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Masters Project: When defining terms of disability, includes the clear position of the Independent Living Movement, which has influenced education in the United States and disability policy since the 1960s. Improving, protecting the civil rights of the people with disabilities, and transitioning to the IL paradigm from the medical model, has defined problems and the range of intervention of those problems in new ways, is infusing new perspectives about the human service system as whole. The new perspectives are evident and have influenced current disability practices specifically in the context of psychiatric rehabilitation, with the introduction of the Recovery Paradigm or better known as the Recovery Model.The Recover Model has inspired processes that facilitate the successful transition from recovery from severe mental illness back to work, which can be difficult. Barriers to employment may include symptoms, self-esteem, quality of life, and clinical and social stability. According to the authors of “The role of work in the recovery of persons with psychiatric disabilities,” qualitative findings are emerging on the subjective experience of work in recovery that outline how social factors have a positive influence on job search and job retention that include the development of a sense of belonging through participation in social activities, the use of professional help for maintaining mental and physical functioning, and the willingness to play an active role in maintaining meaningful relationships with others including friends, relatives, and mental health providers. The authors findings of this are essentially proving that an individual’s proactive strategies in rehabilitation or self determination, social connectedness, and focusing on the process of recovery of persons with severe and persistent mental illness, ratherviiithan the result, is proving to be successful for positive rehabilitation outcomes including returning back to work. Researchers understand that adaptation to disability first is a process to facilitate such positive outcomes.Today biomedical therapy is the first line of treatment for people with severe mental illness which reduces symptoms almost immediately. However, to address other issues in the deterioration from illness that can result in the destruction of quality of life of individuals with severe mental illness, an individual must undergo a psychological restoration of their humanness and re-establishment of social connectedness, which counseling processes and therapeutic interventions facilitate. This proactive process of restoration through counseling and other therapeutic techniques can promote individual empowerment, greater knowledge of self and the environment, self-efficacy, and of course, connections with others.The purpose of the project is to create an outline and study manual for rehabilitation counselors to provide insight on counseling techniques and therapeutic processes that have shown to be effective for people adapting and recovering from severe mental illness. The project proposed is also to assist rehabilitation counselors, mental health providers, employers, and students, to become aware of the potentially of recovery for individuals with psychiatric disabilities and provide tools to assist to facilitate the process.
Citation preview
AN EXPLORATORY STUDY AND PRESENTATION:
COUNSELING AND THERAPUTIC TECHNIQUES
INCLUDED IN THE REHABILITATION PROCESS
FOR PEOPLE RECOVERING
FROM SEVERE MENTAL ILLNESS
By
Michele E. Salas
A Project Submitted to
Dr. Albert Valencia
In Partial Fulfillment for the
Degree of
Master of Science in Rehabilitation Counseling
California State University, Fresno
Fall 2010
i
APPROVAL PAGE
AN EXPLORATORY STUDY AND PRESENTATION:
COUNSELING TECHNIQUES INCLUDED IN THE PSYCHIATRIC REHABILITATION
PROCESS
Michele E. Salas
APPROVED BY
____________________________
Dr. Albert Valencia
Project Advisor
ii
COPYRIGHT 2010
Michele E. Salas
iii
AUTHORIZATION FOR REPRODUCTION OF THE 298 MASTER’S DEGREE
RESEARCH PROJECT
I grant permission for the reproduction of this project or thesis in part
or in its entirety without further authorization from me, on the
condition that the person or agency requesting reproduction absorbs
the cost and provides proper acknowledgment of authorship.
.
Permission to reproduce this project or thesis in part or in its entirety
must be obtained from me.
.
iv
DEDICATION
In honor and in loving memory of his Life,
This project is dedicated to my father
Eudoro (Eduardo) Salas Barajas
Son of Adela Nava Barajas Salas
Born December 19, 1950 in El Colomo (Rancho),
Michoacan, Mexico in Municipio de Aquila (County)
My father died in an airplane accident on June 13, 1994 in Uruapan, Michoacan, and he is buried
in Mexicali, Baja California where he resided before his death. My father was 44years old at the
time of his death and married with no children from his second marriage. I am a daughter from
both my parent’s first marriage and alienated from my father since childhood. During this time
of my father’s tragic death, I was 21 years old, living in Los Angeles attending the University of
Southern California, where I was studying Communications at Annenberg School for
Communications and Journalism. I walked through graduation ceremonies in 1996, and
officially graduated with my Bachelors of Arts Degree in May 2000.
This project is also dedicated to survivors of severe mental illness and psychological violence,
and the victims of malice. With much compassion, I also dedicate this project to my inner child
Michele who I love, support, protect, and honor everyday in pursuit of my Life truth.
“TE QUIERO MUCHO PAPA”
–Michele Eileen Salas
v
ACKNOWLEDGEMENTS
I would like to acknowledge Dr. Valencia, for the patience he has shown me in
helping me to accomplish this project which I was uncertain if I were capable of doing.
Thank you to Dr. Valencia and Fida Taha, Assistant to Dr. Valencia, for guiding me,
editing my work, and being a true inspiration. Additionally, thank you to Joe Perez with
the Department of Rehabilitation who has supported me in pursuing my Masters Degree
to become a Rehabilitation Counselor, and Grace Cha, who introduced me to the Masters
Rehabilitation Counseling Program at Fresno State; without you both I would have
missed this path to self-discovery. Thank you my nano (Papa) Salvador Vizcarra and my
tio Candelario Salas Barajas, tio Gregorio (Goyo) Salas Barajas and my tia Yolanda Salas
Barajas for your love and guidance in absence of my father. To my friend and first
supervisor out of college from University of Southern California, Lydie Levy, an
amazingly intelligent and insightful French Jewish woman, who taught me about the
importance and meaning of counseling and psychology, thank you with much love. I
read “Tales of Enchantment the Meaning of Fairly Tales,” by Bruno Beetleheim over and
over and throughout my recovery process. My deepest respect for her and her inspiration
has helped me survive the onset of severe mental illness and trauma thereafter. Last but
not least, thank you to my grandmother (nana) Adela Nava Barajas Salas who has taught
me about my culture and restored me with her love, kindness, protection and the most
cherished hugs, kisses, and prayer- I feel the depth of authenticity of her heart next to
mine. Collectively, to all my mentors, family, and friends who have supported me
through my rehabilitation and pursuing my Masters Degree, I thank God and thank you,
so much from the deepest part of my living soul, you have given me life again!
vi
To have found this perfect life
And a perfect love so strong
Well there can't be nothing worse
Than a perfect love gone wrong!
“Perfect Love...Gone Wrong” –Sting, from a Brand New Day
vii
CALIFORNIA STATE UNIVERSITY, FRESNO
Kremen School of Education and Human Development
298/Project
TOPIC AREA (select appropriate degree)
Counseling MS ______X________ Option: Counseling and
Student Services
MS ________________ Option: Marriage and
Family Counseling
Education MA _______________
Special Education MA _______________
Name: Michele E. Salas Semester Completed: Spring 2011
Instructor: Dr. Albert Valencia Date Completed: Spring 2011
TITLE: COUNSELING AND THERAPUTIC TECHNIQUES
INCLUDED IN THE REHABILITATION PROCESS
FOR PEOPLE RECOVERING
FROM SEVERE MENTAL ILLNESS
ABSTRACT
Education in America, when defining terms of disability, includes the clear position of
the Independent Living Movement, which has influenced education in the United States and
disability policy since the 1960s. Improving, protecting the civil rights of the people with
disabilities, and transitioning to the IL paradigm from the medical model, has defined problems
and the range of intervention of those problems in new ways, is infusing new perspectives about
the human service system as whole. The new perspectives are evident and have influenced
current disability practices specifically in the context of psychiatric rehabilitation, with the
introduction of the Recovery Paradigm or better known as the Recovery Model.
The Recover Model has inspired processes that facilitate the successful transition from
recovery from severe mental illness back to work, which can be difficult. Barriers to
employment may include symptoms, self-esteem, quality of life, and clinical and social stability.
According to the authors of “The role of work in the recovery of persons with psychiatric
disabilities,” qualitative findings are emerging on the subjective experience of work in recovery
that outline how social factors have a positive influence on job search and job retention that
include the development of a sense of belonging through participation in social activities, the use
of professional help for maintaining mental and physical functioning, and the willingness to play
an active role in maintaining meaningful relationships with others including friends, relatives,
and mental health providers. The authors findings of this are essentially proving that an
individual’s proactive strategies in rehabilitation or self determination, social connectedness, and
focusing on the process of recovery of persons with severe and persistent mental illness, rather
viii
than the result, is proving to be successful for positive rehabilitation outcomes including
returning back to work. Researchers understand that adaptation to disability first is a process to
facilitate such positive outcomes.
Today biomedical therapy is the first line of treatment for people with severe mental
illness which reduces symptoms almost immediately. However, to address other issues in the
deterioration from illness that can result in the destruction of quality of life of individuals with
severe mental illness, an individual must undergo a psychological restoration of their humanness
and re-establishment of social connectedness, which counseling processes and therapeutic
interventions facilitate. This proactive process of restoration through counseling and other
therapeutic techniques can promote individual empowerment, greater knowledge of self and the
environment, self-efficacy, and of course, connections with others.
The purpose of the project is to create an outline and study manual for rehabilitation
counselors to provide insight on counseling techniques and therapeutic processes that have shown
to be effective for people adapting and recovering from severe mental illness. The project proposed
is also to assist rehabilitation counselors, mental health providers, employers, and students, to
become aware of the potentially of recovery for individuals with psychiatric disabilities and
provide tools to assist to facilitate the process. The research question that served to guide this
project was:
1. What counseling therapies and therapeutic techniques are included in the rehabilitation
process, for people recovering from severe mental illness?
ix
TABLE OF CONTENTS
Page
CHAPTER 1 - INTRODUCTION . . . . . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . 1
Background . . . . . . . . . . . . . . . . 5
Statement of the Problem . . . . . . . . . . . . 5
Statement of the Purpose . . . . . . . . . . . . . 11
Research Question . . . . . . . . . . . . . . . 12
Definition of Terms . . . . . . . . . . . . . . . 12
Assumptions . . . . . . . . . . . . . . . . 13
Limitations . . . . . . . . . . . . . . . . 14
Delimitations . . . . . . . . . . . . . . . . 14
Significance of Study . . . . . . . . . . . . . . 14
Chapter Summary . . . . . . . . . . . . . . . 15
CHAPTER 2 - REVIEW OF THE LITERATURE . . . . . . . . . . 18
Introduction . . . . . . . . . . . . . . . . 18
Current Practices of Psychiatric Rehabilitation (PsyR) . . . . . 21
Counseling Therapies . . . . . . . . . . . . . 24
Cognitive Remediation. . . . . . . . . . . . . . 24
Person Centered Therapy . . . . . . . . . . . . . 26
Group Therapy . . . . . . . . . . . . . . . 27
Solution Focused Therapy . . . . . . . . . . . . 30
Psychotherapy. . . . . . . . . . . . . . . 31
Therapeutic Techniques/Other Processes . . . . . . . . . 33
Occupational Therapy . . . . . . . . . . . . . 33
Exercise Therapy . . . . . . . . . . . . . . 36
x
Motivational Interviewing . . . . . . . . . . . . . 37
Religion and Spirituality . . . . . . . . . . . . . 39
Disclosure . . . . . . . . . . . . . . . . 42
Photovoice . . . . . . . . . . . . . . . 46
Role Development . . . . . . . . . . . . . . 48
Leadership Education . . . . . . . . . . . . . 50
Empowerment . . . . . . . . . . . . . . . . 52
Chapter Summary . . . . . . . . . . . . . . . 55
CHAPTER 3 - METHODOLOGY . . . . . . . . . . . . . . 57
Introduction . . . . . . . . . . . . . . . . 57
Population and Sample . . . . . . . . . . . . . 60
Collection of the Materials and Conditions for Inclusion . . . . 61
Chapter Summary . . . . . . . . . . . . . . . 64
CHAPTER 4 - PRESENTATION OF THE PROJECT . . . . . . . . . 66
Introduction . . . . . . . . . . . . . . . . 66
PROJECT STUDY MANUAL . . . . . . . . .
INTRODUCTION . . . . . . . . . . . . 1
COUNSELING THERAPIES . . . . . . . . . 16
OTHER THERAPEUTIC PROCESSES . . . .. . . 21
SUMMARY ON PROCESSES . . . . . . . . . 31
MENTAL DISORDERS AND PSYCHOTHERAPY . . . 38
BARRIERS AND INSIGHT FOR WORKPLACE INCLUSION 45
REFERENCES . . . . . . . . . . . . . 47
Chapter Summary . . . . . . . . . . . . . . . 69
xi
CHAPTER 5 - SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS . . 71
Introduction . . . . . . . . . . . . . . . . 71
Summary . . . . . . . . . . . . . . . . . 73
Conclusions . . . . . . . . . . . . . . . . 79
Recommendations . . . . . . . . . . . . . . . 83
Chapter Summary . . . . . . . . . . . . . . . 84
REFERENCES . . . . . . . . . . . . . . . . . . 85
APPENDICES . . . . . . . . . . . . . . . . . . 88
1
CHAPTER ONE
INTRODUCTION
Introduction
Education in America, when defining terms of disability, includes the clear
position of the Independent Living Movement (IL), which has influenced education in the
United States and disability policy since the 1960s (Dr. Charles Arokiasamy, personal
communication, Professor, California State University, Fresno, December 16, 2010). The
Independent Living term was first coined by Gerben DeJong (1979) in his article
“Independent Living: From Social Movement to Analytic Paradigm.” The Independent
Living Movement moved from a social movement from the 1960s to an analytical
paradigm, where problems are identified and solved. The re-emergence of this analytical
paradigm in 1979 influenced the redirection of professionals and researchers in their
consideration of disability. This re-emergence, independent living was more than a social
movement seeking rights and entitlements for disabled persons, but as a model defining
problems and the range of intervention of those problems (DeJong, 1979). DeJong
(1979) argues Kuhn’s paradigm in The Structure of Scientific Revolutions of natural
sciences can be applied to the context of public policy and professional practice. Because
the paradigm also determines what is relevant for purposes of research, Dejong details the
shift from the Rehabilitation Paradigm that is based on the medical model, to the
Independent Living Paradigm based on the individual’s rights to self-determination.
In the Independent Living analytical paradigm, the environment is seen as the
locus of the problem as opposed to the rehabilitation paradigm, which views the
2
individual as the locus of the problem (DeJong, 1979). The rehabilitation paradigm, is
based on the medical model, and defines the solution to the problem is professional
intervention through the physician, physical therapist, occupational therapist, and
vocational rehabilitation counselor. In the Independent Living paradigm the solution
involves peer counseling advocacy, self help, consumer control, and removal of
environmental barriers (DeJong, 1979). Rehabilitation according to Dejong (1979) has
stressed self care, mobility, and employment where independent living has stressed
additionally to this, the importance of living arrangements, consumer assertiveness,
outdoor mobility, and out-of-home activity. The Independent Living Movement pushed
forward with other social movements as well including, the civil rights movement,
consumerism, self help, demedicalization, and deinstitutionalization (DeJong, 1979).
There are some meaningful developments that have occurred in legislation due to
the Independent Living Movement such as benefit rights including the entitlement to
income, medical assistance, and education (DeJong, 1979). For some “without income
assistance benefits or attendant care benefits, many disabled persons would be
involuntarily confined to a long term care facility” (DeJong, 1979, p. 436). In the
Independent Living Movement, consumers have access to advocacy centers where
advisement to legal rights and benefits is a service for people with disabilities. Also,
demedicalization enable the person with the disability in a role of empowerment as
opposed to a sick role, giving the person a sense of control of his/her life, where the
medical model keeps the person in a state of dependency (DeJong, 1979).
Theoretically, the Independent Living Movement has clearly made significant
contributions to the education of disability in the United States. Improving and
3
protecting the civil rights of the people with disabilities, and transitioning to the IL
paradigm, which defines problems and the range of intervention of those problems in new
ways, is infusing new perspectives about the human service system as whole (Dr. Charles
Arokiasamy, personal communication, Professor, California State University, Fresno,
December 16, 2010; Dr. Juan Garcia, personal communication, Professor, California
State University, Fresno, November 18, 2010). The new perspectives are evident and
have influenced current disability practices, specifically in the context of psychiatric
rehabilitation, with the introduction of the Recovery Paradigm or better known as the
Recovery Model (Dr. Juan Garcia, personal communication, Professor, California State
University, Fresno, November 18, 2010).
According to William A. Anthony at the Center of Psychiatric Rehabilitation at
Boston University, the consumer literature in the 1980s, concluded that severe mental
illness, particularly schizophrenia, was a deteriorative disease (Dana, Gamst, & Der-
karabetia, 2008). Anthony asserts that later work by researcher Desisto, Harding,
McCormick, Ashikaga, and Brooks, (1995a, 1995b), proved that contradictory to the
belief that severe mental illness was a deteriorative disease, recovery from mental illness
was happening (Dana et al., 2008). With these finding, in the 1990s increasing numbers
of states and countries began to adopt the “recovery vision,” which influenced the
thinking of many of today’s system planners and administrators according to Anthony
(Dana et al., 2008, p. 319). The Recovery Oriented System of Care was developed based
on consumer input and involvement, and influenced, by recovery assumptions such,
“recovery demands that a person has choices” (Dana et al., 2008, p. 318). This advocacy
for self-determination and independence reminds researchers of the core values of the
4
Independent Living Movement. The grounding of psychiatric rehabilitation in the
Recovery Model is today’s analytical paradigm for people with disabilities recovering
from severe mental illness.
At the turn of the century before 2000, the U.S. Surgeon General estimated that
approximately 20 percent of the population in the United States is affected by a mental disorder
in a given year, and about 5 percent of the population is considered to have a severe mental
illness (SMI), (U.S. Department of Health and Human Services, 1999). When considering
treatment modalities, the goal values and guiding principles of psychiatric rehabilitation are
influenced by the Independent Living Movement in the Recovery Model (Dr. Charles
Arokiasamy, personal communication, Professor, California State University, Fresno, December
16, 2010). Similar to the IL Movement, the Recovery Model advocates for the individual stating
that the individual “should always receive treatment in the most autonomous setting or
environment that is possible but still effective” (Pratt, Gill, Barrett, & Roberts, 2007, p. 113).
This means, for example, “that no one should be treated in a psychiatric hospital if there is a
community-based programs available where he or she can receive equally effective treatment”
(Pratt et al., 2007, p. 113). This principle of autonomy was developed to uphold the goals of
community integration and deinstitutionalization for people with psychiatric disabilities, which
the Independent Living Movement has essentially influenced, and in turn, preserved the wellness
and preservation of the human psyche (Dr. Juan Garcia, personal communication, Professor,
California State University, Fresno, November 18, 2010).
5
Background
The researcher’s audience for this project is for rehabilitation counselors, mental health
providers, potential employers, students, and victims of severe and persistent mental illness. The
study manual will serve as a training guide and informational resource on counseling and
therapeutic processes that have shown to be effective for people recovering from severe mental
illness. The manual, which is guided by the insightful direction of current psychiatric
rehabilitation practices, encompasses the main goals described below for the Recovery Model.
Pratt et al. (2007) discuss the rehabilitation principles and methodology for psychiatric
rehabilitation as a recovery concept that is unique to each individual. The authors (Pratt et al.,
2007) point out that there is universal agreement on three goals in psychiatric rehabilitation,
which are:
1. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness
achieve recovery.
2. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness
achieve maximum community integration.
3. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness
achieve the highest possible quality of life. (p. 113-114)
These are the goals of the Recovery Model in today current Psychiatric Rehabilitation practices
that provide insightful direction of research practices today.
Statement of the Problem
Employment rates are extremely low for individual with severe and persistent mental
illness, because the transition from illness to work is difficult. According to researchers
6
Provencher, Gregg, Mead, and Mueser (2002) barriers to employment may include symptoms,
self-esteem, quality of life, and clinical and social stability. These barriers to employment are
realized in the analysis of employment rates for people with psychiatric disabilities which range
between 10-20% (Provencher et al., 2002). Researchers also indicate that studies show a small
amount of how people with psychiatric disabilities make decisions in going back to work and
seeking employment (Killeen & O’Day, 2004). Further, studies also show a small amount of
how people with psychiatric disabilities manage other barriers such as attaining and managing
Social Security Programs, vocational rehabilitation programs, or the mental health system
(Killeen & O’Day, 2004). Typically, vocational research has been studied only through
objective measures such as employment status, number of hours worked, earned wages, or job
tenure (Provencher et al., 2002).
According to the authors of “The role of work in the recovery of persons with
psychiatric disabilities” (Provencher et al., 2002), qualitative findings are emerging on the
subjective experience of work in recovery that outline how social factors have a positive
influence on job search and job retention that include the development of a sense of belonging
through participation in social activities. Activities seeking the use of professional help for
maintaining mental and physical functioning, and the willingness to play an active role in
maintaining meaningful relationships with others, including friends, relatives, and mental health
providers show as significant contributors to positive results in the recovery process (Provencher
et al., 2002). These researchers findings of this are essentially uncovering that an individual’s
proactive strategies (self determination) in rehabilitation, social connectedness, and focusing on
the process of recovery for persons with severe and persistent mental illness, rather than the
result, is proving to be successful for positive rehabilitation outcomes such as returning back to
7
work (Dana et al., 2008; Jinhee Park, Personal Communication, Doctoral Student Illinois
Institute of Technology, National Council on Rehabilitation Education Conference, April 8,
2010; Lydie Levy, Personal Communication, Partner/VP Business Development, IPLux Xpertise
S.a.r.l., Social Psychology, Universite Vincennes-Saint-Denis (Paris); Master Business
Administration, Reims Management School; Master Business Law, Universite de Reims
Champagne-Ardenne, Gemstar TV-Guide International, August 1, 1997; Provencher et al.,
2002).
Because concretely schizophrenia is a biological disorder, counseling interventions alone
have proven to be ineffective in reducing symptoms, decreasing hospitalization, or enhancing
community adjustment (Gomes-Schwartz, 1984). The primary treatment for schizophrenia is
through psychopharmacotherapy however, medication compliance is an ongoing issue in the
recovery of people with severe mental illness also, due to adaptation issues to disability and to
the medication and side effects. In the attempt to assist in producing positive outcomes towards
the full recovery of severe mental illness, such as the following points below, the combination of
biomedical therapy and counseling is the best approach to recovery currently.
1. Attaining full independence and achievement of maximum individual potential;
2. Adopting good health habits to manage self and disability such as medication and weight
management;
3. Attaining income flow by returning back to work to provide an income for oneself;
4. Establishment of life meaning and sense of self-satisfaction;
5. Attaining a focusing on the process of recovery and compassion for oneself;
Collectively these positive outcomes for psychiatric rehabilitation can re-establish the
person with a disability’s sense of humanity which can undergo deterioration with the onset of
8
severe and persistent mental illness. Hence, counseling and therapeutic techniques can assist in
facilitating these processes. While experts recognize the individual is faced with modern
treatments through biomedical therapy in conjunction with various counseling therapies and
therapeutic process to adapt to the disability first, then moving towards total recovery, this
combination of process vs. result approach in psychiatric rehabilitation is proving to be effective
Recovery Paradigm (Dr. Juan Garcia, personal communication, Professor, California State
University, Fresno, November 18, 2010).
Techniques that are included in the rehabilitation process to assist with adaptation of
disability and recovery include biomedical therapy which is the first line of treatment for severe
and persistent mental illness, and other therapies assisting with adaption, cognitive restructuring,
and motivational change including, cognitive behavioral therapy, person-centered therapy,
psychotherapy, occupational therapy, and exercise therapy. For example, Pratt et al., (2007)
discuss Carl Rogers person-centered therapy approach as effective and “the basic tenets of
consumer-centered therapy are highly compatible with psychiatric rehabilitation and have an
important influence in the field” (Pratt et al., 2007, p. 152). Other processes include integration
of psychosocial techniques, spirituality, and religion in the total rehabilitation process (Dr. Juan
Garcia, personal communication, Professor, California State University, Fresno, November 18,
2010). In their article “Psychological Adaptation to Disability: Perspectives From Chao and
Complexity Theory,” Hanonch Livneh and Randall M. Parker (2005) offer a relevant definition
to the process of adaptation to disability, which the author of this project finds true based on her
own experience in surviving the onset of severe mental illness. Livneh and Parker (2005) state,
“The process of adaptation, then, is essentially a process of self-organization that unfolds
through experiences of chaos (i.e., emotional turmoil) and complexity (i.e., cognitive and
9
behavioral reorganization) to increase functional dimensionality and renewed stability even if
temporary” (p. 22)
The combination of treatment is the most effective for the recovery from severe mental
illness, by reducing major chemical imbalances in the brain through biomedical therapies and
counseling treatments to promote behavioral change, self-identification, social connectiveness,
and combat stigmatization (Jinhee Park, Personal Communication, Doctoral Student Illinois
Institute of Technology, National Council on Rehabilitation Education Conference, April 8,
2010). In total this process (the combination of treatments) is the closest thing that can ensure
the recovery of individuals stricken with the onset of severe mental illness (Weiten, Lloyd,
Dunn, & Hammer, 2009).
There is no doubt that the first step to achieving a full recovery outcome is through
medication compliance for people with severe mental illness (Weiten et al., 2009). In this
project the researcher will discuss the various therapies that have been proven to be successful in
helping the individual adapt to psychiatric disability along with biomedical therapy, and
empower the individual in gaining command over his or her life through the recovery process
that promotes wellness and meaningful living. In the context of rehabilitation counseling
research, wellness and meaningful living may be recognized though work status, adjustment to
disability, functional ability and quality of life (Frain, Bishop, & Tschopp, 2009)
Research shows (Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition)
there is a higher rate of suicide by individuals with severe mental illness, such as schizophrenia,
severe depression, and bipolar disorder. Without these interventions, such as biomedical
therapy, counseling therapies and other therapeutic processes to assist in individual restoration of
the self, individuals stricken with the onset of severe mental illness such as schizophrenia,
10
experience three phases of the disease known as the prodromal, active, and residual. This is the
most extreme example of human suffering caused by mental illness known to man. The three
phases of schizophrenia are (Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition,
2000; Centre of Addiction and Mental Health (2009). Schizophrenia: An Information Guide.
http://www.camh.net):
Prodromal phase
In the prodromal phase, people may begin to lose interest in their usual activities and to
withdraw from friends and family members. They may become easily confused, have
trouble concentrating, and feel listless and apathetic, preferring to spend most of their
days alone. This phase can last weeks or months.
Active phase
During schizophrenia's active phase, people will have delusions, hallucinations, marked
distortions in thinking and disturbances in behaviour and feelings. This phase is often the
most frightening to the person with schizophrenia, and to others.
Residual phase
After an active phase, people may be listless, have trouble concentrating and be
withdrawn. The symptoms in this phase are similar to those outlined under the prodromal
phase.
To address issues in the deterioration from illness that can result in the destruction of
quality of life of individuals with severe mental illness, an individual must undergo a
psychological restoration of their humanness which counseling processes and therapeutic
11
interventions facilitate (Dr. Juan Garcia, personal communication, Professor, California State
University, Fresno, November 18, 2010). This proactive process of restoration through
counseling and other therapeutic techniques can promote individual empowerment, greater
knowledge of self and the environment, self-efficacy, and connections with others (Jinhee Park,
Personal Communication, Doctoral Student Illinois Institute of Technology, National Council on
Rehabilitation Education Conference, April 8, 2010).
Pratt et al. (2007) application of principles and methodologies of psychiatric
rehabilitation counseling techniques are not recognized as an intervention for psychiatric
rehabilitation; however, they are offered as a supplement to the total rehabilitation
process. In order to provide the best support and likelihood for successful rehabilitation
outcomes, it is essential for service providers, such as rehabilitation counselors, to
become familiar with the total rehabilitation process and its supplements, including
alternative therapeutic techniques for people with severe mental illness. If providers such
as rehabilitation counselors do not become familiar with the total rehabilitation process
for people recovering from severe mental illness, the counselor is not tapping into the
cycle of wellness that promotes recovery today.
Statement of the Purpose
The purpose of this project is to affirm the understanding of the importance of
self-determination and how successful rehabilitation outcomes are realized for people
with psychiatric disabilities through a process of various insights such as acceptance of
the disability, medication management, and attaining independence by attaining a home,
gainful employment, and meaningful relationships. This independence is what is
12
considered as successful rehabilitation outcomes according to the current psychiatric
principles discussed by Pratt et al. (2007). Counseling techniques are a component of the
psychiatric rehabilitation process, and the author will feature in Chapter 4, in study
manual, the specific counseling and therapeutic techniques that are included in successful
rehabilitation outcomes for people with severe mental illness. This will offer service
providers clarity of what has proven to be effective and understanding the techniques that
facilitate efforts for issues such as symptom management, relapse prevention, medication
compliance and psychosocial issues, such as social phobia, and achievement of
independence and community integration.
Research Question
This project will be guided by the following research question:
1. What counseling and therapeutic techniques are included in the rehabilitation process
for individuals recovering from severe mental illness?
Definition of Terms
The Definitions of Terms for this project include the following terms:
1. Psychiatric Rehabilitation Process: The psychiatric rehabilitation process considers
the nature of severe and persistent mental illness, through identification of the
symptoms and etiology of severe mental illness, definition of psychiatric
rehabilitation principles and methodology, and application of these principles and
methodology (Pratt et al., 2007).
13
2. Counseling Techniques: Talk therapies that promote the psychological wellness and
exploration of self.
3. Therapeutic Process: The process of self-engagement that promote the wellness and
recovery for people recovering from severe mental illness.
4. Successful Outcomes: Is recognized in the definition of the term, Quality of Life
(QOL), which is defined by Bishop, Chapin, and Miller (2008) in their research
article titled “Quality of Life Assessment in the Measurement of Rehabilitation
Outcome.” QOL: Quality of life represents the subjective and personally derived
sense of overall well-being that results from an evaluation of happiness or satisfaction
across an aggregate of personally or clinically important domains” (p. 48).
5. Severe Mental Illness: Disease process in the brain based on physiological evidence
that is induced by psychological stress (Pratt et al., 2007).
6. Independent Living: The process of self-determination and independence (DeJong, 1979).
7. Gainful Employment: Meaningful employment where wages are earned in balance with skill.
Assumptions
For the purposes of conducting this project, the researcher assumes the following:
1. Counselors, mental health professions, potential employers, students, and victims of
severe and persistent mental illness will find examples of counseling and other
therapeutic processes applied to psychiatric rehabilitation beneficial.
2. Counselors, mental health professionals, potential employers, students, and victims of
severe and persistent mental illness will benefit from this presentation with an
understanding that biomedical therapy, counseling therapy, and other therapeutic
14
processes are the most effective intervention for the recovery of severe mental illness
today.
Limitations
For the purposes of conducting this project, the researcher assumes the following:
1. This presentation is limited to training and informational purposes for rehabilitation
counselors, mental health providers, potential employers, students, and victims of
severe and persistent mental illness.
Delimitations
For the purposes of conducting this project, the researcher assumes the following:
1. The researcher did not including psychiatric rehabilitation or disability research before 1956.
2. Research is limited to western views of scientific methods of research in psychiatric
rehabilitation and the Recovery Model.
Significance of the Study
This study will be an aid to rehabilitation counselors, mental health professionals,
employers, students, and victims of severe and persistent mental illness. With proper
implementation and support it can be utilized in the following manner:
1. Rehabilitation Counselors: Serves as a training guide for rehabilitation counselors in
the area of counseling techniques included in the rehabilitation process for individuals
with severe mental illness. This training guide will also serve as insight for the
15
rehabilitation counselors for Individualized Plan Development for individuals with
psychiatric disabilities.
2. Mental Health Professionals: Serves as an insight for mental health professionals in
the area of counseling therapies and other therapeutic process when applied to
psychiatric rehabilitation.
3. Employers: Serves as an insight on potential disability accommodations when
individuals with psychiatric disabilities are seeking employment or in job retention
programs.
4. Students: Serves as a supplement to practicum to ensure comprehensive training
combining counseling and case management when working with individuals with
psychiatric disabilities.
5. Victims of severe and persistent mental illness: To help facilitate the process of
recovery through insight and education of current day psychiatric rehabilitation
processes/practices and effective recovery interventions.
Chapter Summary
Improving and protecting the civil rights of the disabled is the primary objective
of the Independent Living Movement, which has influenced education in the United
States and disability policy since the 1960s (Dr. Charles Arokiasamy, personal
communication, Professor, California State University, Fresno, December 16, 2010).
This has resulted in gaining rights for people with disabilities, such as the development of
the American Disabilities Act in the 1990s. This advocacy movement has developed and
influenced modern day rehabilitation models for specific areas of disability, specifically
16
psychiatric rehabilitation. With the introduction of the Recovery Model, described by
William Anthony from the Center of Psychiatric Rehabilitation at Boston University,
researchers found that people were recovering from severe psychiatric disabilities,
originally categorized as a degenerative illness (Dana et al., 2008). The models of
recovery, specifically for psychiatric disability were developed, focusing on the self-
determination of the individual. The recovery model is infusing new perspective on
modern day human service systems, and is similar to what the Independent Living
Movement did in the 1960s (DeJong, 1979). The new perspectives are evident and have
influenced current disability practices with the inclusion of community rehabilitation day
programming, assertive community treatment and case management, vocational
rehabilitation, supported education, residential services and independent living and self-
help and peer delivered services (Pratt et al., 2007). Fostering an environment of
inclusion for all people with disabilities ensures a more diverse and integrated
community, and preservation of our human need for social connectedness.
Research shows, for people with psychiatric disabilities, that the first line of
treatment for severe mental illness is through biomedical therapy, and experts recognize
the individual is faced with adapting to the disability first, then recovery. For individuals
that can work and want to work, barriers to employment may include symptoms, self-
esteem, quality of life, and clinical and social stability. Hence employment rates for
people with psychiatric disabilities range between 10-20% (Provencher et al., 2002) due
to such barriers. Counseling and therapeutic techniques help facilitate this process of
adaptation to the disability first, and recovery through a multi-dimensional rehabilitation
process for individuals recovering from severe and persistent mental illness. By
17
exploring and presenting the various counseling and therapeutic techniques for people
that are recovering from severe mental illness, the researcher hopes this will inspire
service providers with clarity of what has proven to be effective, and gain an
understanding of the techniques that facilitate recovery for such issues as symptom
management, relapse prevention, medication compliance and psychosocial issues such as
social phobia. In order to provide the best support and likelihood for successful
rehabilitation outcomes, it is important for service providers such as rehabilitation
counselors to become familiar with the total rehabilitation process, including counseling
and alternative therapeutic techniques for people with severe mental illness (Dr. Juan
Garcia, personal communication, Professor, California State University, Fresno,
November 18, 2010). If providers such as rehabilitation counselors do not become
familiar with the total rehabilitation process for people with disabilities recovering from
severe mental illness, they may not tap into the total cycle of wellness that promotes
recovery today for people recovering from severe mental illness. The author will present
Chapter Two next, in a review of the literature that includes current practices of
psychiatric rehabilitation, counseling processes, and therapeutic techniques included in
the rehabilitation process for individuals recovering from severe mental illness.
18
CHAPTER TWO
REVIEW OF THE LITERATURE
Introduction
Improving and protecting the civil rights of the people with disabilities, and transition to
the Independent Living paradigm, has defined problems and intervention of those problems in
new ways, has infused new perspectives about the human service system as whole. The new
perspectives are evident and have influenced current disability practices, specifically in the
context of psychiatric rehabilitation and the introduction to the Recovery Model (Dr. Charles
Arokiasamy, personal communication, Professor, California State University, Fresno, December
16, 2010; Dr. Juan Garcia, personal communication, Professor, California State University,
Fresno, November 18, 2010). It is the researcher’s intent to present current practices in
Psychiatric Rehabilitation that are based on the Recovery Model for an audience including
rehabilitation counselors, mental health providers, potential employers, students, and victims of
severe and persistent mental illness. The statement of problem on this topic conveys that
employment rates are very low for people with severe and persistent mental illness, because the
transition from illness to work is difficult (Provencher, Gregg, Mead, and Mueser, 2002).
Barriers to work include symptoms, self-esteem, quality of life, and clinical and social instability
(Provencher et al., 2002). The primary treatment for severe mental illness is through biomedical
therapy; however, medication compliance is an ongoing issue in the recovery of people with
severe mental illness. In the attempt to produce positive outcomes towards the full recovery of
severe mental illness and to have he or she return to work, experts recognize the individual is
faced with adapting to the disability first, then recovery, which counseling and therapeutic
techniques help facilitate. It is the purpose of this project to present specific counseling and
19
therapeutic techniques that are included in the rehabilitation process that facilitate various
insights (such as self-acceptance, self-management, social connectedness, self-esteem) that
produce successful outcomes for people with severe mental illness. This approach will provide
service providers the clarity of what has proven to be effective and understanding the techniques
that facilitate efforts for such issues as symptom management, relapse prevention, medication
compliance and psychosocial issues, such as social phobia. In this chapter, Review of the
Literature, the author will present the current practices of psychiatric rehabilitation (PsyR) and
counseling therapies and therapeutic techniques included in the rehabilitation process for
individuals recovering from severe mental illness. The research question which guided this
project is: What counseling therapies and therapeutic techniques are included in the rehabilitation
process, for people recovering from severe mental illness?
The author’s research for this project includes a collection of information from three
informational sources, including the author’s Master level coursework, two major databases, and
personal readings. First, coursework textbooks that were collected from: Medical Aspects of
Psychiatric Rehabilitation (COUN 251A), Introduction to Counseling and Theory (COUN 174),
Counseling and Mental Health (COUN 176), Rehabilitation Counseling Civic History (COUN
250), Psychosocial Aspects of Disability (REHAB 206), Psychopathology (COUN 232), and
Multicultural Counseling (COUN 201).
Second, the two major databases that were researched for this project presentation. The
first database search is from NARIC (National Rehabilitation Resource Center) a national
resource database focusing and housing research in the area of rehabilitation and disability. This
database was recommended by Dr. Malachy Bishop from University of Kentucky when the
author inquired about resources in the area of rehabilitation and disability. The author
20
established Dr. Bishop as a contact after studying at Southern University, Summer Research
Institute 2009 funded by NIDRR Scholarship, in Baton Rouge, Louisiana where Dr. Bishop
taught meta-analysis and data-mining techniques. The second database that was used for this
project presentation was the Psychiatric Rehabilitation Journal published by the Center for
Psychiatric Rehabilitation at Boston University. A fee of $80.00 was paid by the author for
access to the database.
Lastly, personal readings were used in development of this project presentation limited to
three books from John Bradshaw, Estelle Frankel, and Elyn R. Saks which were referenced in
this section’s literature review and study manual. In summary, the author reviewed a total of 7
textbooks which all were used in this project, 84 articles, and 17 articles were selected from both
databases, with 1 article remaining from the PsycINFO database, Henry Madden Library at
California State University, Fresno. There were a total of 11 different sources used in this
project including 7 Masters level coursework textbooks and articles, 2 major research databases
(NARIC and Boston University Psychiatric Rehabilitation Journal), and 3 personal readings.
Review of the Literature
The literature categories for the literature review include the current practices of
psychiatric rehabilitation, counseling techniques and other therapeutic techniques conveyed as
successful when included in the rehabilitation process for individual recovering from severe
mental illness. Collectively, the processes presented here on counseling therapies include:
Cognitive Behavioral Therapy, Person Centered Therapy, Group Therapy, Solution-Focused
Therapy, and Psychotherapy. The processes presented on therapeutic techniques include:
21
Occupational Therapy, Exercise Therapy, Motivational Interviewing, Religion and Spirituality,
Disclosure, Photovoice, Role Development, Leadership Education, and Empowerment.
Current Practices of Psychiatric Rehabilitation (PsyR).
The psychiatric rehabilitation process considers the nature of severe and persistent mental
illness through identification of the symptoms and etiology of severe mental illness, definition of
psychiatric rehabilitation principles and methodology, and application of these principles and
methodology (Pratt, Gill, Barrett, & Roberts, 2007). These three components encompass the
psychiatric rehabilitation process and successful rehabilitation outcomes for individuals suffering
from severe and persistent mental illness, such as schizophrenia, through understanding the
medical nature of mental illness, interventions and application (Pratt et al., 2007).
Pratt et al. (2007) discuss the rehabilitation principles and methodology for psychiatric
rehabilitation as a recovery concept that is unique to each individual. The authors (Pratt et al.,
2007) point out that there is universal agreement on three goals in psychiatric rehabilitation,
which are:
1. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness
achieve recovery.
2. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness
achieve maximum community integration.
3. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness
achieve the highest possible quality of life. (p. 113-114)
Pratt et al. (2007) also discuss the rehabilitation principles and methodology for
psychiatric rehabilitation in terms of values, as empowering the individual with a disability, and
22
that a person with a severe mental illness is not just a passive recipient of rehabilitation services.
This is indicating that new processes are being based on new values, branching away from the
medical model and sick role. There are five sets of values in today’s psychiatric rehabilitation
processes discussed by Pratt et al. (2007, p. 115-118), which are:
1. Everyone has the right to self-determination, including participation in all decisions that
affect their lives.
2. Psychiatric rehabilitation interventions respect and preserve the dignity and worth of every
human being, regardless of the degree of impairment, disability, or handicap.
3. Optimism regarding the improvement and eventual recovery of persons with severe mental
illness is a critical element of all services.
4. Everyone has the capacity to learn and grow.
5. Psychiatric Rehabilitation Services are sensitive to and respectful of the individual, cultural,
and ethnic differences of each consumer.
Pratt et al. (2007) finally discuss the 13 guiding principles of psychiatric rehabilitation (p.
119-125) which are:
1. Individualization of all services
2. Maximum client involvement, preference, and choice
3. Partnership between service provider and service recipient
4. Normalized and community-based services
5. Strengths focus
6. Situational Assessments
7. Treatment/Rehabilitation Integration, Holistic Approach
8. Ongoing, Accessible, Coordinated Services
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9. Vocational Focus
10. Skills Training
11. Environmental Modifications and Supports
12. Partnership with the Family
13. Evaluation, Assessment, Outcome-Oriented Focus
These goals, values, and principles make-up the psychiatric rehabilitation process, that
reminds academics of the core values of the Independent Living Movement. The Independent
Living Movement began as a social movement, and is now a political movement for change, that
has helped influence policy that funds many psychosocial treatments for people with severe
mental illness such as day programs, assertive community treatment, supported employment, and
family psychoeducation (Dr. Charles Arokiasamy, personal communication, Professor,
California State University, Fresno, December 16, 2007; Dr. Juan Garcia, personal
communication, Professor, California State University, Fresno, November 18, 2010). These
treatment interventions have promoted the recovery and community integration of people with
severe and persistent mental illness and helped individuals achieve independence (Pratt et al.,
2007).
Evidence points out that the etiology of schizophrenia, one of the most severe mental
illnesses, is influenced by the individual’s vulnerability to the illness by both genetic and
prenatal factors (Pratt et al., 2007). Research has also uncovered that parental rejection, realized
through communication stressors such as double-binding messages, is a significant common
factor among individuals with severe mental illness such as schizophrenia, that connote a
negative undertone of intention (Bateson, Jackson, Haley, & Weakland, 1962). Hence,
schizophrenia is due to changes in the structure and functioning of the brain, and it has been
24
proven that individuals with serious mental illness have both different neuroanatomy and
different neural functioning due to chemical imbalances (Pratt et al., 2007). Pratt et al. (2007)
explain that the brain “is an electrochemical organ and neurotransmitters are literally the
chemical messengers of the brain” (p. 55). The neurotransmitters ensure the proper functioning
in the brain, and the “malfunction” accounts for the systems of two neurotransmitters involved
with schizophrenia, dopamine and serotonin. In person’s with schizophrenia the dopamine is
overactive and the serotonin is underactive (Pratt et al., 2007, p. 55).
According to Pratt et al. (2007), schizophrenia being a result of a chemical imbalance of
complex systems in the brain, hence the most effective treatment of schizophrenia is with
biomedical therapies, specifically antipsychotic medication. Studies have shown that
antipsychotic medications “reduce psychotic symptoms in about 70% of patients” (Weiten,
Lloyd, Dunn, & Hammer, 2009, p. 534), and is the first line of treatment for the disease.
According to Weiten et al. (2009), “patients usually begin to respond within one to three weeks”,
and “further improvement may occur for several months” (2009, p. 534). Concretely, counseling
and therapeutic techniques help facilitate the process of adaptation to the disability first, and
recovery through a multi-dimensional rehabilitation process. Researchers recognize that “this
adaptive function, it is argued, is manifested through activities that demonstrative creativity,
spontaneity, and risk taking” (Livneh & Parker, 2005, p. 22).
Counseling Therapies
Cognitive Remediation
Cognitive Remediation is defined by Susan R. McGurk (2008) in her article
“Cognitive Remediation and Vocational Rehabilitation”, as “efforts to improve cognitive
25
functioning” (p. 351). Susan R. McGurk (2008) points out that people with severe
mental illness often face many barriers to securing and maintaining employment due to
cognitive difficulties such as paying attention or concentrating, learning and
remembering information, responding in a reasonable amount of time to environmental
demands, and planning ahead and solving problems. According to author Susan R.
McGurk, these cognitive impairments “are obstacles to receiving the full benefits of
vocational rehabilitation” (2008, p. 350). In the vocational rehabilitation system in
California for example, individuals would be denied services with the Department of
Rehabilitation if the Rehabilitation Counselor concludes that the individual with a
disability, is unable to benefit from services (D. Xiong, personal communication,
Certified Rehabilitation Counselor, California Department of Rehabilitation, Merced
Branch, February 4, 2011).
McGurk (2008) presents in her article that four published studies of cognitive
remediation and vocational programs have indicated improvements in individuals with
severe mental illness (SMI) in cognitive and work functioning. These four studies varied
from one another in terms of how cognitive remediation was applied in a vocational
rehabilitation context. For example one study, evaluated the effects for Neurocognitive
Enhancement Therapy (NET), combining a weekly social information processing group,
a cognitive oriented feedback group (job coaching), and a work therapy program at a
Veteran Administration (VA) Medical Center (McGurk, 2008). This study showed
improved performance on executive functioning and working memory than just work
therapy alone (McGurk, 2008). Another study included an 8-week course of 90 minutes
twice a week, consisting of a small group number (6-8 participants). The objective of the
26
group focused on the practice of attention, verbal memory, and planning. For example,
participants would develop a strategy for memory retention such as repeating back what
the job coach said, practicing what the job coach said, and generalized the strategy to
different work situations aided by “coping cards” (McGurk, 2008). Participants also
practiced cognitive strategies, such as altering their work environment to compensate for
cognitive deficits such as using post-its for instructions and arranging work space to
focus attention on work tasks. Collectively, the four studies showed improvement in
cognitive and work functioning when combining cognitive remediation with vocational
rehabilitation (McGurk, 2008). Additionally, Susan R. McGurk notes that cognitive
flexibility and working memory are important factors in the vocational rehabilitation
process, and although it is difficult to identify what were the specific contributors to
improvements, they nonetheless exist. Hence, the potential to further studying the
positive linkage between cognitive remediation and vocational rehabilitation is relevant
and strong (McGurk, 2008).
Person Centered Therapy
Person Centered Therapy is a nondirective counseling approach that is made up of
the “core conditions” that facilitate the a client’s process of establishing (1) an openness
to experience (2) trust in oneself (3) and an internal locus of evaluation (4) and a
willingness to continue growing (Corey, 2009). As applied to existentialism and
humanism, Person Center Therapy is experiential and relationship-oriented that
recognizes the importance of the therapist’s genuineness towards the client. Person
Center Therapy also recognizes unconditional positive regard and acceptance of the
27
client, and accurate empathic understanding towards the client. Collectively, these
therapist qualities are defined as the “core conditions” of Person Centered Therapy; first
coined by Carl Rogers, and known as Rogerian Therapy (Corey, 2009, p. 165). Pratt et
al. (2007) discuss Carl Rogers person centered approach as effective and “the basic tenets
of consumer-centered therapy are highly compatible with psychiatric rehabilitation and
have an important influence in the field” (p. 152). With severe mental illness, such as
schizophrenia, research shows that communicative disorders exist, such as double-
binding messages that result in feelings of rejection. Person-centered therapy
encompasses a simple yet fundamental therapeutic relationship with the client, where
feelings are accepted and validated genuinely with positive regard which can facilitate a
healing process for an individual recovering from binding messages, and severe mental
illness. Many individuals with severe mental illness such as schizophrenia, have been
victimized by indifferent feelings coming from a primary care giver, typically the same
sex parent, with double binding messages.
Group Therapy
Linda Daniels is a psychologist at the Long Island Jewish Medical Center-Hillside
Division, Department of Psychiatry, in Glenn Oaks, New York and David Roll is a
professor and director of clinical training in the clinical psychology doctoral program at
Long Island University- C.W., Post Campus, New York. Dr. Daniels and Dr. Roll in
their 1998 article titled “Group Treatment of Social Impairment in People with Mental
Illness,” provide insight on the benefits of group therapy for individuals recovering from
severe and persistent mental illness through assessing the relationship between traditional
28
cognitive-behavioral approach to social skills training (SST) compared to a process-
oriented training format known as interactive behavioral training (IBT) (Daniels & Roll,
1998). This study was conducted at Community Residential Program of people with
severe mental illness and included pre- and post-test for the Cognitive-Behavioral
Training Models and Interactive-Behavioral Training Model.
According to researchers, “cognitive-behavioral training is the most widely used
psychosocial intervention today for schizophrenia and other severe and persistent mental
illnesses” (Daniels & Roll, 1998, p. 274). However, Daniels and Roll (1998) assert that
current psychosocial therapies do not “adequately integrate skills learned in training into
the existing social networks and environments of the individual group member” (p. 274).
The researchers of this study suggest that an interactive group treatment may serve as
more effective in influencing the individual’s connection between healthy social
experiences in interactive behavioral training (IBT) and the individual’s social
experiences outside of training sessions (Daniels & Roll, 1998).
The cognitive-behavioral training model or social skills training group in this
study included both behavioral and cognitive social skills components including role
play, feedback, instruction, modeling, and problem solving techniques. SST (social skills
training) included verbal description of alternative behaviors to be enacted, behavioral
demonstration of alternative behaviors to be implemented, and cues or signals given to
the participant during the rehearsal of a scenario (Daniels & Roll, 1998). The group
offered positive and corrective feedback on eye contact voice tone and volume, speech,
body language and speech contact.
29
The Interactive-Behavioral Training Model on the other hand, provides a more
process-focused approach to the standard cognitive-behavioral SST (social skill training)
model according to Daniels and Roll (1998). In interactive behavioral training (IBT),
“group structure is designed specifically to insure the development of group process
factors and interpersonal connections among group members with severe social
impairment” (Daniels & Roll, 1998, p. 274). IBT endorses a more authentic interaction
between group members that incorporates not only cognitive-behavioral approaches to
social skills training (SST) but psychodrama techniques that enhances social relatedness
such as doubling, mirroring, and role reversal (Daniels & Roll, 1998). The IBT group in
this study was divided into four training phases including orientation and cognitive
networking, warm-up and sharing, enactment, and affirmation. These phases or
processes were developed by the researchers of this study to promote group processes
such as altruism, affiliation, and universality and social learning (Daniels & Roll, 1998).
This study showed that although there were not significant results when
comparing the SST and IBT group, there is research potential in further examining this
model as positive. This is based on clinical observations that the process-focused
approach appeared to generate discussions that were more personally and emotionally
meaningful to participants than those in the SST (social skill training) group. Using a
larger and more homogeneous group, for longer training duration are recommended by
the researchers of this study for the next study (Daniels & Roll, 1998).
30
Solution- Focused Therapy
In the current Psychiatric Rehabilitation movement also known as PsyR, there are
specific values that have been instituted to guide professionals in supporting individuals
in recovery from severe mental illnesses. These values essentially foster the process
within individuals to actively achieve recovery (Schott & Conyers, 2003). Solution-
Focused Therapy (SFT) encompasses the values of the PsyR movement identified
through five major constructs: (a) encouragement of self-determination and viewing the
individual in therapy as the expert of his or her life, such as in Rogerian therapy; (b)
focusing on dignity and worth, and drawing on person’s strengths rather than
weaknesses; (c) optimism- solutions vs. problems; (d) individuals’ capacity to learn,
grow and change through new meaning, and; (e) cultural sensitivity, and taking a
collaborative stance (Schott & Conyers, 2003, p. 44-47). These five constructs facilitate
the recovery this of process of personal empowerment and can be recognized as
characteristics of the PsyR professional. Schott and Conyers discuss these five
characteristics of the PsyR professional (2003, p. 44):
1. The PsyR professional communicates the person’s owning the right to self-
determination, where the individual is the expert and solution resides within himself.
2. The PsyR professional acknowledges the dignity and worth of every individual
regardless of the degree of disability. Schott and Conyers give insight, noting when
the locus of power and decision-making comes from a system rather than the
individual, the individual’s worth can be eroded. Problems are seen as separate from
the individual, and repeated focus on strengths, helps individuals recognized and
increase the ability to control their lives.
31
3. The PsyR professional is optimistic regarding the possibility of recovery and every
person is capable of achieving a productive and satisfying life. A focus on the
individuals wishes and resources will essentially restore hope and facilitate the
process to recovery.
4. The PsyR professional acknowledges every person’s capacity to learn and grow.
Learning and change is a process of all individuals.
5. The PsyR professional recognizes the value of the individual cultural and ethnic
differences. Schott and Conyers state that solution-focused therapy is a collaboration
promoting a dialogue that acknowledges a composite of several dimensions of
diversity including class, ethnicity, gender, physical ability, disability, sexual
orientation, religion, etc.
In conclusion, Solution Focused Therapy (SFT) considers the result of the total
rehabilitation process, is the recovery. Solution Focused Therapy (SFT) is also a step-by-
step process facilitated by the PsyR professionals who help people with mental illness
achieve personal empowerment, realize their potential, and restore hope (Schott &
Conyers, 2003).
Psychotherapy
In his article “The Efficacy of Psychodynamic Psychotherapy,” Jonathan Shedler
(2010) asserts his view on mental health community’s disaccreditation of empirical
evidence of psychoanalysis. Shedler (2010) states that medications are effective for
alleviating acute psychiatric symptoms but only on a short term basis. This is
rationalized by the fact that the personality essentially needs undergo a restructuring (for
32
long term effects). Shedler (2010) explains that the process of psychoanalysis looks to
accessing (complexity) of personality process and resolving issues that essentially opens
one’s self up to richer, freer, and more fulfilling life. There are seven distinctive features
of psychodynamic techniques that Shedler (2010) discusses in his article (p. 99-100):
1. Focus on affect and expression of emotion: Psychodynamic Therapy explores the
range of emotion of the patient including contradictory feelings, feelings that are
troubling or threatening, and feelings that the patient may not initially be able to
recognize or acknowledge.
2. Exploration of attempts to avoid distressing thoughts and feelings: Knowing and
unknowingly, we use defenses and resistance (to avoid experience that are troubling),
that may result in an exclusion of affect rather than what is psychologically
meaningful, and our role we play in shaping the events in our lives.
3. Identification of recurring themes and patterns: Psychodynamic therapists work to
identify and explore recurring themes and patterns in the patient’s thoughts, feelings,
self-concept, relationships, and life experiences.
4. Discussion of past experience (developmental focus): Early experiences of
attachment effects our experiences in the present. Looking to the past to provide
insight on current psychological difficulties help patients free themselves from the
bonds of past experiences to live more fully in the present.
5. Focus on interpersonal relations: Psychodynamic therapy has an emphasis on object
relations and attachment, meaning that aspects of the personality and self-concept are
forged in the context of attachment relationship, and psychological difficulties often
33
arise when problematic interpersonal patterns interfere with a person’s ability to meet
emotional needs.
6. Focus on the therapy relationship: Psychodynamic therapy focuses on the relationship
between the therapist and the patient, and essentially help develop flexibility in
interpersonal relationships and enhance capacity to meet interpersonal needs.
7. Exploration of fantasy: Psychodynamic therapy encourage patients to speak freely
about whatever is on their minds including desires, fears, fantasies, dreams,
daydreams, much different from other therapies which maybe actively structured.
Psychodynamic therapy is a process that helps the individual to establish a deeper
level of meaning in his or her life by developing the individual’s inner resources and
capacities in self expression, resolve issues of avoidance, identify recurring
themes/patterns, explore of past experiences, and focus on the interpersonal relationship
(Shedler, 2010).
Other Therapeutic Processes
Occupational Therapy
Authors of the article “Doing Daily Life: How Occupational Therapy Can Inform
Psychiatric Rehabilitation” assert that occupational therapy’s central focus “is on
occupation as a determinant of health and well being” (Krupa, Fossey, Anthony, Brown,
& Pitts, 2009, p. 155).” Occupational therapy specifically is a “field with a strong
theoretical and knowledge base with unique procedures and practices, which include
assessment processes that are highly client-centered and attend to environmental and
situational contexts” (Krupa et al., 2009, p. 160). Occupational Therapy considers three
34
categories to describe the occupation in which clients participate in, which include self
care, productivity, and leisure. Self-care includes personal care and health routines;
productivity includes a range of productive activities such as work, education, and home
upkeep; while leisure includes many activities motivated by personal interests and
enjoyment (Krupa et al., 2009).
Occupational therapy applied to psychiatric rehabilitation is a strong recovery tool
enabling the individual to better adapt to his or her disability, by addressing the
therapeutic method of focusing (Gendlin, 1969). Estelle Frankel, a psychotherapist
describes focus as a “kind of attentiveness to the bodily felt sense of a particular emotion”
(Frankel, 2010, p. 165). Frankel further asserts that “by focusing on the bodily felt sense
of an emotion, we allow it to fully emerge and be expressed” (Frankel, 2010, p. 165).
Researchers of this article describe this process of restoration and recovery as “renewing
hope, moving beyond illness to construct a new self, expanding social roles, building
social connections, learning to manage symptoms, being a citizen and overcoming
stigma, are all elements in the recovery process” (Krupa et al., 2009, p. 160).
Occupational therapy assists in facilitating the focusing process, through analysis of
individual-level practice, environmental-level practice, and the community-level practice,
of occupation (Krupa et al., 2009). For example, authors Krupa et al. (2009) describe six
person-level determinants in occupational therapy as:
1. Spiritual dimensions. Disparities applied to psychiatric rehabilitation, may be
realized by how “personal accounts have described how living with mental illness can
be experienced as a crisis in meaning and purpose that is expressed as profound
occupational disengagement” (p. 156).
35
2. Socio-cultural determinants. Disparities applied to psychiatric rehabilitation may be
realized by the need to negotiate complex social situations due to disability.
3. Physical determinants. Disparities applied to psychiatric rehabilitation may be
realized by the result of occupational deprivation, effects of medical treatments, co-
occurring physical conditions such as weight gain, and changes associated with aging.
4. Cognitive determinants. Disparities applied to psychiatric rehabilitation may be
realized by the impact of mental illness on attention, memory, problem solving, and
other cognitive processes, that can effect the experiences and performance of
occupations according to authors.
5. Neurobehavioral determinants. Disparities applied to psychiatric rehabilitation may
be realized by observable problems in refined motor skills and enactment of task and
social demands of occupations.
6. Psychoemotional determinants. Disparities applied to psychiatric rehabilitation may
be realized by compromised self-esteem, self-efficacy, and loss of self-agency as
many people with severe mental illness have described, according to authors, a
decrease in capacity in pleasure and interest when engaged in occupations.
Hence, it is relevant and effective to use occupational therapy as a recovery tool
for an individual with severe mental illness to promote adaptation and recovery from the
debilitating condition from the illness. Occupational therapy as rehabilitation and
recovery tool addresses various occupational issues in the person with a disability, such
as occupational interruption, occupation imbalance, occupational disengagement,
occupational delay, occupational deprivation, occupational alienation, and occupational
apartheid (Krupa et al., 2009).
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Exercise Therapy
According to researcher Fogarty, Happell and Pinikahana (2004), exercise
training has shown to be ineffective as an alternative or complementary treatment to
severe mental illnesses such as schizophrenia. However, exercise as “a therapeutic
component of any psychosocial rehabilitation program for patients experiencing a long
term mental illness has merit” (Forgarty et al., 2004, p. 176). The researchers of this
study, published in the Psychiatric Rehabilitation Journal titled “The Benefits of an
Exercise Program for People with Schizophrenia: A Pilot Study,” suggest that when a
person with mental illness establishes a proactive approach to the well documented side
effects of weight gain as a result of taking anti-psychotic medications, the individual
establishes a sense of normality in managing his or her disability (Forgarty et al., 2004).
Six individuals participated (N=6) in this study, and the majority of participants reported
increased fitness levels, exercise tolerance, reduced blood pressure levels, perceived
energy levels, and upper body and hand grip strength levels. All participants further
showed a high attendance level which conveyed their motivation and commitment to
recovery and the rehabilitation process (Forgarty et al., 2004). Forgarty et al. (2004)
concluded that exercise therapy incorporated into psychosocial rehabilitation programs or
other type of supportive rehabilitation venues, serve as a therapeutic coping tool for
individuals with mental illness and again, promote a sense of normality in managing their
disability while promoting their physical wellness as well.
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Motivation Interviewing
Christopher C. Wagner and Brian T. McMahon (2004) from Virginia
Commonwealth University, describe Motivational Interviewing (MI) as a “client-
centered, directive counseling approach described to foster client motivation and
initiative” (p. 154). According to Wagner and McMahon (2004), motivational
interviewing facilitates the initiative for personal insight to behavioral change, including
the following three components:
a. A focus on the clients experiences, values, goals, and plans
b. A promotion of client choice and responsibility for implementing change
c. An initiative to provide the Rogerian conditions of empathy, unconditional positive
regard, and genuineness (p. 154).
The supportive and driving factor between Rehabilitation Counseling and
Motivational Interviewing according to Wagner and MacMahon (2004), is the focus of
self-determination. According to Wagner and McMahon the role of self determination in
rehabilitation has been described in Total Rehabilitation by N.G. Wright (1980) as:
“All people have a right to self-determination insofar as they are capable to
responsible judgments; people should make their own decisions, set their own
goals, and also decide how they achieve those goals. This does not mean that the
(counselor) must assume a passive role or be totally nondirective. Active
intervention by the rehabilitation counselor helps the client make decisions by
providing needed information, by fostering the development of self-confidence,
and by facilitating problem-solving. The client is the primary individual in
38
rehabilitation with ultimate decision-making authority and responsibility.” (p.
152)
Motivational interviewing in psychiatric rehabilitation may include counseling
individuals with severe depression, phobia, schizophrenia, or individuals who have been
traumatized and is recovering from an illness such as PTSD. MI counseling interventions
in psychiatric rehabilitation and recovery from severe mental illness essentially focuses
on treatment- related issues such as participation, compliance, and developing insight
(Wagner & McMahon, 2004; Rusch & Corrigan, 2002). The MI counseling for
individuals recovering from severe mental illness is essentially used to promote wellness
and managing symptoms, and hopefully in the process, lessen likelihood for relapse
and/or hospitalization.
Wagner and McMahon (2004) discuss the four principles of motivational
interviewing that promote change which serves as positive insight for rehabilitation
counselors and educators, managing cases for individuals recovering from severe mental
illness, which are:
1. Expression of empathy
2. Roll with resistance where the counselor facilitates an environment that is calm,
supportive even when the client is defensive, argumentative, or withdrawn or behaves
in any other manner that the counselor perceives negatively.
3. Develop discrepancy or confrontation. Meaning the counselor gently explores
discrepancies between current behavior (if they are counterproductive) and desired
future behaviors.
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4. Supportiveness to self-efficacy. Meaning the counselor is to serve in helping the
client gain confidence about, and commitment to, making changes and achieving
goals. (p. 154-155)
Collectively, Motivation Interviewing according to Wagner and McMahon (2004) “is
empirically supported, client-centered, directive counseling approach designed to
promote client motivation and reduce motivational conflicts and barriers to change” (p.
159).
Religion and Spirituality
Andrea Blanch (2007) at the Center for Religious Tolerance in Sarasota, Florida
discusses in her article “Integrating Religion and Spirituality in Mental Health: The
Promise and the Challenge,” the nature of the mental health system comparable to the
“one-eyed giant” with a limited perspective, gaining so much power from its grounding
in a scientific model that it has become almost impossible to challenge (p. 251).
However, Blanch does challenge the scientific model, which is so prevalent in western
society by considering the wisdom of eastern medicine and its applicability to
rehabilitation and wellness of individuals recovering from severe mental illness. The
wisdom of eastern medicine that Blanch (2007) discusses is rooted in the nature of being
human, and suggests new processes in the clinical environment that will maximize the
potential of individuals discovering what it means to be human.
Blanch (2007) gives a historical perspective on integrating science and religion,
our current social context and trends of spirituality and religion, reflections on
spirituality, religion, and recovery, and further suggests strategies for integrating
40
spirituality in today’s mental health practice. Collectively, these strategies include:
having a set of solutions, tools to asking questions, and supporting the wisdom inherent in
the client’s support system (Blanch, 2007). More specifically, these strategies include
four elements for practitioner intervention which are:
1. Spiritual information gathering.
2. Acknowledging the client’s explanatory framework.
3. Expanded consultative model.
4. Using Spiritual and Mystical Practices to Assist with Recovery.
Blanch (2007) describes these tools:
1. Spiritual Information Gathering: Attention would be focused during an assessment
not on making a diagnosis or setting a rehabilitation goal, but on gathering
information about the client’s experiences pertaining to religious and spiritual beliefs,
practices, aspirations, and community, as well as an past experiences, positive or
negative, the affect their psychological and spiritual lives. The goal would be to learn
as much as possible about healing and mental health from the religious or spiritual
viewpoint held by the client.
2. Acknowledging the client’s explanatory framework: A formal acknowledgement of
the client’s explanatory framework and an active attempt to accommodate that
framework. Blanch (2007) discusses that working from the client’s frame of
reference has been shown to increase adherence to treatment plans.
3. Expanded Consultative Model: A consultative spiritual or religious model for mental
health practitioners that is outside their own belief system.
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4. Using Spiritual and Mystical Practices to Assist with Recovery: Essentially
developing a translation of esoteric practices into terms that are understandable to
laypeople. Encompassing a broader scope of recovery to include religious and
spiritual traditions as a part of recovery and rehabilitation processes, that include
techniques such as prayer and other tools for strengthening belief, purification rituals,
self-observation, techniques to develop mastery over thoughts and behaviors,
practices for minimizing or containing the ego and for controlling emotional excesses,
structured processes for confronting the dark side of humanity and for overcoming
fear of death; practices for developing and maintaining calmness in difficult situation,
and so forth (Blanch, 2007).
Blanch (2007) states that the theoretical advances in the integration of eastern and
western medicine, provides a potential bridge (strategy) for successful transition to
another type of recovery model. She states that “new discoveries in quantum physics
suggest that consciousness can be understood in terms of energy and vibration as well as
anatomy and chemistry” (Blanch, 2007, p. 253). Traditional Oriental medicine rests on
an ancient and sophisticated theory of life energy or “prana” flowing through meridians
throughout the body, with seven “chakras” controlling the manifestation of prana in
consciousness and behavior” (Blanch, 2007, p. 253). Blanch (2007) further points out
that by “acknowledging energy and vibration as a legitimate substrate for consciousness
also opens the door for understanding the impact of music, chanting, mantra yoga, and
other techniques that appear to intervene directly at the frequency/vibrational level” (p.
253).
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Finding in the neurochemistry of alternative states and opening the door to
thinking about consciousness as a multidimensional phenomenon is integrating the idea
of biology and religion (Blanch, 2007). Blanch (2007) discusses this phenomenon by
example of the religious practice of forgiveness. She states that “recent studies of the
biology of forgiveness (a traditional religious concern) suggest that resolving religious
issues may have a measurable impact on brain chemistry” (p. 253), in a series of studies
conducted by Dayton, 2003; Halter, 2005; and Sevrens, 2000.
Blanch’s (2007) review of research by Culliford 2002, found that there is
evidence our western culture is shifting from a materialist, positivist and empiricist view
towards a naturalistic understanding that acknowledges the significance of personal
stories, emotions and experiences that cannot be explained purely in terms of science
(Blanch, 2007). The then is a positive direction towards gaining better mental health
outcomes, by allowing individual access to the full range of practices that enable us to
discover what it is like to be human.
Disclosure
In Ruth’s O. Ralph’s article (2002) “The Dynamics of Disclosure: Its impact on
Recovery and Rehabilitation”, she discusses the negative and positive sides of disclosure
of psychiatric disability. According to Webster’s definition, disclosure is the act or
process of revealing or uncovering (Merriam-Webster dictionary, 2006). Barriers to
disclosure according to Ralph (2002) include secrecy and control, shame, and
discrimination and stigma. Proceeding, I will discuss these three barriers beginning with
secrecy and control. First, in secrecy and control, the individual does not want to think
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about the time when his life was out of control therefore non-disclosure is the result of
taking control over one’s life in the present, as a result of a past experience. Psychiatric
disability can be a paralyzing condition, according to Ralph where the “world appears
dark and unfriendly, and you cannot participate because you are afraid” (Ralph, 2002, p.
166). Hence, life is actually out of control “when your psychiatric illness takes hold of
you” (Ralph, 2002, p. 166).
The second barrier to disclosure according to Ralph (2002) is shame. In the book
“Healing the Shame that Binds You,” John Bradshaw (2005) discusses the many faces of
shame and differentiates healthy shame from toxic shame. Bradshaw (2005) defines
shame as “a healthily human feeling that can become a true sickness of the soul” (p. 5).
Just as there are two kinds of cholesterol, HDL (healthily) and LDL (toxic), so also are
there two forms of shame: innate shame and toxic/life-destroying shame” (Bradshaw,
2005, p. 5). Bradshaw (2005) further suggest that “when shame is toxic, it is an
excruciatingly internal experience of unexpected exposure. It is a deep cut felt primarily
from the inside. It divides us from ourselves and others” (p. 5). Toxic shame is the
alienation of the self from the self, according to Bradshaw and “causes one to become
“other-ated” (Bradshaw, 2005, p. 42). “Otheration” is a term uses by a Spanish
philosopher Ortega Y Gasset, according to Bradshaw, to describe dehumanization
(Bradshaw, 2005, p. 42). To be truly human is to have an inner self and a life from
within, and when we as humans no longer have an inner life, we become otherated and
dehumanized according to Bradshaw (2005). Bradshaw (2005) further discusses that
when “toxic shame, with it more-than-human, less-than-human polarization is either
inhuman or dehumanizing”, and concludes “toxic shame is spiritual bankruptcy” (p. 42).
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There is an externalization process for healing toxic shame that Bradshaw outlines, that
supports the positive benefits of disclosure, that externalization process includes
(Bradshaw, 2005, p. 151):
1. Coming out of hiding by social contact, which means honestly sharing our feelings
with significant others.
2. Seeing ourselves mirrored and echoed in the eyes of at least one non-shaming person.
Reestablishing an “interpersonal bridge.”
3. Working a Twelve Step program.
4. Doing shame-reduction work by “legitimizing” our abandonment trauma. We do this
by writing and talking about it (debriefing). Writing especially helps to externalize
past shaming experiences. We can then externalize or feelings about the
abandonment. We can express them, grieve them, clarify them and connect with
them.
5. Externalizing our lost Inner Child. We do this by making conscious contact with the
vulnerable child part of ourselves.
6. Learning to recognize various split-of parts of ourselves. As we make these parts
conscious (externalize them), we can embrace and integrate them.
7. Making new decisions to accept all parts of ourselves with unconditional positive
regard. Learning to say, “I love myself for…” Learning to externalize our needs and
wants by becoming more self assertive.
8. Externalizing unconscious memories from the past, which form collages of shame
scenes, and learning how to heal them.
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9. Externalizing the voices in our heads. These voices keep our shame spirals in
operation. Doing exercises to stop our shaming voices and learning to replace them
with new, nurturing and positive voices.
10. Learning to be aware of certain interpersonal situations most likely to trigger shame
spirals.
11. Learning how to deal with critical and shaming people by practicing assertive
techniques and creating and externalization shame anchor.
12. Learning how to handle our mistakes and having the courage to be imperfect.
13. Finally, learning through prayer and meditation to create an inner place of silence
wherein we are centered and grounded in a personally valued Higher Power.
14. Discovering our life’s purpose and spiritual destiny.
Bradshaw (2005) notes, that all of these externalization methods have been adapted from
the major schools of therapy. Most therapies attempt to make that which is covert and
unconscious to something overt and conscious (Bradshaw, 2005).
The third barrier that Ralph (2002) describes as a barrier to disclosure, is
discrimination and stigma. According to Ralph (2002), discrimination can result in
painful experiences of exclusion and rejection often through subtle day-to-day
interactions (Ralph, 2002). This can occur in a variety of contexts such as the mental
health system and the workplace (Ralph, 2002). Ralph (2002) describes that the
stigmatization existing in the mental health system may include power and control
imposed by providers where consumers are being “treated as having lower status than
staff, regimented and dehumanizing practices, separation from the community, disbelief
that people with psychiatric disability can grow and learn, lack of respect for privacy, and
46
inadequate access to information” (p. 167). These practices have been supplemented
with today’s new practices. With proper psychiatric rehabilitation that preserves the
nature and potential of the human psyche, which influenced by the Independent Living
Movement and reforms such as deinstitutionalization. Second, discrimination and stigma
in the workplace may be felt after the disclosure of the non-apparent disability when
asking for reasonable accommodations, and not getting the job due to prejudice. Ralph
(2002) also describe that the “attitudes of co-employees in the workplace may also be
affected” (p. 167).
Collectively, these three barriers to disclosure can result in a dilemma of whether
or not to disclose a psychiatric disability. Ralph (2002) discusses the advantages for
disclosure which include the fact that “disclosure is therapeutic and can lead to greater
emotional wellness” by letting go of your secrets (p. 169). Also gaining access to
accommodations and rights provided by the ADA, that would include “shorter hours,
flexible work time, released time for therapy visits, planning of your work load so that
you can better plan your tasks and time, or training in areas where you are expected to
produce, but your skills need to be upgraded” (Ralph, 2002, p. 171). Ralph (2002)
recommends that having the freedom of living without a secret is the pathway to wellness
and suggests that disclosure decision should be “tried out” with people who understand
and support you first (p. 171).
Photovoice
In Merriam-Webster dictionary (2006), stigma is defined as a severe social
disapproval of personal characteristics or beliefs that are against cultural norms. The
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Center for Psychiatric Rehabilitation research shows “stigma experienced by persons
with psychiatric disabilities presents a major barrier to recovery” (Recovery and
Rehabilitation, 2008, p. 1). According to Zlatka Russinova (Recovery and
Rehabilitation, 2008), Senior Research Associate at the Center of Psychiatric
Rehabilitation at Sargent College, College of Health and Rehabilitation acknowledges
that, “We now recognize both the negative impact of the illness itself, as well as the
second layer of trauma that comes from the stigma attached to the mental illness”
(Recovery and Rehabilitation, 2008, p.2) As a result of this awareness the “Photovoice
Anti-stigma Empowerment” psychoeducational intervention developed at the Center for
Psychiatric Rehabilitation combines both advocacy and education to help consumer’s
confront stigma (Recovery and Rehabiltation, 2008). By confronting stigma and
incorporating the technique into psychiatric rehabilitation, this will increase consumer’s
participation in communities of choice (Recovery and Rehabiltation, 2008).
Photovoice was originally developed by Professor Caroline Wang at the University of
Michigan School of Public Health and Mary Ann Burris from the Ford Foundation
(Recovery and Rehabilitation, 2008). The application of Photovoice involves putting the
camera in the hands of the consumer and having the consumer developing a narrative,
communicating their experience, exposing the impact of stigma in their lives (Recovery
and Rehabilitation, 2008). An example of Photovoice given by the Center’s research,
includes a picture taken by a consumer of a sewage drain with his narrative reading:
“The drain calls to me because of all the hurtful things people have said to me
over the decades about my mental illness. In sum, I have been told that I am a
drain on the nation, a drain on society, and a drain on multiple individuals’
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resources. Over the years, I have come to believe this, which has been a drain on
me. Education about mental illness (and the effects of trauma) should be able to
reach out to the general public, as well as healthcare professionals. Knowledge
and understanding can be powerful weapons in combating stigma.” (Recovery and
Rehabilitation, 2008, p. 1)
The Center of Psychiatric Rehabilitation has found that “understanding stigma,
eliminating stigma, and changing the way individuals experience stigma must be a key
element in any recovery-oriented program” (Recovery and Rehabilitation, 2008, p. 4).
Hence, the Center has created a curriculum including a workbook and instructor’s guide
that leads student’s “through Photovoice process step-by-step while the instructor’s guide
provides comprehensive instruction in leading Photovoice workshops” (Recovery and
Rehabilitation, 2008, p. 3). The Center finds that “this curriculum will ensue the
intervention may be easily delivered at outpatient mental health and rehabilitation
settings as well as consumer-run programs and centers (Recovery and Rehabilitation,
2008, p. 3).
Role Development
Victoria P. Schindler in her article “Role Development: An Evidenced-Based
Intervention for Individuals Diagnosed with Schizophrenia in a Forensic Facility”
describes the importance of social roles and community involvement for humans. This
concept is asserted famed psychologist, Dr. Alfred Adler who discussed the idea of social
connected as a pivotal part of human development and actualization of our potential as
human beings. This study conducted within a forensic facility, where comprehensive
49
rehabilitation is typically not offered currently (Schindler, 2005), analyzed 84 male
participants diagnosed with schizophrenia and taking antipsychotic medication. The
group was split into two groups: a comparison group and an experimental group.
Quantitative and qualitative measures where used to collect data. The quantitative
assessments used were: The Role Functioning Scale, The Task Skills Scale, and the
Interpersonal Skills Scale, and assessments where conducted at 4, 8, and 12 weeks. The
comparison group followed the conventional structure of a forensic facility defined as
Multi-Departmental Activity Program or MAP (Schindler, 2005). According to
Schindler, “MAP is a non-individualized, therapeutic intervention designed to encourage
the productive use of time and socialization in a group setting” (Schindler, 2005, p. 392).
The experimental group was developed as an enhancement of MAP, however the
treatment is more individualized where trained staff assisted participants to “develop task
as interpersonal skills within meaningful social roles” (Schindler, 2005, p. 392). In this
study roles were developed for a forensic setting including roles of worker, student,
group member, friend for example.
The idea of strengthening self-identification was successful in this study and
finding proved to be statistically significant in the experimental group when compared to
the comparison group. The study showed significant improvement among participants in
three different areas including task skills, interpersonal skills, and role development.
Schindler asserts that both staff and participants were able to successfully implement and
participate in the study within the constructs of a forensic setting (Schindler, 2005).
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Leadership Education
Improved self-efficacy, empowerment, and self-esteem are some of the results of
psychoeducation intervention study, conducted by Wesley A. Bullock, David S. Ensing,
Valerie E. Alloy, and, Cynthia C. Weddle (2000). This study in Leadership Education,
promotes the recovery potential for individuals with severe mental illness, by fostering an
environment of lecture, group processes, experimental learning, and empowerment
through leadership training with an insightful purpose, developing diversity among
government boards, committees, and non-profits to include people with disabilities
(Bullock et al., 2000). In their article titled “Leadership Education: Evaluation of a
Program to Promote Recovery in Persons with Psychiatric Disabilities”, the authors
present their research that evaluates the effects of a 16-week psychoeducational program
that is designed to promote the recovery process for people with psychiatric disabilities.
The research and leadership program personnel alone side of persons with individuals
with psychiatric disabilities, designed and developed the curriculum for the program
training focusing on addressing the recovery process for people with severe and persistent
mental illness.
The program developers created three major segments for the program curriculum
for this 16-week training, that include attitude and self-esteem, group dynamics and
group process, and board/committee functions and policy development. Participants
attended 2 hour training sessions for the 16 weeks and alongside lectures, small group
processes, experimental learning, and weekly topic explorations, participants were given
homework assignments. The study analyzed four groups which included group 1, N=26;
group 2, N=14; group 3, N=12; and group 4 N=16. The method of measurements
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included utilization of The Empowerment Scale, The Community Living Skills Scale,
Recovery Attitudes Questionnaire, The Quality of Life Inventory, Self-Efficacy Scale,
and the COMPASS Treatment Assessment System. The study included a pre-test before
training, post-test after training, and a 6-month follow-up assessment after training. The
results of the study proved to be successful in that participants showed a significant
difference in improvement from pre-training to post-training in many of the recovery
areas measured according to Bullock et al. (2000). The significant improvements include
(Bullock et al., 2000):
1. Psychiatric symptom reduction (particularly reported levels of depression and
anxiety);
2. Self-efficacy (confidence in an ability to control positive, negative, and social
symptoms);
3. Community living skills (particularly personal care and social skills;
4. Empowerment (particularly self-esteem), and;
5. Recovery attitude (p.8).
The study conveyed the shifts in the participant’s feelings of self-efficacy,
empowerment, and self-esteem, and found a reduction on reported psychiatric
symtomatology as well (Bullock et al., 2000). Researchers indicated that the participants
feeling of self efficacy, empowerment, and self-esteem “are more stable indicators of
recovery than psychiatric symptomatology” (Bullock et al., 2000, p. 3).
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Empowerment
In the article titled “Empowerment Variables as Predictors of Outcomes in
Rehabilitation,” Michael P. Frain, Malachy Bishop, and Molly K. Tschopp (2009) state
that the research “was intended to begin empirical validation of those ideas put forth by
past rehabilitation researchers such as Bolton and Brookings (1996)” (p. 33). The
authors’ research included exploration of empowerment variables that are considered
critical in the rehabilitation process from a theoretical model standpoint (Frain et al.,
2009). The authors of this study conveyed that “in the present study we have attempted
to move empowerment from a theoretical concept to a well-defined, multidimensional
construct comprised of empirically measurable variables” (Frain et al., 2009, p. 28).
Hence, it was the researcher’s intent to quantify theory into measurable results, which
more concretely concludes variables of empowerment as effective, and predictors of
positive rehabilitation outcomes.
Researchers measured four areas of empowerment including self-efficacy
(control), self-advocacy (assertiveness), perceived stigma (having a positive self concept,
self-esteem, holding positive self-regard concerning the self), and competence
(autonomous, competent, goal-directed, independent, personally responsible, self-reliant,
and self-montioring). The outcomes identified as important in rehabilitation counseling
were also measure against empowerment variables including quality of life.
Empowerment variables domains include: physical health, mental health, work, leisure
activities, financial situation, relationship with partner, family relationships, other social
relationships, autonomy/independence, religious/spiritual; quality of life variables
include: employment, adjustment to disability and functional status (Frain et al., 2009).
53
Frain et al. (2009) convey that in the theoretical context, personal empowerment include
four dimensions which are (p. 28):
1. Awareness of factors that contribute to and hinder their efforts towards goals;
2. Personal control;
3. Efforts to exert control;
4. Competency and the ability to achieve outcomes.
The quantified results of the study, concluded that the area of self-efficacy and
self-management “may be the most powerful forces individuals may acquire that will
lead to positive rehabilitation outcomes” (Frain et al., 2009, p. 33). The researchers
conclude that this measurable finding agrees with the theoretical concept (four theoretical
dimensions of empowerment) “that empowerment will improve adjustment to disability
outcomes and employment outcomes for individuals with disabilities” (Frain et al., 2009,
p. 33).
The implications of empowerment for practitioner and application of findings into
the rehabilitation processes are argued and include six areas of professional development
to consider as highlighted by Frain et al. (2009, p. 33):
1. The reason practitioner’s work to facilitate empowerment in clients is to help clients
feel a sense of satisfaction and control over important areas of life, not to help them
understand how important some things should be to them.
2. The study supports the idea that finding ways to empower clients will lead to
improved outcomes in rehabilitation.
3. The importance of quality of life areas such as work likely will not change by
empowering clients (however advocates for motivation interview may advocate
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otherwise); however, the amount of satisfaction they get from work can change.
Hence, in can then be assumed support in vocational goals are important to the
process.
4. The amount of control, satisfaction and interference an individual feels about their
disability and physical health is changeable characteristics but the importance of their
health is not through empowerment. Thus, rehabilitation professional can focus on
education that gives clients feelings of control (e.g. teaching clients how different
foods affect their glucose levels) over their health.
5. Rehabilitation counselors can role play interactions with medical providers, in order
to teach assertiveness and ways to have decision making power in these interactions.
6. Professionals have experience with many types of disabilities and understand the
often erratic pattern in the course of these diseases. By working with newly
diagnosed clients on ways to self-manage their disability (e.g. designing plans to
assure medication by using family members as reminders), clients can become more
competent in their own disease management, leading to feelings of empowerment
through self-esteem, confidence, and expanded choices.
The researchers of this study provided insight on empowerment that proved to be
measureable and concluded to agree with theoretical analysis that empowerment makes a
difference in overall mental health and produces positive outcomes in the total
rehabilitation process.
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Chapter Summary
The civil rights of people with disabilities are the primary objective of the Independent
Living Movement, which influenced education in the United States and disability policy since
the 1960s (Dr. Charles Arokiasamy, personal communication, Professor, California State
University, Fresno, December 16, 2010). The Independent Living Movement has resulted in
gaining rights for people with disabilities, such as with development of American Disabilities
Act in the 1990s. This advocacy movement has developed and influenced modern day
rehabilitation models for specific areas of disability, specifically psychiatric rehabilitation. With
the introduction of the Recovery Model, described by William Anthony from the Center of
Psychiatric Rehabilitation at Boston University, researchers found that people were recovering
from severe psychiatric disabilities, originally categorized as a degenerative illness (Dana et al.,
2008). Today’s Recovery Model for psychiatric rehabilitation has been reported to be effective,
and the core values of this model is based on individual self-determination and personal
empowerment (Pratt et al., 2007; Dana et al., 2008). The systems in place that are inspired by
the Recovery Model provide individuals recovering from severe mental illness the freedom to
rehabilitate successfully through choice. This multi-dimensional rehabilitation process is evident
in the counseling and therapeutic techniques, which are processes in themselves, help facilitate
the process of adaptation to the disability first, and then recovery.
The counseling and therapeutic processes presented convey that the public sector systems
support of an individual’s proactive strategies in rehabilitation or self determination and social
connectedness, and focusing on the process of recovery for individuals with severe and persistent
mental illness, rather than the result, is proving successful for positive rehabilitation outcomes
including returning back to work. This is evident through the counseling and therapeutic
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techniques that are a part of the psychiatric rehabilitation process for people with severe mental
illness presented in this project, which are focused on the process of recovery, not the result,
through attaining better mental health. It can then be concluded if an individual focuses on the
process of recovery, he or she can get to the result he or she wants, such as better mental health
and the things that come with that, such as employment and more meaningful relationships.
The counseling processes presented in this chapter include Cognitive Remediation,
Person Centered Therapy, Group Therapy, Solution- Focused Therapy, Psychotherapy. Other
therapeutic techniques included in this chapter are Occupational Therapy, Exercise Therapy,
Motivational Interviewing, Religion and Spirituality, Disclosure, Photovoice, Role Development,
Leadership Education, and Empowerment. It was the author’s intent to present a scope of
processes that help facilitate the process of adaptation and recovery for people with mental
illness successfully. In the next chapter the author will present the methodology of the selection
of processes that made it to the study manual.
57
CHAPTER THREE
METHODOLOGY
Introduction
With the introduction of the Recovery Model and Paradigm new perspectives are evident
in psychiatric rehabilitation. William A. Anthony at the Center of Psychiatric Rehabilitation
(CPR) at Boston University asserts that work by researchers Desisto, Harding, McCormick,
Ashikaga, and Brooks, (1995a; 1995b), conveyed that contradictory to the belief that severe
mental illness was a deteriorative disease, recovery from mental illness was happening (Dana et
al., 2008). With these finding in the 1990s, increasing states and countries began to take on the
“recovery vision,” that influenced the thinking of many of today’s system planners and
administrators according to William Anthony at CPR (Dana et al., 2008, p. 319). The Recovery
Model empirically lead reconstruction of psychiatric rehabilitation practices, is supported by the
earlier grassroots advocacy initiatives for people with disabilities beginning in the 1960s with the
introduction of the Independent Living Movement, later defined by Gerben DeJong (1979) as the
Independent Living Paradigm. The Independent Living Paradigm similar to the Recovery
Model, has also defined problems and the range of intervention to those problems in new ways,
infusing new perspectives about the human service system as whole as well (Dr. Charles
Arokiasamy, personal communication, Professor, California State University, Fresno, December
16, 2010; Dr. Juan Garcia, personal communication, Professor, California State University,
Fresno, November 18, 2010). The new perspectives have influenced current disability practices,
specifically in the context of psychiatric rehabilitation and the development of the Recovery
Model (Dr. Charles Arokiasamy, personal communication, Professor, California State
58
University, Fresno, December 16, 2010; Dr. Juan Garcia, personal communication, Professor,
California State University, Fresno, November 18, 2010).
The audience of this project is rehabilitation counselors, mental health providers,
potential employers, students, and victims of severe and persistent mental illness. The proposed
manual will serve as a study, training guide, and informational resource on counseling and
therapeutic processes that have shown to be effective for people recovering from severe mental
illness. The study guide, which is guided by the insightful direction of current psychiatric
rehabilitation practices, encompasses the main goals from the Recovery Model and presents the
processes that are supported by empirical evidence in facilitating recovery for people with severe
mental illness, leading to more meaningful and fulfilling lives. The statement of the problem is
that employment rates are extremely low for individuals with severe and persistent mental
illness, because the transition from illness to work is difficult (Provencher, Gregg, Mead, and
Mueser, 2002). Barriers to employment may include symptoms, self-esteem, quality of life, and
clinical and social stability. These barriers to employment are conveyed in the analysis of
employment rates for people with psychiatric disabilities which range between 10-20%
(Provencher et al., 2002). The primary treatment for severe mental illness is through
biomedical therapy; however, medication compliance is an ongoing issue in the recovery of
people with severe mental illness (Pratt, Gill, Barrett, & Roberts, 2007). In the attempt to
produce positive outcomes towards the full recovery of severe mental illness and going back to
work, researchers Provencher et al. (2002) recognize the individual is faced with adapting to the
disability first, then recovery, which counseling and therapeutic techniques help facilitate.
Provencher et al. (2002) state “recovery is defined as the process of transcending symptoms,
psychiatric disabilities, and social handicaps” (p. 133). These research findings are uncovering
59
that an individual’s proactive strategies (self-determination) in rehabilitation, social
connectedness, and focusing on the process of recovery for persons with severe and persistent
mental illness, rather than the result, is proving to be successful for positive rehabilitation
outcomes, like returning back to work (Dana et al., 2008; Jinhee Park, Personal Communication,
Doctoral Student Illinois Institute of Technology, National Council on Rehabilitation Education
Conference, April 8, 2010; Lydie Levy, Personal Communication, Partner/VP Business
Development, IPLux Xpertise S.a.r.l., Social Psychology, Universite Vincennes-Saint-Denis
(Paris); Master Business Administration, Reims Management School; Master Business Law,
Universite de Reims Champagne-Ardenne, Gemstar TV-Guide International, August 1, 1997;
Provencher et al., 2002).
The purpose of this project is to affirm the understanding of the importance of self-
determination and how successful rehabilitation outcomes are realized or influenced for people
with psychiatric disabilities through a process of various insights such as acceptance of the
disability, medication management, and attaining independence by attaining a home, gainful
employment, and meaningful relationships. This independence is what is considered as
successful rehabilitation outcomes according to the current psychiatric principles discussed by
Pratt et al. (2007). The research question which guided this project is: What counseling therapies
and therapeutic techniques are included in the rehabilitation process, for people recovering from
severe mental illness? In the following section the author will present project information on
population and sample of the project, collection of the materials and conditions for inclusion of
the final presentation, and the chapter summary.
60
Population and Sample
This project is a literature-driven study manual and collection of “best practices”
of counseling and therapeutic techniques included in current day rehabilitation processes.
The researcher’s audience for this project is for rehabilitation counselors, mental health
providers, potential employers, students, and victims of severe and persistent mental
illness. The manual will serve an informational resource and a training guide on
counseling and therapeutic processes applied to psychiatric rehabilitation, which is shown
to be effective for people recovering from severe mental illness. Additionally, the author
is interested in presenting counseling and therapeutic techniques in psychiatric
rehabilitation process to this group of professionals and individuals to broaden their
insight about mental illness, adaptation to disability, and the best recovery practices in
psychiatric rehabilitation today. The recovery model and process oriented practices that
include counseling and therapeutic techniques applied to psychiatric rehabilitation, also
provide insight into best environments that help restore an individual’s humanness as
conveyed through the Recovery Model and every individual’s right to self-determination.
Further, the author is interested in assisting in expanding the knowledge of mental health
providers, potential employers, students, and victims of severe mental illness about
mental illness through education about the disease, potential for recovery, restoration of
hope, and insight on the best practices in the industry for the restoration and preservation
of every individual’s humanness.
61
Collection of the Materials and Conditions for Inclusion
The author’s final research for this project includes collection of information from
three informational sources including: the author’s Master level coursework, two major
research databases, and personal readings. The author’s research focus was to collect
information that was relevant to the research topic and personally meaningful to the
author, particularly in the selection of counseling processes, therapeutic
techniques/processes, and, severe and persistent mental illness treatments from Arthur E.
Jongsma, Jr. and Mark Peterson (2006) “The Complete Adult Psychotherapy Treatment
Planner.” Due to the fact that the author is a survivor of the onset of severe mental
illness, the author selected articles that provided opportunity and further insight on
personal growth and the healing process from severe and persistent mental illness.
Beginning with the Master level coursework, the textbooks that were collected
from coursework includes: Medical Aspects of Psychiatric Rehabilitation (COUN 251A),
Introduction to Counseling and Theory (COUN 174), Counseling and Mental Health
(COUN 176), Rehabilitation Counseling Civic History (COUN 250), Psychosocial
Aspects of Disability (REHAB 206), Psychopathology (COUN 232) and Multicultural
Counseling (COUN 201). To include material from the textbook “The Complete Adult
Psychotherapy Treatment Planner” by Arthur E. Jongsma, Jr. and Mark Peterson (2006),
from the course Psychopathology (COUN 232), the author of this project contacted the
publisher John Wiley & Sons, Inc. of the book and asked permission for inclusion of
material from the text into the author’s presentation. John Wiley & Sons, Inc. stated:
Permission is hereby granted for the use requested subject to the usual
acknowledgements (The Complete Adult Psychotherapy Treatment Planner /
62
Arthur E. Jongsma, Jr. and Mark Peterson /ISBN; Copyright [2006 and Arthur E.
Jongma, Jr. and L. Mark Peterson]. And the statement “This material is
reproduced with permission of John Wiley & Sons, Inc.”). Any third party
material is expressly excluded from this permission. If any of the material you
wish to use appears within our work with credit to another source, authorization
from that source must be obtained. This permission does not include the right to
grant others permission to photocopy or otherwise reproduce this material except
for versions made by non-profit organizations for use by the blind or handicapped
persons. (Email, October 7, 2011)
The second source of information was, two major research databases that were
researched for this project manual. The first database search is from NARIC (National
Rehabilitation Resource Center) a national resource database focusing and housing research in
the area of rehabilitation and disability. The NARIC database was recommended by Dr.
Malachy Bishop from University of Kentucky when the author inquired about resources in the
area of rehabilitation and disability. The author established Dr. Bishop as a contact after
studying at Southern University, Summer Research Institute 2009 funded by NIDRR
Scholarship, in Baton Rouge, Louisiana where Dr. Bishop taught meta-analysis and data-mining
techniques. The second database that was used for this presentation was the Psychiatric
Rehabilitation Journal published by the Center for Psychiatric Rehabilitation at Boston
University. A fee of $80.00 was paid by the author for access to the database. The author
initially collected approximately 200 articles which were reviewed for inclusion in the final
project. During the second week of December, the author’s backpack was stolen from her car
with most of the literature collected; however, the author recovered most of the articles easily
63
through NARIC and the author’s subscription to the Psychiatric Rehabilitation Journal. The
descriptors for the collection of materials included “psychiatric rehabilitation,” “counseling and
psychiatric rehabilitation,” “counseling therapy and psychiatric rehabilitation,” “counseling
therapies,” “counseling therapy,” “therapeutic processes and psychiatric rehabilitation,”
“therapeutic techniques and psychiatric rehabilitation,” “therapy and psychiatric rehabilitation,”
“biotherapy,” “double-binding,” “psychotherapy and focusing,” “recovery and psychiatric
rehabilitation,” “employment and psychiatric rehabilitation”. The author selected articles that
supported the empirical research in today’s psychiatric rehabilitation processes and the values of
today’s psychiatric rehabilitation Recovery Model:
1. Everyone has the right to SELF-DETERMINATION, including participation in all decisions
that affect their lives.
2. Psychiatric rehabilitation interventions RESPECT and PERSERVE the DIGNITY and
WORTH of every HUMAN being, regardless of the degree of impairment, disability, or
handicap.
3. OPTIMISM regarding the IMPROVEMENT and EVENTUAL RECOVERY of persons with
severe mental illness is a critical element of all services.
4. Everyone has the capacity to LEARN and GROW.
5. Psychiatric Rehabilitation Services are SENSITIVE to and RESPECTFUL of the individual,
CULTURAL and ethnic differences of each consumer (Pratt et al., 2007, p. 115-118).
From here the author narrowed down the research to a broad scope of effective
counseling and therapeutic processes use today in psychiatric rehabilitation, with empirical
evidence. It was important for the author to have a collective and diverse scope of all processes
64
that were also personally meaningful to the author as well in her own recovery processes from
severe mental illness.
The third source of information was the personal readings, which were used in
development of this project study manual limited to two books from John Bradshaw and Estelle
Frankel which were referenced in this section’s literature review. In summary, the author
reviewed a total of seven (7) textbooks which all were used in this project, and 84 articles 17 of
which were selected from both databases, with one (1) article remaining from the PsycINFO
database, Henry Madden Library at California State University, Fresno.
Chapter Summary
The author’s project methodology and project manual are guided by the insightful
direction of current psychiatric rehabilitation practices, encompasses the main goals from
the Recovery Model. The primary treatment for severe mental illness is through
biomedical therapy; however, medication compliance is an ongoing issue in the recovery
of people with severe mental illness. In the attempt to produce positive outcomes
towards the full recovery of severe mental illness and going back to work, experts
recognize the individual is faced with adapting to the disability first, then recovery, which
counseling and therapeutic techniques help facilitate. The researcher’s audience for this
project is for rehabilitation counselors, mental health providers, potential employers,
students, and victims of severe and persistent mental illness. The manual will serve as a
training guide and informational resource on counseling and therapeutic processes that
have shown to be effective for people with and recovering from severe mental illness. In
summary, the author’s research for this project include collection of information from
65
three major informational sources, including the author’s Master level coursework, two
major research databases, and personal readings. In Chapter Four the author will present
her study manual of the project.
66
CHAPTER FOUR
PRESENTATION OF THE PROJECT
Introduction
The new approaches to recovery are evident in psychiatric rehabilitation with the
introduction of the Recovery Model and Paradigm. William A. Anthony at the Center of
Psychiatric Rehabilitation at Boston University points out that work by researcher
Desisto, Harding, McCormick, Ashikaga, and Brooks, (1995a, 1995b), conveyed
contradictory to the belief that severe mental illness was a deteriorative disease, recovery
from mental illness was happening (Dana et al., 2008). With the findings, in the 1990s
increasing states and countries began to take on the “recovery vision,” that influenced the
thinking of many of today’s system planners and administrators according to Anthony
(Dana et al., 2008, p. 319). This empirically lead reconstruction of psychiatric
rehabilitation practices is supported by earlier grassroots advocacy initiatives for people
with disabilities beginning in the 1960s like the Independent Living Movement, with
other pivotal transitions enabling people and breaking barriers of oppression, such as the
civil rights movement, consumerism, self help, demedicalization, and
deinstitutionalization (DeJong, 1979). With the development of the Independent Living
Movement, later defined by Gerben DeJong (1979) as the Independent Living Paradigm,
has also defined and influenced the range of intervention to those problems in new ways,
infusing new perspectives about the human service system as whole also. The new
perspectives are evident and have influenced current disability practices, specifically in
the context of psychiatric rehabilitation and the development of the Recovery Model (Dr.
67
Charles Arokiasamy, personal communication, Professor, California State University,
Fresno, December 16, 2010; Dr. Juan Garcia, personal communication, Professor,
California State University, Fresno, November 18, 2010).
It is the researcher’s intent to present current practices in Psychiatric
Rehabilitation that are based on the Recovery Model for an audience including
rehabilitation counselors, mental health providers, potential employers, students, and
victims of severe and persistent mental illness. The statement of problem on this topic
conveys that employment rates are very low for people with severe and persistent mental
illness, because the transition from illness to work is difficult (Provencher, Gregg, Mead,
and Mueser, 2002). Barriers to work include symptoms, self-esteem, quality of life, and
clinical and social instability (Provencher et al., 2002). The primary treatment for severe
mental illness is through biomedical therapy; however, medication compliance is an
ongoing issue in the recovery of people with severe mental illness. In the attempt to
produce positive outcomes towards the full recovery of severe mental illness and returing
to work, experts recognize the individual is faced with adapting to the disability first, then
recovery, which counseling and therapeutic techniques help facilitate. It is the purpose of
this project to present specific counseling and therapeutic techniques that are included in
the rehabilitation process that facilitate various insights (such as self-acceptance, self-
management, social connectedness, self-esteem) that produce successful outcomes for
people with severe mental illness. This approach will allow service providers to have the
clarity of what has proven to be effective and to understand the techniques that facilitate
efforts for such issues as symptom management, relapse prevention, medication
compliance and psychosocial issues, such as social phobia. In this study guide, the
68
author will highlight the current practices of psychiatric rehabilitation (PsyR) and
counseling therapies and therapeutic techniques included in the rehabilitation process for
individuals recovering from severe mental illness, describe treatments for a selection of
mental illnesses, and articulate recommendations for an insightful workplace on
inclusiveness for a person with a psychiatric disability. The research question which
guided this project is: What counseling therapies and therapeutic techniques are included
in the rehabilitation process, for people recovering from severe mental illness?
69
Chapter Summary
In this chapter the author presented the study manual that includes six major
sections researched for this project including the introduction, counseling therapies, other
therapeutic techniques, summary on processes, psychotherapy interventions on severe
and persistent mental illness, and recommendations for workplace inclusion. First,
introduction included the history of the Independent Living Movement and the
development of Recovery Model; the goals, values and guiding principles of the
Recovery Model; the statement of the problem and the purpose of the project; and the
etiology of severe and persistent mental illness. Additionally, the author presented
insights regarding the adaption to disability; as well as the conditions enabling
adaptation; presentation and comparison of the Resiliency Model to the Recovery model;
and the relevance and acknowledgement of Cognitive Behavioral Therapy in psychiatric
rehabilitation process. Second, the body of the study manual includes counseling and
other therapeutic process included in the rehabilitation process for people recovering
from severe and persistence mental illness, encompassed five counseling processes and
nine alternative types of therapeutic processes enabling the recovery from severe and
persistent mental illness. Third, the author included a brief summary on the each of the
fourteen processes presented from the project literature review. Fourth, the author
included psychotherapy techniques for ten of the most common mental illnesses,
condensed from the Adult Psychothery Treatment Planner by Arthur E. Jongsma, Jr. and
Mark Peterson (2006). Finally the author, presented insights on workplace inclusion
from the Technical Assistance Process Guide Enhancing Workplace Inclusion By Boston
University Center for Psychiatric Rehabilitation (2010). Collectively, the study manual
70
included six different major content sections including the introduction, counseling
processes, other therapeutic processes, summary on the fourteen processes presented in
the project literature review, psychotherapy techniques used for ten of the most common
mental illnesses, and recommendations for workplace inclusion.
71
CHAPTER FIVE
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
Introduction
The background for this project is an audience for rehabilitation counselors,
mental health providers, potential employers, students, and victims of severe and
persistent mental illness. The manual will serve as a study, training guide and
informational resource on counseling and therapeutic processes that have shown to be
effective for people recovering from severe mental illness. The study guide, which is
guided by the insightful direction of current psychiatric rehabilitation practices,
encompasses the main goals from the Recovery Model and presents the processes that are
supported by empirical evidence in facilitating recovery for people with severe mental
illness, leading to more meaningful and fulfilling lives.
The statement of the problem is that employment rates are extremely low for
individuals with severe and persistent mental illness, because the transition from illness
to work is difficult (Provencher, Gregg, Mead, and Mueser, 2002). Barriers to
employment may include symptoms, self-esteem, quality of life, and clinical and social
stability. These barriers to employment (such as symptoms, low self-esteem, quality of
life and clinical and social instability) are conveyed in the analysis of employment rates
for people with psychiatric disabilities which range between 10-20% (Provencher et al.,
2002). The primary treatment for severe mental illness is through biomedical therapy;
however, medication compliance is an ongoing issue in the recovery of people with
severe mental illness. In the attempt to produce positive outcomes towards the full
72
recovery of severe mental illness and going back to work, experts recognize the
individual is faced with adapting to the disability first, then recovery, which counseling
and therapeutic techniques help facilitate. The researcher’s findings of this are
essentially uncovering that an individual’s proactive strategies in rehabilitation, social
connectedness, and focusing on the process of recovery for persons with severe and
persistent mental illness, rather than the result, is proving to be successful for positive
rehabilitation outcomes, like returning back to work (Jinhee Park, Personal
Communication, Doctoral Student Illinois Institute of Technology, National Council on
Rehabilitation Education Conference, April 8, 2010 and Lydie Levy, Personal
Communication, Partner/VP Business Development, IPLux Xpertise S.a.r.l., Social
Psychology, Universite Vincennes-Saint-Denis (Paris); Master Business Administration,
Reims Management School; Master Business Law, Universite de Reims Champagne-
Ardenne, Gemstar TV-Guide International, August 1, 1997; Provencher et al., 2002).
The purpose of this project is to affirm the understanding of the importance of
self-determination and how successful rehabilitation outcomes are realized or influenced
for people with psychiatric disabilities through a process of various insights such as
acceptance of the disability, medication management, and attaining independence by
attaining a home, gainful employment, and meaningful relationships. This independence
is what is considered as successful rehabilitation outcomes according to the current
psychiatric principles discussed by Pratt, Gill, Barrett, and Roberts (2007). The research
question which guided this project is: What counseling therapies and therapeutic
techniques are included in the rehabilitation process, for people recovering from severe
mental illness? In the following sections the author will present summary of counseling
73
and therapeutic techniques presented in the author’s literature review of chapter two, the
author’s conclusions, recommendation, and the chapter summary.
Summary
The Independent Living Movement in the 1960s was a grassroots effort for
change in the civil rights for people with disabilities. This historical movement for
change influenced later efforts for the civil rights for people with severe and persistent
mental illness. With the introduction of the Recovery Model by psychiatrists in 1990s, it
became well known that severe mental illness was not a deteriorative disease (Dana et al.,
2008). As a result of these findings, states and countries began adopting the “recover
vision,” which influenced the thinking of many system planners and administrators (Dana
et al., 2008, p. 319). The Recovery System of Care was developed based on consumer
input and involvement, and influenced by recovery assumptions such, “recovery demands
that a person has choices” (Dana et al., 2008, p. 318). This advocacy for autonomy, self-
determination, and independence reminds researchers of the core values of the
Independent Living Movement, and the grounding of psychiatric rehabilitation in the
Recovery Model is today’s analytical paradigm for people with disabilities recovering
from severe mental illness.
In the first chapter, the author presents the statement of problem on this topic,
which conveys that employment rates are low for people with severe and persistent
mental illness, due to the fact that the transition from illness to work is difficult
(Provencher et al., 2002). Barriers to employment include symptoms, self-esteem,
quality of life, and clinical and social instability (Provencher et al., 2002). It is well know
74
that the primary treatment for severe mental illness is through biomedical therapy;
however, medication compliance is a major issue in the recovery of people with severe
mental illness. In the attempt to produce positive outcomes towards the complete
recovery from severe mental illness and returning to employment, researcher recognize
the individual is faced with adapting to the disability first, then recovery, which
counseling and therapeutic techniques help facilitate. It is the purpose of this project to
present specific process-oriented counseling and therapeutic techniques that are included
in the rehabilitation process facilitating various recovery insights (such as self-
acceptance, self-management, social connectedness, self-esteem) and that produce
successful outcomes for people with severe mental illness. This approach will allow
counselors, students, and service providers, employers, and victims of severe mental
illness, clarity of what has proven to be effective and understanding the techniques that
facilitate efforts for such issues as symptom management, relapse prevention, medication
compliance and psychosocial issues, such as social phobia. The research question which
guided this project is: What counseling therapies and therapeutic techniques are included
in the rehabilitation process, for people recovering from severe mental illness?
In Chapter Two, the author describes current day psychiatric rehabilitation is
about focusing on the process not the result, to attain better mental health. There are
various process-oriented counseling and therapeutic techniques that help facilitate
adaptation and recovery of severe mental illness that were presented in Chapter Two
including:
75
1. Cognitive Remediation: The process of improvement of cognitive functioning
through social information processing, job coaching, work therapy, as well practice of
attention, verbal memory, and planning, and the use of coping cards (McGurk, 2008).
2. Person-Centered Therapy: A process that facilitates the relationship between
Therapist and Client through the core therapist conditions including: 1. congruence
and genuineness, 2. unconditional positive regard and acceptance, 3. accurate
empathic understanding.
3. Group Therapy: A new process-oriented training approach format known as
interactive behavioral training (IBT), integrative approach to group therapy in
psychiatric rehabilitation.
4. Solution Focused Therapy: A process that encompasses the values of the Recovery
Model.
5. Psychotherapy: A therapeutic process helping the individual to establish a deeper
level of meaning in his or her life by developing the individual’s inner resources and
capacities in self expression, resolve issues of avoidance, identify recurring
themes/patterns, explore of past experiences, and focus on the interpersonal
relationship according to publication author Jonathan Shedler (2010).
6. Occupational Therapy: A process encompassing the bodily felt sense of focus as it
applies to occupational tasks that individuals participate in, such as self-care,
productivity, and leisure.
7. Exercise Therapy: A process for the individual to establish a sense of normality in
managing his or her disability (Forgarty et al., 2004)
76
8. Motivational Interviewing: Applied to psychiatric rehabilitation, motivational
interviewing is a process that focuses on treatment related issues such as
participation, compliance, and developing insight; it is essentially used to promote
wellness and managing symptoms, and lessen likelihood for relapse and/or
hospitalization. (Wagner & McMahon, 2004; Rusch & Corrigan, 2002).
9. Spirituality and Religion: A process of integration of spirituality and religion into our
service system processes that calls for 1. Spiritual information gathering, 2.
Acknowledging the client’s explanatory framework, 3. Expanded consultative model,
4. Using Spiritual and Mystical Practices to Assist with Recovery (Blanch, 2007).
10. Disclosure: The process of disclosure involves addressing three major barriers to
psychiatric rehabilitation according to researcher Ruth O. Ralph (2002) which are:
secrecy and control, shame, and discrimination and stigma. Ralph (2002) supports
the idea of disclosure and discusses the advantages for disclosure as “therapeutic and
can lead to greater emotional wellness” (Ralph, 2002, p. 169).
11. Photovoice: This addresses the process of stigma and the negative effects rejection
can have on the human psyche.
12. Role Development: A process of developing positive self-identification through
meaningful social roles (Schindler, 2005).
13. Leadership Education: A process promoting the recovery potential for individuals
with severe mental illness, by fostering an environment of lecture, group processes,
experimental learning, and empowerment through leadership training with an
insightful purpose, developing diversity among government boards, committees, and
non-profits that include people with disabilities (Bullock et al., 2000).
77
14. Empowerment: A process combating oppression. The researchers of this study
provided insight on empowerment as quantifiable against the theoretical model and
concluded to agree with theoretical analysis that empowerment makes a difference in
overall mental health and produces positive outcomes in the total rehabilitation
process.
Collectively, these counseling and therapeutic techniques conveyed that by
focusing on the process and not the result, the individual will achieve the result he or she
wants.
In Chapter Three, which is the Methodology; the author presented the population
and sample for this project and the collection of the materials and conditions for
inclusion. For the population and sample, the researcher’s audience for this project is
rehabilitation counselors, mental health providers, potential employers, students, and
victims of severe and persistent mental illness. The study manual was developed to serve
as an informational resource and a training guide on counseling and therapeutic processes
applied to psychiatric rehabilitation, which is shown to be effective for people recovering
from severe mental illness. Second, the collection of the materials and conditions for
inclusion, the author researched three major information resources including Masters
coursework material, two research databases, and personal readings.
In Chapter Four, the Presentation of the Project, the author developed a
comprehensive study manual including:
1. Independent Living Movement and the Recovery Model in Psychiatric Rehabilitation
2. New Findings: Severe and Persistence Mental Illness is not a deteriorative disease
3. Manifestation of Mental Illness: Example- Schizophrenia
78
4. Impact of Disease: Effects on Quality of Life (QOL)
5. Audience for this Presentation
6. Statement of the Problem (Issue)
7. Statement of the Purpose
8. The Principle of Autonomy- Choice
9. Etiology of Severe and Persistent Mental Illness
10. Three (3) Goals of Current Psychiatric Rehabilitation Process
11. Five (5) Values of Current Psychiatric Rehabilitation Process
12. 13 Guiding Principles of Psychiatric Rehabilitation
13. Predictors of Recovery from Severe and Persistent Mental Illness
14. Treatment of Severe and Persistent Mental Illness
15. Adaption to Chronic Illness and Disability
16. Conditions Enabling Adaption
17. Resiliency Model vs. Recovery Model
18. Psychiatric Rehabilitation is about a Process not the Result: If you focus on the
process you get to the result.
19. Cognitive Behavioral Therapy and Psychiatric Rehabilitation- Most commonly used
treatment for Severe Mental Illness.
20. Counseling Therapies
21. Other Therapeutic Processes
22. Severe Mental Illnesses- Psychotherapy Treatment Planner
23. Application for Employers: Types and Definitions of Workplace Prejudice and
Discrimination -Recognition for Workplace Inclusion
79
24. References
Conclusions
The most important thing that the author learned in this project is that current day
psychiatric rehabilitation is about a process. Empirical evidence supports the notion that
if an individual with severe mental illness focuses on the processes to attaining better
mental health through biomedical therapy, counseling therapy, and other therapeutic
techniques, this combination is the best predictor of recovery (Weiten, Lloyd, Dunn, &
Hammer, 2009). When an individual partakes in counseling and therapeutic processes
during recovery, a stronger individual sense of self, and social connectedness is the result.
This sense of self and social connectedness is marked as significant factors to the
successful outcomes in psychiatric rehabilitation and returning to work, as the author
indicated through the presentation of various studies for this project.
The author also learned that through focusing on the process of rehabilitation, an
individual is more likely to be successful in adapting to his or her disability. It is well
documented that severe and persistent mental illness in the active phase of psychosis
includes delusions, hallucination, hearing voices, racing thoughts, etc. This active phase
of severe mental illness is essentially overactive and underactive chemicals in the brain,
causing electrochemical malfunction. It is the author’s opinion that adaptation to this
chaos is best described by researcher Livneh and Parker (2005) in the article
“Psychological Adaption to Disability,” stating, “the process of adaptation, then, is
essentially a process of self-organization that unfolds through experiences of chaos (i.e.,
emotional turmoil) and complexity (i.e., cognitive and behavioral reorganization) to
80
increased functional dimensionality and renewed stability, even if temporary” (p. 22). It
is clear, however, that this adaptation to disability cannot happen successfully without the
intervention of biomedical therapy, which helps with direct treatment of active phase
symptoms in severe and persistent mental illness. Once symptoms are controlled in
severe mental illness, the individual can then begin further adapt toward full recovery
with aid of counseling and therapeutic techniques that help facilitate a process of
recovery though facilitating processes of social connectedness and self-identification
beyond disability. It is essential in the recovery process to establish and develop
healthily relationships that foster insight and individual growth, as well as interpersonal
growth through counseling therapy which provides a significant opportunity in personal
exploration.
Additionally, the author also felt that the issue of stigma concerning people with
psychiatric disabilities is relevant and also proved to be a significant barrier to recovery.
Because of this the author sought out to find out more information on the topic of stigma
and recently discovered at the National Conference for Rehabilitation Education (NCRE
2011), that stigma can become internalized. Internalized stigma among people with
severe mental illness can result in coping through secrecy and withdraw (Hsin-Ya Liao,
personal communication, Doctoral Student, University of Arizona, NCRE Conference
Poster Presentation Manhattan Beach, April 7, 2011). Hence, it is advantageous for
Rehabilitation Counselors, students, potential employers, and victims of severe and
persistent mental illness to know as much about the disease as possible, and for victims
become socially connected in their environment to combat stigma and the potential for
being stigmatized as well.
81
When I first began developing this project I was not sure what direction it was
going to go. My literature encompassed two major sources of information including my
Masters coursework and two research databases, NARIC and the Psychiatric
Rehabilitation Journal at Boston University, and personal readings. I kept grounded
during this project by asking myself the question “What information is personally
meaningful to me?” Being a survivor of the onset of severe mental illness myself, there
were certain pivotal moments in my recovery that made a significant difference in
overcoming the onset of severe mental illness. Those pivotal moments included the
opportunity of choices and self determination in successfully seeking out services and
treatment for severe mental illness, peer support, continuing my education and finding a
new vocational goal, working with my disability and knowing my limits, and seeking out
opportunities for personal growth beyond disability. Taking on this project was an easy
decision for me, I knew I had a skill set that my experience surviving from severe mental
illness gave me, that if developed, I could provide some insightful information on the
recovery process in psychiatric rehabilitation.
My conclusions for this project includes four points. The first is to follow what is
personally meaningful. I feel that if you can follow a task that is personally meaningful,
that grounding can go a long way. For example, when I first signed up to do the project it
was in Spring 2010. At this time I was not done with my master coursework, and it was
not until Spring 2011, that I had time to focus on really bringing my project together. My
car was also broken into the second week of December 2010, and my backpack with all
my literature was stolen. If this project did not have personal meaning for me, it is
possible that I could have given up from being over extended or from the vandalism. My
82
point is to always do something you love! Second, it is imperative to save all your
literature digitally and email copies of your project to yourself through the progression of
the project. When my car was broken into it was a bit of a task to go back and try to find
my research, hence saving all articles digitally is essential. During my project I also had
a couple of computer malfunctions and those moments of not being able to access my
computer, housing all my research information, was anxiety provoking to say the least.
Hence, I recommend to email yourself a copy of the project during the progression
project development. Third, I recommend to always look outside the box for references.
The databases on campus at Fresno State are highly resourceful; however, the
information was not fitting my exact needs for this project, so I sought out other
resources, which was what I needed to make this project a success. Finding the research
database NARIC and paying a somewhat costly fee for access to the Psychiatric
Rehabilitation Journal through Boston University was worth the extra effort and
investment, because these databases specialize in rehabilitation and accounts for the most
current practices today in psychiatric rehabilitation. Lastly, for the presentation of the
actual project, if you are finding that the research collected cannot be simplified to basic
terms for a PowerPoint presentation, do not be afraid to do a manual. I started off doing a
PowerPoint presentation which was a lot of work, and it was later recommended for me
to translate the information into a manual format. I thought I would lose that time I put
forth for a presentation but this was not the case at all. Patience is a virtue, and the
translation to a manual format was rather simple, and as it turned out it is much more user
friendly and esthetically pleasing; it turned out wonderfully and I was very happy with
the final product.
83
Recommendations
For future researchers, the author’s recommendations for this study would be to
implement a quantitative analysis on how the process of recovery from severe mental
illness, through counseling and other therapeutic techniques, is relevant to the re-
development of flowing affect through a personal felt sense (Gendlin, 1969) and free
expression (Shedler, 2010), and through the connection of self and others (the
relationship). The author understands that Cognitive Behavioral Therapy is very
effective in the treatment of severe mental illness, treatment of the illness in highly
adverse environments; however, in order for the self to heal, the individual must go
through a process of healing from his or her trauma that more process oriented therapies
can address. If a comparative analysis of process therapies versus result therapies could
be completed, perhaps we would discover that the restoration of humanness (process
therapies) rather than righteousness (result therapies) is possible. Hence, the author’s
opinion that both techniques are very needed.
Therefore, the author’s second recommendation accompanying a quantitative
study is the development of the restoration model. The restoration model could
encompass the phases of the human restoration process beginning with result oriented
therapies such as Cognitive Behavioral Therapy, to more process oriented therapies such
as person centered therapy, group therapy (process oriented), and, psychotherapy; a
ranging scope from simple to complex. The author feels that the inclusiveness of a
comparative quantitative analysis between result therapies and process therapies, may
better convey insightful recovery phases of human restoration, which may or may not be
a linear process. Lastly, the author recommends that for the next researcher approaching
84
this research topic, it may be beneficial to seek out process oriented therapies in library
searches. This may account for more literature on the topic of process oriented therapies,
narrow down searches, and may allow for more inclusiveness on previously studied
process oriented therapy studies.
Chapter Summary
The author covered three different topics in this section including a summary on
the project presented, the author’s conclusions on the project, and lastly the author’s
recommendations. First, chapter five includes a collective summary on chapters one: the
Introduction, chapter two: the Literature Review, chapter three: the Methodology, and
chapter four: the Presentation of the Project. Second, in this chapter the author conveyed
conclusions that expressed what the author learned during the progression of this project.
Finally, the author concluded this chapter with recommendations for researchers
embarking on a similar project endeavor in the future.
In final conclusion, for counselors, mental health professions, potential
employers, students, and victims of severe and persistent mental and current and future
researchers, this process of developing a project encompasses the knowledge that I have
attained through my Master coursework, external research sources, and through my
personal experience as well; collectively this has been deeply gratifying to put on paper,
and signifies a phase of accomplishment in my life. My hope that as interested parties
that you find the information presented in my project insightful, resourceful and inspire
you to be further curious and explore issues of mental illness, whether it be through
research, writing, and discussion, without hesitation.
85
REFERENCES
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bind, Fam Proc, 2, 154-161.
Bishop, M., Chapin, M.H., & Miller, S. (2008). Quality of life assessment in the
measurement of rehabilitation outcome. Journal of Rehabilitation, 74(2), 45-54.
Blanch, A. (2007). Integrating religion and spirituality in mental health: The promise and
the challenge. Psychiatric Rehabilitation Journal, 30(4), 251-260.
Boston University Center for Psychiatric Rehabilitation (2010). Technical
assistance process guide: Enhancing workplace inclusion for employees
with psychiatric disabilities. Center for Psychiatric Rehabilitation, College
of Health and Rehabilitation Sciences (Sargent College).
Bradshaw, J. (1988). Healing The Shame that Binds You. Health Communications, Inc.
Bullock, W.A., Ensing, D.S., Alloy, V.E., & Weddle, C.C. (2000). Leadership education:
Evaluation of a program to promote recovery in persons with psychiatric
disabilities. Psychiatric Rehabilitation Journal, 24(1), 3-12.
Corey, G. (2009). Theory and Practice of Counseling and Psychotherapy, Eighth Edition.
Brooks/Cole, Cengage Learning.
Dana, R.H., Gamst, G.C., & Der-Karabetian, A. (2008). CBMCS Multicultural Reader.
Sage Publications, Inc.
Daniels, L. & Roll, D. (1998). Group treatment of social impairment in people with
mental illness. Psychiatric Rehabilitation Journal, 21(3), 273-278.
DeJong, G. (1979). Independent living: From social movement to analytic paradigm.
Archives of Physical Medicine and Rehabilitation, 60, 435-446.
Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition (2009)
Gendlin, E. T. (1969). Psychotherapy: Theory, research and practice. Psychotherapy,
6(1), 4-15.
Fogarty, M., Happell, B., & Pinikahana, J. (2004). The benefits of an exercise program
for people with schizophrenia: A pilot study. Psychiatric Rehabilitation Journal,
28(2), 173-176.
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Frain, M., Bishop, M., & Tschopp, M.K. (2009). Empowerment variables as predictors of
outcomes in rehabilitation. Journal of Rehabilitation, 75(1), 27-35.
Frankel, E. (2003). Sacred Therapy. Shambhala Publishers, Inc.
Johnson, D., Russinova, Z., & Gagne, C. (Eds.) (2008). Using photovoice to fight the
stigma of mental illness. Recovery and Rehabilitation, 4(4), 1-4.
Jongsma Jr., A.E., & Peterson, M.L. (2006). The Complete Adult Psychotherapy
Treatment Planner, Fourth Edition. John Wiley & Sons, Inc.
Kileen, M.B., & O’Day, B.L. (2004). Challenging expectations: how individuals with
psychiatric disabilities find and keep work. Psychiatric Rehabilitation Journal,
28(2), 157-163.
Krupa, T., Fossey, E., Anthony, W.A, Brown, C., & Pitts, D.B. (2009). Doing daily life:
How occupational therapy can inform psychiatric rehabilitation practice.
Psychiatric Rehabilitation Journal, 32(3), 155-161.
Lavee, Y., McCubbin, H., & Patterson, J. (1985). The double ABCX model of family
stress and adaptation: An empirical test by analysis of structural equations with
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Livneh, H. (2001). Psychosocial adaptation to chronic illness and disability: A conceptual
framework. Rehabilitation Counseling Bulletin, 44(3), 151-160.
Livneh, H., & Randall P. (2005). Psychological adaptation to disability: Perspectives
from chaos and complexity theory. Rehabilitation Counseling Bulletin, 49(1), 17-
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McGurk, S.R., & Wykes, T. (2008). Cognitive remediation and vocational rehabilitation.
Psychiatric Rehabilitation Journal, 31(4), 350-359.
Pratt, C.W., Gill, K.J., Barrett, N.M., & Roberts, M. (2007). Psychiatric Rehabilitation,
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Edition. Academic Press.
Provencher, H.L., Gregg, R., Mead, S., & Mueser, K.T. (2002). The role of work in the
recovery of persons with psychiatric disabilities. Psychiatric Rehabilitation
Journal, 26(2), 132-144.
Ralph, R.O. (2002). The dynamics of disclosure: Its impact on recovery and
rehabilitation. Psychiatric Rehabilitation Journal, 26(2), 165-171.
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Rusch, N., & Corrigan, P.W. (2002). Motivational interviewing to improve insight and
treatment adherence in schizophrenia. Psychiatric Rehabilitation Journal. 26(1),
23-32.
Russinova, Z., Bloch, P., Wewiorski, N., & Rosoklija, I. (March, 2006).
Manifestations of psychiatric stigma at the workplace. Paper presented the
Internation Work, Stress and Health Conference, Miami, Florida, March
2-4, 2006
Saks, E. R. (2007). The Center Cannot Hold. Hyperion.
Schindler, V. (2005). Role development: an evidenced-based intervention for individuals
diagnosed with schizophrenia in a forensic facility. Psychiatric Rehabilitation
Journal, 28(4), 391-394.
Schott, S.A., & Conyers, L.M. (2003). A solution-focused approach to psychiatric
rehabilitation. Psychiatric Rehabilitation Journal, 27(1), 43-50.
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American
Psychologist, 65(2), 98-109.
Wagner, C.C., & McMahon, B.T. (2004). Motivational interviewing and rehabilitation
counseling practice. Rehabilitation Counseling Bulletin, 47(3), 152-161.
Weiten, W., Lloyd, M.A., Dunn, D.S., & Hammer, E.Y. (2009). Psychology Applied to
Modern Life, Adustment in the 21st Century, Ninth Edition. Wadsworth Cengage
Learning.
88
APPENDIX
0
Practical Application and Presentation of
Counseling and Therapeutic Techniques Included in the
Rehabilitation Process for
People Recovering from Severe Mental Illness
STUDY MANUAL
AND
PRESENTATION
For Inclusion in the
Psychiatric Rehabilitation Process for
Educational, Informational and Training Purposes
Written and Edited by
Michele E. Salas, M.S.
California State University, Fresno
1
TABLE OF CONTENTS
Page
ACKNOWLEGMENTS . . . . . . . . . . . . . . . . 4
Acknowledgements . . . . . . . . . . . . . . 4
Inspirational Quote by Sting . . . . . . . . . . . . 5
SECTION ONE: INTRODUCTION . . . . . . . . . . . . . 6
Methodology . . . . . . . . . . . . . . . . 6
Independent Living Movement and the Recovery Model in PsyR . . 7
New Findings Mental Illnesses Not a Deteriorative Disease . . . . 7
Manifestation of Mental Illness: An Example . . . . . . . 8
Impact of Disease: Effects on Quality of Life (QOL) . . . . . 8
Audience for this Study Manual . . . . . . . . . . . 8
Statement of the Problem (Issue) . . . . . . . . . . . 9
Statement of the Purpose . . . . . . . . . . . . . 9
Research Question. . . . . . . . . . . . . . . 10
Principle of Autonomy- Choice . . . . . . . . . . . 10
Etiology of Severe and Persistent Mental Illness . . . . . . . 10
Three (3) Goals of Current Psychiatric Rehabilitation Process . . . 11
Five (5) Values of Current Psychiatric Rehabilitation Process . . . 11
Thirteen (13) Guiding Principles of Psychiatric Rehabilitation . . . 11
Predictors of Recovery from Severe and Persistent Mental Illness . . 12
Treatment of Severe and Persistent Mental Illness . . . . . . 12
Adaption to Chronic Illness and Disability . . . . . . . . 13
Conditions Enabling Adaption . . . . . . . . . . . 13
Resiliency Model vs. Recovery Model . . . . . . . . . 13
Psychiatric Rehabilitation as a Process . . . . . . . . . 14
Cognitive Behavioral Therapy (CBT) and PsyR . . . . . . . 15
2
Quote from Elyn R. Saks on CBT . . . . . . . . . . 15
SECTION TWO: COUNSELING THERAPIES . . . . . . . . . . 16
Cognitive Remediation . . . . . . . . . . . . . 16
Person-Centered Therapy . . . . . . . . . . . . . 18
Group Therapy . . . . . . . . . . . . . . . 18
Solution Focused Therapy . . . . . . . . . . . . 19
Psychotherapy . . . . . . . . . . . . . . . . 19
SECTION THREE: OTHER THERAPUETIC TECHNIQUES/PROCESSES . . 21
Occupational Therapy. . . . . . . . . . . . . . 21
Exercise Therapy . . . . . . . . . . . . . . . 22
Motivational Interviewing . . . . . . . . . . . . 22
Spirituality and Religion . . . . . . . . . . . . . 23
Disclosure . . . . . . . . . . . . . . . . . 25
Photovoice. . . . . . . . . . . . . . . . . 26
Role Development . . . . . . . . . . . . . . 27
Leadership . . . . . . . . . . . . . . . . . 27
Empowerment . . . . . . . . . . . . . . . . 28
A Poem by Maya Angelou “I Know Why the Cage Bird Sings” . . . 30
SECTION FOUR: SUMMARY ON PROCESSES . . . . . . . . . 31
Cognitive Remediation . . . . . . . . . . . . . 31
Person-Centered Therapy . . . . . . . . . . . . . 31
Group Therapy . . . . . . . . . . . . . . . 31
Solution Focused Therapy . . . . . . . . . . . . 32
Psychotherapy . . . . . . . . . . . . . . . . 32
Occupational Therapy. . . . . . . . . . . . . . 33
Exercise Therapy . . . . . . . . . . . . . . . 33
Motivational Interviewing . . . . . . . . . . . . 34
3
Spirituality and Religion . . . . . . . . . . . . . 34
Disclosure . . . . . . . . . . . . . . . . . 35
Photovoice. . . . . . . . . . . . . . . . . 35
Role Development . . . . . . . . . . . . . . 36
Leadership . . . . . . . . . . . . . . . . . 36
Empowerment . . . . . . . . . . . . . . . . 37
SECTION FIVE: SEVERE MENTAL ILLNESS AND PSYCHOTHERAPY . . 38
Severe Mental Illnesses from Psychotherapy Treatment Planner . . 38
Anxiety . . . . . . . . . . . . . . . . . 38
Dependency . . . . . . . . . . . . . . . . 39
Depression . . . . . . . . . . . . . . . . 39
Dissociation . . . . . . . . . . . . . . . . 40
Impulse Control Disorder . . . . . . . . . . . . . 41
Low Self Esteem . . . . . . . . . . . . . . . 41
Panic/Agoraphobia . . . . . . . . . . . . . . 42
Psychoicism . . . . . . . . . . . . . . . . 42
Social Discomfort . . . . . . . . . . . . . . . 43
Vocational Stress . . . . . . . . . . . . . . . 44
SECTION SIX: RECOMMENDATIONS FOR WORKPLACE INCLUSIONS. . . 45
Recognition for Workplace Inclusion . . . . . . . . . . 45
Supervisor . . . . . . . . . . . . . . . . 45
Co-Worker . . . . . . . . . . . . . . . . 45
Language. . . . . . . . . . . . . . . . . . 45
Behaviors . . . . . . . . . . . . . . . . . 46
REFERENCES . . . . . . . . . . . . . . . . . . 47
4
ACKNOWLEGEMENTS
I would like to acknowledge Dr. Valencia, for the patience he has shown me in helping
me to accomplish this project which I was uncertain if I were capable of doing. Thank you to
Dr. Valencia and Fida Taha, Assistant to Dr. Valencia, for guiding me, editing my work, and
being a true inspiration. Additionally, thank you to Joe Perez with the Department of
Rehabilitation who has supported me in pursuing my Masters Degree to become a Rehabilitation
Counselor, and Grace Cha, who introduced me to the Masters Rehabilitation Counseling
Program at Fresno State; without you both I would have missed this path to self-discovery.
Thank you my nano (Papa) Salvador Vizcarra and my tio Candelario Salas Barajas, tio Gregorio
(Goyo) Salas Barajas and my tia Yolanda Salas Barajas for your love and guidance in absence of
my father. To my friend and first supervisor out of college from University of Southern
California, Lydie Levy, an amazingly intelligent and insightful French Jewish woman, who
taught me about the importance and meaning of counseling and psychology, thank you with
much love. I read “Tales of Enchantment the Meaning of Fairly Tales,” by Bruno Beetleheim
over and over and throughout my recovery process. My deepest respect for her and her
inspiration has helped me survive the onset of severe mental illness and trauma thereafter. Last
but not least, thank you to my grandmother (nana) Adela Nava Barajas Salas who has taught me
about my culture and restored me with her love, kindness, protection and the most cherished
hugs, kisses, and always prayer- I feel the depth of authenticity of her heart next to mine.
Collectively, to all my mentors, family, and friends who have supported me through my
rehabilitation and pursuing my Masters Degree, I thank God and thank you, so much from the
deepest part of my living soul, you have given me life again!
5
To have found this perfect life
And a perfect love so strong
Well there can't be nothing worse
Than a perfect love gone wrong!
“Perfect Love...Gone Wrong”
–Sting
from a Brand New Day
6
SECTION ONE
INTRODUCTION
The research question which guided this project is: What counseling therapies and therapeutic
techniques are included in the rehabilitation process for people recovering from severe mental illness?
The author’s research for this project includes a collection of information from three informational
sources, including the author’s Master level coursework, two major databases, and personal readings.
First, coursework textbooks that were collected from: Medical Aspects of Psychiatric Rehabilitation
(COUN 251A), Introduction to Counseling and Theory (COUN 174), Counseling and Mental Health
(COUN 176), Rehabilitation Counseling Civic History (COUN 250), Psychosocial Aspects of Disability
(REHAB 206), Psychopathology (COUN 232) and Multicultural Counseling (COUN 201).
Second, the two major databases that were researched for this project presentation. The first
database search is from NARIC (National Rehabilitation Resource Center) a national resource database
focusing and housing research in the area of rehabilitation and disability. This database was
recommended by Dr. Malachy Bishop from University of Kentucky when the author inquired about
resources in the area of rehabilitation and disability. The author established Dr. Bishop as a contact after
studying at Southern University, Summer Research Institute 2009 funded by NIDRR Scholarship, in
Baton Rouge, Louisiana where Dr. Bishop taught meta-analysis and data-mining techniques. The
second database that was used for this project presentation was the Psychiatric Rehabilitation Journal
published by the Center for Psychiatric Rehabilitation at Boston University. A fee of $80.00 was paid
by the author for access to the database. Lastly, personal readings were used in development of this
project presentation limited to two books from John Bradshaw and Estelle Frankel which were
referenced in this section’s literature review. In summary, the author reviewed a total of 7 textbooks
which all were used in this project, and 84 articles and 17 were selected from both databases, with 1
7
article remaining from the PsycINFO database, Henry Madden Library at California State University,
Fresno.
The Independent Living Movement and the Recovery Model in Psychiatric Rehabilitation
The Independent Living movement has clearly made significant contributions to the
education of disability in the United States. Improving and protecting the civil rights of
people with disabilities, and transitioning to the Independent Living (IL) paradigm, which
defines problems and the range of intervention of those problems in new ways, is
infusing new perspectives about the human service system as whole (Dr. Charles
Arokiasamy, personal communication, Professor, California State University, Fresno,
December 16, 2010 & Dr. Juan Garcia, personal communication, Professor, California
State University, Fresno, November 18, 2010).
The new perspectives are evident and have influenced current disability practices,
specifically in the context of psychiatric rehabilitation, with the introduction of the
Recovery Paradigm or better known as the Recovery Model (Dr. Juan Garcia,
personal communication, Professor, California State University, Fresno, November 18,
2010).
New Findings: Severe and Persistence Mental Illness is not a deteriorative disease
According to William A. Anthony at the Center of Psychiatric Rehabilitation at Boston
University, the consumer literature in the 1980s concluded that severe mental illness,
particularly schizophrenia, was a deteriorative disease (Dana, Gamst, & Der-karabetia,
2008).
Anthony asserts that later work by researchers Desisto, Harding, McCormick, Ashikaga,
and Brooks (1995a, 1995b), proved that contradictory to the belief that severe mental
illness was a deteriorative disease, recovery from mental illness was happening (Dana et
al., 2008).
With these finding, in the 1990s increasing numbers of states and countries began to
adopt the “recovery vision,” which influenced the thinking of many of today’s system
planners and administrators according to William A. Anthony (Dana et al., 2008, p. 319).
8
Manifestation of Mental Illness: An Example- Schizophrenia
This is the most extreme example of human suffering caused by mental illness known to
man. These three phases of schizophrenia are (Diagnostic and Statistical Manual of
Mental Disorders, 4th
Edition; Centre of Addiction and Mental Health (2009).
Schizophrenia: An Informational Guide. http://www.camh.net):
Prodromal phase
In the prodromal phase, people may begin to lose interest in their usual activities and to
withdraw from friends and family members. They may become easily confused, have
trouble concentrating, and feel listless and apathetic, preferring to spend most of their
days alone. This phase can last weeks or months.
Active phase
During schizophrenia's active phase, people will have delusions, hallucinations, marked
distortions in thinking and disturbances in behavior and feelings. This phase is often the
most frightening to the person with schizophrenia, and to others.
Residual phase
After an active phase, people may be listless, have trouble concentrating and be
withdrawn. The symptoms in this phase are similar to those outlined under the prodromal
phase.
Impact of Disease: Effects on Quality of Life (QOL)
To address issues in the destruction of quality of life of individuals with severe mental
illness due to the disease, an individual must undergo a psychological restoration of their
humanness which counseling processes and therapeutic interventions facilitate (Dr. Juan
Garcia, personal communication, Professor, California State University, Fresno,
November 18, 2010).
This proactive process of restoration through counseling and other therapeutic techniques
can promote individual empowerment, greater knowledge of self and the environment,
self-efficacy, and connections with others (Jinhee Park, Personal Communication,
Doctoral Student Illinois Institute of Technology, National Council on Rehabilitation
Education Conference, April 8, 2010).
Audience for this Presentation
Rehabilitation Counselors: Serves as a training guide for rehabilitation counselors in the
area of counseling techniques included in the rehabilitation process for individuals with
9
severe mental illness. This training guide will also serve as insight for the rehabilitation
counselors for Individualized Plan Development for individuals with psychiatric
disabilities.
Mental Health Professionals: Serves as an insight for mental health professionals in the
area of counseling therapies and other therapeutic process when applied to psychiatric
rehabilitation.
Potential Employers: Serves as an insight on potential disability accommodations when
individuals with psychiatric disabilities are seeking employment or in job retention
programs.
Students: Serves as a supplement to practicum to ensure comprehensive training
combining counseling and case management when working with individuals with
psychiatric disabilities.
Victims of severe and persistent mental illness: To help facilitate the process of recovery
through insight and education of current day psychiatric rehabilitation process and
effective recovery interventions.
Statement of the Issue
Employment rates are extremely low for individuals with severe and persistent mental
illness because the transition from illness to work is difficult. Barriers to employment
may include symptoms, low self-esteem, poor quality of life, and clinical and social
instability.
These barriers to employment (symptoms, low self-esteem, poor quality of life, and
clinical and social instability) are realized in the analysis of employment rates for people
with psychiatric disabilities which range between 10-20% (Provencher, Gregg, Mead, &
Mueser, 2002).
Statement of the Purpose
The purpose of this project is to affirm the understanding of the importance of self-
determination and how successful rehabilitation outcomes are realized for people with
psychiatric disabilities through a process of various insights such as acceptance of the
disability, medication management, and attaining independence by attaining a
home, gainful employment, and meaningful relationships. This independence is what
is considered as successful rehabilitation outcomes according to the current psychiatric
principles discussed by Pratt et al. (2007).
10
Research Question
The research question which guided this project is:
What counseling therapies and therapeutic techniques are included in the rehabilitation
process, for people recovering from severe mental illness?
The Principle of Autonomy- Choice
Similar to the Independent Living Movement, the Recovery Model advocates for the
individual stating that the individual “should always receive treatment in the most
autonomous setting or environment that is possible but still effective” (Pratt, Gill, Barrett,
& Roberts, 2007 p. 113).
This principle of autonomy was developed to uphold the goals of community
integration and deinstitutionalization for people with psychiatric disabilities, which
the Independent Living Movement has essentially influenced, and in turn, preserved the
wellness and preservation of the human psyche (Dr. Juan Garcia, personal
communication, Professor, California State University, Fresno, November 18, 2010).
Etiology of Severe and Persistent Mental Illness
Research has uncovered that severe and persistent mental illness such as schizophenia is
biological, and is influenced by the individual’s vulnerability to the illness by both
genetic and prenatal factors (Walker, Kestler, Bollini, & Hochman, 2004).
Research has also uncovered that parental rejection, realized through communication
stressors such as double-binding messages, is a significant common factor among
individuals with severe mental illness such as schizophrenia, which cause stress (Bateson,
Jackson, Haley, & Weakland, 1963).
Pratt et al. (2007) explain that the brain “is an electrochemical organ and
neurotransmitters are literally the chemical messengers of the brain” (p. 55). The
neurotransmitters ensure the proper functioning in the brain, and the “malfunction”
accounts for the systems of two neurotransmitters involved with schizophrenia, dopamine
and serotonin. In person’s with schizophrenia the dopamine is overactive and the
serotonin is underactive (Pratt et al., 2007, p. 55).
The progression or recovery of the disease can be influenced by external stressors;
research has concluded that calm environments better promote recovery (Grace Cha,
11
personal communication, rehabilitation counselor, Department of Rehabilitation, San
Francisco, October 1, 2010).
Three (3) Goals of Current Psychiatric Rehabilitation Process
1. Psychiatric Rehabilitation Services are designed to help persons with severe mental
illness achieve RECOVERY.
2. Psychiatric Rehabilitation Services are designed to help persons with severe mental
illness achieve maximum COMMUNITY INTEGRATION.
3. Psychiatric Rehabilitation Services are designed to help persons with severe mental
illness achieve the highest possible QUALITY OF LIFE (QOL). (Pratt, Gill, Barrett, &
Roberts, 2007 p. 113)
Five (5) Values of Current Psychiatric Rehabilitation Process
1. Everyone has the right to SELF-DETERMINATION, including participation in all
decisions that affect their lives.
2. Psychiatric rehabilitation interventions RESPECT and PERSERVE the DIGNITY and
WORTH of every HUMAN being, regardless of the degree of impairment, disability, or
handicap.
3. OPTIMISM regarding the IMPROVEMENT and EVENTUAL RECOVERY of persons
with severe mental illness is a critical element of all services.
4. Everyone has the capacity to LEARN and GROW.
5. Psychiatric Rehabilitation Services are SENSITIVE to and RESPECTFUL of the
individual, CULTURAL and ethnic differences of each consumer (Pratt et al., 2007, p.
115-118).
Thirteen (13) Guiding Principles of Psychiatric Rehabilitation
1. Individualization of all services
2. Maximum client involvement, preference, and choice
3. Partnership between service provider and service recipient
12
4. Normalized and community-based services
5. Strengths focus
6. Situational Assessments
7. Treatment/Rehabilitation Integration, Holistic Approach
8. Ongoing, Accessible, Coordinated Services
9. Vocational Focus
10. Skills Training
11. Environmental Modifications and Supports
12. Partnership with the Family
13. Evaluation, Assessment, Outcome-Oriented Focus (Pratt et al., 2007, p. 119-125)
Predictors of Recovery from Severe and Persistent Mental Illness
1. Self- Identification
2. Social Connectedness
3. Stigmatization
(Jinhee Park, Personal Communication, Doctoral Student Illinois Institute of Technology,
National Council on Rehabilitation Education, April 8, 2010; from research project by
Jinhee Park, Eun-Jeong Lee,Youngshin Park- Illinois Institute of Technology)
Treatment of Severe and Persistent Mental Illness
The first line of treatment for severe and persistent mental illness is medication to
management the chemical imbalances in the brain (Pratt et al., 2007, p. 55).
Adaption to the disability with medication and eventual recovery is a process
accompanied WITH counseling and therapeutic techniques
13
Adaptation to Chronic Illness and Disability
As defined by Hanoch Livneh and Randall M. Parker in there article Psychological
Adaptation to Disability:
“The process of adaptation, then, is essentially a process of self-organization that unfolds
through experiences of chaos (i.e., emotional turmoil) and complexity (i.e., cognitive and
behavioral reorganization) to increased functional dimensionality and renewed stability,
even if temporary”
-Livneh, & Parker (2005).
Conditions Enabling Adaptation
Hanoch Livneh and Randall M. Parker in there article Psychological Adaptation to
Disability state that:
“This adaptive function, it is argued, is manifested through activities that demonstrate
CREATIVITY, SPONANEITY, and RISK TAKING”
-Livneh, & Parker (2005).
Resiliency Model vs. Recovery Model
Resiliency is based on a developmental process. The Recovery Model may seemed to
be defined based on the result (recovery from illness), however the Recovery Model
advocates not only for the right for self-determination but for an environment that fosters
self-determination. This in fact is a process of many factors that include the goals,
values, and guiding principles from the Recovery Model.
The Resiliency Model was developed because the Recovery Model has been coined as
coming from the Medical Model. The Resiliency Model looks at Resiliency to include the
following 7 components. Experts in the rehabilitation field acknowledge that the Resiliency
factor maybe a part of the Recovery Model, and not necessarily separate however:
1. Self-Confidence
2. Goal Oriented
3. Spirituality
4. Hope
14
5. Decision Making
6. Meaning of Life
7. Empowerment
(Dr. Eun-Jeong Lee, personal communication, Doctoral Student Illinois Institute of Technology,
NCRE Conference, Manhattan Beach, CA, April 8, 2011)
Psychiatric Rehabilitation is about a Process not the Result: If you focus on the process you get
to the result. Below is the list of counseling and therapeutic processes researched:
1. Cognitive Behavioral Therapy and Cognitive Remediation
2. Person-Centered Therapy
3. Group Therapy
4. Solution- Focused Therapy
5. Psychotherapy
6. Occupational Therapy
7. Exercise Therapy
8. Motivational Interviewing
9. Spirituality and Religion
10. Disclosure
11. Photovoice
12. Role Development
13. Leadership
14. Empowerment
Quote: “Focusing on the process will get you to the result you want.“ -Lydie Levy, Personal
Communication, Partner/VP Business Development, IPLux Xpertise S.a.r.l., Master Social
Psychology, Universite Vincennes-Saint-Denis (Paris); MBA, Reims Management School;
Master Business Law, Universite de Reims Champagne-Ardenne, Gemstar TV-Guide
International (COO Worldwide CE and Managing Director), August 1, 1997
15
Cognitive Behavioral Therapy (CBT) and Psychiatric Rehabilitation
Cognitive Behavioral Therapy is the most commonly used therapy intervention for
severe and persistent mental illness. Research has shown that Cognitive Behavioral
Therapy is effective in psychiatric rehabilitation and the technique is highly measurable.
Cognitive Behavioral Therapy focuses on behavioral results.
Cognitive Behavioral Therapy is not included in this presentation because it is not a
process therapy but rather a therapy that focuses solely on results.
The author of this presentation makes no judgment as to which therapy is more
effective, but believes a combination of both behavioral and process therapies, with
medication, is the best combination for recovery.
Quote on “CBT” from Elyn R. Saks
“Medication could be one solution, if your body chemistry tolerates it. You might also strive to
make your life as predictable and orderly as possible- to literally control the various ingredients
that make up your life- so that you knew ahead of time what was expected of you, what was
going to happen, and how to prepare for it. Your basic goal would be to eliminate surprises.
Slowly, painstakingly, you would rebuild your own internal regulator, with structure and
predictability. What you lose in the way of spontaneity, you gain by way of sanity.” – Elyn R.
Saks, The Center Cannot Hold (2007), New York Times Bestseller
16
SECTION TWO
COUNSELING THERAPIES
Counseling Therapies
1. Cognitive Behavioral Therapy and Cognitive Remediation
2. Person-Centered Therapy
3. Group Therapy
4. Solution- Focused Therapy
5. Psychotherapy
1. Cognitive Remediation (and CBT): Process of Taking Command over Behavior
Cognitive Remediation is different than Cognitive Behavioral Therapy (CBT) in that it
looks at the process or relationship between cognitive functioning and community
adjustment rather than just the result.
Susan R. McGurk (2008) points out that people with severe mental illness often face
many barriers to securing and maintaining employment due to cognitive difficulties such
as paying attention or concentrating, learning and remembering information,
responding in a reasonable amount of time to environmental demands, and
planning ahead and solving problems. According to author Susan R. McGurk, these
cognitive impairments “are obstacles to receiving the full benefits of vocational
rehabilitation” (2008, p. 350).
Study 1: Neurocognitive Enhancement Therapy (Bell, et al., 2001, 2005)
Computer Training- 5hours for 26week
Weekly Social Information Processing Group
Work Therapy Program- pay in an accommodating setting, combined with job coaching
and cognitively oriented work feedback group, and support group.
Study 2: Neurocogitive Enhancement Therapy and Vocational Rehabilitation Program (Wexler
and Bell, 2005)
Subsidized work
Supported Employment
17
72 hours computer practice which may of included drill and practice approach involving
repetitive tasks, exercise of working memory and problem solving.
Daily performance monetary rewards for cognitive practice sessions.
Social and work processing groups.
Study 3: Computer-Assisted Cognitive Strategy Training (CAST) (Valuth et al., 2005)
8-week course of 90 minute, 2 twice a week, 6-8 participants that focused on attention,
verbal memory, and planning.
Personalized Strategy development: Repeating back what the job coach said, practicing
it, and generalized to work situations, aided by personalized “coping cards”.
Computerized practice of cognitive domain which may of included drill and practice
approach involving repetitive tasks, exercise of working memory and problem solving.
Altered work environments to compensate for cognitive deficits (such as posting
instruction in their work area or arranging work space to focus attention on work tasks.
Study 4: Thinking Skill Work Program (McGurk, Mueser, & Pascais, 2005)
Promotes Integration or combining of cognitive remediation and vocational
rehabilitation programs.
3 months, twice a week computerized cognitive training exercises.
Practice of skills and coping strategies.
Access and consultation with cognitive specialist.
Supported Employment
Supportive employment activities: Job search and job support
Cognitive Remediation Summary: What Worked?
Computer practice
Social Information Processing Group
Altered work environments
Job Coaching
Work feedback group
General support group
Monetary Rewards
Skills and coping strategies
Supportive Employment Activities
18
2. Person-Centered Therapy: Process of Talk Therapy Combating Negative Double-Binding
Messages
Pratt, Gill, Barrett, and Robert (2007) discuss Carl Rogers person centered approach as
effective and “the basic tenets of consumer-centered therapy are highly compatible with
psychiatric rehabilitation and have an important influence in the field” (p. 152).
Person-Centered Therapy facilitates the relationship between Therapist and Client
through the core therapist conditions which are:
1. Congruence and Genuineness – therapist is real, genuine, integrated and
authentic.
2. Unconditional Positive Regard and Acceptance – genuine caring for the client
as a person, and non-judgmental
3. Accurate Empathic Understanding- understanding the client’s feeling
sensitively and empathically and seeing the client’s worldview in the here and
now
Person- Centered Therapy is facilitating a client process of:
1. an openness to experience
2. trust in oneself
3. An internal locus of evaluation
4. A willingness to continue growing (Corey, 2009)
3. Group Therapy: Process of Combating Social Phobia
Social Skills Training (SST) (CBT-based) compared to a process-oriented training format
known as Interactive Behavioral Training (IBT)
IBT endorses a more authentic interaction between group members that incorporates not
only cognitive-behavioral approaches to social skills training (SST) but psychodrama
techniques (acting out of interpersonal concerns or conflicts) that enhances social
relatedness such as doubling, mirroring, and role reversal (Daniels & Roll, 1998).
Four Training Phases promoting group processes such as altruism, affiliation, and
universality and social learning.
1. Orientation and cognitive networking: leaders facilitated interactions among group
members and encouraged social connections between group members.
2. Warm-up and sharing: Strong emphasis on self disclosure.
19
3. Enactment: Doubling, role reversal, and future projection and given cognitive, affective,
and behavioral feedback from group members. Process provides practice in social cue
recognition, behavioral consequences, and problem solving strategies
4. Affirmation: Leader verbally identify and reinforce socially COMPETENT behaviors.
4. Solution Focused Therapy: Process in the Preservation of Humanness
Solution-Focused Therapy (SFT) encompasses the values of the PsyR movement (Schott, &
Conyers, 2003). The PsyR Professional identifies with this values through the relationship:
1. The PsyR professional communicates the person’s owning the right to self-
determination, where the individual is the expert and solution resides within himself.
2. The PsyR professional acknowledges the dignity and worth of every individual
regardless of the degree of disability. Schott and Conyers give insight, noting when the
locus of power and decision-making comes from a system rather than the individual, the
individual’s worth can be eroded. Problems are seen as separate from the individual, and
repeated focus on strengths, helps individuals recognized and increase the ability to
control their lives.
3. The PsyR professional is optimistic regarding the possibility of recovery and every
person is capable of achieving a productive and satisfying life. A focus on the
individuals wishes and resources will essentially restore hope and facilitate the process to
recovery.
4. The PsyR professional acknowledges every person’s capacity to learn and grow.
Learning and change is a process of all individuals.
5. The PsyR professional recognizes the value of the individual cultural and ethnic
differences. Schott and Conyers state that solution-focused therapy is a collaboration
promoting a dialogue that acknowledges a composite of several dimensions of diversity
including class, ethnicity, gender, physical ability, disability, sexual orientation, religion,
etc.
5. Psychotherapy: A Process of Establishing Meaning
1. Focus on affect and expression of emotion: Psychodynamic Therapy explores the
range of emotion of the patient including contradictory feelings, feelings that are
troubling or threatening, and feelings that the patient may not initially be able to
recognize or acknowledge.
2. Exploration of attempts to avoid distressing thoughts and feelings: Knowing and
unknowingly, we use defenses and resistance (to avoid experience that are troubling),
that may result in an exclusion of affect rather than what is psychologically
20
meaningful, and our role we play in shaping the events in our lives. This may take
form such as missing appointments, arriving late, or being evasive.
3. Identification of recurring themes and patterns: Psychodynamic therapists work to
identify and explore recurring themes and patterns in the patient’s thoughts, feelings,
self-concept, relationships, and life experiences.
4. Discussion of past experience (developmental focus): Early experiences of
attachment effects our experiences in the present. Looking to the past to provide
insight on current psychological difficulties help patients free themselves from the
bonds of past experiences to live more fully in the present.
5. Focus on interpersonal relations: Psychodynamic therapy has an emphasis on
object relations and attachment, meaning that aspects of the personality and self-
concept are forged in the context of attachment relationship, and psychological
difficulties often arise when problematic interpersonal patterns interfere with a
person’s ability to meet emotional needs.
6. Focus on the therapy relationship: Psychodynamic therapy focuses on the
relationship between the therapist and the patient, and essentially helps develop
flexibility in interpersonal relationships and enhance capacity to meet interpersonal
needs.
7. Exploration of fantasy: Psychodynamic therapy encourage patients to speak freely
about whatever is on their minds including desires, fears, fantasies, dreams,
daydreams, much different from other therapies which maybe actively structured.
8. Psychodynamic therapy is a process that helps the individual to establish a
deeper level of meaning in his or her life by developing the individual’s inner
resources and capacities in self expression, resolve issues of avoidance, identify
recurring themes/patterns, explore of past experiences, and focus on the interpersonal
relationship (Shedler, 2010).
21
SECTION THREE
OTHER THERAPUETIC TECHNIQUES/PROCESSES
Therapeutic Techniques/Processes
1. Occupational Therapy
2. Exercise Therapy
3. Motivational Interviewing
4. Spirituality and Religion
5. Disclosure
6. Photovoice
7. Role Development
8. Leadership
9. Empowerment
6. Occupational Therapy: Process of Focusing
Occupational therapy as rehabilitation and recovery tool addresses various occupational
issues in the person with a disability, such as occupational interruption, occupation
imbalance, occupational disengagement, occupational delay, occupational deprivation,
occupational alienation, and occupational apartheid (Krupa et al., 2009).
Occupational therapy specifically is a “field with a strong theoretical and knowledge base
with unique procedures and practices, which include assessment processes that are highly
client-centered and attend to environmental and situational contexts” (Krupa et al., 2009,
p. 160).
Occupational therapy applied to psychiatric rehabilitation is a strong recovery tool
enabling the individual to better adapt to his or her disability, by addressing the
therapeutic method of focusing (Gendlin, 1969).
Occupational therapy assists in facilitating the focusing process, through analysis of
individual-level practice, environmental-level practice, and the community-level practice
of occupation (Krupa et al., 2009).
Occupational Therapy considers three categories to describe the occupation in which clients
participate in, which include self care, productivity, and leisure.
22
1. Self-Care: Personal care and health routines.
2. Productivity: A range of productive activities such as work, education, and home
upkeep
3. Leisure: Includes many activities motivated by personal interests and enjoyment
(Krupa et al., 2009).
7. Exercise Therapy: Process of Establishing Normality & Mind- Body Connection
Forgarty et al. (2004) concluded that exercise therapy incorporated into psychosocial
rehabilitation programs or other type of supportive rehabilitation venues, serve as a
therapeutic coping tool for individuals with mental illness and again, promote a sense of
normality in managing their disability while promoting their physical wellness as well.
A proactive approach and process to the well documented side effects of weight gain as
a result of taking anti-psychotic medications.
All participants in this study showed a high attendance level which conveyed their
motivation and commitment to recovery and the rehabilitation process (Forgarty et al.,
2004).
Physical Effects: majority of participants reported increased fitness levels, exercise
tolerance, reduced blood pressure levels, perceived energy levels, and upper body and
hand grip strength levels.
Activities: Walking, swimming, cycling, rowing, boxing, weight training, skipping, and
stretching.
8. Motivational Interviewing: Process of Combating Learned Helplessness
According to Wagner and McMahon (2004), a focus on self-determination and
motivational interviewing facilitates the initiative for personal insight to behavioral
change, including the following components:
1. A focus on the clients experiences, values, goals, and plans
2. A promotion of client choice and responsibility for implementing change
3. An initiative to provide the Rogerian conditions of empathy, unconditional positive
regard, and genuineness (p. 154).
23
Motivational Interview (MI) and Psychiatric Rehabilitation
MI counseling interventions in psychiatric rehabilitation and recovery from severe mental
illness essentially focuses on treatment- related issues such as participation, compliance,
and developing insight (Wagner & McMahon, 2004; Rusch & Corrigan, 2002).
The MI counseling for individuals recovering from severe mental illness is essentially
used to promote wellness and managing symptoms, and hopefully in the process, lessen
the likelihood for relapse and/or hospitalization.
Wagner and McMahon (2004) discuss the four principles of motivational interviewing
that promote change which serves as positive insight for rehabilitation counselors and
educators, managing cases for individuals recovering from severe mental illness, which
are:
1. Expression of empathy
2. Roll with resistance where the counselor facilitates an environment that is calm,
supportive even when the client is defensive, argumentative, or withdrawn or
behaves in any other manner that the counselor perceives negatively.
3. Develop discrepancy or confrontation. Meaning the counselor gently explores
discrepancies between current behavior (if they are counterproductive) and
desired future behaviors.
4. Supportiveness to self-efficacy. Meaning the counselor is to serve in helping the
client gain confidence about, and commitment to, making changes and achieving
goals. (p. 154-155)
Collectively, Motivation Interviewing according to Wagner and McMahon (2004) “is
empirically supported, client-centered, directive counseling approach designed to
promote client motivation and reduce motivational conflicts and barriers to change.” (p.
159)
9. Spirituality and Religion: Process of Feeding the Soul and Knowing our Humanness
Blanch (2007) discussion is rooted in the nature of being human, and suggests new
processes in the clinical environment that will maximize the potential of individuals
discover and experience what it means to be human.
Blanch (2007) gives a historical perspective on integrating science and religion, our
current social context and trends of spirituality and religion, reflections on spirituality,
religion, and recovery, and further suggests strategies for integrating spirituality in
24
today’s mental health practice. She suggests new processes in the clinical
environment that will maximize the potential of individuals to discover and experience
more, a sense of humanness/what it means to be human. Collectively, these strategies
include:
1. Having a set of solutions
2. Tools to asking questions
3. Supporting the wisdom inherent in the client’s support system
Application to PsyR Professionals
Spiritual Information Gathering: Attention would be focused during an assessment
not on making a diagnosis or setting a rehabilitation goal, but on gathering
information about the client’s experiences pertaining to religious and spiritual beliefs,
practices, aspirations, and community, as well as an past experiences, positive or
negative, the affect their psychological and spiritual lives. The goal would be to learn
as much as possible about healing and mental health from the religious or spiritual
viewpoint held by the client.
Acknowledging the client’s explanatory framework: A formal acknowledgement
of the client’s explanatory framework and an active attempt to accommodate that
framework. Blanch (2007) discusses that working from the client’s frame of
reference has been shown to increase adherence to treatment plans.
Expanded Consultative Model: A consultative spiritual or religious model for
mental health practitioners that is outside their own belief system.
Using Spiritual and Mystical Practices to Assist with Recovery: Essentially
developing a translation of esoteric practices into terms that are understandable to
laypeople (Blanch, 2007). Encompassing a broader scope of recovery to include
religious and spiritual traditions as a part of recovery and rehabilitation processes,
that include techniques such as prayer and other tools for strengthening belief,
purification rituals, self-observation, techniques to develop mastery over thoughts and
behaviors, practices for minimizing or containing the ego and for controlling
emotional excesses, structured processes for confronting the dark side of humanity
and for overcoming fear of death; practices for developing and maintaining calmness
in difficult situation, and so forth (Blanch, 2007, p. 257-258).
25
10. Disclosure: Process that Symbolizes Acceptance vs. the Defense Mechanism
of Denial
According to Webster’s definition, disclosure is the act or process of revealing or
uncovering (Merriam-Webster dictionary, 2006). Barriers to disclosure according to
Ralph (2002) include secrecy and control, shame, and discrimination and stigma.
Barriers to Disclosure
1. Secrecy and Control
2. Shame
3. Discrimination and Stigma
Healing Shame
“Healing the Shame that Binds You” (John Bradshaw, 1988, p. 151)
1. Coming out of hiding by social contact, which means honestly sharing our feelings with
significant others.
2. Seeing ourselves mirrored and echoed in the eyes of at least one non-shaming person.
Reestablishing an “interpersonal bridge.”
3. Working a Twelve Step program.
4. Doing shame-reduction work by “legitimizing” our abandonment trauma. We do this
by writing and talking about it (debriefing). Writing especially helps to externalize past
shaming experiences. We can then externalize or feelings about the abandonment. We
can express them, grieve them, clarify them and connect with them.
5. Externalizing our lost Inner Child. We do this by making conscious contact with the
vulnerable child part of ourselves.
6. Learning to recognize various split-of parts of ourselves. As we make these parts
conscious (externalize them), we can embrace and integrate them.
7. Making new decisions to accept all parts of ourselves with unconditional positive
regard. Learning to say, “I love myself for…” Learning to externalize our needs and
wants by becoming more self assertive.
8. Externalizing unconscious memories from the past, which form collages of shame scenes,
and learning how to heal them.
26
9. Externalizing the voices in our heads. These voices keep our shame spirals in operation.
Doing exercises to stop our shaming voices and learning to replace them with new,
nurturing and positive voices.
10. Learning to be aware of certain interpersonal situations most likely to trigger shame
spirals.
11. Learning how to deal with critical and shaming people by practicing assertive techniques
and creating and externalization shame anchor.
12. Learning how to handle our mistakes and having the courage to be imperfect.
13. Finally, learning through prayer and meditation to create an inner place of silence
wherein we are centered and grounded in a personally valued Higher Power.
14. Discovering our life’s purpose and spiritual destiny. (p. 151)
Insights on Internalized Stigma
Coping Factor Result
Perceived Stigma Secrecy Internalized Stigma
Perceived Stigma Withdrawal Internalized Stigma
Social Support- less likely to internalize stigma*
Hsin-Ya Liao, personal communication, Doctoral Student, University of Arizona, NCRE
Conference Poster Presentation Manhattan Beach, April 7, 2011).
11. Photovoice: Process Fostering Resiliency to Disease by Combating Stigmatization
In Merriam-Webster dictionary (2006), stigma is defined as a severe social disapproval
of personal characteristics or beliefs that are against cultural norms. The Center for
Psychiatric Rehabilitation research shows “stigma experienced by persons with
psychiatric disabilities presents a major barrier to recovery” (Recovery and
Rehabilitation, 2008, p. 1).
The application of Photovoice involves putting the camera in the hands of the consumer
and having the consumer developing a narrative, communicating their experience,
exposing the impact of stigma in their lives (Recovery and Rehabilitation, 2008).
27
12. Role Development: Process of Strengthening Self-Identification
The Research Process
Role Development is a theory based intervention in which staff and participant work
collaboratively to identify and develop the participant’s social roles (Schindler, 2005)
Participants to “develop task as interpersonal skills within meaningful social roles”
(Schindler, 2005, p. 392).
The Role Development Program was an enhancement of an existing program:
Multi-Departmental Activity Program or MAP (Schindler, 2005). According to
Schindler, “MAP is a non-individualized, therapeutic intervention designed to encourage
the productive use of time and socialization in a group setting” (Schindler, 2005, p. 392).
Experimental group would receive weekly 15min-period of individual attention to
discuss their development of roles and skills as a part of the Role Development Program.
Training occurred over 12 weeks there were 42 participants and 18 staff members
A Training curriculum and manual was used to train the staff on Role Development.
Rehabilitation Staff where trained to create theory-based interventions to help each
participant develop task and interpersonal skill within meaningful social roles.
There are many types of community roles. Roles in this study were created for a forensic
setting such as worker, student, group member, or friend.
At the end of the program participants could cite specific skills and roles they learned in
the program.
The idea of strengthening self-identification was successful in this study and finding
proved to be statistically significant in the experimental group when compared to the
comparison group.
13. Leadership (Education): Process Promoting Self-Efficiency
This study in Leadership Education, promotes the recovery potential for individuals with
severe mental illness, by fostering an environment of lecture, group processes,
experimental learning, and empowerment through leadership training with an
insightful purpose, developing diversity among government boards, committees, and
non-profits to include people with disabilities (Bullock et al., 2000).
28
Three major segments for the program curriculum for this 16-week training, that include
attitude and self-esteem, group dynamics and group process, and board/committee
functions and policy development.
Participants attended 2 hour training sessions for the 16 weeks and alongside lectures,
small group processes, experimental learning, and weekly topic explorations,
participants were given homework assignments.
The significant improvements include (Bullock et al., 2000):
1. Psychiatric symptom reduction (particularly reported levels of depression and anxiety);
2. Self-efficacy (confidence in an ability to control positive, negative, and social
symptoms);
3. Community living skills (particularly personal care and social skills;
4. Empowerment (particularly self-esteem), and;
5. Recovery attitude. (p.8)
The study conveyed the shifts in the participant’s feelings of self-efficacy, empowerment,
and self-esteem, and found a reduction on reported psychiatric symtomatology as well
(Bullock et al., 2000). Researchers indicated that the participants feeling of self efficacy,
empowerment, and self-esteem “are more stable indicators of recovery than psychiatric
symptomatology” (Bullock et al., 2000, p. 3).
14. Empowerment: A Process Combating Oppression
Michael P. Frain, Malachy Bishop, and Molly K. Tschopp (2009) measured four areas of
empowerment including:
1. Self-efficacy (control),
2. Self-advocacy (assertiveness),
3. Perceived stigma (having a positive self concept, self-esteem, holding positive self-regard
concerning the self),
4. Competence (autonomous, competent, goal-directed, independent, personally
responsible, self-reliant, and self-montioring).
29
Significance of Study
The quantified results of the study, concluded that the area of self-efficacy and self-
management “may be the most powerful forces individuals may acquire that will lead to
positive rehabilitation outcomes (Frain et al., 2009, p. 33).
The researchers conclude that this measurable finding agrees with the theoretical concept
(four theoretical dimensions of empowerment) “that empowerment will improve
adjustment to disability outcomes and employment outcomes for individuals with
disabilities” (Frain et al., 2009, p. 33).
Empowerment: Six (6) points of Implication
Implications applied to Rehabilitation Counseling according to (Frain et al., 2009, p. 33):
1. The reason practitioner’s work to facilitate empowerment in clients is to help clients feel
a sense of satisfaction and control over important areas of life, not to help them
understand how important some things should be to them.
2. The study supports the idea that finding ways to empower clients will lead to improved
outcomes in rehabilitation.
3. The importance of quality of life areas such as work likely will not change by
empowering clients (however advocates for motivation interview may advocate
otherwise); however, the amount of satisfaction they get from work can change. Hence,
in can then be assumed supporting vocational goals, in vocational rehabilitation, are an
important to the process.
4. The amount of control, satisfaction and interference an individual feels about their
disability and physical health are changeable characteristics but the importance of their
health is not through empowerment. Thus rehabilitation professional can focus on
education that gives clients feelings of control (e.g. teaching clients how different foods
affect their glucose levels) over their health.
5. Rehabilitation counselors can role play interactions with medical providers, in order to
teach assertiveness and ways to have decision making power in these interactions.
6. Professionals have experience with many types of disabilities and understand the often
erratic pattern in the course of these diseases. By working with newly diagnosed clients
on ways to self-manage their disability (e.g. designing plans to assure medication by
using family members as reminders) clients can become more competent in their own
disease management, leading to feelings of empowerment through self-esteem,
confidence and expanded choices.
30
A Poem: I Know Why the Caged Bird Sings (People are born with a will to live! –Michele Salas, M.S.)
The free bird leaps
on the back of the win
and floats downstream
till the current ends
and dips his wings
in the orange sun rays
and dares to claim the sky.
But a bird that stalks
down his narrow cage
can seldom see through
his bars of rage
his wings are clipped and
his feet are tied
so he opens his throat to sing.
The caged bird sings
with fearful trill
of the things unknown
but longed for still
and is tune is heard
on the distant hillfor the caged bird
sings of freedom
The free bird thinks of another breeze
an the trade winds soft through the sighing trees
and the fat worms waiting on a dawn-bright lawn
and he names the sky his own.
But a caged bird stands on the grave of dreams
his shadow shouts on a nightmare scream
his wings are clipped and his feet are tied
so he opens his throat to sing
The caged bird sings
with a fearful trill
of things unknown
but longed for still
and his tune is heard
on the distant hill
for the caged bird
sings of freedom.
-Maya Angelo
31
SECTION FOUR
SUMMARY ON PROCESSES
Current day psychiatric rehabilitation is focusing on the process not on the result to attain
better mental health. There are various counseling and therapeutic techniques that help facilitate
adaptation and recovery in severe and persistent mental illness. The summary of research of the
author’s literature review on these cognitive processes, conveying quantitative research studies in
the field of psychiatric rehabilitation are as follows:
Cognitive Remediation: Taking Command over One’s Behavior
1. Cognitive Remediation: The process of improvement of cognitive functioning through social
information processing, job coaching, work therapy, as well practice of attention, verbal
memory, and planning, and the use of coping cards (McGurk, 2008).
Person Centered Therapy: Talk Therapy Combating Negative Double-Binding Messages
2. Person Centered Therapy: Experimental and relationship oriented, this therapy focuses on the
process of respect and acceptance of the individual as well as the client’s self evaluation
facilitation of the establishment (1) an openness to experience (2) trust in oneself (3) and an
internal locus of evaluation (4) and a willingness to continue growing.
Group Therapy: Combating Social Phobia
3. Group Therapy: A new process-oriented training approach format known as interactive
behavioral training (IBT), integrative approach to group therapy in psychiatric rehabilitation.
32
The approach showed more authentic interaction between group members that incorporates
not only cognitive-behavioral approaches to social skills training (SST) but psychodrama
techniques that enhances social relatedness such as doubling, mirroring, and role reversal.
Clinical observations showed that the process-focused approach appeared to generate
discussions that were more personally and emotionally meaningful to participants than those
in the SST (social skill training) group (Daniels & Roll, 1998).
Solution-Focused: Preservation of Humanness
4. Solution Focused Therapy: The values of SFT essentially foster the process within
individuals to actively achieve recovery that include (a) encouragement of self-
determination and viewing the individual in therapy as the expert of his or her life, such as in
Rogerian therapy; (b) focusing on dignity and worth, and drawing on person’s strengths
rather than weaknesses; (c) optimism- solutions vs. problems; (d) individuals’ capacity to
learn, grow and change through new meaning, and; (e) cultural sensitivity, and taking a
collaborative stance (Schott & Conyers, 2003, p. 44-47). Although, Solution Focused
Therapy (SFT) considers the result of the total rehabilitation process, is the recovery, it is still
very clearly a step-by-step process in getting there.
Psychotherapy: Establishing Meaning, and Personality Restructuring
5. Psychotherapy: The ultimate example of a therapeutic process oriented approach that has
been used in the past to address issues of personality integration including psychosis.
Founded by Sigmund Freud, Psychotherapy looks at the complexities of the total personality.
Essentially, according to experts, if subconscious issues are faced and resolved, the structure
33
of the personality will change, hence have long lasting effects on overall mental health and
wellness. The process helps the individual to establish a deeper level of meaning in his or
her life by developing the individual’s inner resources and capacities in self expression,
resolve issues of avoidance, identify recurring themes/patterns, explore of past experiences,
and focus on the interpersonal relationship according to Shedler (2010).
Occupational Therapy: Focus through Functionality and Mind Body Connection
6. Occupational Therapy: Occupational therapy focuses on the bodily felt sense of focus as it
applies to occupational tasks that individuals participate in, such as self-care, productivity,
and leisure.
Exercise Therapy: Weight Gain Management and Mind Body Connection
7. Exercise therapy: In the context of psychiatric rehabilitation exercise therapy is looked at as a
psychosocial approach to recovery. Experts suggest that when a person with mental illness
establishes a proactive approach to the well documented side effects of weight gain as a
result of taking anti-psychotic medications, the individual establishes a sense of normality in
managing his or her disability (Forgarty et al., 2004). Exercise therapy in the context of
psychiatric rehabilitation is a psychosocial process towards rehabilitation with physical
benefits.
Motivation Interviewing: Combating Learned Helplessness
8. Motivation Interviewing: Motivational interviewing according to Wagner and McMahon
(2004) “is empirically supported, client-centered, directive counseling approach designed to
34
promote client motivation and reduce motivational conflicts and barriers to change” (p. 159).
Applied to psychiatric rehabilitation, motivational interviewing is a process that focuses on
treatment related issues such as participation, compliance, and developing insight; it is
essentially used to promote wellness and managing symptoms, and lessen likelihood for
relapse and/or hospitalization. (Wagner & McMahon, 2004; Rusch & Corrigan, 2002).
Religion and Spirituality: Food for the Soul
9. Religion and Spirituality: With the integration of western and eastern medicine, researcher
Andrea Blanch states that “new discoveries in quantum physics suggest that consciousness
can be understood in terms of energy and vibration as well as anatomy and chemistry”
(Blanch, 2007, p. 253). The wisdom of Eastern medicine that Blanch (2007) discusses is
rooted in the nature of being human, and suggests new processes in the clinical environment
that will maximize the potential of individuals discovering what it means to be human.
Blanch (2007) further points out that by “acknowledging energy and vibration as a legitimate
substrate for consciousness also opens the door for understanding the impact of music,
chanting, mantra yoga, and other techniques that appear to intervene directly at the
frequency/vibrational level” (p. 253). This supports the idea (and establishment) of the
bodily felt sense of focus that was termed and described by Gendlin (1969). Applied to
psychiatric rehabilitation the integration of spirituality and religion into our service system
processes might call for 1. Spiritual information gathering, 2. Acknowledging the client’s
explanatory framework, 3. Expanded consultative model, 4. Using spiritual and mystical
practices to assist with recovery (Blanch, 2007).
35
Disclosure: Symbolizes Acceptance vs. the Defense Mechanism of Denial
10. Disclosure: The process of disclosure involves addressing three major barriers according to
researcher Ruth O. Ralph (2002) which are: secrecy and control, shame, and discrimination
and stigma. Ralph (2002) supports the idea of disclosure and discusses the advantages for
disclosure as “therapeutic and can lead to greater emotional wellness” (p. 169). Essentially
there are two basic functionalities to these processes which involve 1. Letting go of secrecy,
control and shame; 2. Confronting discrimination and stigma by accessing the ADA rights
for people with disabilities (Ralph, 2002).
Photovoice: Fosters Resiliency to Disease and Bring Awareness to Stigmatization
11. Photovoice: This addresses the process of stigma and the negative effects rejection can have
on the human psyche. In photovoice the person with the disabilities takes a picture of an
image that connotes meaning (for the individual), and he/or she writes a narrative about it.
This is a cognitive process that exposes the effects of stigmatization. Applied to psychiatric
rehabilitation, it is recommended that photovoice be implemented at outpatient and
rehabilitation settings and consumer-run programs and centers. The Center for Psychiatric
Rehabilitation in Boston has created a curriculum including a workbook and instructor’s
guide conveying this step-by-step process (Recovery and Rehabilitation, 2008, p. 3).
Role Development: Strengthening Interpersonal Self-Identification
12. Role Development: The idea of this study is to “develop task as interpersonal skills within
meaningful social roles” (Schindler, 2005, p. 392). Here, roles were developed for a forensic
setting including roles of worker, student, group member, or friend for example. The study
36
showed significant improvement among participants in three different areas including task
skills, interpersonal skills, and role development. The process of developing a meaningful
role, rooting deeper self-identification, was shown positively significant on the individual’s
mental health.
Leadership Education: Promotes Self-Efficacy
13. Leadership Education: This study in Leadership Education, promotes the recovery potential
for individuals with severe mental illness, by fostering an environment of lecture, group
processes, experimental learning, and empowerment through leadership training with an
insightful purpose, developing diversity among government boards, committees, and non-
profits that include people with disabilities (Bullock et al., 2000). The study conveyed the
shifts in the participant’s feelings of self-efficacy, empowerment, and self-esteem, and found
a reduction on reported psychiatric symtomatology as well (Bullock et al., 2000). Hence the
process of participation and engagement in the course of 16-week training in leadership was
effective.
Empowerment- Combating Oppression
14. Empowerment: The researchers of this study provided insight on empowerment as
quantifiable against the theoretical model and concluded to agree with theoretical analysis
that empowerment makes a difference in overall mental health and produces positive
outcomes in the total rehabilitation process. The quantified results of the study, concluded
that particularly the area of self-efficacy and self-management “may be the most powerful
37
forces individuals may acquire that will lead to positive rehabilitation outcomes (Frain et al.,
2009, p. 33).
Collectively, these counseling and therapeutic techniques conveyed that by focusing on
the process and not the result, you will get to the result you want.
38
SECTION FIVE
SEVERE AND PERSISTENT MENTAL ILLNESSES FROM THE
ADULT PSYCHOTHERAPY TREATMENT PLANNER
By Arthur E. Jongsma, Jr. and Mark Peterson (2006)
Severe Mental Illness Treatment from Adult Psychotherapy Treatment Planner
Anxiety
Dependency
Depression
Dissociation
Impulse Control Disorder
Low Self-Esteem
Panic/Agoraphobia
Psychoticism
Social Discomfort
Vocational Stress
Severe Mental Illness: Anxiety
Help the client gain insight into the notion that worry is a form of avoidance of a feared
problem and that it creates chronic tension.
Assign the client to read psychoeducational sections of books or treatment manuals on
worry and generalized anxiety.
Reinforce insights into the role of his/her past emotional pain and present anxiety
Teach relaxation skills (e.g. progressive muscle relaxation, guided imagery, slow
diaphragmatic breathing) and how to discriminate better between relaxation and tension.
Teach the client how to apply these skills to his daily life.
39
Select initial exposure that have a high likelihood of being a success experience for the
client; develop a plan for managing the negative affect engendered by exposure; mentally
rehearse the procedure.
Instruct to routinely use relaxation, cognitive restructuring, exposure, and problem-
solving exposures as needed to address emergent worries, building them into his/her life
as much as possible (Jongsma et al, 2006).
Severe Mental Illness: Dependency (learned helplessness)
Explore history of emotional dependence extending from unmet childhood needs to
current relationships.
Explore the client’s family of origin for experiences of emotional abandonment.
Assist in identifying the basis for his fear of disappointing others.
Explore and clarify the client’s fears or other negative feelings associated with being
more independent.
Verbally reinforce for any and all signs of assertiveness and independence.
Explore the client’s sensitivity to criticism and help him develop new ways of receiving,
processing and responding to it.
Assign the client to speak his/her mind for one day, and process the results with him.
Assign the client to allow others to do favors for him and to receive without giving.
Process progress and feeling related to this assignment.
Assist in developing new boundaries for not accepting responsibility for others’ actions
or feelings.
Refer to an Al-Anon group to reinforce efforts to break dependency cycle with a
chemically dependent partner (Jongsma et al., 2006).
Severe Mental Illness: Depression
Describe current and past experiences with depression complete with its impact on
function and attempts to resolve it.
Refer the client to psychological testing to assess the depth of depression, the need for
anti-depressant medication, and suicide prevention measures.
40
Monitor and evaluate the client’s psychotropic medication compliance, effectiveness, and
side effects; communicate with the prescribing physician.
Assist the client in developing an awareness of his automatic thoughts that reflect a
depressogenic schemata.
Assign the client to keep a daily journal of automatic thoughts associated with depressive
feelings.
Assist the client in developing coping strategies, such as more physical exercise, less
internal focus, increased social involvement, more assertiveness, greater need sharing,
more anger expression (Jongsma et al., 2006).
Severe Mental Illness: Dissociation
Actively build the level of trust with the client in individual sessions through consistent
eye, active listening, unconditional positive regard, and warm acceptance to help increase
his/her ability to identify and express feelings.
Explore the client’s sources of emotional pain or trauma, and feelings of fear,
inadequacy, rejection or abuse.
Assist the client in accepting a connection between his/her dissociating and avoidance of
facing emotional conflicts/issues.
Facilitate integration of the client’s personality by supporting and encouraging him/her to
stay focused on reality rather than escaping through dissociation.
Emphasize the importance of the here-and-now focus rather than preoccupation with the
traumas of the past and dissociative phenomena associated with that fixation.
Teach the client to be calm and matter-of-fact in the face of brief dissociative phenomena
so as to not accelerate anxiety symptoms, but to stay focused
Arrange and facilitate a session with the client and significant others to assist him/ her in
regaining lost personal information.
Utilize pictures and other memorabilia to gently trigger the client’s memory recall
(Jongsma et al., 2006).
41
Severe Mental Illness: Impulse Control Disorder
Review the client’s behavior pattern to assist him/her in clearly identifying, without
minimization, denial, or projection of blame his/her pattern if impulsivity.
Explore the client’s past experiences to uncover his/her cognitive, emotional, and
situational triggers to impulsive episodes.
Teach the client cognitive methods (thought stopping, thought substitution, reframing,
etc.) for gaining and improving control over impulsive urges and actions.
Teach the client techniques such as progressive relaxation, self-hypnosis, or biofeedback;
encourage him/her to relax whenever he/she feels uncomfortable.
Teach the use of positive behavioral alternative to cope with anxiety (e.g. talking to
someone about the stress, taking a time out to delay any reaction, calling a friend or
family member, engaging in physical exercise.
Use modeling, role-playing and behavior rehearsal, teach the client how to use “stop,
listen, and thing” in day-today living and identify the positive consequences.
Teach the client how to use the assertive formula, “I feel… When you … I would prefer
it if… “in difficult situations (Jongsma et al., 2006).
Severe Mental Illness: Low Self Esteem
Help the client to become aware of his/her fear of rejection and its connection with past
rejection or abandonment experiences.
Discuss, emphasize, and interpret the client’s incidents of abuse.
Assist the client in developing self-talk as a way of boosting his/her confidence and
positive self-image.
Ask the client to complete and process an exercise in the book Ten Days to Self Esteem!
(Burns)
Teach the client the meaning and power of secondary gain in maintaining negative
behavior patterns.
Ask the client to make one positive statement about self daily and record it on a chart or
in a journal.
42
Verbally reinforce the client’s use of positive statements of confidence and
accomplishments.
Assign self-esteem building exercises for a workbook.
Assist the client in identifying and labeling emotions.
Assist the client in identifying and verbalizing his/her needs, met and unmet.
Assist the client in developing a specific action plan to get each need met.
Assist the client to be aware of and acknowledge graciously (without discounting) praise
and compliments from others.
Assign the client to make a list of goals for various areas of life and a plan for steps
toward goal attainment.
Ask the client to list accomplishments; process of integration of these into his/her self-
image (Jongsma et al., 2006).
Severe Mental Illness: Panic/Agoraphobia
Describe the history and the nature of the panic symptoms.
Verbalize an accurate understanding of panic attacks and agoraphobia and their
treatment. Discuss how panic attacks are “false alarms” of danger, not medically
dangerous but often lead to unnecessary avoidance.
Verbalize an understanding of the rationale for treatment of panic. Discuss how exposure
serves as an arena to desensitize learned fear, build confidence, and feel safer by building
a new history of success experiences.
Undergo gradual repeated exposure to feared physical sensations until they are no longer
frightening to experience.
Undergo gradual repeated exposure to feared or avoided situations in which a symptom
attack and its negative consequences are feared (Jongsma et al., 2006).
Severe Mental Illness: Psychoticism
Demonstrate acceptance through calm, nurturing manner, good eye contact and active
listening- Ex Rogerian Person-Centered Therapy
43
Explain the nature of the psychotic process, its biochemical components, and the
confusing effect on rational thought due to chemical imbalances. Ex- Psychoeducation
Refer clients for evaluation by a psychiatrist or mental health center regarding symptoms
and prescription for anti-psychotic medication and have an awareness of medication
compliance. Ex- Biomedical Therapy
Explore the client’s feelings surrounding the stressors that trigger his/her episodes. Probe
underlying needs and feelings such as rejection. Ex- CBT
Assist the family in avoiding double-bind messages that increase anxiety and psychotic
symptoms (Jongsma et al., 2006).
Severe Mental Illness: Social Discomfort
Establish rapport with the client toward building a therapeutic alliance.
Assess the nature of any stimulus, thoughts, or situations that precipitate the client’s
social fear and/or avoidance.
Enroll clients in a small group for social anxiety.
Discuss how social anxiety derives from cognitive biases that overestimate negative
evaluation by others, undervalue the self, distress, and often lead to unnecessary
avoidance.
Discuss how cognitive restructuring and exposure serve as a an arena to desensitize
learned fear, build social skills and confidence, and reality test biased thoughts.
Teach the client relaxation and attention focusing skills (e.g. staying focused externally
and on behavioral goals, muscular relaxation, evenly paced diaphragmatic breathing, ride
the wave of anxiety to manage social anxiety.
Explore the client’s schema and self-talk that immediate his/her social fear response.
Use introduction, modeling, and role-playing to build the client’s general social and/ or
communication skills.
Probe childhood experiences of criticism, abandonment, or abuse that would foster low
self-esteem and shame, and process these (Jongsma et al., 2006).
44
Severe Mental Illness: Vocational Stress
Clarify the nature of the client’s conflicts in the work setting.
Explore possible role of substance abuse in the client’s vocational conflicts.
Explore the client’s tranfer of personal problems to the employment situation.
Explore the client’s patterns of interpersonal conflict that occur beyond the work setting
but are repeated in the work setting.
Reinforce the client’s acceptance of responsibility for his/her behavior and feelings onto
others.
Assign the client to write a plan for constructive action (e.g., polite compliance with
directedness, initiate a smiling greeting, compliment other’s work, avoid critical
judgments) that contains various alternative to coworker or supervisor conflicts.
Train the client in assertiveness skills or refer to assertiveness training class.
Probe and clarify the client’s emotions surrounding his/her vocational stress
Explore the causes for client’s termination of employment that may have been beyond
his/her control.
Probe childhood history for roots of feelings of inadequacy, fear of failure, or fear of
success.
Reinforce realistic self-appraisal of the client’s success and failure at workplace
(Jongsma et al., 2006).
45
SECTION SIX
BARRIERS AND INSIGHT FOR WORKPLACE INCLUSION
Technical Assistance Process Guide Enhancing Workplace Inclusion
By Boston University Center for Psychiatric Rehabilitation,
Adapted from: Russinova, Z., Bloch, P., Wewiorski, N., & Rosoklija, I. (March, 2006)
Application for Employers: Types and Definitions of Workplace Prejudice and Discrimination-
Recognition for Workplace Inclusion (Russinova, Z., Bloch, P., Wewiorski, N., & Rosoklija, I.,
2006, p. 16-17)
Supervisors
Lower standards for work performance
Higher expectations not accounting for limitation due to disability status and lack of
understanding for the person’s need of accommodations.
Co-Workers
Negative response to a receipt of accommodations
Language- Referencing mental illness in general
Metaphoric use of mental illness language: Use of diagnostic language in relation to non-
clinical events or situations, usually in a derogatory or demeaning manner.
Derogatory Labeling- Negative language or “put downs”
Jokes/inappropriate humor
Language toward a co-workers with mental illness
References about the person’s mental health status and/or background
Gossip
Inappropriate humor/ridicule based on the person’s mental health status or background
Use of the person’s mental health background as a manipulation strategy.
46
Behaviors- Work Performance
Micromanagement
Professional Marginalization
Work discrimination- Refusal of hiring
Work discrimination- Denial of training opportunities
Work discrimination- Denial of promotion
Work discrimination- Firing
Behaviors- Social Interactions
Patronizing
Social marginalization
47
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