Schizophrenia Research 66 (2004) 59 – 70

www.elsevier.com/locate/schres

Further validation of the Client Assessment of

Strengths Interests and Goals
Tania Lecomte a,*, Charles J. Wallace b, Jean Caron c,
Michel Perreault c, Jocelin Lecomte d
a
University of British Columbia, 828 West 10th Avenue, Room 214, VGH Research Pavilion, Vancouver, BC, Canada V5Z 1L8
b
UCLA Intervention Research Center for Schizophrenia, USA
c
McGill University, Montreal, Quebec, Canada
d
Douglas Hospital Research Centre, Montreal, Quebec, Canada
Received 10 June 2002; received in revised form 18 October 2002; accepted 24 October 2002

Abstract

The Client Assessment of Strengths Interests and Goals (CASIG), a measure that assesses the treatment outcomes of
individuals with serious and persistent mental illness, has previously shown adequate psychometric properties with an American
sample. Since it assesses quite specific skills and needs, it is necessary to assess its cultural relevance and psychometric
characteristics before using it in a different country. Hence, the purposes of this study were to (1) adapt CASIG to the culture of
a Canadian setting and translate its items and directions into French, (2) determine the psychometric characteristics of the
adapted English and French versions of CASIG, and (3) identify its latent constructs via an exploratory factor analysis.
The CASIG self-report (CASIG-SR) measure was administered to 224 consumers living in the community, and the CASIG
informant (CASIG-I) measure to 31 clinicians answering for 172 consumers. The participating consumers also completed the
Behavior and Symptom Identification Scale-32 (BASIS-32), the Short Form Health Survey-36 (SF-36), and the Camberwell
Assessment of Needs (CAN). The informants also completed the clinician version of the CAN.
The CASIG-SR and the CASIG-I had adequate internal consistency, test – retest, and interrater reliabilities. Correlations of
the consumers’ and informants’ results with the BASIS-32, SF-36, and CAN provided evidence of convergent and discriminant
validity, as did contrasts between higher and lower functioning community consumers. The factor analysis also supports the
construct validity of the assessment. The results confirm the psychometric adequacy of the adapted and translated CASIG in
Canada.
D 2003 Elsevier Science B.V. All rights reserved.

Keywords: Functional assessment; Treatment planning; Serious mental illness

1. Introduction

Public systems of care for individuals with serious

* Corresponding author. Tel.: +1-604-875-4553; fax: +1-604-
and persistent mental illness typically face conflicting
875-4376. demands from their many stakeholders. Consumers
E-mail address: [email protected] (T. Lecomte). and families demand increased and individualized

0920-9964/$ - see front matter D 2003 Elsevier Science B.V. All rights reserved.
doi:10.1016/S0920-9964(02)00496-6
60 T. Lecomte et al. / Schizophrenia Research 66 (2004) 59–70

services; payers demand minimum costs; providers to plan and monitor the specifics of each consumer’s
demand flexibility, independence, and simple require- treatment. Similarly, the Camberwell Assessment of
ments; and accrediting and licensing agencies demand Needs (CAN; Phelan et al., 1995) includes the con-
accountability documented with extensive quantitative sumer’s and the clinician’s perspectives, and covers a
and qualitative evidence (Sartorius, 2000). Balancing comprehensive range of outcomes. Its items, however,
these demands is extraordinarily difficult, but a critical inquire only about general problems and do not include
element in forging a compromise is a system of consumers’ goals, specific skills, and interests.
documentation that thoroughly details consumers’ Silverstein (2000) recently described what he con-
characteristics, the services they receive, the rationale siders the best available functional assessments, one
for those services, and the services’ effectiveness of which is the Client Assessment of Strengths Inter-
expressed in quantitative and qualitative data. As ests and Goals (CASIG; Wallace et al., 2001). CASIG
several authors have noted (Beutler et al., 1999; is a ‘‘new wave’’ assessment instrument because it
Menditto et al., 1999), the ideal system of documen- includes (a) numerous areas essential to community
tation should be: living, (b) its results are directly relevant for treatment
planning, (c) it can be repeatedly administered to
(a) comprehensive, assessing the multiple outcomes assess progress, and (d) it focuses on goals and skills
relevant to consumers and clinicians including as well as symptoms and behavioral or cognitive
clinical (symptoms, side effects), rehabilitative difficulties. CASIG makes consumers active direc-
(social, living, vocational functioning), human- tors/collaborators in planning their own treatment,
itarian (quality of life and treatment, life goals), and the inclusion of their perspectives and those of
and public welfare (prevention of harm). All have the informants via parallel versions of the test in-
been endorsed by NIMH (1991) as essential for creases communication among stakeholders. Addi-
accurately measuring the effects of medical and/or tionally, the psychometric adequacy of CASIG with
psychosocial treatment; an American sample has been documented in a recent
(b) capable of assessing changes over time; study (Wallace et al., 2001).
(c) focused on strengths and skills, not only symp- Thus, CASIG fits the majority of the criteria listed
toms and ‘‘disabilities’’; previously. However, its adaptability to other health
(d) inclusive of the multiple perspectives of family systems remains unknown. Some authors propose that
members, clinicians, and consumers; individuals diagnosed with serious mental illness
(e) easily administered by paraprofessional staff with have similar needs across industrialized countries,
minimal training; and and the same assessments can be used in each
(f) psychometrically sound and generalizable to country, assuming proper translations (Phelan et al.,
numerous systems of care. 1995). CASIG, however, assesses quite specific skills
and needs, and it is necessary to assess its cultural
Compared to these criteria, almost all of the widely relevance and psychometric characteristics before
available assessment systems are deficient. The Behav- using it in a different country. Hence, the purposes
ior and Symptom Identification Scale-32 (BASIS-32; of this study were to (1) adapt CASIG to the culture
Eisen et al., 1994), for example, includes only the of a Canadian setting and translate its items and
consumer’s perspective, and its factor analytically directions into French, (2) determine the psychomet-
derived scales are difficult to interpret for planning ric characteristics of the English and translated
and evaluating treatment. The Multnomah Community CASIG, and (3) identify its latent constructs via an
Assessment Schedule (MCAS; Barker et al., 1994), exploratory factor analysis. The project provided the
and the Health of the Nations Outcome Scale (HoNOS; opportunity to investigate the underlying factor struc-
Wing et al., 1996) have relevant scales, albeit consist- ture of CASIG and further determine its construct
ing of few items, but they are solely limited to the validity. Before discussing the study’s methodology
clinician’s perspective. The Wisconsin Quality of Life and results, however, a brief description of CASIG
questionnaire (Becker et al., 1993) has both consumer self-report (CASIG-SR), and its informant counterpart
and informant perspectives, but its scales are too global (CASIG-I), is in order.
 T. Lecomte et al. / Schizophrenia Research 66 (2004) 59–70 61

2. Method 2.2. CASIG-I

2.1. CASIG-SR CASIG-I is the informant-completed counterpart to

CASIG-R. It consists of the CASIG items phrased for
CASIG-SR (see Wallace et al., 2001 for a complete the third person, minus the Quality of Life and Treat-
description) is a thoroughly structured interview that ment items since they directly assess the respondent’s
assesses a respondent’s (a) goals for improved com- attitudes. It is administered as a questionnaire or as a
munity functioning, (b) his/her current functional and structured in-person or phone interview.1
cognitive skills, (c) medication practices (compliance
and side effects), (d) quality of life and treatment, (e) 2.3. Adaptation and translation
symptoms, and (f) unacceptable community behav-
iors. The respondent’s goals in five broad areas 2.3.1. Adaptation
(residence, vocational/educational, social/family rela- To adapt CASIG to Canadian particularities, it was
tionships, religion/spiritual, and physical/mental first distributed to 50 staff members of the Psychiatric
health) are elicited from three to five open-ended Rehabilitation Program at the Douglas Hospital. The
questions per area. Douglas Hospital is a major hospital that provides
Nine areas of social and independent living skills services to individuals with mental illness living in the
(money management, health management, food prep- Southwest sector of Montreal. The staff thoroughly
aration, vocational, transportation, friends, leisure, reviewed the instrument, and completed a nine-item
personal hygiene, and care of personal possessions) questionnaire about its relevance, liked and disliked
are assessed from four to nine dichotomously scored characteristics, changes that should be made to its
items per area. All items assess performance (‘‘do content and/or format, etc. Their reactions were favor-
you’’), not ability (‘‘can you’’) or motivation (‘‘do you able, and based on their comments, a few CASIG
want to’’). items were altered to fit the specifics of the Canadian
The respondent’s collaboration with his/her pre- health care system such as requiring a Medicare-
scribed medication regimen is assessed with eight Medicaid card rather than a birth certificate, obtaining
items that survey the respondent’s beliefs and attitudes vocational services from several providers rather than
about the medication and its dose. Side effects are a ‘‘Department of Vocational Rehabilitation,’’ and
assessed with 18 dichotomous items. adding volunteer work to the definition of employ-
Quality of life is assessed with ratings on a 5-point ment. The staff members’ comments also prompted
scale (poor, fair, average, good, excellent) of overall several modifications to improve CASIG’s ‘‘usabil-
lifestyle and each of 10 areas of living. Quality of ity’’ including changing fonts, increasing the spacing,
treatment is assessed with five ratings of the respon- adding lines for recording notes, and removing redun-
dent’s psychiatrist and treatment team (if applicable), dancies.
on the same response scale. To increase CASIG’s clinical value, the authors
The respondent’s symptoms in six areas (delusions/ (TL and CJW) added two questions to each of the
thought disorder, hallucinations, anxiety, depression, major goal sections and developed two new scales.
suicidal intentions, and mania) are assessed with The questions assessed a respondent’s assets (skills,
dichotomously scored probe questions that, if an- knowledge, money, experience, time, etc.) and the
swered ‘‘yes’’, are confirmed with open-ended fol- help he/she still needed to achieve the goal (none, a
low-up questions. The scoring criteria, adapted from little, some, a lot). The scales assessed a respondent’s
the UCLA Expanded BPRS (Lukoff et al., 1986), are cognitive functioning, defined by items measuring
biased to detect symptom exacerbation in its earliest recent memory lapses and difficulties concentrating,
stages, i.e., scoring positive on a symptom as soon as
one question pertaining to that symptom is answered
‘‘yes’’. Finally, the respondent’s performance of each
of 10 unacceptable community behaviors is assessed 1
Copies of the CASIG-SR on CASIG-I are available on
with 10 dichotomous items. demand by writing to the first author (TL).
62 T. Lecomte et al. / Schizophrenia Research 66 (2004) 59–70

and his/her knowledge of the laws that define his/her or schizoaffective disorder (78%), affective disorder
rights to shape and participate in his/her own treat- (11%), psychotic NOS (4%), and other psychological
ment. The intent of the cognitive scale was to provide disorders (7%). Sixty-three percent were male; 83%
information in deciding if one or more of the recently were single, 5% were married or cohabitating, 11%
available methods of ‘‘cognitive rehabilitation’’ should divorced or separated, and 1% widowed; 77% had no
be included in the treatment plan. The intent of the children; 82.4% were Caucasian, 11.2% Asian, 3.4%
consumer’s rights scale was to determine if instruction African/Caribbean, 2.4% First Nations, and 0.6%
was needed to ensure that a respondent understood his/ Latino. Their average age was 42.77, and their aver-
her rights, considered to be the first step to empower- age education was 10.79 years. One hundred partic-
ment. After these changes and additions had been ipants completed the French translation and 124
made, they were submitted to the staff, and further completed the corresponding English version. The
alterations were made as they suggested. language version administered to each respondent
matched his/her fluency and preference. A total of 31
2.3.2. Translation clinicians completed the informant version (CASIG-I)
The first author (TL) translated the altered CASIG for 172 participants (range of 1 – 19 completed per
from English into French, and then submitted the clinician).
translation to two bilingual colleagues for their trans-
lation back to English. The original and the back- 2.4.2. Validity and demographic measures
translations were compared, and inconsistencies were Several measures described below were adminis-
resolved by altering the French version. A professio- tered to assess CASIG’s construct validity. All are
nal translator was then given the English and French available in French and English, and all have been
versions, and asked to correct any grammatical errors validated and used in Canada. Two of them, the
and remaining inconsistencies. BASIS-32 and SF-36, were administered in the initial
Once the final translation was produced, the in- CASIG study. The IASPRS Tool Kit (Arns, 1998) was
formant version, CASIG-I, was produced by changing also administered to collect the demographic data
the wording of all items to the third person except for summarized above. Diagnostic information was re-
the Rights and the Quality of Life and Treatment trieved from respondents’ medical records.
items. As mentioned earlier, these were administered
only to the respondent. 2.4.2.1. BASIS-32. The Behavior and Symptom
Identification Scale-32 (BASIS-32; Eisen et al.,
2.3.2.1. Equivalence of the translation. Ten bilin- 1994) is a self-report of the respondent’s difficulties
gual clinicians not associated with the adaptation and during the past week in 32 areas of functioning. Each
translation were asked to think of a recent client and area’s difficulty is rated on a 7-point Likert scale, and
answer the French CASIG-I and, 1 day later, the the 32 ratings are combined to yield totals on five
English version without consulting answers given on factor analytically derived scales: Psychosis, Anxiety/
the initial French version. The clinicians’ answers Depression, Impulsivity, Interpersonal Relations, and
agreed exactly for 94% of the questions. Living Skills.

2.4. Determination of psychometric characteristics 2.4.2.2. SF-36. The Short Form Health Survey-36
(Ware and Sherbourne, 1992) is a self-report of the
2.4.1. Participants respondent’s status in eight areas of health including
A total of 310 individuals who were receiving physical functioning, physical limitations in role func-
outpatient services from the Douglas Hospital or tioning, pain, general health status, vitality, social
clinics were approached and asked to participate. functioning, emotional limitations in role functioning,
Eighty-six declined for various reasons, such as being and general mental health.
not interested (35), fear of talking to strangers (18), or
for no reason in particular (33). The remaining 224 2.4.2.3. CAN. The Camberwell Assessment of
participants had DSM-IV diagnoses of schizophrenia Needs (Phelan et al., 1995) is a self- and clinician’s
 T. Lecomte et al. / Schizophrenia Research 66 (2004) 59–70 63

report of the respondent’s functioning in 22 areas ees had no difficulty; indeed, the initial study (Wallace
including housing, food, cleaning, hygiene, daily et al., 2001; see also Lecomte et al., 1999) was
activities, physical health, psychotic symptoms, treat- conducted with peer inpatient and outpatient inter-
ment or illness information, psychological distress, viewers. Training to administer the Tool Kit, CAN,
personal security, social security, security of others, SF-36, and BASIS-32 consisted of thoroughly review-
alcohol, drugs, social relationships, emotional rela- ing each one’s instructions.
tionships, sexual life, care of children, education, The interviewers were continually monitored
financial tasks, use of the telephone, and use of public throughout the project, and each was observed by
transportation. The respondent and his/her clinician the first author (TL) as they conducted a minimum of
independently rate both the respondent’s difficulty two additional interviews. Each interviewer continued
functioning and the assistance provided to the re- to meet criteria during the entire project.
spondent in each of the 22 areas. These two ratings
are combined to yield one of three possible responses 2.4.5. Administration
per area: (a) no difficulties, (b) no important difficul- The four tests were administered to each partic-
ties, thanks to someone’s intervention, or (c) impor- ipant in a random order. Although BASIS-32 and SF-
tant difficulties. 36 are typically administered as paper-and-pencil
questionnaires, there was sufficient variation in par-
2.4.3. Procedure ticipants’ reading skills that the questions were read to
All individuals with a serious and persistent mental them. Each test’s response scale was copied in large
illness who lived in the community and received type on a section of cardboard, and participants
services from the Douglas Hospital rehabilitation pointed to their responses or said them aloud as the
services were eligible to participate. Only those with questions were read. The median time needed to
a primary diagnosis of a psychotic disorder, between answer CASIG-SR was 1 h with a range of 30 min
the ages of 18 and 65, and who could express to 4 h; the entire assessment process required a
themselves fluently in French or in English were median of 2 h. Breaks were given as requested, and
asked to participate. The rehabilitation services’ pri- participants were thanked at completion and given
mary clinicians were approached, and the study was $20 (CN) for their time.
explained during several group and individual meet- Each participant’s primary clinician (case manager,
ings. The clinicians were asked to review their case occupational therapist, psychiatric nurse, or rehabil-
rosters, select eligible individuals, meet with them at a itation therapist) was asked to complete CASIG-I and
mutually convenient time, explain the study, and refer the informant version of the CAN. A total of 31
them to the project staff if they were at all interested. clinicians completed both for 172 participants. Their
The project staff met with the prospective participants, median time to completion was 45 min each for
explained the study again, answered any and all CASIG-I and CAN.
questions, and enrolled individuals only if they were
capable of giving informed consent.
3. Results
2.4.4. Interviewers
Four interviewers with an undergraduate degree in All analyses were conducted using SPSS version
either occupational therapy or psychology were 10.1.4. Like the initial study (Wallace et al., 2001), the
trained to administer the four measures. Training to analyses focused on reliability and construct validity.
administer CASIG-SR began with explaining its The BASIS-32 and SF-36 were administered in both
rationale, thoroughly reviewing its items and model- studies, and comparisons can be drawn between their
ing the appropriate tone and method of asking each, results here and in the initial study. The CAN was
demonstrating the administration with a participant, included in this study because it has been validated in
and then monitoring each trainee’s administration French and English, and, like CASIG, it is compre-
with two participants whose cognitive dysfunctions hensive and elicits both self- and informant reports.
made the process particularly challenging. The train- Additionally, an exploratory factor analysis was per-
64 T. Lecomte et al. / Schizophrenia Research 66 (2004) 59–70

formed to identify the statistically determined ‘‘con- 3.1.2. Client/case manager agreement
structs’’ underlying CASIG. Table 1 also presents the correlations between the
clients’ CASIG-SR reports and the clinicians’ corre-
3.1. Reliability sponding CASIG-I reports. CASIG-I is a mirror image
of CASIG-SR, and the correlations are a measure of
3.1.1. Internal consistency the agreement between clients and their clinicians. Of
Table 1 presents coefficient alpha for each CASIG- course, this is not ‘‘interrater reliability’’ as typically
SR and CASIG-I scales for this and the initial study operationalized in a psychometric context, i.e., two
(Wallace et al., 2001). The results of this study are well-trained raters observing and independently scor-
almost identical to those of the initial one, and range ing an examinee’s responses. Within that context of
from acceptable to excellent. For both studies, the few ‘‘two reporters of the same event,’’ the results from
scales with lower values of alpha include items that this study not only resembled those reported in the
describe ‘‘low-frequency high-consequence’’ events initial study, but they matched the agreement reported
that can lead to emergencies and a client’s removal in similar studies (Achenbach et al., 1987). Only for
from the community. These items have a low base the Cognitive scale did the two ‘‘reporters’’ seem to be
rate, hence little variance and poor reliability, but their viewing different phenomena. Inspection of the indi-
inclusion fulfills a critical clinical function by alerting vidual items indicated that the clinicians were rating
staff to potentially damaging events. For example, the the clients’ cognitive skills considerably lower than
item ‘‘Steal other’s property in the last 3 months’’ is how the clients rated themselves.
included in the Community Behaviors Scale so that
the staff will elicit the rare positive response that will 3.1.3. Test – retest reliability
alert them to conditions that will substantially affect a Table 1 presents the stability coefficients for 26
client’s tenure in the community. participants who agreed to have CASIG-SR readmi-

Table 1
CASIG-SR and CASIG-I (descriptives for current study and reliability coefficients for current and initial studies)
Coefficient CASIG-SR CASIG-I
Mean (S.D.) Alpha Client/case manager Stability Mean (S.D.) Alpha
Study Current Initial Current Initial Current Initial Current Current Initial Current
N 224 243 224 103 181 25 26 181 103 181
Money management 1.63 (0.27) 0.591 0.586 0.591 0.528 0.732 0.454* 1.60 (0.35) 0.811 0.836
Health management 1.63 (0.31) 0.636 0.741 0.416 0.723 0.831 0.824** 1.57 (0.40) 0.496 0.907
Nutrition 1.57 (0.35) 0.876 0.861 0.642 0.709 0.487 0.899** 1.47 (0.38) 0.901 0.887
Vocational 1.54 (0.24) 0.883 0.844 0.600 0.486 0.797 0.331 1.40 (0.26) 0.830 0.878
Transportation 1.36 (0.21) 0.649 0.693 0.585 0.464 0.909 0.854** 1.46 (0.57) 0.703 0.607
Friends 1.69 (0.30) 0.875 0.867 0.015 0.345 0.445 0.154 1.67 (0.39) 0.392 0.934
Leisure 1.58 (0.21) 0.636 0.526 0.288 0.343 0.637 0.580** 1.53 (0.28) 0.675 0.608
Personal hygiene 1.82 (0.21) 0.556 0.582 0.198 0.222 0.811 0.642** 1.88 (0.25) 0.758 0.891
Care of possessions 1.81 (0.22) 0.800 0.495 0.050 0.310 0.743 0.583** 1.79 (0.27) 0.853 0.719
Medication practices 1.84 (0.17) 0.565 0.525 0.078 0.219 0.827 0.461* 1.81 (0.25) 0.852 0.748
Side effects 1.30 (0.22) 0.881 0.817 0.132 0.157 0.950 0.699** 1.21 (0.21) 0.780 0.812
Rights 1.69 (0.30) NA 0.745 NA NA NA 0.561** NA NA NA
Cognitive difficulties 1.40 (0.33) NA 0.757 NA 0.005 NA 0.401* 1.48 (0.33) NA 0.759
Quality of life 2.63 (0.53) 0.855 0.759 NA NA 0.945 0.780** NA NA NA
Quality of treatment 3.04 (0.55) 0.916 0.894 NA NA 0.917 0.789** NA NA NA
Symptoms 1.46 (0.32) 0.763 0.705 0.257 0.321 0.713 0.815** 1.29 (0.29) 0.708 0.754
Community behaviors 1.06 (0.11) 0.511 0.548 0.298 0.371 0.629 0.623** 1.06 (0.13) 0.643 0.595
NA = not applicable in the study.
* p < 0.05, two-tailed.
** p < 0.01, two-tailed.
 T. Lecomte et al. / Schizophrenia Research 66 (2004) 59–70 65

nistered 2 weeks after their initial testing. The 26 were 3.2.2. CAN
chosen to be representative of the entire sample’s age, The correlations between the CASIG-SR and CAN
education, and gender. Pearson PM correlations were self-report scales, and between the CASIG-I and CAN
calculated, and the values are presented in Table 1 informant scales, provide further evidence of CASIG’s
along with the coefficients from the initial study as a convergent and discriminant validity. A detailed re-
comparison. view of the CAN scales indicated that 10 of its 22
All of the scales have acceptable to excellent scales matched 6 CASIG-I and CASIG-SR scales. As
stability except Friends. One item, ‘‘Did you do things indicated in Table 2, the resulting correlations were
together with your friends,’’ changed during the 2 significant for both CASIG-I and CASIG-SR. How-
weeks for 6 of the 26 participants from ‘‘no’’ to ever, the two CAN scales that assessed interpersonal
‘‘yes.’’ A likely explanation is the reactive effect of functioning, Social Relationships and Emotional Rela-
the question itself. Once the question was posed tionships, were not significantly correlated for either
during the initial testing, participants were prompted the informant or self-report CAN with the Friendship
to consider doing something with a friend in the scale on either CASIG-SR or CASIG-I. The distribu-
subsequent 2 weeks. The stability of the Vocational tions of responses to the two CAN scales for both the
scale was also somewhat lower than expected; how- self-report and informant versions were markedly
ever, the changes reflected the introduction of a skewed, with the vast majority of respondents indicat-
supported employment program at Douglas Hospital ing ‘‘no difficulty.’’ This restricted variance limited the
in the interim between the two testings. Three of the correlations of these scales with all other variables.
twenty-six were accepted into the program.
3.2.3. SF-36
3.2. Validity Based on the results of the initial CASIG study, it
was anticipated that the SF-36’s eight scales would
3.2.1. BASIS-32 correlate with CASIG-SR’s Symptoms and Side
The correlations of the CASIG-SR scales with the Effects scales. The results are presented in Table 3,
five scales of the BASIS-32 provide evidence of and provide strong evidence of convergent validity.
CASIG’s convergent and discriminant validity (Camp- This study’s significant correlations between CASIG-
bell and Fiske, 1959). As in the initial study, the
CASIG-SR Symptom scale total converged with the
Table 2
BASIS-32 Psychosis and Anxiety/Depression scales
Correlations between CAN and matching CASIG-SR/-I scales
(r = 0.546, df = 221, p < 0.0001; r = 0.609, df = 221,
CAN scale CASIG scale CASIG-SR CASIG-I
p < 0.001, respectively); the total of the CASIG Com- r (N = 204) r (N = 140)
munity Behaviors scale converged with the BASIS-32
Food Nutrition 0.662 0.455
Impulsivity scale (r = 0.394, df = 221, p < 0.001); Hygiene Personal hygiene 0.409 0.616
CASIG Friends scale converged with the BASIS-32 Cleaning Care of 0.432 0.410
Relationships scale (r = 0.279, df = 221, p < 0.001); possessions
and CASIG Quality of Life scale converged with Transportation Transportation 0.460 0.217
the BASIS-32 Role Performance scale (r = 0.470, Psychotic Symptoms 0.183 0.211
symptoms
df = 221, p < 0.001). One of the added scales, Cogni- Psychological Symptoms 0.494 0.521
tive Difficulties, was significantly correlated with the distress
BASIS-32 Role Performance scale (r = 0.485, df = 221, Alcohol Community 0.222 0.327
p < 0.001). Those respondents having difficulties with behaviors
their cognitive functions such as memory and attention Drugs Community 0.270 0.514
behaviors
would likely have difficulties fulfilling their major Self safety Community 0.218 0.187
instrumental roles such as being wage earners and behaviors
spouses. All of the other correlations were nonsignifi- Others’ safety Community 0.188 0.256
cant as anticipated, confirming CASIG’s discriminant behaviors
validity. All correlations p < 0.001, two-tailed, df = 221.
66 T. Lecomte et al. / Schizophrenia Research 66 (2004) 59–70

Table 3
Correlations between SF-36 and matching CASIG scales
CASIG-SR (N = 223) SF-36
Physical Physical Pain General Vitality Social Emotion Mental
function limit health function limit health
Symptoms 0.276** 0.406** 0.337** 0.371** 0.267** 0.450** 0.492** 0.375**
Cognitive difficulty 0.199* 0.374** 0.316** 0.396** 0.309** 0.442** 0.460** 0.272**
Side effects 0.301** 0.388** 0.343** 0.359** 0.277** 0.288** 0.309** 0.264**
Quality of life 0.189* 0.262** 0.236** 0.404** 0.469** 0.436** 0.428** 0.207*
* p < 0.01, two-tailed, df = 221.
** p < 0.001, two-tailed, df = 221.

SR’s Quality of Life scale and each of the SF-36 and treatment, and medication compliance and side
scales were not found in the initial study. These effects did not discriminate the special needs from the
correlations replicate the negative relationship noted vocational service participants. Furthermore, the self-
in various literature reviews (e.g., Diener, 2000) report cognitive difficulties did not significantly differ
between chronic illness and subjective well-being in between the two groups.
the general populace. One of the two added CASIG The results for CASIG-I were quite similar to those
scales, Cognitive Difficulties, was also significantly for CASIG-SR, except for the Personal Hygiene, Side
correlated with the SF-36 scales, perhaps indicating Effects, and Community Behaviors scales. Both
that difficulties concentrating and remembering were groups were rated by their clinicians as close to the
seen as part of generally poor physical and mental maximum on the Personal Hygiene scale, and the
functioning. markedly skewed distributions left little ‘‘room’’ to
detect differences. As expected, the clinicians rated
3.2.4. Contrasted groups the special needs group as engaging in significantly
Two groups of participants with maximally differ-
ent functioning levels were selected, and their scores
were compared to determine if CASIG could discrim- Table 4
inate between them. One group was receiving services t values of comparisons between participants in lower vs. higher
functioning settings
in a ‘‘special needs’’ program designed to offer basic
occupational therapy activities to individuals who had Scale CASIG-SR CASIG-I
been institutionalized for many years and now lived in Money t(157) = 6.82*** t(121) = 5.61***
group homes. The other group consisted of higher Health t(157) = 6.86*** t(126) = 8.83***
Nutrition t(156) = 5.23*** t(118) = 5.30***
functioning individuals who lived independently and Vocational t(157) = 3.67*** t(130) = 11.56***
were seeking to return to work, and who were re- Transportation t(157) = 3.30*** t(128) = 2.17*
ceiving community vocational services at the Well- Friends t(157) = 2.08* t(123) = 4.05***
ington Center. Eighty-eight participants were in the Leisure t(157) = 2.22* t(126) = 6.28***
first group and 72 were in the other. The two groups Personal hygiene t(157) = 3.39*** t(128) = 1.20
Care of possessions t(157) = 3.21* t(114) = 3.84***
did not significantly differ in their sociodemographic Medication practices t(155) = 1.90 t(122) = 1.62
data, apart from the ‘‘special needs’’ group being Side effects t(153) = 0.44 t(119) = 2.67*
slightly older (mean age: 45.5 vs. 41.9) and consisting Rights t(156) = 3.94*** NA
of more single participants (85% vs. 79%). As indi- Cognitive difficulties t(157) = 1.32 t(126) = 1.85
cated in Table 4, the CASIG-SR scales assessing Quality of life t(157) = 1.88 NA
Quality of treatment t(157) = 1.49 NA
living skills and community functioning were, as Symptoms t(157) = 0.55 t(127) = 1.53
expected, significantly higher for participants receiv- Community behaviors t(157) = 1.25 t(128) = 3.03**
ing the vocational services than for participants * Two-tailed, p < 0.05.
receiving the special needs services. However, the ** Two-tailed, p < 0.01.
CASIG-SR scales assessing symptoms, quality of life *** Two-tailed, p < 0.001.
 T. Lecomte et al. / Schizophrenia Research 66 (2004) 59–70 67

more unacceptable community behaviors than the medication regimen, or removal from current hous-
vocational services group. The clinicians also rated ing.
the latter as experiencing significantly more medica- Despite this emphasis on utility, the items and
tions’ side effects than the former, but this may have scales generated appeared to cluster into several
been due to the clinicians at the Wellington Center meaningful domains: independent living skills, symp-
setting being less certain about their ratings (54% of toms and medications (compliance and side effects),
the assessments were rated as very accurate) than quality of life and treatment, and unacceptable com-
clinicians at the special needs program (91% of the munity behaviors. Hence, an exploratory factor anal-
assessments were rated as very accurate). ysis, Principal Components with Varimax rotation and
Kaiser normalization, was conducted to determine if
3.3. Construct validity the scales clustered as anticipated.
The results are presented in Table 5, and suggest
As described in detail in the initial article, CASIG that the relationships among the 17 scales are more
was developed to provide clinicians with the compre- complex than the simple structure of four domains
hensive information needed to plan and evaluate suggested above. The scree plot revealed that the most
individualized services. Thus, no consideration was variance was explained by the first three factors,
given in its development to statistical considerations explaining a cumulative 39.1% of the variance, with
such as normally distributed responses or on cluster- a second drop after the sixth factor adding an extra
ing grouping of items on a distribution. This approach 23.25% to the variance explained (a seventh factor
included items with extreme base rates and markedly would have added less than 5% to the variance). Six
skewed distributions that, although unsuited to ana- factors were extracted with eigenvalues greater than 1,
lytic methods such as factor analysis, alerted them to accounting for a cumulative 62.37% of the variance of
impending infrequent but costly events such as a the 17 scales. The first factor confirmed the expected
relapse of symptoms, a change in adherence to a domain of independent living skills, and indicated

Table 5
Factor loadingsa and communalities of the scales
Scale Factors and communalities
1 2 3 4 5 6 h2
Money 0.690 0.567
Health 0.847 0.759
Nutrition 0.835 0.713
Transportation 0.384 0.577 0.495
Leisure 0.391 0.622 566
Personal hygiene 0.363 0.584 0.578
Care of possessions 0.423 0.430 0.467
Rights 0.541 0.356
Friends 0.787 0.678
Vocational 0.804 0.713
Medication practices 0.512 0.340 0.468
Side effects 0.795 0.676
Symptoms 0.785 0.689
Cognitive difficulties 0.769 0.646
Quality of life 0.423 0.662 730
Quality of treatment 0.862 0.771
Community behaviors 0.738 0.728
Eigenvalues 3.468 2.524 1.272 1.231 1.057 1.050 NA
Percent variancea 17.689 12.592 8.842 8.676 7.320 7.251 62.37b
a
After rotation.
b
Cumulative loading z 0.30.
68 T. Lecomte et al. / Schizophrenia Research 66 (2004) 59–70

that, except for friendship, these skills are relatively and appear to resemble those of the original study.
unitary and generally independent of symptoms and The internal consistency and stability coefficients
medications. The second factor seemed to reflect were similar, and the ‘‘client/case manager agree-
discomfort and distress. The loadings indicated that ment’’ reliability was also adequate in this study.
symptoms, medication side effects, and difficulties The reliability coefficients of the two added scales,
with concentration and memory are associated with Cognitive Difficulties and Rights, were generally
lower ratings of one’s quality of life. The third and acceptable, and their good internal consistency re-
fifth factors included high positive loadings on adher- flected their development as measures of constructs
ence with medication; the third also included high (difficulty thinking, knowledge of one’s rights) rather
positive loadings on quality of life and treatment, and than low base-rate observations potentially useful for
the fifth included a high positive loading on perform- clinical decision making.
ing personal hygiene behaviors and a high negative The validity coefficients for the BASIS-32 and SF-
loading on performing unacceptable community be- 36 administered in both studies were similar and
haviors. reflected good convergent validity. The contrasted-
The fourth and sixth factors likely reflected the groups results were also similar or superior in this
unique characteristics of this sample. The fourth study, although the two studies are not strictly com-
included positive loadings on leisure, friends, and parable. The lower functioning respondents in the
care of personal possessions. The factor seemed to initial study were administered a specialized version
reflect those respondents who lived independently, of CASIG’s independent living skills tailored for their
cared for their own residences, and engaged in the long-term inpatient setting. This study administered
more interpersonal leisure activities (e.g., go to a only the community-oriented version for all respond-
movie with a friend vs. read a newspaper). Hence, ents. Finally, the results of the correlations of CASIG
they responded on the friendship scale that they with CAN confirmed all of the other discriminant and
engaged in activities with their friends. The sixth convergent validity coefficients.
factor likely reflected the fact that respondents who Hence, the results confirm the psychometric ade-
worked used their own or the public transportation quacy of the adapted and translated CASIG-SR and
system to get to and from their workplaces. Respond- CASIG-I, and indicate that CASIG will retain its
ents who did not work did not use any means of advantages in Canada. It measures a large array of
transportation on a consistent basis. domains relevant to community functioning; it focu-
ses on skills and goals and not only on deficits and
maintenance of the status quo; it includes consumer
4. Discussion and stakeholder perspectives; its results provide infor-
mation that is directly applicable to planning and
The results indicate that the study fulfilled its three evaluating treatment services; and it can be repeatedly
purposes. First, adapting CASIG’s items to the spe- administered in multiple settings as consumers tran-
cifics of the Canadian system of mental health care sition among different treatment facilities.
was straightforward, with changes made to only a few CASIG does not, however, assess the resources
items. The other changes—increasing the spacing and and constraints of various treatment settings. As Pratt
size of the font and adding the Cognitive Difficulties and Mueser (2002) noted, optimizing interventions
and Rights scales—enhanced CASIG’s user-friend- to achieve individualized treatment success depends
liness and coverage, and will be incorporated in the on thorough assessments of the individual—his/her
USA version. More importantly, the anecdotal com- strengths, deficits, symptoms, and co-morbid condi-
ments of the clinicians, clients, and test administrators tions—and the environmental conditions that will
were positive and quite similar to those made when affect the interventions’ implementations and out-
the USA version was developed and validated (Wal- comes. At present, this environmental assessment
lace et al., 2001). depends upon the clinicians’ detailed knowledge of
Second, the psychometric characteristics of the myriad local details about the available treatment and
translated CASIG-SR and CASIG-I were acceptable residential settings. Though CASIG covers many areas
 T. Lecomte et al. / Schizophrenia Research 66 (2004) 59–70 69

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