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Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20
A Team Format for the Global Assessment Scale: Reliability and Validity on an Inpatient Unit Thomas Kuhlman , Michael Bernstein , James Kloss , Virginia Sincaban & Linda Harris Published online: 10 Jun 2010.
To cite this article: Thomas Kuhlman , Michael Bernstein , James Kloss , Virginia Sincaban & Linda Harris (1991) A Team Format for the Global Assessment Scale: Reliability and Validity on an Inpatient Unit, Journal of Personality Assessment, 56:2, 335-347, DOI: 10.1207/s15327752jpa5602_12 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5602_12
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JOURNAL OF PERSONALITY ASSESSMENT, 1991, 56(2), 335-347 Copyright o 1991, Lawrence Erlbaum Associates, Inc.
A Team Format for the Global Assessment Scale: Reliability and Validity on an Inpatient Unit
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Thomas Kuhlman Hennepin County Mental Health Center and Augsburg College Minneapolis, M N
Michael Bernstein Mendota Mental Health Institute Madison, WI
James Kloss Mississippi River Human Services Center Blair, WI
Virginia Sincaban and Linda Harris Mendota Mental Health Institute Madison, W I
The Global Assessment Scale (GAS) is a 100-point rating instrument which purports to measure psychological adjustment o n a continuum from selfactualization to severe regression. Its reliability and validity were examined o n the admitting ward of a state hospital where G A S ratings are assigned to patients by computing a mean of the individual ratings assigned by a team of clinicians. Results showed such team G A S ratings to have good reliability. As for validity, team GAS predicted the outcomes of court hearings at two stages of the civil commitment process and showed construct validity in its relevant correlations with the Psychotic Inpatient Profile. A predicted association between team GAS and a ward atmosphere measure was not obtained. Taken as a whole, the results support the use of team G A S ratings in inpatient settings.
We continue to investigate the Global Assessment Scale (GAS), a 180-point unidimensional rating scale which purports to measure the range of adult
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adjustment, from self-actualizationto severe regression (Endicott, Spitzer, Fleiss, & Cohen, 1976; see Table 1). The GAS was designed for both normal and clinical samples and was recently adapted for use in the assignment of Axis V diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-Ill-R]; American Psychiatric Association, 1987). It is frequently used as a standard of comparison for new clinical instruments (e.g., TABLE 1 The GAS
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Range
Description Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of the person's warmth and integrity. No symptoms. Good functioning in all areas, many interests, socially effective, generally satisfied with life. There may or may not be transient symptoms and "everyday" worries that occasionally get out of hand. No more than slight impairment in functioning, varying degrees of "everyday" worries and problems that sometimes get out of hand. Minimal symptoms may or may not be present. Some mild symptoms (e.g., depressive mood and mild insomnia) or some difficulty in several areas of functioning, but generally functioning pretty well, has some meaningful interpersonal relationships, and most untrained people would not consider the person 'sick." Moderate symptoms or generally functioning with some difficulty (e.g., few friends and flat affect, depressed mood and pathological self-doubt, euphoric mood and pressure of speech, moderately severe antisocial behavior). Any serious symptomatology or impairment in functioning that most clinicians would think obviously requires treatment or attention (e.g., suicidal preoccupation or gesture, severe obsessional rituals, frequent anxiety attacks, serious antisocial behavior, compulsive drinking, mild but definite manic syndrome). Major impairment in several areas, such as work, family relations, judgment, thinking or mood (e.g., depressed woman avoids friends, neglects family, unable to do housework); or some impairment in reality testing or communication (e.g., speech is at times obscure, illogical or irrelevant); or single suicide attempt. Unable to function in almost all areas (e.g., stays in bed all day); or behavior is considerably influenced by either delusions or hallucinations; or serious impairment in communication (e.g., sometimes incoherent or unresponsive); or judgment (e.g., acts grossly inappropriately). Needs some supervision to prevent hurting self, others, or to maintain minimal personal hygiene (e.g., repeated suicide attemtps, frequently violent, manic excitement, smears feces); or gross impairment in communication (e.g., largely incoherent or mute). Needs constant supervision for several days to prevent hurting self or others (e.g., requires an intensive care unit with special observation by staff), makes no attempt to maintain minimal personal hygiene, or serious suicide act with clear intent and expectation of death.
Note. Instructions: Rate the subject's lowest level of functioning in the last week (see Endicott et al., 1976).
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Harder, Greenwald, Wechsler, & Ritzler, 1984; Johnson, Magaro, & Stern, 1986; Summers et al., 1983) and as a dependent variable in clinical research (e.g., Battista, 1982; Curran, Miller, Zurich, Monti, & Stout, 1980; Husby, 1985). The GAS is also used widely in applied settings for outcome research and program evaluation; Dekker (1983) found the GAS was used in five statewide evaluation systems involving 700,000 patients and 1.5 million ratings during a single year. Do reliability and validity data justify such widespread use of the GAS? Dekker also reviewed 31 studies which ~roduceda median interrater reliability coefficient of 80, but a National Institute of Mental Health study group recommended that GAS reliability be independently assessed for different settings and populations (Ciarlo, Brown, Edward, Kiresuk, & Newman, 1986). The validity of the GAS has scarcely been evaluated, in piart because GAS was derived from the Health-Sickness Rating Scale (Luborsky, 1962) which had previously been acclaimed the best global scale for outcotne research (Waskow & Parloff, 1975). In addition to this "ancestral validity," only two studies have specifically addressed the GAS' validity empirically. Pjositive findings were obtained by Endicott, Spitzer, Fleiss, and Cohen, who des~gnedthe GAS. Their sample consisted of psychiatric inpatients who were evaluated upon admission to the hospital and 6 months after discharge. GAS ratings on these subjects were compared with relevant indices from the Family Evaluation Form, the Mental Status Examination Record, and the Psychiatric Status Schedule. Results showed correlations that were in the predicted direction at the time of admission, but ranged only from - .19 to - .44 between the GAS and the criterion measures. The correlation range improved to .37 to - .62 at the second data collection point (6 months postdischarge). The authors ,Further reported that GAS ratings below 40 successfully predicted rehospitalization for discharged patients and that GAS scores were more sensitive to clirtical change than the other measures used in the study. A second validity study (Dekker, 1983) was conducted with an outpatient sample in a community mental health center. The Minnesota Multiphasic Personality Inventory (MMPI) served as the criterion, and the range of correlations between GAS ratings and various MMPI severity indices was a modest .29 to .36. The present study was undertaken to add to the sparse validity base underlying this popular scale. It addressed both criterion-related and construct validity aspects of GAS on the locked admitting ward of a state hospital in Wisconsin. This ward operates under a multidisciplinary team philosophy: Psychiatrists provide for a patient's medical and psychopharmacological needs, while psychologists provide testing and individual and group therapies. Social workers help the patient relate with family and community resources, while occupational and recreational therapists offer workshops and various other activities on and off ward. Ongoing 24-hr assessment and supervision is provided by a nursing staff.
-
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Before the GAS was introduced to the ward, it was decided that the multifaceted view of the patient derived from these separate perspectives and ways of relating to the patient would be muted if GAS ratings were made by a single team member. Forms and procedures were therefore devised so that each staff involved with a patient could make an independent GAS rating of the patient upon admission and at weekly htervals thereafter. These ratings are combined into a single team GAS rating by simply taking the mean of all team members' individual ratings. It is the reliability and validity of this team GAS method which is addressed herein.
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METHOD The ward's professional staff were trained in the use of the GAS according to the manual provided by the scale's authors. Training entailed the assignment of ratings of 21 printed cases; the feedback key provided for these cases included the correct ratings and the scale authors' rationales for them. Training was done individually in two self-study sessions: Ten cases were rated in the first session, followed by the correct answers and rationales. This process was repeated in the second session for the remaining 11 cases. After all staff had been trained in this manner, GAS ratings were introduced on to the ward as described next. Ten months later, the training protocol was repeated for all raters as a refresher course. Data collection was initiated after this second training experience. The inpatient subjects of this study were drawn from the 323 adults admitted to the ward between November 1986 and December 1987. This subject pool was 60% male, 5% minority, and ranged in age from 18 to 55. The majority were chronic patients with extensive treatment histories. Their average length of stay was 20 days. Diagnostically, schizophrenia and major affective disorder were the most common diagnoses. Most patients had been involuntarily admitted to and detained on the ward through a civil commitment process involving a probable cause hearing (within 3 days after a patient's emergency admission) and, if necessary, a subsequent commitment hearing (2 weeks after a finding ~f probable cause). Subjects were rated under two different conditions. The first is the admission staffing during which the team meets with the patient in a group interview situation shortly after admission. At admission staffings, a patient's legal rights and related questions are addressed first; a standard ~ s ~ c h i a t rhistory ic is then taken, and a mental status exam is administered. Next, the patient is excused, and the team discusses the clinical presentation and formulates a prdvisional diagnosis and treatment ~ l a nFinally, . each team member independently assigns the patient an admission GAS rating to cover the patient's condition during the week leading up to and including the admission staffing. Team members record
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their individual ratings privately on separate slips of paper. The mean of these ratings serves as the patient's admission GAS rating. Subjects were also GAS-rated during weekly progress reviews. Those were meetings mandated by the Joint Commission for the Accreditation of Hospitals (JCAH) for the purpose of reviewing progress during the previous week. The patient is not present during these reviews, which begin with a staff member's reading aloud a summary of the patient's hospital chart notes for the week in question. Next, significant observations of the patient during that week, which had not been recorded in the hospital chart, are reported by the staff member who observed them. Finally, each team member privately records a GAS rating for the patient, a rating based upon a combination of the team member's individual experience with the patient that week plus the team's collective experience as reflected in the progress review just completed. After one rating is completed, the staff moves on to the next patient and repleats the process until all patients have been rated. The mean of team members' ratings of a patient serves as the patient's weekly GAS rating for that week. Individual ratings were kept independent of each other from rater to rater and week to week. Rater-to-rater independence was achieved by the use of private rating sheets. Week-to-week independence was achieved by withholding the team results from staff until after the patient was discharged. In additilon, staff were instructed not to store and retrieve their earlier rarings of patients, and because 15 to 17 patients are rated during each l-hr progress review, it would have been exceedingly difficult for them to do otherwise.
Reliability The reliability of GAS was estimated in two ways on the sample of patients who served as subjects in the construct validity phase of this research (discussed next), The first reliability estimate involved the traditional correlation of GAS ratings made by a team member with those of all other team members. However, insofar as the mean rating of team members serves as the key GAS measure for the ward, a second reliability estimate was made by breaking the multidisciplinary team into two subteams. These subteams were arranged so as to be comparable in terms of educational level, clinical experience, and variety of professions represented. One subteam consisted of a psychiatrist, a psychologist, a social worker, and an occupational therapist; the second subteam consisted of two psychiatrists, the head nurse, a social worker, and a recreational therapist. Two separate subtearn mean GAS ratings were then computed for the patient sample in question, and the correlation of these represented the interteam (as opposed to interrater) reliability estimate. Because this second reliability estimate entailed splitting the team into two subteams (therebv reducing the typical cohort of raters by 50%)' it was necessary to apply the Spearman-Brown formula to this second coefficient in order to correct for the attenuation of normal team strength.
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Predictive Validity Wisconsin's statutory requirements for court-ordered involuntary hospitalization specify that proof of mental illness and dangerousness must first be established at a probable cause proceeding, held within 3 days of an emergency admission. When extended hospitalization appears necessary, relevant evidence must be submitted 2 weeks later at a civil commitment hearing. Both of these court proceedings culminate in dichotomous decisions (i.e., continued involuntary hospitalization or immediate discharge) which are rendered by a judge or court commissioner. Such decisions are well suited to serve as GAS validity criteria for two reasons. First, team GAS ratings on the ward typically range from the 10s to the 30s during the first 21/2 weeks of a patient's stay; a cursory examination of the scale reveals that its content in these ranges orients the rater to psychiatric symptoms and dangerous behaviors, a dual focus identical to the concerns of the court. Second, the commitment process was established in a way that excludes hospital staff from providing input to the court, thereby precluding conflict of interest dilemmas. Probable cause hearings are taken up with testimony from police officers, family members, and other observers of a patient's mentally ill and dangerous behavior prior to the emergency hospitalization. Evidence for the civil commitment hearing 2 weeks later is provided by two independent clinical examiners appointed by the court for that expressed purpose. These expert withnesses examine the patient on the ward and often read the hospital chart, but must form their own opinions about the patient. They are not given access to GAS ratings. As a result, there is no contamination of predictor with criterion because GAS ratings do not enter as evidence into either probable cause or commitment proceedings. In both situations, the decision to extend hospitalization or discharge the patient is made by the judge, not the hospital staff. Two specific GAS validity predictions were therefore formulated: (a) the admission GAS ratings of emergency admissions whose hospitalizations are subsequently extended at their probable cause hearings will be significantly lower than those of patients who are discharged at their probable cause hearings (lower ratings signify greater psychopathology) and (b)the weekly GAS ratings of patients whose hospitalizations are later extended at their civil commitment hearings will be significantly lower than those of patients who are discharged at their civil commitment hearings. As corollaries of these two hypotheses, it was further hypothesized that the hit rates for hospitalization decisions dictated by team GAS ratings would exceed the base rates for such decisions within the two patient samples. Given the nature of these criteria, voluntary patients who did not go through these judicial processes were excluded from the study. Involuntary patients who changed to voluntary status at any point in the emergency
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admission to probable cause to civil commitment process were dropped from the study when they became voluntary.
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Construct Validity The Psychotic Inpatient Profile (PIP; Lorr & Vestre, 1968) was chosen to assess the construct validity of team GAS. The PIP is a staff observational tool designed for inpatient settings and generates t scores for 12 symptom complexes (excitement, hostile belligerence, paranoid projection, anxious depression, retardation, seclusiveness, care needed, psychotic disorganization, grandiosity, perceptual disorganization, depressive mood, and disorientation). It was hypothesized that, as a global scale, the GAS would not correlate significantly with these specific PIP scales but would correlate significantly with a global psychopathology index, such as the sum of all PIP scales. The 39 patients-in this phase of the research were evaluated on both the PIP and team GAS during their second or fourth week of hospitalization. A psychologist, serving as PIP rater, filled out the PIP for no nnore than two subjects during any designated week. When doing so the psychologist was given access to the same data base that the rest of the team used to generate a weekly GAS rating for that week. This PIP rater never contributed to a subject's team GAS rating during the week that he filled out the PIP.
Ward Atmosphere The last phase of the study examined whether the mean GAS rating of all patients on the ward at a given time could be viewed as a valid measure of the ward's acuity (more colloquially referred to as a ward's "highness"). A disturbed group of patients interacting with one another in a closed environment generates more tension, acuity, and, as a result, more controlling behaviors by the staff than does a less disturbed group. It was therefore hypothesized that a significant positive correlation would be obtained between the average GAS rating of all patients on the ward during a given week and the degree of permissive behaviors exhibited by staff during the same week. The design of the building where the ward is housed permitted an unobtrusive way to measure staff3 permissive behaviors. The ward is separated from its cafeteria by a locked door. The cafeteria is an unsecured area; when trouble erupts with a patient, help is at least one locked door and a telephone call (rather than a shout) away. For this reason, only patients trusted by staff not to act out or wander off can be permitted to leave the ward and eat in the cafeteria. The rest take their meals in the dayroom on the ward. Therefore, one measure of staffs permissiveness is the percentage of all patient meals taken off a ward during a given week (a percentage score corrects for fluctuations in the ward's
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census). As this percentage increases, the staff behaves in increasingly permissive ways. Thus, a significant, positive correlation between the ward's average GAS rating and the percentage of meals eaten in the cafeteria was predicted. The average GAS rating for a given week was easily obtained from existing procedures. Data on meals taken in the cafeteria versus the ward were provided by the hospital's dietary department.
RESULTS
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Reliability Interrater reliability was estimated by correlating the GAS ratings assigned to a sample of 39 patients by individual team members with the corresponding ratings assigned by the eight other team members. This generated a matrix of 36 coefficients with a mean of .73 and a median of .72. The interteam reliability of team GAS ratings obtained by dividing the nine raters into two subteams was considerably higher. Correlating the mean GAS ratings of these two subteams for the same sample of 39 patients yielded a reliability coefficient of .90, a figure that increased to .95 when the Spearman-Brown formula was applied.
Predictive Validity Predictive validity data is presented in Table 2. In the probable cause phase of the study there were 59 patients (33 male and 26 female) whose hospitalizations were extended because their mental illness and dangerousness were established in court and 50 patients (30 male and 20 female) who were discharged because mental illness and dangerousness could not be thus established in court. O n admission GAS, the continued hospitalization group had a mean team GAS rating of 25.1 with a standard deviation of 9.6; the mean and standard deviation for the discharged group were 36.9 and 11.6, respectively. This difference was significant, t(107) = 5.84, p < .0005. Compared to the hospitalization base rate of 54% within this sample, the obtained team GAS hit rate of 76% for such decisions represented significant predictive power, X2(1,N = 109) = 29.47, p < .001. Thus the hypothesis that admission GAS ratings would predict the outcomes of probable cause hearings was confirmed. In the civil commitment phase, there were 22 patients (15 male and 7 female) whose hospitalizations were extended because mental illness and dangerousness was established at civil commitment hearings and 11 patients (3 male and 8 female) who were discharged for lack of sufficient evidence of mental illness and dangerousness at their civil commitment hearings. The mean weekly team GAS rating of the civilly committed group was 29.9 with a standard deviation of 8.6;
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TABLE 2 Predictive Validity of Team GAS For Court-Ordered Involuntary Hospitalizations Team GAS
N
M
SD
59 50
25.1 36.9
9.6 11.6
22 11
29.9 42.6
8.6 8.9
-
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I. 109 Probable Cause Hearings Outcomea Continued hospitalization Unconditional discharge Hit rate analysisb Team GAS "hits" for hospitalization decisions = 76% Base rate for hospitalization decisions = 54% 11. 33 Civil Commitment Hearings Outcomec Continued hospitalization Unconditional discharge Hit rate analysisd Team GAS "hits" for hospitalization decisions = 73% Base rate for hospitalization decisions = 67%
-
"t(107) = 5.84, p < .0005. bX2(1,N = 109) = 29.47, p < .001. 't(31) = 3.96, p < .0005. d ~ 2 ( 1 , N = 33) = 9.02, p < .01.
the mean and standard deviation for the discharged group were 42.6 and 8.9, respectively. This difference was also significant, t(31) = 3.96, P < .0005. Compared to the hospitalization base rate of 67% within this sample, the obtained team GAS hit rate of 73% for such decisions represented significant predictive power, X2(1,N = 33) = 9.02, P < .01. Thus the hypothesis that weekly GAS ratings would predict the outcomes of civil c~ommitmentproceedings was confirmed.
Construct Validity Correlations between weekly GAS ratings and the PIP scores of 39 patients (21 male, 18female) are presented in Table 3. Application of the Bonferroni formula to adjust for family alpha error (Harris, 1975)established that correlations of the magnitude of .44 and greater are reliable. As hypothesized, team GAS correlated significantly with the global PIP measure (r = -.64), and this was its highest correlation among all PIP measures. Also as predicted, team GAS did not correlate significantly with 9 of the 11 specific scales; however, its associations with the Care Needed (-.56) and Seclusiveness (-.48) scales were statistically significant.
Ward Atmosphere The hypothesis of a positive correlation between the average of all patients' GAS ratings for a given week and staffs permissiveness toward those patients with.
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KUHLMAN, BERNSTEIN, KLOSS, SINCABAN, HARRIS TABLE 3 Correlations Between Team GAS and Psychotic Inpatient Profile Scalesa
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PIP Scale Excitement Hostility Paranoid Projection Anxious Depression Retardation Seclusiveness Care Needed Psychotic Disorganization Grandiosity Perceptual Distortion Depressive Mood Global PIP (sum of all scales)
-
--
-
-
Pearson r
- .30 -.I8 -.31 - .24 -.31 - .48 - .56 - .29 -.31 .10 .09 - .64
ns ns ns ns ns < .005 < ,0005 ns ns ns ns < .001
"N = 39. cafeteria privileges was not confirmed. To the contrary, in an initial 19-week data collection period a significant negative correlation of - .48 ( p < .05) was obtained. An attempt to replicate this unexpected finding over a second data collection period of 18 weeks failed when a nonsignificant correlation of .13 was obtained for this second period.
DISCUSSION To summarize the results, team GAS ratings proved more reliable than GAS ratings made by individual raters, and three of four hypotheses which addressed team GAS validity were confirmed. The higher interteam reliability obtained here argues for adoption of the team approach over reliance on individual raters. The median interrater reliability coefficient of .72 is lower than the .80 median reported by Dekker (1983). However, it must be remembered that the various raters of this study interacted with the patients in different formats and functions. And although there was a common data base for ratings in the progress review meetings, it is also reasonable to assume that individual ratings were somewhat affected by the raters' unique experiences with the patients. Multiple perspectives are, of course, the basic argument underlying the popularity of multidisciplinary teams in inpatient work. If the individual interrater coefficients were much higher, one could infer that too much cohesion and redundancy exists to justify the team GAS approach. Confirmation of the predictive validity hypotheses is important because "mentally ill" and "dangerous" has been widely adopted as the standard for
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public sector hospitalizations in the U.S. at the present time. In conjunction with the Endicott et al. (1976) findings that the GAS ~redictsrehospitalization, the scale has now been shown to correlate with both admission and discharge decisions concerning hospitalization. With regard to construct validity, 10 of 12 predictions concerning the relationship between team GAS and the PIP were confirmed. These included one significant association between team GAS and a PIP index of global psychopathology and 10 nonsignificant associations involving team GAS and focal PIP symptom complexes. Careful consideration of the two predictions which failed-team GAS did correlate with the focal PIP scales of Care Needed and Seclusiveness-reveals these two PIP scales are the least symptom specific of the set. The greater statistical affinity of these two scales with the GAS is best explained by the fact that generalized deficits in self-care and socialization skills characterize all patients who are admitted to the state hospital regardless of diagnosis or specific syrnptomatology. Our findings should generalize to day treatment centers, sheltered work sites, and other treatment settings where extensive observation and contact with patients is typical. It is doubtful that they would apply to traditional outpatient settings where 1 hr of weekly contact with patients is the norm. In such contexts, GAS ratings, which correlate weekly with self-report on the MMPI (Dekker, 1983), necessarily rely on patients' self-report instead of daily observation and contact with many staff. There are also questions as to the GAS' content validity when it is applied to subjects who are less disturbed than those of this study. Ciarlo, Edwards, Kinesuk, Newman, and Brown (1981-cited in Dekker, 1983) noted that, although the lower half of GAS cites 23 behavioral examples with which to anchor ratings 1-50, there are only 7 such behavioral descriptions to anchor the upper half of the scale (51-100). This reflects the field's continuing problem in defining what behaviors constitute mental health. The efiect of this problem on reliability and validity is considerable- note that the typical patient in this study was admitted with a GAS rating of 26, averaged a rating of 33-35 on any given week, and was discharged with a rating of 42. Only a few subjects had GAS ratings that ranged over 50, and none were rated as high as 70. Obviously this study did not address the upper half of the scale. A final caution must be raised about generalizing from research on the GAS to the Global Assessment of Functioning Scale (GAF) of the DSM-111-R. There is a significant difference in the instructions used with the two scales: GAF calls for an assessment of lowest level of functioning, whereas GAF calls for current level of functioning and highest level of functioning during the past year. This means that the GAF diagnostician must often work within the middle and upper rangles of the scale; although it is laudable that there is such a focus on strengths in the present diagnostic scheme, the fact remains that there is
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demonstrable validity only for the lower ranges of the scale at this time. Research efforts are needed to address the measurement of global functioning in mildly impaired and healthy subjects; until then, generalizations from the GAS to the GAF are unwarranted.
ACKNOWLEDGMENTS
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This article was presented to the 96th annual meeting of the American Psychological Association in Atlanta, August 1988. We acknowledge the varied contributions of Stan Barry, Betty Havlik, Wendy Koch, Jim LeClair, Jack Sherman, and Barbara White to the completion of this project.
REFERENCES American Psychiatric Association. (1987). The diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. Battista, J. R. (1982). Empirical test of Vaillant's hierarchy of ego functions. American Journal of Psychiatry, 139,356-357. Ciarlo, J. A., Brown, T. R., Edward, D. W., Kiresuk, T. J., & Newman, F. L. (1986).Assessing mental health outcome measurement techniques. Rockville, MD: National Institute of Mental Health. Curran, J. P., Miller, I. W., Zurich, W. R., Monti, P. M., & Stout, R. L. (1980). The socially inadequate patient: Incidence rate, demographic and clinical features, and hospital and posthospital functioning. Journal of Consulting and Clinical Psychology, 48(3), 375-382. Dekker, D. J. (1983). A study of the validity of the Global Assessment Scale. Unpublished doctoral dissertation, Western Michigan University. Endicott, J., Spitzer, R. L., Fleiss, J. L., & Cohen, J. (1976). The Global Assessment Scale: A procedure for measuring overall severity of psychiatric disturbance. Archzves of General Psychiany, 33, 766-77 1. Harder, D. W., Greenwald, D. J., Wechsler, S., & Ritzler, B. A. (1984). The Urist Rorschach Mutuality of Autonomy Scale as an indicator of psychopathology.Journal of Clinical Psychology, 40(4), 1078-1083. Harris, R. J. (1975). A primer of multivariate statistics. New York: Academic. Husby, R. (1985). Short-term dynamic psychotherapy:V. Global Assessment Scale as an instrument for description and measurement of changes for 33 neurotic patients. Psychotherapy and Psychosomatics, 43, 28-31. Johnson, M. H., Magaro, P. A., & Stern, S. L. (1986). Use of the SADS-C as a diagnostic and symptom severity measure. Jouml of Consulting and Clinical Psychology, 54(4), 546-551. Lorr, M., & Vestre, N. (1968). The psychotic inpatient profile. Los Angeles: Western Psychological Services. Luborsky, L. (1962). Clinicians' judgments of mental health. Archives of General Psychiatry, 7, 407-417. Summers, W. K., Marsh, G. M., Chiong, B., Burgo~ne,R. M., Swenson, S. W., &Walker, N. R. (1983).The General Adult Inpatient PsychiatricAssessment Scale (GAIPAS).Psychiatry Research, 10, 217-236.
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Waskow, I. E., &Padoff, M. B. (Eds.). (1975). Psychotherapy change measures @HEW Publication No. ADM 74-120). Washington, DC: U.S. Government Printing Office.
Thomas Kuhlman Hennepin County Mental Health Center 525 Portland Avenue South Minneapolis, MN 55415
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Received January 23, 1990 Revised April 30, 1990
Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20
A Team Format for the Global Assessment Scale: Reliability and Validity on an Inpatient Unit Thomas Kuhlman , Michael Bernstein , James Kloss , Virginia Sincaban & Linda Harris Published online: 10 Jun 2010.
To cite this article: Thomas Kuhlman , Michael Bernstein , James Kloss , Virginia Sincaban & Linda Harris (1991) A Team Format for the Global Assessment Scale: Reliability and Validity on an Inpatient Unit, Journal of Personality Assessment, 56:2, 335-347, DOI: 10.1207/s15327752jpa5602_12 To link to this article: http://dx.doi.org/10.1207/s15327752jpa5602_12
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JOURNAL OF PERSONALITY ASSESSMENT, 1991, 56(2), 335-347 Copyright o 1991, Lawrence Erlbaum Associates, Inc.
A Team Format for the Global Assessment Scale: Reliability and Validity on an Inpatient Unit
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Thomas Kuhlman Hennepin County Mental Health Center and Augsburg College Minneapolis, M N
Michael Bernstein Mendota Mental Health Institute Madison, WI
James Kloss Mississippi River Human Services Center Blair, WI
Virginia Sincaban and Linda Harris Mendota Mental Health Institute Madison, W I
The Global Assessment Scale (GAS) is a 100-point rating instrument which purports to measure psychological adjustment o n a continuum from selfactualization to severe regression. Its reliability and validity were examined o n the admitting ward of a state hospital where G A S ratings are assigned to patients by computing a mean of the individual ratings assigned by a team of clinicians. Results showed such team G A S ratings to have good reliability. As for validity, team GAS predicted the outcomes of court hearings at two stages of the civil commitment process and showed construct validity in its relevant correlations with the Psychotic Inpatient Profile. A predicted association between team GAS and a ward atmosphere measure was not obtained. Taken as a whole, the results support the use of team G A S ratings in inpatient settings.
We continue to investigate the Global Assessment Scale (GAS), a 180-point unidimensional rating scale which purports to measure the range of adult
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adjustment, from self-actualizationto severe regression (Endicott, Spitzer, Fleiss, & Cohen, 1976; see Table 1). The GAS was designed for both normal and clinical samples and was recently adapted for use in the assignment of Axis V diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-Ill-R]; American Psychiatric Association, 1987). It is frequently used as a standard of comparison for new clinical instruments (e.g., TABLE 1 The GAS
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Range
Description Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of the person's warmth and integrity. No symptoms. Good functioning in all areas, many interests, socially effective, generally satisfied with life. There may or may not be transient symptoms and "everyday" worries that occasionally get out of hand. No more than slight impairment in functioning, varying degrees of "everyday" worries and problems that sometimes get out of hand. Minimal symptoms may or may not be present. Some mild symptoms (e.g., depressive mood and mild insomnia) or some difficulty in several areas of functioning, but generally functioning pretty well, has some meaningful interpersonal relationships, and most untrained people would not consider the person 'sick." Moderate symptoms or generally functioning with some difficulty (e.g., few friends and flat affect, depressed mood and pathological self-doubt, euphoric mood and pressure of speech, moderately severe antisocial behavior). Any serious symptomatology or impairment in functioning that most clinicians would think obviously requires treatment or attention (e.g., suicidal preoccupation or gesture, severe obsessional rituals, frequent anxiety attacks, serious antisocial behavior, compulsive drinking, mild but definite manic syndrome). Major impairment in several areas, such as work, family relations, judgment, thinking or mood (e.g., depressed woman avoids friends, neglects family, unable to do housework); or some impairment in reality testing or communication (e.g., speech is at times obscure, illogical or irrelevant); or single suicide attempt. Unable to function in almost all areas (e.g., stays in bed all day); or behavior is considerably influenced by either delusions or hallucinations; or serious impairment in communication (e.g., sometimes incoherent or unresponsive); or judgment (e.g., acts grossly inappropriately). Needs some supervision to prevent hurting self, others, or to maintain minimal personal hygiene (e.g., repeated suicide attemtps, frequently violent, manic excitement, smears feces); or gross impairment in communication (e.g., largely incoherent or mute). Needs constant supervision for several days to prevent hurting self or others (e.g., requires an intensive care unit with special observation by staff), makes no attempt to maintain minimal personal hygiene, or serious suicide act with clear intent and expectation of death.
Note. Instructions: Rate the subject's lowest level of functioning in the last week (see Endicott et al., 1976).
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Harder, Greenwald, Wechsler, & Ritzler, 1984; Johnson, Magaro, & Stern, 1986; Summers et al., 1983) and as a dependent variable in clinical research (e.g., Battista, 1982; Curran, Miller, Zurich, Monti, & Stout, 1980; Husby, 1985). The GAS is also used widely in applied settings for outcome research and program evaluation; Dekker (1983) found the GAS was used in five statewide evaluation systems involving 700,000 patients and 1.5 million ratings during a single year. Do reliability and validity data justify such widespread use of the GAS? Dekker also reviewed 31 studies which ~roduceda median interrater reliability coefficient of 80, but a National Institute of Mental Health study group recommended that GAS reliability be independently assessed for different settings and populations (Ciarlo, Brown, Edward, Kiresuk, & Newman, 1986). The validity of the GAS has scarcely been evaluated, in piart because GAS was derived from the Health-Sickness Rating Scale (Luborsky, 1962) which had previously been acclaimed the best global scale for outcotne research (Waskow & Parloff, 1975). In addition to this "ancestral validity," only two studies have specifically addressed the GAS' validity empirically. Pjositive findings were obtained by Endicott, Spitzer, Fleiss, and Cohen, who des~gnedthe GAS. Their sample consisted of psychiatric inpatients who were evaluated upon admission to the hospital and 6 months after discharge. GAS ratings on these subjects were compared with relevant indices from the Family Evaluation Form, the Mental Status Examination Record, and the Psychiatric Status Schedule. Results showed correlations that were in the predicted direction at the time of admission, but ranged only from - .19 to - .44 between the GAS and the criterion measures. The correlation range improved to .37 to - .62 at the second data collection point (6 months postdischarge). The authors ,Further reported that GAS ratings below 40 successfully predicted rehospitalization for discharged patients and that GAS scores were more sensitive to clirtical change than the other measures used in the study. A second validity study (Dekker, 1983) was conducted with an outpatient sample in a community mental health center. The Minnesota Multiphasic Personality Inventory (MMPI) served as the criterion, and the range of correlations between GAS ratings and various MMPI severity indices was a modest .29 to .36. The present study was undertaken to add to the sparse validity base underlying this popular scale. It addressed both criterion-related and construct validity aspects of GAS on the locked admitting ward of a state hospital in Wisconsin. This ward operates under a multidisciplinary team philosophy: Psychiatrists provide for a patient's medical and psychopharmacological needs, while psychologists provide testing and individual and group therapies. Social workers help the patient relate with family and community resources, while occupational and recreational therapists offer workshops and various other activities on and off ward. Ongoing 24-hr assessment and supervision is provided by a nursing staff.
-
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Before the GAS was introduced to the ward, it was decided that the multifaceted view of the patient derived from these separate perspectives and ways of relating to the patient would be muted if GAS ratings were made by a single team member. Forms and procedures were therefore devised so that each staff involved with a patient could make an independent GAS rating of the patient upon admission and at weekly htervals thereafter. These ratings are combined into a single team GAS rating by simply taking the mean of all team members' individual ratings. It is the reliability and validity of this team GAS method which is addressed herein.
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METHOD The ward's professional staff were trained in the use of the GAS according to the manual provided by the scale's authors. Training entailed the assignment of ratings of 21 printed cases; the feedback key provided for these cases included the correct ratings and the scale authors' rationales for them. Training was done individually in two self-study sessions: Ten cases were rated in the first session, followed by the correct answers and rationales. This process was repeated in the second session for the remaining 11 cases. After all staff had been trained in this manner, GAS ratings were introduced on to the ward as described next. Ten months later, the training protocol was repeated for all raters as a refresher course. Data collection was initiated after this second training experience. The inpatient subjects of this study were drawn from the 323 adults admitted to the ward between November 1986 and December 1987. This subject pool was 60% male, 5% minority, and ranged in age from 18 to 55. The majority were chronic patients with extensive treatment histories. Their average length of stay was 20 days. Diagnostically, schizophrenia and major affective disorder were the most common diagnoses. Most patients had been involuntarily admitted to and detained on the ward through a civil commitment process involving a probable cause hearing (within 3 days after a patient's emergency admission) and, if necessary, a subsequent commitment hearing (2 weeks after a finding ~f probable cause). Subjects were rated under two different conditions. The first is the admission staffing during which the team meets with the patient in a group interview situation shortly after admission. At admission staffings, a patient's legal rights and related questions are addressed first; a standard ~ s ~ c h i a t rhistory ic is then taken, and a mental status exam is administered. Next, the patient is excused, and the team discusses the clinical presentation and formulates a prdvisional diagnosis and treatment ~ l a nFinally, . each team member independently assigns the patient an admission GAS rating to cover the patient's condition during the week leading up to and including the admission staffing. Team members record
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their individual ratings privately on separate slips of paper. The mean of these ratings serves as the patient's admission GAS rating. Subjects were also GAS-rated during weekly progress reviews. Those were meetings mandated by the Joint Commission for the Accreditation of Hospitals (JCAH) for the purpose of reviewing progress during the previous week. The patient is not present during these reviews, which begin with a staff member's reading aloud a summary of the patient's hospital chart notes for the week in question. Next, significant observations of the patient during that week, which had not been recorded in the hospital chart, are reported by the staff member who observed them. Finally, each team member privately records a GAS rating for the patient, a rating based upon a combination of the team member's individual experience with the patient that week plus the team's collective experience as reflected in the progress review just completed. After one rating is completed, the staff moves on to the next patient and repleats the process until all patients have been rated. The mean of team members' ratings of a patient serves as the patient's weekly GAS rating for that week. Individual ratings were kept independent of each other from rater to rater and week to week. Rater-to-rater independence was achieved by the use of private rating sheets. Week-to-week independence was achieved by withholding the team results from staff until after the patient was discharged. In additilon, staff were instructed not to store and retrieve their earlier rarings of patients, and because 15 to 17 patients are rated during each l-hr progress review, it would have been exceedingly difficult for them to do otherwise.
Reliability The reliability of GAS was estimated in two ways on the sample of patients who served as subjects in the construct validity phase of this research (discussed next), The first reliability estimate involved the traditional correlation of GAS ratings made by a team member with those of all other team members. However, insofar as the mean rating of team members serves as the key GAS measure for the ward, a second reliability estimate was made by breaking the multidisciplinary team into two subteams. These subteams were arranged so as to be comparable in terms of educational level, clinical experience, and variety of professions represented. One subteam consisted of a psychiatrist, a psychologist, a social worker, and an occupational therapist; the second subteam consisted of two psychiatrists, the head nurse, a social worker, and a recreational therapist. Two separate subtearn mean GAS ratings were then computed for the patient sample in question, and the correlation of these represented the interteam (as opposed to interrater) reliability estimate. Because this second reliability estimate entailed splitting the team into two subteams (therebv reducing the typical cohort of raters by 50%)' it was necessary to apply the Spearman-Brown formula to this second coefficient in order to correct for the attenuation of normal team strength.
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Predictive Validity Wisconsin's statutory requirements for court-ordered involuntary hospitalization specify that proof of mental illness and dangerousness must first be established at a probable cause proceeding, held within 3 days of an emergency admission. When extended hospitalization appears necessary, relevant evidence must be submitted 2 weeks later at a civil commitment hearing. Both of these court proceedings culminate in dichotomous decisions (i.e., continued involuntary hospitalization or immediate discharge) which are rendered by a judge or court commissioner. Such decisions are well suited to serve as GAS validity criteria for two reasons. First, team GAS ratings on the ward typically range from the 10s to the 30s during the first 21/2 weeks of a patient's stay; a cursory examination of the scale reveals that its content in these ranges orients the rater to psychiatric symptoms and dangerous behaviors, a dual focus identical to the concerns of the court. Second, the commitment process was established in a way that excludes hospital staff from providing input to the court, thereby precluding conflict of interest dilemmas. Probable cause hearings are taken up with testimony from police officers, family members, and other observers of a patient's mentally ill and dangerous behavior prior to the emergency hospitalization. Evidence for the civil commitment hearing 2 weeks later is provided by two independent clinical examiners appointed by the court for that expressed purpose. These expert withnesses examine the patient on the ward and often read the hospital chart, but must form their own opinions about the patient. They are not given access to GAS ratings. As a result, there is no contamination of predictor with criterion because GAS ratings do not enter as evidence into either probable cause or commitment proceedings. In both situations, the decision to extend hospitalization or discharge the patient is made by the judge, not the hospital staff. Two specific GAS validity predictions were therefore formulated: (a) the admission GAS ratings of emergency admissions whose hospitalizations are subsequently extended at their probable cause hearings will be significantly lower than those of patients who are discharged at their probable cause hearings (lower ratings signify greater psychopathology) and (b)the weekly GAS ratings of patients whose hospitalizations are later extended at their civil commitment hearings will be significantly lower than those of patients who are discharged at their civil commitment hearings. As corollaries of these two hypotheses, it was further hypothesized that the hit rates for hospitalization decisions dictated by team GAS ratings would exceed the base rates for such decisions within the two patient samples. Given the nature of these criteria, voluntary patients who did not go through these judicial processes were excluded from the study. Involuntary patients who changed to voluntary status at any point in the emergency
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admission to probable cause to civil commitment process were dropped from the study when they became voluntary.
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Construct Validity The Psychotic Inpatient Profile (PIP; Lorr & Vestre, 1968) was chosen to assess the construct validity of team GAS. The PIP is a staff observational tool designed for inpatient settings and generates t scores for 12 symptom complexes (excitement, hostile belligerence, paranoid projection, anxious depression, retardation, seclusiveness, care needed, psychotic disorganization, grandiosity, perceptual disorganization, depressive mood, and disorientation). It was hypothesized that, as a global scale, the GAS would not correlate significantly with these specific PIP scales but would correlate significantly with a global psychopathology index, such as the sum of all PIP scales. The 39 patients-in this phase of the research were evaluated on both the PIP and team GAS during their second or fourth week of hospitalization. A psychologist, serving as PIP rater, filled out the PIP for no nnore than two subjects during any designated week. When doing so the psychologist was given access to the same data base that the rest of the team used to generate a weekly GAS rating for that week. This PIP rater never contributed to a subject's team GAS rating during the week that he filled out the PIP.
Ward Atmosphere The last phase of the study examined whether the mean GAS rating of all patients on the ward at a given time could be viewed as a valid measure of the ward's acuity (more colloquially referred to as a ward's "highness"). A disturbed group of patients interacting with one another in a closed environment generates more tension, acuity, and, as a result, more controlling behaviors by the staff than does a less disturbed group. It was therefore hypothesized that a significant positive correlation would be obtained between the average GAS rating of all patients on the ward during a given week and the degree of permissive behaviors exhibited by staff during the same week. The design of the building where the ward is housed permitted an unobtrusive way to measure staff3 permissive behaviors. The ward is separated from its cafeteria by a locked door. The cafeteria is an unsecured area; when trouble erupts with a patient, help is at least one locked door and a telephone call (rather than a shout) away. For this reason, only patients trusted by staff not to act out or wander off can be permitted to leave the ward and eat in the cafeteria. The rest take their meals in the dayroom on the ward. Therefore, one measure of staffs permissiveness is the percentage of all patient meals taken off a ward during a given week (a percentage score corrects for fluctuations in the ward's
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census). As this percentage increases, the staff behaves in increasingly permissive ways. Thus, a significant, positive correlation between the ward's average GAS rating and the percentage of meals eaten in the cafeteria was predicted. The average GAS rating for a given week was easily obtained from existing procedures. Data on meals taken in the cafeteria versus the ward were provided by the hospital's dietary department.
RESULTS
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Reliability Interrater reliability was estimated by correlating the GAS ratings assigned to a sample of 39 patients by individual team members with the corresponding ratings assigned by the eight other team members. This generated a matrix of 36 coefficients with a mean of .73 and a median of .72. The interteam reliability of team GAS ratings obtained by dividing the nine raters into two subteams was considerably higher. Correlating the mean GAS ratings of these two subteams for the same sample of 39 patients yielded a reliability coefficient of .90, a figure that increased to .95 when the Spearman-Brown formula was applied.
Predictive Validity Predictive validity data is presented in Table 2. In the probable cause phase of the study there were 59 patients (33 male and 26 female) whose hospitalizations were extended because their mental illness and dangerousness were established in court and 50 patients (30 male and 20 female) who were discharged because mental illness and dangerousness could not be thus established in court. O n admission GAS, the continued hospitalization group had a mean team GAS rating of 25.1 with a standard deviation of 9.6; the mean and standard deviation for the discharged group were 36.9 and 11.6, respectively. This difference was significant, t(107) = 5.84, p < .0005. Compared to the hospitalization base rate of 54% within this sample, the obtained team GAS hit rate of 76% for such decisions represented significant predictive power, X2(1,N = 109) = 29.47, p < .001. Thus the hypothesis that admission GAS ratings would predict the outcomes of probable cause hearings was confirmed. In the civil commitment phase, there were 22 patients (15 male and 7 female) whose hospitalizations were extended because mental illness and dangerousness was established at civil commitment hearings and 11 patients (3 male and 8 female) who were discharged for lack of sufficient evidence of mental illness and dangerousness at their civil commitment hearings. The mean weekly team GAS rating of the civilly committed group was 29.9 with a standard deviation of 8.6;
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TABLE 2 Predictive Validity of Team GAS For Court-Ordered Involuntary Hospitalizations Team GAS
N
M
SD
59 50
25.1 36.9
9.6 11.6
22 11
29.9 42.6
8.6 8.9
-
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I. 109 Probable Cause Hearings Outcomea Continued hospitalization Unconditional discharge Hit rate analysisb Team GAS "hits" for hospitalization decisions = 76% Base rate for hospitalization decisions = 54% 11. 33 Civil Commitment Hearings Outcomec Continued hospitalization Unconditional discharge Hit rate analysisd Team GAS "hits" for hospitalization decisions = 73% Base rate for hospitalization decisions = 67%
-
"t(107) = 5.84, p < .0005. bX2(1,N = 109) = 29.47, p < .001. 't(31) = 3.96, p < .0005. d ~ 2 ( 1 , N = 33) = 9.02, p < .01.
the mean and standard deviation for the discharged group were 42.6 and 8.9, respectively. This difference was also significant, t(31) = 3.96, P < .0005. Compared to the hospitalization base rate of 67% within this sample, the obtained team GAS hit rate of 73% for such decisions represented significant predictive power, X2(1,N = 33) = 9.02, P < .01. Thus the hypothesis that weekly GAS ratings would predict the outcomes of civil c~ommitmentproceedings was confirmed.
Construct Validity Correlations between weekly GAS ratings and the PIP scores of 39 patients (21 male, 18female) are presented in Table 3. Application of the Bonferroni formula to adjust for family alpha error (Harris, 1975)established that correlations of the magnitude of .44 and greater are reliable. As hypothesized, team GAS correlated significantly with the global PIP measure (r = -.64), and this was its highest correlation among all PIP measures. Also as predicted, team GAS did not correlate significantly with 9 of the 11 specific scales; however, its associations with the Care Needed (-.56) and Seclusiveness (-.48) scales were statistically significant.
Ward Atmosphere The hypothesis of a positive correlation between the average of all patients' GAS ratings for a given week and staffs permissiveness toward those patients with.
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KUHLMAN, BERNSTEIN, KLOSS, SINCABAN, HARRIS TABLE 3 Correlations Between Team GAS and Psychotic Inpatient Profile Scalesa
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PIP Scale Excitement Hostility Paranoid Projection Anxious Depression Retardation Seclusiveness Care Needed Psychotic Disorganization Grandiosity Perceptual Distortion Depressive Mood Global PIP (sum of all scales)
-
--
-
-
Pearson r
- .30 -.I8 -.31 - .24 -.31 - .48 - .56 - .29 -.31 .10 .09 - .64
ns ns ns ns ns < .005 < ,0005 ns ns ns ns < .001
"N = 39. cafeteria privileges was not confirmed. To the contrary, in an initial 19-week data collection period a significant negative correlation of - .48 ( p < .05) was obtained. An attempt to replicate this unexpected finding over a second data collection period of 18 weeks failed when a nonsignificant correlation of .13 was obtained for this second period.
DISCUSSION To summarize the results, team GAS ratings proved more reliable than GAS ratings made by individual raters, and three of four hypotheses which addressed team GAS validity were confirmed. The higher interteam reliability obtained here argues for adoption of the team approach over reliance on individual raters. The median interrater reliability coefficient of .72 is lower than the .80 median reported by Dekker (1983). However, it must be remembered that the various raters of this study interacted with the patients in different formats and functions. And although there was a common data base for ratings in the progress review meetings, it is also reasonable to assume that individual ratings were somewhat affected by the raters' unique experiences with the patients. Multiple perspectives are, of course, the basic argument underlying the popularity of multidisciplinary teams in inpatient work. If the individual interrater coefficients were much higher, one could infer that too much cohesion and redundancy exists to justify the team GAS approach. Confirmation of the predictive validity hypotheses is important because "mentally ill" and "dangerous" has been widely adopted as the standard for
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public sector hospitalizations in the U.S. at the present time. In conjunction with the Endicott et al. (1976) findings that the GAS ~redictsrehospitalization, the scale has now been shown to correlate with both admission and discharge decisions concerning hospitalization. With regard to construct validity, 10 of 12 predictions concerning the relationship between team GAS and the PIP were confirmed. These included one significant association between team GAS and a PIP index of global psychopathology and 10 nonsignificant associations involving team GAS and focal PIP symptom complexes. Careful consideration of the two predictions which failed-team GAS did correlate with the focal PIP scales of Care Needed and Seclusiveness-reveals these two PIP scales are the least symptom specific of the set. The greater statistical affinity of these two scales with the GAS is best explained by the fact that generalized deficits in self-care and socialization skills characterize all patients who are admitted to the state hospital regardless of diagnosis or specific syrnptomatology. Our findings should generalize to day treatment centers, sheltered work sites, and other treatment settings where extensive observation and contact with patients is typical. It is doubtful that they would apply to traditional outpatient settings where 1 hr of weekly contact with patients is the norm. In such contexts, GAS ratings, which correlate weekly with self-report on the MMPI (Dekker, 1983), necessarily rely on patients' self-report instead of daily observation and contact with many staff. There are also questions as to the GAS' content validity when it is applied to subjects who are less disturbed than those of this study. Ciarlo, Edwards, Kinesuk, Newman, and Brown (1981-cited in Dekker, 1983) noted that, although the lower half of GAS cites 23 behavioral examples with which to anchor ratings 1-50, there are only 7 such behavioral descriptions to anchor the upper half of the scale (51-100). This reflects the field's continuing problem in defining what behaviors constitute mental health. The efiect of this problem on reliability and validity is considerable- note that the typical patient in this study was admitted with a GAS rating of 26, averaged a rating of 33-35 on any given week, and was discharged with a rating of 42. Only a few subjects had GAS ratings that ranged over 50, and none were rated as high as 70. Obviously this study did not address the upper half of the scale. A final caution must be raised about generalizing from research on the GAS to the Global Assessment of Functioning Scale (GAF) of the DSM-111-R. There is a significant difference in the instructions used with the two scales: GAF calls for an assessment of lowest level of functioning, whereas GAF calls for current level of functioning and highest level of functioning during the past year. This means that the GAF diagnostician must often work within the middle and upper rangles of the scale; although it is laudable that there is such a focus on strengths in the present diagnostic scheme, the fact remains that there is
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demonstrable validity only for the lower ranges of the scale at this time. Research efforts are needed to address the measurement of global functioning in mildly impaired and healthy subjects; until then, generalizations from the GAS to the GAF are unwarranted.
ACKNOWLEDGMENTS
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This article was presented to the 96th annual meeting of the American Psychological Association in Atlanta, August 1988. We acknowledge the varied contributions of Stan Barry, Betty Havlik, Wendy Koch, Jim LeClair, Jack Sherman, and Barbara White to the completion of this project.
REFERENCES American Psychiatric Association. (1987). The diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. Battista, J. R. (1982). Empirical test of Vaillant's hierarchy of ego functions. American Journal of Psychiatry, 139,356-357. Ciarlo, J. A., Brown, T. R., Edward, D. W., Kiresuk, T. J., & Newman, F. L. (1986).Assessing mental health outcome measurement techniques. Rockville, MD: National Institute of Mental Health. Curran, J. P., Miller, I. W., Zurich, W. R., Monti, P. M., & Stout, R. L. (1980). The socially inadequate patient: Incidence rate, demographic and clinical features, and hospital and posthospital functioning. Journal of Consulting and Clinical Psychology, 48(3), 375-382. Dekker, D. J. (1983). A study of the validity of the Global Assessment Scale. Unpublished doctoral dissertation, Western Michigan University. Endicott, J., Spitzer, R. L., Fleiss, J. L., & Cohen, J. (1976). The Global Assessment Scale: A procedure for measuring overall severity of psychiatric disturbance. Archzves of General Psychiany, 33, 766-77 1. Harder, D. W., Greenwald, D. J., Wechsler, S., & Ritzler, B. A. (1984). The Urist Rorschach Mutuality of Autonomy Scale as an indicator of psychopathology.Journal of Clinical Psychology, 40(4), 1078-1083. Harris, R. J. (1975). A primer of multivariate statistics. New York: Academic. Husby, R. (1985). Short-term dynamic psychotherapy:V. Global Assessment Scale as an instrument for description and measurement of changes for 33 neurotic patients. Psychotherapy and Psychosomatics, 43, 28-31. Johnson, M. H., Magaro, P. A., & Stern, S. L. (1986). Use of the SADS-C as a diagnostic and symptom severity measure. Jouml of Consulting and Clinical Psychology, 54(4), 546-551. Lorr, M., & Vestre, N. (1968). The psychotic inpatient profile. Los Angeles: Western Psychological Services. Luborsky, L. (1962). Clinicians' judgments of mental health. Archives of General Psychiatry, 7, 407-417. Summers, W. K., Marsh, G. M., Chiong, B., Burgo~ne,R. M., Swenson, S. W., &Walker, N. R. (1983).The General Adult Inpatient PsychiatricAssessment Scale (GAIPAS).Psychiatry Research, 10, 217-236.
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Waskow, I. E., &Padoff, M. B. (Eds.). (1975). Psychotherapy change measures @HEW Publication No. ADM 74-120). Washington, DC: U.S. Government Printing Office.
Thomas Kuhlman Hennepin County Mental Health Center 525 Portland Avenue South Minneapolis, MN 55415
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Received January 23, 1990 Revised April 30, 1990
