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ELEMENTS OF GROUP WORK IN RECOVERY, WELLNESS, AND QUALITY OF
LIFE AMONG PEOPLE DIAGNOSED WITH SCHIZOPHRENIA
Zachary Knapp
B.A., University Of California, Irvine, 2009
Jeff Parrish
B.A., California State University, Sacramento, 2008
PROJECT
Submitted in partial satisfaction of
the requirements for the degrees of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2011
© 2011
Zachary Knapp and Jeff Parrish
ALL RIGHTS RESERVED
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ELEMENTS OF GROUP WORK IN RECOVERY, WELLNESS, AND QUALITY OF
LIFE AMONG PEOPLE DIAGNOSED WITH SCHIZOPHRENIA
A Project
by
Zachary Knapp
and
Jeff Parrish
Approved by:
__________________________________, Committee Chair
Susan Taylor, Ph.D.
____________________________
Date
iii
Students: Zachary Knapp
Jeff Parish
I certify that these students have met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library and
credit is to be awarded for the project.
___________________________, Graduate Coordinator
Teiahsha Bankhead, Ph.D., LCSW
Division of Social Work
iv
_______________________
Date
Abstract
of
ELEMENTS OF GROUP WORK IN RECOVERY, WELLNESS AND QUALITY OF
LIFE AMONG PEOPLE DIAGNOSED WITH SCHIZOPHRENIA
by
Zachary Knapp
Jeff Parrish
This project was written through the equal contributions of both researchers Zachary
Knapp and Jeff Parrish on all five chapters. The researchers noticed that when working
with individuals with schizophrenia, positive outcomes are most often defined in terms of
symptom reduction. The prominence awarded to treating pathology makes increasing
subjective well-being seem either unimportant or unfeasible for this population. The
present study aims to address this issue by creating a group designed to enhance
subjective well-being for people labeled with schizophrenia. Six modules were developed
by the researchers and evaluated by 13 mental health clinicians. The clinician-participants
provided valuable quantitative and qualitative data about the components of the group,
which will be used in finalizing the curriculum. While some participants advised minor
changes, the modules were found to be effective for this population.
, Committee Chair
Susan Taylor, Ph.D.
______________________
Date
v
ACKNOWLEDGMENTS
One theme that emerged while studying subjective well-being is the importance
of social support. So it is in acknowledging this truth that I would like to thank the
following friends for not only making this project possible, but also for helping me on my
own quest towards happiness: David Ian Allison, Michael Awbrey, Cindy Clark, Mike
Clark, Omar Esquivel, Wayne Her, Peter Kuser, David and Alicia La’Rock, Seraphina
Marquez, Tyler Pehlke, Nathan Stuckey, and Merita Wolfe. I would also like to express
my gratitude –which increases subjective well-being by the way-for my family. Honestly,
words can’t express my love and appreciation for all of you Knapp’s, Richards’, and
Spangler’s. Also to Dr. Susan Taylor, for your compassion, patience, and wisdom. You
are such a great mentor, and you embody what Social Work is all about. I am blessed to
have crossed paths with you. To Buddy, my co-pilot, Daddy loves you and is sorry we
had to cut back on the river walks. To Jeff Parrish, not only do I value your friendship,
your hard work has been instrumental in completing this project. Your sense of humor,
technical mastery, and utter genius have been invaluable. Additionally, thanks to all of
those who participated for sharing their time, knowledge, and commitment to helping
individuals labeled with mental illnesses. And to my Higher Power, God, the Universal
Intelligence; I am in awe and wonder at this miracle called life.
- Zach
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To Kolbi: your love and companionship makes my life complete. Zacker, you
have been a stellar and patient thesis partner. I wish you happiness and success in this
new phase of life. Dr. T, your experience and presence has played an instrumental role in
every stage of this project. I am indebted to you for your time, your wisdom, and for
explaining what to do if someone wants to shoot me with a gun. Jon Daily, you have been
my greatest mentor. To my kittens, Alyss and Maui, born on 9-9-09, you are good luck
charms, and I hope you can forgive me for making you wait for chunky-monkey food
while I worked on this thesis. Thank you to my dear fellow MSW friends – Cynthia
“CRC” Clark, DJ Mike Colossal, Nathan “epic abs” Stuckey, and Omar “still haven’t
watched all your Harry Potter movies yet” Esquivel. Charizard C. Hode, thanks for the
good times on Faxon Place. A small thanks to Zach’s roommate, whose barbecue grill
fuel indicator was sacrificed unintentionally; and to her canine companion Cowboy for
his warmth, and for letting me eat one of his dog biscuits. Mom and Dad, I love you and
owe so much of my success to both of you. Robespierre, you’re a good brother, but a bad
friend. Ergo, irrevocably, concordantly, vis-à-vis. Cronbach, you salty old seadog, your
contribution to psychology provides a life template for us all. Berielle, thanks for letting
the coins shower over us, and for keeping Elliot from turning everything to cinder.
Special thanks to J.B. Maloney of Hoony Apple Cider. Finally, I must note that without
the dedication of our participants, this study would not have been possible.
- Jeff
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TABLE OF CONTENTS
Page
Acknowledgments.............................................................................................................. vi
List of Tables ..................................................................................................................... xi
Chapter
1. THE PROBLEM ............................................................................................................. 1
Introduction ............................................................................................................. 1
Statement of Collaboration ..................................................................................... 3
Background of the Problem .................................................................................... 4
Statement of the Research Problem ........................................................................ 5
Purpose of the Study ............................................................................................... 6
Theoretical Framework ........................................................................................... 7
Definition of Terms............................................................................................... 10
Assumptions.......................................................................................................... 11
Justification ........................................................................................................... 12
Limitations ............................................................................................................ 13
2. REVIEW OF THE LITERATURE .............................................................................. 14
Introduction ........................................................................................................... 14
Section I: Treatment of the Mentally Ill Across Time .......................................... 14
CBT and the Recovery and Wellness Model ........................................................ 17
Positive Psychology .............................................................................................. 19
Section II: “The How of Happiness” .................................................................... 20
Neuroplasticity ...................................................................................................... 22
Using Mindfulness to Change The Brain.............................................................. 24
Section III: Introduction ........................................................................................ 27
Module 1: Outline of Schizophrenia ..................................................................... 27
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Module 2: The Benefits of Social Support ........................................................... 31
Module 3: Practicing Gratitude ............................................................................. 32
Module 4: Avoiding Overthinking and Social Comparisons ................................ 34
Module 5: Cultivating Strengths ........................................................................... 36
Module 6: Mindfulness and the Present Moment ................................................. 38
Conclusion ............................................................................................................ 40
3. METHODS ................................................................................................................... 41
Introduction ........................................................................................................... 41
Study Design ......................................................................................................... 41
Sampling Procedures ............................................................................................ 42
Data Collection Procedures................................................................................... 42
Materials ............................................................................................................... 43
Data Analysis ........................................................................................................ 44
Protocol for the Protection of Human Subjects .................................................... 44
4. FINDINGS .................................................................................................................... 46
Introduction ........................................................................................................... 46
Demographics ....................................................................................................... 46
Module Effectiveness............................................................................................ 48
Individual Module and Component Evaluation .................................................... 50
Qualitative Item Responses................................................................................... 54
Wellness and Recovery Orientation...................................................................... 57
Significant Demographic Effects upon Module Evaluation ................................. 58
Summary ............................................................................................................... 59
5. CONCLUSIONS........................................................................................................... 61
Introduction ........................................................................................................... 61
Discussion of Results ............................................................................................ 61
Limitations ............................................................................................................ 63
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Recommendations ................................................................................................. 64
Implications........................................................................................................... 65
Final Thoughts ...................................................................................................... 66
Appendix A. Informed Consent ...................................................................................... 68
Appendix B. Module Outlines ........................................................................................ 71
Appendix C. Survey ........................................................................................................ 78
References ......................................................................................................................... 87
x
LIST OF TABLES
Page
1.
Table 1 Academic degrees of participants. ............................................................... 47
2.
Table 2 Participant experience in mental health ....................................................... 48
3.
Table 3 Most effective modules. ............................................................................... 49
4.
Table 4 Least effective modules. .............................................................................. 49
5.
Table 5 Module evaluation –individual item statistics. ............................................ 51
6.
Table 6 Qualitative feedback .................................................................................... 55
7.
Table 7 Wellness and recovery orientation of each module. .................................... 58
8.
Table 8 Effects of academic degree upon module evaluation item responses. ......... 59
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1
Chapter 1
THE PROBLEM
Introduction
Schizophrenia can be a debilitating disease, and its onset presents a significant life
stressor. Some common experiences among sufferers include a loss of self from the
previous developed identity, grief combined with hopelessness about the future, and fear
of pharmacological side effects. These disheartening experiences contribute to a deep
sense of shame, and embarrassment. Stigma leads to social isolation for many people
diagnosed with schizophrenia (Aldridge & Stevenson, 2001; Hensley, 2002; Horowitz,
2002; Rudge & Morse, 2001; Usher, 2001). People with schizophrenia often find
themselves incarcerated, homeless, victimized, chronically unemployed, forgotten by
friends and family, addicted to alcohol and other drugs, and/or suicidal (Ashton et al.,
2001).
Schizophrenia is common, with a lifetime prevalence of about 1% of the general
US population (Cardno & Gottesman, 2000). About half of the people admitted to
psychiatric hospitals in 2009 had a diagnosis of schizophrenia (King, 2010). People with
schizophrenia are eight times more likely to commit suicide than people without a
diagnosis of schizophrenia (Pompili et al., 2007). According to Torrey (2006), of the
people with schizophrenia: 6% are homeless, 6% live in jails or prisons, 5-6% live in
hospitals, 10% live in nursing homes, 25% live with a family member, 28% live
independently, and 20% live in supervised housing.
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Currently, there is no cure for schizophrenia; the condition is long term, usually
chronic, and severe. It adversely affects a person’s mental, physical, occupational and
social functioning (Meijer, Koeter, Sprangers, & Schene, 2009). A significant portion of
people do not return to their pre-episodic level of functioning. One study found the full
recovery rate to be 13.7% two years after initial contact with healthcare professionals
(Robinson, Woerner, McMeniman, Mendelowitz, & Bilder, 2004). Another study found
that between 18% and 33% of participants were in full remission at any given time from
two to 15 years after initial treatment (Harrow, Grossman, Jobe, & Herbener, 2005).
Schizophrenia is commonly treated with antipsychotic drugs, of which there are
two types: neuroleptics and atypicals (King, 2010). Neuroleptics are more extensively
used, and many have been available for over 50 years. A shortcoming of neuroleptics is
that they often lead to permanent extrapyramidal symptoms (EPS) such as tardive
dyskinesia, which causes involuntary muscle movements in about 20% of cases (Garver,
2006). Examples of neuroleptic antipsychotics are Haldol (haloperidol) and Thorazine
(chlorpromazine). Atypical antipsychotics were introduced in the 1990s and have been
successful in reducing psychotic symptoms with less devastating side effects than
neuroleptics (King, 2010). Examples of these drugs are Clozaril (clozapine), Zyprexa
(olanzapine), Risperdal (risperidone), Geodon (ziprasidon), Seroquel (quetiapine), and
Abilify (aripiprazole) (King, 2010).
Nemade and Dombeck (2009), cite studies about the efficacy of antipsychotics
that found about 70% of patients show improvement while taking an antipsychotic drug,
3
25% show minimal improvement, and 5% showed decline (p.1). Historically,
“improvement” has meant the reduction of positive (e.g., hallucinations and delusions)
and negative symptoms (e.g., flat affect, behavioral deficits, alogia). The patient’s
perspective, such as subjective well-being and quality of life (QOL), has rarely been used
as an outcome measure (De Haan, Duivenvoorden, Mulder, Staring, Van der Gaag,
2009).
Schizophrenia is usually treated with medication therapy to reduce symptoms.
Outcome studies and intervention strategies rarely place importance on the subjective
well-being and QOL of the patient.
Statement of Collaboration
Jeff has worked as a therapist in a dual diagnosis treatment setting for 2.5 years,
and was an MSW intern for two semesters at a residential crisis mental health program.
Zach worked as an MSW intern for two semesters at an adult day health center with a
diverse population of consumers, including some diagnosed with schizophrenia, and is
currently an MSW intern at an outpatient community mental health center for homeless
adults.
Shared passion in the fields of positive psychology, neuroscience, recovery and
wellness, and even spirituality, has inspired our collaboration on this project. Together,
we have an interest in mental “health” as opposed to mental “illness.” In our professional
settings and at school, we often find ourselves having to focus on labeling and ‘treating’
mental illness, instead of identifying strengths and the components of mental health. With
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the freedom allotted a thesis project, we have chosen to pursue the latter, as we would
like to delineate strategies for enhancing well-being and QOL.
Background of the Problem
Within the dominant explanatory framework, the biomedical model, the primary
purpose of mental health services is to treat mental illness. Slade (2009) identifies four
problems with this. The first is evidenced by the overreliance on diagnosis. In medicine, a
diagnosis implies identification of the etiology and an evidence based prognosis. While
this method has proven efficacious in treating physiological illness, its relevancy to
psychological disorders is more ambiguous. Psychological disorders are, on the whole,
much more complex, involving multiple poorly or insufficiently understood variables.
A second problem with using this model is the questionable validity of mental
health diagnoses. The history of the DSM shows how diagnostic categories are often
based on social constructions, socio-political climates, and culture, rather than scientific
evidence (e.g., homosexuality). The debate over ‘schizophrenia’ as a diagnostic label is
widely documented (Read, Mosher, & Bentall, 2004; Maddux, 2002; Boyle, 2002). In
addition to the hazy criteria and the variance between those diagnosed with
schizophrenia, the field has yet to identify a disease marker. Therefore, overreliance on
diagnosing and discovering a biological explanation seems unwarranted (Kingdon, 2007;
Slade, 2009).
A third problem is that the assessment and subsequent labeling process generates
stigma. This causes de-individuation, as the diversity among people with the label is
5
ignored in favor of negative generalizations that confirm their similarities to each other
and deviations from the dominant group. Assessment and diagnosis also negates the
importance of environment, placing responsibility on the individual as the source of
deficiencies while ignoring the possibility of contributing factors (e.g., social and
environmental). Axis IV of the DSM diagnosis methodology, citing environmental
stressors, is by far of least importance to medical professionals, insurance companies, and
social welfare systems. The term ‘schizophrenic’ has a negative connotation, leading to a
biased and deficits-based opinion of those who receive this label (Slade, 2009).
The final error in this method is that current psychiatric treatment does not lead to
a cure. In medicine, the cause of a disorder typically guides the clinician’s prescription.
In psychiatry, the reverse is true as treatment guides the explanation (Slade, 2009). This
is similar to saying that because aspirin alleviates a headache; the headache was caused
by a lack of aspirin (e.g., the dopamine hypothesis). This shortcoming results from an
overreliance on the medical model in psychiatry. Viewing psychiatric conditions, the
same way as medical conditions, limits progression in the field of health and human
services, and is disempowering for consumers.
Statement of the Research Problem
Knowledge seeking under the biomedical paradigm is driven by reducing deficits.
Clinical preoccupations too often revolve around symptom reduction, risk management
and crisis containment, negating the value of increased well-being, and amplifying
existing strengths (Slade, 2009). There is a difference between a lessening of pain and an
6
increase of pleasure. It is time for the mental health field to include increasing happiness
as an important part of treatment, if not more important, than reducing pathology.
Purpose of the Study
The primary purpose of this study is to identify those elements that would
contribute to the development of a “Happiness Group” for people labeled with
schizophrenia. This group is designed to increase well-being by presenting six modules
based on proven wellness strategies and expert opinions from professionals in the field of
mental health. The intended outcome of attending the group is enhanced purpose,
meaning, and subjective well-being. A basic tenet of this group is that increased wellbeing is possible, even with the ongoing presence of symptoms.
The secondary benefit of this study is that it will contribute to the knowledge base
in positive psychology, the recovery model, and psychological wellness. According to
Ridgway (2001), only recently has the professional literature recognized the fact that
people with schizophrenia “can grow beyond the limits of their condition and reclaim full
lives” (335). The group techniques being developed are ‘approach oriented’ in that they
are positive and forward looking. This is different from traditional psychology which has
emphasized avoidance motivation, and completely changes the job of mental health
professionals (Slade, 2009). Increasing the practice base for well-being enhancing
strategies will help facilitate the paradigm shift towards mental “health” and recovery and
wellness. The evidence from this study may be compelling enough for community
programs to adopt the group curriculum.
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Theoretical Framework
This project draws from a variety of theoretical orientations. The four main
theories include: (1) The biopsychosocial model of psychological disorders (Engel,
1977); (2) The strengths perspective (Saleebey, 1997); (3) Cognitive-behavioral therapy
(Rector & Beck, 2002); (4) Encouraging the adoption of healthier neural circuits (Saxena,
Brody, Schwartz, & Baxter, 1998); and (5) Building healthy affect regulation through
earned secure attachment (Schore, 2003; Cozolino, 2006).
The biopsychosocial approach to mental disorders goes beyond the typical
medical model of illness. The medical model adheres to the notion that psychological
disorders originate from internal, organic causes such as genetics, physical illness, and
other environmental effects, resulting in neuroanatomical or neurotransmitter
dysfunction. Thus, medicine has looked from a biological or biochemical cause to a
biochemical intervention. The biopsychosocial approach is more holistic because in
addition to biology, it considers other parallel causes such as psychological and
sociocultural factors. Psychological and sociocultural factors warrant consideration
because if schizophrenia was caused solely by biology and genetics, the chances that
identical twins would have concordant rates of schizophrenia would be 100% instead of
48% (Cardno & Gottesman, 2000; King, 2010). This project utilizes this theory not only
as a framework for better understanding the possible causes of schizophrenia, but also as
a basic tenet of the group, especially in Module 2, “The Benefits of Social Support.”
8
The strengths perspective is one of the guiding theories social workers use when
working with consumers. From this perspective, the social worker seeks out the “positive
qualities and undeveloped potential” of people with schizophrenia (Saleebey, 1997). The
strengths perspective is congruent with the recovery and wellness model, because it not
only recognizes that each individual has the possibility for positive change, it also
supports their innate and learned abilities. The strengths perspective symbolizes a
collaboration between the social worker and the consumer, which translates into shared
power, as the consumer is the expert in how they have coped with adversity (Saleebey,
1997). Furthermore, the techniques or “happiness strategies” that will be proposed are not
going to appeal or be appropriate for everyone. The key is for group members to choose
the strategies that most resonate with their personal strengths (Lyubomirsky, 2007).
Module 5, “Cultivating Strengths,” is a direct application of the strengths perspective.
Cognitive-behavioral therapy (CBT) is rooted in both cognitive and behavioral
psychology. Cognitive theory focuses on how people think about themselves and the
world. Distorted perceptions and interpretations, as well as improper logic, lead to
cognitive dysfunction. Behavioral theory aims to describe human beings through
observing and measuring behavior. The combination of these two theories leads to
intervention strategies that aim to change the thoughts that influence a person’s behavior
(King, 2010).
The proposed group could be considered a CBT intervention for people diagnosed
with schizophrenia. CBT is evidence based, in fact, it has the most empirical evidence
9
supporting its efficacy for treating a broad range of disorders from depression to
substance abuse and eating disorders (Butler, Chapman, Forman, Beck, 2006; Cooper,
2008). The application of CBT is now being researched to address schizophrenia as well
(Rector & Beck, 2002). According to Lysaker & Silverstein (2009), CBT is relevant in
addressing cognitive distortions such as maladaptive beliefs about the self, and the
tendency to believe others have malicious intentions. The purpose of CBT is to challenge
these notions through examination, discovery and replacement of negative beliefs and
predictions. Participating in CBT has been shown in controlled trials to reduce both
positive and negative symptoms of schizophrenia and improve psychological and social
functioning (Lysaker & Silverstein, 2009). Additionally, advancements in neuroscience
are allowing researchers to explore the effects of CBT on the brain, and now suggest that
CBT may create changes structural and functional changes in the brain (Schwartz &
Begley, 2002; Siegel, 2009; Slade, 2010)
Modern neuroscience is confirming that the adult brain is not static, as was once
believed. Neuroplasticity, which means that the brain is flexible and capable of changing
throughout the lifespan (Siegel, 2009), is the final guiding theory for this study. It is a
basic tenet of neuroscience that mental states (such as thoughts and emotions) are created
by neuronal processes in the brain. This type of causality is called bottom-up causality. A
revolutionary idea in modern neuroscience is top-down causality, which asserts that
mental states also exert control over the lower level brain events or neuronal processes
(Schwartz & Begley, 2002). While the present study will not use the techniques of
10
neuroscience such as fMRI or electrophysiology to measure brain changes, it draws from
research on mindfulness that seems to demonstrate the potential of the mind to change the
brain (Schwartz & Begley, 2002; Begley, 2007).
During the last 15 years, advanced brain imaging techniques have allowed
researchers to link the literature on attachment relationships to brain structure and
function. A lack of secure attachment in early years has been correlated with emotional
difficulties later in life, as well as brain development and functional deficits (Siegel,
1999; Cozolino, 2006). Security in attachment relationships allows individuals to be more
resilient when faced with life stressors. The present study incorporates the implications of
attachment theory by building earned secure attachment through group activities. By
providing a consistent, resonating and supportive group environment, consumers will
hopefully develop a positive internal working model of the group that they will carry to
post-group experiences. Overall, this will lead to better affect regulation (Siegel &
Hartzell, 2004).
Definition of Terms
Schizophrenia - A mental condition typified by disordered thought processes or
cognitions. These disordered cognitions are categorized as psychotic because they
significantly deviate from the majority’s experience of reality (King, 2010). The
symptoms of schizophrenia fall within three typologies: positive, negative, and cognitive
deficits (National Institute of Mental Health (NIMH), 2006). Positive symptoms are
distortions in excess of normal functioning, such as hallucinations and delusions.
11
Negative symptoms refer to behaviors that are deficient of normal functioning and
include social withdrawal, flat affect, and grave lack of goal oriented behavior. The
cognitive symptoms of schizophrenia include but are not limited to: an inability to
maintain focus, memory deficits, and difficulty processing information (NIMH, 2006).
Recovery – “Recovery is a deeply personal process of changing one’s attitudes,
feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful life even
with the limitations imposed by disability. It involves developing new meaning and
purpose in life as one grows beyond the catastrophic effects of illness/injury.” (Anthony,
1993, p. 17)
Positive Psychology - The discipline committed to the study of increasing
happiness as opposed to simply reducing suffering (Seligman, Steen, Park & Peterson,
2005).
Subjective Well-being/ Quality of Life (QOL) – Can be understood as life
satisfaction, optimism, happiness, the absence of negative emotions, the presence of
positive emotions (Diener & Chan, 2011).
Assumptions
The assumptions to be considered for this study include: (1) People diagnosed
with schizophrenia are concerned about their subjective well-being. (2) People diagnosed
with schizophrenia will benefit from happiness strategies used with other populations. (3)
Recovery and well-being is encouraged by working with mental health professionals who
are sensitive to individual needs, see the person instead of the illness, and believe in their
12
ability to live happy and fulfilling lives. (4) There is a general lack of professional
knowledge regarding concrete and efficient practices that increase well-being for this
population. (5) The sampled professionals’ opinions of what will work with this
population are accurate.
Justification
This study is congruent with one of social work’s foundations: to alleviate the
suffering of oppressed populations. Oppressive forces working against those with
schizophrenia include: (1) a dehumanizing medical model that historically measured
outcomes through alleviation of psychotic symptoms and negated the importance of
QOL, treating patients as an illness rather than a person; and (2) decline of interpersonal
and occupational functioning because of pathology, fear, and stigmatization by the
dominant group. Social welfare is inadequate to fully address the complex needs of those
made vulnerable by schizophrenia. The authors’ primary purpose, as previously stated, is
to help improve QOL for this marginalized group. In addition, participants’ are seen as
individuals, and the authors have unconditional positive regard for them.
Empowerment and self-determination are foundations of this group. Faulkner &
Layzell (2000) (as cited in Slade, 2009, p. 52) found that consumers want the following
from mental health services: acceptance, shared experience and identity with peers,
emotional support, a reason for living, finding meaning and purpose in their lives, peace
of mind, relaxation, taking control and having choices, security and safety, and pleasure.
The goal of the group is to present material that encompasses these values. Consumers
13
will be encouraged to only practice the strategies that resonate with them personally.
These strategies are only suggestions; however they are based on scientific literature in
the field of positive psychology. Always remembering the participant is the expert in
what works for them is empowering for a population that has historically had treatments
done to them. Furthermore, as experts, participants will be encouraged to share
alternative suggestions with the group. This will ideally create a reciprocal environment
of learning and sharing between the group facilitators and group members.
Limitations
Due to the small sample size (n=15), generalizations to the greater population are
greatly limited. If results appear promising there will be room to perform more sound
research. However for the present study, there is no way to tell if this sample is
representative of the greater population of mental health professionals.
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Chapter 2
REVIEW OF THE LITERATURE
Introduction
Pertinent literature has been divided into three main sections. Section I is a
chronological exploration of multiple treatment paradigms for schizophrenia, beginning
with moral treatment in the late 1800s, and ending with recovery and wellness and
positive psychology. Section II begins by discussing the work of Sonja Lyubomirsky,
which sets the stage for how individuals can intentionally engage in activities to increase
subjective well-being, followed by a subsection on neuroplasticity. Section III introduces
the group modules by defining concepts, presenting evidence, and outlining specific
strategies.
Section I: Treatment of the Mentally Ill Across Time
Those with severe and persistent mental illness have a long history of being
subjected to inhumane treatment. According to Whitaker (2002), prior to the moral
treatment movement of the 1800s, those with mental illnesses were expelled from their
communities, locked in cells, and physically abused. The widespread introduction of
moral treatment is attributed to the efforts of the French physician Phillipe Pinnel. In a
recent historical text on the treatment of the mentally ill, Cockerham (2006) added,
“moral treatment was essentially a program of re-education in which mental patients were
to be taught how to behave normally within the context of sympathetic living conditions”
(p.24).
15
Moral treatment was the dominant model in psychiatry for less than a century.
Numerous factors led to its decline. There was no consistent model for implementation,
making it difficult to train new employees or compare success rates. A rising number of
critics viewed moral treatment as an attempt to gain conformity rather than an effective
remedy for mental illness. Symptoms were addressed, but not the cause. Additionally,
mental illness often had comorbidities such as alcoholism, which were not understood or
addressed. Mental asylums eventually became warehouses of society’s rejects. This led to
widespread contempt for asylums and their inhabitants, especially because the public
institutions were financed by taxpayer dollars (Whitaker, 2002). The fourth reason for the
decline of moral treatment was that mental illness began to be seen as incurable. All of
these factors set the stage for psychiatrists to present a new theory about the etiology of
mental illness, that physiological abnormalities cause mental abnormalities (Cockerham,
2006). This viewpoint is the basis for the medical model of treatment which has
dominated psychiatry since the time of adoption in the middle of the 20th century.
A few egregious examples of the medical model are the psychosurgeries such as
tooth and intestinal extraction and pre-frontal lobotomies (Whitaker, 2002). Another
physical intervention is electroshock therapy (EST) or electroconvulsive therapy.
Practitioners justified these treatments because it was thought that diseased cells were the
etiology of mental disorder and removing or terminating these diseased cells would
alleviate the problem (Whitaker, 2002). While these treatments have largely been
16
replaced, it is interesting to note that ECT is still used for the most severe patients, such
as catatonic schizophrenia or severe depression (Cockerham, 2006).
The introduction of the antipsychotic chlorpromazine (trade name Thorazine) in
1952 changed the course of psychiatric intervention. By the early 1960s, treatments for
schizophrenia had markedly shifted from the physical to the pharmaceutical (Whitaker,
2002). Antipsychotics did alleviate many of the positive symptoms of schizophrenia, but
cause side effects including but not limited to tremors, rigid muscles, and tardive
dyskinesia (Alptekin et al., 2009), and other types of enduring neurological damage
(Bassman, 2007).
The relative success of pharmacological treatments led to a general acceptance
that schizophrenia was a brain disease – taking some stigma away from parents of people
with schizophrenia, who often received harsh criticism from practitioners. This has also
led to a strict dependence on antipsychotic drugs as the primary form of intervention to
control symptoms, despite numerous side effects (Breeding, 2008).
The current medical paradigm sees schizophrenia as a “chronic, sever, and
disabling brain disease…the best one can hope for is to keep it under control with
neuroleptic drugs” (Breeding, 2008, p. 494). Whitaker (2002) asserts that recovery from
schizophrenia using antipsychotics is “virtually nill,” and even claims that prior to the
advent of these drugs, people with schizophrenia experienced recovery about 60% of the
time (as cited in Breeding, 2008, pp.494-495).
17
CBT and the Recovery and Wellness Model
Currently, a paradigm shift is occurring in mental health service orientation.
Under the medical model, symptom reduction is the primary objective. Now, treatment
outcomes are becoming more consumer driven as the patient’s perspective is being
considered (Karow & Naber, 2002). QOL is the paramount concern in the recovery and
wellness model, and instead of focusing on a cure, it focuses on a multidimensional and
individualized journey of personal growth. Deegan (1997) discusses her own narrative in
regards to becoming disempowered by the medical model, and her subsequent
experiences as a recovering person. She states:
[Recovery] is a way of approaching the day and the challenges I face.
Being in recovery means that I know I have certain limitations and things
I can’t do. But rather than letting these limitations be an occasion for
despair and giving up, I have learned that in knowing what I can’t do, I
also open up the possibilities of all the things I can do. (pp.20-21).
As more and more attention is afforded to the likelihood of recovery from
schizophrenia, many researchers are interested in examining the role of psychotherapy as
part of the treatment regimen (Lysaker & Silverstein, 2009). For example, Gumley et al.
(2006) conducted a study testing the efficacy of CBT to combat the effects of negative
beliefs and lowered self-esteem regarding relapse. Relapse was operationalized as a
return to the hospital or increased positive symptoms for at least 7 days. The study lasted
12 months and included participants with schizophrenia spectrum disorders (N = 144)
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(Gumley et al., 2006, p. 247). The participants were randomized to either receive
treatment as usual (n = 72) or CBT (n = 72) (Gumley et al., 2006, p. 247). Each group
filled out a Personal Beliefs About Illness Questionnaire (PBIQ) and a Rosenberg Self
Esteem Scale (RSES) upon entry into the study and at three month intervals thereafter.
The results indicated that the group receiving CBT showed significantly greater
improvements in both the PBIQ and the RSES. This study also showed a significant
positive correlation between the following constructs: relapse, increased negative beliefs
about illness, and lower self-esteem (Gumley et al., 2006, pp. 252-254). It would be
beneficial for future studies to test CBT as a relapse prevention method (Gumley et al.,
2006).
Ridgeway (2001) -who is in recovery from schizophrenia- suggests that recovery
is about reclaiming a full life. Having a job is one part of that for most people (Ridgeway,
2001, p. 335). A study by Lysaker, Davis, Bryson, & Bell (2009), utilized the
Indianapolis Vocational Intervention Program (IVIP), a program using CBT individual
and group sessions to assist people with schizophrenia persevere and perform better at
work. Participants with schizophrenia spectrum disorders (N = 100) were given six month
job placements (Lysaker et al., 2009, p. 186). The individuals were randomized to receive
either IVIP (n = 50), or equally intense support services (n = 50) (Lysaker et al., 2009, p.
186). Outcomes were measured through number of hours worked weekly, and job
performance as indicated by the Work Behavior Inventory biweekly. The results
indicated the participants receiving IVIP scored significantly higher in both measures,
19
suggesting the efficacy of CBT in assisting the vocational aspirations of people with
schizophrenia (Lysaker et al., 2009).
Critics may suggest CBT is as deficient as the biomedical model because
outcomes are primarily based on symptom reduction. Thus, it is helpful to look at a study
based on the recovery and wellness model, which values QOL over symptom reduction.
Ridgway (2001) collected qualitative data from four women who shared their personal
accounts of psychiatric disability and subsequent recovery. The purpose of the study was
to delineate any commonalities in the recovery experience of the participants. Ridgway
(2001) noted several themes using a comparative analysis of the narratives. These include
the “reawakening of hope after despair, achieving acceptance of one’s condition, actively
participating in life, and practicing active coping rather than passive adjustment”
(Ridgway, 2001, pp. 337-338). These narratives also describe recovery as a journey that
involves the help of many people, including paraprofessionals in recovery from
prolonged psychiatric disabilities. Ridgway (2001) asserts that operationalizing recovery
is a complex task, and that the ultimate goal of research should be to gather knowledge
aimed towards fostering recovery in as many lives as possible.
Positive Psychology
Most would agree the desire to live a “good life” is a common goal for human
beings. Ancient and modern philosophers in every culture have mused about the topic,
through study of ethics and morality. Positive psychology is the division of psychological
research which aims to identify what is needed to live the “good life” (Slade, 2010).
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Positive psychologists separate their discipline from traditional psychology because it
focuses on strengths, positive emotions, and practices that cultivate happiness, instead of
human suffering, weakness, and disorder (Seligman et al., 2005). Positive psychology’s
attempt to describe well-being has gained popularity as a scientifically valuable endeavor
in the last 25 years.
According to Slade (2010) positive psychology is complimentary to the recovery
and wellness model of mental health. Similarities include a holistic aim to complement
medical treatment and enhance the patient’s subjective purpose and well-being. Both
approaches acknowledge the importance of remaining client centered, in addition to
focusing on strengths. Finally, both approaches can be used to inform policy at a societal
level, and are of value in challenging stigma and discrimination. The next section will
demonstrate some of the emerging evidence base from the field of positive psychology.
Section II: “The How of Happiness”
Sonja Lyubomirsky (2007) has done extensive research in positive psychology,
and suggests an eclectic approach to cultivate increased well-being. This project will
incorporate some of the recommended strategies based on studies from the field of
positive psychology found in her book, The How of Happiness. For example, Module 3 is
called: “Practicing Gratitude.” One of the suggestions in this module is about counting
one’s blessings, and this practice is described in Lyubomirsky (2007)’s book. This
practice is based on a study conducted by Emmons & McCullough (2003). They had
participants write a list once a week for ten weeks about five things they were grateful
21
for. In the post-test, participants reported more optimism and satisfaction with their lives
compared to the control group (Emmons & McCullough, 2003, p. 377). Another example
of the types of interventions found in Lyubomirsky (2007) that influenced the
development of this group are strategies for increasing optimism. One intervention, based
on a study conducted by King (2001) asked participants to spend 20 minutes a day for
four consecutive days writing about their “best possible future selves.” The results
indicated that participants experienced significant increases in positive moods and were
happier several weeks later than those who wrote about the non-emotional control topic
regarding the person’s plans for the day (King, 2001, p. 805).
Lyubomirsky (2007) presents what she calls the “Pie Chart Theory of Happiness”
(pp.20-22). This model provides much of the rationale for the happiness interventions
suggested in this paper, and asserts that there are three components of subjective wellbeing. Genetics is said to account for 50% of one’s happiness, and twin studies cited by
Lyubomirsky (2007) seemed to substantiate that people inherit a “baseline” level of
happiness. The second factor is one’s life circumstances, which Lyubomirsky attributes
10% of one’s happiness. Life circumstances include but are not limited to one’s
attractiveness, geographic location, and material affluence (p. 21). One will notice this is
the smallest piece of the pie. The final factor, consists of intentional activities, and
accounts for 40% of one’s happiness within this model. This has substantial implications,
because it suggests that people have the ability to increase their happiness by 40%,
22
merely by engaging in intentional behaviors, many of which are suggested in the book (p.
22).
The first obvious question one will ask is how accurate is the pie chart theory of
happiness? Answering this question is beyond the scope of this project; however modern
neuroscience offers an explanation for Lyubomirsky (2007)’s assertion that people can
intentionally foster greater feelings of well-being.
Neuroplasticity
Neuroplasticity is a term which refers to the brain’s ability to change. The
malleability of the adult brain represents a paradigm shift in neuroscience. Formerly,
neuroscientists believed the adult brain was fixed. According to Begley (2007), this belief
was primarily based on two assumptions about the adult mammalian brain: (1)
neurogenesis, the development of new neurons, does not occur; (2) the functions of
certain brain structures such as the motor, auditory, and visual cortexes are fixed. More
recent neuroscience research contradicts both assumptions. Eriksson et al. (1998) showed
that new neurons develop in the adult human hippocampus, becoming the first
researchers to provide evidence of neurogenesis (Begley, 2007). Several studies address
the second assumption.
Studies demonstrating a phenomenon called cortical remapping provide
compelling evidence for neuroplasticity. When cortical areas that were once devoted to
processing one type of information cease to receive input, the same areas take on
information processing from another part of the body. For instance, V. S. Ramachandran
23
uncovered cortical remapping in a seventeen year old boy named Victor (as cited in
Schwartz & Begley, 2002, p. 185). Victor had just lost his left arm in a car crash, but still
reported that he could feel his left arm. Ramachandran had Victor close his eyes, and
Ramachandran subsequently touched his cheek with a cotton swab. Amazingly, Victor
reported feeling the cotton swab on both his left cheek, and the back of his missing hand.
The cortical remapping that had occurred was so specific that touching underneath
Victor’s nose produced a feeling that his missing index finger was being touched. The
somatotopic map in Victor’s somatosensory cortex that previously received signals from
his left arm had reorganized itself to receive signals from the left side of his face.
Cortical remapping has clinical and rehabilitative implications as shown first by
Taub’s constraint-induced movement (CIM) therapy for chronic stroke patients who lose
voluntary movement to part of the body (as cited in Schwartz & Begley, 2002, p. 190). In
CIM therapy, the patient’s good arm is constrained 90% of waking hours for two weeks.
Concurrently for ten days the patient receives six hours of therapy to encourage use of the
affected arm such as eating, throwing a ball, and playing board games. The results
indicated a 97% increase in ability to perform movement tasks one month after one
month of treatment. Even two years later, patients who received CIM therapy vastly
outperformed control subjects (Schwartz & Begley, 2002, p. 195). Leipert et al. (1998)
demonstrated the mechanisms of neuroplasticity that are involved in CIM therapy.
Investigating the brain changes of six patients before and after two weeks of treatment
showed:
24
an increase of excitability of the neural networks in the damaged
hemisphere…. Following CIM therapy, the formerly shrunken cortical
representation of the affected limb was reversed…. Only two weeks of CIM
therapy induced motor cortex changes up to seventeen years after the stroke.
(as cited in Schwartz & Begley, 2002, pp. 192-193).
Using Mindfulness to Change The Brain
An intriguing idea that is relevant to the present study is the possibility of selfdirected neuroplasticity. Schwartz & Begley (2002) believe work using a mindfulnessbased cognitive- behavioral therapy with those who suffer from obsessive compulsive
disorder (OCD) shows that self-directed neuroplasticity is possible. They speculate that
individuals can change their neuronal circuitry simply by using directed mental effort.
This effort consists of close attention and willfulness, and results in changing the way one
thinks about their own cognitions. Schwartz & Begley (2002) assert that this mental
effort literally has the power to change the structure of the cerebral cortex (p. 94). This
method of top-down causality posits the mind’s ability to change the brain.
By the early 1990s Schwartz had developed a mindfulness-based CBT called the
Four Step Method to treat OCD. The first step is “Relabeling.” Whenever a participant
experienced an obsessive thought, Schwartz advised them to use mindfulness to
recognize that the thought is just the manifestation of a biochemical imbalance in their
brain. They were not told to just resist the obsessive thought or compulsion to act; instead
Schwartz encouraged them to recognize what it was. By recognizing the obsessions and
25
compulsions as symptoms, the participants became aware of their condition, and even
took mental notes of their experiences. By stepping back and simply noticing the
thoughts and urges, participants began to view them from a space of observation. They
also recognized that these symptoms were “false and misleading” (Schwartz & Begley,
2002, pp. 79-80).
The second step, “Reattribute” refers to the process of identifying obsessions and
compulsions as a brain disease and not one’s true “self.” In practice, Schwartz would tell
patients, “The brain’s gonna do what the brain’s gonna do, but you don’t have to let it
push you around” (Schwartz & Begley, 2002, p. 81).
The third step is called “Refocusing.” The goal is that after noticing the onset of
the OCD circuit (symptoms), the person consciously focuses on an adaptive behavior, in
effect, reconditioning themselves. This ends up substituting a positive behavior for a
pathological one. In practice, this might look like: every time participant A feels the need
to count cans, they instead do some needlepoint (Schwartz & Begley, 2002, p. 84). One
way to perform this practice is to keep a journal or “refocus diary” that keeps track of
how the person resists their urges. Looking back on the diary also increases confidence
because they can note where they have been successful. Progress on this step is difficult;
Schwartz describes this as the hardest step and it requires “will and courage” and selfdirection (Schwartz & Begley, 2002, p. 83).
The last step “Revaluing,” is a more profound version of “Relabeling.” Schwartz
bases this step on a Buddhist philosophy called “wise attention,” which means to see
26
“matters as they really are or, literally in accordance with the truth” (Schwartz & Begley,
2002, p.88). This allows the person to view their symptoms as the result of faulty neural
circuits not worth paying attention to or acting on.
Having already noted positive behavioral changes as a result of the four step
method, Schwartz set out to discover if these behavioral changes were accompanied by
the brain changes he suspected. With the help of a colleague at UCLA, Lew Baxter,
Schwartz recruited 18 drug free OCD patients. Before and after ten weeks of Four Step
Treatment and once or twice weekly individual therapy sessions, the patients underwent
positron emission tomography (PET) scans. The results marked the first time a nonpharmacological or surgical treatment for mental illness could “change faulty brain
chemistry in a well identified brain circuit” (Schwartz & Begley, 2002, p. 90). A
significant decrease in metabolic activity was shown in the right caudate, a brain circuit
associated with OCD in 12 out of 18 patients (Schwartz & Begley, 2002, p. 89).
Schwartz believes this is evidence of how mindfulness and thought redirection
can change the structure of the human brain. Pascual-Leone et al. (1995) showed that
thinking about performing an activity results in brain activity in the same areas which are
active when physically engaging in the activity. For several trials, one group of
participants practiced a five finger piano exercise, while another group merely visualized
the same exercise. The activation found in each group’s motor cortexes through
neuroimaging techniques were identical, showing that “merely thinking about moving
27
[their fingers] produced brain changes comparable to those triggered by actually moving”
(as cited in Schwartz & Begley, 2002, p. 217).
Section III: Introduction
The following is a review of the proposed group modules. Many of these modules
present intentional activities, shown to increase well-being. The basic premise is that if
these activities are practiced, the power of neuroplasticity will be harnessed to induce
greater feelings of subjective well-being among the group members. A handout of these
modules will be given to the study participants (as opposed to group participants) in order
to gather professional opinions about the potential efficacy of these modules.
Module 1: Outline of Schizophrenia
This module is designed to enhance consumer knowledge by introducing the
clinical perspective of the disorder. The facilitator will begin by defining the label,
followed by a brief discussion of the various treatment options. The goal, as described by
Slade (2009), is to discuss potential resources; however the presented material should in
no way be seen as providing the answers. According to Slade (2009) “receiving a
diagnosis can be immensely helpful” (p.146). It can make sense out of symptoms, and be
crucial in the consumer’s quest to develop personal meaning. However, personal, rather
than clinical meaning is of utmost importance. An underlying philosophy of this group
will be to remain grounded in recovery and wellness, and the participants’ experiences
take precedence over clinical explanations. In fact, some of the consumers may reject the
diagnostic label. To stay true to the underlying group philosophy, the facilitators will
28
afford paramount respect to individual experiences and opinions. Also, the facilitators
hope to encourage recognition of symptoms as separate from their personal identity. This
will help avoid what Johnstone (2000) was referring to when she wrote: “Personal
meaning is the first and biggest casualty of the biomedical model” (p.81).
Anxiety may be reduced as participants realize they are not experiencing this
disorder alone. Hopefully, participants will feel comfortable enough to share their
experiences with each other, and possibly even recognize similarities in their experiences.
Sharing of personal experiences in an environment where they are respected and heard
will create an experience of being attuned to. Through this attunement, participants may
begin to develop an internal working model of the group which, with repetition, can lead
to earned secure attachment and increased resilience (Siegel, 1999). Pekkala & Merinder
(2002), conducted a systematic review of 10 randomized control trials on the efficacy of
psychoeducation, and found that willingness to take medication was improved, while
relapse and readmission rates at 9-18 months were decreased compared to standard care.
In addition, they state that “Generally, findings were consistent with the possibility that
psychoeducation has a positive effect on a person’s well-being.”
The following psychoeducation regarding schizophrenia will be presented during
the first group session and was adapted from the 2007 Canadian Psychiatric Association’s
(CPA) manual: Schizophrenia: The Journey to Recovery. Schizophrenia is defined as
follows: “Schizophrenia is a severe yet treatable brain disorder,” that affects a person’s
ability to distinguish reality. Common symptoms include delusions, hallucinations,
29
thought and communication disturbances and social withdrawal. These symptoms may
cause worsening grades or declines in occupational functioning; withdrawal from loved
ones; “moodiness, suspicion, anxiety;” changes in attention to hygiene; loss of interest,
feelings, motivations, or emotions. The cause(s) of schizophrenia are unknown; however
researchers are studying factors that may affect brain development such as injury, toxicity
or disease. Evidence also suggests a genetic link (CPA, 2007, p.3).
According to the CPA (2007, pp. 16-20), the most common treatment for
schizophrenia is medication. Medication varies, depending on symptoms, general health,
and the presence of other conditions. It typically involves 2nd generation antipsychotics
(atypicals) such as Zyprexa, Risperdal, Seroquel or Clozaril. Successful medication
therapy involves the ongoing monitoring of medications, dosage, and potential side
effects.
According to the CPA (2007) it is best to treat schizophrenia using a combination
of medication therapy and psychosocial approaches (p. 21). While medication therapy
addresses symptoms, the purpose of psychosocial approaches is to increase social
functioning. According to the CPA (2007) psychosocial approaches “help people in their
relationships with others, groups, and society as a whole” (p. 21).
The CPA (2007, pp. 27-28) recommends the following psychosocial approaches
for individuals diagnosed with schizophrenia: (1) Psychoeducation: Education about the
illness including symptom management and relapse prevention; (2)Vocational: Training
individuals’ skills to help them interact most efficiently and effectively with the
30
environment based upon their needs. Vocational training may entail setting employment
goals and providing assistance in reaching those goals. Types of work include “volunteer
and supported or transitional employment” (p. 27); (3) Social Skills Training: Helping
individuals “who are having difficulty and/or experiencing stress and anxiety about social
situations” (p. 27); (4) Life skills Training: Focuses on daily activities such as basic selfcare and money management; (5) Cognitive behavioral approaches: Changing feelings
and behaviors by changing thoughts. CBT has proven efficacy in “treating stress, anxiety
and depression in people with schizophrenia” (p. 28); (6) Family Approaches: “Education
and support programs for family members” (p.28); (7) Peer support, self-help and
recovery: Consumer driven mental health services, skills training and support groups, and
public education by psychiatric survivors themselves; (8) Substance Use: Providing
people with schizophrenia and co-occurring substance abuse issues integrated support
through addictions counseling and/or support groups such as Dual Recovery Anonymous
(DRA) meetings.
Since personal meaning is paramount, the treatment strategies suggested in this
module including medication therapy and the psychosocial approaches are not
prescriptive, they are merely suggestions. Recovery is an individual process. The material
will be presented in a manner that emphasizes hope and self-empowerment through
making informed decisions about possible treatment options.
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Module 2: The Benefits of Social Support
Social isolation is a negative symptom of schizophrenia. Attending a support
group is one way to improve social participation and meaningful relationships, which
have both been shown to increase subjective well-being (Lyubomirsky, 2007). One of the
group’s primary purposes is to expand opportunities for social support. Social support
can be tangible (e.g., getting a ride), emotional (e.g., sharing our stories with one another,
giving hugs), and informational (e.g., advising someone about community resources)
(Lyubomirsky, 2007, p. 139). In congruence with the recovery model, participants’ will
be encouraged to express their personal narratives and coping strategies with each other
(Ridgway, 2001). Social support will be cultivated through identifying with one another,
and learning how to give and receive different types of social support in a safe
environment.
According to Lyubomirsky, King, and Diener (2005), fostering better
relationships leads not only to increased well-being, but also to a longer life. The
relationship between social connection and well-being appears bidirectional, as positive
relationships lead to increased well-being, and increased well-being leads to a greater
number of positive relationships. This is what positive psychology calls an “upward
spiral” (Lyubomirsky, 2007, p.139). Concerning persons with schizophrenia, the CPA
(2007) reports that peer support among those with schizophrenia enhances self-esteem,
self-worth, and the development of social networks (p. 23). Martin (2009) suggests that
purpose and meaning are enhanced through helping others and educating the public about
32
mental illness, “Playing a supportive role empowers people and protects them from selfstigma” (p. 4). Individuals and their family’s value peer support as it helps them get a
better understanding of the illness and become engaged in learning how to cope (Martin,
2009).
The following will be provided to group members as suggestions to cultivate
social relationships: (1) Joining or starting a support group (Lyubomirsky, 2007, p. 271);
(2) Practice kindness and compassion, for example giving compliments or volunteering
time with people who could use help (Lyubomirsky, 2007, p. 130; Baraz & Alexander,
2010, p. 241); (3) Listening to others (Lyubomirsky, 2007, 148); (4) Self-disclosing
(Lyubomirsky, 2007, p. 148); (5) Being supportive of friends, and helping them celebrate
their victories (Lyubomirsky, 2007, p. 148).
The authors, based on both personal and professional experience, developed these
final suggestions: (6) Engaging in physical activities with others; (7) Going to Wellness
and Recovery Centers; (8) Attending social events, such as the “Art Walk” in
Sacramento; (9) Taking classes; (10) Joining online groups and social networking; (11)
Going to places of religious and/or spiritual worship.
Module 3: Practicing Gratitude
This group session will begin with a brief discussion about the definition of
gratitude. According to Lyubomirsky (2007), gratitude is more than thanking someone; it
is a way of being characterized by appreciation. Gratitude means looking at the cup as
half full even when it seems half empty.
33
If hard times are present, one can make a decision to focus on the positive. For
instance, if someone recently lost a spouse, they might focus on appreciating the quality
time they did share with that person. According to Baraz & Alexander (2010), suffering
allows people to refocus on what aspects of life they have to be grateful for. They also
state, “suffering itself deepens us, maturing our perspective on life, making us more
compassionate and wiser than we would have been without it” (Baraz & Alexander,
2010, p. 69). A decision to focus on the positive cultivates an “attitude of gratitude.” In
fact, gratitude and positive thinking go hand in hand. Gratitude encourages us to look at
the good in life which leads away from ruminating on the negative.
Research points to the benefits of cultivating gratitude. One study showed that
participants who wrote a list once a week for ten weeks about five things they were
grateful for reported more optimism and satisfaction with their lives compared to a
control group (Emmons & McCullough, 2003). Martin Seligman, one of the founders of
Positive Psychology, had a group of severely depressed people write about three good
things that happened to them for fifteen days. The outcome was that 94% of the
participants felt a decrease in depression and 92% said their happiness actually increased
(as cited by Baraz & Alexander, 2010, p. 72). Lyubomirsky (2007) asserts that gratitude
leads to increased well-being because it encourages: the savoring of positive life
experiences; increased self-efficacy; diminished negative emotions; and coping with
stress and trauma (pp. 92-93).
34
The following will be provided as suggestions for developing a gratitude practice:
(1) Writing a gratitude letter, talking or phoning someone we are appreciative of
(Seligman et al., 2005, p. 416); (2) Writing about 5 things we are grateful for in a
gratitude journal each week (Lyubomirsky, 2007, p. 96); (3) Contemplating what we are
grateful for at a fixed time daily or weekly (Lyubomirsky, 2007, p. 96; Baraz &
Alexander, 2010, p. 77); (4) Appreciating one thing each day we usually take for granted
(Lyubomirsky, 2007, p. 96); (5) Sharing a “blessings list” with a gratitude partner
(Lyubomirsky, 2007, p. 97; Baraz & Alexander, 2010, p. 75); (6) Substitute one grateful
thought for one ungrateful thought each day (Lyubomirsky, 2007, p. 96); (7) “Express
gratitude through art” (Lyubomirsky, 2007, p. 97); (8) Say grace before a meal (Baraz &
Alexander, 2010, p. 77); (9) Gratitude games (e.g. every time we find ourselves
complaining say, “and my life is very blessed.” Or instead of saying “I have to,” try
saying, “I get to.”) (Baraz & Alexander, 2010, p. 71); (10) Think about three good things
that happen each day, and write them down. This practice was empirically validated by
Seligman et al. (2005, p. 416).
Module 4: Avoiding Overthinking and Social Comparisons
According to Lyubomirsky (2007), “overthinking is thinking too much,
needlessly, passively, endlessly, and excessively pondering meanings, causes, and
consequences of your character, your feelings, and your problems” (p. 112). A study by
Lyubomirsky and Tkach (2003) discusses the adverse consequences of overthinking
saying it leads to deepening sadness, increased negative thinking, impaired problem
35
solving, weakened motivation, and interference with concentration. The key to
surmounting overthinking is to redirect negative ruminations towards more positive and
wholesome thoughts.
Making social comparisons or noticing what other people are doing or have is
hard to avoid. Lyubomirsky (2007) asserts social comparisons can be detrimental whether
they are “upward” or “downward”. While upward can lead to feelings of insecurity and
inadequacy, downward comparisons can result in guilt, disconnection, or “the need to
cope with others’ envy and resentment” (Lyubomirsky, 2007, p. 116). Anything that
makes us feel different from the majority presents an opportunity for comparison with
others, and receiving a diagnosis of schizophrenia may incline us to make upward
comparisons.
The following are suggestions that will be provided in group to combat
overthinking and social comparisons: (1) Distraction, such as listening to music, or
engaging in physical activity (Lyubomirsky, 2007, pp. 120-121); (2) Forcing oneself to
stop ruminating or comparing by simply telling yourself to “Stop!” (Lyubomirsky, 2007,
p. 120); (3) Talking to someone who is supportive and will listen to your thoughts and
problems (Lyubomirsky, 2007, p. 120); (4) Developing a concrete plan to alleviate
problems. For instance setting up an appointment with a counselor or case manager who
can help access needed resources (Lyubomirsky, 2007, p. 121); (5) Avoiding situations
that trigger overthinking by keeping a list of people, places and things to avoid
(Lyubomirsky, 2007, p. 122); (6) Meditation by focusing on each inhalation and
36
exhalation (Lyubomirsky, 2007, p. 122); (7) Look at the big picture by asking if this will
still be a problem in a year (Lyubomirsky, 2007, p. 123); (8) Developing radical
acceptance by pondering statements such as “I don’t mind what happens” (author).
Module 5: Cultivating Strengths
Focusing on strengths is an implicit value in each group session, and the specific
focus of this module. Recognizing one’s strengths has been shown to increase well-being
(Seligman, et. al, 2005). Furthermore, utilizing strengths is empowering because it
encourages active rather than passive participation in the healing process. Strengths
include but are not limited to a person’s abilities, resilience, talents, skills, interests,
knowledge and resources (internal and external). Everyone has strengths, and often they
are unrecognized (Saleeby, 1992).
One of the major tenets in the disciplines of Social Work and Positive Psychology
is recognizing and utilizing strengths. Positive Psychologists Peterson & Seligman (2004)
have delineated 24 character strengths into six different areas of virtue including:
“Wisdom and Knowledge; Courage; Humanity; Justice; Temperance; and
Transcendence” (pp. 29-30). Within each of these areas of virtue (which they define),
Peterson & Seligman (2004) have identified anywhere from three to six character
strengths. For instance, “Courage” is defined as “Emotional strengths that involve the
exercise of will to accomplish goals in the face of opposition, external or internal”
(Peterson & Seligman, 2004, p. 29). The strengths that exemplify this virtue include
“Authenticity: Speaking the truth and presenting oneself in a genuine way; Bravery: Not
37
shrinking from threat, challenge, difficulty, or pain; Persistence: Finishing what one
starts; and Zest: Approaching life with excitement and energy” (Peterson & Seligman,
2004, p. 29). A handout of Peterson & Seligman (2004)’s Table: “Classification of 6
Virtues and 24 Character Strengths” will be distributed to both the study participants and
the group members.
During this session, group members will be asked to engage in one or more of the
following exercises: (1) Recall a time when you successfully responded to a challenging
situation in your life. How did you do it? What strengths did you use (Seligman et al.,
2005, p. 416); (2) Using the Peterson & Seligman (2004) handout, identify some of your
personal strengths, and if you feel comfortable, share your findings with the group; (3)
Identify the eternal resources you have access to such as benefits, support persons, and
the Wellness & Recovery Centers; (4) Identify a recent or specific example of one of
your strengths (Seligman et al., 2005, p. 416).
After these group exercises, participants will be asked to complete a “Recovery
Task” between sessions. Rather than being expected, participants will merely be
encouraged to engage in one or both of these activities during the next week: (1) Recall a
story that demonstrates you at your best, and identify the strengths you used. Reflect on
this story every day, and focus on the strengths you recognized (Seligman et. al., 2005, p.
416); (2) Each day this week try to use one of the strengths you identified in a “new and
different way” (Seligman et al., 2005, p. 416).
38
Module 6: Mindfulness and the Present Moment
Mindfulness entails being engaged with “what is,” or being “in tune” with the
present moment. Instead of being caught up in the persistent, unending mental
commentary or stories and histories the mind brings to most situations, mindfulness is
about “nonjudgmental” awareness (Spradlin, 2003, p. 52). It is awareness akin to seeing,
touching, tasting, hearing, or smelling something for the first time. Becoming mindful
takes a conscious effort to be present with whatever you are experiencing in the moment.
The efficacy of mindfulness is well established. In addition to the previous
discussion about Schwartz’s findings, Davidson et al. (2003) conducted a study testing
the effects of mindfulness training on a group of employees in the biotech industry. For
two months, participants attended a weekly class on mindfulness meditation, and were
encouraged to practice mindfulness meditation at home for 45 minutes each day. The
study concluded with a one day mindfulness retreat. Compared to the control group, at
the end of the study, the treatment group reported a decrease in negative emotions, and
increases in both positive emotions and immune function (Davidson et al., 2003, p. 569).
Being in the moment or present is what mindfulness is all about. Two ways
Lyubomirsky (2007) identifies that foster orientation in the present are “flow
experiences” and “savoring.” The former refers to activities that are completely engaging
such as playing sports or creating art (p. 181). The goal is to strike a balance between
challenging oneself and utilizing one’s own skills. If an activity is too challenging, one
will become overwhelmed; whereas if the activity is not challenging enough, one will
39
become bored. The idea is to have some sense of mastery, but still finding the task
challenging (Lyubomirsky, 2007, p. 181).
“Savoring” is described by Lyubomirsky (2007) as completely enjoying the
positive experiences in one’s life in the present moment, even when reminiscing about
the past, or anticipating positive events in the future (p. 191). Savoring can occur during
the most mundane tasks, it just involves shifting one’s perspective. It is not mutually
exclusive from an attitude of gratitude.
The following are the proposed mindfulness activities, flow experiences, and
savoring opportunities that will be presented to the group. The mindfulness activities
include: (1) Use your senses to describe a flower; (2) Notice how you are feeling
physically and mentally right now. How does your body feel, do you feel tense or
relaxed? Tired or energetic? Notice the sounds around you, and recognize or become
aware of the fact you are hearing. Observe your thoughts without making judgments of
them (Baraz & Alexander, 2010, p. 33); (3) Take deep breaths and notice each inhalation
and exhalation. Does your chest or stomach rise? Can you feel the cool air in your
nostrils? Every time your mind wanders, “gently return to the breath” (Baraz &
Alexander, 2010, p. 45).
Lyubomirsky (2007) suggests, “we can experience flow in almost anything we
do” (p.182), however activities that promote flow will vary from person to person. Here
are a few examples, however the group will also be asked to provide their own
suggestions as well: (1) Playing sports, dancing, or doing other physical activities
40
(Lyubomirsky, 2007, p. 182); (2) Drawing (Lyubomirsky, 2007, p. 184); (3) Gardening
(Lyubomirsky, 2007, p. 182); (4) Learning a new skill (Lyubomirsky, 2007, p. 184); (5)
Listening to music; (6) Singing (Lyubomirsky, 2007, p. 186).
The last set of suggestions are intended to provide opportunities for savoring.
They include: (1) Taking time to appreciate each bite and sensation when eating a
favorite food (Lyubomirsky, 2007, p. 193); (2) Enjoying each second in the shower or a
warm bath (Lyubomirsky, 2007, p. 193); (3) Focusing on the beauty of each step during a
hike in nature (Lyubomirsky, 2007, p. 198).
Conclusion
The intention of this literature review was to provide the rationale behind the
potential benefits of designing a support group aimed at increasing subjective well-being
for people labeled with schizophrenia. The present study will provide an opportunity to
link the scientific literature with the experience of mental health professionals who work
or have worked directly with this population. The final product will be an evidencedbased group curriculum specifically tailored to consumers suffering from schizophrenia.
The next chapter discusses the research methods.
41
Chapter 3
METHODS
Introduction
For the present study, clinicians were asked to use their expertise in evaluating a
proposed group curriculum for people with schizophrenia. Current literature in
mindfulness and positive psychology was used to create the curriculum. The survey was
designed in parallel with the group modules to collect participants’ experience-based
opinions. Sampling occurred through convenience to the researchers. All procedures were
approved by a human subjects protection committee prior to data collection.
Study Design
Nonexperimental, exploratory methods were used for this study. No deception
was employed. Expert opinions were gathered regarding the effectiveness of a wellnessoriented psychoeducation and discussion group curriculum for people diagnosed with
schizophrenia (Appendix B). Participants were given the curriculum for review, then were
asked to respond to multiple choice and free response items, critiquing the proposed
group. Participants’ answers were aggregated and statistics were compiled using SPSS 19
(IBM, 2010). Data were evaluated for both trends and individual differences, and
apparent outliers were considered within the context of that participant’s experience and
any qualitative written data provided. Additionally, highest degree obtained, length of
mental health experience, and breadth of experience were used as independent variables.
42
The effects of these three variables upon participants’ feedback on individual items were
analyzed.
Sampling Procedures
Thirteen clinician participants were recruited for the study. Participants were
professionals in the mental health field consisting of supervisors, fellow employees, and
professors of the researchers. Criterion for inclusion was at least two years providing
professional services to consumers with a diagnosis of schizophrenia. Participants with
less than two years of experience were not considered for the study. Recruiting began
with the researchers’ supervisors, professors and colleagues who were known to meet the
inclusion criteria. Participants were asked if they are willing to spend up to one hour
evaluating the components of a recovery group for people diagnosed with schizophrenia.
They were informed that no compensation would be provided. The snowball method was
employed for the last several participants, as the target of fifteen was not met through
convenience. All persons approached were willing to participate. Informed consent was
verbally explained to participants prior to the beginning of the research. They then were
asked to carefully read the consent form (Appendix A) and sign their consent. All
participants provided consent.
Data Collection Procedures
A standard email template was sent to each participant, explaining the length of
participation, confidentiality, the basic procedures, and their right to decline to
participate. They were informed that their expertise was requested to be used in drafting a
43
group curriculum for people diagnosed with schizophrenia. Upon choosing to participate,
participants were discretely given a copy of informed consent in a manila envelope, and a
copy of the group modules and survey in another manila envelope. Instructions were
given to read and sign the consent, then read through the modules. After reviewing the
packet of modules, participants were asked to complete a survey (Appendix C) about the
strengths and deficits of the group design. Participants were asked to securely return the
materials to the researchers in the manila envelopes. The envelopes were not opened until
all data had been collected to maintain some level of anonymity.
Materials
Six modules were created by the researchers to provide psychoeducation and
discussion topics for structured group sessions. Each module was designed to increase the
subjective well-being of group members. Feedback about the effectiveness and structure
of the group modules was collected through a survey, also created by the researchers
(Appendix C). The survey was intended to elicit feedback about each facet of the group
modules. Six sections, one for each module, used five-point scaled items. Seventeen
items implemented a scale of importance, and 58 items used an agreement scale. Three
scaled item asked participants to use a likelihood scale. Participants were encouraged via
instructions on the survey to be “candid and specific,” in their responses and to use the
space provided for written comments. Two items asked participants to rate the most and
least effective modules. Six items asked participants to rate the congruence of the
modules with a wellness and recovery orientation. Items relating to professional and
44
academic experience of participants were placed at the end of the survey.
Data Analysis
Data was entered and aggregated using SPSS 19 (IBM, 2010). Mean, standard
deviation, and range were used as measures of central tendency and variance when
considering responses to each question. Scale response points were assumed to be evenly
spaced along the continuum and converted to numerical values for analysis, vs. treating
the points as ordinal (e.g. Strongly Disagree = 0, Disagree = 1, Both Agree and Disagree
= 2, Agree = 3, Strongly Agree = 4). Outliers were individually interpreted, especially
when comments at the end of each survey provided a reasonable explanation, or the
participant had significantly more experience in a related area than other participants. The
cutoff for changing a module was < 2.5, indicating that more than half of the participants
did not fully approve of the curriculum. Written comments were sorted by module and
collected into a spreadsheet. This list of additional comments was used when considering
revisions for each group module. Repeated responses were given more importance, but
occasionally a response given by only one participant was weighted heavily if that
participant had more experience in the area which they provided feedback compared to
other participants, or if the comments were deemed to provide a nuanced insight.
Protocol for the Protection of Human Subjects
The methods of the present study were approved by the Committee for the
Protection of Human Subjects in the Department of Social Work at California State
University Sacramento on 1/24/2011, prior to the beginning of data collection. The study
45
was marked as minimal risk to participants. The only known potential risk to a participant
is that the research brings up unresolved trauma from working in the mental health
setting. Risk has been minimized by the protection of confidentiality of study data,
describing potential risks to participants ahead of time, providing participants with access
to psychological support services if needed, and consultation with a thesis advisor during
the procedure design. The informed consent form clearly encouraged participants to
discontinue their participation in the study at any time if they felt uncomfortable. All
participants provided informed consent. Envelopes containing informed consent and
measures were not opened until data collection was over. Completed surveys were not
directly traceable to an individual participant.
46
Chapter 4
FINDINGS
Introduction
This chapter will present the data results of the survey, which provides feedback
upon the effectiveness of the group modules for people with schizophrenia. First, the
demographic characteristics of the participants will be presented. Then a review of the
survey data analysis will take place. Throughout this chapter, tables will follow a
description of the findings. Qualitative data have been summarized and reported in their
entirety, and will receive more discussion in Chapter 5. Overall, participants reported that
the curriculum would be helpful in improving quality of life for people with
schizophrenia. Several of the modules were found to need minor adjustment.
Additionally, participants’ experience was used as an independent variable and its effects
upon individual item responses were analyzed.
Demographics
Thirteen participants were used in this study (N = 13). None were excluded. All
were mental health clinicians. Eight had masters degrees, all of which were either in
social work or psychology with an emphasis in marriage and family therapy, or were
unstated. Five participants had doctoral degrees. Three stated having Ph.Ds in Social
Work, one of which also held a Ph.D in clinical psychology. One participant had a Psy.D,
and one a Ph.D in clinical psychology.
47
Table 1 Academic degrees of participants
n
Percent
Masters
8
61.5
Doctoral
5
38.5
Total
13
100.0
Twenty-five separate modalities of mental health practice were assessed for in the
demographic questionnaire. A twenty-sixth item allowed participants to write in more
modalities in which they had experience. The total number of modalities were analyzed
to aid in understanding individual experience. Years of mental health experience was also
used as an identifier of experience. The mean number of modalities was more than half of
those listed (M=15.46), and the standard deviation was SD = 3.33. The average years of
experience providing mental health services was high, with a large range and standard
deviation (M = 14.81, [2, 28], SD = 10.02). Having more mental health experience did
not significantly correlate with working in more modalities.
48
Table 2 Participant experience in mental health
Total
N
Min.
Max.
M
SD
13
9
20
15.46
3.33
13
2
28
14.81
10.02
Modalities
MH
Experience
Module Effectiveness
Participants reported the most effective module was Module Two: The Benefits of
Social Support. It was followed by Module 5: Cultivating Strengths, which received the
same number of votes as “all modules are equally effective.” Rated least effective was
Module Six: Mindfulness in the Present Moment, which will be partially disputed by the
researchers in chapter five due to qualitative data. Participants also rated Module Three:
Practicing Gratitude and Module Four: Avoiding Overthinking and Social Comparisons
as least effective. None of the modules were rated both “most effective” and “least
effective.”
49
Table 3 Most effective modules
n
Percent
Module Two:
5
38.5
4
30.8
All equally
effective
4
30.8
Total
13
100.0
Social Support
Module Five:
Strengths
Table 4 Least effective modules
N
Percent
Module Three:
Gratitude
3
23.1
Module Four:
Overthinking
1
7.7
Module Six:
Mindfulness
5
38.5
All equally
effective
Total
4
30.8
13
100.0
50
Individual Module and Component Evaluation
Some items were missing values for either one or two (but not more) participants.
No missing value analysis (MVA) was performed. MVA was thought to be typically
reserved for larger samples and more heavily quantitative study designs.
Items addressing each module as a whole and in its component parts were present
on the survey. Since all items employed five-point ordinal scales, converted to continuous
numerical values (0 for lowest possible score, 4 for highest possible score), they were
analyzed similarly. As both trends and outliers were of interest, items were deemed
worthy of considered revision if: 1) mean scores were at or below 2.50; 2) the standard
deviation was 1.00 or above; or 3) the range was 4.
Modules three and four had the lowest group mean scores (M = 2.80 and M =
2.71, respectively). This was still in the acceptable range, suggesting that all modules
were viewed as effective by participants.
Overall, participants answered with much variance on the following items:
Importance of beginning with a definition of schizophrenia (range = 4, SD = 1.18),
Importance of beginning with a definition of gratitude (range=4, SD=1.25), evaluating
the gratitude games (range=4, SD=1.28), going to wellness and recovery center
(range=3,SD=1.07) the definition of mindfulness (range=4, SD=1.00), and evaluating the
wellness & recovery orientation of module one (range=4).
51
Table 5 Module evaluation –individual item statistics
Item (corresponds to survey,
N
Range
Min.
Max.
M
Group
Group
M
SD
3.40
0.70
SD
Appendix C)
M1a_Defining_schizophrenia
13
4
0
4
3.31
1.18
M1b_1_Medication
13
2
2
4
3.46
0.78
M1b_2_Psychoeducation
13
1
3
4
3.62
0.51
M1b_3_Vocational
13
3
1
4
3.08
0.76
M1b_4_Social_Skills
13
1
3
4
3.62
0.51
M1b_5_CBT
13
3
1
4
3.00
0.91
M1b_6_Family_approaches
13
2
2
4
3.31
0.63
M1b_7_Peer_selfhelp
13
2
2
4
3.62
0.65
M1b_8_Tx_associated_cond
13
2
2
4
3.23
0.73
M1b_9_Substances
13
1
3
4
3.54
0.52
M1b_10_Recovery_wellness
13
1
3
4
3.62
0.51
M2a_Defining_social_support
12
2
2
4
3.33
0.78
M2b_1_Practice_compassion
13
1
3
4
3.46
0.52
M2b_2_Listening
13
1
3
4
3.46
0.52
M2b_3_Self_disclosure
13
2
2
4
2.92
0.86
M2b_4_Supportive
13
1
3
4
3.46
0.52
M2b_5_Exercise
13
2
2
4
3.38
0.65
M2b_6_Wellness_centers
13
3
1
4
3.15
1.07
M2b_7_Events
13
2
2
4
3.15
0.80
M2b_8_School
13
2
2
4
3.00
0.58
M2b_9_Online_group
13
3
1
4
2.31
0.85
M2b_10_Religious_attendance
13
2
2
4
2.46
0.66
52
M2b_11_Twelve_step
13
2
2
4
2.69
0.75
M2c_1_Positive_relationships
13
1
3
4
3.92
0.28
M2c_2_Increased_wellbeing
13
3
1
4
3.54
0.88
M2c_3_Peers_enhance_SE
13
2
2
4
3.62
0.65
M2c_4_Peers_enhance_SW
13
2
2
4
3.54
0.66
M2c_5_Peers_enhance_soc_net
13
1
3
4
3.54
0.52
M2c_6_Helping_incr_purpose
13
2
2
4
3.31
0.85
M2d_Social_interaction_appropriate
13
2
2
4
3.54
0.66
M3a_Include_gratitude
13
2
2
4
3.08
0.76
M3b_Begin_gratitude_def
13
4
0
4
2.69
1.25
M3c_Focus_positive
12
2
2
4
3.08
0.79
M3d_1_Write_gratitude_letter
12
3
1
4
2.83
0.94
M3d_2_Phone_appreciation
13
2
2
4
3.08
0.64
M3d_3_Gratitude_journal
13
2
2
4
2.77
0.73
M3d_4_Contemplating_gratitude
13
3
1
4
2.92
0.95
M3d_5_Identify_takeforgranted
13
3
1
4
3.08
0.86
M3d_6_Share_gratitude_list
13
2
2
4
2.92
0.64
M3d_7_Substitute_ungrateful
13
3
1
4
2.54
0.88
M3d_8_Gratitude_art
13
2
2
4
3.38
0.65
M3d_9_Say_grace
13
3
0
3
1.85
0.99
M3d_10_Gratitude_games
13
4
0
4
1.85
1.28
M3d_11_Three_good_things
13
2
2
4
3.15
0.80
M4a_Overthinking
13
2
2
4
2.85
0.69
M4b_1_Distraction
13
1
2
3
2.77
0.44
M4b_2_Stop_ruminating
13
3
1
4
2.15
0.99
3.25
0.69
2.80
0.87
53
M4b_3_Talk_support
13
2
2
4
3.15
0.80
M4b_4_Take_action
13
2
2
4
3.08
0.64
M4b_5_Avoid_triggers
12
2
2
4
3.42
0.79
M4b_6_Meditating
13
3
1
4
2.69
0.95
M4b_7_Impermanence_of_problem
11
2
1
3
2.00
1.00
M4b_8_Big_picture
12
3
1
4
2.75
1.14
M4b_9_Radical_acceptance
12
3
1
4
2.67
0.89
M4c_Module_effective_explanation
12
2
2
4
2.33
0.65
M5a_Necessity
13
0
4
4
4.00
0.00
M5b_1_Recall
13
1
3
4
3.69
0.48
M5b_2_Personal_strengths
13
1
3
4
3.85
0.38
M5b_3_Resource_access
13
1
3
4
3.85
0.38
M5b_4_Recent_example
13
1
3
4
3.77
0.44
M5c_Homework
13
3
1
4
2.23
0.93
M6a_Importance_mindfulness
13
2
2
4
2.85
0.69
M6b_Mindfulness_comprehension
13
4
0
4
2.00
1.00
M6c_1_Flower_meditation
13
2
2
4
3.00
0.71
M6c_2_Body_meditation
13
2
2
4
3.08
0.64
M6c_3_Breathing_meditation
13
1
3
4
3.38
0.51
M6d_1_Flow_sports
13
2
2
4
3.08
0.64
M6d_2_Art
13
2
2
4
3.31
0.63
M6d_3_Gardening
13
2
2
4
3.23
0.60
M6d_4_New_skill
12
2
2
4
3.33
0.78
M6d_5_Listen_music
13
2
2
4
3.46
0.66
M6d_6_Singing
13
2
2
4
3.23
0.60
2.71
0.82
3.56
0.43
54
M6e_1_Savor_food
13
3
1
4
3.08
1.12
M6e_2_Bath
13
3
1
4
3.15
1.07
M6e_3_Hike
13
2
2
4
3.08
0.76
3.09
0.74
Qualitative Item Responses
Several themes were present in qualitative responses. Occurring most frequently
was the suggestion that the group facilitator(s) perspective and delivery were at least as
important in maintaining a wellness orientation as the curriculum. Also prevalent was the
idea that consumers who are newly diagnosed or not stable on medications would likely
receive little benefit from Module Six: Mindfulness and the present moment, and the
group as a whole. Some of the components were reported to be likely difficult for
consumers due to their thought disorders, potentially creating unnecessary frustration.
There were repeated comments about excluding or changing information relating
to religiosity and twelve step groups. One item assumed consumers would say grace
before meals, which was highly discouraged by participants. Assuming the necessity of
twelve step programs for consumers was similarly discouraged. Module Three: Practicing
Gratitude in particular had several comments about religiosity. The gratitude games were
pointed out as being “Christian,” and as seeming “cheezy” and unrealistic for the
population. Low quantitative scores correspond to these complaints.
Other suggestions were small additions to the curriculum which would better
serve consumers with schizophrenia, instead of being universalized for a large-scope
mental health agency or the general public. Including methods of dealing with medication
55
side effects and schizophrenia symptoms was advised. Spending more time describing
available services to people with schizophrenia was also recommended.
Table 6 Qualitative feedback
Comment ID
Module One: Defining Schizophrenia
1
main importance is who and how it is delivered
2
stability with housing - important
3
placing education over meds may get buy-in from group members
4
they already know what schizophrenia is
5
take care to not pathologize their experience of the world
6
i like the breadth of treatment modalities listed. missing housing
7
include medication side effects
8
suggest adding continued medication tx beyond decrease of sx
9
many consumers need information about side effects from medications
Module Two: The Benefits of Social Support
10
depends on how the person with schizophrenia interprets or internalizes the other
persons intentions
11
careful with religiosity. not all clients have substance abuse and therefore do not
need 12 step.
12
not all consumers need 12 step so don't assume
13
religious is a dangerous word...try spiritual
Module Three: Practicing Gratitude
14
best if gratitude is authentic, not force-fed
56
15
item 9 - grace assumes religious beliefs, like everyone should do this
16
applicable for some but not for others
17
the gratitude games and spirituality is mostly christian based and could be off
putting to folks who aren't christian
18
keep in mind consumers have a thought disorder and may struggle with thought
substitution
19
the gratitude games seem cheezy and dont make sense
20
be sure to be patient and support unconditionally
21
use caution with approaches and words that lean toward spiritual or religious
beliefs.
22
this could be very difficult for consumers who are early in disease onset or
treatment
Module Four: Avoiding Overthinking and Social Comparisons
23
module involves a lot of thinking. if consumer is not stabilized on meds, their
thought disorder can become heightened
24
careful, again they have thought disorders so feel out the group
25
radical acceptance will probably confuse clients the way it is worded
26
the implementation and reading of the group is key, could be excellent, could be
invalidating or incorrect
27
meditation might worsen thought distortions and other symptoms. looking at the
big picture can be difficult when trying to manage the moment.
28
highly dependent on the client and the status of medications
Module Five: Cultivating Strengths (includes homework assignment)
29
write down list of assignments with case worker. make daily list.
57
30
laying out a premise that "i believe" people have examples to use every day with
what they are dealing with and how they are doing
31
make it ok whether someone decides to do it or not
32
create attitude of no shame if it is not done
33
help them feel a sense of ownership in the assignment
34
create a meaningful reward system. not written. tell grp members it will be the first
thing next gone over next grp. give them something meaningful when assigning it,
like a ribbon or stone, carry it.
35
depends on their motivation and thought distortions
36
give time to do the homework during the group
Additional Comments
37
module 6 is difficult or impossible if housing & environment are not stable
38
more info needed to deal with hallucinations, delusions and paranoia - practice
skills that can be immediately implemented
39
congruence will ultimately depend on the leader
40
the agency's treatment of clients and human interaction between professionals and
consumers is just as important as the group curriculum
Wellness and Recovery Orientation
In keeping with this project’s goal of creating an anti-pathology, strengths and
wellness based group, participants were asked to rate the “wellness and recovery
orientation” of each module. The highest rated module was Module One: Defining
Schizophrenia, with a standard deviation in the acceptable range. The researchers
consider this data a success, as the definition of schizophrenia tends to be highly
58
pathologized. Module Three: Practicing Gratitude had the lowest mean and highest
variance (M = 2.77, SD = 1.09).
Table 7 Wellness and recovery orientation of each module
Module
n
M
SD
One
13
3.69
0.95
Two
13
3.46
0.78
Three
13
2.77
1.09
Four
13
2.85
0.99
Five
13
3.62
0.65
Six
13
3.23
0.73
Significant Demographic Effects upon Module Evaluation
The effects of demographic variables upon individual item scores were tested
using three one-way ANOVAs. First, all survey items were correlated with the three
demographic variables: 1) years of mental health experience; 2) total modalities worked;
3) academic degree. The significant correlations were separated out and one-way
ANOVAs were performed with each of the demographic variables as IVs and each of the
correlated individual items as DVs, to determine causality.
No significant effects were found for the IV years of mental health experience.
For IV total modalities worked, a significant effect was found for item M3D-7, which
involved having participants substitute ungrateful thoughts with grateful thoughts (N =
59
13, r = -.662, F = 8.731, df = 8, p = .026). Thus working in fewer modalities caused
participants to rate item M3D-7 lower.
Four significant ANOVA results were found for IV academic degree. Table 9
shows only significant ANOVA data. The column “r” indicates the Pearson correlation.
All correlations were negative, thus having a doctoral degree caused lower scores on the
items. Three of the items were in regards to Module 2: The Benefits of Social Support.
Table 8 Effects of academic degree upon module evaluation item responses
n
r
Sum of
Squares
df
F
p
12
-0.605
2.438
1
5.766
0.037
13
-0.569
2.492
1
5.272
0.042
13
-0.570
1.300
1
5.296
0.042
13
-0.601
3.894
1
6.231
0.030
M2a Importance of
defining social support
M2b-7 Attending social
events
M2b-8 Going to school or
vocational training
O7c Module 1 wellness
orientation
Summary
While minor changes were advised by some participants, the modules were found
to be effective for the purpose for which they were designed. The clinician-participants
provided valuable quantitative and qualitative insight about the components of the
60
happiness group. The collected demographic variables played little role in overall item
responses. In the next chapter, data will be further interpreted, and implications for
further practice will be described.
61
Chapter 5
CONCLUSIONS
Introduction
This chapter will provide interpretation of data, limitations and implications of
this study. The results presented in Chapter 4 will be compared to the literature review in
Chapter 2. Ideas for further research and practice in the area of wellness groups for
people with schizophrenia will be outlined, with an emphasis on the implications for
social workers. The chapter will end with a summary and impart some final conclusions
from this study.
Discussion of Results
The feedback from participants about the general strength of the modules’ likely
effectiveness coincides with the reviewed literature. As the modules were assembled
predominately from substantiated materials, it makes sense that most of the critical
feedback was in the interest of tailoring the group to consumers with schizophrenia. The
suggested changes and additions will be made in the final version of the group
curriculum.
Module Six: Mindfulness and the Present moment received some of the least
favorable reviews. As reported in Chapter 4, Module Six received the most votes as least
effective module (n = 5). This was surprising to the researchers, as mindfulness and
meditation are currently hot topics in social work and psychology. The individual items
did not indicate problems with the module. When looking at qualitative data, participants
62
seemed to think that the mindfulness group, along with Module Four: Avoiding
Overthinking and Social Comparisons, and even Module Three: Practicing Gratitude,
would be much less effective if consumers were not stabilized on medications, or if
consumers were experiencing debilitating symptoms. While the researchers did not
intend to implement the group with consumers who were not stable, this fact was omitted
in the materials given to participants.
That this principle critique of the modules was already accounted for by the
researches may denote that the modules are largely effective and in need of relatively
minor revision. At the same time, this oversight and accompanying omission may have
distracted participants from giving other evaluative comments.
Other suggestions included ensuring that saying grace is not required, but only a
suggestion. All of the items related to religion scored low in accordance with the written
comments. These changes will be made in the final version of the group. Similarly,
changes will be made to make twelve step meetings a suggestion only in the case that a
consumer acknowledges having dependency issues. The gratitude games were interpreted
by one participant as being religious, but the researchers believe with some revision they
could be salvaged without being perceived as pushing a religious agenda.
There were several additions proposed to the modules. It was suggested that time
be spent explaining which services are available to people with schizophrenia. The
researchers are considering putting together a seventh module to be implemented early in
the curriculum which would include information on resources, medication side effects,
63
and frequently asked questions for people diagnosed with schizophrenia. Finally, of the
suggestions for getting consumers to do the homework in Module Five: Cultivating
Strengths (which was the highest rated module), the following will be used in future
groups: creating an attitude of no shame if they do not do the homework, and helping
consumers feel a sense of ownership or personal meaning in the assignment.
Limitations
Far too few demographic variables were collected. When crafting the study,
demographics were kept brief to: 1) help provide some level of anonymity and
confidentiality to participants who were personally known to the researchers, and who
may review the contents of this study; and 2) keep the length of the already hefty survey
down. As a side note, the length of the module outlines and survey did appear to be a
problem, as in some responses it appeared participants did not read the outline carefully.
While initially convenient, the few demographic variables allowed for little
understanding of how diversity affects evaluation of the group modules.
While significant results were found for two of the demographic variables upon
item responses, the lack of participants (N = 12 and N = 13) yields low statistical power.
A power analysis was not conducted for this reason.
The researchers had direct contact and relationships with all of the participants.
Any effects of prior relationships upon the results are unknown. It is possible that
numbers have been inflated by participants due to not wanting to upset the researchers.
64
All participants were mental health clinicians. While the demographic data on
experience in different modalities indicates some variability, the training and experience
of participants was still, overall, highly homogenous. The spectrum of generalizability is
thus highly restricted.
Recommendations
Inclusion of more demographic variables would be a necessity for future research
in this area. Much more than most other disciplines, social workers are focused on how
the environment and experiences affect populations. Opinions from underserved and
underrepresented populations are protected by the field of social work. Further study
could take a more meaningful look at how different demographic variables correlate with
and cause differing opinions on the success of the group modules. A sample size of at
least 30 is recommended for each level of any independent variables in the future as well,
to add more statistical power to significant results.
Three changes could be made to sampling procedures to increase validity of the
study. First, participants could be sampled through method other than convenience.
Convenience is probably the least statistically relevant sampling method. Random
sampling of persons serving consumers with schizophrenia would be ideal. Second,
inclusion of participants of varying academic degrees and disciplines would add valuable
insight to future research. For example, a sample of nurses and paraprofessionals would
provide different and (arguably) equally valuable insight into the success of the proposed
group. Third, implementing the group with real consumers, then having them complete
65
an evaluation would provide another level of understanding to the effectiveness of the
curriculum.
Future data may be more accurate if it is made clear to participants that the group
is designed for consumers who are stabilized on medications. The researchers believe this
would likely yield no different results, but the fact remains that including this information
could open up new avenues of thought in evaluators. Continued research could also look
at the effects of a happiness group upon medication adherance, symptom reduction, stable
housing, employment, and other more common variables of study for people diagnosed
with schizophrenia.
Implications
It is a clear that participants thought, if consumers are stable on medications, and
the group facilitator is strengths and recovery oriented, the group would be effective at
increasing happiness and quality of life for people with schizophrenia. These results
provide some evidence that such a group is worthy of public funding. This study lays the
groundwork for happiness groups to begin to gain equal consideration to medication as
modalities of treatment. It is particularly timely in light of recent devastating cuts to nonmedication services for the indigent mentally ill in the researchers’ county of residence.
In direct practice, the results provide evidence that experts support happiness
groups as a legitimate component of treatment for people with schizophrenia. A credible
handbook has been created outlining wellness and recovery oriented ways to assist
consumers with understanding their illness, using social support, practicing gratitude and
66
CBT methods to combat thought distortions, cultivating their strengths, and using
mindfulness and meditation practices to minimize stress, increase focus, and increase
feelings of well-being. Groups are cost effective and often the method of choice for
delivering standardized services to clients.
Final Thoughts
This is an exciting time in mental health, as the recovery movement is gaining
momentum, and neuroscience is showing that individuals can use intentional activities to
harness the power of neuroplasticity and increase their subjective well-being. The study
of strengths as opposed to deficits, and the components of mental “health” as opposed to
mental “illness” have gained credibility as valuable endeavors in both science and life in
general. In addition to having been exposed to uplifting material, after reading this paper,
you might realize true happiness is attainable for those of us considered “normal” as well
as those of us considered “mentally ill.” This idea has the power to transform how we
approach our own lives and the lives of those we work with.
This research does not end here, as the final group curriculum is still under
construction, considering the suggestions provided by the clinician participants. In
addition, consumer input has yet to be gathered, which will contribute to the further
evolution of this happiness group. In other words, the curriculum is not fixed, and just as
the concept of “recovery” entails an individualized journey, so too, does the pursuit of
happiness. Therefore, the modules are just suggestions; of greater importance is that
consumers identify happiness strategies that resonate with their own personalities.
67
APPENDICES
68
APPENDIX A
Informed Consent
69
70
71
APPENDIX B
Module Outlines
72
73
74
75
76
77
78
APPENDIX C
Survey
79
80
81
82
83
84
85
86
87
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