Letter to the Editor Received: March 29, 2013 Accepted after revision: October 9, 2013 Published online: January 22, 2014
Psychother Psychosom 2014;83:122–124 DOI: 10.1159/000356332
A Brief Goal-Setting and Planning Intervention to Improve Well-Being for People with Psychiatric Disorders Lorna Farquharson, Andrew K. MacLeod Royal Holloway, University of London, Egham, UK
Recent policy developments in the UK [1, 2] and internationally [3] have highlighted the need for mental health professionals to adjust their working practices and place more emphasis on promoting well-being. However, it has also been recognised that workforce skills in this area may be lacking and that more emphasis should be placed on developing the evidence base to help mental health professionals promote well-being and support recovery [4]. The benefits of incorporating approaches from positive psychology into existing understandings of mental health problems have been discussed [4, 5] and there have been a few recent studies that have taken preliminary steps to establish the efficacy of interventions focused on well-being with particular clinical groups [6–8]. However, the research literature in this area is still very limited.
The aim of the current study was to develop the evidence for a brief intervention that targets goal-setting and planning skills (GAP) to improve well-being. Having goals for the future and being able to make progress towards them are key components of many theoretical approaches to well-being [9] and GAP has shown promising results with non-clinical populations [10], as well as for people with depression [6] and forensic inpatients [7]. We investigated whether GAP could be effectively implemented for people with psychiatric disorders accessing specialist mental health services. As a secondary aim, the study design allowed for some exploration of the feasibility of mental health professionals incorporating a brief intervention focused on well-being into their routine practice. A total of 82 service users were recruited through a large mental health trust in the Greater London area. Participants were eligible for the study if they were: (1) aged 18 or over, (2) in contact (or eligible for contact) with specialist mental health services provided by the trust and (3) willing to take part in a group. Insufficient understanding of verbal and written English was used as an exclusion criterion due to the nature of the intervention. A cross-over design was used, with participants initially randomly allocated to either the intervention or a waiting-list control group. Participants allocated to the waiting-list condition were offered the intervention after they had completed their measures as controls and follow-up measures were taken from all participants 1 month after completing the intervention (see fig. 1).
Randomisation (n = 82)
Allocated to GAP intervention (n = 41) Completed time 1 measures (n = 33) Completed GAP intervention and time 2 measures (n = 22)
Allocated to waiting-list group (n = 41) Completed time 1 measures (n = 40) Completed waiting period and time 2 measures (n = 34)
Commenced GAP and completed pre-measures (n = 32) Completed GAP and postintervention measures (n = 25)
Fig. 1. Flow of participants through the
Completed follow-up (n = 20)
study.
© 2014 S. Karger AG, Basel 0033–3190/14/0832–0122$39.50/0 E-Mail [email protected] www.karger.com/pps
Dr. Lorna Farquharson Department of Psychology Royal Holloway, University of London Egham, Surrey TW20 0EX (UK) E-Mail lorna.farquharson @ rhul.ac.uk
Completed follow-up (n = 23)
Table 1. Means, SDs and significance levels for each outcome measure
a Group differences
SWLS PA NA BHS OutEff
Intervention (n = 22)
Waiting list (n = 34)
time 1
time 2
time 1
time 2
15.4 (7.2) 25.5 (10.9) 20.8 (9.7) 6.4 (5.6) 18.9 (8.8)
17.5 (7.7) 28.4 (10.4) 19.4 (9.9) 6.8 (5.7) 24.0 (8.7)
12.7 (6.6) 24.5 (8.5) 25.4 (9.5) 10.5 (4.8) 16.3 (7.1)
11.8 (5.4) 23.9 (8.7) 28.2 (10.9) 11.2 (5.7) 16.5 (6.8)
F
p value
8.51 3.70 5.12 1.08 10.90
0.005 0.06 0.03 0.30 0.02
b Maintenance effects for the whole sample (including cross-over from waiting list, n = 43)
SWLS PA NA BHS OutEff
Pre-intervention
Post-intervention
Follow-up
13.9 (6.2) 25.0 (9.0) 24.2 (9.9) 8.3 (5.9) 17.6 (7.4)
16.2 (7.1)* 29.0 (8.8)** 21.7 (9.4) 7.0 (5.6) 23.6 (7.1)**
17.1 (6.8)** 28.2 (11.1)* 21.5 (8.8) 6.2 (5.4)* 21.6 (7.9)**
* p < 0.05, ** p < 0.01, compared with pre-intervention.
The initial intervention group consisted of 11 males and 11 females with a mean age of 45.2 years (SD = 10.4); 9 had a primary diagnosis of schizophrenia, 8 bipolar disorder, 4 mood disorder and 1 other. The control group consisted of 15 males and 19 females with a mean age of 44.7 years (SD = 10.4); 15 had a primary diagnosis of schizophrenia, 7 bipolar disorder, 9 mood disorder and 3 other. The groups did not differ significantly on any demographic or clinical variables. The intervention was an adapted version of the GAP intervention used in previous studies [7, 10], consisting of four 2-hour group sessions provided on a weekly basis. All groups were facilitated by two members of staff who had pre-existing roles in the services included in the study. The staff were from a range of professional backgrounds, including occupational therapists, graduate mental health workers and mental health support workers. Facilitators received initial training in delivering the intervention and an hour of supervision following the second session. Outcome measures were those used in previous GAP studies [7, 10]: positive affect (PA), negative affect (NA), satisfaction with life (SWLS), Beck Hopelessness Scale (BHS) and a measure of outcome expectancy and efficacy for goals (OutEff). Analyses of covariance (ANCOVAs) compared the groups on each outcome measure separately at time 2, with time 1 scores as a covariate. At follow-up with the whole sample receiving GAP, the three time points were compared using one-way ANOVAs with follow-up post hoc tests where the overall ANOVA was significant. At time 2 the GAP group were significantly higher on SWLS and OutEff than controls and significantly lower on NA. PA showed a trend to be higher and BHS showed no effect. At followup with all participants receiving GAP, SWLS, OutEff, PA and BHS
all showed improved scores, but NA no longer showed any benefit (see table 1 for full results). The overall results are strongly suggestive of the efficacy and value of the GAP intervention for promoting well-being in this population. The results are most clear for the positively focused outcome measures, although NA and BHS did also show beneficial effects. The findings support the value to users of mental health services of interventions that are not symptom focused, but rather focused on enhancing positive aspects of people’s experience. It also appears that the minimal training and supervision provided to facilitators resulted in the effective delivery of GAP. This provides a potential model for disseminating specific well-being knowledge and skills to mental health professionals, as has been recommended [4]. There were some limitations of the study. Firstly, there was a high drop-out rate between initial randomisation and completing the intervention for both the GAP and waiting-list control groups. Secondly, there were no formal measures of participant adherence to the intervention, although facilitators did complete a checklist of content delivered after each session and the intervention was highly manualised. Finally, it was not possible to specify the mechanism of change and the cross-over design meant that follow-up data were from a single sample, all of whom received GAP. Future studies could recruit larger samples, incorporate objective measures as well as participant feedback on the intervention, investigate mediators of change and have a more equal balance of well-being and clinical outcome measures. Measures based on different conceptualisations of well-being could also be used. Furthermore, measures of resilience and recovery could be incorpo-
Letter to the Editor
Psychother Psychosom 2014;83:122–124 DOI: 10.1159/000356332
123
rated given the current policy agenda and recent findings from a preliminary evaluation of another positive psychology intervention with a similar clinical population [8]. This study suggests that GAP could be an effective intervention for enhancing the well-being of people with schizophrenia and other psychiatric disorders, enhancing the existing evidence base for the clinical application of GAP. It also provides a potential model for incorporating a well-being intervention into existing mental health service provision. References 1 HM Government/Department of Health: No health without mental health: a cross-governmental health outcomes strategy for people of all ages. London, HMG/DH, 2011. 2 Shepherd G, Boardman J, Slade M: Making Recovery a Reality. London, Sainsbury Centre for Mental Health, 2008. 3 Mental Health Commission of Canada: Toward Recovery and Well-Being. Calgary, Mental Health Commission of Canada, 2009.
124
Psychother Psychosom 2014;83:122–124 DOI: 10.1159/000356332
4 Slade M: Mental illness and well-being: the central importance of positive psychology and recovery approaches. BMC Health Serv Res 2011;10:26. 5 Wood AM, Tarrier N: Positive clinical psychology: a new vision and strategy for integrated research and practice. Clin Psychol Rev 2010;30: 819–829. 6 Coote HMJ, MacLeod AK: A self-help, positive goal-focused intervention to increase well-being in people with depression. Clin Psychol Psychother 2012;19:305–315. 7 Ferguson G, Conway C, Endersbury L, MacLeod A: Increasing subjective well-being in long-term forensic rehabilitation: evaluation of well-being therapy. J Forensic Psychiatr Psychol 2009;20:906–918. 8 Meyer PS, Johnson DP, Parks A, Iwanski C, Penn DL: Positive living: a pilot study of group positive psychotherapy for people with schizophrenia. J Posit Psychol 2012;7:239–248. 9 MacLeod AK: Goals and plans: their relationship to well-being; in Efklides A, Moraitou D (eds): A Positive Psychological Perspective on Quality of Life. Dordrecht, Springer, 2013, pp 33–50. 10 MacLeod A, Coates E, Hetherton J: Increasing well-being through teaching goal-setting and planning skills: results of a brief intervention. J Happiness Stud 2008;9:185–196.
Letter to the Editor
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Psychother Psychosom 2014;83:122–124 DOI: 10.1159/000356332
A Brief Goal-Setting and Planning Intervention to Improve Well-Being for People with Psychiatric Disorders Lorna Farquharson, Andrew K. MacLeod Royal Holloway, University of London, Egham, UK
Recent policy developments in the UK [1, 2] and internationally [3] have highlighted the need for mental health professionals to adjust their working practices and place more emphasis on promoting well-being. However, it has also been recognised that workforce skills in this area may be lacking and that more emphasis should be placed on developing the evidence base to help mental health professionals promote well-being and support recovery [4]. The benefits of incorporating approaches from positive psychology into existing understandings of mental health problems have been discussed [4, 5] and there have been a few recent studies that have taken preliminary steps to establish the efficacy of interventions focused on well-being with particular clinical groups [6–8]. However, the research literature in this area is still very limited.
The aim of the current study was to develop the evidence for a brief intervention that targets goal-setting and planning skills (GAP) to improve well-being. Having goals for the future and being able to make progress towards them are key components of many theoretical approaches to well-being [9] and GAP has shown promising results with non-clinical populations [10], as well as for people with depression [6] and forensic inpatients [7]. We investigated whether GAP could be effectively implemented for people with psychiatric disorders accessing specialist mental health services. As a secondary aim, the study design allowed for some exploration of the feasibility of mental health professionals incorporating a brief intervention focused on well-being into their routine practice. A total of 82 service users were recruited through a large mental health trust in the Greater London area. Participants were eligible for the study if they were: (1) aged 18 or over, (2) in contact (or eligible for contact) with specialist mental health services provided by the trust and (3) willing to take part in a group. Insufficient understanding of verbal and written English was used as an exclusion criterion due to the nature of the intervention. A cross-over design was used, with participants initially randomly allocated to either the intervention or a waiting-list control group. Participants allocated to the waiting-list condition were offered the intervention after they had completed their measures as controls and follow-up measures were taken from all participants 1 month after completing the intervention (see fig. 1).
Randomisation (n = 82)
Allocated to GAP intervention (n = 41) Completed time 1 measures (n = 33) Completed GAP intervention and time 2 measures (n = 22)
Allocated to waiting-list group (n = 41) Completed time 1 measures (n = 40) Completed waiting period and time 2 measures (n = 34)
Commenced GAP and completed pre-measures (n = 32) Completed GAP and postintervention measures (n = 25)
Fig. 1. Flow of participants through the
Completed follow-up (n = 20)
study.
© 2014 S. Karger AG, Basel 0033–3190/14/0832–0122$39.50/0 E-Mail [email protected] www.karger.com/pps
Dr. Lorna Farquharson Department of Psychology Royal Holloway, University of London Egham, Surrey TW20 0EX (UK) E-Mail lorna.farquharson @ rhul.ac.uk
Completed follow-up (n = 23)
Table 1. Means, SDs and significance levels for each outcome measure
a Group differences
SWLS PA NA BHS OutEff
Intervention (n = 22)
Waiting list (n = 34)
time 1
time 2
time 1
time 2
15.4 (7.2) 25.5 (10.9) 20.8 (9.7) 6.4 (5.6) 18.9 (8.8)
17.5 (7.7) 28.4 (10.4) 19.4 (9.9) 6.8 (5.7) 24.0 (8.7)
12.7 (6.6) 24.5 (8.5) 25.4 (9.5) 10.5 (4.8) 16.3 (7.1)
11.8 (5.4) 23.9 (8.7) 28.2 (10.9) 11.2 (5.7) 16.5 (6.8)
F
p value
8.51 3.70 5.12 1.08 10.90
0.005 0.06 0.03 0.30 0.02
b Maintenance effects for the whole sample (including cross-over from waiting list, n = 43)
SWLS PA NA BHS OutEff
Pre-intervention
Post-intervention
Follow-up
13.9 (6.2) 25.0 (9.0) 24.2 (9.9) 8.3 (5.9) 17.6 (7.4)
16.2 (7.1)* 29.0 (8.8)** 21.7 (9.4) 7.0 (5.6) 23.6 (7.1)**
17.1 (6.8)** 28.2 (11.1)* 21.5 (8.8) 6.2 (5.4)* 21.6 (7.9)**
* p < 0.05, ** p < 0.01, compared with pre-intervention.
The initial intervention group consisted of 11 males and 11 females with a mean age of 45.2 years (SD = 10.4); 9 had a primary diagnosis of schizophrenia, 8 bipolar disorder, 4 mood disorder and 1 other. The control group consisted of 15 males and 19 females with a mean age of 44.7 years (SD = 10.4); 15 had a primary diagnosis of schizophrenia, 7 bipolar disorder, 9 mood disorder and 3 other. The groups did not differ significantly on any demographic or clinical variables. The intervention was an adapted version of the GAP intervention used in previous studies [7, 10], consisting of four 2-hour group sessions provided on a weekly basis. All groups were facilitated by two members of staff who had pre-existing roles in the services included in the study. The staff were from a range of professional backgrounds, including occupational therapists, graduate mental health workers and mental health support workers. Facilitators received initial training in delivering the intervention and an hour of supervision following the second session. Outcome measures were those used in previous GAP studies [7, 10]: positive affect (PA), negative affect (NA), satisfaction with life (SWLS), Beck Hopelessness Scale (BHS) and a measure of outcome expectancy and efficacy for goals (OutEff). Analyses of covariance (ANCOVAs) compared the groups on each outcome measure separately at time 2, with time 1 scores as a covariate. At follow-up with the whole sample receiving GAP, the three time points were compared using one-way ANOVAs with follow-up post hoc tests where the overall ANOVA was significant. At time 2 the GAP group were significantly higher on SWLS and OutEff than controls and significantly lower on NA. PA showed a trend to be higher and BHS showed no effect. At followup with all participants receiving GAP, SWLS, OutEff, PA and BHS
all showed improved scores, but NA no longer showed any benefit (see table 1 for full results). The overall results are strongly suggestive of the efficacy and value of the GAP intervention for promoting well-being in this population. The results are most clear for the positively focused outcome measures, although NA and BHS did also show beneficial effects. The findings support the value to users of mental health services of interventions that are not symptom focused, but rather focused on enhancing positive aspects of people’s experience. It also appears that the minimal training and supervision provided to facilitators resulted in the effective delivery of GAP. This provides a potential model for disseminating specific well-being knowledge and skills to mental health professionals, as has been recommended [4]. There were some limitations of the study. Firstly, there was a high drop-out rate between initial randomisation and completing the intervention for both the GAP and waiting-list control groups. Secondly, there were no formal measures of participant adherence to the intervention, although facilitators did complete a checklist of content delivered after each session and the intervention was highly manualised. Finally, it was not possible to specify the mechanism of change and the cross-over design meant that follow-up data were from a single sample, all of whom received GAP. Future studies could recruit larger samples, incorporate objective measures as well as participant feedback on the intervention, investigate mediators of change and have a more equal balance of well-being and clinical outcome measures. Measures based on different conceptualisations of well-being could also be used. Furthermore, measures of resilience and recovery could be incorpo-
Letter to the Editor
Psychother Psychosom 2014;83:122–124 DOI: 10.1159/000356332
123
rated given the current policy agenda and recent findings from a preliminary evaluation of another positive psychology intervention with a similar clinical population [8]. This study suggests that GAP could be an effective intervention for enhancing the well-being of people with schizophrenia and other psychiatric disorders, enhancing the existing evidence base for the clinical application of GAP. It also provides a potential model for incorporating a well-being intervention into existing mental health service provision. References 1 HM Government/Department of Health: No health without mental health: a cross-governmental health outcomes strategy for people of all ages. London, HMG/DH, 2011. 2 Shepherd G, Boardman J, Slade M: Making Recovery a Reality. London, Sainsbury Centre for Mental Health, 2008. 3 Mental Health Commission of Canada: Toward Recovery and Well-Being. Calgary, Mental Health Commission of Canada, 2009.
124
Psychother Psychosom 2014;83:122–124 DOI: 10.1159/000356332
4 Slade M: Mental illness and well-being: the central importance of positive psychology and recovery approaches. BMC Health Serv Res 2011;10:26. 5 Wood AM, Tarrier N: Positive clinical psychology: a new vision and strategy for integrated research and practice. Clin Psychol Rev 2010;30: 819–829. 6 Coote HMJ, MacLeod AK: A self-help, positive goal-focused intervention to increase well-being in people with depression. Clin Psychol Psychother 2012;19:305–315. 7 Ferguson G, Conway C, Endersbury L, MacLeod A: Increasing subjective well-being in long-term forensic rehabilitation: evaluation of well-being therapy. J Forensic Psychiatr Psychol 2009;20:906–918. 8 Meyer PS, Johnson DP, Parks A, Iwanski C, Penn DL: Positive living: a pilot study of group positive psychotherapy for people with schizophrenia. J Posit Psychol 2012;7:239–248. 9 MacLeod AK: Goals and plans: their relationship to well-being; in Efklides A, Moraitou D (eds): A Positive Psychological Perspective on Quality of Life. Dordrecht, Springer, 2013, pp 33–50. 10 MacLeod A, Coates E, Hetherton J: Increasing well-being through teaching goal-setting and planning skills: results of a brief intervention. J Happiness Stud 2008;9:185–196.
Letter to the Editor
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
