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Published Online: 1 September 2017

Relationship Between Psychiatric-Service Consumers’ and Providers’ Goal Concordance and Consumers’ Personal Goal Attainment

Abstract

Objective:

This study tested concordance between consumers’ and providers’ reports of personal goal setting and its relationship to self-reported goal attainment.

Methods:

Data are from the Israeli Psychiatric Rehabilitation Patient Reported Outcome Measurement project. Consumers (N=2,885) and the providers who were most knowledgeable about their care indicated two domains from a list of ten in which consumers had set goals during the previous year. Consumers reported on goal attainment in each domain.

Results:

A total of 2,345 consumers (82%) reported a personal goal. Overall, consumer-provider concordance reached 54%. Concordance was greatest in the employment (76%), housing (71%), and intimate relationship (52%) domains and lowest in family relationships (23%) and finances (15%). For most domains, concordance was less than 50%. On average, 75% of consumers reported having achieved their goals. Consumer-provider concordance was associated with goal attainment (p<.001).

Conclusions:

These findings emphasize the importance of agreed-upon goals and call for conceptualizing goal setting as an interpersonal process central to recovery.
Setting personally meaningful goals and acquiring the skills and support needed to progress toward their attainment is one of the basic foundations of psychiatric rehabilitation and recovery (1,2). Interestingly, research has revealed little concordance between psychiatric-service consumers and their providers in goal setting (3,4).
The importance of provider-consumer agreement on the goals of treatment and rehabilitation has long been recognized (5). Without a joint process of goal setting, consumers feel less motivated and are less likely to attain their goals (6). A recent meta-analysis (3) indicated that psychotherapy outcomes are considerably enhanced when client and therapist are actively involved in a cooperative relationship based on goal consensus. Yet despite its importance, research on personal goal setting is scarce, mostly descriptive, and based on small samples and a limited number of domains (2,6). To fill these gaps, this study assessed concordance between consumers of psychiatric services and their providers for a broad range of personal domains and whether consumer-provider concordance was related to consumers’ self-reported goal attainment.

Methods

Data were collected as part of the Israeli Psychiatric Rehabilitation Patient Reported Outcome Measurement (PR-PROM) project (7), in which consumer-reported outcomes for a range of rehabilitation realms, including goal-setting domains, are collected yearly. This information is linked at the service level and to demographic, clinical, and administrative data, with the overall aim of informing policy and practice at the local and national levels. The study was approved by the Ministry of Health’s Helsinki committee.
All users of psychiatric rehabilitation services in northern and central Israel were approached between April 2013 and April 2015 to partake in the PR-PROM. Of the total 13,264 psychiatric rehabilitation–service users, 7,292 (55%) signed informed consent and 4,584 (63%) completed the self-report questionnaires. Of the survey respondents, 3,236 (71%) had information that could be linked to the diagnoses data file. For 2,885 (89%) consumers, a service provider also completed a survey regarding their rehabilitation outcomes, and these consumers constituted the study sample. Consumers’ mean±SD age was 46.4±12.6 years. A total of 1,644 (57%) were men; 1,760 (61%) had 12 years of education or fewer; and 2,423 (84%) were diagnosed as having schizophrenia.
In comparison with participants who received psychiatric rehabilitation services but did not complete the assessment (N=3,281), the current study’s respondents were on average three years older (p<.05), were more likely to be men (p<.01), and had longer overall hospitalization stays (p<.05).
Consumers were asked to indicate up to two domains in which they had set a goal within the previous year from the following list: work, education, housing, social relations, leisure activities, mental health, physical health, financial situation, intimate relationship (partner), and family relationships. Providers were likewise asked to indicate up to two of the domains listed above in which they believed the consumer had set a goal. Because each consumer could have had more than one provider, we selected providers according to the person most knowledgeable about the consumer.
For each of the domains, consumers were asked to rate the degree to which their goal was achieved during the previous year (1=goal was not achieved at all, 2=goal was partly achieved, or 3=goal was achieved). We also created a dichotomous variable (0=goal was not achieved at all or 1=goal was at least partially achieved). We coded provider-consumer concordance in each domain as 1 if consumers and their providers indicated that the consumer had a goal and as 0 if consumers indicated having a goal but the provider did not. These measures were specific to each goal, such that for consumers who indicated having goals in two domains, concordance and goal attainment were examined for each goal separately.
A cross-sectional study design was used. We linked the consumer-reported data with the Ministry of Health’s data warehouse. All data were deidentified upon merging. We performed descriptive analysis to assess the percentage of goals identified by consumers and the providers by domain type. Chi-square analyses were performed to test the association between consumers' and providers' indication of goal setting in each domain. Chi-square analyses and logistic regression were used to test the association between concordance and consumer-reported goal attainment. We used SPSS, version 19, to manage and analyze the data.

Results

A total of 2,345 consumers (82%) reported setting a goal during the previous year. A higher number of providers reported goal setting by consumers (N=2,654, 92%). The most common domain in which a goal was set according to consumers’ and providers’ reports was work (N=1,182, 41%, and N=1,673, 58%, respectively). The least common domain that providers identified was family relationships (N=173, 6%) and that consumers identified was finances (N=115, 4%). In six of the 10 domains (work, family relationships, social ties, leisure, housing, and physical health), providers overestimated consumers’ having goals. In all other domains (intimate relationship, education, finances, and mental health), providers underestimated consumers’ having goals. Mental health was the domain most underestimated by providers (13% of providers vs. 20% of consumers).
Overall, provider-consumer concordance reached 54.4% (Table 1). The domains with the highest concordance were employment (76%), housing (71%), and intimate relationship (partner) (52%); domains with the lowest concordance were family (23%) and finances (15%). Overall, for most domains (seven of 10), provider-consumer concordance was less than 50%.
TABLE 1. Concordance between consumers and providers in goal setting by 2,345 consumers and association with goal attainmenta
   Goal attainmentb 
 Consumers with consumer-provider concordance (N=2,345)No concordanceConcordance 
Domain of goalN%N%N%p
Any domain1,27654761701,02180<.001
Work/vocation714761767857881.438
Housing23671162714477.039
Intimate relationship (partner)15752128616876.003
Education205481516817686<.001
Physical health11637222773582.045
Leisure10434240783386.048
Social ties6427179821685.910
Mental health1122642824387.291
Family28239478486.047
Finances5415103673871.584
a
Consumers were asked to indicate up to two domains in which they had set a goal within the previous year. Proportions were compared by chi-square tests.
b
Ns represent the number of goals in each category; therefore, the percentages reflect a different N for each goal.
On average, 75% (N=1,759) of consumers reported having achieved their goals, at least partly (ranging from 68% [N=1,595] who achieved financial goals to 85% [N=1,993] who achieved mental health goals). In all domains, consumers reported greater degrees of goal attainment than did their providers. For most domains (seven of 10), this difference achieved statistical significance (p=.045 to <.001). Examination of the percentage of self-reported goal attainment according to the summary measure of concordance on any of the goals showed that when providers acknowledge their consumers having goals (concordance), 80% of the goals are achieved, versus only 70% when there is no concordance (p<.001). The domains in which this gap was significant were housing, intimate relationship, education, physical health, leisure, and family (Table 1). Additionally, the results of the logistic regression analysis showed that when concordance was reached in any of the domains, the odds of self-reported goal attainment were 1.70 (confidence interval=1.40–2.06).

Discussion

This study revealed large gaps between psychiatric service consumers and providers on the domains in which consumers report having personal goals. The importance of goal concordance was highlighted by the finding that consumer-provider concordance was associated with higher rates of goal attainment.
A major aspect of a good therapeutic alliance is agreement on goals and ways to achieve them (5). Unfortunately, research has consistently shown that consumers and providers tend to disagree on a wide range of treatment issues, including goal setting (7,8). In the current study, for all domains, with the exception of work and housing, concordance reached 50% or less, indicating the more personal and potentially less self-evident nature of domains such as leisure, finances, and family.
Agreement on goals is fundamental (9,10) and should be systematically assessed and discussed rather than assumed. Such an effort is exemplified by the PR-PROM project (7), in which participants are given feedback by using simple visual graphs reflecting their self-reported evaluation across a broad range of areas, including goal setting and attainment. The idea behind this feedback is that the consumer, if he or she desires, can initiate a discussion with the practitioner regarding the recovery process and thereby enrich the dialogue, which may improve consumer-provider communication (11) and possibly agreement on goals.
Several limitations should be noted. First, the differences between our study population and other consumers of mental health services should be considered when extrapolating our results to the general population of consumers of mental health services. Also, because our measures were self-reported, future studies should examine the relationship between concordance and more objective outcomes. Finally, further studies should explore consumer and provider characteristics that may affect goal concordance and goal attainment, the degree to which consumers and providers actually discuss and agree on goals, and whether and how feedback tools, such as those developed as part of the PR-PROM project, are implemented.

Conclusions

Goal setting is at the heart of psychiatric rehabilitation and is a master signifier of the vision of recovery, because it translates into and motivates the process of creating a personally meaningful life. The current findings emphasize the importance of agreed-upon goals and call for the need to conceptualize goal setting as an interpersonal process in which building an alliance is key rather than a declarative goal-setting process that holds the danger of unnoticed disagreement followed by low goal attainment.

Acknowledgments

The authors thank the staff at the Department of Rehabilitation and the Department of Information and Evaluation at the Mental Health Services Division of the Ministry of Health as well as the entire team of the Psychiatric Rehabilitation Patient Reported Outcome Measurement project for their ongoing contributions.

Footnote

These views represent the opinions of the authors and not necessarily those of the Israeli Ministry of Health or the Laszlo N. Tauber Family Foundation.

References

1.
Corrigan PW, Mueser KT, Bond GR, et al: Principles and Practice of Psychiatric Rehabilitation: An Empirical Approach. New York, Guilford, 2012
2.
Tabak NT, Link PC, Holden J, et al: Goal attainment scaling: tracking goal achievement in consumers with serious mental illness. American Journal of Psychiatric Rehabilitation 18:173–186, 2015
3.
Tryon GS, Winograd G: Goal consensus and collaboration. Psychotherapy 48:50–57, 2011
4.
Drebing CE, Van Ormer EA, Schutt RK, et al: Client goals for participating in VHA vocational rehabilitation: distribution and relationship to outcome. Rehabilitation Counseling Bulletin 47:162–172, 2004
5.
Bordin E: The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy 16:252–260, 1979
6.
Sivaraman Nair KP: Life goals: the concept and its relevance to rehabilitation. Clinical Rehabilitation 17:192–202, 2003
7.
Roe D, Gelkopf M, Gornemann MI, et al: Implementing routine outcome measurement in psychiatric rehabilitation services in Israel. International Review of Psychiatry 27:345–353, 2015
8.
Hasson-Ohayon I, Roe D, Kravetz S, et al: The relationship between consumer insight and provider-consumer agreement regarding consumer’s quality of life. Community Mental Health Journal 47:607–612, 2011
9.
Aviram U, Ginath Y, Roe D: Mental health reforms in Europe: Israel’s rehabilitation in the community of persons with mental disabilities law: challenges and opportunities. Psychiatric Services 63:110–112, 2012
10.
Scobbie L, Dixon D, Wyke S: Goal setting and action planning in the rehabilitation setting: development of a theoretically informed practice framework. Clinical Rehabilitation 25:468–482, 2011
11.
Unsworth G, Cowie H, Green A: Therapists’ and clients’ perceptions of routine outcome measurement in the NHS: a qualitative study. Counselling and Psychotherapy Research: Linking Research with Practice 12:71–80, 2012

Information & Authors

Information

Published In

Go to Psychiatric Services
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Cover: New York City Views. Skaters Near 59th Street, Samuel H. Gottscho. Museum of the City of New York. Photo credit: Museum of the City of New York/Art Resource, New York City.

Psychiatric Services
Pages: 1312 - 1314
PubMed: 28859583

History

Received: 18 December 2016
Revision received: 3 April 2017
Revision received: 14 May 2017
Accepted: 22 June 2017
Published online: 1 September 2017
Published in print: December 01, 2017

Keywords

  1. Goal concordance
  2. Goal attainment
  3. Psychiatric rehabilitation services

Authors

Details

Efrat Shadmi, Ph.D. [email protected]
Dr. Shadmi, Dr. Gelkopf, Dr. Garber-Epstein, Dr. Scialom, and Dr. Roe are with the University of Haifa, Haifa, Israel. Dr. Shadmi is with the Department of Nursing. He is also with the Center for Community Mental Health Research, Training, Services and Policy, where Dr. Gelkopf, Dr. Garber-Epstein, and Dr. Roe are affiliated. Dr. Gelkopf and Dr. Roe are also with the Department of Community Mental Health, and Dr. Scialom is with the School of Public Health. Dr. Garber-Epstein is also with the Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel. Dr. Baloush-Kleinman and Ms. Dudai are with the Department of Rehabilitation, Mental Health Services at the Ministry of Health, Jerusalem.
Marc Gelkopf, Ph.D.
Dr. Shadmi, Dr. Gelkopf, Dr. Garber-Epstein, Dr. Scialom, and Dr. Roe are with the University of Haifa, Haifa, Israel. Dr. Shadmi is with the Department of Nursing. He is also with the Center for Community Mental Health Research, Training, Services and Policy, where Dr. Gelkopf, Dr. Garber-Epstein, and Dr. Roe are affiliated. Dr. Gelkopf and Dr. Roe are also with the Department of Community Mental Health, and Dr. Scialom is with the School of Public Health. Dr. Garber-Epstein is also with the Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel. Dr. Baloush-Kleinman and Ms. Dudai are with the Department of Rehabilitation, Mental Health Services at the Ministry of Health, Jerusalem.
Paula Garber-Epstein, Ph.D.
Dr. Shadmi, Dr. Gelkopf, Dr. Garber-Epstein, Dr. Scialom, and Dr. Roe are with the University of Haifa, Haifa, Israel. Dr. Shadmi is with the Department of Nursing. He is also with the Center for Community Mental Health Research, Training, Services and Policy, where Dr. Gelkopf, Dr. Garber-Epstein, and Dr. Roe are affiliated. Dr. Gelkopf and Dr. Roe are also with the Department of Community Mental Health, and Dr. Scialom is with the School of Public Health. Dr. Garber-Epstein is also with the Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel. Dr. Baloush-Kleinman and Ms. Dudai are with the Department of Rehabilitation, Mental Health Services at the Ministry of Health, Jerusalem.
Vered Baloush-Kleinman, Ph.D.
Dr. Shadmi, Dr. Gelkopf, Dr. Garber-Epstein, Dr. Scialom, and Dr. Roe are with the University of Haifa, Haifa, Israel. Dr. Shadmi is with the Department of Nursing. He is also with the Center for Community Mental Health Research, Training, Services and Policy, where Dr. Gelkopf, Dr. Garber-Epstein, and Dr. Roe are affiliated. Dr. Gelkopf and Dr. Roe are also with the Department of Community Mental Health, and Dr. Scialom is with the School of Public Health. Dr. Garber-Epstein is also with the Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel. Dr. Baloush-Kleinman and Ms. Dudai are with the Department of Rehabilitation, Mental Health Services at the Ministry of Health, Jerusalem.
Ronit Dudai, M.A.
Dr. Shadmi, Dr. Gelkopf, Dr. Garber-Epstein, Dr. Scialom, and Dr. Roe are with the University of Haifa, Haifa, Israel. Dr. Shadmi is with the Department of Nursing. He is also with the Center for Community Mental Health Research, Training, Services and Policy, where Dr. Gelkopf, Dr. Garber-Epstein, and Dr. Roe are affiliated. Dr. Gelkopf and Dr. Roe are also with the Department of Community Mental Health, and Dr. Scialom is with the School of Public Health. Dr. Garber-Epstein is also with the Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel. Dr. Baloush-Kleinman and Ms. Dudai are with the Department of Rehabilitation, Mental Health Services at the Ministry of Health, Jerusalem.
Silvia Lea Scialom, M.D., M.P.H.
Dr. Shadmi, Dr. Gelkopf, Dr. Garber-Epstein, Dr. Scialom, and Dr. Roe are with the University of Haifa, Haifa, Israel. Dr. Shadmi is with the Department of Nursing. He is also with the Center for Community Mental Health Research, Training, Services and Policy, where Dr. Gelkopf, Dr. Garber-Epstein, and Dr. Roe are affiliated. Dr. Gelkopf and Dr. Roe are also with the Department of Community Mental Health, and Dr. Scialom is with the School of Public Health. Dr. Garber-Epstein is also with the Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel. Dr. Baloush-Kleinman and Ms. Dudai are with the Department of Rehabilitation, Mental Health Services at the Ministry of Health, Jerusalem.
David Roe, Ph.D.
Dr. Shadmi, Dr. Gelkopf, Dr. Garber-Epstein, Dr. Scialom, and Dr. Roe are with the University of Haifa, Haifa, Israel. Dr. Shadmi is with the Department of Nursing. He is also with the Center for Community Mental Health Research, Training, Services and Policy, where Dr. Gelkopf, Dr. Garber-Epstein, and Dr. Roe are affiliated. Dr. Gelkopf and Dr. Roe are also with the Department of Community Mental Health, and Dr. Scialom is with the School of Public Health. Dr. Garber-Epstein is also with the Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel. Dr. Baloush-Kleinman and Ms. Dudai are with the Department of Rehabilitation, Mental Health Services at the Ministry of Health, Jerusalem.

Notes

Send correspondence to Dr. Shadmi (e-mail: [email protected]).

Competing Interests

The authors report no financial relationships with commercial interests.

Funding Information

The Isreali Ministry of Health:
The Laszlo N. Tauber Family Foundation:
This study was supported in part by the Israeli Ministry of Health and the Laszlo N. Tauber Family Foundation.

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