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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 ii 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 vi 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 vii 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 viii 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 ix 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 xi 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. 2 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 4 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. 7 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. 14 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) 18 (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). 20 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. 31 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 REFERENCES Aldridge, D., & Stevenson, C. (2001). Social poetics as research and practice: Living in and learning from the process of research. Nursing Inquiry, 8(1), 19–27. doi: 10.1046/j.1440-1800.2001.00085.x Alptekin, K., Gheorghe, M., Thomas, P., Mauri, M., Olivares, J.M., & Riedel, M. (2009). Management of patients presenting with acute psychotic episodes of schizophrenia. 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