chronic mental illness from eithercounseling (McConnaughy, Prochaska, & Velicer, 1983; psychiatrists or clinical psychologists; (b) received or currently receivingProchaska & Prochaska, 1999), case management (Levesque, inpatient or outpatient psychiatric treatment; (c) participating in a psychi-Prochaska, & Prochaska, 1999), and rehabilitation programming atric rehabilitation program such as daily skill training, community supportwith different types of disabilities, such as arthritis (Keefe et al., program, or vocational rehabilitation; (d) psychologically stable to com-2000), chronic pain (Jensen, 1996), cardiovascular disease (Amick plete a 90-min survey evaluated by professionals; and (e) at least a Grade
SPECIAL SECTION: STAGES OF CHANGE 416 reading level. No signiﬁcant differences were found among participants “I am conﬁdent in my ability to get along with my supervisor”). Items wererecruited from Hong Kong and Taiwan on demographic variables, with the rated on a 6-point Likert scale (1 ϭ not conﬁdent at all to 6 ϭ completelyexception of age at time of ﬁrst receiving treatment. Participants from conﬁdent). In the current study, internal consistency reliability coefﬁcientsHong Kong received ﬁrst-time treatment at a younger age (M ϭ 22.92, for the four scales ranged from .77 to .84.SD ϭ 7.54) than did those from Taiwan (M ϭ 27.53, SD ϭ 9.22). Overall, Outcome-Expectancy Scale for People With Mental Illness (OES-PMI).this study included 120 participants: 58 (48%) men and 62 (52%) women The OES-PMI was developed by Chou (2003) to operationalize outcome(age range ϭ 16 – 62 years; M ϭ 36.48, SD ϭ 10.13). Among these, 49.2% expectancy for coping with mental illness problems in different life do-(n ϭ 59) had a primary diagnosis of schizophrenia; 19.2% (n ϭ 23), mains. The OES-PMI is composed of three expectancy subscales: (a)bipolar disorder; 13.3% (n ϭ 16), depression; 2.5% (n ϭ 3), anxiety Social and Coping Skills, with 16 items assessing clients’ perception of thedisorder; 1.7% (n ϭ 2), obsessive– compulsive disorder; and 9.7% (n ϭ beneﬁts of coping positively with their mental illness such as having good17), other disorder. Eighty-seven percent (n ϭ 105) were currently pre- social and family relationships, avoiding risky behaviors, asking help fromscribed psychiatric medications, and 56% (n ϭ 67) reported side effects professionals, and committing to change (e.g., “Coping with my mentalfrom the medication. The mean number of hospitalizations was 3.94 (SD ϭ illness will help me have better control of my life”); (b) Work-Related5.88). Regarding education level, 50.8% (n ϭ 61) were high school Skills, with nine items assessing clients’ perception of the beneﬁts of goodgraduates, 27.5% (n ϭ 33) had only some high school education, 20.8% working behavior such as going to work on time and having good work(n ϭ 25) had a college degree, and 0.8% (n ϭ 1) had a master’s degree. In habits and good relationships with coworkers (e.g., “Getting along with myterms of marital and living status, 67.5% (n ϭ 81) were single, and 59.2% coworkers will help me keep my job”); and (c) Symptom Management(n ϭ 71) were living with family members. With respect to income, 34.2% Skills, with four items assessing clients’ perception of the beneﬁts of(n ϭ 41) indicated receiving support from social welfare, 29.2% (n ϭ 35) performing symptom management skills (e.g., “If I can manage symptomsfrom family members, and 14.2% (n ϭ 17) from work; 22.4% (n ϭ 27) of my mental illness, I will feel better about myself”). Items were rated onreported not having any income. In terms of working status, only 12.5% a 6-point Likert-type scale (1 ϭ not agree at all to 6 ϭ totally agree). In(n ϭ 15) of the participants reported that they were currently holding a the current study, internal consistency reliability coefﬁcients for the threefull-time job. subscales were computed to be .94, .93, and .86, respectively.Instruments Procedures Change Assessment Questionnaire for People With Severe and Persis- Participants were recruited from cooperating psychiatric rehabilitationtent Mental Illness (CAQ-SPMI). The CAQ-SPMI was adapted from the programs after we contacted the directors of the selected facilities andChange Assessment Questionnaire (CAQ) by Hilburger (1995). The orig- received approval of the research boards at those facilities. Two researchinal CAQ scale was developed by McConnaughy et al. (1983) to opera- assistants in Hong Kong and two psychiatric nurses in Taiwan were hiredtionalize SOCs for patients in outpatient psychotherapy clinics. Hilburger to recruit participants, administer the instruments, and collect data. The(1995) modiﬁed items from the original CAQ to reﬂect issues relevant to survey administrators met with participants, explained the research, andmental illness by replacing the word “problem” with “mental illness” in provided survey packets to those individuals who agreed to participate.each of the original items. The CAQ-SPMI is composed of 32 items with Participants received the research packet attached to a cover letter explain-four subscales: (a) Precontemplation (e.g., “As far as I am concerned, I ing the research purpose, potential risks, and beneﬁts of participation asdon’t have any mental health problems that need changing”), (b) Contem- well as an informed consent form. After providing demographic informa-plation (e.g., “I think I might be ready to work on improving myself”), (c) tion, research participants completed the CAQ-SPMI, TSSES-PMI, andAction (e.g., “I am ﬁnally doing some work on my mental health prob- OES-PMI. Completion of all instruments required 60 to 90 min.lems”), and (d) Maintenance (e.g., “I may need a boost right now to helpme maintain the changes I have already made”). Items were rated foragreement on a 5-point Likert scale. Hilburger reported internal consis- Resultstency reliability coefﬁcients for the four scales ranging from .79 to .89. TheCAQ-SPMI was ﬁrst translated from English to Chinese by Chih Chin Predominant SOCs Participant ClustersChou and then translated back from Chinese to English by a professionaltranslator and a professor in the Department of Comparative Literature at The correlations, means, and standard deviations for the sub-the University of Don-Huaw, Taiwan. A comparison of the translated scales of the CAQ-SPMI for the Chinese sample in the currentversion with the American version indicated no important loss of meaning study and the American sample in Hilburger and Lam (1999)’sacross the 32 items. study are presented in Table 1. Task-Speciﬁc Self-Efﬁcacy Scale for People With Mental Illness As can be observed, the Precontemplation subscale in the cur-(TSSES-PMI). Prochaska and DiClemente (1992) indicated that people indifferent SOCs use different skills (processes) to cope with their problem rent study has relatively low correlations with the rest of thebehaviors in different life domains (levels). The TSSES-PMI was devel- subscales, whereas the Contemplation subscale correlated theoped by Chou (2003) to operationalize these speciﬁc coping skills pertain- highest with the Action subscale, and the Action subscale corre-ing to people with mental illness in psychiatric rehabilitation. The TSSE- lated the highest with the Maintenance scale. The correlationPMI is composed of four subscales: (a) Interpersonal Skills, with seven between the Precontemplation and Contemplation subscales in theitems measuring skills and behaviors that are essential in establishing and current study is Ϫ.16 compared to Ϫ.51 in Hilburger and Lam’smaintaining good interpersonal relationships (e.g., “I am conﬁdent in my study. The magnitude of the correlation indexes among the Con-ability to control negative emotions in social situations”); (b) Symptom templation, Action, and Maintenance subscales is similar to theManagement, with four items measuring ability to take medication, main- moderately high correlations reported by Hilburger and Lamtain a stable mood, and seek professional attention when needed (e.g., “I (1999). Also, the American sample in the Hilburger and Lam studyam conﬁdent in my ability to take medication daily as prescribed”); (c)Help-Seeking Skills, with four items measuring the ability to seek help had higher mean scores in Contemplation, Action, and Mainte-from mental health professionals with difﬁculties in daily life (e.g., “I am nance than the Chinese sample in the current study. Conversely,conﬁdent in my ability to seek professional help for my relationship the Chinese sample had a higher Precontemplation score than theproblems”); and (d) Work-Related Skills, with ﬁve items measuring skills Americans.and behaviors that are important to obtaining and maintaining a job (e.g., Cluster analysis was used to identify groups of participants on
42 CHOU, CHAN, AND TSANGTable 1 mise between maximizing cluster homogeneity and providing aCorrelations, Means, and Standard Deviations for the Subscales limited number of participant clusters. The mean item scores forof the CAQ-SPMI for the Current Study and Hilburger each of the four clusters on each of the CAQ-SPMI subscales areand Lam (1999) provided in Table 2. For ease of interpretation, the mean item Pearson correlation scores are transformed into standardized T scores and included in the table. A graphic representation of the SOCs group proﬁles is Subscale M SD 1 2 3 4 presented in Figure 1.Current study Cluster 1: Contemplation. Cluster 1 was composed of 23 1. Precontemplation 2.97 .61 — Ϫ.16* .19 .31* participants (19%), with the highest score on Contemplation and 2. Contemplation 2.20 .49 — .64** .53** lower scores on Precontemplation, Action, and Maintenance. The 3. Action 2.14 .56 — .68** 4. Maintenance 2.37 .69 — low score on the Precontemplation subscale suggested that peopleHilburger and Lam (1999) in this group are aware of their mental illness problems and that 1. Precontemplation 2.42 .77 Ϫ.51 Ϫ.37 Ϫ.24 something might need to be changed. The score on the Contem- 2. Contemplation 4.02 .57 — .64 .57 plation subscale indicated that members of this group might be 3. Action 3.90 .56 — — .42 4. Maintenance 3.42 .69 — — — making tentative efforts to change. However, they are not ready to make a major commitment to change, as indicated by lower scoresNote. CAQ-SPMI ϭ Change Assessment Questionnaire for People With on the Action and Maintenance subscales. This cluster is similar toSevere and Persistent Mental Illness.* p Ͻ .05. ** p Ͻ .01. the Contemplation group identiﬁed by McConnaughy et al. (1989) and Hilburger and Lam (1999), with members somewhat involved in thinking about change and attending to the existence ofthe basis of their mean scores on each of the four CAQ-SPMI the problem.subscales: Precontemplation, Contemplation, Action, and Mainte- Cluster 2: Ambivalent– conforming. Cluster 2 was composednance. Ward’s hierarchical agglomerative clustering method was of 79 participants (66%) with moderately high scores on all fourused, with squared Euclidean distance as the index of pairwise subscales: Precontemplation, Contemplation, Action, and Mainte-similarity– dissimilarity between participant proﬁles. This method nance. Their scores suggest active participation in treatment, butwas used to examine sample SOCs proﬁles in previous studies by their moderately high Precontemplation scores also suggest thatMcConnaughy et al. (McConnaughy et al., 1983; McConnaughy, they might not fully acknowledge the existence of their mentalDiClemente, Prochaska, & Velicer, 1989) as well as Lam et al. illness and associated needs for treatment. As a result, they may be(Lam et al., 1991; Hilburger & Lam, 1999). Because the SOCs “going through the motions” in their participation, perhaps toproﬁles among Chinese people with mental illness are relatively satisfy family, friends, or others who may have encouraged treat-unknown, the use of cluster analysis for exploratory purposes ment, lacking internal motivation to treatment and change. Thisseems warranted. cluster is the largest in the sample and is similar to the conforming To identify an optimal grouping of participants in the clustering cluster identiﬁed by Cardoso, Chan, Berven, and Thomas (2003) inhierarchy, the agglomeration schedule was examined to ﬁnd a late their study of people with substance abuse problems whose par-stage in the hierarchy, with a relatively small number of participant ticipation in rehabilitation was mandated by court.clusters, in which the error sum of squares coefﬁcients increased Cluster 3: Action–maintenance. Cluster 3 was composed of 8dramatically at subsequent stages in the hierarchy after relatively participants (7%) with the lowest score on Precontemplation andsmall increases at previous stages (see Berven & Hubert, 1977). high scores (about 2 SDs above the mean) on Contemplation,The stage producing four clusters of participants had relatively Action, and Maintenance. People in this group are aware of theirsmall increases of 4.6, 6.2, and 9.0 in the error sum of squares from problems, are actively involved in their treatment, and may haveone stage to the next at the three stages preceding the four-cluster already made signiﬁcant changes in coping with their mentalstage compared with increases of 15.2, 19.3, and 36.9 at the three illness. Because the proﬁle of this cluster fell in between the actionsubsequent stages in the hierarchy. Thus, cluster homogeneity and maintenance clusters described in earlier studies (Hilburger &dropped substantially after this stage, after much smaller decreases Lam, 1999; McConnaughey et al., 1989), this cluster may repre-at previous stages, and it thus seemed to provide a good compro- sent a combination of those clusters. The combination of the twoTable 2Means and Standard Deviations on CAQ-SPMI for the Four Participant Clusters SOC cluster Cluster 1 (n ϭ 23) Cluster 2 (n ϭ 79) Cluster 3 (n ϭ 8) Cluster 4 (n ϭ 10) Subscale T score M SD T score M SD T score M SD T score M SDPrecontemplation 35.6 2.17 0.57 54.0 3.19 0.43 47.8 2.84 0.33 53.5 3.16 0.55Contemplation 50.9 2.21 0.40 49.7 2.14 0.34 70.1 3.10 0.29 34.1 1.41 0.25Action 44.0 1.83 0.36 51.8 2.19 0.32 68.8 2.98 0.24 34.4 1.39 0.29Maintenance 42.2 1.85 0.36 52.3 2.43 0.38 69.2 3.42 0.33 34.3 1.38 0.25Note. Cluster 1 ϭ contemplation; Cluster 2 ϭ ambivalent– conforming; Cluster 3 ϭ action–maintenance; Cluster 4 ϭ precontemplation. CAQ-SPMI ϭChange Assessment Questionnaire for People With Severe and Persistent Mental Illness; SOC ϭ stages of change.
SPECIAL SECTION: STAGES OF CHANGE 43 from each other on the four TSSES-PMI subscales. Because of group size differences among the identiﬁed clusters, Levene’s test and Box’s M test were conducted to assess whether the assumption of homogeneity of variance– covariance matrices might be vio- lated. The results of Levene’s test for all dependent variables were nonsigniﬁcant so that the equal group variances assumption was met. However, the signiﬁcant result of the Box’s M, F(30, 2307) ϭ 2.467, p Ͻ .01, suggested a violation of the assumption of equal covariance matrices across groups. Although Lindman (1974) stated that the MANOVA is quite robust against violations of the homogeneity assumption, other researchers have raised concerns when interpreting the results. Olsen (1976) indicated that, with small or unequal sample sizes, Pillai’s trace is more robust than Wilks’s lambda for testing the multivariate effect to produceFigure 1. Change Assessment Questionnaire for People With Severe and acceptable power and control Type I error. Therefore, Pillai’s tracePersistent Mental Illness proﬁles for the four participant clusters. was used to evaluate the main effect among the four SOCs groups. On ﬁnding a signiﬁcant multivariate Pillai’s trace ϭ .663, F(12,stages may indicate that people realized that behavior change is, as 345) ϭ 8.16, p Ͻ .00, 2 ϭ .21, a univariate analysis of varianceProchaska and DiClemente (1983) have pointed out, a continuous (ANOVA) was computed for each dependent variable. The alphaprocess that requires ongoing endeavor to participate in behavioral level was divided by four for each pairwise comparison to controlchange and maintain the mastery of these changes. Interestingly, for Type I error (␣ ϭ .01/4 ϭ .0025). The results indicatedcompared with other cluster groups, members of this group are the signiﬁcant differences on three of the four task-speciﬁc self-efﬁ-youngest (M ϭ 33.38 years, SD ϭ 9.25), with the highest educa- cacy factors: interpersonal skills, symptom management skills, andtion (37.5% have a high school degree and 37.5% a college help-seeking skills. There is no difference among the four clusterdegree), and the largest number of people living indepen- groups on work-related skills. The mean item scores for each of thedently (38%). four clusters on each of the TSSES-PMI subscales are provided in Cluster 4: Precontemplation. Cluster 4 was composed of 10 Table 3.participants (8% of the total sample), with the highest score on Post hoc comparisons using the Bonferroni procedure indicatedPrecontemplation and lower scores on Contemplation, Action, and that participants in the action–maintenance group and the ambiv-Maintenance. The relatively high Precontemplation score and low alent– conforming groups expressed higher self-efﬁcacy in inter-other SOC scores (2 SD differences) indicated that people in this personal skills than did individuals in the precontemplation andgroup were not aware of their problems. They are content with contemplation groups. Similarly, they also expressed higher self-their current lifestyle and might not be thinking about changing efﬁcacy in help-seeking skills than did individuals in the precon-their ways to cope with their mental illness issues. The proﬁle of templation and the contemplation groups. Moreover, the action–this cluster corresponded closely to the precontemplation group maintenance group expressed signiﬁcantly higher self-efﬁcacy inidentiﬁed by McConnaughy et al. (1989) and Hilburger (1995). symptom management skills than did those in the other three readiness stages: precontemplation, contemplation, and ambiv-SOCs and Task-Speciﬁc Self-Efﬁcacy alent– conforming groups. Finally, people in the contemplation Multivariate analysis of variance (MANOVA) was used to group expressed higher self-efﬁcacy in symptom managementdetermine whether participants in the four SOCs clusters differ skills than did those in the precontemplation group. Table 3 Means, Standard Deviations, and F Values on the TSSES-PMI Subscales for the Four SOC Groups SOC group Ambivalent– Action– Precontemplation Contemplation conforming maintenance (n ϭ 10) (n ϭ 23) (n ϭ 79) (n ϭ 8) Factor M SD M SD M SD M SD F(3, 116) SEIS 1.56 0.57 2.13 1.04 3.02 0.95 3.96 0.88 13.39*a SESM 1.40 0.61 1.98 0.90 2.27 0.68 4.13 0.13 24.94*b SEHS 1.78 1.19 2.13 0.88 3.22 1.13 4.19 0.81 13.55*c SEWS 2.84 1.01 2.29 0.93 2.96 0.96 3.28 0.37 3.74 Note. TSSES-PMI ϭ Task-Speciﬁc Self-Efﬁcacy Scale for People With Mental Illness; SOC ϭ stages of change; SEIS ϭ self-efﬁcacy of interpersonal skills; SESM ϭ self-efﬁcacy of symptom management skills; SEHS ϭ self-efﬁcacy of help-seeking skills; SEWS ϭ self-efﬁcacy of work-related skills. ϭ .26. b 2 ϭ .39. c 2 ϭ .26. a 2 * p Ͻ .01.
44 CHOU, CHAN, AND TSANGSOCs and Outcome Expectancies patterns, with the senior member always accorded a wide range of prerogatives and authority with respect to the junior (Bond & A MANOVA was computed to determine whether participants Hwang, 1987). Today these hierarchical relationships are alsoin the four SOCs clusters differ from each other on the three generalized to prescribe proper behaviors in educational, voca-OES-PMI subscales (outcome expectancies). A signiﬁcant multi- tional, and social settings. In addition, as long as each member ofvariate F was found, Pillai’s trace ϭ .15, F(9, 348) ϭ 2.07, p Ͻ the unit is conscientious in following the requirements of his or her.05, 2 ϭ .05. Univariate ANOVAs were then conducted for each role, harmony will be achieved.dependent variable. The alpha level was divided by three for each Confucian philosophy strongly advocates the virtue of sacriﬁc-pair comparison to control for Type I error (␣ ϭ .01/3 ϭ .0033). ing individual needs for the good of the group. The family is theThe results indicated a signiﬁcant difference on one of the three most basic and important unit in the society (i.e., three of the ﬁveoutcome expectancy domains: the social and coping skills domain.Individuals in different readiness stages expected similar beneﬁts cardinal relationships pertain to the family), and the parents are thefor performing good work-related skills and symptom manage- highest authority in the family. To strive for harmony in thement skills. The mean item scores for each of the four clusters on family, child-rearing practices in Chinese society tend to placeeach of the OES-PMI subscales are provided in Table 4. great emphasis on obedience, proper conduct, control of emotion, Post hoc comparisons using the Bonferroni procedure indicated moral training, impulse control, achievement, and the acceptancethat individuals in the precontemplation cluster (M ϭ 1.22) dem- of social obligations in contrast to the lack of emphasis placed ononstrated less positive outcome expectancy in social and coping independence, assertiveness, and creativity (Bond & Hwang,skills than did people in the ambivalent– conforming (M ϭ 2.05) 1987). This tendency to conform extends to professional relation-and action–maintenance (M ϭ 2.45) groups. No other signiﬁcance ships. Chan, Wong, Lam, Leung, and Fang (1988) indicated thatwas found. the concepts of hierarchical relations and obedience can perhaps best explain the preference of Chinese clients for more directive Discussion and structured counseling. Therefore, out of politeness and obedi- ence, many Chinese people with mental illness would actively Using cluster analysis, four SOCs groups (precontemplation, participate in rehabilitation activities without necessarily having ancontemplation, ambivalent– conforming, and action–maintenance) internal motivation for change (i.e., ambivalent– conforming).were found for Chinese people with mental illness. The results In addition, because of social stigma, Chinese families tend toseem to generally support the validity of the SOC model for people conceal their family members with mental illness from the public.with mental illness in both the American and Chinese cultures. Therefore, the majority of the Chinese people with mental illness Interestingly, ambivalent– conforming is the largest SOC group and their family members may be ambivalent about rehabilitation,among Chinese people with mental illness in the current study. especially when the goal is community integration, which mayAccording to Bond and Hwang (1987), the inﬂuence of Confucian require people with mental illness to be visible and identiﬁable. Inideology and teachings is still prevalent in Chinese culture, phi- fact, Chinese people with mental illness may be afraid to integratelosophy, and social structure. Fundamentally, Confucius believed assertively into the community. Tsang et al. (2003) examinedthat people exist in relationship to others, and within each rela- 1,007 Hong Kong residents’ attitudes toward people with mentaltionship there are well-deﬁned rules of correct behaviors in terms illness on a range of education, social, family, and employmentof rights and responsibilities (Bond & Hwang, 1987). Speciﬁcally, issues. They reported that 60% of the sample strongly opposed theﬁve cardinal relations are of paramount importance in the Confu- establishment of psychiatric rehabilitation facilities in the commu-cian tradition: those between sovereign and subject, father and son, nity. Tsang, Chan, and Chan (in press) indicated that the perceivedelder brother and younger brother, husband and wife, and friend level of threat is still a dominant factor in the formation of negativeand friend. These relationships were constructed in hierarchical attitudes toward people with mental illness. Therefore, based on Table 4 Means, Standard Deviations, and F Values on the OES-PMI Subscales for the Four SOC Groups SOC group Ambivalent– Action– Precontemplation Contemplation conforming maintenance (n ϭ 10) (n ϭ 23) (n ϭ 79) (n ϭ 8) Factor M SD M SD M SD M SD F(3, 116) OEC 1.22 0.35 1.93 0.65 2.05 0.77 2.45 0.63 5.17*a OEW 2.39 1.29 1.99 0.73 2.50 1.26 2.40 0.87 0.94 OES 1.50 0.94 1.98 0.82 2.19 0.99 2.31 0.95 1.85 Note. OES-PMI ϭ Outcome-Expectancy Scale for People With Mental Illness; SOC ϭ stages of change; OEC ϭ outcome expectancy of social and coping skills; OEW ϭ outcome expectancy of work-related skills; OES ϭ outcome expectancy of symptom management skills. ϭ .12. a 2 * p Ͻ .01.
SPECIAL SECTION: STAGES OF CHANGE 45cultural factors and social stigma toward people with mental Given that Chinese people with mental illness experience signiﬁ-illness, it is not surprising that the majority of the Chinese with cant difﬁculties in ﬁnding and maintaining employment in themental illness in the current study belong to the ambivalent– community, their work-related self-efﬁcacy may be appreciablyconforming group. underdeveloped. Therefore, work-related skills may have little, if Contrary to the Hilburger and Lam (1999) and Rogers et al. any, effect on their level of readiness to change. It is also possible(2001) studies, SOCs were found to relate to self-efﬁcacy in the that in Chinese societies people with mental illness are frequentlycurrent study. Our ﬁndings underscore the importance of the study left at home with families and are not expected to work or assumeof self-efﬁcacy in the context of speciﬁc skills required to function ﬁnancial responsibilities (Tsang et al., 2003). Work, although seenoptimally in the community (i.e., task-speciﬁc self-efﬁcacy). As as therapeutic in Western societies, may not be viewed as relevantpredicted in the SOC model, people with mental illness in the later to psychiatric rehabilitation in Chinese societies. Therefore, it wasSOCs appeared to exhibit higher task-speciﬁc self-efﬁcacy than no surprise that we found minimal association between the self-did those in the early SOCs. A clear pattern emerged by which efﬁcacy in work skills and the SOCs.people in the action–maintenance group exhibited the highest Results of the current study also provided some evidence of thetask-speciﬁc self-efﬁcacy and those in the precontemplation group effect of outcome expectancy on SOCs. As predicted in the SOCexhibited the lowest. These results differ from those of Hilburger model, people in the later stages of change (ambivalent– conform-and Lam in their attempts to link general self-efﬁcacy with SOCs. ing and action–maintenance) appeared to expect more positiveHilburger and Lam found that individuals in the precontemplation outcomes in performing good social and coping skills than didstage did not perceive themselves as having low self-efﬁcacy. those in the early SOCs.However, the results of the current study are consistent withﬁndings of other studies on the SOC model, indicating that in-creasing self-efﬁcacy was related to the movement of SOCs for Clinical Implicationspeople in smoking cessation (DiClemente, Prochaska, & Gibertini, The current study could have signiﬁcant clinical implications for1985), substance abuse (DiClemente & Hughes, 1990), and HIV psychiatric rehabilitation in Westernized Chinese societies such asprevention (Polacsek, Celentano, O’Campo, & Santelli, 1999) Hong Kong and Taiwan because professionals there tend to haveprograms. a high propensity to want to adopt Western rehabilitation philos- Although task-speciﬁc self-efﬁcacy was related to SOCs, clear ophy and approaches in their practices. The results of the currentdifferentiation between every stage was not found. Speciﬁcally,people in the precontemplation and contemplation groups did not study suggest that the disability rights– community integrationdiffer in their self-efﬁcacy in interpersonal, help-seeking, and approaches to psychiatric rehabilitation must be adopted withwork-related skills. This ﬁnding is consistent with the research caution. That is, within the context of the Chinese culture (aliterature in SOCs. Grimley, Prochaska, Velicer, Blais, and Di- collectivism culture), not all clients necessarily want to be inde-Clemente (1994) pointed out that self-efﬁcacy does not emerge as pendent and assume an assertive role in the community. The SOCrelevant in early stage movement compared with later stage move- approach would allow professionals to determine the readiness ofment, although the development of self-efﬁcacy is necessary for Chinese clients with mental illness and their families to engage inbehavioral change through all stage movements. Malotte et al. meaningful community-based rehabilitation services.(2000) suggested that intervention for people in the early stages The ﬁndings of the current study suggest that an effectiveshould include a self-efﬁcacy component in speciﬁc dimensions treatment plan for people in the early SOCs should focus onbased on the empirical evidence with different populations. enhancing cognitive-oriented programs (e.g., outcome expectancy, In this study, we found that the precontemplation and contem- especially in exploring the positive outcomes of performing goodplation groups differed from each other in the self-efﬁcacy area of social, coping, and help-seeking behaviors), gradually shifting thesymptom management skills. This ﬁnding suggests that interven- focus to skill-oriented programs (e.g., self-efﬁcacy in performingtion strategies that focus on developing self-efﬁcacy in managing interpersonal, symptom management, and help-seeking skills), asmental illness symptoms rather than other self-efﬁcacy dimensions one moves through the higher SOCs.might be the ﬁrst priority when helping people with mental illness Chinese people with mental illness in this study indicated lowin the precontemplation stage progress to the contemplation or self-efﬁcacy in work-related skills and low outcome expectancieslater stages. In terms of work-related skills, this dimension of for the beneﬁts of acquiring work-related skills in relation to theirself-efﬁcacy is not part of the original integrative model of change rehabilitation. However, work is considered therapeutic and essen-advanced by Prochaska et al. (e.g., Prochaska, DiClemente, & tial for both the physiological survival and psychological well-Norcross, 1992). The work dimension was added in this study being of people in contemporary societies (Dawis, 1987). Recog-because of its central value in vocational rehabilitation. However, nizing the importance of work, rehabilitation professionals infor Chinese people with mental illness, work-related skills ap- developed countries have consistently advocated for work as apeared to be less predictive of stage movement than did the other fundamental human right of people with disabilities. The lowself-efﬁcacy domains that were identiﬁed in the original model. self-efﬁcacy and low outcome expectancy for work-related skillsOne possible explanation is that people with mental illness often among Chinese people with mental illness in this study may be dueencounter great difﬁculties in obtaining and maintaining employ- to the difﬁculty for them to obtain employment in Hong Kong andment (Anthony, 1994), so that their self-efﬁcacy in work-related Taiwan. Nevertheless, rehabilitation professionals need to incor-skills may remain low across all readiness stages. According to porate the work component in rehabilitation treatment plans toBandura’s (1986) social cognitive theory, one’s self-efﬁcacy level help people with mental illness in Chinese societies who want toin performing speciﬁc tasks (e.g., work-related skills) is enhanced ﬁnd jobs, integrate into the community, and ultimately achieveby the mastery of past successful experiences (e.g., employment). rehabilitation goals.
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