The International Journal of Psychosocial Rehabilitation

Development and Implementation of a Functional Skills Measure for Rehabilitation Therapy in a Forensic Psychiatric Inpatient Facility

James Neville, MA, CTRS
Chief of Central Program Services

James Vess, Ph.D.
Senior Supervising Psychologist

Citation:
Nevelle, J., & Vess, J.  (2001)  Development and implementation of a functional skills measure for rehabilitation therapy
in a forensic psychiatric inpatient facility.  International Journal of Psychosocial Rehabilitation. 5, 135-146


 Author Note:
James Neville is the Chief of Central Program Services at Atascadero State Hospital. James Vess is a Senior Supervising Psychologist, directing the Evaluation and Outcome Services at Atascadero State Hospital. Correspondence concerning this article should be addressed to the second author at Evaluation and Outcome Services, Atascadero State Hospital, P. O. Box 7001, Atascadero, California, 93423. The telephone number is (805) 468-2091, and the fax number is (805) 468-2124. Electronic mail may be sent to: jvess@dmhash.state.ca.us.


Abstract
Following the adoption of a biopsychosocial rehabilitation orientation to treatment, the rehabilitation therapy service at Atascadero State Hospital began to search for assessment and treatment planning measures to facilitate and support this approach. Failing to find existing measures which adequately served these functions for the hospitalís forensic psychiatric population, the Functional Skills Assessment Ė Rehabilitation (FSA-R) was developed to measure functional skills related to the delivery of rehabilitation therapy treatment activities in a secure inpatient facility. The FSA-R is now a standard part of the rehabilitation therapy assessment and treatment planning process, whereby all patients are evaluated upon admission and quarterly throughout their course of hospitalization. The FSA-R is a reliable and valid measure of patient performance. Standardized measures such as the FSA-R support several aspects of performance improvement, including effective treatment planning, service delivery, and program development.


Introduction
Forensic psychiatric inpatients are difficult to treat. They are involuntarily committed for treatment, and few would seek inpatient treatment of their own volition, despite or perhaps because of gross psychiatric and functional impairment. Treatment of this population is also expensive, with an average annual cost of $105,000 per patient in Californiaís maximum-security forensic state hospital. The effective delivery of rehabilitation therapy services in this setting demands a focused process of assessment and treatment activity explicitly linked to expected outcomes. These outcomes must be defined in terms of patient functioning necessary for successful adaptation to the anticipated discharge environment. (Brown et al, 1979; Lang and Mattson, 1985).

The treatment setting and target population
Atascadero State Hospital (ASH) is one of four California State hospitals. It is the maximum-security forensic facility which houses approximately one thousand judicially committed male patients from the stateís criminal justice system. Average age is 41.5, with a range of 19 to 85 years. 48% are White, 29% African-American and 18% Hispanic. Patient records indicate that 68% have never married, 21% are divorced or separated and 9% married. Average reported education is eleventh grade. The distribution of primary diagnoses consists of 61% psychotic disorders (mostly schizophrenia and schizoaffective) and 26% non-psychotic sexual disorders (mostly paraphilias). The remaining 13% are mainly a mixture of mood and substance abuse disorders, often with psychotic features. Most patients also demonstrate features of personality disorder, and most have a history of violent behavior.

There are three primary commitment types. 41% of patients are mentally disordered offenders who have served their sentence in prison and subsequently been paroled to Atascadero State Hospital for mental health treatment prior to release to the community. Another 17% are inmates from the department of corrections who require psychiatric treatment unavailable in the stateís prisons. Following treatment, these patients are typically returned to the Department of Corrections to serve the remainder of their sentences. Finally, a statute enacted in 1996 has resulted in the civil commitment of a sex offender population mandated to receive treatment following their prison sentence and prior to release to the community. This group currently represents 30% of patients in residence. The remaining 12% consists of other commitment types, including individuals found incompetent to stand trial and those found not guilty by reason of insanity. Patients are treated on one of twenty-eight residential treatment units of between 30 and 50 patients. Units are organized into six different treatment programs, which are primarily specific to one commitment type.

This diversity of commitment types introduces differences in treatment goals. Patients being prepared for return to the Department of Corrections present different discharge criteria from those being prepared for release to the community under the supervision of the stateís conditional release programs or parole. These disparate discharge environments impose different demands in terms of functional skill level and psychiatric stability. The Functional Skills Assessment - Rehabilitation (FSA-R) was developed to accommodate this range of commitment types, diagnoses, and associated treatment goals, allowing it to be used in a standardized fashion across the facilityís patient population.

The FSA-R was designed to contribute to the facilityís performance improvement efforts in several ways. It organizes the initial functional assessment of the patient in areas relevant to rehabilitation therapy. It facilitates treatment planning, whereby levels of functioning are used to determine the assignment of treatment activities. It provides a basis for program evaluation, so that service delivery can be better matched to assessed patient needs. And it supports outcome evaluation, both in terms of response to the treatment provided during hospitalization and the association of functional level with post-discharge outcomes.

The treatment planing process. ASH has adopted a biopsychosocial rehabilitation (BPSR) approach to treatment, which emphasizes reduction of psychiatric symptoms, primarily through medication, and the development of functional skills associated with relapse prevention and adaptation to less restrictive environments. Treatment planning is based on a locally developed assessment of functional skills, the Atascadero Skills Profile (Vess, 2000). This instrument covers ten areas of functional skill determined to be critical to the functioning of a forensic psychiatric inpatient population in the anticipated discharge environments. Discipline specific assessments, including assessment conducted by rehabilitation therapists, are designed to relate directly to the domains of functional skill delineated by the Atascadero Skills Profile.

Optimally, treatment is explicitly aligned with specific assessment findings and intended patient outcomes. The treatment process is dynamic, influenced significantly by patient response to treatment. Evaluating this response to treatment involves staff observations of patient behavior using patientsí return demonstration of skills, patient interview, chart review and standardized assessment instruments. Since treatment recommendations are based upon assessment, it is important that assessment data be reliable, valid, and relevant. Figure 1 illustrates the sequence of assessment and treatment planning for rehabilitation therapy.

Figure 1. Treatment Planning Process


 
Prescribe  Treatment
All treatment activities at ASH, including those of rehabilitation therapy, are defined by written protocols describing a group of strategies or actions initiated in response to identified deficits or specific symptoms (Grote, Hasl, Krider, & Martin-Mortensen, 1995). These protocols are not intended to be descriptions that define a single rehabilitation therapy discipline or modality, but rather specific interventions that lead to expected treatment outcomes (Knight and Johnson, 1991). The rehabilitation therapy protocols define treatment activities designed to help the patient recognize the importance of a healthy lifestyle and realize the value of his involvement in constructive leisure activities. Most groups are designed to facilitate the patientís experience of the value in productive choices and natural consequences of his behavior. Assessments in this setting need to capture the content and scope of leisure behavior (Dunn, 1984; Stumbo & Rickards 1986; Witt, Connolly, & Compton, 1980) while evaluating characteristics common in a forensic setting, including minimizing problems, projecting blame, not accepting responsibility, and substance abuse issues.
 
Rehabilitation Therapy at ASH
Within the biopsychosocial rehabilitation framework, rehabilitation therapists seek to increase patient skills in specific areas of functioning. ASH employs 49 rehabilitation therapists, including the disciplines of art therapy, dance/movement therapy, music therapy, occupational therapy and recreation therapy. The rehabilitation therapist provides goal-oriented treatment services in the following areas:
  • Stress and Anger Management
  • Recreation and Leisure
  • Independent Living
  • Interpersonal Skills
  • Substance Abuse Education and Prevention
  • All patients admitted to ASH are evaluated on the admissions unit. These are locked units because of the patientsí acute condition, lack of stability on medication, and their potential for violence. Patients in this phase of their hospitalization often have difficulty orienting or adjusting to the facility. The rehabilitation therapists on the admission units provide groups to help the patient orient to treatment at ASH and establish a baseline to document patient needs and subsequent progress.

    The rehabilitation therapist conducts an individualized assessment, collecting data including strengths, interests, abilities and deficits to determine appropriate interventions for treatment planning. The FSA-R provides the rehabilitation therapist with a baseline of skills relevant to all the disciplines. When patients are transferred from admissions to their next residential treatment unit, treatment planning is handed over to the interdisciplinary treatment team on the receiving unit. The FSA-R provides a standardized measure from one treatment team to the next, maintaining a continuity of care for the patient that was previously lacking.

    Rehabilitation Therapy Assessment
    Thorough and comprehensive patient assessment is an essential prerequisite to the appropriate provision of rehabilitation therapy services (Witt et al., 1980; Wehman & Schlein, 1980). The treatment process at ASH begins with an assessment of functional skill level and the identification of patient interests. The evaluation process is completed during the first seven days after admission and every 90 days thereafter. This process includes utilization of standardized assessment procedures for each clinical discipline (e.g. psychiatry, psychology, social work, nursing, and rehabilitation therapy) and collaboration among members of the interdisciplinary treatment team.

    In a continuing effort to more accurately capture the unique needs of the forensic population and measure patient progress, an explicit search for a comprehensive and focused rehabilitation therapy assessment instrument began in 1995. It has been observed that there is a general lack of standardized assessment tools in rehabilitation therapy (Stumbo, 1991). Further, most available measures have limited content and scope, and lack psychometric adequacy. In considering the vital role assessment plays in planning appropriate intervention, it became increasingly apparent that the needs of forensic psychiatric patients are unique. Whereas rehabilitation therapists in other psychiatric settings must address patientsí social skills and cognitive deficits, patients at ASH also present legal and characterological issues, often involving their potential for violence and history of institutionalization.

    Development of the FSA-R
    An instrument that addresses the needs of this population within the parameters of the treatment setting must serve several purposes:

  • Assist with treatment planning and program development within a biopsychosocial rehabilitation framework.
  • Assist with JCAHO accreditation by demonstrating a means of tracking patient progress and provide clinical justification for specific treatment.
  • Align with the facilityís overall treatment evaluation tool, the Atascadero Skills Profile.
  • Assist with state-required documentation responsibilities.
  • Transfer information efficiently from data collected on the admissions unit to be utilized by the receiving treatment unit.
  • Provide sufficient standardization to allow data aggregation and analysis.
  • Be sufficiently broad in scope to remain relevant for all rehabilitation therapy disciplines.
  • In order to meet the identified assessment and treatment planning needs, a measurement committee was formed to review available published instruments that might serve these purposes. The search discovered a variety of well-established tools focused on leisure attitudes, barriers to participation, leisure activity skills and interests. Among the instruments reviewed was the Leisure Diagnostic Battery, which assesses a clientís perceived freedom in leisure and potential barriers to leisure activities (Ellis and Witt, 1982). The Functional Assessment of Characteristics for Therapeutic Recreation, or FACTR, examines functional skills and behaviors considered to be prerequisite to leisure involvement (Burlingame and Blaschko, 1990). The Leisure Activities Blank measures past leisure participation and intentions regarding future involvement (McKechnie, 1975). Finally, the Comprehensive Evaluation in Recreation Therapy-Psychiatric/Behavioral, or CERT-Psych, measures 25 behaviors required in a variety of leisure activities, including general, individual and group behaviors (Parker, Ellison, Kirby and Short, 1975). The CERT was initially implemented at this facility before being replaced by the FSA-R as a more effective measure of patient functioning.

    While some instruments were appropriate for the psychiatric setting, none were considered to adequately meet the needs of a forensic inpatient population. A decision was reached to develop a local measure based on the relevant constructs. An effort was made to follow procedures to develop an instrument with credibility, standardization, generalization and adequate psychometric qualities, such as validity and reliability (Burlingame & Blaschko, 1990; Kinney, 1980; Stumbo & Rickards, 1986; Touchstone, 1975).

    A work group was formed to identify behaviors that could easily be assessed within a maximum-security inpatient setting. In addition to the concerns previously mentioned, the work group was challenged to define the construct of motivation in terms of observable behavior within a secure setting. In the relationship between intrinsic motivation and mental health, rehabilitation therapy can be seen as having value in planning and promoting experiences which satisfy intrinsic needs (Levy, 1971). Similarly, mental illness may be seen as associated with the failure to find satisfying recreational activities that meet intrinsic needs (Levy 1978). Part of the goal of rehabilitation therapy services at ASH is to move patients from a reliance on extrinsic factors to more intrinsic forms of motivation.

    For ASH patients to make positive and purposeful choices about their free time and experience the value inherent in good decision making, the structured environment must provide the patient with the opportunity to recognize the benefits of such choices. The social environment needs to allow the patient to safely experience the consequences of unhealthy choices that are harmful, disruptive or destructive, and the differences between these and healthier choices. Consistent with the BPSR model, interventions align with the functioning level of the patient. In rehabilitation therapy, the stages of BPSR are viewed as steps through which the patient acquires skills leading toward increasingly positive decision-making in his daily life (Neville, Taylor and Craig, 2000).

    In the treatment readiness phase the rehabilitation therapist identifies patients whose thinking and behaviors are detrimental to self or others, such as fighting, suicidality, criminal thinking, or poor eating, sleeping and exercise habits. These patients will be placed in treatment readiness groups to remediate these deficits. Here the job is to motivate the patients toward making healthier choices in thoughts and actions.

    Skill building is the second stage of the BPSR treatment model. If the rehabilitation therapist observes a patient who participates in groups but does not truly involve himself, then skill building is the goal. While the patient may attend treatment activities to pass the time or possibly to look good for his court hearing, the rehabilitation therapist teaches in this phase the benefits and values of a healthy, active lifestyle and the importance of emotional connection to oneís environment.

    The third stage is discharge readiness. A patient in the discharge readiness stage consistently applies what he has learned. The rehabilitation therapist will facilitate opportunities for the patient to independently chose and schedule activities in which his behaviors must reflect his learning. Discharge readiness will also include leadership and time management skills and will gradually increase the patientís freedom of choice.

    The measurement committee attempted to identify interventions that maximize healthy internal control in a maximum-security, externally controlled environment. As indicated, the interventions vary according to functional ability, along with the specific focus or goal. A concentrated effort was made to identify the behavioral aspects of a patientís leisure choices and lifestyle and measure the patientís perception of value and benefits of his participation or constructive use of free time. An initial list of behaviors consistently observed from all five rehabilitation therapy disciplines was identified, focusing on social skills, cognitive skills, wellness/well being and the patientís perception of value in constructive use of free time. The list of behaviors was presented to all rehabilitation therapists in the form of a data collection sheet. Each rehabilitation therapist was asked to observe and record these behaviors in randomly selected treatment groups.

    These groups ranged from cognitive based treatment activities to scheduled leisure opportunities. The random sample of groups included a cross section of various interventions. All groups provided the patient with opportunities to examine thoughts and feelings that affect choices and behavior (e.g., anger, trust, denial, etc.), to demonstrate skills in a variety of settings, to work with others in cooperative efforts, deal with frustration, and to experience success in group process.

    The staff completed their observations during a twelve-week period. Following data collection, staff were asked to evaluate the measurement process. Responses to a survey conducted with all rehabilitation therapists indicated that most agreed that data collection provided information about the patientís condition which helped in making appropriate referrals to treatment groups. The information gathered was viewed as an effective measure of patientsí performance abilities and identified important strengths and weaknesses. Survey results also confirmed that the information gathered aligned with other assessment measures in use by the interdisciplinary treatment team. The group concluded that use of the measure should continue.

    A useful by-product of this process and the resulting measurement tool was the unifying effect within the rehabilitation therapy staff. Because the target behaviors were chosen so as to span the activities of all rehabilitation therapy disciplines, staff now had a common language and conceptual framework for patient assessment and treatment planning.

    The pilot study and evaluation process confirmed that behaviors in the areas of social skills, participation, interests, values, perceptions, and benefits of leisure were identified that were observable within the hospital environment and shared across the rehabilitation therapy disciplines. These behaviors were then divided into four sub-components and defined as follows:

    Social Interaction Ė The patientís ability to communicate thoughts and feelings effectively, recognizing that the absence of adequate social interaction skills can be as much a barrier to appropriate involvement/participation as the lack physical skills or knowledge.

    Scope of Involvement Ė The patientís ability to recognize and internalize the value of constructive involvement and to demonstrate healthy, positive choices.

    Performance Abilities Ė The patientís ability to concentrate, attend to task and/or exhibit a sustained interest in activity.

    Competence/Control Ė The patientís ability to select an activity to participate in and control the nature and intensity of their involvement related to enjoyment and self-expression.

    The initial version of the FSA-R consisted of five behavioral items in each of the four sub-components just described. Principal components factor analysis with varimax rotation was conducted on 383 administrations of this form of the instrument. This resulted in the identification of two primary factors. Examination of the factor loadings for each item suggested that these factors reflected the constructs of level of involvement and performance abilities. Level of involvement was defined as a measure of the patientís willingness to make positive choices regarding his lifestyle, ability to modulate the nature and intensity of his involvement, and recognition of the value of constructive activities to prevent relapse. Performance abilities were seen as a measure of the patientís ability to access opportunities in his environment, through appropriate verbal expression and task related skills, such as concentration and attention to the task. The organization of the instrument was then revised to reflect these two domains, and several items were modified to identify them more clearly with the construct to which they belonged. The total number of items was reduced from 20 to 18.

    Psychometric and descriptive statistics
    Reliability. Internal consistency was evaluated using Cronbachís alpha. Observed alpha coefficients were .95 for Involvement, .93 for Performance, and .96 for the total scale, indicating excellent internal consistency. Interrater reliability was evaluated using three pairs of Rehabilitation Therapists, with each pair rating 10 patients familiar to both raters. Reliability coefficients for each pair of raters ranged from .87 to .98 for the entire instrument, indicating good interrater reliability.

    Validity. Two types of content validity can be evaluated for the FSA-R. One is face validity, which refers to the extent to which an instrument looks as if it measures what it is intended to measure. Any instrument that is intended to have content validity must meet this standard, although face validity alone is not sufficient. The FSA-R has been found by users to address issues relevant to the patient population, and therefore to have face validity.

    A second type of content validity is logical or sampling validity. While face validity is evaluated after the instrument is constructed, logical or sampling reliability refers to the method by which an instrument is constructed. It involves the use of expertise to define an area of interest, drawing a representative sample of ideas or issues from this area, and preparing instrument items that match these ideas or issues (Roscoe, 1975). In the construction of the FSA-R, the existing professional literature on assessment instruments and the expertise of rehabilitation therapy staff were used to define the content areas relevant to the patient population. A group of experienced clinicians then developed items that assess patient functioning in these areas, based on their experience with the ASH patient population.

    The third type of validity evaluated for the FSA-R is a form of construct validity referred to as factorial validity. Based on factor analysis, clusters of highly correlated items are considered to represent the distinct constructs measured by an instrument (Nunnally, 1970). To evaluate the factor structure of the revised FSA-R, a principal components analysis was conducted using varimax rotation on the FSA-R ratings of a sample of 309 patients. The results of this analysis are presented in Table 1.

    Table 1. Results of Factor Analysis of FSR-A scores.
     
    FSA-R Item
    Factor 1
    Factor 2
    LEVEL OF INVOLVEMENT
       
    A. Contributes ideas, thoughts, and feelings .817 .205
    B. Participates in rehab therapy treatment .766 .219
    C. Demonstrates effective listening skills .605 .562
    D. Accepts various group roles .802 .322
    E. Encourages and supports the involvement of others .821 .225
    F. Varies form of participation .821 .262
    G. Participates in leisure time activities .802 .171
    H. Uses available leisure/recreational resources .833 .234
    I. Identifies benefits of leisure in relapse prevention planning .828 .322
    PERFORMANCE ABILITES
       
    A. Provides feedback to peers .790 .288
    B. Cooperatively assists others .743 .366
    C. Accepts structure and rules .487 .732
    D. Directs and maintains attention .652 .447
    E. Independently carries out tasks to completion .719 .368
    F. Return-demonstrates learning of specific skills .732 .394
    G. Refrains from derogatory/negative comments .076 .877
    H. Accepts constructive criticism from peer and staff .349 .839
    I. Handles conflicts effectively .292 .858

    Factor analysis of FSA-R scores yielded a two factor solution. The Eigenvalue of the first factor was 11.3, accounting for 62.8% of the total variance. This factor consists of items focusing on level of involvement or participation in rehabilitation therapy activities. The Eigenvalue for the second factor was 1.7 and accounted for 9.5% of the variance. This factor appears related to the patientís adjustment to the structure and process of the activities. Several items correlate substantially with both factors, indicating a somewhat mixed factorial composition. Examination of the content of items which load on both factors suggests that listening skills, maintaining attention and accepting structure are behaviors common to both constructs of patient involvement and performance in rehabilitation therapy activities. Thus while the division of the instrument into Level of Involvement and Performance Abilities domains is useful conceptually for those utilizing the measure, it is recognized that several items are significantly related to both dimensions of rehabilitation therapy assessment.

    Descriptive statistics. Means, standard deviations, and sample sizes for various patient commitment types are reported in Table 2.

    Table 2. FSA-R Means and Standard Deviations for Various Patient Commitment Types
     
    Patient Commitment Type
    N
    Involvement

    Mean / (S.D.)

    Performance

    Mean / (S.D.)

    Overall

    Mean / (S.D.)

    Patients from Corrections 
    50
    17.7 (7.0)
    19.1 (5.7)
    37.2 (12.3)
    Mentally Disordered Offenders
    308
    18.7 (7.1)
    20.9 (6.8)
    39.5 (13.5)
    Sexually Violent Predators
    226
    18.7 (8.3)
    19.9 (8.0)
    38.4 (15.4)
    Other
    35
    18.3 (8.1)
    19.8 (7.5)
    38.1 (15.1)
    Total
    619
    18.6 (7.6)
    20.3 (7.2)
    38.8 (14.2)

    As can be seen in Table 2, the means for different patient commitment types do not vary significantly. The lowest scores are observed for patients referred from the Department of Corrections, who are generally considered the most acutely disturbed patients among the commitment types examined.

    Application of the FSA-R at ASH
    Staff training. The implications for staff training are significant. Of primary importance is the standardization of assessments, treatment plans and outcome measures. A scoring manual has been developed to ensure consistency in patient ratings across rehabilitation therapy disciplines and patient commitment types. Scoring descriptions are based on the frequency and adequacy of observable patient behavior. All rehabilitation therapists receive a two hour orientation training by the senior author and other rehabilitation therapists who were involved in the instrumentís development. Newly hired rehabilitation therapists also receive orientation and guidance in the scoring of the FSA-R as part of their clinical supervision during the first year of their employment.

    Data collection and treatment planning. Assessment is an essential component for designing treatment and measuring patient progress. Patients often present with similar diagnoses but significantly different functional abilities. The three elements of assessment data, treatment objectives, and therapeutic resources must be aligned to ensure that the patient is given the opportunity to learn and demonstrate those skills which will allow him to successfully adapt to the post-discharge environment. The FSA-R defines the observable behaviors associated with this treatment process.

    FSA-R data are collected at the time of the 10 day treatment planning conference following admission to the hospital, and at each subsequent quarterly treatment planning conference. Through assessment, the rehabilitation therapist aligns the identified patient needs and deficits with appropriated treatment opportunities as defined by protocols. Using the FSA-R, a patientís current level of functioning is identified and recommendations are based on his profile of strengths and weaknesses. In relation to outcomes, the FSA-R has provided data indicating patient improvement in level of functioning and objectives met, thereby allowing evaluation of treatment efficacy.

    Program Evaluation. The FSA-R has proven to be a useful tool for program development. By aggregating patient scores, data generated from the FSA-R is evaluated to determine the current functioning of the patient population for each treatment unit or program. The distribution of patient scores on each of the areas assessed by the FSA-R provides information regarding the amount and content of treatment activities that are currently needed to facilitate patient progress towards discharge readiness.

    These data have been used to evaluate the content, process and outcomes of rehabilitation therapy services provided. For example, FSA-R data aggregated by patient commitment types has helped determine staff allocation and organizational structure related to program needs. The information has proven helpful in determining which commitment populations require a more intense level of intervention than others and has allowed the scheduling of staff time and room availability to meet these treatment concerns. Regarding the content and process of treatment activities, the FSA-R data has determined the level of intervention and types of groups needed for each residential treatment unit.

    Summary
    The FSA-R was developed at Atascadero State Hospital when existing rehabilitation therapy assessment instruments were found inadequate for treatment planning and outcome evaluation with a forensic inpatient population. It has demonstrated adequate psychometric properties and a high degree of clinical utility. It supports the facilityís adoption of a biopsychosocial rehabilitation approach to treatment. Besides assisting with individual treatment planning, the FSA-R provides data that facilitate program evaluation and resource allocation. It has contributed to the standardization of rehabilitation therapy procedures, and assisted in quantifying the contribution made by rehabilitation therapists in the treatment of a challenging patient population.


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