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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

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

COPYRIGHT 2010

Michele E. Salas

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AUTHORIZATION FOR REPRODUCTION OF THE 298 MASTERS 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 parents first marriage and alienated from my father since childhood. During this time of my fathers 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!

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) MS ______X________ MS ________________ Education Special Education MA _______________ MA _______________ Semester Completed: Spring 2011 Date Completed: Spring 2011 Option: Option: Counseling and Student Services Marriage and Family Counseling

Counseling

Name: Michele E. Salas Instructor: Dr. Albert Valencia

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 individuals 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 vii

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 . Introduction Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 5 5 11 12 12 13 14 14 14 15

Statement of the Problem . Statement of the Purpose . Research Question . . Definition of Terms . . Assumptions . Limitations . . . . . . . . . . . . . .

Delimitations .

Significance of Study . Chapter Summary . .

CHAPTER 2 - REVIEW OF THE LITERATURE . Introduction . . . . . . .

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Current Practices of Psychiatric Rehabilitation (PsyR) . Counseling Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cognitive Remediation. . Person Centered Therapy . Group Therapy . . .

Solution Focused Therapy Psychotherapy. . .

Therapeutic Techniques/Other Processes . Occupational Therapy Exercise Therapy . . . . . ix . . . . . .

Motivational Interviewing . . Religion and Spirituality . Disclosure Photovoice . . . . . . . . . . . . . . . . . . . . .

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Role Development Leadership Education Empowerment . .

Chapter Summary .

CHAPTER 3 - METHODOLOGY . Introduction . . .

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Population and Sample

Collection of the Materials and Conditions for Inclusion Chapter Summary . . . . . . . . . . .

CHAPTER 4 - PRESENTATION OF THE PROJECT . . Introduction . . . . . . . . . . . . . . . . . .

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PROJECT STUDY MANUAL INTRODUCTION . . .

COUNSELING THERAPIES

OTHER THERAPEUTIC PROCESSES . SUMMARY ON PROCESSES . . . .

MENTAL DISORDERS AND PSYCHOTHERAPY

BARRIERS AND INSIGHT FOR WORKPLACE INCLUSION 45 REFERENCES Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . 47 . . 69

CHAPTER 5 - SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS . Introduction Summary . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Recommendations . Chapter Summary .

REFERENCES

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APPENDICES

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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 Kuhns 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 individuals rights to self-determination. In the Independent Living analytical paradigm, the environment is seen as the locus of the problem as opposed to the rehabilitation paradigm, which views the

2 individual as the locus of the problem (DeJong, 1979). The rehabilitation paradigm, is based on the medical model, and defines the solution to the problem is professional intervention through the physician, physical therapist, occupational therapist, and vocational rehabilitation counselor. In the Independent Living paradigm the solution involves peer counseling advocacy, self help, consumer control, and removal of environmental barriers (DeJong, 1979). Rehabilitation according to Dejong (1979) has stressed self care, mobility, and employment where independent living has stressed additionally to this, the importance of living arrangements, consumer assertiveness, outdoor mobility, and out-of-home activity. The Independent Living Movement pushed forward with other social movements as well including, the civil rights movement, consumerism, self help, demedicalization, and deinstitutionalization (DeJong, 1979). There are some meaningful developments that have occurred in legislation due to the Independent Living Movement such as benefit rights including the entitlement to income, medical assistance, and education (DeJong, 1979). For some without income assistance benefits or attendant care benefits, many disabled persons would be involuntarily confined to a long term care facility (DeJong, 1979, p. 436). In the Independent Living Movement, consumers have access to advocacy centers where advisement to legal rights and benefits is a service for people with disabilities. Also, demedicalization enable the person with the disability in a role of empowerment as opposed to a sick role, giving the person a sense of control of his/her life, where the medical model keeps the person in a state of dependency (DeJong, 1979). Theoretically, the Independent Living Movement has clearly made significant contributions to the education of disability in the United States. Improving and

3 protecting the civil rights of the people with disabilities, and transitioning to the IL paradigm, which defines problems and the range of intervention of those problems in new ways, is infusing new perspectives about the human service system as whole (Dr. Charles Arokiasamy, personal communication, Professor, California State University, Fresno, December 16, 2010; Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010). The new perspectives are evident and have influenced current disability practices, specifically in the context of psychiatric rehabilitation, with the introduction of the Recovery Paradigm or better known as the Recovery Model (Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010). According to William A. Anthony at the Center of Psychiatric Rehabilitation at Boston University, the consumer literature in the 1980s, concluded that severe mental illness, particularly schizophrenia, was a deteriorative disease (Dana, Gamst, & Derkarabetia, 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 todays system planners and administrators according to Anthony (Dana et al., 2008, p. 319). The Recovery Oriented System of Care was developed based on consumer input and involvement, and influenced, by recovery assumptions such, recovery demands that a person has choices (Dana et al., 2008, p. 318). This advocacy for self-determination and independence reminds researchers of the core values of the

4 Independent Living Movement. The grounding of psychiatric rehabilitation in the Recovery Model is todays analytical paradigm for people with disabilities recovering from severe mental illness. At the turn of the century before 2000, the U.S. Surgeon General estimated that approximately 20 percent of the population in the United States is affected by a mental disorder in a given year, and about 5 percent of the population is considered to have a severe mental illness (SMI), (U.S. Department of Health and Human Services, 1999). When considering treatment modalities, the goal values and guiding principles of psychiatric rehabilitation are influenced by the Independent Living Movement in the Recovery Model (Dr. Charles Arokiasamy, personal communication, Professor, California State University, Fresno, December 16, 2010). Similar to the IL Movement, the Recovery Model advocates for the individual stating that the individual should always receive treatment in the most autonomous setting or environment that is possible but still effective (Pratt, Gill, Barrett, & Roberts, 2007, p. 113). This means, for example, that no one should be treated in a psychiatric hospital if there is a community-based programs available where he or she can receive equally effective treatment (Pratt et al., 2007, p. 113). This principle of autonomy was developed to uphold the goals of community integration and deinstitutionalization for people with psychiatric disabilities, which the Independent Living Movement has essentially influenced, and in turn, preserved the wellness and preservation of the human psyche (Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010).

5 Background The researchers audience for this project is for rehabilitation counselors, mental health providers, potential employers, students, and victims of severe and persistent mental illness. The study manual will serve as a training guide and informational resource on counseling and therapeutic processes that have shown to be effective for people recovering from severe mental illness. The manual, which is guided by the insightful direction of current psychiatric rehabilitation practices, encompasses the main goals described below for the Recovery Model. Pratt et al. (2007) discuss the rehabilitation principles and methodology for psychiatric rehabilitation as a recovery concept that is unique to each individual. The authors (Pratt et al., 2007) point out that there is universal agreement on three goals in psychiatric rehabilitation, which are: 1. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness achieve recovery. 2. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness achieve maximum community integration. 3. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness achieve the highest possible quality of life. (p. 113-114) These are the goals of the Recovery Model in today current Psychiatric Rehabilitation practices that provide insightful direction of research practices today.

Statement of the Problem Employment rates are extremely low for individual with severe and persistent mental illness, because the transition from illness to work is difficult. According to researchers

6 Provencher, Gregg, Mead, and Mueser (2002) barriers to employment may include symptoms, self-esteem, quality of life, and clinical and social stability. These barriers to employment are realized in the analysis of employment rates for people with psychiatric disabilities which range between 10-20% (Provencher et al., 2002). Researchers also indicate that studies show a small amount of how people with psychiatric disabilities make decisions in going back to work and seeking employment (Killeen & ODay, 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 & ODay, 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 individuals proactive strategies (self determination) in rehabilitation, social connectedness, and focusing on the process of recovery for persons with severe and persistent mental illness, rather than the result, is proving to be successful for positive rehabilitation outcomes such as returning back to

7 work (Dana et al., 2008; Jinhee Park, Personal Communication, Doctoral Student Illinois Institute of Technology, National Council on Rehabilitation Education Conference, April 8, 2010; Lydie Levy, Personal Communication, Partner/VP Business Development, IPLux Xpertise S.a.r.l., Social Psychology, Universite Vincennes-Saint-Denis (Paris); Master Business Administration, Reims Management School; Master Business Law, Universite de Reims Champagne-Ardenne, Gemstar TV-Guide International, August 1, 1997; Provencher et al., 2002). Because concretely schizophrenia is a biological disorder, counseling interventions alone have proven to be ineffective in reducing symptoms, decreasing hospitalization, or enhancing community adjustment (Gomes-Schwartz, 1984). The primary treatment for schizophrenia is through psychopharmacotherapy however, medication compliance is an ongoing issue in the recovery of people with severe mental illness also, due to adaptation issues to disability and to the medication and side effects. In the attempt to assist in producing positive outcomes towards the full recovery of severe mental illness, such as the following points below, the combination of biomedical therapy and counseling is the best approach to recovery currently. 1. Attaining full independence and achievement of maximum individual potential; 2. Adopting good health habits to manage self and disability such as medication and weight management; 3. Attaining income flow by returning back to work to provide an income for oneself; 4. Establishment of life meaning and sense of self-satisfaction; 5. Attaining a focusing on the process of recovery and compassion for oneself; Collectively these positive outcomes for psychiatric rehabilitation can re-establish the person with a disabilitys sense of humanity which can undergo deterioration with the onset of

8 severe and persistent mental illness. Hence, counseling and therapeutic techniques can assist in facilitating these processes. While experts recognize the individual is faced with modern treatments through biomedical therapy in conjunction with various counseling therapies and therapeutic process to adapt to the disability first, then moving towards total recovery, this combination of process vs. result approach in psychiatric rehabilitation is proving to be effective Recovery Paradigm (Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010). Techniques that are included in the rehabilitation process to assist with adaptation of disability and recovery include biomedical therapy which is the first line of treatment for severe and persistent mental illness, and other therapies assisting with adaption, cognitive restructuring, and motivational change including, cognitive behavioral therapy, person-centered therapy, psychotherapy, occupational therapy, and exercise therapy. For example, Pratt et al., (2007) discuss Carl Rogers person-centered therapy approach as effective and the basic tenets of consumer-centered therapy are highly compatible with psychiatric rehabilitation and have an important influence in the field (Pratt et al., 2007, p. 152). Other processes include integration of psychosocial techniques, spirituality, and religion in the total rehabilitation process (Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010). In their article Psychological Adaptation to Disability: Perspectives From Chao and Complexity Theory, Hanonch Livneh and Randall M. Parker (2005) offer a relevant definition to the process of adaptation to disability, which the author of this project finds true based on her own experience in surviving the onset of severe mental illness. Livneh and Parker (2005) state, The process of adaptation, then, is essentially a process of self-organization that unfolds through experiences of chaos (i.e., emotional turmoil) and complexity (i.e., cognitive and

9 behavioral reorganization) to increase functional dimensionality and renewed stability even if temporary (p. 22) The combination of treatment is the most effective for the recovery from severe mental illness, by reducing major chemical imbalances in the brain through biomedical therapies and counseling treatments to promote behavioral change, self-identification, social connectiveness, and combat stigmatization (Jinhee Park, Personal Communication, Doctoral Student Illinois Institute of Technology, National Council on Rehabilitation Education Conference, April 8, 2010). In total this process (the combination of treatments) is the closest thing that can ensure the recovery of individuals stricken with the onset of severe mental illness (Weiten, Lloyd, Dunn, & Hammer, 2009). There is no doubt that the first step to achieving a full recovery outcome is through medication compliance for people with severe mental illness (Weiten et al., 2009). In this project the researcher will discuss the various therapies that have been proven to be successful in helping the individual adapt to psychiatric disability along with biomedical therapy, and empower the individual in gaining command over his or her life through the recovery process that promotes wellness and meaningful living. In the context of rehabilitation counseling research, wellness and meaningful living may be recognized though work status, adjustment to disability, functional ability and quality of life (Frain, Bishop, & Tschopp, 2009) Research shows (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) there is a higher rate of suicide by individuals with severe mental illness, such as schizophrenia, severe depression, and bipolar disorder. Without these interventions, such as biomedical therapy, counseling therapies and other therapeutic processes to assist in individual restoration of the self, individuals stricken with the onset of severe mental illness such as schizophrenia,

10 experience three phases of the disease known as the prodromal, active, and residual. This is the most extreme example of human suffering caused by mental illness known to man. The three phases of schizophrenia are (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, 2000; Centre of Addiction and Mental Health (2009). Schizophrenia: An Information Guide. http://www.camh.net):

Prodromal phase In the prodromal phase, people may begin to lose interest in their usual activities and to withdraw from friends and family members. They may become easily confused, have trouble concentrating, and feel listless and apathetic, preferring to spend most of their days alone. This phase can last weeks or months.

Active phase During schizophrenia's active phase, people will have delusions, hallucinations, marked distortions in thinking and disturbances in behaviour and feelings. This phase is often the most frightening to the person with schizophrenia, and to others.

Residual phase After an active phase, people may be listless, have trouble concentrating and be withdrawn. The symptoms in this phase are similar to those outlined under the prodromal phase.

To address issues in the deterioration from illness that can result in the destruction of quality of life of individuals with severe mental illness, an individual must undergo a psychological restoration of their humanness which counseling processes and therapeutic

11 interventions facilitate (Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010). This proactive process of restoration through counseling and other therapeutic techniques can promote individual empowerment, greater knowledge of self and the environment, self-efficacy, and connections with others (Jinhee Park, Personal Communication, Doctoral Student Illinois Institute of Technology, National Council on Rehabilitation Education Conference, April 8, 2010). Pratt et al. (2007) application of principles and methodologies of psychiatric rehabilitation counseling techniques are not recognized as an intervention for psychiatric rehabilitation; however, they are offered as a supplement to the total rehabilitation process. In order to provide the best support and likelihood for successful rehabilitation outcomes, it is essential for service providers, such as rehabilitation counselors, to become familiar with the total rehabilitation process and its supplements, including alternative therapeutic techniques for people with severe mental illness. If providers such as rehabilitation counselors do not become familiar with the total rehabilitation process for people recovering from severe mental illness, the counselor is not tapping into the cycle of wellness that promotes recovery today.

Statement of the Purpose The purpose of this project is to affirm the understanding of the importance of self-determination and how successful rehabilitation outcomes are realized for people with psychiatric disabilities through a process of various insights such as acceptance of the disability, medication management, and attaining independence by attaining a home, gainful employment, and meaningful relationships. This independence is what is

12 considered as successful rehabilitation outcomes according to the current psychiatric principles discussed by Pratt et al. (2007). Counseling techniques are a component of the psychiatric rehabilitation process, and the author will feature in Chapter 4, in study manual, the specific counseling and therapeutic techniques that are included in successful rehabilitation outcomes for people with severe mental illness. This will offer service providers clarity of what has proven to be effective and understanding the techniques that facilitate efforts for issues such as symptom management, relapse prevention, medication compliance and psychosocial issues, such as social phobia, and achievement of independence and community integration.

Research Question This project will be guided by the following research question: 1. What counseling and therapeutic techniques are included in the rehabilitation process for individuals recovering from severe mental illness?

Definition of Terms The Definitions of Terms for this project include the following terms: 1. Psychiatric Rehabilitation Process: The psychiatric rehabilitation process considers the nature of severe and persistent mental illness, through identification of the symptoms and etiology of severe mental illness, definition of psychiatric rehabilitation principles and methodology, and application of these principles and methodology (Pratt et al., 2007).

13 2. Counseling Techniques: Talk therapies that promote the psychological wellness and exploration of self. 3. Therapeutic Process: The process of self-engagement that promote the wellness and recovery for people recovering from severe mental illness. 4. Successful Outcomes: Is recognized in the definition of the term, Quality of Life (QOL), which is defined by Bishop, Chapin, and Miller (2008) in their research article titled Quality of Life Assessment in the Measurement of Rehabilitation Outcome. QOL: Quality of life represents the subjective and personally derived sense of overall well-being that results from an evaluation of happiness or satisfaction across an aggregate of personally or clinically important domains (p. 48). 5. Severe Mental Illness: Disease process in the brain based on physiological evidence that is induced by psychological stress (Pratt et al., 2007). 6. Independent Living: The process of self-determination and independence (DeJong, 1979). 7. Gainful Employment: Meaningful employment where wages are earned in balance with skill.

Assumptions For the purposes of conducting this project, the researcher assumes the following: 1. Counselors, mental health professions, potential employers, students, and victims of severe and persistent mental illness will find examples of counseling and other therapeutic processes applied to psychiatric rehabilitation beneficial. 2. Counselors, mental health professionals, potential employers, students, and victims of severe and persistent mental illness will benefit from this presentation with an understanding that biomedical therapy, counseling therapy, and other therapeutic

14 processes are the most effective intervention for the recovery of severe mental illness today.

Limitations For the purposes of conducting this project, the researcher assumes the following: 1. This presentation is limited to training and informational purposes for rehabilitation counselors, mental health providers, potential employers, students, and victims of severe and persistent mental illness.

Delimitations For the purposes of conducting this project, the researcher assumes the following: 1. The researcher did not including psychiatric rehabilitation or disability research before 1956. 2. Research is limited to western views of scientific methods of research in psychiatric rehabilitation and the Recovery Model.

Significance of the Study This study will be an aid to rehabilitation counselors, mental health professionals, employers, students, and victims of severe and persistent mental illness. With proper implementation and support it can be utilized in the following manner: 1. Rehabilitation Counselors: Serves as a training guide for rehabilitation counselors in the area of counseling techniques included in the rehabilitation process for individuals with severe mental illness. This training guide will also serve as insight for the

15 rehabilitation counselors for Individualized Plan Development for individuals with psychiatric disabilities. 2. Mental Health Professionals: Serves as an insight for mental health professionals in the area of counseling therapies and other therapeutic process when applied to psychiatric rehabilitation. 3. Employers: Serves as an insight on potential disability accommodations when individuals with psychiatric disabilities are seeking employment or in job retention programs. 4. Students: Serves as a supplement to practicum to ensure comprehensive training combining counseling and case management when working with individuals with psychiatric disabilities. 5. Victims of severe and persistent mental illness: To help facilitate the process of recovery through insight and education of current day psychiatric rehabilitation processes/practices and effective recovery interventions.

Chapter Summary Improving and protecting the civil rights of the disabled is the primary objective of the Independent Living Movement, which has influenced education in the United States and disability policy since the 1960s (Dr. Charles Arokiasamy, personal communication, Professor, California State University, Fresno, December 16, 2010). This has resulted in gaining rights for people with disabilities, such as the development of the American Disabilities Act in the 1990s. This advocacy movement has developed and influenced modern day rehabilitation models for specific areas of disability, specifically

16 psychiatric rehabilitation. With the introduction of the Recovery Model, described by William Anthony from the Center of Psychiatric Rehabilitation at Boston University, researchers found that people were recovering from severe psychiatric disabilities, originally categorized as a degenerative illness (Dana et al., 2008). The models of recovery, specifically for psychiatric disability were developed, focusing on the selfdetermination 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 selfhelp 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, selfesteem, quality of life, and clinical and social stability. Hence employment rates for people with psychiatric disabilities range between 10-20% (Provencher et al., 2002) due to such barriers. Counseling and therapeutic techniques help facilitate this process of adaptation to the disability first, and recovery through a multi-dimensional rehabilitation process for individuals recovering from severe and persistent mental illness. By

17 exploring and presenting the various counseling and therapeutic techniques for people that are recovering from severe mental illness, the researcher hopes this will inspire service providers with clarity of what has proven to be effective, and gain an understanding of the techniques that facilitate recovery for such issues as symptom management, relapse prevention, medication compliance and psychosocial issues such as social phobia. In order to provide the best support and likelihood for successful rehabilitation outcomes, it is important for service providers such as rehabilitation counselors to become familiar with the total rehabilitation process, including counseling and alternative therapeutic techniques for people with severe mental illness (Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010). If providers such as rehabilitation counselors do not become familiar with the total rehabilitation process for people with disabilities recovering from severe mental illness, they may not tap into the total cycle of wellness that promotes recovery today for people recovering from severe mental illness. The author will present Chapter Two next, in a review of the literature that includes current practices of psychiatric rehabilitation, counseling processes, and therapeutic techniques included in the rehabilitation process for individuals recovering from severe mental illness.

18 CHAPTER TWO REVIEW OF THE LITERATURE Introduction Improving and protecting the civil rights of the people with disabilities, and transition to the Independent Living paradigm, has defined problems and intervention of those problems in new ways, has infused new perspectives about the human service system as whole. The new perspectives are evident and have influenced current disability practices, specifically in the context of psychiatric rehabilitation and the introduction to the Recovery Model (Dr. Charles Arokiasamy, personal communication, Professor, California State University, Fresno, December 16, 2010; Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010). It is the researchers intent to present current practices in Psychiatric Rehabilitation that are based on the Recovery Model for an audience including rehabilitation counselors, mental health providers, potential employers, students, and victims of severe and persistent mental illness. The statement of problem on this topic conveys that employment rates are very low for people with severe and persistent mental illness, because the transition from illness to work is difficult (Provencher, Gregg, Mead, and Mueser, 2002). Barriers to work include symptoms, self-esteem, quality of life, and clinical and social instability (Provencher et al., 2002). The primary treatment for severe mental illness is through biomedical therapy; however, medication compliance is an ongoing issue in the recovery of people with severe mental illness. In the attempt to produce positive outcomes towards the full recovery of severe mental illness and to have he or she return to work, experts recognize the individual is faced with adapting to the disability first, then recovery, which counseling and therapeutic techniques help facilitate. It is the purpose of this project to present specific counseling and

19 therapeutic techniques that are included in the rehabilitation process that facilitate various insights (such as self-acceptance, self-management, social connectedness, self-esteem) that produce successful outcomes for people with severe mental illness. This approach will provide service providers the clarity of what has proven to be effective and understanding the techniques that facilitate efforts for such issues as symptom management, relapse prevention, medication compliance and psychosocial issues, such as social phobia. In this chapter, Review of the Literature, the author will present the current practices of psychiatric rehabilitation (PsyR) and counseling therapies and therapeutic techniques included in the rehabilitation process for individuals recovering from severe mental illness. The research question which guided this project is: What counseling therapies and therapeutic techniques are included in the rehabilitation process, for people recovering from severe mental illness? The authors research for this project includes a collection of information from three informational sources, including the authors 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 sections literature review and study manual. In summary, the author reviewed a total of 7 textbooks which all were used in this project, 84 articles, and 17 articles were selected from both databases, with 1 article remaining from the PsycINFO database, Henry Madden Library at California State University, Fresno. There were a total of 11 different sources used in this project including 7 Masters level coursework textbooks and articles, 2 major research databases (NARIC and Boston University Psychiatric Rehabilitation Journal), and 3 personal readings.

Review of the Literature The literature categories for the literature review include the current practices of psychiatric rehabilitation, counseling techniques and other therapeutic techniques conveyed as successful when included in the rehabilitation process for individual recovering from severe mental illness. Collectively, the processes presented here on counseling therapies include: Cognitive Behavioral Therapy, Person Centered Therapy, Group Therapy, Solution-Focused Therapy, and Psychotherapy. The processes presented on therapeutic techniques include:

21 Occupational Therapy, Exercise Therapy, Motivational Interviewing, Religion and Spirituality, Disclosure, Photovoice, Role Development, Leadership Education, and Empowerment.

Current Practices of Psychiatric Rehabilitation (PsyR). The psychiatric rehabilitation process considers the nature of severe and persistent mental illness through identification of the symptoms and etiology of severe mental illness, definition of psychiatric rehabilitation principles and methodology, and application of these principles and methodology (Pratt, Gill, Barrett, & Roberts, 2007). These three components encompass the psychiatric rehabilitation process and successful rehabilitation outcomes for individuals suffering from severe and persistent mental illness, such as schizophrenia, through understanding the medical nature of mental illness, interventions and application (Pratt et al., 2007). Pratt et al. (2007) discuss the rehabilitation principles and methodology for psychiatric rehabilitation as a recovery concept that is unique to each individual. The authors (Pratt et al., 2007) point out that there is universal agreement on three goals in psychiatric rehabilitation, which are: 1. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness achieve recovery. 2. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness achieve maximum community integration. 3. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness achieve the highest possible quality of life. (p. 113-114) Pratt et al. (2007) also discuss the rehabilitation principles and methodology for psychiatric rehabilitation in terms of values, as empowering the individual with a disability, and

22 that a person with a severe mental illness is not just a passive recipient of rehabilitation services. This is indicating that new processes are being based on new values, branching away from the medical model and sick role. There are five sets of values in todays 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

23 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 individuals 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 persons 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 clients 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 therapists 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 doublebinding 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 processoriented 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 individuals connection between healthy social experiences in interactive behavioral training (IBT) and the individuals 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). SolutionFocused 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 persons 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 persons owning the right to selfdetermination, 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 individuals 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 persons 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-bystep 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 communitys 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 ones 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 patients 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 persons 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 individuals 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 therapys 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, cooccurring 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.

37 Motivation Interviewing Christopher C. Wagner and Brian T. McMahon (2004) from Virginia Commonwealth University, describe Motivational Interviewing (MI) as a clientcentered, directive counseling approach described to foster client motivation and initiative (p. 154). According to Wagner and McMahon (2004), motivational interviewing facilitates the initiative for personal insight to behavioral change, including the following three components: a. A focus on the clients experiences, values, goals, and plans b. A promotion of client choice and responsibility for implementing change c. An initiative to provide the Rogerian conditions of empathy, unconditional positive regard, and genuineness (p. 154). The supportive and driving factor between Rehabilitation Counseling and Motivational Interviewing according to Wagner and MacMahon (2004), is the focus of self-determination. According to Wagner and McMahon the role of self determination in rehabilitation has been described in Total Rehabilitation by N.G. Wright (1980) as: All people have a right to self-determination insofar as they are capable to responsible judgments; people should make their own decisions, set their own goals, and also decide how they achieve those goals. This does not mean that the (counselor) must assume a passive role or be totally nondirective. Active intervention by the rehabilitation counselor helps the client make decisions by providing needed information, by fostering the development of self-confidence, and by facilitating problem-solving. The client is the primary individual in

38 rehabilitation with ultimate decision-making authority and responsibility. (p. 152) Motivational interviewing in psychiatric rehabilitation may include counseling individuals with severe depression, phobia, schizophrenia, or individuals who have been traumatized and is recovering from an illness such as PTSD. MI counseling interventions in psychiatric rehabilitation and recovery from severe mental illness essentially focuses on treatment- related issues such as participation, compliance, and developing insight (Wagner & McMahon, 2004; Rusch & Corrigan, 2002). The MI counseling for individuals recovering from severe mental illness is essentially used to promote wellness and managing symptoms, and hopefully in the process, lessen likelihood for relapse and/or hospitalization. Wagner and McMahon (2004) discuss the four principles of motivational interviewing that promote change which serves as positive insight for rehabilitation counselors and educators, managing cases for individuals recovering from severe mental illness, which are: 1. Expression of empathy 2. Roll with resistance where the counselor facilitates an environment that is calm, supportive even when the client is defensive, argumentative, or withdrawn or behaves in any other manner that the counselor perceives negatively. 3. Develop discrepancy or confrontation. Meaning the counselor gently explores discrepancies between current behavior (if they are counterproductive) and desired future behaviors.

39 4. Supportiveness to self-efficacy. Meaning the counselor is to serve in helping the client gain confidence about, and commitment to, making changes and achieving goals. (p. 154-155) Collectively, Motivation Interviewing according to Wagner and McMahon (2004) is empirically supported, client-centered, directive counseling approach designed to promote client motivation and reduce motivational conflicts and barriers to change (p. 159).

Religion and Spirituality Andrea Blanch (2007) at the Center for Religious Tolerance in Sarasota, Florida discusses in her article Integrating Religion and Spirituality in Mental Health: The Promise and the Challenge, the nature of the mental health system comparable to the one-eyed giant with a limited perspective, gaining so much power from its grounding in a scientific model that it has become almost impossible to challenge (p. 251). However, Blanch does challenge the scientific model, which is so prevalent in western society by considering the wisdom of eastern medicine and its applicability to rehabilitation and wellness of individuals recovering from severe mental illness. The wisdom of eastern medicine that Blanch (2007) discusses is rooted in the nature of being human, and suggests new processes in the clinical environment that will maximize the potential of individuals discovering what it means to be human. Blanch (2007) gives a historical perspective on integrating science and religion, our current social context and trends of spirituality and religion, reflections on spirituality, religion, and recovery, and further suggests strategies for integrating

40 spirituality in todays mental health practice. Collectively, these strategies include: having a set of solutions, tools to asking questions, and supporting the wisdom inherent in the clients support system (Blanch, 2007). More specifically, these strategies include four elements for practitioner intervention which are: 1. Spiritual information gathering. 2. Acknowledging the clients 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 clients 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 clients explanatory framework: A formal acknowledgement of the clients explanatory framework and an active attempt to accommodate that framework. Blanch (2007) discusses that working from the clients 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.

41 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).

42 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. Blanchs (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 Ruths O. Ralphs 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 Websters 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

43 about the time when his life was out of control therefore non-disclosure is the result of taking control over ones 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.

45 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 lifes purpose and spiritual destiny. Bradshaw (2005) notes, that all of these externalization methods have been adapted from the major schools of therapy. Most therapies attempt to make that which is covert and unconscious to something overt and conscious (Bradshaw, 2005). The third barrier that Ralph (2002) describes as a barrier to disclosure, is discrimination and stigma. According to Ralph (2002), discrimination can result in painful experiences of exclusion and rejection often through subtle day-to-day interactions (Ralph, 2002). This can occur in a variety of contexts such as the mental health system and the workplace (Ralph, 2002). Ralph (2002) describes that the stigmatization existing in the mental health system may include power and control imposed by providers where consumers are being treated as having lower status than staff, regimented and dehumanizing practices, separation from the community, disbelief that people with psychiatric disability can grow and learn, lack of respect for privacy, and

46 inadequate access to information (p. 167). These practices have been supplemented with todays 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

47 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 consumers confront stigma (Recovery and Rehabiltation, 2008). By confronting stigma and incorporating the technique into psychiatric rehabilitation, this will increase consumers 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 Centers 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

48 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 instructors guide that leads students through Photovoice process step-by-step while the instructors guide provides comprehensive instruction in leading Photovoice workshops (Recovery and Rehabilitation, 2008, p. 3). The Center finds that this curriculum will ensue the intervention may be easily delivered at outpatient mental health and rehabilitation settings as well as consumer-run programs and centers (Recovery and Rehabilitation, 2008, p. 3).

Role Development Victoria P. Schindler in her article Role Development: An Evidenced-Based Intervention for Individuals Diagnosed with Schizophrenia in a Forensic Facility describes the importance of social roles and community involvement for humans. This concept is asserted famed psychologist, Dr. Alfred Adler who discussed the idea of social connected as a pivotal part of human development and actualization of our potential as human beings. This study conducted within a forensic facility, where comprehensive

49 rehabilitation is typically not offered currently (Schindler, 2005), analyzed 84 male participants diagnosed with schizophrenia and taking antipsychotic medication. The group was split into two groups: a comparison group and an experimental group. Quantitative and qualitative measures where used to collect data. The quantitative assessments used were: The Role Functioning Scale, The Task Skills Scale, and the Interpersonal Skills Scale, and assessments where conducted at 4, 8, and 12 weeks. The comparison group followed the conventional structure of a forensic facility defined as Multi-Departmental Activity Program or MAP (Schindler, 2005). According to Schindler, MAP is a non-individualized, therapeutic intervention designed to encourage the productive use of time and socialization in a group setting (Schindler, 2005, p. 392). The experimental group was developed as an enhancement of MAP, however the treatment is more individualized where trained staff assisted participants to develop task as interpersonal skills within meaningful social roles (Schindler, 2005, p. 392). In this study roles were developed for a forensic setting including roles of worker, student, group member, friend for example. The idea of strengthening self-identification was successful in this study and finding proved to be statistically significant in the experimental group when compared to the comparison group. The study showed significant improvement among participants in three different areas including task skills, interpersonal skills, and role development. Schindler asserts that both staff and participants were able to successfully implement and participate in the study within the constructs of a forensic setting (Schindler, 2005).

50 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

51 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 participants 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).

52 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 researchers intent to quantify theory into measurable results, which more concretely concludes variables of empowerment as effective, and predictors of positive rehabilitation outcomes. Researchers measured four areas of empowerment including self-efficacy (control), self-advocacy (assertiveness), perceived stigma (having a positive self concept, self-esteem, holding positive self-regard concerning the self), and competence (autonomous, competent, goal-directed, independent, personally responsible, self-reliant, and self-montioring). The outcomes identified as important in rehabilitation counseling were also measure against empowerment variables including quality of life. Empowerment variables domains include: physical health, mental health, work, leisure activities, financial situation, relationship with partner, family relationships, other social relationships, autonomy/independence, religious/spiritual; quality of life variables include: employment, adjustment to disability and functional status (Frain et al., 2009).

53 Frain et al. (2009) convey that in the theoretical context, personal empowerment include four dimensions which are (p. 28): 1. Awareness of factors that contribute to and hinder their efforts towards goals; 2. Personal control; 3. Efforts to exert control; 4. Competency and the ability to achieve outcomes. The quantified results of the study, concluded that the area of self-efficacy and self-management may be the most powerful forces individuals may acquire that will lead to positive rehabilitation outcomes (Frain et al., 2009, p. 33). The researchers conclude that this measurable finding agrees with the theoretical concept (four theoretical dimensions of empowerment) that empowerment will improve adjustment to disability outcomes and employment outcomes for individuals with disabilities (Frain et al., 2009, p. 33). The implications of empowerment for practitioner and application of findings into the rehabilitation processes are argued and include six areas of professional development to consider as highlighted by Frain et al. (2009, p. 33): 1. The reason practitioners 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

54 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.

55 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). Todays 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 individuals 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

56 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 authors intent to present a scope of processes that help facilitate the process of adaptation and recovery for people with mental illness successfully. In the next chapter the author will present the methodology of the selection of processes that made it to the study manual.

57 CHAPTER THREE METHODOLOGY

Introduction With the introduction of the Recovery Model and Paradigm new perspectives are evident in psychiatric rehabilitation. William A. Anthony at the Center of Psychiatric Rehabilitation (CPR) at Boston University asserts that work by researchers Desisto, Harding, McCormick, Ashikaga, and Brooks, (1995a; 1995b), conveyed that contradictory to the belief that severe mental illness was a deteriorative disease, recovery from mental illness was happening (Dana et al., 2008). With these finding in the 1990s, increasing states and countries began to take on the recovery vision, that influenced the thinking of many of todays system planners and administrators according to William Anthony at CPR (Dana et al., 2008, p. 319). The Recovery Model empirically lead reconstruction of psychiatric rehabilitation practices, is supported by the earlier grassroots advocacy initiatives for people with disabilities beginning in the 1960s with the introduction of the Independent Living Movement, later defined by Gerben DeJong (1979) as the Independent Living Paradigm. The Independent Living Paradigm similar to the Recovery Model, has also defined problems and the range of intervention to those problems in new ways, infusing new perspectives about the human service system as whole as well (Dr. Charles Arokiasamy, personal communication, Professor, California State University, Fresno, December 16, 2010; Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010). The new perspectives have influenced current disability practices, specifically in the context of psychiatric rehabilitation and the development of the Recovery Model (Dr. Charles Arokiasamy, personal communication, Professor, California State

58 University, Fresno, December 16, 2010; Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010). The audience of this project is rehabilitation counselors, mental health providers, potential employers, students, and victims of severe and persistent mental illness. The proposed manual will serve as a study, training guide, and informational resource on counseling and therapeutic processes that have shown to be effective for people recovering from severe mental illness. The study guide, which is guided by the insightful direction of current psychiatric rehabilitation practices, encompasses the main goals from the Recovery Model and presents the processes that are supported by empirical evidence in facilitating recovery for people with severe mental illness, leading to more meaningful and fulfilling lives. The statement of the problem is that employment rates are extremely low for individuals with severe and persistent mental illness, because the transition from illness to work is difficult (Provencher, Gregg, Mead, and Mueser, 2002). Barriers to employment may include symptoms, self-esteem, quality of life, and clinical and social stability. These barriers to employment are conveyed in the analysis of employment rates for people with psychiatric disabilities which range between 10-20% (Provencher et al., 2002). The primary treatment for severe mental illness is through

biomedical therapy; however, medication compliance is an ongoing issue in the recovery of people with severe mental illness (Pratt, Gill, Barrett, & Roberts, 2007). In the attempt to produce positive outcomes towards the full recovery of severe mental illness and going back to work, researchers Provencher et al. (2002) recognize the individual is faced with adapting to the disability first, then recovery, which counseling and therapeutic techniques help facilitate. Provencher et al. (2002) state recovery is defined as the process of transcending symptoms, psychiatric disabilities, and social handicaps (p. 133). These research findings are uncovering

59 that an individuals 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 selfdetermination and how successful rehabilitation outcomes are realized or influenced for people with psychiatric disabilities through a process of various insights such as acceptance of the disability, medication management, and attaining independence by attaining a home, gainful employment, and meaningful relationships. This independence is what is considered as successful rehabilitation outcomes according to the current psychiatric principles discussed by Pratt et al. (2007). The research question which guided this project is: What counseling therapies and therapeutic techniques are included in the rehabilitation process, for people recovering from severe mental illness? In the following section the author will present project information on population and sample of the project, collection of the materials and conditions for inclusion of the final presentation, and the chapter summary.

60 Population and Sample This project is a literature-driven study manual and collection of best practices of counseling and therapeutic techniques included in current day rehabilitation processes. The researchers 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 individuals humanness as conveyed through the Recovery Model and every individuals 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 individuals humanness.

61 Collection of the Materials and Conditions for Inclusion The authors final research for this project includes collection of information from three informational sources including: the authors Master level coursework, two major research databases, and personal readings. The authors 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 authors presentation. John Wiley & Sons, Inc. stated: Permission is hereby granted for the use requested subject to the usual acknowledgements (The Complete Adult Psychotherapy Treatment Planner /

62 Arthur E. Jongsma, Jr. and Mark Peterson /ISBN; Copyright [2006 and Arthur E. Jongma, Jr. and L. Mark Peterson]. And the statement This material is reproduced with permission of John Wiley & Sons, Inc.). Any third party material is expressly excluded from this permission. If any of the material you wish to use appears within our work with credit to another source, authorization from that source must be obtained. This permission does not include the right to grant others permission to photocopy or otherwise reproduce this material except for versions made by non-profit organizations for use by the blind or handicapped persons. (Email, October 7, 2011) The second source of information was, two major research databases that were researched for this project manual. The first database search is from NARIC (National Rehabilitation Resource Center) a national resource database focusing and housing research in the area of rehabilitation and disability. The NARIC database was recommended by Dr. Malachy Bishop from University of Kentucky when the author inquired about resources in the area of rehabilitation and disability. The author established Dr. Bishop as a contact after studying at Southern University, Summer Research Institute 2009 funded by NIDRR Scholarship, in Baton Rouge, Louisiana where Dr. Bishop taught meta-analysis and data-mining techniques. The second database that was used for this presentation was the Psychiatric Rehabilitation Journal published by the Center for Psychiatric Rehabilitation at Boston University. A fee of $80.00 was paid by the author for access to the database. The author initially collected approximately 200 articles which were reviewed for inclusion in the final project. During the second week of December, the authors 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 authors 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 todays psychiatric rehabilitation processes and the values of todays 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 sections 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 authors 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 researchers 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 authors research for this project include collection of information from

65 three major informational sources, including the authors 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 todays system planners and administrators according to Anthony (Dana et al., 2008, p. 319). This empirically lead reconstruction of psychiatric rehabilitation practices is supported by earlier grassroots advocacy initiatives for people with disabilities beginning in the 1960s like the Independent Living Movement, with other pivotal transitions enabling people and breaking barriers of oppression, such as the civil rights movement, consumerism, self help, demedicalization, and deinstitutionalization (DeJong, 1979). With the development of the Independent Living Movement, later defined by Gerben DeJong (1979) as the Independent Living Paradigm, has also defined and influenced the range of intervention to those problems in new ways, infusing new perspectives about the human service system as whole also. The new perspectives are evident and have influenced current disability practices, specifically in the context of psychiatric rehabilitation and the development of the Recovery Model (Dr.

67 Charles Arokiasamy, personal communication, Professor, California State University, Fresno, December 16, 2010; Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010). It is the researchers 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, selfmanagement, 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 researchers findings of this are essentially uncovering that an individuals 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 ChampagneArdenne, 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 authors literature review of chapter two, the authors 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, selfdetermination, and independence reminds researchers of the core values of the Independent Living Movement, and the grounding of psychiatric rehabilitation in the Recovery Model is todays 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 selfacceptance, 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 individuals inner resources and capacities in self expression, resolve issues of avoidance, identify recurring themes/patterns, explore of past experiences, and focus on the interpersonal relationship according to publication author Jonathan Shedler (2010). 6. Occupational Therapy: A process encompassing the bodily felt sense of focus as it applies to occupational tasks that individuals participate in, such as self-care, productivity, and leisure. 7. Exercise Therapy: A process for the individual to establish a sense of normality in managing his or her disability (Forgarty et al., 2004)

76 8. Motivational Interviewing: Applied to psychiatric rehabilitation, motivational interviewing is a process that focuses on treatment related issues such as participation, compliance, and developing insight; it is essentially used to promote wellness and managing symptoms, and lessen likelihood for relapse and/or hospitalization. (Wagner & McMahon, 2004; Rusch & Corrigan, 2002). 9. Spirituality and Religion: A process of integration of spirituality and religion into our service system processes that calls for 1. Spiritual information gathering, 2. Acknowledging the clients explanatory framework, 3. Expanded consultative model, 4. Using Spiritual and Mystical Practices to Assist with Recovery (Blanch, 2007). 10. Disclosure: The process of disclosure involves addressing three major barriers to psychiatric rehabilitation according to researcher Ruth O. Ralph (2002) which are: secrecy and control, shame, and discrimination and stigma. Ralph (2002) supports the idea of disclosure and discusses the advantages for disclosure as therapeutic and can lead to greater emotional wellness (Ralph, 2002, p. 169). 11. Photovoice: This addresses the process of stigma and the negative effects rejection can have on the human psyche. 12. Role Development: A process of developing positive self-identification through meaningful social roles (Schindler, 2005). 13. Leadership Education: A process promoting the recovery potential for individuals with severe mental illness, by fostering an environment of lecture, group processes, experimental learning, and empowerment through leadership training with an insightful purpose, developing diversity among government boards, committees, and non-profits that include people with disabilities (Bullock et al., 2000).

77 14. Empowerment: A process combating oppression. The researchers of this study provided insight on empowerment as quantifiable against the theoretical model and concluded to agree with theoretical analysis that empowerment makes a difference in overall mental health and produces positive outcomes in the total rehabilitation process. Collectively, these counseling and therapeutic techniques conveyed that by focusing on the process and not the result, the individual will achieve the result he or she wants. In Chapter Three, which is the Methodology; the author presented the population and sample for this project and the collection of the materials and conditions for inclusion. For the population and sample, the researchers audience for this project is rehabilitation counselors, mental health providers, potential employers, students, and victims of severe and persistent mental illness. The study manual was developed to serve as an informational resource and a training guide on counseling and therapeutic processes applied to psychiatric rehabilitation, which is shown to be effective for people recovering from severe mental illness. Second, the collection of the materials and conditions for inclusion, the author researched three major information resources including Masters coursework material, two research databases, and personal readings. In Chapter Four, the Presentation of the Project, the author developed a comprehensive study manual including: 1. Independent Living Movement and the Recovery Model in Psychiatric Rehabilitation 2. New Findings: Severe and Persistence Mental Illness is not a deteriorative disease 3. Manifestation of Mental Illness: Example- Schizophrenia

78 4. Impact of Disease: Effects on Quality of Life (QOL) 5. Audience for this Presentation 6. Statement of the Problem (Issue) 7. Statement of the Purpose 8. The Principle of Autonomy- Choice 9. Etiology of Severe and Persistent Mental Illness 10. Three (3) Goals of Current Psychiatric Rehabilitation Process 11. Five (5) Values of Current Psychiatric Rehabilitation Process 12. 13 Guiding Principles of Psychiatric Rehabilitation 13. Predictors of Recovery from Severe and Persistent Mental Illness 14. Treatment of Severe and Persistent Mental Illness 15. Adaption to Chronic Illness and Disability 16. Conditions Enabling Adaption 17. Resiliency Model vs. Recovery Model 18. Psychiatric Rehabilitation is about a Process not the Result: If you focus on the process you get to the result. 19. Cognitive Behavioral Therapy and Psychiatric Rehabilitation- Most commonly used treatment for Severe Mental Illness. 20. Counseling Therapies 21. Other Therapeutic Processes 22. Severe Mental Illnesses- Psychotherapy Treatment Planner 23. Application for Employers: Types and Definitions of Workplace Prejudice and Discrimination -Recognition for Workplace Inclusion

79 24. References

Conclusions The most important thing that the author learned in this project is that current day psychiatric rehabilitation is about a process. Empirical evidence supports the notion that if an individual with severe mental illness focuses on the processes to attaining better mental health through biomedical therapy, counseling therapy, and other therapeutic techniques, this combination is the best predictor of recovery (Weiten, Lloyd, Dunn, & Hammer, 2009). When an individual partakes in counseling and therapeutic processes during recovery, a stronger individual sense of self, and social connectedness is the result. This sense of self and social connectedness is marked as significant factors to the successful outcomes in psychiatric rehabilitation and returning to work, as the author indicated through the presentation of various studies for this project. The author also learned that through focusing on the process of rehabilitation, an individual is more likely to be successful in adapting to his or her disability. It is well documented that severe and persistent mental illness in the active phase of psychosis includes delusions, hallucination, hearing voices, racing thoughts, etc. This active phase of severe mental illness is essentially overactive and underactive chemicals in the brain, causing electrochemical malfunction. It is the authors opinion that adaptation to this chaos is best described by researcher Livneh and Parker (2005) in the article Psychological Adaption to Disability, stating, the process of adaptation, then, is essentially a process of self-organization that unfolds through experiences of chaos (i.e., emotional turmoil) and complexity (i.e., cognitive and behavioral reorganization) to

80 increased functional dimensionality and renewed stability, even if temporary (p. 22). It is clear, however, that this adaptation to disability cannot happen successfully without the intervention of biomedical therapy, which helps with direct treatment of active phase symptoms in severe and persistent mental illness. Once symptoms are controlled in severe mental illness, the individual can then begin further adapt toward full recovery with aid of counseling and therapeutic techniques that help facilitate a process of recovery though facilitating processes of social connectedness and self-identification beyond disability. It is essential in the recovery process to establish and develop healthily relationships that foster insight and individual growth, as well as interpersonal growth through counseling therapy which provides a significant opportunity in personal exploration. Additionally, the author also felt that the issue of stigma concerning people with psychiatric disabilities is relevant and also proved to be a significant barrier to recovery. Because of this the author sought out to find out more information on the topic of stigma and recently discovered at the National Conference for Rehabilitation Education (NCRE 2011), that stigma can become internalized. Internalized stigma among people with severe mental illness can result in coping through secrecy and withdraw (Hsin-Ya Liao, personal communication, Doctoral Student, University of Arizona, NCRE Conference Poster Presentation Manhattan Beach, April 7, 2011). Hence, it is advantageous for Rehabilitation Counselors, students, potential employers, and victims of severe and persistent mental illness to know as much about the disease as possible, and for victims become socially connected in their environment to combat stigma and the potential for being stigmatized as well.

81 When I first began developing this project I was not sure what direction it was going to go. My literature encompassed two major sources of information including my Masters coursework and two research databases, NARIC and the Psychiatric Rehabilitation Journal at Boston University, and personal readings. I kept grounded during this project by asking myself the question What information is personally meaningful to me? Being a survivor of the onset of severe mental illness myself, there were certain pivotal moments in my recovery that made a significant difference in overcoming the onset of severe mental illness. Those pivotal moments included the opportunity of choices and self determination in successfully seeking out services and treatment for severe mental illness, peer support, continuing my education and finding a new vocational goal, working with my disability and knowing my limits, and seeking out opportunities for personal growth beyond disability. Taking on this project was an easy decision for me, I knew I had a skill set that my experience surviving from severe mental illness gave me, that if developed, I could provide some insightful information on the recovery process in psychiatric rehabilitation. My conclusions for this project includes four points. The first is to follow what is personally meaningful. I feel that if you can follow a task that is personally meaningful, that grounding can go a long way. For example, when I first signed up to do the project it was in Spring 2010. At this time I was not done with my master coursework, and it was not until Spring 2011, that I had time to focus on really bringing my project together. My car was also broken into the second week of December 2010, and my backpack with all my literature was stolen. If this project did not have personal meaning for me, it is possible that I could have given up from being over extended or from the vandalism. My

82 point is to always do something you love! Second, it is imperative to save all your literature digitally and email copies of your project to yourself through the progression of the project. When my car was broken into it was a bit of a task to go back and try to find my research, hence saving all articles digitally is essential. During my project I also had a couple of computer malfunctions and those moments of not being able to access my computer, housing all my research information, was anxiety provoking to say the least. Hence, I recommend to email yourself a copy of the project during the progression project development. Third, I recommend to always look outside the box for references. The databases on campus at Fresno State are highly resourceful; however, the information was not fitting my exact needs for this project, so I sought out other resources, which was what I needed to make this project a success. Finding the research database NARIC and paying a somewhat costly fee for access to the Psychiatric Rehabilitation Journal through Boston University was worth the extra effort and investment, because these databases specialize in rehabilitation and accounts for the most current practices today in psychiatric rehabilitation. Lastly, for the presentation of the actual project, if you are finding that the research collected cannot be simplified to basic terms for a PowerPoint presentation, do not be afraid to do a manual. I started off doing a PowerPoint presentation which was a lot of work, and it was later recommended for me to translate the information into a manual format. I thought I would lose that time I put forth for a presentation but this was not the case at all. Patience is a virtue, and the translation to a manual format was rather simple, and as it turned out it is much more user friendly and esthetically pleasing; it turned out wonderfully and I was very happy with the final product.

83 Recommendations For future researchers, the authors 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 redevelopment 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 authors opinion that both techniques are very needed. Therefore, the authors 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 authors conclusions on the project, and lastly the authors 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., & ODay, 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), 1728. McGurk, S.R., & Wykes, T. (2008). Cognitive remediation and vocational rehabilitation. Psychiatric Rehabilitation Journal, 31(4), 350-359. Pratt, C.W., Gill, K.J., Barrett, N.M., & Roberts, M. (2007). Psychiatric Rehabilitation, 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 rehabilitation. Psychiatric Rehabilitation Journal, 27(1), 43-50. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109. Wagner, C.C., & McMahon, B.T. (2004). Motivational interviewing and rehabilitation counseling practice. Rehabilitation Counseling Bulletin, 47(3), 152-161. Weiten, W., Lloyd, M.A., Dunn, D.S., & Hammer, E.Y. (2009). Psychology Applied to Modern Life, Adustment in the 21st Century, Ninth Edition. Wadsworth Cengage Learning.

88 APPENDIX

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

TABLE OF CONTENTS Page ACKNOWLEGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4 5 6 6 7 7 8 8 8 9 9 10 10 10 11 11 11 12 12 13 13 13 14 15

Acknowledgements

Inspirational Quote by Sting . SECTION ONE: INTRODUCTION Methodology . . . . . . .

Independent Living Movement and the Recovery Model in PsyR New Findings Mental Illnesses Not a Deteriorative Disease . Manifestation of Mental Illness: An Example . . . . . . . . . . . . . . . . . . . . . . . . . . .

Impact of Disease: Effects on Quality of Life (QOL) Audience for this Study Manual . Statement of the Problem (Issue) . Statement of the Purpose . Research Question. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Principle of Autonomy- Choice .

Etiology of Severe and Persistent Mental Illness .

Three (3) Goals of Current Psychiatric Rehabilitation Process . Five (5) Values of Current Psychiatric Rehabilitation Process . Thirteen (13) Guiding Principles of Psychiatric Rehabilitation .

Predictors of Recovery from Severe and Persistent Mental Illness . Treatment of Severe and Persistent Mental Illness Adaption to Chronic Illness and Disability Conditions Enabling Adaption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Resiliency Model vs. Recovery Model Psychiatric Rehabilitation as a Process

Cognitive Behavioral Therapy (CBT) and PsyR .

Quote from Elyn R. Saks on CBT

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15 16 16 18 18 19 19 21 21 22 22 23 25 26 27 27 28 30 31 31 31 31 32 32 33 33 34

SECTION TWO: COUNSELING THERAPIES . Cognitive Remediation . . . . . . . . . . . . . . . .

Person-Centered Therapy . Group Therapy . . .

Solution Focused Therapy Psychotherapy . . . .

SECTION THREE: OTHER THERAPUETIC TECHNIQUES/PROCESSES Occupational Therapy. Exercise Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Motivational Interviewing Spirituality and Religion . Disclosure . Photovoice. . . . . . . . . . . . . . .

Role Development Leadership . . . .

Empowerment .

A Poem by Maya Angelou I Know Why the Cage Bird Sings . SECTION FOUR: SUMMARY ON PROCESSES Cognitive Remediation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Person-Centered Therapy . Group Therapy . . .

Solution Focused Therapy Psychotherapy . . . . . .

Occupational Therapy. Exercise Therapy . .

Motivational Interviewing

Spirituality and Religion . Disclosure . Photovoice. . . . . . . . . . . . . . .

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34 35 35 36 36 37 38 38 38 39 39 40 41 41 42 42 43 44 45 45 45 45 45 46 47

Role Development Leadership . . . .

Empowerment .

SECTION FIVE: SEVERE MENTAL ILLNESS AND PSYCHOTHERAPY Severe Mental Illnesses from Psychotherapy Treatment Planner Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dependency . Depression .

Dissociation .

Impulse Control Disorder . Low Self Esteem . Panic/Agoraphobia Psychoicism . . . . . . . . . . . .

Social Discomfort . Vocational Stress .

SECTION SIX: RECOMMENDATIONS FOR WORKPLACE INCLUSIONS. . Recognition for Workplace Inclusion . Supervisor Co-Worker Language. . Behaviors . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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!

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

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 authors research for this project includes a collection of information from three informational sources, including the authors 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 sections 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

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 todays system planners and administrators according to William A. Anthony (Dana et al., 2008, p. 319).

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

severe mental illness. This training guide will also serve as insight for the rehabilitation counselors for Individualized Plan Development for individuals with psychiatric disabilities. Mental Health Professionals: Serves as an insight for mental health professionals in the area of counseling therapies and other therapeutic process when applied to psychiatric rehabilitation. Potential Employers: Serves as an insight on potential disability accommodations when individuals with psychiatric disabilities are seeking employment or in job retention programs. Students: Serves as a supplement to practicum to ensure comprehensive training combining counseling and case management when working with individuals with psychiatric disabilities. Victims of severe and persistent mental illness: To help facilitate the process of recovery through insight and education of current day psychiatric rehabilitation process and effective recovery interventions.

Statement of the Issue Employment rates are extremely low for individuals with severe and persistent mental illness because the transition from illness to work is difficult. Barriers to employment may include symptoms, low self-esteem, poor quality of life, and clinical and social instability. These barriers to employment (symptoms, low self-esteem, poor quality of life, and clinical and social instability) are realized in the analysis of employment rates for people with psychiatric disabilities which range between 10-20% (Provencher, Gregg, Mead, & Mueser, 2002).

Statement of the Purpose The purpose of this project is to affirm the understanding of the importance of selfdetermination 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).

Research Question The research question which guided this project is: What counseling therapies and therapeutic techniques are included in the rehabilitation process, for people recovering from severe mental illness?

The Principle of Autonomy- Choice Similar to the Independent Living Movement, the Recovery Model advocates for the individual stating that the individual should always receive treatment in the most autonomous setting or environment that is possible but still effective (Pratt, Gill, Barrett, & Roberts, 2007 p. 113). This principle of autonomy was developed to uphold the goals of community integration and deinstitutionalization for people with psychiatric disabilities, which the Independent Living Movement has essentially influenced, and in turn, preserved the wellness and preservation of the human psyche (Dr. Juan Garcia, personal communication, Professor, California State University, Fresno, November 18, 2010).

Etiology of Severe and Persistent Mental Illness Research has uncovered that severe and persistent mental illness such as schizophenia is biological, and is influenced by the individuals 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 persons 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,

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personal communication, rehabilitation counselor, Department of Rehabilitation, San Francisco, October 1, 2010).

Three (3) Goals of Current Psychiatric Rehabilitation Process 1. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness achieve RECOVERY. 2. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness achieve maximum COMMUNITY INTEGRATION. 3. Psychiatric Rehabilitation Services are designed to help persons with severe mental illness achieve the highest possible QUALITY OF LIFE (QOL). (Pratt, Gill, Barrett, & Roberts, 2007 p. 113)

Five (5) Values of Current Psychiatric Rehabilitation Process 1. Everyone has the right to SELF-DETERMINATION, including participation in all decisions that affect their lives. 2. Psychiatric rehabilitation interventions RESPECT and PERSERVE the DIGNITY and WORTH of every HUMAN being, regardless of the degree of impairment, disability, or handicap. 3. OPTIMISM regarding the IMPROVEMENT and EVENTUAL RECOVERY of persons with severe mental illness is a critical element of all services. 4. Everyone has the capacity to LEARN and GROW. 5. Psychiatric Rehabilitation Services are SENSITIVE to and RESPECTFUL of the individual, CULTURAL and ethnic differences of each consumer (Pratt et al., 2007, p. 115-118).

Thirteen (13) Guiding Principles of Psychiatric Rehabilitation 1. Individualization of all services 2. Maximum client involvement, preference, and choice 3. Partnership between service provider and service recipient

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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

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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

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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

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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

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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

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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

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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 clients feeling sensitively and empathically and seeing the clients 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.

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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 persons owning the right to selfdetermination, 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 individuals 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 persons 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

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3.

4.

5.

6.

7.

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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. Identification of recurring themes and patterns: Psychodynamic therapists work to identify and explore recurring themes and patterns in the patients thoughts, feelings, self-concept, relationships, and life experiences. 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. Focus on interpersonal relations: Psychodynamic therapy has an emphasis on object relations and attachment, meaning that aspects of the personality and selfconcept are forged in the context of attachment relationship, and psychological difficulties often arise when problematic interpersonal patterns interfere with a persons ability to meet emotional needs. 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. 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 individuals 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).

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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.

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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).

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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

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todays 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 clients 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 clients 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 clients explanatory framework: A formal acknowledgement of the clients explanatory framework and an active attempt to accommodate that framework. Blanch (2007) discusses that working from the clients 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).

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10. Disclosure: Process that Symbolizes Acceptance vs. the Defense Mechanism of Denial According to Websters 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.

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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 lifes purpose and spiritual destiny. (p. 151) Insights on Internalized Stigma Coping Factor Perceived Stigma Perceived Stigma Secrecy Withdrawal Result Internalized Stigma 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).

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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 participants 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).

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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 participants 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).

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Significance of Study The quantified results of the study, concluded that the area of self-efficacy and selfmanagement 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 practitioners 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.

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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

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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 authors literature review on these cognitive processes, conveying quantitative research studies in the field of psychiatric rehabilitation are as follows:

Cognitive Remediation: Taking Command over Ones 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 clients 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.

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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 selfdetermination 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 persons 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

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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 individuals 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

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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 clients explanatory framework, 3. Expanded consultative model, 4. Using spiritual and mystical practices to assist with recovery (Blanch, 2007).

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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 instructors 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

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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 individuals 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 nonprofits that include people with disabilities (Bullock et al., 2000). The study conveyed the shifts in the participants 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

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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.

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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.

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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 problemsolving 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 clients family of origin for experiences of emotional abandonment. Assist in identifying the basis for his fear of disappointing others. Explore and clarify the clients fears or other negative feelings associated with being more independent. Verbally reinforce for any and all signs of assertiveness and independence. Explore the clients 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.

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Monitor and evaluate the clients 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 clients 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 clients 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 clients memory recall (Jongsma et al., 2006).

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Severe Mental Illness: Impulse Control Disorder Review the clients behavior pattern to assist him/her in clearly identifying, without minimization, denial, or projection of blame his/her pattern if impulsivity. Explore the clients 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 clients 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.

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Verbally reinforce the clients 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 selfimage (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

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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 clients 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 clients 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 clients schema and self-talk that immediate his/her social fear response. Use introduction, modeling, and role-playing to build the clients 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).

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Severe Mental Illness: Vocational Stress Clarify the nature of the clients conflicts in the work setting. Explore possible role of substance abuse in the clients vocational conflicts. Explore the clients tranfer of personal problems to the employment situation. Explore the clients patterns of interpersonal conflict that occur beyond the work setting but are repeated in the work setting. Reinforce the clients 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 others 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 clients emotions surrounding his/her vocational stress Explore the causes for clients 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 clients success and failure at workplace (Jongsma et al., 2006).

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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 DiscriminationRecognition 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 persons 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 nonclinical 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 persons mental health status and/or background Gossip Inappropriate humor/ridicule based on the persons mental health status or background Use of the persons mental health background as a manipulation strategy.

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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

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REFERENCES

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