2010-2011 Outstanding Masters Project-Thesis CSUF Kremen School of Education and Human Development

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

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COPYRIGHT 2010

Michele E. Salas

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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.

.

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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

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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!

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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

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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?

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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

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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

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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

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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

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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

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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).

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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.


achieve maximum community integration.


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

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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

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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

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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

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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


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


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


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.

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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


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


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:


achieve recovery.


achieve maximum community integration.


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).

36

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

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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

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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).

44

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

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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

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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).

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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.

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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


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,


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.

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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.

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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 /

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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,


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)

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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).

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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

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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

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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.

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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

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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

Bateson, G., Jackson, D.D., Haley, J., & Weakland, J.H. (1962). A Note on the double

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.

86

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

latent Variables. Journal of Marriage and the Family, 811-825.

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-

28.

McGurk, S.R., & Wykes, T. (2008). Cognitive remediation and vocational rehabilitation.


Pratt, C.W., Gill, K.J., Barrett, N.M., & Roberts, M. (2007). Psychiatric Rehabilitation,

2nd

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.

87

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


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


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


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


Psychotherapy . . . . . . . . . . . . . . . . 32

Occupational Therapy. . . . . . . . . . . . . . 33

Exercise Therapy . . . . . . . . . . . . . . . 33

Motivational Interviewing . . . . . . . . . . . . 34

3

Spirituality and Religion . . . . . . . . . . . . . 34

Disclosure . . . . . . . . . . . . . . . . . 35

Photovoice. . . . . . . . . . . . . . . . . 35


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


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


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.


illness achieve maximum COMMUNITY INTEGRATION.


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

REFERENCES

Bateson, G., Jackson, D.D., Haley, J., & Weakland, J.H. (1962). A Note on the double

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.

48

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.


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

latent Variables. Journal of Marriage and the Family, 811-825.

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-

28.

McGurk, S.R., & Wykes, T. (2008). Cognitive remediation and vocational rehabilitation.


Pratt, C.W., Gill, K.J., Barrett, N.M., & Roberts, M. (2007). Psychiatric Rehabilitation,

2nd

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


49

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


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.

2010-2011 Outstanding Masters Project-Thesis CSUF Kremen School of Education and Human Development

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