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Hope, power and perception of self in individuals recovering from schizophrenia: a Rogerian perspective.

ABSTRACT

This study explored the relations among hope, power, and perception of self in individuals recovering from schizophrenia, from the perspective of the Science of Unitary Human Beings. An exploratory correlational design provided beginning information about the experience and awareness of human-environmental integrality in a sample of 107 individuals participating in community-based psychiatric rehabilitation programs. The study variables were measured by the following instruments: the Miller Hope Scale, the Power as Knowing Participation in Change Tool, Version II, and the Human Field Image Metaphor Scale.

Pearson--product moment correlations and hierarchical multiple regression were used to analyze the relations among hope, power, and perception of self. Statistically significant relations were found between the predictor variables, hope and power, and perception of self. Hope and power together, however, did not account for more variance of perception of self than hope accounted for alone. The role of hope in recovering from schizophrenia requires further study, as does the nature of the relation between hope and power. A major contribution of this study is the explication of a conceptual system, the Science of Unitary Human Beings, for understanding the experience of schizophrenia and recovery as expressions of the life process.

Key Words Science of Unitary Human Beings, recovering from schizophrenia, hope, power, and perception of self

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Schizophrenia, a serious disorder found in all cultures throughout the world, affects "the human properties considered most precious and distinguishing" (Carpenter & Buchanan, 1994, p. 681). Schizophrenia is traditionally viewed as a severe and persistent disorder with long-term consequences that have a negative impact on every aspect of a person's life. A substantial degree of the morbidity associated with the experience of schizophrenia involves functional disabilities, which impede an individual's ability to meet role expectations in one or more major areas of functioning (American Psychiatric Association, 2000). Over two million people in the United States experience this severely disabling disorder, which has a worldwide prevalence rate of approximately 1 across diverse geographic, cultural, and socioeconomic groups (National Institute of Mental Health, 1999; Gershon & Rieder, 1992).

Despite evidence to the contrary, the assumption persists that the natural course of schizophrenia is a recurring pattern of acute exacerbations and remissions with increasing residual impairment after each episode (Harding, Zubin, & Strauss, 1992). Although recovering from schizophrenia is increasingly reported in personal testimony, theoretical articles, and qualitative studies (Anthony, Cohen, Farkas, & Gagne, 2002; Davidson & Strauss, 1992; Deegan, 1988; Jacobson, 2001; Williamson & Collins, 1999), the concept and process of recovering are not well understood (Estroff, 1994; Strauss, 1997). According to Ciompi (1987), lack of conceptual models that encompass the diverse manifestations presented by individuals experiencing schizophrenia preclude a true understanding of schizophrenia and recovery.

The Science of Unitary Human Beings (Rogers, 1970, 1990) embraces the diversity of all individuals, including those with a label of schizophrenia. Within Rogerian science, individuals are viewed as unitary human beings evolving in a dynamic, nonlinear process characterized by increasingly diverse field patterns. Understanding the factors related to recovering from schizophrenia is important if nurses and other clinicians are to assist individuals in finding new meaning and purpose that transcend the lived experience of schizophrenia and its associated disabilities. This study is concerned with the phenomenon of perception of self as manifested by individuals recovering from schizophrenia and its association with the pattern manifestations of hope and power. There are no reported empirical studies of the relations of these variables in individuals recovering from the experience of schizophrenia. The relevance of hope, power, and perception of self was suggested by testimony of individuals who are recovering (Deegan, 1988, 1997; Leete, 1989; Lovejoy, 1984), as well as a small number of qualitative studies (Byrne, et al., 1994; Davidson & Strauss, 1992; Jacobson, 2001; Young & Ensing, 1999; Williams & Collins, 1999).

Theoretical Framework

Within the Science of Unitary Human Beings (Rogers, 1970, 1990), recovering from the experience of schizophrenia is viewed as an expression of the life process. The meaning of the phenomena of schizophrenia and recovery is derived from an understanding of the life process of the individual in his/her totality. Through awareness of self as integral with the environment, individuals recovering from the experience of schizophrenia knowingly participate in creating new meaning and purpose in their lives. The process of recovering requires active participation in changing one's attitudes, values, feelings, and goals (Deegan, 1988). While the common definition of the term recovering is inconsistent with the Science of Unitary Human Beings, the process of recovering from the experience of schizophrenia is not. The recovering process reflects an evolutionary emergence. Recovering is an ongoing, nonlinear process of discovery (Deegan, 1988), responsibility (Williams & Collins, 1999), and gaining a unitary awareness of who I am (Clay, 1994). Recovering is characterized by enlarging one's perceived boundaries of possibilities (Lynch, 1965), actualizing one's potential for a more functional life (Anthony, Cohen, Farkas, & Gagne, 2002), and gradually developing a unitary perception of oneself (Davidson & Strauss, 1992). Recovering from the experience of schizophrenia and associated disabilities is a transcendent, "truly unifying human experience" (Anthony, 1993, p. 15).

Perception of self, conceptualized within the Science of Unitary Human Beings as Human Field Image, is the unitary perception one has of one's self (Johnston, 1993, 1994). Phillips (1990), a Rogerian scholar, introduced the concept of Human Field Image, which he characterized as "an evolving manifestation of the human field pattern that synthesizes all past and future images into a f pandimensionall picture of human beings (pp. 13-14). Human Field Image provides a way of perceiving and understanding human field patterns such as the pattern manifestations of emerging human potentials of individuals recovering from the experience of schizophrenia. Human Field Image is defined as the individual's awareness of the infinite wholeness of the human field (Rogers, 1991) as it evolves within the human-environmental field process (Johnston, 1993, p. 16). Recovery, within this framework, is viewed as actualizing one's potentials for well being and involves the individual's capacity to participate knowingly in change characterized by continuous patterning of the mutual human-environmental field (Barrett, 1983). Recovery does not imply cure nor does it mean that the person is symptom free (Anthony, 1993; Deegan, 1988). It is a way of living a satisfying, hopeful, and contributing life. Recovering, a life-long process, refers to the lived experiences of individuals as they meet the challenges of schizophrenia and its associated disabilities, and thereby gain a new and valued sense of self.

Hope is an intrinsic energizing life force (Fromm, 1968; Korner, 1970) characterized by a confident yet uncertain anticipation of a future good which is realistically possible and personally significant to the hoping person (Dufault & Martocchio, 1985; Miller, 1986). Although Rogers (1974) did not specifically address hope, she did identify feeling, used in its broadest sense, as an expression of unity, noting that feelings encompass the totality of the individual. Through a beginning awareness of the integrality of the human-environmental field, hope emerges as a pattern manifestation in the recovery process of individuals labeled with schizophrenia. Hope is associated with a sense of the possible and a commitment to change (Fromm, 1968). Wishing, which includes imagination, mutuality, passion, and the belief that desired changes are possible to achieve, is an antecedent to hope. It provides the initial source of energy necessary for hope to emerge (Averill, Catlin, & Chon, 1990; Lynch, 1965). The birth of hope occurs in integral process with other people who remain hopeful that the individual's recovery from the experience of schizophrenia is possible (Deegan, 1988; Lovejoy, 1984). A sense of hope emerges from despair (Marcel, 1978) when an individual labeled with schizophrenia has "dawning awareness" (Davidson & Strauss, 1992, p. 135) of an aspect of oneself that holds promise for a more satisfying life. This dawning awareness offers the individual hope that recovery is possible. The awakening of hope, according to Strauss and Davidson, occurs throughout the recovery process, engendering an awareness of additional possibilities at crucial times.

Power, according to Barrett (1983, 1990) is the capacity to participate knowingly in the nature of change. Barrett's theory of power, derived from Rogerian science (1970), conceptualizes power as the way human beings share in the creation of reality by engaging in mutual process with their environment to actualize some potentials rather than others. The observation of Anthony, Cohen, and Farkas (1990) that individuals recovering from schizophrenia are active participants in their recovery process was supported by findings from a longitudinal study (Davidson and Strauss (1992). A series of semi-structured research interviews, conducted over a three year period with individuals ([N.bar] = 66) diagnosed with schizophrenia and other serious long-term mental illnesses, revealed that the participants who were actively recovering identified and executed desired goal-directed activity. Williams and Collins (1999), using life-history interviews to explore the lived-experience of recovering with 15 individuals diagnosed with schizophrenia, found that the participants' subjective framework for recovering included moving from being a passive victim to being an active agent who participated knowingly in desired life changes.

Recovering from schizophrenia is experienced as gaining a perception of a functional self associated with a sense of hope, willingness to act, followed by responsible action (Davidson & Strauss, 1992; Deegan, 1988). This investigator theorized that hope provides the motivating energizing life force that facilitates a greater awareness of possibilities, as well as the courage to participate knowingly in creating new meaning and purpose in life. Within the Science of Unitary Human Beings, it is hypothesized that the experience and awareness of human-environmental integrality, as manifested by hope and power, is associated with perception of self in individuals recovering from the experience of schizophrenia.

Method

An exploratory correlational study was designed to examine the relations among hope, power, and perception of self in individuals recovering from schizophrenia. This investigator selected quantitative methodology to examine the relations among the study variables. This decision was based on previously cited testimony of recovering individuals and qualitative studies that indicated that hope, power, and perception of self were integral to the process of recovering from the experience of schizophrenia. The availability of instruments that were developed within and/or are compatible with the Science of Unitary Human Beings further justified the use of a quantitative methodology.

The research questions were answered using Pearson product-moment correlations and hierarchical multiple regression analysis. Supplemental analyses were conducted to investigate the relations among the background variables and the main study variables, as well as the relations of the four dimensions of power and perception of self. An ([alpha] level of .05 was used for all statistical tests. The research questions were:

1. Is there a positive relation between hope and perception of self in individuals recovering from schizophrenia?

2. Is there a positive relation between power and perception of self in individuals recovering from schizophrenia?

3. Does the combination of hope and power account for more variance of perception of self in individuals recovering from schizophrenia than either variable alone?

Sample

The population for this study was adult women and men who were active participants in community-based psychiatric rehabilitation programs certified by New York State Office of Mental Health. These programs operated in accordance with a statewide program model designed to provide a hope-filled, humanizing environment (Sheets, 1994) that invites individuals to participate in their recovery process. Thus, these community-based psychiatric rehabilitation programs provided an appropriate population from which to recruit individuals for this study. The program model explicitly addresses power and implicitly incorporates hope and the provides opportunity for recovering individuals to develop a unitary perception of self (Sheets, Bucciferro & O'Brien, 1991).

The sampling unit consisted of 61 psychiatric rehabilitation programs that were certified at the time data collection was initiated. The sampling frame included 20 psychiatric rehabilitation programs randomly selected from programs throughout New York State. The selection of the 15 programs included in this study was in accordance with the order of response to the investigator's written request to meet with program representatives to explain the study purpose and data collection procedures, as well as to request assistance in identifying individuals who met the study inclusion criteria. The sample size was determined by the number of predictor variables in a single regression equation. As the study included up to five predictor variables in a single regression equation, a sample of at least 100 participants was required (Tabachnick & Fidell, 1989). Once the required sample size was reached no further meetings with program directors were scheduled. The sample consisted of 107 volunteer participants who were diagnosed with schizophrenia, had a high school or general education diploma, and who could read and write English. The participants ranged in age from 19 to 63 years, with an average age of 38. Men represented slightly more than half of the sample (51 %). Forty percent of the sample had either a high school or general equivalency diploma and 60% had attended college, with 33% earning a degree. The majority of participants were under age 30 when first diagnosed with schizophrenia and when first hospitalized for mental illness. Ten percent were never hospitalized for a psychiatric illness. Thirty five percent of the participants attended the psychiatric rehabilitation program for over 12 months and 23 % attended for less than three months. Nearly half the participants (45 %) identified a family member as the person who provided them with the most support.

Data Collection Procedures

After receiving approval from a university institutional review board, a letter of introduction was sent to the directors of the 20 selected psychiatric rehabilitation programs. After the initial meeting with representatives at each program site, a formal application was sent to the agency review body. When approval to conduct the study was received, the program director distributed a flyer prepared by the investigator to potential participants who met the study inclusion criteria. The flyer invited potential participants to meet with the investigator at a specific date, time, and location to discuss the nature of the study. The investigator provided a written and verbal description of the study's purpose, significance, and data collection procedures during the meeting. The potential participants were assured of confidentiality. Of the 112 potential participants who attended the meetings, three individuals decided not to participate in the study. One woman said that she did not want to think about her feelings at this time and another woman and a man provided no explanation for their decision not to participate. Two additional participants were eliminated from the study because they did not complete one of the instruments (Power as Knowing Participation in Change Tool, Version 11) in accordance with the written instructions. Those individuals who voluntarily chose to participate signed a consent form, which was collected prior to distributing a booklet that contained three instruments and a background information form. The investigator remained in the room until the last participant completed the questionnaire booklet and placed it in a locked box.

Instruments

Perception of self, conceptualized within the Science of Unitary Human Beings as Human Field Image, is defined as the unitary perception one has of one's self (Johnston, 1993, 1994), manifested by an individual's awareness of the infinite wholeness of the human field (Rogers, 1991). Perception of self was measured by the Human Field Image Metaphor Scale (HFIMS) (Johnston, 1993, 1994). The 25-item, 5-point, Likert-type scale uses metaphor as a means of promoting unitary field expression. A higher score on the HFIMS represents expressions of a strong sense of integrality and an expanded perception of potential; whereas, a lower score represents a greater sense of isolation and a diminished perception of potential. Johnston established content validity by submitting a list of metaphors, identified from a review of literature and a concept analysis, to two groups of Rogerian experts for evaluation. The resultant list of metaphors was further evaluated for content relevancy, consistency with the theoretical framework, and clarity by three different groups of Rogerian experts. Construct validity was determined by loadings on factors, which supported Johnston's theoretically proposed structure of Human Field Image. Construct validity was also supported by the correlation of scores ([r.bar] .67, [p.bar] = < .01) of the HFIMS and the Index of Human Field Energy (Gueldner, 1993 as cited in Johnston, 1993, 1994). Johnston reported an internal consistency reliability coefficient of .91. Cronbach's alpha for the current study was .93.

Power is defined as "the capacity to participate knowingly in the nature of change characterizing the continuous patterning of the human and environmental fields as manifested by awareness, choices, freedom to act intentionally, and involvement in creating change" (Barrett. 1990, p. 108). Power was measured by the Power as Knowing Participation in Change Tool, Version II (PKPCT, VII) (Barrett, 1987, 1998). The 48-item tool uses a semantic differential format to rate the four dimensions of power (awareness, choices, freedom to act intentionally, and involvement in creating change). Higher scores on the PKPCT, VII indicate relatively greater power than lower scores. To establish initial content validity of the Power z Knowing Participation in Change Tool (PKPCT), Barrett (1983) submitted a list of concept-context items for evaluation to two panels of judges knowledgeable in Rogerian science and measurement. Construct validity was evidenced by loadings on factors, which supported Barrett's theoretically proposed construct of Power. Barrett reported reliabilities, ranging from .63 to .99, as variances of factor scores obtained for each of the four dimensions of power, awareness, choices, freedom to act intentionally, and involvement in creating change. Cronbach's alpha coefficient for the current sample was .97.

Hope is defined as an intrinsic energizing life force (Fromm, 1968; Korner, 1970) characterized by a confident yet uncertain anticipation of a future good, which is realistically possible and personally significant to the hoping person (Dufault & Martocchio, 1985; Miller, 1986). Hope was measured by the Miller Hope Scale (MHS) (Miller, 1986; Miller & Powers, 1988). A higher score on the MHS, which is a 40-item, 6-point Likert-type scale, represents a relatively higher level of perceived hope than a lower score. Miller identified eleven critical elements of hope from a comprehensive review of the literature and a qualitative study of 59 individuals who survived a life-threatening illness. The critical elements of hope, which include mutuality-affiliation, sense of the possible, avoidance of absolutizing, achieving goals, psychological well-being, purpose and meaning in life, freedom, reality surveillance, optimism, and mental activation, provided the framework for generating the items for the MHS. To evaluate for content validity, Miller submitted the items to a panel of four judges with expertise about hope. Construct validity was supported by loadings on factors that supported Miller's conceptualization of hope. Construct validity was further evidenced by the correlation of scores ([r.bar] = .82, [p.bar] = < .01) of the MHS and the Existential Well-Being Scale (Paloutzian & Ellison, 1982). Miller reported an internal consistency reliability coefficient of .95. Cronbach's alpha coefficient for the current study was .96.

Results

The zero-order correlation between the criterion variable, perception of self, and hope was [r.bar] = .73 ([p.bar] = .000), which indicated a strong positive relation between these two variables in the sample of individuals recovering from schizophrenia. The zero-order correlations between perception of self and power was [r.bar] = .58 ([p.bar] = .000), which indicated a moderately positive relation between perception of self and power in the sample of individuals recovering from schizophrenia.

The amount of variance of perception of self accounted for by a combination of hope and power was examined using hierarchical multiple regression analysis. This type of regression analysis was selected so that the investigator could control the order of entry in the regression equation of the predictor variables, hope and power. From a review of the literature, which included testimony of individuals recovering from the experience of schizophrenia (Deegan, 1988; Leete, 1984), theoretical perspectives (Lynch, 1965; Marcel, 1978), and qualitative studies (Davidson & Strauss, 1992; Williams & Collins, 1999; Young & Ensing, 1999), it was suggested that the emergence of hope precedes power. Thus, hope was entered into the regression equation on the first step and accounted for 52.83% of the variance of perception of self, which was statistically significant ([E.bar](1,105) = 1 17.61, [p.bar] = .000). On step two, power was entered into the regression equation, producing an [R.bar] square change of .0036, which was not statistically significant ([p.bar] = .37). With hope in the equation, the addition of power as a predictor variable did not produce a statically significant increase in the variance accounted for by perception of self in individuals recovering from schizophrenia. Thus, hope and power did not account statistically significantly for more variance of perception of self than was accounted for by hope alone.

Although the third research question was answered, the investigator did a second hierarchical analysis to assess the unique contribution of hope to the variance of perception of self. Power was entered on the first step of the regression equation, and contributed 33.08% of the variance of perception of self, which was statistically significant ([F.bar] (1,105) = 51.91, [p.bar] = .000). Hope was entered next on the second step of the analysis, producing a statistically significant [R.bar] square change of .2011 ([p.bar] = .000). As indicated by the R square change, hope uniquely contributed 20.11 % of the variance of perception of self in individuals recovering from schizophrenia after controlling for power.

The concept and process of recovering from schizophrenia is beginning to interest practitioners and researchers (Strauss, 1997; Whitehorn, Lazier, & Kopala, 1998; Williams & Collins, 1999). Descriptive characteristics of individuals and the experience of recovering from schizophrenia are beginning to appear in the literature. Analyses of descriptive information of the participants in this study in relation to the hope, power, and perception of self contribute to this nascent body of knowledge.

Analyses of background information variables and the study main variables, hope, power, and perception of self, were conducted using Pearson product moment correlations, t-tests, analyses of variance, and hierarchical multiple regression. Statistically significant correlations were found between hope, power, and perception of self and age when first diagnosed with mental illness and age when first hospitalized for mental illness. No evidence of a correlation was found between the main study variables and current age, gender, education, length of participation in the psychiatric rehabilitation program, or source of most support.

A statistically significant correlation was found between age when first diagnosed with mental illness and age when first hospitalized for mental illness ([r.bar] = .36, [p.bar] = .000). Differences in levels of hope, power, and perception of self between participants age 25 and older when first diagnosed with mental illness and those less than age 25 were examined by two-tailed t-tests. The participants who were age 25 or older had statistically significantly ([p.bar] < .05) lower levels of hope, power, and perception of self than participants who were less than age 25 when first diagnosed with mental illness.

Differences in hope, power, and perception of self in participants who were never hospitalized for mental illness, those who were age 25 or older when first hospitalized, and those who were less than age 25 when first hospitalized were examined by one-way analyses of variance. The level of hope was not statistically significantly different ([p.bar] > .05) among the three groups. The levels of power and perception of self, however, were significantly different ([p.bar] = .05). Those who were never hospitalized had statistically significantly higher levels of power and perception of self than participants who were age 25 or older when first hospitalized, but their levels of power and perception of self were not statistically significantly different from participants who were first hospitalized before age 25.

Supplementary analyses of the dimensions of power and perception of self were also conducted using Pearson product-moment correlations and hierarchical multiple regression analysis. Statistically significant strong relations were found between the four dimensions of power and perception of self. Hierarchical multiple regression analysis, however, indicated that of the four dimensions of power, only choices made a statistically significant contribution to the variance of perception of self ([r.bar] = .37, [p.bar] .000). When hope was entered into the equation, however, choices contributed only a small additional amount (1.1 %) to the variance of perception of self, which was statistically significant ([p.bar] = .05).

Discussion of Findings

Support for a positive relation between hope and perception of self was demonstrated by the participants in this study. The concept of hope is characterized by a confident yet uncertain anticipation of a future good which is realistically possible and personally significant to the hoping person (Default & Martocchio, 1985; Miller, 1986; Miller & Powers, 1988). Hope, described as a multidimensional integral process of feeling, thought, and action, is a commitment to becoming. This description of hope is congruent with Rogerian science (1970, 1992) as it reflects a hoping individual's experience and awareness of integrality with his/her environment.

Although no empirical studies have examined the relation of hope and perception of self, philosophical and theoretical literature, as well as qualitative studies and personal testimony refer to a strong association between these two concepts. Philosophers and theologians describe hope as a mystery, a special gift emerging from a time of trial, which allows an individual to transcend perceived limitations (Lain cited in Mermal, 1970; Marcel, 1978; Meissner, 1973). According to Lynch 11965), hope liberates individuals who are experiencing illness, not by denying the experience, but by enlarging their perception of who they are and who they can become.

The role of hope is self-evident in therapeutic interventions associated with a goal of increasing one's sense of self (Nunn, 1996). Rogers (1961), in defining the characteristics of a therapeutic relationship, emphasized the importance of meeting an individual as a person who is becoming. A therapist who can view a person from this perspective can help awaken hope and by so doing allow the individual to discover and "confirm or make real [his/her] potentialities" (Rogers, p. 55) "to be that self one truly is" (Kierkegaard, 1849/1983, p. 29).

Parse (1990, 1999) found a relation between hope and perception of self in two qualitative studies in which the lived experience of hope was examined. She concluded that hope is a universal experience of health that emerges as a way of becoming in the mutual integral process of the individual and his/her environment. Parse's conceptualization of hope is congruent with testimony of individuals recovering from schizophrenia (Deegan, 1988, 1997; Lovejoy, 1984), who acknowledge that an emerging sense of hope is a cornerstone of becoming, i. e., developing a unitary perception of self through envisioning possibilities.

In a qualitative component of the Yale Longitudinal Study of Prolonged Psychiatric Disorders (Strauss, Harding, Hafez, & Lieberman, 1985), Davidson and Strauss 992) explored the ways in which an individual's perception of self may be central to recovering from serious mental illness. The recovering participants ([n.bar] = 32) described experiences of discovery of and development of a dynamic self in the midst of dysfunction. The researchers suggested that the process of recovering is initiated by dawning awareness of the possibility (hope) of a more functional self (a valued perception of "who I am") [Clay, 1994].

Support was provided for a positive relation between power and perception of self in individuals recovering from schizophrenia. Barrett (1983, 1990) described power, conceptualized as the synergistic relations of awareness, choice, freedom to act intentionally, and involvement in creating change, as the way human beings create reality in mutual process with their environment to actualize some potentials rather than others. According to Phillips (1997), "the openness of the human-environment [field] gives people the ability to participate knowingly in their becoming" (p. 25). Power is an inherent aspect of the life process by which individuals express their being in the world (May, 1972; Nietzsche, 1883-88/1968). May (1953) observed that awareness of self and freedom are correlated. The more self-awareness an individual has, the more freedom and range of choices increase. May further suggested that with each exercise of freedom, one's sense of self also increases. Writing from the perspective of an existentialist therapist, May observed that a human being becomes a self by actively participating in the process of becoming.

The experience of individuals recovering from schizophrenia also support a relationship between power and perception of self. Leete (1987) indicated that when she realized that she had the power to decide what her life would be like and who she could be, she began to participate knowingly in learning how to live with and beyond the experience of schizophrenia. Lovejoy (1984) wrote that with the help of staff members, she slowly began to take responsibility for herself by beginning to make choices and actively engage in learning new behaviors that changed her perception of who she was and who she could become.

In an exploration of the lived experience of individuals diagnosed with schizophrenia, Williams and Collins (1999) reported that a feeling of power made a difference in how recovering participants conceptualized their future possible selves. The participants indicated that for them to feel they were recovering, they needed to actively participate in creating changes related to their experience of schizophrenia, as well as to other important areas of their life.

Analysis of the narratives of the participants in Davidson and Strauss' (1992) qualitative study of individuals recovering from schizophrenia and other prolonged psychiatric conditions revealed the integral, nonlinear nature of developing a functional sense of self, which the researchers suggested is equated to recovering. Putting the self into action, a manifestation of power, is an activity which the participants emphasized they must initiate themselves if it is to be effective in helping them enhance their perception of a functional self.

Supplementary analyses were performed to examine more closely the four concepts of power, awareness, choices, freedom to act intentionally, and involvement in creating change and their relations to perception of self. Power, as described by Barrett (1983), is a unitary concept, reflecting the synergistic field behaviors of awareness, choices, freedom to act intentionally, and involvement in creating change. These field behaviors, according to Barrett, can fluctuate in quality and quantity. In different situations or life experiences, one of the four dimensions of power may be primary. Of the four dimensions of power, only choices made a statistically significant contribution to the variance of perception of self among participants in this study. This finding may indicate that the study participants are more familiar with the dimension of choices than they are with the other three power concepts. The psychiatric rehabilitation program in which the participants were enrolled explicitly focuses on choices as a key component of the recovery process (Lamberti, Melburg, & Madi, 1998). Choices may also be the power dimension most valued by individuals with a label of schizophrenia. Once an individual is diagnosed with schizophrenia, being allowed to make choices associated with activities of daily living, treatment options, or preferred life goals is an uncommon experience (Deegan, 1988; Dzurec, 1986; Leete, 1989).

Hope and power together did not statistically significantly contribute to more of the variance of perception of self than hope alone in this sample of individuals recovering from the experience of schizophrenia. Although there was a strong correlation between hope and power ([r.bar] = .74, [p.bar] = .000), a review of the theoretical framework for the study indicated that these variables represented different concepts. In reviewing the conceptualizations of hope (Miller, 1986) and power (Barrett, 1983, 1990), this investigator observed considerable overlap between these two multidimensional concepts. Differences between hope and power, however were also identified. Two of the eleven dimensions of hope, mutuality-affiliation and anticipation, are not explicitly included in the power construct. Although Barrett described power as a field manifestation emerging out of the mutual process of the human-environmental field, the Power as Knowing Participation in Change Tool, VII (Barrett, 1987, 1998) does not reflect mutuality-affiliation as defined by Miller. Neither is anticipation mentioned in Barrett's conceptual definition of power nor is it reflected in the power tool. The Miller Hope Scale (Miller, 1986; Miller & Powers, 1988), on the other hand, has four items reflecting mutuality-affiliation and six items related to anticipation. Thus, it may be that 20% of the variance in perception of self among participants in this study, which was uniquely accounted for by hope after controlling for power, is attributable to the dimensions of mutuality-affiliation and anticipation.

Positive correlations among hope, power, and perception of self may indicate that these pattern manifestations, which emerge from the continuous mutual process of human and environmental fields, are integrative experiences for individuals who are recovering. Hope, which is manifested by dawning awareness of possibilities, may provide the initial energy and courage for recovering individuals to participate knowingly in creating new meaning and purpose in life that transcend the label of schizophrenia and its associated disabilities.

Age when first diagnosed with mental illness and age when first hospitalized for mental illness, however were found to have statistically significant low negative relations with hope, power, and perception of self. Participants who were first diagnosed with schizophrenia at a younger age (under 25 years old) showed statistically significantly higher levels of hope, power, and perception of self than those who were older when first diagnosed. This investigator considered whether time since first diagnosis and first hospitalization might help to explain these differences. There was nearly an age difference of 20 years between participants who had first been diagnosed with mental illness less than six years ago and those who were first diagnosed with mental illness over 20 years ago. The age difference was similar for participants in relation to age when first hospitalized for mental illness.

Being diagnosed with serious mental illness and being hospitalized for the first time are transitional events that present a strong challenge to an individual's perception of self (Lally, 1989). Previously learned and culturally shaped negative beliefs about mental illness and individuals who are labeled mentally ill become personally applicable when an individual formally enters this stigmatized class (Goffman, 1963). Awareness of stigmatization was illustrated by Fisher (cited in Reidy, 1994) when he commented that once you are labeled with schizophrenia, "you just can't get rid of it, from your records or from your heart" (p. 7). Lally contends that individuals diagnosed with schizophrenia are not passive recipients of the label of mental patient. They can either accept the label by increasingly organizing their self-image around the role of mental patient or they can resist internalizing the label by integrating and transcending the experience of schizophrenia within their evolving perception of self. As the life process evolves, individuals who are recovering begin to define their experience of schizophrenia in a way that constructs and maintains a competent perception of who they truly are (Davidson & Strauss, 1992; Deegan, 1988; Jacobson, 2001, Williams & Collins, 1999).

Implications for Further Research and Practice

The findings from this study suggest possibilities for further research on recovering from schizophrenia. A major contribution of this study is the explication of a paradigm for understanding the experience of schizophrenia and recovery as expressions of the life process. Within this paradigm, recovering from the experience of schizophrenia is viewed as gaining a unitary perception of self, which allows the individual to live a satisfying, contributing, and valued life. This lifelong process occurs by recognizing possibilities for a more positive life and active involvement in knowingly creating changes with the goal of finding new purpose and meaning within and beyond schizophrenia and associated disabilities. Recovery viewed from this perspective has implications for nursing research and practice.

The role of hope in recovering from schizophrenia requires further study. Specifically, the role of others in awakening hope needs to be examined. Understanding how hope for a more positive life is awakened and sustained over time is particularly important as the recovery potential of many individuals labeled with schizophrenia is currently unrecognized (Anthony, 1993; Keith, Regier, & Rae, 1991).

The nature of the relation between hope and power also requires further study. Understanding the nature of the relation between these two variables can contribute to the knowledge required to assist individuals experiencing schizophrenia in identifying and actualizing their potentials to achieve maximum well-being, which is unique for each individual.

Specific suggestions for further research include replication of this study with consideration for certain conceptual and methodological issues:

1. Assess changes in the levels of hope, power, and perception of self at different times during the life process of individuals recovering from the experience of schizophrenia and associated disabilities.

2. Replicate this study with individuals experiencing schizophrenia who are participating in different types of treatment and peer support programs, as well as those who are not currently participating in any therapeutic or social programs.

3. Qualitatively explore the role of supportive relationships in facilitating the recovery process in this population.

4. Examine stigma in relation to hope, power, perception of self, and time since first identified as a mental patient.

With supporting data from future research, it may be appropriate to consider the implications of this study for nursing practice, as well as the clinical practice of other mental health disciplines. In developing trusting, supportive therapeutic relationships, nurses and other clinicians may be able to help individuals labeled with schizophrenia become aware of possibilities for developing new meaning and purpose, which may provide them with the strength and courage to become actively involved in creating desired changes in their life, and thereby, gaining a unitary perception of who I am and who I want to become.

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Elizabeth Meehan Salerno, RN, PhD, CNAA

Chief Quality Systems Officer

The Center for Mental Health, Inc.

2041 Martin Luther King Jr., Avenue, SE, Suite 307 Washington, DC 20020

Telephone Number: (202) 678-3000

email: esalerno@cmhinc.org

Received May, 2002

Accepted September, 2002
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Author:Salerno, Elizabeth Meehan
Publication:Visions: The Journal of Rogerian Nursing Science
Article Type:Clinical report
Geographic Code:1USA
Date:Jan 1, 2002
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