1. Rehabilitation Psychology Copyright 2004 by the Educational Publishing Foundation
2004, Vol. 49, No. 1, 39 – 47 0090-5550/04/$12.00 DOI: 10.1037/0090-5550.49.1.39
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 most
for 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 and
Song & 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). The
clients, especially those who are judged to be less responsive to major challenge for Chinese professionals, therefore, is to improve
medication, 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 insensitive
length 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 against
runs 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 culture
Rao, & 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 frequently
tion service approaches (e.g., supported employment) to help fa- viewed as shameful because it implies an inferior origin of the
cilitate community integration of people with mental illness in family, failure of the parents, or even sin committed by the parents
these two Westernized Chinese societies (Tsang, Chan, & Bond, in or their ancestors (Tsang et al., 2003). Hence, many Chinese
press). 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 et
ideology and rehabilitation philosophy. For example, institution-
al., 2003). The stigmatization of mental illness in Chinese societies
alization is still considered to be a valid approach to the rehabil-
is so severe that it might also deter individuals with mental illness
itation 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 the
ogy and Special Education, University of Wisconsin—Madison; Hector
community) among Chinese people with mental illness, even in
W. H. Tsang, Department of Rehabilitation Sciences, The Hong Kong
those Westernized Chinese societies such as Hong Kong and
Polytechnic 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, in
tion, University of Wisconsin, 432 North Murray Street, Madison, WI the recovery process, people with severe mental illness may vary
53706. E-mail: chan@education.wisc.edu in the degree to which they are ready to adapt to a psychosocial or
39

2. 40 CHOU, CHAN, AND TSANG
rehabilitation 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 severe
Anthony, & Farkas, 1997). Several rehabilitation researchers have and persistent mental illness (Hilburger & Lam, 1999; Rogers et
adopted 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 of
United States (Hilburger & Lam, 1999; Rogers et al., 2001). This change, to provide understanding and intervention in facilitating
line 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) and
Chinese 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 studies
high cost of social stigma. The fear of social stigma and the lack indicated that people with severe mental illness exhibit similar
of skills and experience to live in the community because of the patterns regarding the stages for change as presented in the SOC
long concealment efforts of the family could result in different model. They found that people with severe mental illness could be
levels 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 the
attempting 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 Hilburger
al., 1991; DiClemente & Prochaska, 1982; Prochaska & Di- and Lam (1999) and Rogers et al. (2001) found little or no
Clemente, 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 in
intention 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 of
In the contemplation stage, the individual has become aware of the outcome expectancies on SOCs in their studies. Investigating these
existence of a problem and has begun to think about making two variables in terms of their relationships to SOCs can provide
changes but has not yet made a commitment to action in accom- further information on the applicability of the SOC model to
plishing 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 for
attempts at change in the recent past (e.g., short-term reduction in working with Chinese people with mental illness in psychiatric
addictive 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 ambivalent
changing behavior and overcoming the problem and has success- about rehabilitation and might lack the necessary requisite skills to
fully changed the behavior for some period of time. In the main- change than their American counterparts. Therefore, it is important
tenance stage, the individual commits substantial time and effort to for rehabilitation professionals to carefully gauge the readiness of
consolidate changes that have occurred and to prevent resumption their Chinese clients for rehabilitation services and to provide
of the problem behaviors. Prochaska and DiClemente (1983) con- interventions that are best suited to their level of readiness for
ceptualize 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 the
cling through the stages as change progresses. The model also applicability of the SOCs model to Chinese people with mental
incorporates self-efficacy and decisional balance– outcome expect- illness and (b) to determine the effects of task-specific self-efficacy
ancy 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 readiness
other 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 to
other health risk behaviors, such as lack of exercise, poor nutrition, Participants
failure 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 the
applied to understanding change in general psychotherapy and
following criteria: (a) a diagnosis of a chronic mental illness from either
counseling (McConnaughy, Prochaska, & Velicer, 1983; psychiatrists or clinical psychologists; (b) received or currently receiving
Prochaska & 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 support
with 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

3. SPECIAL SECTION: STAGES OF CHANGE 41
6 reading level. No significant differences were found among participants “I am confident in my ability to get along with my supervisor”). Items were
recruited 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 completely
exception of age at time of first receiving treatment. Participants from confident). In the current study, internal consistency reliability coefficients
Hong 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 the
disorder; 1.7% (n ϭ 2), obsessive– compulsive disorder; and 9.7% (n ϭ benefits of coping positively with their mental illness such as having good
17), other disorder. Eighty-seven percent (n ϭ 105) were currently pre- social and family relationships, avoiding risky behaviors, asking help from
scribed psychiatric medications, and 56% (n ϭ 67) reported side effects professionals, and committing to change (e.g., “Coping with my mental
from the medication. The mean number of hospitalizations was 3.94 (SD ϭ illness will help me have better control of my life”); (b) Work-Related
5.88). Regarding education level, 50.8% (n ϭ 61) were high school Skills, with nine items assessing clients’ perception of the benefits of good
graduates, 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 my
terms 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 symptoms
from 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 on
reported 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 three
full-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 rehabilitation
tent Mental Illness (CAQ-SPMI). The CAQ-SPMI was adapted from the programs after we contacted the directors of the selected facilities and
Change Assessment Questionnaire (CAQ) by Hilburger (1995). The orig- received approval of the research boards at those facilities. Two research
inal CAQ scale was developed by McConnaughy et al. (1983) to opera- assistants in Hong Kong and two psychiatric nurses in Taiwan were hired
tionalize 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, and
mental 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 as
don’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, and
Action (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 help
me maintain the changes I have already made”). Items were rated for
agreement on a 5-point Likert scale. Hilburger reported internal consis- Results
tency reliability coefficients for the four scales ranging from .79 to .89. The
CAQ-SPMI was first translated from English to Chinese by Chih Chin Predominant SOCs Participant Clusters
Chou and then translated back from Chinese to English by a professional
translator 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 current
version with the American version indicated no important loss of meaning study and the American sample in Hilburger and Lam (1999)’s
across 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 in
different SOCs use different skills (processes) to cope with their problem
rent study has relatively low correlations with the rest of the
behaviors in different life domains (levels). The TSSES-PMI was devel- subscales, whereas the Contemplation subscale correlated the
oped 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 correlation
PMI is composed of four subscales: (a) Interpersonal Skills, with seven between the Precontemplation and Contemplation subscales in the
items measuring skills and behaviors that are essential in establishing and current study is Ϫ.16 compared to Ϫ.51 in Hilburger and Lam’s
maintaining 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 the
Management, with four items measuring ability to take medication, main- moderately high correlations reported by Hilburger and Lam
tain a stable mood, and seek professional attention when needed (e.g., “I
(1999). Also, the American sample in the Hilburger and Lam study
am 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 the
problems”); 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

4. 42 CHOU, CHAN, AND TSANG
Table 1 mise between maximizing cluster homogeneity and providing a
Correlations, Means, and Standard Deviations for the Subscales limited number of participant clusters. The mean item scores for
of the CAQ-SPMI for the Current Study and Hilburger each of the four clusters on each of the CAQ-SPMI subscales are
and 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 people
Hilburger 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 scores
Note. CAQ-SPMI ϭ Change Assessment Questionnaire for People With on the Action and Maintenance subscales. This cluster is similar to
Severe 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 of
the 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 composed
nance. Ward’s hierarchical agglomerative clustering method was of 79 participants (66%) with moderately high scores on all four
used, 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, but
was used to examine sample SOCs profiles in previous studies by their moderately high Precontemplation scores also suggest that
McConnaughy et al. (McConnaughy et al., 1983; McConnaughy, they might not fully acknowledge the existence of their mental
DiClemente, 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 to
profiles 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. This
seems 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) in
hierarchy, 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 8
dramatically at subsequent stages in the hierarchy after relatively participants (7%) with the lowest score on Precontemplation and
small 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 their
small 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 have
one stage to the next at the three stages preceding the four-cluster already made significant changes in coping with their mental
stage 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 action
subsequent 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 two
Table 2
Means 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 SD
Precontemplation 35.6 2.17 0.57 54.0 3.19 0.43 47.8 2.84 0.33 53.5 3.16 0.55
Contemplation 50.9 2.21 0.40 49.7 2.14 0.34 70.1 3.10 0.29 34.1 1.41 0.25
Action 44.0 1.83 0.36 51.8 2.19 0.32 68.8 2.98 0.24 34.4 1.39 0.29
Maintenance 42.2 1.85 0.36 52.3 2.43 0.38 69.2 3.42 0.33 34.3 1.38 0.25
Note. Cluster 1 ϭ contemplation; Cluster 2 ϭ ambivalent– conforming; Cluster 3 ϭ action–maintenance; Cluster 4 ϭ precontemplation. CAQ-SPMI ϭ
Change Assessment Questionnaire for People With Severe and Persistent Mental Illness; SOC ϭ stages of change.

5. 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 produce
Figure 1. Change Assessment Questionnaire for People With Severe and acceptable power and control Type I error. Therefore, Pillai’s trace
Persistent 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 variance
Prochaska and DiClemente (1983) have pointed out, a continuous (ANOVA) was computed for each dependent variable. The alpha
process that requires ongoing endeavor to participate in behavioral level was divided by four for each pairwise comparison to control
change and maintain the mastery of these changes. Interestingly, for Type I error (␣ ϭ .01/4 ϭ .0025). The results indicated
compared 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, and
tion (37.5% have a high school degree and 37.5% a college help-seeking skills. There is no difference among the four cluster
degree), and the largest number of people living indepen- groups on work-related skills. The mean item scores for each of the
dently (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 indicated
Precontemplation 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 and
group 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 in
identified 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 management
determine 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.

6. 44 CHOU, CHAN, AND TSANG
SOCs 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 also
in 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 of
variate 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 the
The results indicated a significant difference on one of the three
most basic and important unit in the society (i.e., three of the five
outcome 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 the
for performing good work-related skills and symptom manage- highest authority in the family. To strive for harmony in the
ment skills. The mean item scores for each of the four clusters on family, child-rearing practices in Chinese society tend to place
each 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 acceptance
that individuals in the precontemplation cluster (M ϭ 1.22) dem- of social obligations in contrast to the lack of emphasis placed on
onstrated 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 that
was 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 an
contemplation, 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 to
seem 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 may
According to Bond and Hwang (1987), the influence of Confucian require people with mental illness to be visible and identifiable. In
ideology and teachings is still prevalent in Chinese culture, phi- fact, Chinese people with mental illness may be afraid to integrate
losophy, and social structure. Fundamentally, Confucius believed assertively into the community. Tsang et al. (2003) examined
that people exist in relationship to others, and within each rela- 1,007 Hong Kong residents’ attitudes toward people with mental
tionship there are well-defined rules of correct behaviors in terms illness on a range of education, social, family, and employment
of rights and responsibilities (Bond & Hwang, 1987). Specifically, issues. They reported that 60% of the sample strongly opposed the
five 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 perceived
elder brother and younger brother, husband and wife, and friend level of threat is still a dominant factor in the formation of negative
and 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.

7. SPECIAL SECTION: STAGES OF CHANGE 45
cultural 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 the
mental illness in the current study belong to the ambivalent– community, their work-related self-efficacy may be appreciably
conforming 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 frequently
current study. Our findings underscore the importance of the study left at home with families and are not expected to work or assume
of self-efficacy in the context of specific skills required to function financial responsibilities (Tsang et al., 2003). Work, although seen
optimally in the community (i.e., task-specific self-efficacy). As as therapeutic in Western societies, may not be viewed as relevant
predicted in the SOC model, people with mental illness in the later to psychiatric rehabilitation in Chinese societies. Therefore, it was
SOCs 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 the
task-specific self-efficacy and those in the precontemplation group effect of outcome expectancy on SOCs. As predicted in the SOC
exhibited 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 positive
Hilburger and Lam found that individuals in the precontemplation outcomes in performing good social and coping skills than did
stage did not perceive themselves as having low self-efficacy. those in the early SOCs.
However, the results of the current study are consistent with
findings of other studies on the SOC model, indicating that in-
creasing self-efficacy was related to the movement of SOCs for Clinical Implications
people in smoking cessation (DiClemente, Prochaska, & Gibertini,
The current study could have significant clinical implications for
1985), substance abuse (DiClemente & Hughes, 1990), and HIV
psychiatric rehabilitation in Westernized Chinese societies such as
prevention (Polacsek, Celentano, O’Campo, & Santelli, 1999)
Hong Kong and Taiwan because professionals there tend to have
programs.
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 current
differentiation between every stage was not found. Specifically,
people in the precontemplation and contemplation groups did not study suggest that the disability rights– community integration
differ in their self-efficacy in interpersonal, help-seeking, and approaches to psychiatric rehabilitation must be adopted with
work-related skills. This finding is consistent with the research caution. That is, within the context of the Chinese culture (a
literature 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 SOC
relevant in early stage movement compared with later stage move- approach would allow professionals to determine the readiness of
ment, although the development of self-efficacy is necessary for Chinese clients with mental illness and their families to engage in
behavioral 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 effective
should include a self-efficacy component in specific dimensions treatment plan for people in the early SOCs should focus on
based 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 good
plation groups differed from each other in the self-efficacy area of social, coping, and help-seeking behaviors), gradually shifting the
symptom management skills. This finding suggests that interven- focus to skill-oriented programs (e.g., self-efficacy in performing
tion strategies that focus on developing self-efficacy in managing interpersonal, symptom management, and help-seeking skills), as
mental 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 low
in the precontemplation stage progress to the contemplation or self-efficacy in work-related skills and low outcome expectancies
later stages. In terms of work-related skills, this dimension of for the benefits of acquiring work-related skills in relation to their
self-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 in
for Chinese people with mental illness, work-related skills ap- developed countries have consistently advocated for work as a
peared to be less predictive of stage movement than did the other fundamental human right of people with disabilities. The low
self-efficacy domains that were identified in the original model. self-efficacy and low outcome expectancy for work-related skills
One possible explanation is that people with mental illness often among Chinese people with mental illness in this study may be due
encounter great difficulties in obtaining and maintaining employ- to the difficulty for them to obtain employment in Hong Kong and
ment (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 to
Bandura’s (1986) social cognitive theory, one’s self-efficacy level help people with mental illness in Chinese societies who want to
in performing specific tasks (e.g., work-related skills) is enhanced find jobs, integrate into the community, and ultimately achieve
by the mastery of past successful experiences (e.g., employment). rehabilitation goals.

8. 46 CHOU, CHAN, AND TSANG
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alone. Journal of Vocational Behavior, 10, 69 – 81.
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results found here with other subgroups of Chinese individuals people. In M. H. Bond (Ed.), The psychology of Chinese people (pp.
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sizes among the four SOCs clusters might affect the power of the Belton, L., et al. (2000). Tailoring and targeting a worksite health
MANOVA to detect significant differences among the cluster promotion program to address multiple health behaviors among blue-
groups. Therefore, this study must be considered preliminary, and collar women. American Journal of Health Promotion, 14, 306 –313.
future research with sufficient sample size must be conducted to Cardoso, E., Chan, F., Berven, N., & Thomas, K. R. (2003). Readiness for
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Chan, F., Hedl, J. J., Parker, H. J., Lam, C. S., Chan, T. N., & Yu, B.
Summary
(1988). Differential attitudes of Chinese high school students toward
three major disability groups: A cross-cultural perspective. International
The SOC model has been extensively researched in the United Journal of Social Psychiatry, 34, 267–273.
States, and the SOC construct appears to replicate across multiple Chan, F., Wong, D. W., Lam, C. S., Leung, P., & Fang, X. Z. (1988).
therapy (psychotherapy, smoking cessation, substance abuse) and Counseling Chinese Americans who are disabled: A cross-cultural per-
disability (traumatic brain injury and mental illness) groups. The SOC spective. Journal of Applied Rehabilitation Counseling, 19, 21–25.
structure is not as well defined in terms of the four change stages Cheng, T. (1985). A study of sociocultural characteristics and outcome of
(precontemplation, contemplation, action, and maintenance) in Chi- care of psychotic patients in Taiwan. Chinese Journal of Mental Health,
nese people with mental illness. However, the model shows promise 2, 117–133.
as a conceptual framework for understanding behavior of Chinese Cheung, H. K. (2001). A 2-year prospective study of patients from Castle
people with mental illness in rehabilitation. Particularly, for people Peak Hospital discharged to the first long-stay care home in Hong Kong.
who are ambivalent about the value of rehabilitation, the initial focus Hong Kong Journal of Psychiatry, 11, 1–12.
should be on enhancing their outcome expectancy for the benefits of Chou, C. C. (2003). Psychometric validation of the Task-Specific Self-
Efficacy Scale and the Outcome-Expectancy Scale for People With
rehabilitation in terms of improved social and coping skills to their
Mental Illness in Hong Kong and Taiwan. Unpublished doctoral disser-
quality of life. In addition, they should be provided with training in
tation, University of Wisconsin—Madison.
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disabilities to contribute more to the general welfare of the community outpatient alcoholism treatment. Journal of Substance Abuse, 2,
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