Sunday, April 14, 2013

Brief Summary: Recovery, Wellness, and QOL Among People with Schizophrenia

With an increasing interest in the recovery and wellness model of mental health, researchers are now trying to delineate the strategies individuals with severe and persistent mental illness can use to increase their subjective well being. Treatment outcomes are too often based on symptom reduction, but this study argues that evaluations should also consider quality of life as an important treatment outcome. This paper has analyzed the literature and notes the importance of several techniques that should be further tested in order to help those who suffer from mental illnesses such as schizophrenia achieve levels of happiness once thought unattainable for this population and to develop an evidence base for the recovery and wellness model.  The key strategies identified in this paper include investing in social relationships, practicing gratitude, avoiding over thinking and social comparisons, and avoiding stress by staying in the present moment (Ridgway, 2001; Lyubomirsky & Tkach, 2003; Lyubomirsky, King & Diener, 2005).

The Problem
Increasing subjective well-being in people diagnosed with schizophrenia
Schizophrenia is a mental condition typified by disordered thought processes or cognitions (King, 2010). These disordered cognitions are categorized as psychotic because they significantly deviate from the majority’s experience of reality (King). The symptoms of schizophrenia fall within three different typologies: positive, negative, and cognitive deficits (NIMH, 2006). According to King, positive symptoms refer to distortions in excess of normal functioning such as hallucinations and delusions. Negative symptoms refer to behaviors that are deficient of normal functioning and include social withdrawal, flat affect, and 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. There is currently no cure schizophrenia; (natural, nutrition besides drugs?) the condition is long term and severe, adversely affecting a person’s psychiatric, physical, and social functioning (Meijer, Koeter, Sprangers, Schene, 2009).
Schizophrenia is fairly common with a lifetime prevalence of about 1% in the general population (King, 2010). About half of the people admitted to psychiatric hospitals have schizophrenia (King, 2010), and people with schizophrenia are eight times more likely to commit suicide than the general population (Pompili, Amador, Girardi, Harkavy-Friedman, et al., 2007).  People with schizophrenia are relatively invisible to society and according to Torrey (2006):  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.
The typical treatment of schizophrenia is with antipsychotic drugs, of which there are two types, the neuroleptics and the more newly developed atypicals (King, 2010). The nueroleptics are the most extensively used and have been on the market for over 50 years. Neuroleptics have potent side effects, such as tardive dyskinesia, which causes involuntary muscle movements and affects up to 20% of the people taking these antipsychotics (fix) (Garver, 2006). The atypicals were introduced in the 1990s and have shown promise in reducing psychotic symptoms with less extensive side effects than neuroleptics (King).  According to Nemade and Dombeck (2009), about 70% of patients show improvement while taking antipsychotics, 25% show minimal improvement, and 5% actually decline. Two important things to consider about outcome studies regarding antipsychotics: (1) Historically, improvement  was measured by efficacy in reduction of positive symptoms (e.g. hallucinations and delusions), while physical side effects and their impact on subjective quality of life was not (De Haan, Duivenvoorden, Mulder, Staring, Van der Gaag, 2009); and (2) Only since the introduction of the atypicals has the patient’s perspective, or subjective well being and quality of life become an outcome measurement (Karow & Naber, 2002).   
While the biomedical model was focused on alleviating symptoms in outcomes studies, a new model, recovery and wellness, in conjunction with atypical antipsychotics, has influenced the rising interest in research on subjective well being and quality of life (Karow & Naber, 2002). 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 (p. 335).” The recovery and wellness model is congruent with a philosophy of life that sees happiness as a universal possibility; a state of mind that is attainable for those labeled “mentally ill” as well as those considered “normal.”

* look for other sources besides King, 2010 - may be overused
* a source needs to be cited only once unless it is broken up by another source
Purpose of the Study
There are numerous reasons why studies aimed at increasing well-being for those diagnosed with schizophrenia are important. First of all, attempting to increase subjective well being is vital to the social work profession because one of the profession’s foundations is to alleviate the suffering of oppressed populations. Oppressive forces working against those with schizophrenia include: (1) A medical model that has historically measured outcomes through alleviation of psychotic symptoms, negated the importance of subjective quality of life, and treated patients as an illness rather than a person; and (2) decline of interpersonal and occupational functioning as a result of pathology, fear, and stigmatization.
Trying to contend with a disorder that causes internal fear, chaos, and loss of hope, and a treatment regimen that causes significant side effects and additional stigmatization, means people recovering from extreme states of mind would probably benefit from happiness increasing activities (awk). A paradigm shift is underway towards the recovery and wellness model, and the aim of this study is to add to the knowledge base that recognizes subjective well being is a legitimate outcome measurement. Furthermore, if the techniques measured in this study do increase subjective well being among people with schizophrenia, the recognition of their validity could be used to help other populations as well.
Instead of just focusing on reducing suffering, asking how can we increase happiness? (Positive Psychology). Therapy has long focused on troubles and not on strengths. Therefor, a final aim of this paper is to help reorient health services around promoting well-being interventions. (Positive Psychology)  The goal for the consumer is to enhance purpose and meaning (why), giving primacy to increasing well-being rather than just treating illness.
Theoretical Framework
        People with schizophrenia would benefit from working with mental health professionals who are sensitive to their needs, see them as a person instead of an illness, and advocate for their ability to live happy and fulfilling lives.
Scientific progress is built upon the work of others, and this study is no exception. In fact, this study draws from a variety of theoretical orientations, spanning across different disciplines. To achieve these goals, this study will draw from four main theoretical frameworks to guide the research: (1) The biopsychosocial model of psychological disorders (King, 2010 - this did not originally come from King); (2) cognitive-behavioral therapy (Rector & Beck, 2002);  (3) the strengths perspective (Saleeby, 1997); and (4) neuroplasticity (Schwartz, 2002).
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 and neurotransmitter functioning. Believing schizophrenia is caused by a chemical imbalance (also lack of development of brain structures) in the brain explains why doctors have looked solely to biological interventions to treat schizophrenia. The biopsychosocial approach is more holistic because in addition to biology, it considers psychological factors such as childhood experiences, and sociocultural factors such as gender. Psychological and sociocultural factors warrant consideration because if mental disorders were based solely on biology and genetics, then the chances that identical twins would have concordant rates of schizophrenia would be 100% instead of 48% (include another couple twin studies - strengthen point) (King, 2010).
Cognitive-behavioral therapy (CBT) is rooted in both cognitive and behavioral theory. Cognitive theory focuses on how people think about themselves and the world, and how distorted perceptions and interpretations lead to cognitive dysfunction (King, 2010). 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 behavior.
       CBT is crucial to this study for several reasons. First, this form of psychotherapy has the most empirical evidence supporting its efficacy for treating a broad range of disorders from depression to substance abuse and eating disorders (King, 2010). 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 and replacement of negative beliefs and predictions. Attending CBT has been shown in controlled trials to reduce both positive and negative symptoms of schizophrenia and improve psychological and social functioning (Lysaker & Silverstein). The interventions suggested in this study, based on Lyubomirsky (2007)’s research, are CBT strategies. (ALSO SEE p. 8 of Slade, 2010 ).
        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” (Saleeby, 1997) of people with schizophrenia. 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 the fact that every human being has innate abilities. The strengths perspective also symbolizes a collaboration between the social worker and the participant (Saleeby, 1997), which translates into shared power, as the participant is the expert in how they have coped with adversity. Furthermore, the techniques or “happiness strategies” that will be proposed are not going to appeal or be appropriate for everyone. The key is for the participant to choose the strategies that most resonate with their personal strengths (Lyubomirsky, 2007). more on how specifically the strengths perspective is carried out - strategies
The final theoretical framework guiding this study is neuroplasticity. Modern neuroscience is pointing towards the fact that the adult brain is not static, as was once believed (and still may be in some circles). In fact, the brain is flexible and capable of changing throughout the lifespan (Siegel, 2009). Furthermore, many researchers now believe there may be two way causality between the brain and the mind. It is a basic tenet of neuroscience that mental states (such as thoughts and emotions) are influenced or caused by neuronal processes in the brain (Begley & Schwartz, 2002). This type of causality is called bottom-up causality. The more revolutionary idea of modern neuroscience is top-down causality, which asserts that mental states also exert control over the lower level brain events or neuronal processes (Begley & Schwartz). While this research will not use the techniques of neuroscience such as fMRIs or PET scans to measure brain changes, it draws from studies on mindfulness that seem to demonstrate the potential of the mind to change the brain (Begley, 2007; Begley & Scwartz).  

*attachment & role in emotional regulation
*earned secure attachment through the group, positive psychology, etc

Review of the Literature
This section will review the literature, and is divided into four major headings. The first area explores the history of oppressive treatments of the mentally ill due in part to an over-reliance on the medical model. The second area presents a brief overview (case studies, anecdotes?) of common experiences among people with schizophrenia, reiterating the import of a paradigm shift in mental health service delivery. The third area explores the emergence of the recovery and wellness model by defining the approach and examining several studies looking at the efficacy of CBT and the recovery model. The final area will review the work of Professor Sonja Lyubomirsky from U.C. Riverside who has conducted extensive research on increasing subjective well being using happiness enhancing techniques.
The Treatment of the Mentally Ill Across Time
Those with severe and persistent mental illness have a long history of being subjected to less than humane treatment. According to Whitaker (2002), prior to the moral treatment movement of the 1800’s, 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.  Cockerham in 2006 added that, “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.”
As noted by Whitaker (2002), moral treatment was the dominant model in psychiatry lasted less than a century. There are numerous factors that led to this decline. First of all there was no consistent model for its’ implementation, making it difficult, for instance, to train new employees. Secondly, critics viewed moral treatment as merely an attempt to gain conformity, rather than an effective remedy for mental illness. Additionally, mental illness often has co morbidities such as alcoholism and mental asylums became warehouses for all of societies’ rejects, not just the mentally ill. This led to widespread contempt for asylums and their inhabitants, especially because the public institutions were financed by taxpayer dollars. 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 middle of the 20th century. It is important to note that the medical model is still based upon the idea that mental illness is incurable, despite the fact more recent evidence shows that people with schizophrenia can “recover” (Breeding, 2008).
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). The reasoning behind each of these treatments is that it is possible to remove or terminate the diseased cells that are the etiology of mental disorder (Whitaker). While these treatments have largely been replaced, it is interesting to note that EST is still used for the most sever patients, such as catatonic schizophrenia (Cockerham, 2006).
The introduction of chlorpromazine –a psychotropic drug- in 1952 changed the course of psychiatric intervention, and by the early 1960s, treatments for schizophrenia had clearly shifted from the physical to the pharmaceutical (Whitaker, 2002). Unfortunately, although antipsychotics do alleviate many of the positive symptoms of schizophrenia they do cause extrapyramidal symptoms (EPS) including but not limited to tremors, rigidity, and tardive dyskinesia (Alptekin, Gheorghe, Thomas, et al. 2009), and in some cases, “permanent neurological damage” (Bassman, 2007). The view that schizophrenia is a brain disease has lead to a strict dependence on antipsychotic drugs –despite the numerous side effects- as the main form of intervention to control symptoms (Breeding, 2008).
The biomedical paradigm of schizophrenia sees it 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).  Breeding goes on to assert that recovery from schizophrenia using antipsychotics is “virtually nill,” while Whitaker (2002) challenges the efficacy of antipsychotics, by stating  that prior to the advent of these drugs, the recovery rates for schizophrenia were about 60%.
How it Feels to Suffer from Schizophrenia
Few would argue that the onset of schizophrenia presents a significant life stressor. Some common experiences among sufferers including a loss of ‘self’ from the previous identity they had developed; grief over this loss combined with a sense of hopelessness about the future; and pharmacological side effects that in conjunction with the former, contribute to a sense of shame, embarrassment, and stigma, leading to social isolation (Aldridge & Stevenson, 2001; Hensley, 2002; Horowitz, 2002; Rudge & Morse, 2001; Usher, 2001).  According to Ashton, Lamberti, Price, Schwarzkopf, Trompeter, and Weisman (2001), people with schizophrenia also find themselves incarcerated, homeless, victimized, unemployed, addicted to drugs and alcohol, or suicidal.
A Paradigm Shift Towards Recovery and Wellness
Currently, a paradigm shift is occurring in mental health service orientation. Under the biological model alleviating symptoms was the primary objective, but now, treatment outcomes are becoming more consumer driven as the patient’s perspectives are being considered (Karow & Naber, 2002). Quality of life 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 (Deegan, 1997). Deegan 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 (p. 20-21).”
As more and more attention is now being afforded to the likelihood of recovery from schizophrenia, many researchers are interested in examining the role of psychotherapy as part of the treatment regiment (Lysaker & Silverstein, 2009). For example, Gumley, Karatzias, Power, Reilly, McNay, and O’Grady (2006) conducted a study testing the efficacy of CBT to combat the effects of negative beliefs and lowered self esteem regarding relapse (which was operationalized as a return to the hospital or increased positive symptoms for at least 7 days). This study lasted 12 months and had a total of 144 participants with schizophrenia spectrum disorders. The participants were randomized to either receive treatment as usual (n=72) or CBT (n=72). 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 greater improvements in both the PBIQ and the RSES. This study also showed a correlation between relapse and increased negative beliefs about illness and lower self esteem, which is why it would be beneficial for future studies to test CBT as a relapse prevention.
Changing gears slightly, several recovering persons, such as Ridgway (2001), suggest that recovery is about reclaiming a full life. For many, having a job is one part of that, which is why this next study investigates employment. Lysaker, Davis, Bryson, and Bell (2008), utilized the Indianapolis Vocational Intervention Program (IVIP) a program using cognitive behavioral group and individual interventions, to assist people with schizophrenia persevere and perform better at work. This study offered 100 participants with schizophrenia spectrum disorders six month job placements. The individuals were randomized to receive either IVIP (n=50), or equally intense support services (n=50). 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 higher in both measures, suggesting the efficacy of CBT in assisting the vocational aspirations of people with schizophrenia.
At this point, one might suggest practicing CBT is similar to the biomedical model because outcomes are primarily based on reducing symptamology. This seems partially true, which is why the last study fits exclusively within the context of the recovery and wellness model. Using inductive reasoning, Ridgway (2001), collected qualitative data from the narratives of 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 noted several important themes using a comparative analysis of the narratives. Some of these themes 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” (pp. 337-338). These narratives also describe recovery as a journey that involves the help of many other people, including formal helpers who have experienced prolonged psychiatric disabilities. In conclusion, Ridgway asserts that operationalizing recovery is a complex process, and that the ultimate goal is to gather knowledge in an attempt to foster recovery in as many lives as possible. Another area of knowledge that could contribute to the movement towards recovery and wellness is positive psychology.
Positive Psychology
 Positive psychology is a branch of psychology that aims to identify what is needed to live the “good life” (Slade, 2010). Positive psychologists separate their discipline which focuses on strengths, positive emotions, and practices that cultivate happiness, from traditional psychology that has typically focused on human suffering, weakness, and disorder (Seligman, Steen, Park & Peterson; 2005). Much value has been gained from studying human suffering, however positive psychology’s attempt to scientifically evaluate well-being, is gaining popularity as a valuable endeavor in its own right.
While differences exist, the positive psychology approach is complimentary to the recovery and wellness model of mental health (Slade, 2010). A few similiarities include the fact that both areas of knowledge offset the traditional focus of treating illness, aiming instead to enhance purpose and well being. Both approaches acknowledge the importance of remaining client centered, in addition to focusing on strengths. Finnally, both approaches can be used to inform policy at a societal level, and are of value in challenging stigma and discrimination (Slade). The next section will demonstrate some of the emerging evidence base from the field of positive psychology.
“The How of Happiness”   
Lyubomirsky (2007) has done extensive research in positive psychology, and suggests many different strategies to cultivate increased well being, some of which will be tested in this study. A few examples of her work include one study that showed 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). Another study she discusses by King (2001) focused on increasing optimism by having participants spend 20 minutes a day for four consecutive days writing about their “best possible future selves” (p. 798). King found that these participants experienced immediate increases in positive moods and were happier several weeks later than those who wrote about other topics.
The basis of these interventions is Professor Lyubomirsky’s “pie chart” theory of happiness. This concept asserts that there are three main factors influencing happiness: (1) A genetic set point which accounts for 50% of one’s happiness. This is supported by research on identical and fraternal twins and suggests that one inherits a certain happiness set point from their biological parents. (2) Circumstances account for 10% of one’s happiness. This means that wealth, beauty, geographic location, and so on, only account for a very small portion of subjective well being. (3) Intentional activities account for 40% of one’s happiness. This means that we each have the ability to increase our subjective well being by 40% by engaging in certain behaviors, some of which Lyubomirsky identifies in her book. The question is how accurate is the pie chart theory of happiness in regards to those who suffer from extreme states of mind such as schizophrenia? While this question may be hard to answer conclusively, neuroplasticity offers an explanation as to how these strategies might work.
Using Mindfulness to Change the Brain
Neuroplasticity refers to the brain’s ability to change. The malleability of the adult brain represents a paradigm shift for neuroscientists because the dogma used to be that the adult brain is fixed. According to Begley (2007) this belief was primarily based on two assumptions about the adult mammalian brain: (1) Neurogenesis, or the development of new neurons does not occur; and (2) The functions of certain brain structures such as the motor, auditory, and visual cortexes are fixed. Modern neuroscience questions the validity of these assumptions. In addressing neurogenesis, in 1998, Ericksson & Gage (from Schwartz (253)) proported to show that new neurons do develop in the hippocampus of human adults. To address the second point of classic neuroscience, there are several studies that prove this assumption was incorrect.  
Modern neuroscientists now agree that the adult brain exhibits plasticity. This is demonstrated by studies showing cortical remapping, which is what happens for instance when cortical areas that were once devoted to taking in information from one body part switches and begins to take on information from another. For instance, in 1993 Ramachandran (p.185) reported the cortical remapping that occurred in a case study on a seventeen year old boy named Victor. Victor  had just lost his left arm in a car crash, but still reported that he could feel his left arm. Based on the findings from a primate study (the Silver Springs monkeys), Ramachandran had Victor close his eyes, and touched his cheek with a cotton swab. The boy reported feeling this touch not only on his left cheek, but also on the back of his missing hand. In brief, 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. Basically, the part of Victor’s somatosensory cortex that previously received signals from his left arm had reorganized itself to now receive signals from the left side of his face.
Cortical remapping has clinical and rehabilitative implications as shown first by Taub (1993)’s constraint-induced movement therapy for chronic stroke patients (once again this work owes its beginnings to the Silver Springs monkey findings, see ???). In constraint-induced movement the patients good arm is constrained 90% of waking hours four two weeks. In addition, for ten days they also receive 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 their ability to perform daily-living activities one month after the treatment started. Even two years later, the patients receiving this therapy outperformed the controls. Leipert et al. (1998) were able to demonstrate the mechanisms of neuroplasticity that are involved in constraint-induced movement therapy. Investigating the brain changes of six patients before and after two weeks of treatment showed “an increase of excitability of the neural networks in the damaged hemisphere. Following CI therapy, the formerly shrunken cortical representation of the affected limb was reversed…two weeks of CI therapy induced motor cortex changes up to seventeen years after the stroke.”  
An intriguing idea that is relevant to this study is the possibility of self-directed neuroplasticity, Schwartz (2002) believes his work using a mindfulness-based cognitive- behavioral therapy with those who suffer from obsessive compulsive disorder (OCD) proves it is a reality. Schwartz posits that one can change one’s 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 says this mental force literally has the power to change the structure of the cerebral cortex. This top-down causality demonstrates the mind’s ability to change the brain, and the following study according to Schwartz demonstrates this concept using hard science.
By the early 1990s Schwartz had developed a mindfulness-based cognitive- behavioral therapy called the Four Step Method (See strategy in Methods section) to treat OCD. Schwartz was already aware of the positive behavioral changes of this method, so he 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 a week individual sessions, the patients underwent positron emission tomography (PET) scans. The results marked the first time a non-pharmacological treatment for a mental illness could indeed “change faulty brain chemistry in a well identified brain circuit” (Begley & Schwartz, 2002, p. 90). Schwartz and Baxter showed a significant decrease in metabolic activity in the right caudate (rCd) –a brain circuit associated with OCD- in 12 of 18 of these patients.
One last study that seems to bridge the gap between the changes that occur in the brain due to new sensory inputs, and Schwart’s assertion that “changing the way they think about their thoughts, also changes their brain” might have been established with Pascual-Leone’s experiement in 1995. One group of participants “practice a five finger piano exercise, and a comparable group merely think about practicing it.” The actual physical changes found in each groups motor cortexes were identical, showing that “merely thinking about moving produced brain changes comparable to those triggered by actually moving” (Scwartz, 2002, p. 217).

The following areas will describe the nature of the study and the methods used to gather and evaluate the data. The first area describes research design and the second describes data collection. The second area also has four sub-headings used to describe the specific CBT strategies that will be tested. The last few sections describe the measurement instruments, ethical considerations, data analysis, and study limitations.
Research Design
According to Rubin and Babbie (2011) this study would fit the criteria as both exploratory and evaluative. It is exploratory because the use of CBT strategies to enhance the subjective well being of people with schizophrenia is a rather recent field of inquiry. This study is attempting to explore whether or not certain happiness interventions as proposed by Lyubomirsky (2007) can be used to help people on their quest towards increased well-being and recovery from extreme states of mind. At the same time, this study is evaluative because it is attempting to evaluate the effectiveness of the specific interventions. (Rubin & Babbie).
This research study is deductive because it is based on the theory that these strategies will increase subjective well being for people with schizophrenia. The data collected will either show an association between the independent variables –happiness strategies- and the dependent variable –subjective well being- or it will not. It is also important to note that although there may be an association between the independent and dependent variables, it will be much harder to prove causation.

Data Collection
        This study is quasi-experimental because there will be a pretest, intervention, and posttest;  however there will not be a control group or randomization. The sample size will be relatively small, anywhere between five and ten participants with schizophrenia spectrum disorders, and the sample will be drawn from an outpatient community mental health clinic. The researcher will approach participants at the mental health clinic, and ask them if they are willing to participate in this study, which will be briefly described to them.  The instrument used will be a closed ended questionnaire aimed at gathering information pertaining to subjective well-being administered once upon entry into the study, and once again upon the study’s conclusion. In between the questionnaires, participants will learn the following intervention techniques adopted from Lyubomirsky’s research: (1) investing in social relationships; (2) practicing gratitude; (3); avoiding over thinking and social comparisons; and (4) staying in the present moment. Once the data has been collected, it will then be coded and entered into the Statistical Program for the Social Sciences (SPSS) for quantitative analysis. The following is a brief description of the interventions.
Investing in Social Relationships
According to Lyubomirsky, King, and Diener (2005) fostering better relationships leads not only to increased well being, but also to a longer life. Research also suggests that the “causal relationship between social relationships and happiness is clearly bidirectional.” What this means is that positive relationships lead to increased well-being, and increased well being leads a greater number of relationships. This is what psychologists call an upward spiral (Lyubomirsky).
One way to make new friends and enhance well-being, is to attend a support group where participants are able to give and receive emotional and informational support from each other. Indeed, one of the main tenets of the recovery and wellness model is expressing one’s personal narrative and coping strategies with others (Ridgway, 2001). Research shows that peer support enhances self esteem, self worth, and the development of social networks (Schizophrenia: The Journey to Recovery). Additional benefits of a support group could include the alleviation of some of the negative symptoms of schizophrenia such as social isolation, and the provision of a safe and supportive atmosphere within which participants learn additional strategies to boost subjective well-being. Martin (2009) states that individuals and their families value peer support and it helps them get a better understanding of the illness, “build support, and learn to cope.” Furthermore, purpose and meaning are enhanced through helping others with their illness and educating the public. “Playing a supportive role empowers people and protects them from self stigma” (Martin, 2009).   
Lyubomirsky (2007) offers several suggestions to cultivate social relationships, including:
1 Join or start a support group
2 Practice kindness and compassion. Anything from giving someone a compliment, to volunteering time with people who could use our help. This strategy will not only help us feel good about ourselves, it also makes others like us! Even if they don’t respond to our kindness, we benefit for trying to make the world a better place.  
3 Listening to others
4 Self disclosure (p.148)
5 Be supportive of your friends, and help them celebrate their victories.      
Practicing Gratitude
Several studies point to the benefits of cultivating gratitude. One study that showed 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). Seligman (2002) had a group of severly 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. Lyubomirsky identifies many ways gratitude boosts well-being, including: the savoring of positive life experiences; increased self efficacy; diminished negative emotions; and coping with stress and trauma.
According to Lyubomirsky (2007), gratitude is more than simply saying ‘thank you,’ it is a way of being characterized by appreciation and wonder at life.  One exercise Lyubomirsky suggests is to write down three positive things about each day. This cultivates an attitude of gratitude that inclines us to focus on the good in our lives. Gratitude means we look at the cup as half full. Even if it seems half empty, such as when we are experiencing hard times –life is full of suffering- we can still choose 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. Suffering itself allows us to refocus on what we have to be grateful for . According to Baraz & Alexander (2010), “suffering itself deepens us, maturing our perspective on life, making us more compassionate and wiser than we would have been without it.” This can be done in a variety of ways, including writing a gratitude list once a week, or just taking time to contemplate individual objects of gratitude.
Gratitude and positive thinking go hand in hand. Gratitude encourages us to look at the good in our lives which leads away from ruminating on the negative. It is all about counting one’s blessings. Here are several activities for practicing gratitude, the source of the activity cited next to it:

  1. Writing a gratitude letter, talking or phoning someone we are appreciative of –Seligman
  2. Weekly gratitude journal about 5 things per week –Lyubomirsky
  3. Merely contemplating what we a re grateful for at a fixed time daily or weekly –Lyubomirsky
  4. Identify one thing each day we usually take for granted and ordinarily goes unappreciated- Lyubomirsky
  5. Share a blessings list with a gratitude partner –Lyubomirsky
  6. Substitute one grateful thought for one ungrateful thought each day –Lyubomirsky
  7. Express gratitude through art –Lyubomirsky
  8. Say grace before a meal –Baraz
  9. Gratitude games; everytime we find ourselves complaining say, “and my life is very blessed.” Or instead of saying “I have to,” try saying, “I get to.” –Baraz
  10. Three good things. Think about three good things that happen each day, write them down. This practice has been empirically validated by Seligman et. al. (2005).
According to Baraz, it is also important not to force this practice. If we are not feeling grateful, practice being mindful and simply notice that feeling without judgment.
Avoiding Overthinking and Social Comparisons
According to Lyubomirsky (2007, p. 112) “overthinking is thinking too much, needlessly, passively, endlessly, and excessively pondering meanings, causes, and consequences of your character, your feelings, and your problems.” A study by Lyubomirsky and Tkach (2003) discusses the adverse consequences of overthinking saying it leads to deepening sadness, increased negative thinking, impaired problem solving, weakened motivation, and interference with concentration.  The key to surmounting overthinking is to redirect negative ruminations towards more positive and wholesome thoughts.
Noticing what other people are doing or have is hard to avoid. However, Lyubomirsky (2007) asserts social comparisons can be detrimental whether they are “upward” or “downward.” For instance, comparing ourselves to someone who has something we want can lead to lower self esteem and insecurity, while comparing to someone who has less can lead to feelings of guilt or “the need to cope with others’ envy and resentment.” The bottom line is we can always find someone we perceive to be better or worse off than ourselves. The key seems to be accepting ourselves as being right where we are supposed to be.
Here are a few strategies Lyubomirsky suggests to combat overthinking and social comparrisons:
1 Distraction: such as listening to music, or engaging in physical activity.
2 Forcing yourself to stop ruminating or comparing by simply telling yourself to “Stop!”
3 Talk to someone who is supportive and will listen to your thoughts and problems.
4 Take action, which means actively engaging in behavior to alleviate your problems. For instance you can set up an appointment with a councilor or case manager who can help you access the resources you might need.
5 Avoid situations that trigger your overthinking. You might want to write down a list of people, places, or situations that seem to trigger your overthinking.
6 Try meditation which might enable you to step back from your worries and replace them with positive thoughts.
7 Ask yourself if this problem will bother you in a year.
8 Look at the big picture: Our problems really are insignifigant in the grand scheme of things (see pg. 123).
Cultivating Strengths
The strengths perspective is very important to this study, and a major tenet of positive psychology is recognizing “positive character traits and enabling institutions (Seligman et al., 2005). Recognizing one’s strengths has been scientifically shown to increase well-being (Seligman, et. al, 2005). Utilizing our own strengths is empowering because it means we actively participate in the helping process (Saleeby, 1992). Strengths include but are not limited to a person’s abilities, resilience, talents, skills, interests, knowledge and resources (internal and external). Everyone has strengths, although sometimes they are unrecognized (Saleeby, 1992). Here are a few examples of strengths from Peterson & Seligman, 2004:
Classification of 6 Virtues and 24 Character Strengths (Peterson & Seligman, 2004)
Virtue and strength Definition
1. Wisdom and knowledge Cognitive strengths that entail the acquisition and use of     knowledge
Creativity Thinking of novel and productive ways to do things
Curiosity Taking an interest in all of ongoing experience
Open-mindedness Thinking things through and examining them from all sides
Love of learning Mastering new skills, topics, and bodies of knowledge
Perspective Being able to provide wise counsel to others
2. Courage Emotional strengths that involve the exercise of will to       accomplish goals in the face of opposition, external
or internal
Authenticity Speaking the truth and presenting oneself in a genuine way
Bravery Not shrinking from threat, challenge, difficulty, or pain
Persistence Finishing what one starts
Zest Approaching life with excitement and energy
3. Humanity Interpersonal strengths that involve “tending and  befriending” others
Kindness Doing favors and good deeds for others
Love Valuing close relations with others
Social intelligence Being aware of the motives and feelings of self and others
4. Justice Civic strengths that underlie healthy community life
Fairness Treating all people the same according to notions of                      fairness and justice
Leadership Organizing group activities and seeing that they happen
Teamwork Working well as member of a group or team
5. Temperance Strengths that protect against excess
Forgiveness Forgiving those who have done wrong
Modesty Letting one’s accomplishments speak for themselves
Prudence Being careful about one’s choices; not saying or doing things that might later be regretted
Self-regulation Regulating what one feels and does
6. Transcendence Strengths that forge connections to the larger universe and provide meaning
Appreciation of beauty & excellence Noticing and appreciating beauty, excellence, and/or skilled
performance in all domains of life
Gratitude Being aware of and thankful for the good things that happen
Hope Expecting the best and working to achieve it
Humor Liking to laugh and tease; bringing smiles to other people Spirituality Having coherent beliefs about the  higher purpose meaning of life

A few exercises that will allow us to examine our strengths:
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?
2 What do you consider to be your personal strengths?
3 What resources do you have access to?
4 You at your best! Recall a story that demonstrates you at your best, and identify the strengths you demonstrated. Reflect on this story everyday, and focus on the strengths you identified. (Seligman, et. al, 2005).
5 Identify a strength and give a recent or specific example.
Each day this week try to use one of the strengths you identified, and if your comfortable with it, share it with the group next week.
Staying Present and Practicing Mindfulness
Staying present or in the moment is another activity that will be taught in this study, and Lyubomirksy and her colleagues have shown that it too increases subjective well being. This concept entails being engaged with “what is” in the present moment, because after all, the only thing we are really guaranteed is this moment.  The two strategies Lyubomirsky describes that foster staying present are “flow experiences” and “savoring.” The former refers to engaging in activities that are completely engaging such as playing sports or doing art work. The idea is to focus all of one’s attention on the task at hand. Savoring means to completely enjoy the positive experiences in one’s life in the present moment, but it can also mean reminiscing about the past, and anticipating positive events in the future.
Mindfulness is all about being in tune with the moment. Instead of being caught up in the persistent, unending mental commentary or stories and history we bring to most situations, mindfulness is about “nonjudgemental awareness.” It is awareness akin to seeing, touching, tasting, hearing, or smelling something for the first time.
Becoming mindfull takes a conscious effort to be present with whatever you are experiencing in the moment. The benefits of mindfulness are well established scientifically, including the study conducted by Schawrtz that was previously discussed.  Lyubomirksy and her colleagues have also shown that “staying present” increases subjective well being. This concept entails being engaged with “what is” in the present moment, because after all, the only thing we are really guaranteed is this moment.  Davidson and Kabit-Zinn conducted a study testing the effects of mindfulness training on a group of employess in the biotech industry. (Baraz,p.31) The treatment lasted for two months and consisted of a weekly class on mindfulness meditation and a one time, one day mindfulness retreat. They were also encouraged to practice mindfulness meditation at home for 45 minutes each day. Compared to the control group, at the end of the study, the treatment group reported a decrease in negative emotions and an increase in positive emotions, and showed “increased immune function.”
Several people have developed mindfulness techniques. For instance, Dr. Schwartz developed the Four Step method to treat patients with OCD. The first step(p.79) is called “Relabling.” Whenver 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 compulsions as symptoms, the participants became aware of their condition, and even took mental notes of their experiences. By stepping back and just noticing the thoughts and urges, allowed them to come from a space of observation. They also recognized that these symptoms we “false and misleading.”
The second step (p. 81) “Reattribute” refers to the process the person uses when they identify these obsessions and compulsions as a brain disease and not their true “self.” In practice, Schwartz would say, “The brain’s gonna do what the brain’s gonna do, but you don’t have to let it push you around.”
The third step (p. 83) is called “Refocusing.” The goal of this step is that after noticing the onset of the OCD circuit, 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: Everytime participant A feels the need to count cans, they instead do some needlepoint (Begley & Schwartz, 2002). 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 self-direction.
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 “matters as they really are or, literally ‘in accordance with the truth.’” This allows the person to see view their symptoms as the result of faulty neural circuits not worth paying attention to or acting on.
In addition The two strategies Lyubomirsky describes that foster staying present are “flow experiences” and “savoring.” The former refers to engaging in activities that are completely engaging such as playing sports or doing art work. They depend on a balance between challenging oneself and utilizing one’s own skills. If an activity is too challenging, one will become overwhelmed, wheras if the activity is not challenging enough, one will become bored. The idea is to focus all of one’s attention on the task at hand.
A few examples of flow experiences might be: Gardening, any type of exercise or creative pursuit, or learning a new skill or subject, listening to music. Even paying close attention to what the other person is saying or doing in a conversation can be a flow experience (p. 187).   
Savoring means to completely enjoy the positive experiences in one’s life in the present moment. Taking time to appreciate each spoonful of a bowl of ice cream; enjoying each second in the shower or a warm bath; each step during a hike in nature. 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.
A few mindfulness exercises:
1) Notice five things you see. Notice five things you hear. Notice five things you feel. Go 5-4-3-2-1 with each sensation. (From Mimi Lewis’s class)
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 judgements of them. (Baraz)
3) Take deep breaths and notice the inhale and exhale. Does your chest or stomach rise?Can you feel the cool air in your nostrils (Baraz, p.45) everytime your mind wanders, gently return to the breath.

Measure Instruments
As previously discussed, the measure instrument will be a closed ended questionnaire intended to measure subjective well being, consisting of no more than 20 questions that should take between five and ten minutes to fill out. Admittedly, it is difficult to operationalize subjective well being, because this means many different things to many different people. This is why careful consideration will be given to using a previously designed questionnaire that other researchers agree has validity and reliability.
Human Subjects Protection
This study will be carefully analyzed prior to its application, in order to evaluate whether or not there is any risk of social, psychological, or physical harm to the participants or the researcher. An application will be submitted to the Sacramento State Department of Social Work by the Fall 2010 semester.
Data Analysis
The data collected from the questionnaire will be entered into SPSS, and coded in such a way that several statistical tests can be conducted. In addition to measuring central tendencies, the researcher plans on testing correlation coefficients and using regression analyses. The data from the first questioner will be compared to the second questionnaire to test the research hypothesis that these strategies will increase subjective well being.
Study Limitations
Though not all of the study limitations may be clear at such a preliminary stage, there are a few limitations that already stand out. First of all, the sample size is rather small, meaning generalizing to the greater population the sample was drawn from is dubious. Furthermore, there is no way to tell if this sample is representative of the greater population of people with schizophrenia due to geographic and socioeconomic location. Also, as previously alluded to, operationalizing subjective well being is difficult, and may not stand up to tests of validity and reliability. Finally, the author has limited clinical and research experience, which draws into question the competency with which these interventions are taught and the subsequent analysis of the results.


The final section of this paper is organized into three additional areas. The first area explores some of the major findings from the literature review. The second area discusses both the micro and macro practice implications of this study for the field of social work, and the final area will provide recomendations for future social work research into this topic.
Major Findings
As evidenced by the literature review, strict adherance to the medical model for treating people with schizophrenia is severely limiting, and historically one might even assert it has been inhumane (Whitaker, 2002). This model typically measures outcomes through alleviation of psychotic symptoms, negates the importance of subjective quality of life, and treats the individual as an illness instead of a person (Deegan, 1997). Fortunately, for a little more than a decade, a paradigm shift towards the recovery and wellness model has been occuring. This model measures outcomes such as subjective well-being, which are more consumer driven (Karow & Naber, 2002).
This paper has been heavily influenced by the happiness research carried out by Sonja Lyubomirsky and her collegues. The first study of interest, conducted by Lyubomirsky et al. (2005), concluded that fostering better social relationships leads to increased well-being and a longer life. Another study performed by Lyubomirsky in 2007, found that practicing gratitude also leads to increased well-being. Lyubomirsky & Tkach (2003) found that excessive overthinking and social comparrisons lead to decreased well-being, and finally, Lyubomirsky et al. have shown that focusing on the present moment is an effective way to combat stress.
Implications For Social Work
This study adds to the growing body of research into the recovery and wellness model, and has several micro practice implications. If the efficacy of these strategies is proven,  they will be considered evidence based practices, which means increasing numbers of social workers will be willing to use these methods with consumers. This would benefit the social work practitioner by providing a clearer framework for the implimentation of recovery oriented intervention strategies. More importantly, the recovery and well being of mental health care consumers will be enhanced, as the consumer and practitioner collaboratively implement these practices into their daily lives.
The fact this study could provide a clearer framework for the implementation of the recovery and wellness model of mental health service delivery has macro implications as well. With increasing evidence of the efficacy of the recovery and wellness paradigm, the delivery of mental health services could be permanently altered. Overal outcomes measures of specific agencies utilizing these procedures would improve, and consumers would become more willing to seek assistance. Furthermore, the societal ramifications of this trend would be profound. As it becomes more common for people with severe mental health issues to lead contented lives, their value (socially and occupationally) in society would increase, and  the stigma associated with their conditions would decrease. Meanwhile, reducing the stigma associated with severe and persistent mental illness, further promotes the well-being of this population.

Suggestions For Future Research
Currently, research into the recovery and wellness model is limited, and furthermore, operationalizing the concept of “recovery” is difficult because it means many things for many people. This is why, researchers need to continue to define this paradigm, and strive to provide increasing recovery options for their consumers.
As far as specific topics for future research, this author has several suggestions. The benefits of adhering to a fitness regiment and a healthy diet have long been shown to increase both physical and psychological health (Lyubomirsky, 2007). Many studies also point towards the benefits of religion and spirituality (Lyubomirsky). Finnaly, assisting those with persistent and severe mental illness commit to dedicated goal persuit such as continuing their education, seeking employment opportunities or finding independent living situations should enhance their self efficacy and contribute to increased well being.
Since the movement towards increasing subjective well being is in its early stages, the opportunities for future research topics could be expanded ad infinitum, and are only limited by the inventiveness of the researchers. By now, the point should be apparent: There are many ways a person can take intentional action to increase their well-being. In conducting research, one premise of recovery that should always be remembered is that this is an individual process. This is why techniques that work for some, may not work for others. Instead of becoming discouraged, researchers might realize the necessity of identifying a variety of strategies because this increases the chances that an individual will discover the ones that reasonate most with their own personality, therby promoting the recovery of a greater number of people.

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