LIVING WITH SERIOUS MENTAL ILLNESS:

THE ROLE OF PERSONAL LOSS IN RECOVERY AND QUALITY OF LIFE

Danielle Nicole Potokar

A Dissertation

Submitted to the Graduate College of Bowling Green

State University in partial fulfillment of
the requirements for the degree of:

DOCTOR OF PHILOSOPHY

December 2008

Committee:

Catherine Stein, Ph.D., Advisor

Alexander Goberman, Ph.D.,

Graduate Faculty Representative

Dryw Dworsky, Ph.D.

Jennifer Gillespie, Ph.D.

 © 2008

Danielle Nicole Potokar

All Rights Reserved

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ABSTRACT

Catherine Stein, Ph.D., Advisor

As the mental health field is moving towards a recovery based model of serious mental

illness for both conceptualization and treatment, further research into the factors which may

impact recovery and quality of life are needed. Currently, there are no studies which examine

how personal loss due to mental illness or cognitive insight relate to factors such as quality of

life and recovery. The purpose of the present study was to investigate the relative contribution of

demographic factors, self-reports of psychiatric symptoms, and individual factors of cognitive

insight and personal loss in describing variation in reports of quality of life and recovery from

mental illness. It was hypothesized that cognitive insight and personal loss would each predict a

significant portion of the variance in scores of quality of life and recovery from mental illness. A

sample of 65 veterans with serious mental illness from the Minneapolis Veterans Affairs Medical

Center completed structured interviews regarding psychiatric symptomotology and quality of life

and completed questionnaires related to demographics, cognitive insight, personal loss due to

mental illness, and recovery. Thirteen significant hierarchical regression models emerged.

Results indicate that personal loss is the strongest predictor of facets of quality of life and

recovery from serious mental illness, explaining incremental variance in ten of the regression

models. Cognitive insight, however, was found to only explain incremental variance in one

aspect of quality of life. Additionally, psychiatric symptoms and demographic variables such as

diagnosis and living arrangement were also found to be significant predictors of aspects of

quality of life and recovery. These findings highlight the importance of personal loss due to

mental illness as a construct for further investigation and which has powerful implications for

clinical intervention. Additionally, these results suggest the need for further examination of
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cognitive insight. The implications of these findings for future research and clinical practice, as

well as the limitations of the study are discussed.

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To the woman who taught me, mostly through her own actions, the importance of kindness,

compassion, and humility

And

To the man who inspired me with his own drive and intellectual curiosity…

Mom and Dad this is dedicated to you.

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ACKNOWLEDGMENTS

I would first like to thank my advisor, Dr. Catherine Stein, who took me under her wing

when I was an orphaned graduate student. She inspired me with her passion for working with

people with serious mental illness, and without this exposure, I may never have found my true

calling. Thank you. I also thank my dedicated committee members, Drs. Dryw Dworsky,

Jennifer Gillespie, and Alex Goberman for their feedback on this project. To my many

colleagues at the Minneapolis VA Medical Center, thank you for your referrals, support, and

encouragement throughout this process. Special thanks to my VA mentor, Dr. Bridget Hegeman

for her input on this project and her commitment to the recovery of people with SMI.

I would also like to thank my friends, especially “The VA Girls”, for fun times and much

needed breaks from the writing. Special thanks to my good friend and stats guru, Dr. Melissa

Cohen, for her statistical guidance and her humor. To my dear friend, Meghan Kahn, thank you

for reminding me how much I have learned on this journey when I started to get discouraged. We

have come so far and I wouldn’t trade my experiences over these long years for anything!

To my family, thank you for always believing in me and supporting me every step of the

way. I am proud to be a member of this family, where love and understanding really are the

guiding principles. To my husband, John, words cannot express what you mean to me. Thank

you for your patience and dedication to me throughout this very long journey. I promised you it

would work out in the end, and here we are. Now we can start the next chapter of our lives

together. I love you.

Finally, I thank the veterans who participated in this study. I am truly awestruck by your

courage and your perseverance. You have taught me more about myself and the personal

strength of people than I could have learned anywhere else. You have also taught me that

recovery is not just a theoretical concept but a reality. I feel truly honored to serve you.
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TABLE OF CONTENTS

Page

INTRODUCTION ..........................................................................................................................1

CHAPTER I: SERIOUS MENTAL ILLNESS: AN OVERVIEW…………………………….....3

Definitions............................................................................................................................3

Recovery in Serious Mental Illness ...................................................................................5

Approaches to Recovery......................................................................................................7

“Objective” Scientific Definitions...........................................................................7

“Subjective” Consumer Definitions.........................................................................9

Recovery and the Present Study…………………………………………………………13

CHAPTER II: THE STUDY OF QUALITY OF LIFE: AN OVERVIEW……………………...15

Definitions......................................................................................................................... 15

Objective Indicators of Quality of Life..................................................................16

Subjective Indicators of Quality of Life................................................................16

Measuring Quality of Life ................................................................................................17

Quality of Life and Serious Mental Illness .......................................................................20

Psychopathology and Quality of Life....................................................................22

Protective Factors...................................................................................................23

Medication Side-effects.........................................................................................24

Insight....................................................................................................................24

Recovery................................................................................................................27

Quality of Life and the Present Study................................................................................28

CHAPTER III: THE STUDY OF PERSONAL LOSS: AN OVERVIEW ………….……….....32

Definitions………………………………………………………………………………..32
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Personal Loss and Serious Mental Illness .........................................................................33

Personal Loss and Present Study.......................................................................................35

CHAPTER IV: SUMMARY & CRITIQUE...…………………………………………….…….38

Present Study.....................................................................................................................40

CHAPTER V: METHODS............................................................................................................41

Recruitment of Participants...........................................................................................….41

Participant Characteristics............................................................................................….41

Procedure...........................................................................................................................42

Measures ...........................................................................................................................43

Beck Cognitive Insight Scale (BCIS)……………………………………………43

Brief Psychiatric Rating Scale (BPRS), Expanded Version……………………..44

Demographics Questionnaire ................................................................................44

Personal Loss due to Mental Illness Scale (PLMI)……………………………....44

Quality of Life Interview (QOLI)..........................................................................45

Recovery Assessment Scale (RAS).......................................................................46

CHAPTER VI: RESULTS.............................................................................................................47

Analytic Procedures......................................................................................................….47

Descriptives........................................................................................................................47

Cognitive Insight…………………………………………………………………48

Personal Loss……………….................................................................................48

Quality of Life……………………………………………………………………49

Recovery………………………............................................................................50

Analysis of Variance Procedures……………………………………………...…………50

Demographic Differences in Participants’ Reports of Recovery…...……………50

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Demographic Differences in Participants’ Reports of Quality of Life…..………51

Correlational Analyses……………………………………………...……………………55

Correlations of Recovery and Demographic Variables……….………………....55

Correlations of Quality of Life and Demographic Variables……….…………....55

Hierarchical Regression Analyses……………………………………………………….56

Predictors of Recovery…………………………………………………………………...57

Predictors of Overall Recovery (RAS Total Score)...…………………………....57

Predictors of Personal Confidence and Hope (RAS Subscale)…………………..57

Predictors of Willingness to Ask for Help (RAS Subscale)……………………..58

Predictors of Goal and Success Orientation (RAS Subscale)……………………58

Predictors of Reliance on Others (RAS Subscale)………………….……………58

Predictors of No Domination by Symptoms (RAS Subscale)…………...………59

Predictors of Quality of Life..............................................................................................60

Predictors of General Life Satisfaction (QOLI Score)…………………………..60

Predictors of Number of Daily Activities (QOLI Score)….……………………..60

Predictors of Number of Family Contacts (QOLI Score)………………………..60

Predictors of Number of Social Contacts (QOLI Score)….……………………..61

Predictors of Financial Adequacy (QOLI Score)….……………………………..61

Predictors of Spending Money (QOLI Score)…………………………………...62

Predictors of Satisfaction with Living Situation (Subjective QOLI Subscale)…..62

Predictors of Satisfaction with Daily Activities (Subjective QOLI Subscale)…..63

Predictors of Satisfaction with Family Relations (Subjective QOLI Subscale)…63

Predictors of Satisfaction with Social Relations (Subjective QOLI Subscale)…..64

Predictors of Satisfaction with Finances (Subjective QOLI Subscale)……….....64

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Predictors of Satisfaction with Employment (Subjective QOLI Subscale)……...65

Predictors of Satisfaction with Legal and Safety Issues (Subjective QOLI

Subscale)……………………………………………….……………………….. 65

Predictors of Satisfaction with Health (Subjective QOLI Subscale)………….....65

Predictors of Global Rating of Quality of Life (QOLI Score)……….…………..66

CHAPTER VII: DISCUSSION.....................................................................................................68

Predictors of Adults’ Reports of Recovery from Serious Mental Illness………………..70

Predictors of Adults’ Reports of Quality of Life……………………….………………..73

Clinical and Research Implications……………………………………………………...78

Limitations of the Present Research……………………………………………………..81

REFERENCES............................................................................................................................. 83

APPENDIX A. FLYER FOR RECRUITMENT………………………………………………...99

APPENDIX B. RECRUITMENT LETTER……………………………………………………100

APPENDIX C. VETERANS AFFAIRS CONSENT FORM…………………………………..101

APPENDIX D. VETERANS AFFAIRS HIPPA FORM ………………………………………104

APPENDIX E. BECK COGNITIVE INSIGHT SCALE (BCIS)................................................107

APPENDIX F. BRIEF PSYCHIATRIC RATING SCALE, EXPANDED VERSION………..109

APPENDIX G. DEMOGRAPHICS QUESTIONNAIRE...........................................................127

APPENDIX H. PERSONAL LOSS DUE TO MENTAL ILLNESS SCALE (PLMI)...............128

APPENDIX I. QUALITY OF LIFE INTERVIEW (QOLI) …………………………………...130

APPENDIX J. RECOVERY ASSESSMENT SCALE (RAS)…………………………………141

APPENDIX K. SUBSCALE ITEMS FOR EACH MEASURE ……………………………….143

APPENDIX L. MEANS, STANDARD DEVIATIONS, AND RANGES FOR EACH

MEASURE……………………………………………………………………………………..147
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APPENDIX M. SIGNIFICANT T-TEST FINDINGS ………………………………………...151

APPENDIX N. SIGNIFICANT ANOVA FINDINGS ……………………………………...…154

APPENDIX O. CORRELATION MATRIX FOR ALL CONTINUOUS DEMOGRAPHIC AND

CLINICAL VARIABLES……………………………………………………………………...159

APPENDIX P. INTERCORRELATIONS OF CRITERION MEASURES………………...…167

TABLES ……………………………………………………………………………………….169
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LIST OF TABLES

Table Page

1 Demographic and Clinical Characteristics: Frequency and Percentage of

Participants……………………………………………………………………………...169

2 Demographic and Clinical Characteristics: Means, Standard Deviations, and Ranges...171

3 Medications: Frequency and Percentage of Participants……………………………….172

4 Means, Standard Deviations and Ranges for Overall Scores for Each Measure……….174

5 Hierarchical Regression of Variables Predicting Participants’ Overall Recovery from

Serious Mental Illness (N=65)………………………………………………………….175

6 Hierarchical Regression of Variables Predicting Participants’ Personal Confidence and

Hope (N=65)……………………………………………… ……………………….......176

7 Hierarchical Regression of Variables Predicting Participants’ Willingness to Ask for Help

(N=65)…………………………………………………………..………………………177

8 Hierarchical Regression of Variables Predicting Participants’ Goal and Success

Orientation (N=65)……………………………………………...………………………178

9 Hierarchical Regression of Variables Predicting Participants’ Reliance on Others

(N=65)…………………………………………………………………………………..179

10 Hierarchical Regression of Variables Predicting Participants’ No Domination by

Symptoms (N=65)………………………………………………………………………180

11 Hierarchical Regression of Variables Predicting Participants’ General Life Satisfaction

(N=65)…………………………………………………………………………………..181

12 Hierarchical Regression of Variables Predicting Participants’ Number of Daily Activities

(N=65)…………………………………………………………………………………..182
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13 Hierarchical Regression of Variables Predicting Participants’ Number of Family Contacts

(N=65)…………………………………………………………………………..………183

14 Hierarchical Regression of Variables Predicting Participants’ Number of Social Contacts

(N=65)…………………………………………………………………………………..184

15 Hierarchical Regression of Variables Predicting Participants’ Financial Adequacy

(N=65)…………………………………………………………………………………..185

16 Hierarchical Regression of Variables Predicting Participants’ Spending Money

(N=59)…………………………………………………………..………………………186

17 Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Living

Situation (N=65)………………………………………………………………..………187

18 Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Daily

Activities (N=65)……………………………………………………………………….188

19 Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Family

Relations (N=65)…………… …………………………………………………….........189

20 Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Social

Relations (N=65)……………………………………………………………………..…190

21 Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Finances

(N=65)…………………………………………………………………………………..191

22 Hierarchical Regression of Variables Predicting Participants’ Satisfaction with

Employment (N=23)……………………………. …………………………………..…192

23 Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Legal and

Safety (N=65)… ………………………………………………………………………..193

24 Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Health

(N=65) ……… …………………………………………………………………………194

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25 Hierarchical Regression of Variables Predicting Participants’ Global Rating of Quality of

Life (N=65)………………………………………………………………..……………195
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INTRODUCTION

According to recent data, an estimated 26.2 percent of American adults suffer from a

diagnosable mental disorder in a given year, with an estimated 6 percent of people living with a

serious mental illness (Kessler, Chiu, Demler, & Walters, 2005). When applied to the 2004 U.S.

Census residential population estimate for ages 18 and older, this figure translates to

approximately 13 million people in the United States currently living with serious mental illness

(U.S. Census Bureau, 2004). It is our jobs as mental health professionals to understand the

experiences of people with serious mental illness, create and implement therapeutic programs

and interventions, and empower these individuals to go on to have meaningful lives. Despite this

growing interest in recovery, little is known about how the perceived impact of mental illness

(i.e., personal loss due to mental illness) affects individual reports of quality of life and overall

recovery. Additionally, little is known about how cognitive insight (ability to self-reflect,

acknowledge the possibility of being mistaken, to be open to feedback, and to refrain from

overconfidence (Beck, Baruch, Balter, Steer, & Warman, 2004) relates to an individual’s sense

of loss, quality of life, and overall recovery. Better understanding of the relationships of these

factors is important for the creation and implementation of more effective recovery-based

interventions.

The present study examined the role of demographics, current psychiatric symptoms,

cognitive insight, and experience of personal loss due to mental illness on adults’ perceptions of

recovery from illness and overall quality of life. Specifically, the relative contribution of

demographic, symptom severity scores, and scores on individual factors such as cognitive insight

and perceptions of personal loss in accounting for variation in self-reports of recovery from

mental illness and quality of life were examined. A review of relevant literature regarding
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recovery from serious mental illness, quality of life and personal loss is presented to provide a

framework for the present research.

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CHAPER I: SERIOUS MENTAL ILLNESS: AN OVERVIEW

According to the Diagnostic and Statistical Manual – Fourth Edition (American

Psychiatric Association, 1994), what constitutes a “serious” mental illness is a significant portion

of time since the onset of the disorder where one or more major areas of functioning (i.e., work,

independent living, and self-care) is markedly below expected levels. However, the problem with

this definition is that it could fit multiple mental disorders. Currently there is no clear consensus

about which disorders should be considered “serious.” For the purposes of this paper and the

present study, “serious mental illness” will be conceptualized as comprised of schizophrenia,

schizoaffective disorder, or bipolar I disorder.

Definitions

Schizophrenia is a disorder involving disorganization of thought, serious difficulty

distinguishing reality from fantasy, frequent delusions and hallucinations, and abnormalities in

emotional expression, interpersonal relationships, attention, motivation, and drive (Andreasen,

Arndt, Alliger, Miller, & Flaum, 1995). The defining features of schizophrenia are psychotic

symptoms such as hallucinations, delusions, and disorder of thought. It is also considered to be a

heterogeneous disorder with an often-changing presentation. This causes researchers to have

trouble determining etiology, treatment, and even classification for individual patients

(Andreasen & Carpenter, 1993; Malla, 1995a; 1995b). Schizophrenia is regarded by many to be

a chronic, recurring disorder that is likely to affect multiple brain systems (Andreasen et al.,

1995; Malla, 1995a; Schultz & Andreasen, 1999).

The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text

Revision (DSM-IV-TR; American Psychiatric Association, 2000) presents diagnostic criteria for

schizophrenia requiring that two or more active characteristic symptoms be present for at least
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one month, and signs of the disorder to be present for at least six months. The characteristic

symptoms consist of delusions, hallucinations, disorganized speech, grossly disorganized or

catatonic behavior, and negative symptoms. Additionally, decreased functioning in one or more

major life areas, such as employment, education, interpersonal relations, or self-care is also

required. There is general agreement that a diagnosis of schizophrenia can only be given to an

individual who has at least several of the diagnostically relevant symptoms (American

Psychiatric Association, 2000; Strauss, Carpenter, & Bartko, 1974).

A disorder that is related to schizophrenia is schizoaffective disorder, in which an

individual experiences an uninterrupted period of illness during which he or she also experiences

a major depressive, manic, or mixed episode concurrent with the symptoms of schizophrenia

(American Psychiatric Association, 2000). Specifically, the individual must experience

symptoms of schizophrenia for the majority of the time during a one-month period. Additionally,

during the same period of illness, delusions or hallucinations must have been present for at least

two weeks in the absence of an affective disturbance.

Bipolar I disorder is characterized by the occurrence of one or more manic or mixed

episodes. According to DSM-IV-TR (American Psychiatric Association, 2000) diagnostic

criteria, a major depressive episode is not required for bipolar I disorder diagnosis, although

individuals often do experience a depressive episode opposite of a manic episode. To meet

criteria for a manic episode, an individual must experience three or more of the following

symptoms lasting for at least a week: inflated self-esteem or grandiosity, decreased need for

sleep, pressured speech, flight of ideas, distractibility, increased goal-directed behavior, or

excessive involvement in pleasurable activities (American Psychiatric Association, 2000). These

symptoms cannot be due to substances or a general medical condition. Additionally, there must

be evidence of decreased level of functioning in one or more major life areas, such as
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employment, education, interpersonal relations, or self-care (American Psychiatric Association,

2000).

Historically, the prognosis of individuals with serious mental illness, and schizophrenia

more specifically, has been poor. Kraepelin (1919) coined the term ‘dementia praecox’ in the late

1800’s. He highlighted the idea that individuals with schizophrenia will inevitably experience a

progressive downhill course, leading to significantly poor outcomes. Fortunately,

conceptualization of treatment outcome in serious mental illness has dramatically changed,

especially in the past thirty years (Lysaker, Buck, Hammoud, Taylor, & Roe, 2006). Specifically,

research has shown that a declining course of schizophrenia is the exception rather than the rule

(Harding, Zubin & Strauss, 1992; Hoffman & Kupper, 2002), leading treatment to expand to

include the achievement of the personally defined goals of individuals (Gingerich & Mueser,

2005). Along with this change, stability of disease has been replaced as the treatment outcome

with the achievement of health across multiple domains of recovery (Anthony, 1993; Corrigan,

2003; Liberman, Kopelowicz, Ventura, & Gutkind, 2002; Spaniol, Wewiorski, Gagne, &

Anthony, 2002; Roe, 2001; Whitehorn et al., 2002).

Recovery from Serious Mental Illness

The concept of recovery, while quite common in the field of physical illness and

disability (Wright, 1983), had received little attention in the mental health field until the 1980’s

(Spaniol, 1991). The shift towards recovery in mental health gained momentum when consumers

(individuals who live with serious mental illness) began publishing accounts of their recovery.

Many people believed that their diagnosis came with a “prognosis of doom” (Deegan, 1996)

which left them with no hope of recovery or having a satisfying life. However, as these accounts

demonstrate, many individuals managed to overcome the problems imposed by the illness and

went on to live a full life. Since then, the consumer movement has been working towards
 6

breaking down the notion that serious mental illness, and schizophrenia in particular, necessarily

has a long-term deteriorating course (Andresen, Oades, & Caputi, 2003).

The recovery movement has grown considerably since its inception. The expanded

recovery philosophy is now widely endorsed and promoted by many. These supporters include

the National Alliance for the Mentally Ill (NAMI), several state mental health systems, the

Veteran’s Administration, and by the President’s New Freedom Commission on Mental Health.

The President’s New Freedom Commission (2003) called for a transformation of the mental

health system to a consumer- and family-driven, recovery-focused system (Anthony, Rogers &

Farkas, 2003), thereby injecting hope into the national mental health care system. More

specifically, NAMI has launched a national campaign, “Invest in Recovery,” soliciting donations

to bring the message that treatment works and that hope for a meaningful life is possible to

citizens and public officials of all 50 states. NAMI has been a powerful advocate for enhanced

services for the seriously mentally ill, serving as a promoter for evidence-based treatments that

can promote recovery (Liberman & Kopelowicz, 2002).

The notion of “recovery” from serious mental illness is more than a sociopolitical

movement. There is a growing scientific literature demonstrating that recovery from serious

mental illness is possible. Specifically, long-term outcome studies of schizophrenia have shown

20-70% recovery rates, with the modal recovery rate of 50% (Carpenter & Kilpatrick, 1988;

Davidson & McGlashan, 1997; Harrow et al., 2005; Liberman & Kopelowicz, 2005; Whitehorn

et al., 2002). These results are promising, and yet it has been argued by Bellack (2006) that this

recovery estimate may actually be an underestimate. He argues that individuals who function at

higher levels in the community (and therefore potentially in recovery) may be less likely to seek

mental health treatment and therefore less likely to be included in recovery studies.
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There is increasing recognition that recovery is not only possible, but that it may even be

common (Bellack, 2006). Moreover, there is mounting consumer and political pressure for more

empirical studies to identify correlates of recovery orientation and to develop recovery-oriented

interventions. However, the word “recovery” lacks precision. It has been argued by Liberman

and Kopelowicz (2002) that until a clear operational definition of recovery emerges, “this

research agenda within the recovery movement cannot advance.” Although there is little

consensus about how to define recovery, two theoretical camps have emerged each proposing

operational definitions for research in this area.

Approaches to Recovery

As used in the literature, the term “recovery” has two meanings that have emerged from

differing methodological attempts to define recovery in serious mental illness; a scientifically-

based outcome approach and a consumer-driven process approach. The first, as in conventional

usage, relates to an objective outcome, a point at which there is a lack of evidence of illness. The

second meaning relates to a subjective attitude or orientation. This approach asserts that

regardless of their state of illness or health, people can have hope, feel capable of expanding their

personal abilities, and make their own choices (Leucht & Lasser, 2006; Resnick, Rosenheck &

Lehman, 2004). Although two main approaches to recovery exist and will be highlighted here,

emphasis in this paper will be given to the subjective approach as it coincides with the

conceptualization of recovery for the present study.

“Objective” Scientific Definitions. According to the perspective of many researchers in

the field, recovery is viewed from a medical/disease model. Therefore, recovery is largely

accepted to be defined as the elimination or reduction of symptoms and a return to premorbid

levels of functioning (Bellack, 2006). Individuals who accept this view of recovery consider it to

be an outcome to be measured, typically operationalized as contingent on reduction of symptoms

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over a certain period of time (e.g., 2 years), along with clinician determined restoration of social

functioning. For example, Liberman, Kopelowicz, Ventura and Gutkind (2002) proposed an

operational definition of recovery from schizophrenia that includes symptom remission,

improved vocational functioning, independent living and improved peer relationships.

Specifically, symptom remission requires individuals to obtain a moderate score (4 or less) on

both positive and negative symptoms of Brief Psychiatric Rating Scale (BPRS) for a two year

period. Improved vocational functioning is defined by engaging in either part-time work, part-

time schooling, or if retired part-time recreational or vocational activities. Independent living is

defined as maintaining own money management, laundry, shopping, food preparation, and

personal hygiene without day-to-day supervision. Finally, improved peer relationships are

defined by engaging in a social event or conversation with a peer outside of the family at least

once per week. Of note, nowhere in this operational definition is the perspective of the individual

accounted for in determining “recovery.”

Whitehorn and colleagues (2002) expanded on recovery theory and proposed their own

operational criteria for recovery consisting of five symptom dimensions (positive symptoms,

negative symptoms, disorganized/cognitive symptoms, anxiety/depressive symptoms, and

excitement) and two functional dimensions (global assessment of functioning and social and

occupational functioning). To test their model, 103 individuals with schizophrenia-spectrum

disorders enrolled in the Nova Scotia Early Psychosis Program were assessed on the above

dimensions at baseline, 6 months, and one year. They found that after one year of treatment 67%

of individuals met criteria for “recovery” based only on reduction of positive and negative

symptoms. Additionally, 50% met criteria for overall functional recovery and 42% met criteria

for “recovery” on all five dimensions assessed (both symptom and function dimensions).

However, recovery was measured only by symptomology and clinician-rated functioning using
 9

Global Assessment of Functioning (GAF) and Social and Occupational Functioning Assessment

Scale (SOFAS) scores; study participants were not asked whether they felt they had recovered.

This point has been a major critique of this approach to the conceptualization and study of

recovery. Specifically, Bellack (2006) has argued that such approaches may lead to “a person

being judged recovered by a professional interviewer yet feeling distressed by residual

symptoms, stigmatized by the illness, frustrated by the inability to achieve one’s ambitions, and

hopeless about the future.” This calls to question whether this approach to recovery is truly

reflective of the spirit of recovery and individual empowerment.

“Subjective” Consumer Definitions. While many researchers subscribe to the above

conceptualization of recovery, there has been a large consumer movement which views recovery

as more of a process. According to this model, recovery represents healing, hope, and living a

meaningful life, regardless of symptom status (Bellack, 2006). Recovery has been described as a

deeply personal, unique process of changing one’s attitude, values, feelings, goals, skills, and/or

roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused

by illness. Recovery involves the development of new meaning and purpose in one’s life as one

grows beyond the catastrophic effects of mental illness (Anthony, 1993). Deegan (1992), who is

herself living with schizophrenia, suggests that recovery is “marked by an ever deepening

acceptance of our own limitations … we find that our personal limitations are the ground from

which spring our own unique possibilities. It is a way of life, an attitude of approaching the day’s

challenges.”

Lysaker, Buck, Hammoud, Taylor, and Roe (2006) argue that as a person with

schizophrenia views himself as more capable and able to cope, it becomes easier for him to

manage his symptoms, regardless of their severity. Lysaker and colleagues (2006) therefore

suggested that objective indicators of recovery, which rely heavily on the reduction of
 10

symptomology, may be missing the mark since recovery can exist in the presence of psychiatric

symptomology. Moreover, moving away from medical model outcomes would promote a more

consistent empowerment model approach, which is more favored by the recovery movement

(Ahern & Fisher, 2001).

There has been a recent shift in the treatment of serious mental illness in many settings.

Greater emphasis has been placed on the optimization of quality of life and full recovery, rather

than the simple reduction of the most visible symptoms of schizophrenia (Lambert & Naber,

2004). This shift is heavily visible within the Veteran’s Administration (VA), which proposed an

initiative for recovery-based services for serious mental illness system-wide. Since the VA is the

largest health care system in the country (Bellack, 2006), it is hopeful that private health care

systems will follow in the footsteps of the VA system, as they have regarding other initiatives

(i.e., computerized patient record systems).

Given the spirit which drives this approach to recovery, it is not surprising that much of

the research in this area utilizes qualitative methodology. Qualitative inquiry allows the

researcher to better capture the experience of the individual. For example, Young and Ensing

(1999) conducted semi-structured qualitative interviews with eighteen individuals with

psychiatric disabilities in order to examine the meaning of recovery from the perspective of

individuals. Participants in this study carried diagnoses such as bipolar disorder, schizophrenia,

major depression, schizoaffective disorder, borderline personality disorder, anxiety (including

one individual with PTSD), claustrophobia, bulimarexia, and mental retardation. These

interviews were conducted both on an individual level and within focus groups. Five themes

were derived from these accounts, which reflect the process of recovery from serious mental

illness: “overcoming stuckness,” “discovering and fostering self-empowerment,” “learning and

self-redefinition,” “returning to basic functioning,” and “improving quality of life.” This study
 11

also highlighted the importance of spirituality in the recovery process; spiritual development was

seen by many participants as a key component to the recovery process. Young and Ensing’s use

of a strictly qualitative approach to uncover thematic representation of the recovery process is a

unique and valuable addition to the literature in this area. The use of qualitative methodology

allows for in-depth understanding of participant experiences through their own words, and can

shed light on issues not previously thought of by researchers in quantitative studies.

In a similar study, Tooth, Kalyanasundaram, Glover, and Momenzadah (2003) examined

recovery from the perspective of individuals with schizophrenia. This study had two aims, to

better understand the experience of these individuals and to generate a consumer definition of

recovery. Two focus groups of consumers were used to generate appropriate qualitative

questions for the study. The focus groups resulted in a four-part interview which was used for the

study. A total of fifty-seven individuals with schizophrenia were interviewed about their

experiences. From these narratives, seven common themes emerged: “the role of active sense of

self,” “understanding of their illness,” “accepting of their illness,” “medication and health

professionals,” “transformational aspects of recovery,” “networks”, and “turning point.”

Additionally, approximately one-third of the participants defined recovery as “taking

responsibility and having structure and organization in their life.” These narratives reflected

renewed ways these individuals had developed to view themselves despite their psychiatric

diagnosis. It was suggested that in order to help facilitate recovery in individuals with serious

mental illness, one needs to understand how these individuals feel about and function with

serious mental illness from their own perspective.

Extending previous self-perspective research, Lysaker and colleagues (2006) were

interested in examining how self-experience of individuals with serious mental illness is related

to other measures of health, such as symptom severity and hope. They interviewed sixty-five
 12

individuals with schizophrenia or schizoaffective disorder who were deemed to be in a “post

acute phase” of illness defined by no changes in medications or housing and no psychiatric

hospitalizations within the past month. Lysaker and colleagues (2006) used both qualitative and

quantitative measures to assess psychiatric symptoms, psychosocial functioning, hope, insight,

and self-experience. Self experience was measured using STAND, a measure developed by

Lysaker, Wickett, Campbell, and Buck (2003) to code personal narratives across four subscales:

social worth, social alienation, personal agency and illness conception. They found that higher

scores on the STAND (reflecting high self worth, low social isolation, high personal agency, and

high illness conception) was associated with better psychosocial functioning, greater

expectations of perseverance, and less psychiatric symptomology. Overall, the authors suggest

that better self-experience, as measured by construction of personal narratives, is related to better

functional outcomes (Lysaker et al., 2003).

Much of the literature to date has focused on assessing recovery from either the objective

or subjective perspective. However, a recent study by Resnick, Rosenheck and Lehman (2004)

combined both models of recovery in an exploratory analysis to uncover correlates of recovery.

For this study, a total of 825 individuals with schizophrenia were interviewed; 577 of the

participants were part of the original Schizophrenia Patient Outcome Research Team (PORT)

study and 248 were part of the Veteran’s Affairs PORT extension. Study participants were

interviewed and data gathered regarding demographics, symptoms (using Symptom Checklist-

90), alcohol/drug use (using CAGE), and perceptions related to medication side-effects and

mental health services. Additionally, a recovery oriented questionnaire, derived from selecting

items from the PORT client survey, was used to assess subjective aspects of recovery. Factor

analysis revealed four distinct factor loadings representing four domains of recovery orientation:

“satisfaction with life,” “hope and optimism,” “perceived knowledge about mental illness and
 13

services,” and “empowerment.” Results suggested a strong inverse relationship between

depressive symptoms and all four domains of recovery orientation. Medication side-effects were

inversely related to all recovery domains except “perceived knowledge about mental illness and

services.” Additionally, family psychoeducation was directly related to all recovery domains

except “satisfaction with life.” Further results highlighted specific significant relationships with

each recovery domain. Overall, the authors suggested that reduced symptoms and medication

side effects as well as participation in family psychoeducation are especially important correlates

of recovery orientation among individuals with schizophrenia. The authors concluded by arguing

that more collaboration is needed between researchers since they found the two models of

recovery to be reinforcing in this study. Taken together, the current research on recovery

highlights the complexity of the recovery orientation and its subsequent conceptualization and

measurement.

Recovery and the Present Study

For the present study, emphasis was given to the individual’s perspective on recovery

rather than the objective, medical-model influenced, view of recovery. Therefore, the Recovery

Assessment Scale (RAS), which is based on a process model of recovery, was chosen for

inclusion in this study. This measure was originally developed for use as an outcome measure in

program evaluations. The RAS was developed by Giffort, Schmook, Woody, Vollendorf, and

Gervain (1995) through narrative analysis of four individuals’ stories of recovery. These stories

were then reviewed by an independent group of additional individuals with serious mental

illness, ultimately yielding a 41-item scale. Factor analysis (Corrigan et al., 2004) has suggested

five specific factors: “personal confidence and hope”, “willingness to ask for help,” “goal and

success orientation,” “Reliance on Others,” and “No Domination by Symptoms.” Additionally,

 14

the RAS has demonstrated adequate psychometric properties (see Corrigan et al., 1999; Corrigan

et al., 2004 for review of psychometric properties).

Unfortunately, there is very little use of the RAS in existing literature; a review of the

literature revealed six studies. These studies focused on individuals in either partial psychiatric

hospitalization, or who were involved in consumer-operated projects such as clubhouses.

Previous research using RAS has suggested direct relationships between recovery and size of

social support network, self-esteem, empowerment, peer support, quality of life, and leisure

motivation. Additionally, recovery using RAS has been shown to be inversely related to

psychiatric symptoms and age (Corrigan, 2006; Corrigan et al., 1999; Corrigan et al., 2004;

Corrigan & Phelan, 2004; Lloyd et al., 2007). Further studies will be needed to examine the

utility of the RAS as a recovery measure and to help uncover further correlates of recovery.

In summary, research on the recovery of individuals with serious mental illness is

promising. General estimates demonstrate that up to 50% of individuals show signs of recovery

(Carpenter & Kilpatrick, 1988; Davidson & McGlashan, 1997; Harrow et al., 2005; Liberman &

Kopelowicz, 2005; Whitehorn et al., 2002). However, lack of agreement in the field regarding

operational definitions and measurement of recovery could prevent research progress. More

work is needed to better operationalize and measure recovery. Moreover, integration of both

objectively and subjectively operationalized definitions of recovery will be needed to help propel

the field and our understanding of what makes recovery from serious mental illness possible.
 15

CHAPTER II: THE STUDY OF QUALITY OF LIFE: AN OVERVIEW

Interest in assessing the quality of life of individuals with serious mental illness was

generated most strongly in the mid-1970s by the Community Support Program (CSP). This

initiative by the National Institute of Mental Health was designed to stimulate state and local

agencies to develop more comprehensive community-based services for the chronically mentally

ill (Lehman, 1988). The stated goal of the CSP was to improve the quality of life of patients,

which was defined as the extent to which “improvements in system performance actually

translate into humane, dignified, and satisfying conditions of community living for chronically

disabled clients” (Tessler & Goldman, 1982). Although interest in the quality of life of

individuals with serious mental illness started to bloom at this time, research in this area did not

truly blossom until the 1980s.

The deinstitutionalization movement in the 1980’s and subsequent community living of

many individuals with serious mental illness catapulted the study of quality of life within the

mental health field. The issue of patient quality of life became very salient due to growing

concern that community dwellings were just another form of institutionalization (Lehman, Ward

& Linn, 1982). This led to much debate about what is quality of life (i.e., how should it be

operationalized) and how should it be measured. Although research on quality of life continued

throughout the 1980s at least to some extent, interest in quality of life was largely renewed in the

1990s with the development of atypical antipsychotic medications. Since that time, quality of life

has been used as an important outcome measure in clinical trials of atypical antipsychotic drugs

(Lambert & Naber, 2004).

Definitions

The World Health Organization defines quality of life as “individual’s perception of their

position in life in the context of culture and value systems in which they live and in relation to
 16

their goals, expectations, standards, and concerns” (Saxena & Orley, 1997). Although there is no

universally accepted definition of quality of life, there is general agreement that quality of life

consists of “access to resources and opportunities, fulfillment of life’s roles, level of functioning,

and a sense of well being or life satisfaction (Attikisson, Cook, & Karno, 1992). There has been

much debate about how to operationalize and subsequently measure quality of life, with the field

being generally split into considering objective versus subjective indicators of quality of life.

Objective Indicators of Quality of Life. The earliest approaches to the measurement of

quality of life explored social indicators. Objective indicators of quality of life are assessed by

comparing the individual to a larger population on a variety of social indicators. Examples of

social indicators include things such as employment, housing status, income, the size and nature

of one’s social network, opportunities for leisure, and access to certain commonly accepted

social goods (TV, radio, car, etc.) (Holloway & Carson, 2002). Objective indicators typically

have more appeal because they are tangible, reflect accepted norms of function and life-style,

and more directly address conditions that can be manipulated in service programs (Lehman,

1983). However, their major disadvantage is that they tell little about how the individual feels

about his/her life, therefore potentially omitting individual input from treatment of program

planning.

Subjective Indicators of Quality of Life. An alternative view of quality of life is that in

essence it relates to “a person’s sense of well-being, his satisfaction with life, or his happiness or

unhappiness” (Baker & Intagliata, 1982). Typically this is conceptualized as a global measure of

well-being or life satisfaction (Holloway & Carson, 2002), but has also been broken down into

satisfaction within specific life domains. Lehman (1983) undertook ground-breaking research

that demonstrated the capacity of people with serious mental illness to report their subjective and

objective quality of life and presented a model that brought these constructs together. He
 17

maintained that subjective quality of life implies a relatively stable self-assessment of life

conditions and is influenced by expectations, prior experiences, and perceptions of current

conditions (Lehman, 1983). Similarly, Frisch (1994) described subjective quality of life as

composed of two parts. The first component involves positive affect. The second component is

cognitive, in which an individual judges whether needs and wishes have been fulfilled, and

relates this to personal satisfaction. Lehman (1983) has argued that rather than engage in

theoretical debates about the validity of the two types of quality of life, one should recognize that

they do indeed measure different and complementary aspects of an individual’s life experiences.

He therefore suggests that both types of measures be used whenever possible to reflect the

overall experience of the individual.

Measuring Quality of Life

Over the past few years a growing body of research has supported the notion that

subjective self-reports can be both measured and reliably quantified (Awad et al., 1995; Hogan &

Awad, 1992; Lehman, 1983; Naber et al., 1994; Voruganti et al., 1998). For example, Lehman

(1983) was interested in studying what variables (personal characteristics, objective indicators,

and subjective indicators) were most related to general well-being in individuals with serious

mental illness. For this study, 278 individuals residing in board-and-care homes in the Los

Angeles area were administered the Quality of Life Interview (QOLI). Participants in this study

carried a wide range of diagnoses, with 63% of participants diagnosed with schizophrenia.

Results showed that individuals with chronic psychiatric disorders were able to provide

statistically reliable responses on the QOLI. Their responses explained a substantial amount of

the variance (48% to 58%) in subjective quality of life, and were much better predictors of global

well-being compared with objective indicators in the same life domains. Additionally, results

showed that global well-being was most consistently associated with personal safety, finances,
 18

leisure, social relations, and health care variables. Lehman (1983) noted that these findings

parallel studies of quality of life in the general population. He also highlighted his optimism that

such quality of life assessments can be applied to the study of chronic mental patients.

Voruganti and colleagues (1998) extended research on the reliability of quality of life

self-reports. They confirmed that the reliability coefficient of a patient’s self-report measured

weekly over a four-week period was statistically significant. In addition, they also found

significant concordance between a patient’s subjective self-report and objective measures

conducted by clinicians. Moreover, repeated analysis of variance failed to detect any group by

week interaction effects for the severity of symptoms, side effects, neurocognitive deficits,

antipsychotic drug dose, or attitudes toward medication. The authors concluded that the lack of

such interactions confirms that subjective self-reported scores remained consistent for all

subgroups over time.

Although there is evidence that individuals with serious mental illness are able to give

reliable accounts of quality of life, skepticism remains. For example, Lambert and colleagues

(2003) argued that it remains unclear whether patients with severe psychiatric symptoms,

extensive cognitive deficits, or lack of insight are able to evaluate their quality of life in a context

that could provide clinicians with useful information. To minimize bias in subjective self-reports,

Awad and Voruganti (2000) suggested using multidimensional approaches rather than a global

self-report rating. They suggested that using a global self-rating can be misleading as it has been

observed that psychiatric patients generally report higher scores, projecting themselves as

somewhat better.

Several quality of life measures have been developed over the years, addressing various

aspects of quality of life (please see Bobes et al., 2005; Lehman, 1996a for review of existing
 19

quality of life instruments). Lehman (1996b) has addressed several issues related to selection of

quality of life measures in research. These are as follows:

1. The investigator must determine his or her particular purpose and needs before selecting a

specific measure; this includes an operational definition of quality of life, means to measure

the domains under consideration, ability to make comparisons to other relevant populations

(other psychiatrically impaired, physically disabled, general population, economically

disadvantaged, etc.), selection of a time frame (longitudinal or not) to study quality of life,

and, the ability to apply quality of life results to interventions and evaluations with patients;

2. The measure chosen should assess both subjective and objective domains of life;

3. The assessment should be based upon a comprehensive quality of life model;

4. The measure should be developed for or applicable to the population of interest;

5. Training of administrators and time involved in the assessment must be considered; and

6. Consideration of the psychometric properties of the measure (e.g., reliability, validity, etc.) is

important.

Although Lehman’s model is fairly comprehensive, additional concerns regarding

selection of a quality of life measure should also be considered. Specifically, Russo, Roy-Byrne,

Reeder, Alexander, Dwyer-O’Connor, and Dagadakis (1997) have suggested that the following

factors should be considered: whether or not responses may be biased by patient

psychopathology, whether the measure validly differentiates patients with different severity of

illness (e.g., inpatient versus community living) and housing status (homeless versus domiciled),

and whether the measure assesses symptoms that are nonredundant with the anhedonia common

to depression. It has been recommended by many authors (Awad & Voruganti, 2000; Bobes et

al., 2005; Lehman, 1996b; Russo et al., 1997) that researchers carefully select a quality of life

measure based upon the needs of the study and the specific characteristics of the measure.
 20

Quality of Life and Serious Mental Illness

Several clinical and psychosocial factors have been associated with quality of life in

serious mental illness. In general, individuals with serious mental illness have been shown to

report lower subjective satisfaction than do individuals without mental illness (Lehman, Ward &

Linn, 1982). However, there are important factors which have been shown to be associated with

quality of life within the serious mental illness population. Briefly, in patients with serious

mental illness, quality of life has been associated with cognitive abilities (e.g., Corrigan &

Buican, 1995), duration of untreated psychosis (e.g., Browne et al., 2000), education (e.g.,

Swanson et al., 1998), employment (e.g., Dixon et al., 2001), finances (e.g., Heider et al., 2007;

Lehman, 1983), inpatient status (e.g., Lehman, Possidente, & Hawker, 1986), insight into mental

illness (e.g., Hasson-Ohayon et al., 2006; Lysaker et al., 1998), medication side-effects (e.g.,

Allison, Mackell & McDonnell, 2003; Meltzer, 1992), protective factors (e.g., Ritsner et al.,

2003; Ritsner, Gibel & Ratner, 2006), recovery (e.g., Corrigan et al., 1999), safety (e.g., Lehman

1983), social relationships (e.g., Ritsner, et al., 2000), and severity of psychopathology including

hospital readmissions (e.g., Levitt, Hogan & Bucosky, 1990) and symptomology (e.g., Bow-

Thomas et al., 1999; Dickerson, Ringel & Parente, 1998; Ritsner, Gibel & Ratner, 2006; UK700

Group, 1999).

Literature on quality of life models and the determinants of quality of life in serious

mental illness has been mixed. For example, Lehman and colleagues, using the Quality of Life

Interview, identified safety, unemployment, financial issues, and family and social relations as

primary determinants of quality of life (Lehman, 1983; Lehman, Ward & Linn, 1982). A similar

study conducted in Mississippi by Sullivan, Wells and Leake (1991) also found social relations

and finances as main determinants of quality of life of individuals with serious mental illness.

For this study, 101 individuals with schizophrenia living in a very poor, rural area were
 21

interviewed using the Quality of Life Interview. They found that patients who lived with family

members and reported high support from family expressed significantly less dissatisfaction in all

life domains except finances/income. It was presumed that the positive and supportive

relationship with family members increased patient life satisfaction, even when the subject was

living in adverse conditions. However, a Canadian study involving seventy patients in a day-

treatment program identified somewhat different dimensions as the best predictors of quality of

life. Specifically, Levitt, Hogan and Bucosky (1990) found that the number of readmissions in

the previous year, frequency of family contacts, satisfaction with social life, mental health and

adult education were the best predictors of subjective quality of life in a sample of 70 individuals

with serious mental illness. Also in contrast, Awad, Voruganti and Heslegrave (1997), using a

single indicator of an individual’s subjective quality of life, found that severity of illness and

subjective response to antipsychotic drugs emerged as the key determinants of quality of life in a

sample of 62 clinically stable schizophrenic patients.

The disparate findings in the quality of life literature led further researchers to assess

more globally what types of factors may be contributing to quality of life in serious mental

illness. For example, researchers involved in the UK700 study, the largest case management

study in the United Kingdom at that time, were interested in examining the clinical and social

variables which may be associated with quality of life in individuals with psychotic disorders

(UK700 Group, 1999). For this study, researchers assessed a total of 708 patients with serious

mental illness (87% of which were diagnosed with schizophrenia or schizoaffective disorder) at

baseline and then were randomized to two years of either intensive or standard case management

and completed follow-up assessments at 12 and 24 months. The longitudinal design was part of a

larger study, but only baseline information was presented in this paper. Participants were

assessed regarding psychiatric symptomology (using the Comprehensive Psychopathological

 22

Rating Scale and Scale for the Assessment of Negative Symptoms), quality of life (using

modified version of Lehman Quality of Life Interview), and need (using Camberwell

Assessment of Need). They found that social variables (such as living situation, treatment,

employment) accounted for 7% of the variance in quality of life. Clinical variables (such as

symptoms and medications) accounted for 19% of the variance. Unmet needs (such as basic,

social, health, and service) accounted for 20% of the variance in quality of life. Once combined,

these variables accounted for 27% of the variance in quality of life. Of note, negative symptoms

did not predict quality of life, therefore the effect of psychopathology on quality of life was

assumed by the authors to be due to positive symptoms. The authors argued that these results

identify priority areas for further investigation (UK700 Group, 1999).

Psychopathology & Quality of Life. Other research has focused on understanding the

relationship between psychopathology (type and severity) and quality of life in individuals with

serious mental illness. In these studies, the type of psychopathology is usually broken down into

positive psychotic symptoms (i.e. hallucinations, delusions), negative psychotic symptoms (i.e.,

avolition, flat affect, alogia), and depression. However, the evidence for relationships between

quality of life and psychopathology is mixed. Some studies have shown that quality of life is

inversely related to positive psychotic symptoms (Bow-Thomas et al., 1999; Heider et al., 2007;

Ritsner, Gibel & Ratner, 2006; UK700 Group, 1999). Other studies have shown inverse

relationship to negative symptoms (Bow-Thomas et al., 1999; Browne et al., 1996), whereas

others show inverse relationships to depression (Dickerson, Ringel & Parente, 1998; Fitzgerald

et al., 2001; Ritsner, Gibel & Ratner, 2006; Sim et al., 2004).Yet other studies find contradictory

evidence within a single study. For example, Norman and colleagues (2000) found certain

aspects of psychopathology related to different aspects of quality of life, depending on how they

were measured. In this study, 128 individuals with schizophrenia or schizoaffective disorder
 23

were assessed on quality of life (using both Quality of Life Scale (QLS) and General Well-Being

(GWB) Scale), symptoms (using Scales for Assessment of Positive Symptoms and Scales for

Assessment of Negative Symptoms) and community adaptation (using the Life Skills Profile).

They found that quality of life as measured by the QLS was inversely related to both positive and

negative psychotic symptoms. Additionally, quality of life measured by GWB scale was only

inversely related to positive psychotic symptoms. These results highlight the importance of

measurement tool selection when studying quality of life since objective (QLS) and subjective

(GWB) measures revealed differing results.

Further studies have focused on the relationship between quality of life and severity of

symptoms. Specifically, researchers have found inverse correlations between quality of life and

the severity of symptoms (Browne et al., 1996; Voruganti et al., 1998). For example, Voruganti

and colleagues (1998) found that in a sample of 63 individuals with schizophrenia, severity of

symptoms as measured by the Positive and Negative Syndrome Scale inversely correlated with

both subjective and objective measures of quality of life.

Protective Factors. Although much of the research on quality of life in serious mental

illness has focused on factors negatively impacting quality of life, recently the focus has shifted

to protective factors. Various protective factors have been identified and have been found to play

a significant role in quality of life outcomes. Examples of these factors include self-esteem, self-

efficacy, coping with stressful situations, personality traits, expressed emotions and social

support (Ritsner, Ben-Avi, Ponizovsky, Timinsky, Bistrov, & Modai, 2003; Ritsner, Farkas &

Gibel, 2003; Ritsner, Gibel & Ratner, 2006). Moreover, according to Ritsner, Ponizovsky,

Endicott, Nechamkin, Rauchverger, Silver, and Modai (2002), the contribution of protective

factors has been shown to explain 20.9% of the variability in subjective quality of life. In a

recent study, Ritsner, Ben-Avi, Ponizovsky, Timinsky, Bistrov, and Modai (2003) were
 24

interested in assessing possible contribution of personality factors and coping styles to quality of

life and coping of individuals with serious mental illness. They found that quality of life was

highly negatively correlated with psychological distress and low to moderately correlated with

most psychopathological symptoms. Additionally, they demonstrated that emotion-oriented

coping was inversely associated with quality of life, while other coping styles showed direct

correlation with quality of life. Although protective factors are important in the study of quality

of life they will not be highlighted as part of the present study.

Medication Side-effects. Antipsychotic agents have a wide range of adverse effects that

may cause physical and/or psychological harm to individuals with serious mental illness.

Although research on the effects of medication on quality of life is varied, quality of life seems

to be highly related to the presence or absence of neurological side-effects. Extrapyramidal

symptoms (EPS) are especially seen with conventional (“typical”) antipsychotic medications and

have been associated with deteriorating quality of life. For example, Browne and colleagues

(1996) showed that in a sample of 64 schizophrenia patients, individuals with tardive dyskinesia

(a side-effect of conventional antipsychotic medication) reported significantly more negative

symptoms and poorer quality of life. Besides EPS, adverse events such as weight gain, sedation

and sexual dysfunction have also been associated with quality of life (Allison, Mackell &

McDonnell, 2003; Hofer et al., 2002). However, other studies report that atypical antipsychotics,

which tend to produce less EPS, are associated with less negative symptoms and better quality of

life (Meltzer, 1992).

Insight. The term “insight” used here refers to the ability of an individual to acknowledge

his/her mental illness and the need for treatment (McEvoy et al., 1989). Insight has been an

important area for research and has been linked to symptomology (e.g., Sevy et al. 2004),

treatment compliance (i.e. Kamali et al., 2001), cognitive impairment (e.g., Mohamed et al.,
 25

1999), suicidality (e.g., Amador et al., 1996), and quality of life (e.g., Hasson-Ohayon et al.,

2006).

The influence of insight on quality of life remains unclear as the literature in this area

shows diverse results. While Lysaker and colleagues (1998) found a positive relationship

between insight into having a mental illness and social ability (a proxy for quality of life in this

study), Browne, Garavan, Gervin, Roe, Larkin, and O’Callaghan (1998) did not find a significant

relationship between insight and social ability. Additionally, other researchers have found

negative relationships between insight into mental illness and quality of life. A recent study by

Hasson-Ohayon and colleagues (2006) examined the relationship between insight and quality of

life, spurred by the mixed evidence that currently exists on the topic. For this study 131

individuals with schizophrenia or schizoaffective disorder who were receiving services for at

least 6 months at psychiatric rehabilitation facilities were assessed on insight (using Scale of

Unawareness of Mental Disorder), psychotic symptoms (using Brief Psychiatric Rating Scale),

and quality of life (using The Human Service Scale). They found that general insight into having

a mental illness was negatively related to emotional well-being, economic satisfaction, and

vocational status. The authors noted that these findings do not support the notion held by other

researchers that insight into mental illness leads to improved quality of life. However, they also

found that individuals who reported more insight into the advantages of medications reported

higher levels of emotional well-being. Additionally, insight was not related to overall psychiatric

symptoms or depression more specifically. The results of this study add to the mixed picture of

the role of insight in quality of life.

For the current study, the relationship between insight and quality of life was examined

differently than previous research. Specifically, cognitive insight, as defined by Beck and

colleagues (2004) was examined. Briefly, cognitive insight refers to the ability to self-reflect, to
 26

acknowledge the possibility of being mistaken, to be open to feedback, and to refrain from

overconfidence. Beck and colleagues (2004) argued that the existing conceptualization and

measurement of “insight” does not directly address the patient’s limited capacity to make

judgments about their experience. It has been argued that this is the result of cognitive

deficiencies which have been shown to be associated with serious mental illness, and

schizophrenia in particular (see Heinrichs & Zakzanis, 1998 for discussion). Therefore they

designed a new measure to specifically tap cognitive insight. The Beck Cognitive Insight Scale

(BCIS) (Beck et al., 2004) is a 15-item self-report measure that assesses how individuals

evaluate their own judgment. The scale has two factors, “Self-Reflectiveness” and “Self-

Certainty.” Self-Reflectiveness includes items related to willingness to acknowledge fallibility,

the recognition of having jumped to conclusions at times, and the possibility of having

misinterpreted unusual experiences. Self-Certainty includes items related to over-confidence. It

is speculated that over-confidence may serve to impair Self-Reflectiveness. Therefore the

“composite index” was created to capture the person’s overall cognitive insight. The composite

index is determined by subtracting the individual’s “Self-Certainty” score from his/her “Self-

Reflectiveness” score (Warman, Lysaker, & Martin, 2007).

Research on the BCIS has suggested that individuals with serious mental illness are

significantly less self-reflective and more over-confident than normal, healthy controls (Beck et

al., 2004). Additionally, severity of positive symptoms has been shown to be positively

correlated with overconfidence (Pedrelli et al., 2004). In a recent study, Warman, Lysaker and

Martin (2007) expanded on the existing research by examining the impact of active delusions on

cognitive insight. They assessed 49 individuals with serious mental illness (schizophrenia or

schizoaffective disorder) and 60 healthy controls. Of the individuals with serious mental illness,

37 demonstrated active delusions while 12 did not have active delusions. Overall they found that
 27

regardless of delusional state, individuals with serious mental illness had less cognitive insight

than healthy controls. Additionally, they found that delusional state did differentiate the type of

impairment in cognitive insight. Specifically, individuals with active delusions were more

overconfident than either controls or non-delusional individuals. Moreover, the non-delusional

individuals demonstrated impaired Self-Reflectiveness compared to actively delusional patients

and controls.

Although the current research on cognitive insight has shown impaired insight in

psychotic patients, there has been no investigation of how this may impact patient functioning, or

more importantly their quality of life. Currently there is no published research which examines

the relationship between cognitive insight and quality of life. It will be important for future

research to examine this relationship to add to our understanding of how individuals with serious

mental illness cope with and make sense of their lives.

Recovery. Recovery has been defined as a person with serious mental illness living a

satisfying life within the constraints of his/her mental illness (Anthony, 1993; Deegan, 1988,

1996; Leete, 1989; Unzicker, 1989). Recently, the relationship between recovery and quality of

life has been empirically examined. For example, Corrigan and colleagues (1999) were

interested in exploring the relationship between recovery (using Recovery Assessment Scale),

needs, psychiatric symptoms, psychosocial factors (empowerment, quality of life, social support,

and self esteem), and verbal intelligence. They assessed 35 individuals with serious mental

illness for this study. They found that recovery was directly associated with quality of life, size

of social network, self-esteem, and empowerment, whereas it was inversely associated with

psychiatric symptoms.

Overall, research on quality of life in serious mental illness has demonstrated varied

results regarding key determinants of quality of life, the effect of symptomology, insight into
 28

illness, recovery, and medication on quality of life. These differing results are reflective of the

multitude of measures used to capture quality of life. There remains little agreement about

whether any of these instruments are measuring the same construct, especially since few studies

specifically address what aspect of quality of life they are assessing in their study. Thus, care

must be taken when selecting a quality of life measure and especially when comparing findings

to other studies which purport to study quality of life.

Quality of Life and the Present Study

For the present study, quality of life was conceptualized as having both objective and

subjective components, with a strong emphasis on the subjective experience of the individual. It

is important to ascertain how an individual feels about his life in order to truly understand his

experience and ultimately how he copes with mental illness. Therefore, Lehman’s Quality of

Life Interview - Brief Version (QOLI; Lehman, 1988; 1996a) was selected for inclusion in the

present study. The QOLI is a structured, self-report interview, which elicits patients’ ratings

about their quality of life. It was developed based on the model of quality of life derived from

earlier studies of life satisfaction in the general US population (Andrews & Withy, 1976;

Campbell, Converse & Rodgers, 1976). Briefly, according to this model, personal characteristics,

objective life conditions, and subjective satisfaction with life conditions combine to give a sense

of global well-being (Levitt, Hogan, & Bucosky, 1990). The overall purpose of the QOLI is to

assess the life circumstances of individuals with serious mental illness both in terms of what they

actually do and experience (“objective” quality of life) and their feelings about these experiences

(“subjective” quality of life). The interview provides a broad-based assessment of the recent and

current life experiences of the respondent in a wide variety of life areas of potential interest.

Factors assessed by this measure includes living situation, family relationships, social relations,

leisure activities, finances, safety and legal problems, work and school, and health and in
 29

addition has two measures of global well-being (Lehman, 1988). The psychometric properties of

the QOLI have been examined extensively in the literature (see Lehman, 1996a for discussion of

psychometric properties).

Initial studies on the QOLI were completed with patients in board and care homes,

supervised community residences, and psychiatric hospitals. Research with the QOLI has shown

differences between various groups and their quality of life. When considering community

residents versus hospitalized patients, it was found that regardless of length of stay in the

particular placement, the community residents more favorably rated their living conditions, had

access to more financial resources, and were less likely to be assaulted in the past year than the

hospitalized patients (Lehman, Possidente, & Hawker, 1986.) Factors that best predicted the

quality of life of individuals with chronic psychiatric illness attending a day treatment program

were found to be the number of admissions to the hospital in the past year, frequency of family

contacts, satisfaction with social life, psychiatric health, and adult education (Levitt, Hogan, &

Bucosky, 1990). In addition, of the patients in day treatment, those not of Caucasian race, and/or

those with higher levels of anxiety and depression (as measured by the Brief Psychiatric Rating

Scale) rated their quality of life as significantly lower than other participants. Moreover, a study

discussed previously involving the QOLI indicated that seriously mentally ill patients who lived

with family members in a very poor and rural area expressed significantly less dissatisfaction in

all life domains except finances/income when they perceived high support from those family

members (Sullivan, Wells, & Leake, 1991). Additional research involving the QOLI has

determined that, with the possible exception of social relationships, there are no differences in

the patient reports of quality of life between men and women with schizophrenia, which was

shown not only in the United States but also in Canada and Cuba (Vandiver, 1998).
 30

In a recent study using the QOLI, Heider and colleagues (2007) examined quality of life

in individuals with schizophrenia longitudinally in three European countries (Germany, UK, and

France). A total of 810 individuals were assessed at 6 month intervals over a two year period on

quality of life (using Quality of Life Interview-Brief Version), depression (using Calgary

Depression Scale for Schizophrenia), psychiatric symptoms (using Positive and Negative

Syndrome Scale), global assessment of functioning (using GAF score), and sociodemographic

factors. They found that objective quality of life scores were generally found to be related to the

equivalent subjective quality of life score. Peoples’ financial situation, depressive symptoms,

and positive psychotic symptoms had a general effect on almost all subjective quality of life

domains. Specifically, the more money an individual had available to them was associated with

better quality of life across all subjective domains except work and school. It was noteworthy

that finances were found to be the best predictor of overall subjective quality of life.

Additionally, this study upheld findings of significant inverse relationships between subjective

quality of life and depressive and positive psychotic symptoms (e.g., Bow-Thomas et al., 1999;

Fitzgerald, 2001).

In summary, research on the quality of life of individuals with serious mental illness is

mixed, with much contradiction in findings across this area of research. One problem that is

likely responsible is the difficulty operationalizing the construct of ‘quality of life.’ Although

there is no overall definition of quality of life, most researchers seem to agree that a patient’s

statements on satisfaction with major life domains and daily functioning are relevant factors to

subjective quality of life (Lehman, 1996a; Priebe, Roeder-Wanner & Kaiser, 2000; WHOQOL

Group, 2005). The lack of an accepted definition, however, continues to be problematic for

research in this area. It will be important for the field to work towards an accepted definition of
 31

quality of life to better illuminate how serious mental illness impacts quality of life across

multiple domains.
 32

CHAPTER III: THE STUDY OF PERSONAL LOSS: AN OVERVIEW

All people experience some type of personal loss in their lifetime. Consequently, there

has been a push in recent decades to study and understand how people perceive and adjust to loss

(Murray, 2001). Specifically, Harvey & Miller (1998) urged the field of psychology to embrace a

new field of empirical study, a “psychology of loss,” as an avenue to further explore how loss

impacts individuals.

Definitions

Harvey & Miller (1998) have defined loss as “a reduction in resources, whether tangible

or intangible, in which a person has a significant emotional investment.” In their

conceptualization of loss, they highlight the necessity of both subjective (i.e., the individual feels

he/she experienced a personal loss) and objective (i.e., personal loss is recognized by others)

aspects to determine whether the loss is of sufficient magnitude to constitute a “major loss.”

Additionally, the notion of primary and secondary loss has been raised, where primary loss refers

to the actual event and secondary loss is a consequence of the primary loss. For example, loss of

capacity as a result of an accident or illness (Kelley, 1998) may also involve a changed future,

changed relationships, or financial insecurity which are all examples of secondary loss. Murray

(2001) has argued that many of these secondary losses only become clear over time and may

even alter the progress of grieving the primary loss. Regardless of the loss, it has been suggested

that personal loss contributes to personal identity and forces individuals to make adaptations for

the loss (Harvey, 2001). Furthermore, researchers such as Emmons, Colby, and Kaiser (1998)

emphasize the necessity of making sense out of loss, by finding or creating meaning, as an

effective way of coping.

Research on personal loss has explored the impact of several types of loss on individuals,

including loss due to death of a loved one (e.g., Davis, Nolen-Hoeksema & Larson, 1998), loss
 33

due to physical illness or disease (e.g., Shepherd, Sparkes & Hattersley, 2003) loss due to

separation or divorce (e.g., Harvey, 2000), loss due to a natural disaster (e.g., Harvey et al.,

1995), and loss due to mental illness (e.g., Ryan, 1993; Stein et al., 2005). Additional research

has highlighted that individual reactions to personal loss are also affected by social support (e.g.,

Raphael, 1984), positive individual qualities (e.g., Krupp, 1987), and overall coping ability (e.g.,

Parkes, 1986). It has been suggested that regardless of the type of loss, there are commonalities

across diverse loss experiences (Harvey & Miller, 1998).

Personal Loss and Serious Mental Illness

Personal loss has been described as a central experience among families who have family

members living with serious mental illness (Davis & Schultz, 1998; Jones, 2004; MacGregor,

1994). Families containing a member with serious mental illness have been found to experience

significant levels of emotional and psychological distress and disruption to their lives (Bulger,

Wandersman & Goldman, 1993; Martens & Addington, 2001; Winefield & Harvey, 1993). This

type of personal loss is complicated since the person has not died, yet he/she is not the same as

before the onset of illness. This type of loss obviously differs from loss due to death, but it has

been argued that the response of family members to the loss due to mental illness may be similar

to grief reactions to death (Solomon & Draine, 1996). However, it has been suggested that

viewing the onset of serious mental illness as similar to the death of a loved one is potentially

harmful, given that in many instances families are trying to find ways to help their ill family

member live a meaningful life (Stein & Wemmerus, 2001).

Personal loss research in the area of serious mental illness has focused primarily on the

experiences of families, and more specifically caregivers, of the mentally ill. However, many of

these studies have focused on the grief reactions of family members rather than examining

perceptions of the loss. Studies have shown that parents of individuals with serious mental illness
 34

do experience significant loss and subsequent grief reactions related to their child’s illness

(Davis & Schultz, 1998; Miller et al., 1990; Solomon & Draine, 1996). Moreover, Parker (1993)

suggests that with the onset of schizophrenia parents lose the child they once knew and

consequently “grieve the death of the hopes and dreams both they and the ill person had.”

Overall, research has shown that grieving appears to be a normal and adaptive response to

parenting a child with a serious mental illness. Further, it has been suggested that this grief may

be a lingering process influenced by ongoing reminders of loss (Davis & Schultz, 1998).

Although much of the existing research in this area focuses on family’s grief reactions to the

serious mental illness of a loved one, it is important to note that loss and grief are different

concepts. Specifically, grief has been defined as “the emotional response to loss” (Raphael,

1984). Whereas grief is an important concept in the literature, the focus of this paper and the

present study is the perceptions and experiences of loss rather than grief reactions.

The studies that examine the construct of personal loss as it relates to serious mental

illness have mainly focused on the perceptions of loss of family members. Many of these studies

have used qualitative approaches to uncover the experience of the family coping with the mental

illness of a loved one (e.g., Jones, 2004; Ryan, 1993). For example, Ryan (1993) was interested

in examining the experiences of mothers of individuals with schizophrenia. For this study, five

mothers were interviewed about their experiences. From these narratives, an overarching theme

“a lifetime of mothering” was identified comprised of the domains “disruption” and “loss.”

“Disruption” referred to the experiences of these mothers 1) as illness disrupting their

relationships with their child and 2) as illness disrupting their own lives. The domain of “loss”

derived from these accounts comprised of 1) “loss of the child’s potential to lead a normal life”

and 2) “loss of freedom in the mother’s life.”

 35

Ryan (1993) highlighted the importance of understanding loss due to mental illness from

the parent’s perspective. However, it has been argued by Stein and Wemmerus (2001) that

omitting individuals with serious mental illness from family studies may reinforce the notion that

the ill member is not a meaningful family member. In response to such general omission of

individuals with serious mental illness from family studies in the literature, Stein and Wemmerus

(2001) used a life course perspective to examine the personal accounts of individuals with

schizophrenia, their parents, and well-siblings from six families. For this study, twenty-two

individuals were interviewed separately about their experiences related to an ill family member’s

decline and diagnosis, their beliefs about schizophrenia, the impact of the illness, their views on

mental health, and general aspects of family life. From these narratives came the overarching

theme of “loss of a normal life” from the perspectives of the individual with schizophrenia and

the family members. These narratives also revealed that despite the overarching sense of loss

experienced by family members, these families were “doing things” to help them cope with the

loss. Overall, this study reinforces that although families experience loss due to mental illness,

they also take steps towards making accommodations for the family, thus making life more

meaningful (Stein & Wemmerus, 2001).

Personal Loss and the Present Study

Although it is important to understand how families are coping with the loss of the

mental illness of a loved one, little research has explored how individuals with serious mental

illness experience their illness. For the present study, personal loss was assessed from the

perspective of the individual with serious mental illness. Therefore, the Personal Loss due to

Mental Illness Scale (PLMI) was chosen for inclusion in this study. The PLMI is a newly

developed scale which assesses the perceptions of loss due to having a mental illness. The PLMI

was developed by Stein and colleagues (2005) to reflect the personal, relationship, and
 36

psychosocial losses reflected in the literature, ultimately yielding a 20-item scale. Factor analysis

(Stein et al., 2005) has revealed four distinct factors: “Loss of Roles and Routines,” “Loss of

Former Relationships,” “Loss of Former Self,” and “Loss of Future.” Additionally, the PLMI

has demonstrated adequate psychometric properties. Briefly, it showed convergent validity with

measures of loneliness, psychiatric symptoms, and alcoholism and divergent validity with

personal growth and positive well-being (see Stein et al., 2005 for full discussion of

psychometric properties).

A review of the literature revealed three published studies of personal loss due to mental

illness to date. Research in this area has shown personal loss due to mental illness to be related

to aspirations and strivings for college (Stein, 2005) and religious-coping and meaning making

(Phillips & Stein, 2007). For example, Stein (2005) was interested in examining the factors

associated with the pursuit of higher education in a sample of 80 adults with serious mental

illness. For this study participants were assessed regarding their views about starting or returning

to college (using Views about College Questionnaire), personal loss (using PLMI), and

demographics. Results suggest that individuals who reported fewer aspirations for college also

reported a significantly greater sense of personal Loss of Roles and Routines and Loss of Former

Self. Greater personal Loss of Roles and Routines, greater Loss of Former Self, and greater loss

of a sense of the future were also significantly related to reports of less positive emotional and

intellectual capacity for college. Additionally, personal loss was found to account for a

significant portion of the variance in college aspirations and plans, above and beyond

demographics and hospitalizations (Stein, 2005).

In summary, studies have shown that individuals with serious mental illness do

experience personal loss as a result of their illness. Further studies of the PLMI are needed to

understand how individuals perceive their illness as well as what factors are related to
 37

perceptions of loss. A better understanding of how the mentally ill experience loss has

implications for therapeutic interventions and policy within the mental health field. Specifically

of importance are questions such as how does personal loss impact overall functioning, quality of

life, and recovery.

 38

CHAPTER IV: SUMMARY & CRITIQUE

The concept of “recovery” from serious mental illness was originally promoted by the

consumer movement in the 1980’s (Andresen et al., 2003). Since that time it has grown

nationally with support from many local, state, and federal agencies as an accepted model of

treatment of serious mental illness. Current research suggests that approximately 50% of

individuals with serious mental illness show signs of partial or full recovery from symptoms

(Whitehorn et al., 2002).

Although recovery has been embraced by public mental health, there is still disagreement

regarding the definition and measurement of recovery. Two theoretical camps have emerged

which view recovery as either an objective outcome or a subjective attitude and process.

However, much of the previous research on recovery has examined objective outcomes as a

measure of recovery (i.e. reduction in psychiatric symptoms) without considering the perspective

of the individual with serious mental illness. More research is needed that empirically examines

how individuals’ perceptions of recovery relate to other aspect of illness, personal factors, and

overall functioning.

The concept of quality of life was initially introduced in the mental health field in the

1970’s as a way to better understand the lives of individuals with serious mental illness. The

push for deinstitutionalization and more community support for individuals with serious mental

illness has propelled the field to strongly consider the quality of life of individuals with serious

mental illness. Moreover, the development of atypical antipsychotic medications continued to

drive this force, with quality of life being used as an outcome measure in many studies on these

medications (Lambert & Naber, 2004; Lehman, 1988). This shift has also allowed for more

consumer input in program evaluations and treatment. However, as with the field of recovery,

researchers who study quality of life are split in terms of how to operationalize and measure
 39

quality of life, examining either subjective ratings or objective indicators of quality of life. As

with recovery, it is important to understand the experience of the individual and how he/she

perceives the quality of his/her life. However, it is also important to understand how objective

indicators of quality of life (i.e., finances, amount of contacts with others) relate to subjective

perceptions of quality of life. Further research which examines both the objective and subjective

components of quality of life are needed to help advance our understanding of the construct of

quality of life as well as how individuals with serious mental illness perceive their lives.

The concept of “insight” has been examined related to factors such as psychiatric

symptoms and quality of life. However, “cognitive insight”, as defined by Beck and colleagues

(2004) is a fairly new concept in the field. Cognitive insight refers to the ability to self-reflect,

acknowledge the possibility of being mistaken, to be open to feedback, and to refrain from over-

confidence. Cognitive insight has been shown to be impaired in individuals with serious mental

illness (Beck et al., 2004; Warman, Lysaker & Martin, 2007). However, little is know about the

relationship of cognitive insight to individuals’ perceptions of recovery, quality of life, or

personal loss.

The study of personal loss has grown considerably over the past decade, examining the

multitude of ways people react to different types of loss. More recently, the impact of serious

mental illness on individuals has been examined empirically. The study of personal loss related

to serious mental illness to date has largely focused on experiences of family members.

Although important, there has been a recent push in the field (Stein & Wemmerus, 2001; Stein et

al., 2005) to understand how individuals with serious mental illness perceive their illness. How

people view themselves in response to serious mental illness has powerful implications for

treatment planning, program development and individual empowerment. Further research which
 40

examines how personal loss is related to multiple domains is needed to broaden our

understanding of the experience of living with serious mental illness.

Issues related to quality of life and recovery from mental illness are the hallmarks of the

recovery movement in public mental health (Bellack, 2006; Lambert & Naber, 2004; Liberman

& Kopelowicz, 2002; President’s New Freedom Commission, 2003). Yet, few empirical studies

examine the multiple factors which may impact perceptions of recovery and quality of life for

individuals living with serious mental illness. Such research is a necessary first step in the

development of more comprehensive therapeutic interventions which address the needs of this

population. The present research examined the role of demographic, symptom severity, and

individual factors in describing adults’ perceptions of the quality of their lives and the status of

their recovery from mental illness.

The Present Study

The goal of the present research was to understand the relative contribution of

demographic factors, self-reports of psychiatric symptoms, and individual factors of cognitive

insight and personal loss in describing variation in adults’ reports of quality of life and recovery

from mental illness. The relationship between adults’ perceptions of their recovery from mental

illness and their quality of life was also examined. It was hypothesized that individual factors of

cognitive insight and perceptions of personal loss due to mental illness will statistically predict

variations in quality of life and recovery from mental illness over and above that of demographic

factors and symptom severity.

 41

CHAPTER V: METHODS

Recruitment of Participants

Participants were recruited from the Minneapolis Veteran’s Affairs Medical Center

through referrals from psychiatry and mental health, recruiting flyers placed in the waiting area

of the Mental Health Clinic (Appendix A), and from a large multi-year study of individuals with

serious mental illness (Appendix B). A total of 332 people were contacted about possible

participation in the study via letter and/or telephone. Of this group, 72 individuals agreed to

participate; a response rate of 22%. Potential participants were screened either by review of their

medical records or interview to exclude for the following: (a) current substance abuse or

dependence, (b) history of traumatic brain injury, stroke, dementia, or other neurological illness.

One individual dropped out of the study after enrolling and six individuals were ruled out due to

current substance abuse/dependence, yielding 65 individuals who completed the study.

Participant Characteristics

Participants were 65 veterans (54 males and 11 females) diagnosed with DSM-IV-TR

(American Psychiatric Association, 2000) schizophrenia (52%), schizoaffective disorder (34%),

or bipolar disorder (14%). Participants had a mean age of 51 years (SD = 9.81, Range =28-69)

and a mean educational attainment of 14 years (SD = 1.8, Range = 11-19). In general, the sample

was Caucasian (86%), currently unemployed (65%), on disability (95%), living independently

(74%), with 2-5 lifetime psychiatric hospitalizations (43%) and single, never married (49%). The

mean annual income for the sample is $29,641 (SD = $19,240.96, Range =$480 - $108,000),

with the majority of participants (34%) falling in the annual income bracket of $10,000-$20,000.

Participants had a mean length of treatment of 240 months (SD = 140.40, Range = 4-

480). Respondents participated in a total of 9 different treatment services including case

management (98%), medication management (95%), intensive case management (12%),

 42

individual psychotherapy (75%), supportive group psychotherapy (49%), skills-based group

psychotherapy (20%), recreational therapy (11%), psychoeducational groups (28%) and partial

hospitalization (31%). Tables 1 and 2 contain a summary of the demographic and clinical

characteristics for participants.

In terms of medication, the mean number of medications currently taken was 2.74 (SD =

1.31, Range = 0-6). In this sample, 92% were currently taking antipsychotics, 49% currently

taking antidepressants, 31% currently taking anxiolytics, 39% currently taking mood stabilizers,

28% currently taking hypnotics, and 19% currently taking antiparkinsonians (for extrapyramidal

side-effects of antipsychotics). Of those taking antipsychotics, 86% were taking an atypical

antipsychotic, 11% were taking a typical antipsychotic, and 5% were taking both typical and

atypical antipsychotics. A majority of participants were taking 3 different medications (37%) and

taking medication from 3 different classes of drugs (39%). Table 3 contains a summary of the

medication characteristics for participants.

Procedure

The present study received full board approval by the Human Subjects Review Board at

Bowling Green State University and the Institutional Review Board at the Minneapolis Veteran’s

Affairs Medical Center (VAMC). Once individuals identified themselves as interested in study

participation, and met study criteria, they were scheduled to meet with the researcher. Upon

entering the study, each participant was asked to provide written consent after reading through a

detailed consent form and research authorization form, and each participant was provided with a

copy of their signed forms (Appendix C & D). Once consent was given participants completed

four questionnaires and underwent two brief structured interviews. The average time

commitment per participant was approximately 2 hours. Each participant was given $5 for

his/her participation in the study.

 43

Measures

Participants completed questionnaires on demographics, recovery, personal loss due to

mental illness, and insight. Individuals were administered two structured interviews; one

interview regarding psychiatric symptoms and the other regarding quality of life. The researcher

completed 10 hours of training to administer the Brief Psychiatric Rating Scale and did achieve

adequate inter-rater reliability with gold standard prior to data collection (ICC =.95). See

Appendix K for the specific items which load on each subscale for each measure described

below.

Beck Cognitive Insight Scale (Appendix E; BCIS; Beck, Baruch, Balter, Steer, &

Warman, 2004.) The BCIS is a 15-item instrument designed to measure cognitive insight. The

items on this scale load on two distinct subscales: 9-item Self-Reflectiveness subscale and 6-item

Self-Certainty subscale. The Self-Reflectiveness scale includes items relevant to objectivity,

reflectiveness, and openness to feedback. The Self-Certainty scale includes items related to

jumping to conclusions, certainty about being right, and resistance to correction. It has been

speculated by Beck et al. (2004) that over-confidence may serve to impair Self-Reflectiveness,

therefore the Composite Index, the measure of the person’s overall cognitive insight, is

determined by subtracting the individual’s Self-Certainty score from his/her Self-Reflectiveness

score. Participants rated each item on a 4-point Likert scale ranging from 0 (do not agree at all)

to 3 (agree completely). Psychometric evaluations have reported adequate internal consistency

(ranging from α =.60 to α = .68) and adequate convergent validity with being aware of having a

mental disorder on Scale to Assess Unawareness of Mental Disorders (r = -.62 p<.05) and Self-

Reflectiveness subscale with being aware of delusions on Scale to Assess Unawareness of

Mental Disorders (r = -.67, p<.05); Beck, Baruch, Balter, Steer, & Warman, 2004). The present
 44

study demonstrated adequate internal consistency on Self-Reflectiveness subscale (α = .74) and

the Self-Certainty subscale (α = .69).

Brief Psychiatric Rating Scale, Expanded Version (Appendix F; BPRS; Lukoff,

Nuechterlein & Ventura, 1986). The Expanded BPRS is a 24-item structured interview designed

to measure psychiatric symptomology. For each item, the individual was rated on a 7-point scale

based on the severity of the symptom (from not present to extremely severe). Specific factors for

consideration in this study incorporated the factor structure identified by Ventura et al., (2000)

for the Expanded BPRS. This structure incorporates symptom factors of Manic-Excitement,

Negative Symptoms, Positive Symptoms, and Depression-Anxiety. In addition to subscales, a

total score may be calculated and used as a measure of overall symptom severity. This total

symptom score was used in the present study as a predictor variable in regression analyses.

Psychometric evaluations have reported adequate internal consistency (ranging from α =.49 to α

= .81; Burger et al., 1997 and from α =.48 to α = .79; Velligan et al., 2005) and acceptable

reliability estimates (ranging from r = .71 to .78; Velligan et al., 2005). The present study also

demonstrated adequate internal consistency (α = .71).

Demographics (Appendix G). All participants completed a demographics questionnaire

as part of the study. This questionnaire contained questions concerning participant age, ethnicity,

marital status, mental health diagnosis, mental health treatment involvement, psychiatric

hospitalizations, and living arrangements. Additionally, medical records were checked for

diagnostic accuracy. Disability status, whether a participant is receiving either SSDI or service

connection payments from the VA, was assessed as part of the Quality of Life Interview.

Personal Loss from Mental Illness Scale (Appendix H; PLMI; Stein, Dworsky, Phillips,

& Hunt, 2005). The PLMI is a 20-item instrument designed to measure experience of personal

loss due to serious mental illness. The items on this scale load on four distinct subscales: loss of
 45

roles and routine, Loss of Former Relationships, Loss of Former Self, and Loss of Future due to

mental illness. In addition to subscales, a total score was calculated and used as a measure of

overall personal loss. For each item, participants rated each statement on a 5-point Likert scale

ranging from 1 (strongly disagree) to 5 (strongly agree). Psychometric evaluations have reported

adequate internal consistency (ranging from α = .68 to α = .98) and acceptable test-retest

reliability (overall r = .75; Stein, Dworsky, Phillips, & Hunt, 2005). The present study also

demonstrated adequate internal consistency (α = .76).

Quality of Life Interview – Brief Version (Appendix I; QOLI -Brief; Lehman, 1988). The

QOLI- Brief is an interview designed to measure life circumstances of individuals with serious

mental illness. It consists of two global measure of life satisfaction (General Life Satisfaction,

GLS and Global Rating of Quality of Life, GR) and measures of objective and subjective quality

of life in the eight life domains: living situation, daily activities & functioning, family relations,

social relations, finances, work, legal & safety issues, and health. For each life domain objective

measures of quality of life are obtained first followed by information regarding the subjective

degree of satisfaction with one's life. This measure yields both objective and subjective

indicators of quality of life for each of the life domains, except health which does not have an

objective component. For this study, five single scores of objective quality of life and eight

subjective quality of life composite scores were used. For most items on the QOLI, participants

rated each statement on a 7-point Likert scale ranging from 1 (terrible) to 7 (delighted). Other

items required participants to select an answer or answer yes or no questions. Psychometric

evaluations of the QOLI have reported generally adequate internal consistency (ranging from α

=.44 to α = .88) and test-retest reliabilities ranging from r = .28 to r = .98 (Lehman, 1996). This

measure has also shown good construct and predictive validity (Lehman, Ward, & Linn, 1982).
 46

The present study also demonstrated adequate internal consistency (ranging from α = .75 to α =

.96 on subscales of QOLI).

Recovery Assessment Scale (Appendix J; RAS; Giffort, Schmook, Woody, Vollendorf, &

Gervain, 1995). The RAS is a 41-item instrument designed to measure recovery from mental

illness. For each item, participants rated each statement on a 5-point Likert scale ranging from 1

(strongly disagree) to 5 (strongly agree). Sample items include, “I understand how to control the

symptoms of my mental illness,” “I can handle it if I get sick again,” and “I have a desire to

succeed.” The items on this scale load on five distinct subscales: personal confidence and hope,

willingness to ask for help, goal and success orientation, Reliance on Others, and No Domination

by Symptoms (Corrigan et al., 2004). In addition to subscales, a total score may be calculated

and used as a measure of overall recovery. In the present study, the overall recovery score was

used as a criterion variable in regression analyses. Psychometric evaluations have reported good

internal consistency (α = .93) and acceptable short term test-retest reliability (r = .88) and

concurrent validity with Rosenberg Self-Esteem scale (.55), Empowerment scale, self-orientation

(-.71), Social Support Questionnaire (SSQ) size of support network (.48), Brief Psychiatric

Rating Scale (-.44), and Quality of Life scale (.62); Corrigan, Giffort, Rashid, Leary, & Okeke,

1999). The present study also demonstrated adequate internal consistency (α = .94).
 47

CHAPTER VI: RESULTS

Analytic Procedures

The first step of the statistical analyses was to calculate descriptive statistics for all

demographic, predictor, and criterion variables. Next, the relationships between demographic

variables and criterion measures were analyzed. Bivariate Pearson correlational analyses were

conducted for continuous variables and ANOVA procedures (one-way ANOVA or independent

sample t-test as appropriate) for relationships when demographic variables were categorical.

Additionally, intercorrelations of all measures were calculated to identify potential

multicollinearity. Finally, separate hierarchical multiple regression equations were run for each

predictor category and each criterion measure. These regression equations were constructed in

four blocks. Demographic variables were entered into the first block of the equation and

psychiatric symptoms in the second block of the equation. The final predictors, cognitive insight

and personal loss were entered in for blocks 3 and 4. Since there is not sufficient research to

suggest which factor (cognitive insight or personal loss) should be entered first into the

regression, the order of the cognitive insight and personal loss blocks was reversed in separate

regression equations in order to determine whether their relative contribution differs when order

of entry is reversed, to test for suppressor effects. Variables accounting for significant variance in

the criterion variable were identified. Whenever the first block was significant, standardized beta

weights were examined for statistical significance to determine which predictor was accounting

for the unique variance in that block.

Descriptives

Participants were asked to report on their psychiatric symptoms, cognitive insight,

personal loss due to mental illness, quality of life across multiple domains, and recovery from

mental illness. Descriptive statistics, including means, standard deviations and ranges, were
 48

calculated for all scales and are displayed in entirety in Appendix L. Table 4 presents the

descriptives for the major scores from each scale.

Cognitive Insight. Current levels of cognitive insight were measured by the Beck

Cognitive Insight Scale (BCIS). Descriptive statistics for the BCIS are presented in Appendix L.

Comparison of scores from the present study with normative data is used to place present results

in a larger context. In the initial study using the Beck Cognitive Insight Scale with a sample of

32 adults with schizophrenia and 43 adults with schizoaffective disorder, Beck and colleagues

(2004) reported mean scores for the Beck Cognitive Insight Scale for each diagnostic group. For

individuals with schizophrenia they reported the following scores: Self-Reflectiveness (M=

12.97; SD= 5.00), Self-Certainty (M= 7.94; SD= 3.78), and Composite Index (Self-

Reflectiveness – Self-Certainty) (M = 5.03; SD = 5.76). For individuals with schizoaffective

disorder they reported the following scores: Self-Reflectiveness (M= 13.26; SD= 4.70), Self-

Certainty (M= 6.53; SD= 3.45), and Composite Index (Self-Reflectiveness – Self-Certainty) (M =

6.63; SD = 5.78). These results suggest that Beck and colleagues’ (2004) sample did not differ

from the sample in the present study on any scores of cognitive insight, regardless of diagnosis.

Comparison with adults with schizophrenia yielded the following results: Self-Reflectiveness,

t(95) = 0.92, p =.36 n/s, Self-Certainty , t(95) = 1.80, p =.08 n/s, Composite Index , t(95) = 1.68,

p =.10 n/s. Comparison with adults with schizoaffective disorder yielded the following results:

Self-Reflectiveness, t(106) = 0.73, p =.47 n/s, Self-Certainty , t(106) = 0.01, p =.99 n/s,

Composite Index , t(106) = 0.62, p =.54 n/s.

Personal Loss. Current levels of personal loss were measured by the Personal Loss due to

Mental Illness Scale (PLMI). Descriptive statistics for the PLMI are presented in Appendix L.

Comparison of scores from the present study with normative data is used to place present results

in a larger context. In the initial study using the Personal Loss due to Mental Illness Scale with a
 49

sample of 158 adults with serious mental illness, Stein and colleagues (2005) reported mean

scores for the Personal Loss due to Mental Illness Scales as follows: Loss of Roles and Routine

(M= 3.2; SD= 0.89), Loss of Former Relationships (M= 3.1; SD= 0.94), Loss of Former Self (M=

3.6; SD= 1.0), Loss of Future (M= 3.4; SD= 0.80), and Overall Loss (M= 3.3; SD=0.67). These

results suggest that compared to the sample in the present study, Stein and colleagues’ (2005)

sample showed significantly higher levels of perceived Loss of Roles and Routines, t(221) =

3.22, p < .01, Loss of Future, t(221) = 2.39, p < .05, and Overall Loss t(221) = 3.15, p < .01.

However, there were no significant differences found between samples regarding Loss of Former

Relationships, t(221) = 0.99, p = .32 n/s or Loss of Former Self, t(221) = 1.58, p =.12 n/s.

Quality of Life. Objective and subjective indicators of quality of life were measured by

the Quality of Life Interview – Brief Version (QOLI). Descriptive statistics for the QOLI are

presented in Appendix L. Comparison of scores from the present study with normative data is

used to place present results in a larger context. Although normative data was not published in

the initial study using the Quality of Life Interview (QOLI), in a later study using the QOLI with

a sample of 1208 adults with schizophrenia living in Germany (N=618), France (N=288), and the

United Kingdom (N=302), Marwaha and colleagues (2008) reported mean scores for subjective

quality of life as follows: satisfaction with Living Situation (M= 5.0; SD= 1.3), Daily Activities

(M= 4.7; SD= 1.2), Family Relations (M= 4.8; SD= 1.5), Social Relations (M= 4.9; SD= 1.2),

Finances (M= 4.2; SD= 1.6), Employment (M= 5.0; SD= 1.2), Legal and Safety (M= 4.9; SD=

1.3), Health (M= 4.5; SD= 1.3), and Life in General (M= 4.6; SD= 1.3). These results suggest

that Marwaha and colleagues’ (2008) sample did not differ from the sample in the present study

on any subjective ratings of quality of life, across all domains; Living Situation, t(1271) = 0.12,

p =.90 n/s, Daily Activities t(1271) = 0.26, p =.79 n/s, Family Relations t(1271) = 0.63, p = .53

n/s, Social Relations t(1271) = 0.92, p =.36 n/s, Finances t(1271) = 1.08, p =.28 n/s,
 50

Employment, t(1271) = 0.26, p =.79 n/s, Legal and Safety t(1271) = 1.57, p =.12 n/s, Health

t(1271) = 0.73, p =.47 n/s, and Life in General, t(1271) = 0.12, p =.90 n/s.

Recovery. Recovery from mental illness was measured by the Recovery Assessment

Scale (RAS). Descriptive statistics for the RAS are presented in Appendix L. Comparison of

scores from the present study with normative data is used to place present results in a larger

context. Although normative data was not published in the initial study using the Recovery

Assessment Scale (RAS), in a later study using the RAS with a sample of 176 adults with serious

mental illness, Corrigan and Phelan (2004) reported mean scores for the RAS as follows:

Personal Confidence and Hope (M= 33.2; SD= 6.1), Willingness to Ask for Help (M= 11.8; SD=

2.4), Goal and Success Orientation (M= 19.6; SD= 3.4), Reliance on Others (M= 15.8; SD= 2.7),

and No Domination by Symptoms (M= 9.9; SD=2.8). They did not report mean scores for

Overall Recovery. These results suggest that Corrigan and Phelan’s (2004) sample did not differ

from the sample in the present study on any scores of recovery, across all subscales; Personal

Confidence and Hope , t(239) = 0.83, p =.41 n/s, Willingness to Ask for Help , t(239) = 0.67, p

=.51 n/s, Goal and Success Orientation , t(239) = 0.39, p =.70 n/s, Reliance on Others, t(239) =

0.50, p =.62 n/s, and No Domination by Symptoms, t(239) = 0.65, p =.52 n/s.

Analysis of Variance Procedures

Independent sample t-tests and ANOVAs were calculated to assess the relationships of

categorical demographic variables with criterion and predictor variables. Appendices M and N

provide a summary of all significant t-test and ANOVA findings, respectively. Significant t-test

and ANOVA findings relevant to demographics and criterion variables examined in this study

are discussed below.

Demographic Differences in Participants’ Reports of Recovery. A series of independent t

tests were used to examine mean differences in recovery as a function of demographic

 51

characteristics. Gender, ethnicity (Caucasian, non-Caucasian), and disability status (Disability,

No Disability), and employment status served as independent variables and the five RAS

subscales and the overall recovery score from the RAS served as dependent variables. Results

yielded a significant main effect for disability and No Domination by Symptoms recovery

subscale, t(63) = -2.10, p < .05. The average No Domination by Symptoms score was different

depending on disability status; on average, those on disability reported significantly higher

scores on No Domination by Symptoms (disability, M = 3.45, SD = 0.99; no disability, M =

2.22, SD = 1.07).

A series of one-way ANOVAs were used to examine mean differences in recovery as a

function of demographic characteristics. Number of hospitalizations, diagnosis, marital status,

and living arrangements served as independent variables and the five RAS subscales and the

overall recovery score served as dependent variables. There were no significant findings from these

analyses.

Demographic Differences in Participants’ Reports of Quality of Life. A series of

independent t- tests were used to examine mean differences in quality of life as a function of

demographic characteristics. Gender, ethnicity (Caucasian, non-Caucasian), disability status

(Disabilty, No Disability), and Employment Status served as independent variables and the eight

subjective QOLI subscales, each of the five objective indicator scores of QOLI, the General Life

Satisfaction score, and the Global Rating of Quality of Life served as dependent variables.

Results yielded a significant main effect for disability and six facets of quality of life. A

significant main effect was found for disability and satisfaction with Living Situation subscale,

t(63) = -2.18, p < .05. The average satisfaction with Living Situation score was different

depending on disability status; on average, those on disability reported significantly higher

satisfaction with their Living Situation (disability, M = 5.10, SD = 1.29; no disability, M = 3.44,
 52

SD = 1.17). A significant main effect was also found for disability and satisfaction with Daily

Activities subscale, t(63) = -2.02, p < .05. The average satisfaction with Daily Activities score

was different depending on disability status; on average, those on disability reported significantly

higher satisfaction with their Daily Activities (disability, M = 4.80, SD = 1.01; no disability, M

= 3.58, SD = 1.29). Results also yielded a significant main effect for disability and satisfaction

with Finances subscale, t(63) = -2.09, p < .05. The average satisfaction with Finances score was

different depending on disability status; on average, those on disability reported significantly

higher satisfaction with their Finances (disability, M = 4.51, SD = 1.57; no disability, M = 2.56,

SD = 1.89). A significant main effect was also found for disability and General Life Satisfaction,

t(63) = -2.12, p < .05. The average General Life Satisfaction score was different depending on

disability status; on average, those on disability reported significantly higher General Life

Satisfaction (disability, M = 4.69, SD = 1.34; no disability, M = 3.00, SD = 1.73). Results also

yielded a significant main effect for disability and Financial Adequacy, t(63) = -3.48, p < .001.

The average Financial Adequacy score was different depending on disability status; on average,

those on disability reported significantly higher Financial Adequacy (disability, M = 0.90, SD =

0.18; no disability, M = 0.12, SD = 0.53). Finally, a significant main effect was also found for

disability and Global Rating of quality of life, t(63) = -2.45, p < .05. The average Global Rating

of quality of life score was different depending on disability status; on average, those on

disability reported significantly higher Global Rating of quality of life (disability, M = 4.87, SD

= 1.27; no disability, M = 3.00, SD = 1.73).

A series of one-way ANOVAs were used to examine mean differences in quality of life

as a function of demographic characteristics. Number of hospitalizations, diagnosis, marital

status, and living arrangements served as independent variables and the eight subjective QOLI

subscales, each of the five objective indicator scores of QOLI, the General Life Satisfaction
 53

score, and the Global Rating of Quality of Life served as dependent variables. Results indicated a

significant main effect for diagnosis and four facets of quality of life. A significant main effect

was found for diagnosis and satisfaction with Legal and Safety, F (2, 62) = 3.43, p < .05. Follow

up Tukey HSD post-hoc testing indicated that, on average individuals with Bipolar Disorder (M=

5.96; SD= 0.86) reported significantly higher satisfaction with Legal and Safety than individuals

with Schizoaffective Disorder (M= 4.68; SD= 1.63; p < .05). Results also indicated a main effect

was found for diagnosis and General Life Satisfaction, F (2, 62) = 5.03, p < .01. Follow up

Tukey HSD post-hoc testing indicated that, on average individuals with Schizophrenia (M= 5.09;

SD= 1.29) reported significantly higher General Life Satisfaction than individuals with Bipolar

Disorder (M= 3.78; SD= 1.56; p < .05) and individuals with Schizophrenia (M= 5.09; SD= 1.29)

reported significantly higher General Life Satisfaction than individuals with Schizoaffective

Disorder (M= 4.23; SD= 1.23; p < .05). A significant main effect was also found for diagnosis

and number of Social Contacts, F (2, 62) = 3.26, p < .05. Follow up Tukey HSD post-hoc testing

indicated that on average, individuals with Schizoaffective Disorder (M= 3.38; SD= 0.68)

reported significantly more Social Contacts than individuals with Schizophrenia (M= 2.81; SD=

0.86; p < .05). Finally, results also yielded a significant main effect for diagnosis and Global

Rating of quality of life, F (2, 62) = 4.57, p < .05. Follow up Tukey HSD post-hoc testing

indicated that, on average individuals with Schizophrenia (M= 5.24; SD= 1.21) reported

significantly higher Global Rating of quality of life than individuals with Schizoaffective

Disorder (M= 4.23; SD= 1.15; p < .05).

ANOVA results also yielded a significant main effect for living arrangement and five

facets of quality of life. A significant main effect was found for living arrangement and

satisfaction with Family Relations, F (2, 62) = 3.85, p < .05. Follow up Tukey HSD post-hoc

testing indicated that, on average individuals living independently (M= 4.94; SD= 1.17) reported
 54

significantly higher satisfaction with Family Relations than individuals living semi-

independently (M= 3.75; SD= 1.65; p < .05). Results also suggested a main effect for living

arrangement and General Life Satisfaction, F (2, 62) = 6.24, p < .01. Follow up Tukey HSD

post-hoc testing indicated that, on average individuals living independently (M= 4.92; SD= 1.20)

reported significantly higher General Life Satisfaction than individuals living semi-

independently (M= 3.25; SD= 1.39; p < .01). A significant main effect was also found for living

arrangement and number of Daily Activities, F (2, 62) = 4.34, p < .05. Follow up Tukey HSD

post-hoc testing indicated that, on average individuals living independently (M= 5.15; SD= 1.49)

reported significantly more Daily Activities than individuals living semi-independently (M=

3.50; SD= 1.93; p < .05). Results also suggested a significant main effect for living arrangement

and number of Social Contacts, F (2, 62) = 4.46, p < .05. Follow up Tukey HSD post-hoc testing

indicated that, on average individuals living independently (M= 3.20; SD= 0.85) reported

significantly more Social Contacts than individuals in assisted living (M= 2.33; SD= 0.59; p <

.05). Finally, results also yielded a significant main effect for living arrangement and Global

Rating of quality of life, F (2, 62) = 4.80, p < .05. Follow up Tukey HSD post-hoc testing

indicated that, on average individuals living independently (M= 5.00; SD= 1.13) reported

significantly higher Global Rating of quality of life than individuals living semi-independently

(M= 3.50; SD= 1.41; p < .01).

Analyses also yielded significant findings between quality of life variables and marital

status; however, these analyses rarely led to significant post-hoc testing and were not determined

to be a significant factor to enter in subsequent analyses. Therefore, these findings will not be

reviewed here; for a review of these findings, see Appendices M and N. Based on the overall

analyses of recovery and quality of life criterion variables, diagnosis, disability status and living

arrangement were entered in regression analyses.

 55

Correlational Analyses

Pearson bivariate correlations were computed for all continuous variables and are

displayed in a correlation matrix in Appendix O. For intercorrelations of RAS and QOLI

subscales with overall measure scores see Appendix P. Correlations relevant to the demographic

and criterion variables examined in this study are discussed below.

Correlations of Recovery and Demographic Variables. For these analyses, age,

education, number of medications, number of categories of medications, number of

antipsychotics, number of antidepressants, number of Anxiolytics, number of mood stabilizers,

number of treatment services, and length of treatment were the demographic variables under

consideration. Age was found to be positively correlated with No Domination by Symptoms

subscale (r = .25, p < .05) and years of education was found to be negatively correlated with

Willingness to Ask for Help subscale (r = -.24, p < .05). There were no other significant

relationships found between demographics and recovery.

Correlations of Quality of Life and Demographic Variables. As with recovery, for these

analyses, age, education, number of medications, number of categories of medications, number

of antipsychotics, number of antidepressants, number of Anxiolytics, number of mood

stabilizers, number of treatment services, and length of treatment were the demographic variables

under consideration. The latter eight variables are thought to be a proxy for symptomology,

which is already being entered in the regression analyses. Although there were significant

relationships discovered, these findings will not be reviewed here; for a review of these findings,

see Appendix O. Age was found to be positively correlated with satisfaction with employment (r

= .46, p < .05). Based on these analyses, age and education (in addition to diagnosis, living

arrangement, and disability status) were entered in subsequent regression analyses.

 56

Hierarchical Regression Analyses

It was hypothesized that individual factors of cognitive insight and perceptions of

personal loss due to mental illness will statistically predict variations in quality of life and

recovery from mental illness over and above that of demographic factors and symptom severity.

Hierarchical regression analysis was used to examine the relative contribution of demographic

information, psychiatric symptoms, cognitive insight, and perceptions of personal loss in

accounting for variation in participants’ recovery and quality of life. A total of 21 separate

hierarchical regressions were conducted. Six regressions examined the prediction of various

aspects of recovery; each of the five subscales of the RAS and the overall recovery score on RAS

served as criterion variables for these regressions. Fifteen regressions examined the prediction of

various aspects of quality of life; each of the eight subjective QOLI subscales, each of the five

objective indicator scores of QOLI, the General Life Satisfaction score, and the Global Rating of

Quality of Life served as criterion variables for these regressions.

The predictor variables in each of the 21 separate regressions consisted of four blocks.

The first block included demographic factors of age, educational attainment, diagnosis, living

arrangements, and disability status. For the variables diagnosis, living arrangement, and

disability status dummy-coded variables were created. Diagnosis classified participants into one

of three groups (schizophrenia, schizoaffective disorder, bipolar disorder) and was dummy-coded

into two variables with schizophrenia (the largest group) serving as the reference group. Living

arrangements classified participants into one of three groups (independent, semi-independent,

assisted) and was dummy-coded into two variables with independent (the largest group) serving

as the reference group. Disability status classified participants into one of two groups (disability,

no disability) and was dummy-coded into one variable with disability (the largest group) serving

as the reference group. The second block included current psychiatric symptoms (total score
 57

from the Brief Psychiatric Rating Scale). As stated previously, two regression equations were

initially calculated for each criterion variable, reversing the order of blocks 3 and 4 to test for

suppression effects. There was no evidence of suppression found in these analyses. Therefore,

the third block included cognitive insight (composite score from the Beck Cognitive Insight

Scale) and the fourth block included perceptions of personal loss (overall loss score from the

Personal Loss due to Mental Illness Scale) in the final regression models. The results of these

analyses are presented below.

Predictors of Recovery

Predictors of Overall Recovery (RAS Total Score). In predicting variation in overall

recovery, R was significantly different from zero with all of the predictors in the equation, R =

.58, R2 = .34, F(10,54) = 2.76, p < .01. Block 1 demographic variables together did not account

for a significant portion of the variance in overall recovery (ΔR2 = .09; F(7,57) = .81, p = .59

n/s). The addition of block 2, psychiatric symptoms, did not account for a significant portion of

the variance in overall recovery (ΔR2 = .02; F(1,56) = .87, p = .36 n/s). The addition of block 3,

cognitive insight, also did not account for a significant portion of the variance in overall recovery

(ΔR2 = .01; F(1,55) = .48, p = .49 n/s). However, the inclusion of block 4, personal loss,

accounted for a significant portion of the variance in overall recovery over and above

demographics, symptoms, and cognitive insight (ΔR2 = .23; F(1,54) = 18.45, p < .001). See

Table 5 for complete results of this analysis.

Predictors of Personal Confidence and Hope(RAS subscale). The Personal Confidence

and Hope subscale assessed the degree to which individuals like themselves, have hope for the

future, and are able to handle stress. Results of regression analyses indicate that in predicting

variation in Personal Confidence and Hope, R was significantly different from zero with all of

the predictors in the equation, R = .65, R2 = .42, F(10,54) = 3.97, p < .001. Block 1 demographic
 58

variables together did not account for a significant portion of the variance in recovery factor

Personal Confidence and Hope(ΔR2 = .09; F(7,57) = .84, p = .56 n/s). The addition of block 2,

psychiatric symptoms, did not account for a significant portion of the variance in recovery factor

Personal Confidence and Hope(ΔR2 = .000; F(1,56) = .03, p = .86 n/s). The addition of block 3,

cognitive insight, also did not account for a significant portion of the variance in recovery factor

Personal Confidence and Hope(ΔR2 = .02; F(1,55) = 1.50, p = .23 n/s). However, the inclusion of

block 4, personal loss, accounted for a significant portion of the variance in recovery factor

Personal Confidence and Hope over and above demographics, symptoms, and cognitive insight

(ΔR2 = .31; F(1,54) = 28.68, p < .001). See Table 6 for complete results of this analysis.

Predictors of Willingness to Ask for Help (RAS subscale). The Willingness to Ask for

Help subscale assessed the degree to which individuals are seeking help from others. Results of

regression analyses indicate that in predicting variation in Willingness to Ask for Help, R was

not significantly different from zero with all of the predictors in the equation, R = .39, R2 = .15,

F(10,54) = .94, p = .50 n/s. See Table 7 for complete results of this analysis.

Predictors of Goal and Success Orientation (RAS subscale). The Goal and Success

Orientation subscale assessed the degree to which individuals have a desire to succeed and are

able to meet their goals. Results of regression analyses indicate that in predicting variation in

Goal and Success Orientation, R was not significantly different from zero with all of the

predictors in the equation, R = .33, R2 = .11, F(10,54) = .66, p = .75 n/s. See Table 8 for

complete results of this analysis.

Predictors of Reliance on Others (RAS subscale). The Reliance on Others subscale

assessed the degree to which individuals are able to rely on others, highlighting the importance

of other people in the process of recovery. Results of regression analyses indicate that in

predicting variation in Reliance on Others, R was significantly different from zero with all of the
 59

predictors in the equation, R = .53, R2 = .28, F(10,54) = 2.14, p < .01. Block 1 demographic

variables together did not account for a significant portion of the variance in recovery factor

Reliance on Others (ΔR2 = .04; F(7,57) = .34, p = .94 n/s). The addition of block 2, psychiatric

symptoms, did not account for a significant portion of the variance in recovery factor Reliance

on Others (ΔR2 = .05; F(1,56) = 3.00, p = .09 n/s). The addition of block 3, cognitive insight,

also did not account for a significant portion of the variance in recovery factor Reliance on

Others (ΔR2 = .06; F(1,55) = 3.80, p = .06 n/s). However, the inclusion of block 4, personal loss,

accounted for a significant portion of the variance in recovery factor Reliance on Others over and

above demographics, symptoms, and cognitive insight (ΔR2 = .14; F(1,54) = 10.31, p < .01). See

Table 9 for complete results of this analysis.

Predictors of No Domination by Symptoms (RAS subscale). The No Domination by

Symptoms subscale assessed the degree to which psychiatric symptoms are no longer the center

or focus of an individual’s life. Results of regression analyses indicate that in predicting variation

in No Domination by Symptoms, R was significantly different from zero with all of the

predictors in the equation, R = .58, R2 = .33, F(10,54) = 2.67, p < .01. Block 1 demographic

variables together did not account for a significant portion of the variance in recovery factor No

Domination by Symptoms (ΔR2 = .19; F(7,57) = 1.85, p = .10 n/s). The addition of block 2,

psychiatric symptoms, did not account for a significant portion of the variance in recovery factor

No Domination by Symptoms (ΔR2 = .04; F(1,56) = 2.48, p = .12 n/s). The addition of block 3,

cognitive insight, also did not account for a significant portion of the variance in recovery factor

No Domination by Symptoms (ΔR2 = .03; F(1,55) = 1.94, p = .17 n/s). However, the inclusion of

block 4, personal loss, accounted for a significant portion of the variance in recovery factor No

Domination by Symptoms over and above demographics, symptoms, and cognitive insight (ΔR2

= .08; F(1,54) = 6.80, p < .05). See Table 10 for complete results of this analysis.
 60

Predictors of Quality of Life

Predictors of General Life Satisfaction (QOLI score). The General Life Satisfaction

subscale assessed the degree to which individuals are satisfied with life overall. Results of

regression analyses indicate that in predicting variation in General Life Satisfaction, R was

significantly different from zero with all of the predictors in the equation, R = .66, R2 = .43,

F(10,54) = 4.08, p < .001. Block 1 demographic variables together did account for a significant

portion of the variance in General Life Satisfaction (ΔR2 = .31; F(7,57) = 3.67, p < .01). Of these

demographic variables, both dummy-coded diagnosis variables and one dummy-coded living

arrangement variable were significant predictors of General Life Satisfaction (β = -.27, p < .05; β

= -.31, p < .05; β = -.26, p < .05, respectively). The addition of block 2, psychiatric symptoms,

did not account for a significant portion of the variance in General Life Satisfaction (ΔR2 = .03;

F(1,56) = 2.70, p = .11 n/s). The addition of block 3, cognitive insight, also did not account for a

significant portion of the variance in General Life Satisfaction (ΔR2 = .01; F(1,55) = .81, p = .37

n/s). Finally, the inclusion of block 4, personal loss, accounted for a significant portion of the

variance in General Life Satisfaction over and above demographics, symptoms, and cognitive

insight (ΔR2 = .08; F(1,54) = 7.44, p < .01). See Table 11 for complete results of this analysis.

Predictors of Number of Daily Activities (QOLI score). The Number of Daily Activities

subscale is an objective indicator of quality of life, assessing the average amount of daily

activities an individual participated in during the past week. Results of regression analyses

indicate that in predicting variation in number of daily activities, R was not significantly different

from zero with all of the predictors in the equation, R = .46, R2 = .21, F(10,54) = 1.42, p = .20

n/s. See Table 12 for complete results of this analysis.

Predictors of Number of Family Contacts (QOLI score). The Number of Family Contacts

subscale is an objective indicator of quality of life, assessing the average amount of contacts with
 61

family members during the past year. Results of regression analyses indicate that in predicting

variation in number of family contacts, R was not significantly different from zero with all of the

predictors in the equation, R = .40, R2 = .16, F(10,54) = 1.00, p = .46 n/s. See Table 13 for

complete results of this analysis.

Predictors of Number of Social Contacts (QOLI score). The Number of Social Contacts

subscale is an objective indicator of quality of life, assessing the average amount of social

contacts with non-family members during the past year. Results of regression analyses indicate

that in predicting variation in number of social contacts, R was significantly different from zero

with all of the predictors in the equation, R = .58, R2 = .34, F(10,54) = 2.76, p < .01. Block 1

demographic variables together did account for a significant portion of the variance in number of

social contacts (ΔR2 = .22; F(7,57) = 2.26, p < .05). Of these demographic variables, one of the

dummy-coded diagnosis variables and one dummy-coded living arrangement variable were

significant predictors of number of social contacts in different directions (β = .28, p < .05; β = -

.29, p < .05, respectively). The addition of block 2, psychiatric symptoms, did not account for a

significant portion of the variance in number of social contacts (ΔR2 = .000; F(1,56) = .03, p =

.87 n/s). The addition of block 3, cognitive insight, also did not account for a significant portion

of the variance in number of social contacts (ΔR2 = .03; F(1,55) = 2.26, p = .14 n/s). Finally, the

inclusion of block 4, personal loss, accounted for a significant portion of the variance in number

of social contacts over and above demographics, symptoms, and cognitive insight (ΔR2 = .09;

F(1,54) = 7.30, p < .01). See Table 14 for complete results of this analysis.

Predictors of Financial Adequacy (QOLI score). The Financial Adequacy subscale is an

objective indicator of quality of life, assessing the percentile out of five costs that can be

adequately covered by available monthly finances. Results of regression analyses indicate that in

predicting variation in financial adequacy, R was significantly different from zero with all of the
 62

predictors in the equation, R = .52, R2 = .27, F(10,54) = 2.02, p < .05. Block 1 demographic

variables together did not account for a significant portion of the variance in financial adequacy

(ΔR2 = .19; F(7,57) = 1.86, p = .09 n/s). The addition of block 2, psychiatric symptoms, did not

account for a significant portion of the variance in financial adequacy (ΔR2 = .01; F(1,56) = .78,

p = .38 n/s). The addition of block 3, cognitive insight, did account for a significant portion of

the variance in financial adequacy over and above that of demographics and psychiatric

symptoms (ΔR2 = .06; F(1,55) = 4.69, p < .05). Finally, the inclusion of block 4, personal loss,

did not account for a significant portion of the variance in financial adequacy over and above

demographics, symptoms, and cognitive insight (ΔR2 = .01; F(1,54) = .90, p = .35 n/s). See Table

15 for complete results of this analysis.

Predictors of Spending Money (QOLI score). The Spending Money subscale is an

objective indicator of quality of life, it is a single score reflecting how much spending money an

individual has had in the past month. Results of regression analyses indicate that in predicting

variation in spending money, R was not significantly different from zero with all of the

predictors in the equation, R = .38, R2 = .14, F(10,48) = .80, p = .63 n/s. See Table 12 for

complete results of this analysis. See Table 16 for complete results of this analysis.

Predictors of Satisfaction with Living Situation (Subjective QOLI subscale). The Living

Situation subscale is a subjective measure of quality of life, assessing the degree to which

individuals were satisfied with their current living situation. Results of regression analyses

indicate that in predicting variation in satisfaction with Living Situation, R was significantly

different from zero with all of the predictors in the equation, R = .62, R2 = .39, F(10,54) = 3.41, p

< .01. Block 1 demographic variables together did not account for a significant portion of the

variance in satisfaction with Living Situation, (ΔR2 = .13; F(7,57) = 1.25, p = .29 n/s). The

addition of block 2, psychiatric symptoms, did account for a significant portion of the variance in
 63

satisfaction with Living Situation over and above demographics, (ΔR2 = .23; F(1,56) = 20.68, p <

.001). The addition of block 3, cognitive insight, did not account for a significant portion of the

variance in satisfaction with Living Situation, (ΔR2 = .01; F(1,55) = .97, p = .33 n/s). Finally, the

inclusion of block 4, personal loss, did not account for a significant portion of the variance in

satisfaction with Living Situation, over and above demographics, symptoms, and cognitive

insight (ΔR2 = .01; F(1,54) = .81, p = .37 n/s). See Table 17 for complete results of this analysis.

Predictors of Satisfaction with Daily Activities (Subjective QOLI subscale). The Daily

Activities subscale is a subjective measure of quality of life, assessing the degree to which

individuals were satisfied with their current daily activities. Results of regression analyses

indicate that in predicting variation in satisfaction with Daily Activities, R was significantly

different from zero with all of the predictors in the equation, R = .64, R2 = .41, F(10,54) = 3.70, p

< .001. Block 1 demographic variables together did not account for a significant portion of the

variance in satisfaction with Daily Activities (ΔR2 = .18; F(7,57) = 1.75, p = .12 n/s). The

addition of block 2, psychiatric symptoms, did account for a significant portion of the variance in

satisfaction with Daily Activities, over above that of demographics (ΔR2 = .08; F(1,56) = 5.79, p

< .05). The addition of block 3, cognitive insight, did not account for a significant portion of the

variance in satisfaction with Daily Activities (ΔR2 = .01; F(1,55) = .53, p = .47 n/s). Finally, the

inclusion of block 4, personal loss, accounted for a significant portion of the variance in

satisfaction with Daily Activities over and above demographics, symptoms, and cognitive insight

(ΔR2 = .15; F(1,54) = 13.23, p < .001). See Table 18 for complete results of this analysis.

Predictors of Satisfaction with Family Relations (Subjective QOLI subscale). The Family

Relations subscale is a subjective measure of quality of life, assessing the degree to which

individuals were satisfied with their current relationships with family. Results of regression

analyses indicate that in predicting variation in satisfaction with Family Relations, R was
 64

significantly different from zero with all of the predictors in the equation, R = .62, R2 = .38,

F(10,54) = 3.28, p < .01. Block 1 demographic variables together did not account for a

significant portion of the variance in satisfaction with Family Relations (ΔR2 = .14; F(7,57) =

1.33, p = .25 n/s). The addition of block 2, psychiatric symptoms, did account for a significant

portion of the variance in satisfaction with Family Relations over and above that of

demographics (ΔR2 = .06; F(1,56) = 4.41, p < .05). The addition of block 3, cognitive insight, did

not account for a significant portion of the variance in satisfaction with Family Relations (ΔR2 =

.02; F(1,55) = 1.05, p = .31 n/s). Finally, the inclusion of block 4, personal loss, accounted for a

significant portion of the variance in satisfaction with Family Relations over and above

demographics, symptoms, and cognitive insight (ΔR2 = .16; F(1,54) = 13.84, p < .001). See

Table 19 for complete results of this analysis.

Predictors of Satisfaction with Social Relations (Subjective QOLI subscale). The Social

Relations subscale is a subjective measure of quality of life, assessing the degree to which

individuals were satisfied with their current relationships with non-family members. Results of

regression analyses indicate that in predicting variation in satisfaction with social relations, R

was not significantly different from zero with all of the predictors in the equation, R = .42, R2 =

.17, F(10,54) = 1.12, p = .37 n/s. See Table 20 for complete results of this analysis.

Predictors of Satisfaction with Finances (Subjective QOLI subscale). The Finances

subscale is a subjective measure of quality of life, assessing the degree to which individuals were

satisfied with their current financial situation. Results of regression analyses indicate that in

predicting variation in satisfaction with finances, R was not significantly different from zero with

all of the predictors in the equation, R = .44, R2 = .19, F(10,54) = 1.30, p = .26 n/s. See Table 21

for complete results of this analysis.

 65

Predictors of Satisfaction with Employment (Subjective QOLI subscale). The

Employment subscale is a subjective measure of quality of life, assessing the degree to which

individuals were satisfied with their current jobs. Results of regression analyses indicate that in

predicting variation in satisfaction with employment, R was not significantly different from zero

with all of the predictors in the equation, R = .64, R2 = .41, F(9,13) = .98, p = .50 n/s. See Table

22 for complete results of this analysis.

Predictors of Satisfaction with Legal and Safety (Subjective QOLI subscale). The Legal

and Safety subscale is a subjective measure of quality of life, assessing the degree to which

individuals were satisfied with their perceived level of safety. Results of regression analyses

indicate that in predicting variation in satisfaction with Legal and Safety, R was significantly

different from zero with all of the predictors in the equation, R = .55, R2 = .30, F(10,54) = 2.30, p

< .05. Block 1 demographic variables together did not account for a significant portion of the

variance in satisfaction with Legal and Safety (ΔR2 = .12; F(7,57) = 1.13, p = .36 n/s). The

addition of block 2, psychiatric symptoms, did account for a significant portion of the variance in

satisfaction with Legal and Safety over and above demographics (ΔR2 = .12; F(1,56) = 8.75, p <

.01). The addition of block 3, cognitive insight, did not account for a significant portion of the

variance in satisfaction with Legal and Safety (ΔR2 = .01; F(1,55) = .38, p = .54 n/s). Finally, the

inclusion of block 4, personal loss, accounted for a significant portion of the variance in

satisfaction with Legal and Safety over and above demographics, symptoms, and cognitive

insight (ΔR2 = .05; F(1,54) = 4.07, p < .05). See Table 23 for complete results of this analysis.

Predictors of Satisfaction with Health (Subjective QOLI subscale). The Health subscale is

a subjective measure of quality of life, assessing the degree to which individuals were satisfied

with their current levels of physical and emotional health. Results of regression analyses indicate

that in predicting variation in satisfaction with Health, R was significantly different from zero
 66

with all of the predictors in the equation, R = .69, R2 = .48, F(10,54) = 4.95, p < .001. Block 1

demographic variables together did not account for a significant portion of the variance in

satisfaction with Health (ΔR2 = .14; F(7,57) = 1.38, p = .23 n/s). The addition of block 2,

psychiatric symptoms, did account for a significant portion of the variance in satisfaction with

Health over and above demographics (ΔR2 = .09; F(1,56) = 6.48, p <.05). The addition of block

3, cognitive insight, did not account for a significant portion of the variance in satisfaction with

Health (ΔR2 = .001; F(1,55) = .05, p = .82 n/s). Finally, the inclusion of block 4, personal loss,

accounted for a significant portion of the variance in satisfaction with Health over and above

demographics, symptoms, and cognitive insight (ΔR2 = .24; F(1,54) = 25.29, p < .001). See

Table 24 for complete results of this analysis.

Predictors of Global Rating of Quality of Life (QOLI score). The Global Rating subscale

is a subjective measure of quality of life, assessing the degree to which individuals rated their

satisfaction with their life in general. Results of regression analyses indicate that in predicting

variation in Global Rating of Quality of Life, R was significantly different from zero with all of

the predictors in the equation, R = .74, R2 = .55, F(10,54) = 6.49, p < .001. Block 1 demographic

variables together did account for a significant portion of the variance in Global Rating of

Quality of Life (ΔR2 = .29; F(7,57) = 3.33, p < .01). Of these demographic variables, one

dummy-coded diagnosis variable was a significant predictor of General Life Satisfaction (β = -

.35, p < .01).The addition of block 2, psychiatric symptoms, did not account for a significant

portion of the variance in Global Rating of Quality of Life (ΔR2 = .04; F(1,56) = 2.90, p = .09

n/s). The addition of block 3, cognitive insight, also did not account for a significant portion of

the variance in Global Rating of Quality of Life (ΔR2 = .01; F(1,55) = .58, p = .45 n/s). Finally,

the inclusion of block 4, personal loss, accounted for a significant portion of the variance in
 67

Global Rating of Quality of Life over and above demographics, symptoms, and cognitive insight

(ΔR2 = .21; F(1,54) = 25.40, p < .001). See Table 25 for complete results of this analysis.
 68

CHAPTER VII: DISCUSSION

The purpose of the present study was to investigate factors that may contribute to reports

of quality of life and recovery in a sample of 65 adults with serious mental illness. Specifically,

the relative contribution of demographics, symptom severity, cognitive insight, and personal loss

due to mental illness in accounting for variation in perceptions of quality of life and recovery

were examined. Additionally, the relationships between demographics, symptom severity,

cognitive insight, personal loss, quality of life, and recovery were investigated. Previous

research (e.g., Corrigan et al., 1999) has examined certain aspects of the relationships between

psychiatric symptomology, recovery, and quality of life but has yet to explore how cognitive

insight and personal loss relate to reports of recovery and quality of life. Moreover, much of the

prior research has focused on objective indicators of quality of life and recovery, with little

examination of how the subjective experiences of individuals relates to other relevant domains

(e.g., personal loss and/or cognitive insight).

Results indicate that personal loss was negatively related to reports of recovery, as

expected. Specifically, those who reported more overall loss also reported less Personal

Confidence and Hope, less Reliance on Others, more Domination by Symptoms, and less overall

recovery. Personal loss was also negatively related to perceptions of quality of life, as expected.

Specifically, those who reported more overall loss also reported lower General Life Satisfaction,

lower Global Rating of quality of life, less Social Contacts, and less satisfaction with Daily

Activities, Family Relations, Legal and Safety issues, and health. Moreover, personal loss

predicted a significant portion of variation in each of the aforementioned criterion variables.

Cognitive insight was positively related to reports of recovery and quality of life. Specifically,

individuals with more cognitive insight also reported more Reliance on Others, more satisfaction

with their Living Situation and more satisfaction with Social Relationships. Additionally, higher
 69

levels of recovery were associated with being older, having less education, being on disability,

and not taking mood stabilizers. Finally, better quality of life was associated with having a

diagnosis of schizophrenia, being on disability, living independently, taking less number of

medications, not taking antidepressants, and not taking anxiolytics.

The main goal of the present study was to examine the relative contribution of select

demographic and clinical variables (such as psychiatric symptoms, cognitive insight, and

personal loss) in accounting for variation in reports of quality of life and recovery from serious

mental illness. Regression results show that all thirteen of the significant models are accounting

for more than 25% of the variation in the criterion variable. The full model predicted 55% of the

variation in reports of Global Rating of quality of life, with diagnosis accounting for 29% of the

unique variation and personal loss accounting for an additional 21% of the variation over and

above all other variables in the model. Similarly, the full model predicted 43% of the variation in

reports of General Life Satisfaction, with diagnosis and living arrangement accounting for 31%

of the unique variation and personal loss accounting for an additional 8% of the variation over

and above all other variables in the model. In terms of overall recovery, the full model accounted

for 34% of the variation, with personal loss accounting for 23% of the unique variation in reports

of overall recovery from serious mental illness.

It was hypothesized that both cognitive insight and personal loss would account for a

significant portion of the variation in reports of recovery and quality of life over and above

demographics and symptom severity. This hypothesis was only partially supported. Across all

reports of recovery and quality of life, cognitive insight only predicted one objective indicator of

quality of life. Perceptions of personal loss due to mental illness, in contrast, explained

significant variation in reports of recovery, objective indicators of quality of life, and reports of
 70

subjective quality of life. The predictive relationships of these variables with reports of

recovery and quality of life will be discussed in more detail in the following sections.

Predictors of Adult’s Reports of Recovery from Serious Mental Illness

Demographics did not account for any unique variation in any aspect of reports of

recovery. This finding is consistent with previous research by Corrigan and colleagues (1999)

which also did not show any predictive power of demographics in explaining variation in reports

of overall recovery. However, Corrigan (2006) found that gender was predictive of reports of

Personal Confidence and Hope and Willingness to Ask for Help, race was predictive of Personal

Confidence and Hope and Goal and Success Orientation, and age was predictive of Goal and

Success Orientation. The disparate findings could be explained by the small sample size used in

the present study. Future studies using a larger, more diverse sample could help explain the

differential results regarding the role of demographics in explaining variation in reports of

recovery.

Similarly, psychiatric symptoms were not predictive of reports of recovery in the present

study. This finding contradicts the medical/disease model view of recovery, used by researchers

such as Liberman, Kopelowicz, Ventura and Gutkind (2002), which operationalizes “recovery”

as a reduction or elimination of symptomology. The discrepancy between findings regarding

symptoms and reports of recovery is interesting and further suggests the importance of relying on

individual reports of recovery rather than objective indicators such as symptomology.

Fortunately, the results of the present study suggest that individuals do experience recovery in

spite of their symptoms. This finding is refreshing, given that psychotic symptoms may never

remit for some individuals; living with serious mental illness does not necessarily mean doom

and loss of hope, regardless of symptomology. This finding is also consistent with the view of

recovery as a process where despite psychiatric symptoms individuals retain hope and drive
 71

towards life goals (Lysaker et al., 2006). Moreover, sharing this notion with individuals with

serious mental illness can lead to empower them, as they learn to live each day to the fullest in

spite of symptomology.

Comparable to the findings of demographics and symptom severity, cognitive insight also

did not explain significant variation in reports of recovery. However, it is noteworthy that,

although not significant, there was a trend towards cognitive insight explaining variation in

reports of Reliance on Others. It is possible that this non-significant finding is due to the small

sample size used in the present study. With a larger sample, if cognitive insight was shown to

predict variation in reports of Reliance on Others, this finding would make sense. If lower levels

of cognitive insight reflect more certainty in one’s own judgment, it would logically follow that

these individuals would be less likely to rely on others for help. Since there are no other studies

which assess the relationship between cognitive insight and recovery, it is difficult to put these

results in a larger context. Moreover, there are no existing studies which examine other

conceptualizations of “insight” in regard to subjective reports of recovery. Previous research on

cognitive insight suggests a strong relationship with cognitive insight and psychiatric

symptomology (e.g., Bora et al., 2007; Pedrelli et al., 2004). Given this relationship and the non-

significant findings of symptoms in predicting variation in reports of recovery, it is not surprising

that cognitive insight also did not demonstrate significant prediction in variation in reports of

recovery. Future research on the relationships between cognitive insight and reports of recovery

is needed to gain a better understanding not only of what “cognitive insight” is, but also how it

relates to more important outcome measures like recovery. Additionally, further research with a

larger sample is needed to investigate whether a predictive relationship exists between cognitive

insight and Reliance on Others, and what it might mean for the treatment of individuals with

serious mental illness.

 72

Personal loss due to mental illness, in contrast, accounted for a significant portion of the

variation in four aspects of recovery, including reports of overall recovery. Interestingly, there

were no significant predictive relationships found for two aspects of recovery: reports of

Willingness to Ask for Help or reports of Goal and Success Orientation. There is only one prior

study which examined factors which may predict variation in reports of subscale aspects of

recovery. Specifically, Corrigan (2006) found that whether an individual had engaged in peer

support predicted significant variation in their reports of Personal Confidence and Hope,

Willingness to Ask for Help, Goal and Success Orientation, and Reliance on Others. However,

engagement in peer support did not predict variation in reports of no domination by symptoms.

Unfortunately, there is no published discussion of the nuances of these subscale aspects

of recovery to aid in the interpretation of the current results. Items on the Willingness to Ask for

Help subscale reflect knowing when to ask for help and willingness to ask for help. The lack of

significant prediction of perceptions of personal loss in variation of Willingness to Ask for Help

indicates that in this sample, even when individuals are experiencing a great sense of loss they

are still willing to seek help. Similarly, items on the Goal and Success Orientation subscale

reflect a desire to succeed, having a purpose in life, and believing in one’s ability to achieve

personal goals. The lack of significant prediction of perceptions of personal loss in variation of

Goal and Success Orientation indicates that in this sample, even when individuals are

experiencing a great sense of loss they are still focused on generating and achieving life goals.

The results of the present study are in direct contrast to previous research by Stein (2005) which

showed that perceptions of loss did predict variation in reports of aspirations and plans for

college and perceived emotional and intellectual capacity for college in a sample of individuals

with serious mental illness. It could be suggested that aspirations and plans for college reflect

recovery orientation, and perhaps Goal and Success Orientation more specifically. Based on
 73

previous findings, it is therefore surprising that the present study did not demonstrate that

perceptions of personal loss are accounting for significant variation in reports of Goal and

Success Orientation. These non-significant findings, however, are refreshing, and may reflect

how the individuals in this sample have learned through recovery-oriented services that even

when they are feeling great loss due to their mental illness, they need to ask for help and can still

plan and achieve their goals. These findings may be particular to the individuals in the current

study, given their commitment to engaging in recovery services and recovery-oriented research

at the Minneapolis VA Medical Center. These disparate results speak to the need of continued

research with personal loss and recovery in order to determine whether this phenomenon is

replicated, or whether it may be due to the sample used in the present study. Future research

would benefit from studying individuals who are not engaged in recovery services to make direct

comparisons to the present study.

Predictors of Adult’s Reports of Quality of Life

Although not a main focus of the present study, an investigation of the relationships

between objective indicators and subjective ratings of quality of life is important to highlight to

add context to the regression findings regarding reports of quality of life. Correlational results

found that only one objective indicator of quality of life, number of Daily Activities, was related

to General Life Satisfaction and Global Rating of quality of life. Interestingly, number of Social

Contacts and Financial Adequacy were the only objective indicators related to satisfaction with

Family Relations; number of Family Contacts was not related to satisfaction with Family

Relations. Conversely, number of Social Contacts was the only objective indicator related to

satisfaction with Social Contacts. Moreover, both Financial Adequacy and Spending Money

were related to satisfaction with Finances. However, none of the objective indicators were

related to satisfaction with Daily Activities, satisfaction with Employment, satisfaction with
 74

Legal and Safety, or satisfaction with Health. These results are consistent with recent findings by

Narvaez and colleagues (2008) which also failed to show significant relationships between

objective and subjective quality of life scores using this measure. These findings are important

because they show that objective indicators are not necessarily related to subjective ratings of

quality of life within the same domain. These results suggest caution to researchers who are

using objective indicators as a measure of how individuals feel about their lives, and encourage

the examination of subjective and objective indicators of quality of life independently. Based

upon previous research, as well as the preliminary analyses of the present study, it is therefore

not surprising that differential patterns of prediction for objective and subjective reports of

quality of life were found in the present study.

Demographic factors accounted for unique variance in three of the regression models,

explaining more than 20% of the variance in number of Social Contacts and Global Rating of

quality of life and more than 30% of the variance in General Life Satisfaction. The predictive

demographics in the explaining variation in reports of quality of life in the present study were

diagnosis and living arrangement. Previous research by Marwaha and colleagues (2008) also

found living arrangement to be a significant predictor of subjective quality of life. However,

Chan and Yeung (2008) did not find type of living arrangement to be predictive of reports of

quality of life. Additionally, the findings regarding diagnosis in the present study are in contrast

to previous studies. Specifically, neither Marwaha and colleagues (2008) nor Narvaez and

colleagues (2008) found diagnosis to be a significant predictor of quality of life. The findings of

the present study add to the mixed picture of the role of demographics in quality of life and

suggest the need for continued examination of the relationship of these factors.

Additionally, psychiatric symptoms accounted for unique variance in five of the

regression models, explaining more than 10% of the variance in reports of satisfaction with
 75

Living Situation and satisfaction with Legal and Safety issues. Of note, psychiatric symptoms

were not predictive on any objective indicators of quality of life. These findings only partially

support previous research by Voruganti and colleagues (1998), which showed that overall

symptom severity is inversely related to both objective and subjective indicators of quality of

life. However, the findings of the present study are consistent with previous research by Eack

and colleagues (2007), which shows the differential role of symptoms in explaining objective

and subjective quality of life. Specifically, they found that while psychiatric symptomology was

not predictive of objective indicators of quality of life, psychiatric symptomology did

substantially predict subjective reports of quality of life, explaining 17% of unique variation in

subjective reports of quality of life. The differential findings regarding predictors of objective

and subjective quality of life reinforce the notion proposed by Lehman (1983) that these factors

do indeed measure different and complementary aspects of an individual’s life experiences.

Cognitive insight only accounted for variation in reported Financial Adequacy, an

objective indicator of quality of life, with no other predictive power in any other reports of

quality of life. However, it should be noted that since cognitive insight was not significantly

correlated with Financial Adequacy, the significant predictive relationship is likely a statistical

artifact and should not be interpreted as a true finding. The findings of the present study are in

contrast to previous research by Hasson-Ohayon and colleagues (2006) that showed higher levels

of insight into having a mental illness were associated with lower ratings of quality of life. It

should be noted, however, that Hasson-Ohayon and colleagues (2006) assess insight using a

different measure, and therefore may preclude direct comparison to the findings of the present

study. However, since general insight into having a mental illness has been shown to directly

relate to cognitive insight (e.g. Bora et al., 2007), some comparisons can be made. Regardless,

cognitive insight was not found to predict reports in quality of life. It is possible that significant
 76

predictive relationships between cognitive insight and reports of quality of life were not found

over and above demographics and symptoms because of the highly correlative relationship

between symptoms and insight. Moreover, it is likely that cognitive insight is simply an

extension of the underlying cognitive dysfunction of disorders such as schizophrenia, which

would be reflected in the psychiatric symptomology scores. For example, previous research has

consistently shown that cognitive insight is directly related to positive psychotic symptoms,

negative psychotic symptoms, and depressive symptoms (e.g., Beck et al., 2004; Bora et al.,

2007; Warman et al., 2007). Another possibility is there was insufficient power to detect the

hypothesized predictions. However, since personal loss was significantly predictive of reports of

recovery and quality of life in multiple domains, this suggests that power may not have

necessarily compromised this analysis. Further research on cognitive insight is needed to address

these issues and expand our knowledge of how insight may relate to personal factors such as

quality of life.

Personal loss due to mental illness, in contrast, accounted for a significant portion of the

variation in reports of General Life Satisfaction, Global Rating of quality of life, one objective

indicator of quality of life (number of Social Contacts), and four subjective indicators of quality

of life, over and above demographics, psychiatric symptomology, and cognitive insight.

However, there were no significant predictive relationships found for three objective indicators

of quality of life (number of Daily Activities, number of Family Contacts, and Spending Money),

or three subjective indicators of quality of life (satisfaction with Social Relations, satisfaction

with Finances, and satisfaction with Employment).

It is interesting to note that while perceptions of personal loss were predictive of number

of social contacts, it was not predictive of reports of satisfaction with social contacts. Moreover,

the opposite results were found regarding family; while perceptions of personal loss did not
 77

predict the number of family contacts, it did predict reports of satisfaction with family relations.

Unfortunately, most studies assess objective and subjective reports of quality of life as predictor

variables of global quality of life, rather than assessing these domains as separate criterion

variables. Therefore, this precludes direct comparison of the present study to previous research

to aid in the interpretation of these findings. Although not directly related to quality of life,

Corrigan and Phelan (2004) found that reports of recovery (as measured by the RAS) were

associated with the number of people in an individual’s friend and professional health networks

but not those in his/her family networks. A possible interpretation of these results from the

present study is that while individuals often do not have much control over how often they have

contact with their families, the opposite is true of social engagements. If an individual typically

sees members of his/her family weekly, it is likely that these meetings will occur regardless of

the amount of loss he/she is experiencing. Conversely, if an individual is experiencing more

personal loss due to having a mental illness, it is more likely that he/she would limit the

frequency of social contacts. Additionally, if an individual is only seeking social contacts when

their perceived loss is low, it would follow that loss would not be predictive of the satisfaction

with the social relationships, since perceptions of loss have already, in a sense, been controlled

for by the individual. Conversely, in regards to satisfaction with family relations, since it is

likely that an individual is not altering the frequency of family contact in conjunction with

perceptions of loss, it would make sense that increased feelings of loss would predict reports of

satisfaction with family relations, as interaction with family members may induce feelings of

shame and loss (Jones, 2004). Although causality cannot be implied from this cross-sectional

study, it is possible that spending time with family may trigger feelings of personal loss due to

mental illness. Further research in this area is needed to replicate these findings as well as help
 78

elucidate some of the relationships between personal interactions and perceptions of personal

loss.

As mentioned previously, the differential findings of personal loss in explaining objective

and subjective reports of quality of life is not surprising. Lehman (1983) also demonstrated

differential prediction of objective and subjective quality of life within the same domain. These

findings again emphasize the importance of assessing both objective and subjective reports of

quality of life to gain a better understanding of the multitude of factors which impact an

individual’s life.

Taken together, the results of the present study suggest that there is preliminary evidence

that perceptions of personal loss are predictive of reports of quality of life and overall recovery

from serious mental illness over and above demographics, psychiatric symptoms, and cognitive

insight. Moreover, perceptions of personal loss were found to be the most robust predictor of

reports of recovery and quality of life. The results of this study are a valuable addition to the

body of literature and have important implications for treatment and future research.

Clinical and Research Implications

The present study is the first to examine the relationships of cognitive insight and

personal loss with quality of life and recovery from mental illness. Since there is little existing

research exploring these constructs, the results suggest several important implications for clinical

practice and future research endeavors.

The primary implication of the results of this study is for clinical treatment of individuals

with serious mental illness. Given the highly predictive power of personal loss in explaining

recovery and quality of life, personal loss can be a point of intervention. This can be

accomplished by assessing levels of personal loss for all individuals receiving treatment, as part

of individual case management and treatment planning. Additionally, this can be accomplished
 79

through assessing dimensions of personal loss with intake materials when individuals first enter

treatment. Interventions for individuals who are reporting personal loss due to mental illness can

therefore be integrated into other treatment protocols, i.e. individual and group psychotherapy.

Decreasing the amount of personal loss an individual experiences due to his/her mental illness

could also lead to empowerment and destigmatization. It has been suggested by Corrigan (1998)

that teaching individuals to challenge their self-stigmatizing views, themes of which are

incorporated within personal loss due to mental illness items such as “I liked myself better before I

became mentally ill,” can lead to empowerment and increased recovery from serious mental

illness. Specifically, by focusing on ways to reduce personal loss experienced by these

individuals, we may also serve to increase recovery and quality of life.

Indeed, research will need to assess whether treating personal loss does impact recovery

and quality of life, as may be anticipated. This could be accomplished by measuring changes in

personal loss after an individual has engaged in recovery-oriented services which target

reduction in loss. Additionally, personal loss could be used as an outcome measure in a

treatment study or in a program evaluation capacity. Reduction in personal loss could prove to be

a powerful intervention that will not only reduce experiences of loss, but could also lead to

increased recovery and quality of life. In a clinical setting, after personal loss has been measured

and an intervention completed which acts to reduce levels of personal loss, personal loss would

be assessed again, followed by measures of recovery and quality of life. Additionally, this

intervention could also be tested as a roll-out study across multiple VA or community sites. By

extending this cross-sectional research to examine how treatment which reduces the perceptions

of loss at time one, influences recovery and quality of life at time two would add greatly to our

understanding of the factors which influence recovery and quality of life.

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It is also important that providers of mental health services subscribe to and believe in

recovery from serious mental illness to make an optimal impact on the lives of the individual

they treat. Unfortunately, studies have shown (e.g. Keane, 1990; Lyons & Ziviani, 1995) that

mental health providers do not necessarily believe in the notion of recovery, rather believing in

the notion of a poor prognosis of individuals with serious mental illness. This is potentially

dangerous, and may lead to individuals with serious mental illness not being offered the type of

recovery-oriented treatments which they deserve. Therefore, mental health providers are

encouraged to work with their clients to help them reduce their personal loss due to mental

illness and learn strategies to enhance their quality of life and sense of recovery, regardless of

their symptoms or the beliefs of the provider. Moreover, treatments should include more

opportunities for dealing with loss and meaning-making through writing narratives about illness

and recovery. It has been suggested that this type of approach is central to reducing

stigmatization and enhancing individual empowerment (Rappaport, 1995; Stein & Wemmerus,

2001). Many mental health systems, including the Veterans Administration, have already begun

to incorporate this approach into the treatment of individuals with serious mental illness through

Illness and Recovery Management and Psychosocial Rehabilitation programs. Further

longitudinal evaluation of these programs is needed to assess the effectiveness of these

interventions. Regardless, by decreasing stigmatization and increasing the empowerment of the

individual with serious mental illness, we can help these individuals to lead a meaningful life

despite the illness.

An additional area in need of further study is the relationship of cognitive insight and

recovery and quality of life. Although the present study did uncover some relationships between

these variables, it was not to the level that was expected. Is it possible that cognitive insight is

not related to these other factors, or were these factors not examined sufficiently? These
 81

questions require further attention. Once there is better understanding about the relationships

between cognitive insight, recovery, and quality of life, therapeutic interventions can be

designed.

Limitations of the Present Research

Although the present study has many important implications for future treatment and

research endeavors, there are several limitations that require consideration. First, this study was

limited to a small sample of veterans with schizophrenia, schizoaffective disorder or bipolar

disorder. The smaller sample size may have restricted some power to detect significant findings,

especially in the area of cognitive insight. Second, individuals with current substance abuse or

dependence were excluded from this study. Therefore, the results of this study cannot be

generalized to individuals with serious mental illness who are actively abusing or dependent on

substances. Third, the sample was recruited from a large research Veterans Affairs Medical

Center. This veteran sample possibly limits generalizability since these individuals, generally,

are very committed to their treatment, are involved in a variety of recovery-oriented treatment

services, are predominantly male, and all have some form of military training and experience.

Additionally, individuals who are willing to participate in research studies may not be a

generalizable sample; they may be higher functioning or more focused on recovery-oriented

services, and therefore may be very different than the average individual with serious mental

illness. Future research would benefit from the inclusion of a larger, more diverse, and gender

balanced sample to better understand the multitude of factors that may contribute to an

individuals’ quality of life and/or recovery from serious mental illness. Fourth, the data collected

was largely by participant self-report. It may be beneficial for future studies to also include input

from the participants’ mental health providers and more thorough behavioral observations of

participants to ensure the collection of richer data. Finally, the present study used a cross-
 82

sectional design, which does not allow for inferences on causal relationships between variables.

Future studies employing a variety of research methodologies (including longitudinal designs

and treatment-outcome studies) are needed to better understand the relationships between

symptoms, cognitive insight, personal loss, recovery, and quality of life. Despite these

limitations, the current study provides valuable information about how personal loss due to

mental illness may impact an individual’s quality of life and/or recovery from serious mental

illness.

In close, this study further strengthens the evidence base that quality of life and recovery

from serious mental illness are valuable constructs both to the research and treatment of

individuals with serious mental illness. With increased understanding the factors which impact

individual recovery, hopefully future treatments can further improve lifetime recovery rates over

the current 50% estimate (Whitehorn et al., 2002). Overall, the results of the present study

highlight the nuanced and complex nature of the factors which impact quality of life and

recovery from serious mental illness. Moreover, the main finding is the significant role that

personal loss plays in quality of life and recovery from serious mental illness. Although further

research is required to replicate present findings, the present study is a critical first step in a

systematic understanding of factors related to perceived quality of life and sense of recovery for

individuals coping with serious mental illness.

 83

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 99

APPENDIX A

FLYER FOR RECRUITMENT

RESEARCH STUDY ON MENTAL ILLNESS

• Do you have a diagnosis of Schizophrenia, Schizoaffective Disorder or

Bipolar Disorder?

• Would you like to talk to someone who cares about how your illness has
affected your life?

• Can you spare about 2 hours of your time?

• Would you like to earn $5 as a token of appreciation for participating in this

study?

IF SO ….

Please contact Danielle Potokar, Research Coordinator, at (612) 467-2805

if interested in participating in this research study.

• I am interested in learning how you understand and cope with your mental
illness.

• I will ask you to complete four questionnaires and talk with me briefly about
your experiences

*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*
This is a Minneapolis VAMC study, conducted at the VAMC under Dr.
Bridget Hegeman, as principal investigator. The purpose of the study is to
learn about how individuals with mental illness feel about their mental health
diagnosis and how they cope in their everyday lives.
 100

APPENDIX B

RECRUITMENT LETTER

DEPARTMENT OF VETERANS AFFAIRS

Medical Center
One Veterans Drive
Minneapolis, MN 55417

January 1, 2008 116A9

Dear _________________,
You are being invited to participate in a research study. I understand that you have been part of a
family study conducted by Dr. Scott Sponheim, a Clinical Psychologist, at the Minneapolis VA
Medical Center. Dr. Sponheim has given me your name as someone who might be interested in
participating in future research studies.

The study that I am conducting is about how certain individuals feel about their health conditions
and how they cope with their everyday lives.

The total time commitment is approximately 90 minutes. If you agree to participate, you will be
asked to complete four questionnaires and talk with me briefly about your experiences.
Additionally, you will receive $5 as a token of appreciation for participation in this study.

Please indicate below whether you wish to be contacted by study staff and return this letter in the
enclosed envelope:

 I am willing to be contacted to discuss my possible participation in the study. My

phone number and best times to reach me are ________________________________________

 Do not contact me to discuss possible participation in the study.

If you would prefer, you may contact me at (612) 467-2805 to discuss the study and see if you
would like to participate. If I do not answer, please leave a message and your call will be
returned as soon as possible. You may also call this number if you are not interested in being
contacted.

If for some reason I do not receive this letter or otherwise hear from you within 2 weeks, I will
try to contact you directly to discuss possible study participation. Thank you for your time.

Sincerely,

Danielle N. Potokar, M.A.

Research Coordinator/Health Science Specialist
Minneapolis VA Medical Center
 101

APPENDIX C

Department of Veterans Affairs VA RESEARCH CONSENT FORM

Protocol # 3921-A
Subject Name: ______________________________ Date __________________

Title of Study: Living with serious mental illness: The role of personal loss in recovery and
quality of life

Principal Investigator: Bridget Hegeman, Ph.D., L.P. VAMC: Minneapolis

INTRODUCTION
It is important that you read and understand the following explanation of the proposed research
study before you agree to participate. This consent form describes:
• The purpose,
• The description of the study,
• The benefits,
• The risks and/or discomforts,
• Steps taken to decrease or eliminate the risks and/or discomforts,
• Confidentiality and use of research results.
Whether you decide to participate or not, treatment at the VA for which you are eligible will not
be affected.

This consent form may contain words you do not understand. Please ask the study doctor
or the study staff to explain any words or information unclear to you.

PURPOSE OF THE STUDY

You are being asked to voluntarily participate in a research study to learn about how individuals
with mental illness feel about their mental health diagnosis and how they cope in their everyday
lives. You have been asked to participate in this study because you have a mental health
diagnosis of Schizophrenia, Schizoaffective Disorder, or Bipolar Disorder I. Your participation is
expected to last about 2 hours, and approximately 100 people will be in the study at this site.

DESCRIPTION OF STUDY
The following information describes what will happen while you participate in the study. You
will be asked to complete four questionnaires and participate in two brief structured interviews.
The questionnaires and interviews will ask you about your mental health diagnosis, your
symptoms, and how your symptoms and diagnosis affect your life. It will take you about 2 hours
to complete the questionnaires and interviews.

RISKS AND/OR DISCOMFORTS

It is possible that you may become bored or tired while completing the questionnaires and
interviews. Also, it is possible that you may feel uncomfortable discussing some private issues
during the interviews. However, you will be asked questions similar to those that your mental
health providers might ask you.
 102

BENEFITS
There are no direct benefits to you for participating in this study. However, the results of this
study will help us understand how people with serious mental illness cope and what may help or
hinder their recovery. These results may also aid in the development of new patient-centered
interventions for veterans like you.

COMPENSATION
You will be paid five dollars for your participation. You will receive payment at the time of
completing the study.

CONFIDENTIALITY AND USE OF RESEARCH RESULTS

The results of this study may be published or presented but your identity and records will not be
revealed unless required by Federal Law. A Federal Law allows the U.S. Food and Drug
Administration, Office for Human Research Protections, Government Accounting Office and
other Federal agencies, the Research and Development Committee and/or the Institutional
Review Board (IRB)/Human Studies Subcommittee of the VA Medical Center to review records.
Because of the need for these inspections, absolute confidentiality cannot be guaranteed.

COSTS TO YOU FOR PARTICIPATING

There is no cost to you for taking part in this study. All the study costs, including any
procedures related directly to the study, will be paid for by the VA Medical Center. There should
be no additional medical costs to you for taking part in this study.

MEDICAL CARE IF YOU ARE INJURED

In case you are injured from this research study, treatment will be available, including first aid,
emergency treatment and follow-up care, as needed, by the VA Medical Center. In the event you
cannot reach a VA facility, the VA will consider payment for necessary medical care for any
injury or illness directly related to your participation in this research study. If you receive this
type of medical care, you must contact the Research Investigator for this study. You can find
contact information in the section of this consent titled “Compensation for Any Injuries”.

COMPENSATION FOR ANY INJURIES

You have not released the VA Medical Center from liability by signing this form. This includes
but is not limited to: 1) free medical care other than as described in this consent form, 2)
payment of lost wages, or 3) compensation for pain and suffering. Compensation for those items
from the VA may be available under applicable Federal Law. You should immediately report
any injuries resulting from your participation in this study to Dr. Hegeman at (612) 467-4010
during the day and during the evenings or week-ends, by calling the VA operator at (612) 725-
2000 and ask to have the psychiatrist on call paged. Tell the operator you are in a research study.
(If you do not live in the metropolitan area, you may call the toll-free number: 1-866-414-5058.)

OTHER INFORMATION

It is possible, although not likely, that the study may be discontinued if you feel too distressed to
continue. If you feel you cannot continue with the study due to distress, please tell us. We will
contact your treatment provider to help you manage your distress. You will receive pro-rated
compensation for your participation in this event.
 103

RESEARCH SUBJECT'S RIGHTS: I have read or have had read to me all of the above.
___________________ has explained the study to me and answered all of my questions. I have
been told of the risks or discomforts and possible benefits of the study.

I understand that I do not have to take part in this study and my refusal to participate will
involve no penalty or loss of rights to which I am entitled. I may withdraw from this study
at any time without penalty or loss of VA or other benefits to which I am entitled.

The results of this study may be published but my identity and records will not be revealed
unless required by law.
In case I become distressed or have questions, I have been told I can call Dr. Hegeman at (612)
467-4010 during the day and the VA operator at (612) 725-2000 after hours and ask to have the
psychiatrist on call paged. I will tell the operator I am in a research study. (If I do not live in the
metropolitan area, I may call the toll-free number: 1-866-414-5058.)

If any medical problems occur in connection with this study the VA will provide emergency
care.

If I have any questions about the rights of a research subject, I understand that I may contact the
Patient Representative at (612) 725-2106

My questions have been answered and I voluntarily consent to participate in this study. By
signing this form, I have not given away any of my legal rights, which I have as a subject of this
research study. I will receive a signed copy of this consent form.

Subject's Signature Date/Time

___________________________________ _____________
Signature of Investigator Date/Time

______________________________________
Printed name of person obtaining consent if other
Than the investigator

________________________________ _____________
Signature of Person obtaining consent if other Date/Time
than the investigator

_____________
Witness to the Signature Date/Time
 104

APPENDIX D

Department of Veterans Affairs RESEARCH AUTHORIZATION FORM

Protocol # 3921-A
Subject Name: ______________________________ Date __________________

Title of Study: Living with serious mental illness: The role of personal loss in recovery and
quality of life

Principal Investigator: Bridget Hegeman, Ph.D., L.P. VAMC: Minneapolis

Authorization for Use and Disclosure of Protected Health Information

In
Research

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal privacy
law. This law prevents your health information from being used without your permission.
Health information that has your name or other unique facts that could reveal your identity is
known as Protected Health Information (PHI). PHI is collected in order to answer the research
question. The researcher is limited to collecting and disclosing only the information needed to
conduct the study.

Before any researcher can use or disclose your PHI in a research study s/he must have your
approval.

By signing this document, you will authorize the Veterans Health Administration (VHA) to
provide the investigators Dr. Bridget Hegeman and Danielle Potokar and their research team
with permission to use your PHI.

‘USE’ of PHI means the use of personal information identifying you would be limited to
within the Veterans Health Administration (VHA).

‘DISCLOSURE’ of PHI means the sharing of personal identifying information with non-
VHA research agencies and sponsors working on this study and government regulatory agencies,
as needed.

If my PHI is disclosed, a record of the disclosure will be kept in my medical record.\

My PHI that may be used (within the VHA) and disclosed (outside of the VHA) includes:
♦ Demographic information i.e. name, SSN#, date of birth, marital status, living
arrangement
♦ Mental health history, i.e. diagnosis, medications
♦ Mental health treatment history, i.e. psychiatric hospitalizations, therapy (individual
and/or groups), case management
 105

♦ The information that may be released includes information regarding the following
conditions:
__X___Drug Abuse
__X__Alcoholism or Alcohol Abuse

My above PHI will be used to conduct a research study that will:

investigate how individuals with mental illness feel about their mental health diagnosis and how
they cope in their everyday lives.

The research team may also need to disclose the information to others as part of the study
process. My above PHI will be used and shared with:
♦ Veterans Health Administration
♦ Dr. Hegeman’s research team
♦ Myself

I understand once my PHI has been used, my information may no longer be protected
under this authorization.

The VHA complies with the requirements of the Health Insurance Portability and Accountability
Act of 1996 and its privacy regulations and all other applicable laws that protect my privacy.
The researchers will protect my information according to these laws.

RESEARCH SUBJECTS’ RIGHTS: I have read or have had read to me all of the above. I
understand that I do not have to sign this authorization and my refusal will not affect my
treatment, or result in the loss of VA or other benefits to which I am entitled. If I do not sign
this authorization, I will not be able to participate in this study.

After signing this authorization, I can change my mind and not allow the researcher to use
my PHI:

♦ If I change my mind and revoke (take back) my authorization, I will not be allowed
to continue participating in the study.
♦ If I decide to take back my authorization I must give the researcher a letter telling her
of my decision. This letter should be sent to Danielle Potokar, 1 Veteran’s Drive
116A9, Veteran’s Affairs Medical Center, Minneapolis, MN 55417. This letter will
be given to the Release of Information Office and included in my medical chart.
♦ If I revoke this authorization, the researchers may only use the PHI that was collected
before my written notice was received by the Release of Information Office.

This authorization expires at the end of the research study. If a research database or
research repository is created as part of this research study, this authorization has no
expiration date.

The VHA Notice of Privacy Practices (a separate document) provides more information on
how my information is protected. I may request a copy of the Privacy Notice. If I have any
questions or concerns about my privacy rights, I should contact the VA’s Privacy Officer at
612-467-2121.
 106

My questions have been answered and I voluntarily authorize the use of my protected
health information as described in this form.

___________________________________ _______________________
Subject’s Signature SSN Date/Time

___________________________________ ______________________________
Signature of Investigator Date/Time Signature of Person obtaining
authorization if other than the
investigator

___________________________________
Signature of Witness

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to respond to, a collection of
information unless it displays a valid OMB number. We expect that the time expended by all individuals completing this form will
average 2 minutes. This includes the time to read the instructions, gather the necessary facts and fill out the form. The purpose of this
form is to specifically outline the circumstances under which we may disclose data.

The execution of this form does not authorize the release of information other than that specifically described. The information
requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information that you specify in accordance
with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164.5 U.S.C. 552a, and 38 U.S.C. 5701 and 7332.
Your disclosure of information requested on this form is voluntary. However if the information, including Social Security Number
(SSN) (the SSN will be used to locate records for release) is not furnished completely and accurately, Department of Veterans Affairs
will be unable to comply with the request.
 107

APPENDIX E

Beck Cognitive Insight Scale

Below is a list of sentences about how people think and feel. Please read each sentence in the list carefully.
Indicate how much you agree with each statement by circling the number in the corresponding space in the
column next to the statement. Do not Do not
Agree Agree Agree Agree write in
at all slightly a lot completely this area
R C
1. At times, I have misunderstood other people’s attitudes towards me. 0 1 2 3 ___

2. My interpretations of my experiences are definitely right. 0 1 2 3 ___

3. Other people can understand the cause of my unusual experiences better 0 1 2 3 ___
than I can.

4. I have jumped to conclusions too fast. 0 1 2 3 ___

5. Some of my experiences that have seemed very real may have been due to my 0 1 2 3
___
imagination.

6. Some of the ideas I was certain were true turned out to be false. 0 1 2 3
___

7. If something feels right, it means that it is 0 1 2 3 ___

8. Even though I feel strongly that I am right, I could be wrong. 0 1 2 3 ___

9. I know better than anyone else what my problems are. 0 1 2 3 ___

10. When people disagree with me, they are generally wrong. 0 1 2 3 ___

11. I cannot trust other people’s opinions about my experiences. 0 1 2 3 ___

12. If somebody points out that my beliefs are wrong, I am willing to consider it. 0 1 2 3
___

13. I can trust my own judgment at all 0 1 2 3 ___

14. There is often more than one possible explanation for why people act the way
0 1 2 3 ___
way they do.

15. My unusual experiences may be due to my being extremely upset or stressed.

0 1 2 3 ___

___ ___
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Beck Cognitive Insight Scale (BCIS) Scoring

Self-Reflectiveness factor: R = ___ Composite Index Score =

R – C = ___
1. have misunderstood
3. other more objective
4. jumped to conclusions
5. due to imagination
6. ideas were false
8. could be wrong
12. willing to consider
14. possible explanations
15. due to stress

Self-Certainty factor: C = ___

2. definitely right
7. feels right is right
9. know problems
10. people are wrong
11. cannot trust opinion
13. can trust own judgment
 109

APPENDIX F

BRIEF PSYCHIATRIC RATING SCALE (BPRS), Expanded Version (4.0)

Introduction
This section reproduces an interview schedule, symptom definitions, and specific anchor points
for rating symptoms on the BPRS. Clinicians intending to use the BPRS should also consult the
detailed guidelines for administration contained in the reference below.

Scale Items and Anchor Points

Rate items 1-14 on the basis of individual's self-report. Note items 7, 12 and 13 are also rated on
the basis of observed behavior. Items 15-24 are rated on the basis of observed behavior and
speech.

1. Somatic Concern
Degree of concern over present bodily health. Rate the degree to which physical health is
perceived as a problem by the individual, whether complaints have realistic bases or not. Somatic
delusions should be rated in the severe range with or without somatic concern. Note: be sure to
assess the degree of impairment due to somatic concerns only and not other symptoms, e.g.,
depression. In addition, if the individual rates 6 or 7 due to somatic delusions, then you must rate
Unusual Thought Content at least 4 or above.

2 Very mild Occasional somatic concerns that tend to be kept to self.

3 Mild Occasional somatic concerns that tend to be voiced to others (e.g., family, doctor).

4 Moderate Frequent expressions of somatic concern or exaggerations of existing ills OR some

preoccupation, but no impairment in functioning. Not delusional.

5 Moderately severe Frequent expressions of somatic concern or exaggerations of

existing ills OR some preoccupation and moderate impairment of functioning. Not
delusional.
6 Severe Preoccupation with somatic complaints with much impairment in functioning OR
somatic delusions without acting on them or disclosing to others.

7 Extremely severe Preoccupation with somatic complaints with severe impairment in

functioning OR somatic delusions that tend to be acted on or disclosed to others.

"Have you been concerned about your physical health?" "Have you had any physical illness or
seen a medical doctor lately? (What does your doctor say is wrong? How serious is it?)"

"Has anything changed regarding your appearance?"

"Has it interfered with your ability to perform your usual activities and/or work?"

"Did you ever feel that parts of your body had changed or stopped working?"
 110

[If individual reports any somatic concerns/delusions, ask the following]:

"How often are you concerned about [use individual's description]?"

"Have you expressed any of these concerns to others?"

2. Anxiety
Reported apprehension, tension, fear, panic or worry. Rate only the individual's statements - not
observed anxiety which is rated under Tension.

2 Very mild Reports some discomfort due to worry OR infrequent worries that occur more than
usual for most normal individuals.

3 Mild Worried frequently but can readily turn attention to other things.

4 Moderate Worried most of the time and cannot turn attention to other things easily but no
impairment in functioning OR occasional anxiety with autonomic accompaniment but no
impairment in functioning.

5 Moderately Severe Frequent, but not daily, periods of anxiety with autonomic accompaniment
OR some areas of functioning are disrupted by anxiety or worry.

6 Severe Anxiety with autonomic accompaniment daily but not persisting throughout the day
OR many areas of functioning are disrupted by anxiety or constant worry.

7 Extremely Severe Anxiety with autonomic accompaniment persisting throughout the day OR
most areas of functioning are disrupted by anxiety or constant worry.

"Have you been worried a lot during [mention time frame]? Have you been nervous or
apprehensive? (What do you worry about?)"

"Are you concerned about anything? How about finances or the future?"

"When you are feeling nervous, do your palms sweat or does your heart beat fast (or
shortness of breath, trembling, choking)?"

[If individual reports anxiety or autonomic accompaniment, ask the following]:

"How much of the time have you been [use individual's description]?"

"Has it interfered with your ability to perform your usual activities/work?"

3. Depression
Include sadness, unhappiness, anhedonia and preoccupation with depressing topics (can't attend
to TV or conversations due to depression), hopeless, loss of self-esteem (dissatisfied or disgusted
with self or feelings of worthlessness). Do not include vegetative symptoms, e.g., motor
retardation, early waking or the amotivation that accompanies the deficit syndrome.

2 Very mild Occasionally feels sad, unhappy or depressed.

 111

3 Mild Frequently feels sad or unhappy but can readily turn attention to other things.

4 Moderate Frequent periods of feeling very sad, unhappy, moderately depressed, but able to
function with extra effort.

5 Moderately Severe Frequent, but not daily, periods of deep depression OR some areas of
functioning are disrupted by depression.

6 Severe Deeply depressed daily but not persisting throughout the day OR many areas of
functioning are disrupted by depression.

7 Extremely Severe Deeply depressed daily OR most areas of functioning are disrupted by
depression.

"How has your mood been recently? Have you felt depressed (sad, down, unhappy, as if
you didn't care)?"

"Are you able to switch your attention to more pleasant topics when you want to?"

"Do you find that you have lost interest in or get less pleasure from things you used to
enjoy, like family, friends, hobbies, watching TV, eating?"

[If individual reports feelings of depression, ask the following]:

"How long do these feelings last?" "Has it interfered with your ability to perform your
usual activities?"

4. Suicidality
Expressed desire, intent, or actions to harm or kill self.

2 Very mild Occasional feelings of being tired of living. No overt suicidal thoughts.

3 Mild Occasional suicidal thoughts without intent or specific plan OR he/she feels they would
be better off dead.

4 Moderate Suicidal thoughts frequent without intent or plan.

5 Moderately Severe Many fantasies of suicide by various methods. May seriously consider
making an attempt with specific time and plan OR impulsive suicide attempt using non-lethal
method or in full view of potential saviors.

6 Severe Clearly wants to kill self. Searches for appropriate means and time, OR potentially
serious suicide attempt with individual knowledge of possible rescue.

7 Extremely Severe Specific suicidal plan and intent (e.g., "as soon as ________ I will
do it by doing X"), OR suicide attempt characterised by plan individual thought was lethal
or attempt in secluded environment.
 112

"Have you felt that lifewasn't worth living? Have you thought about harming or killing
yourself?”

“Have you felt tired of living or as though you would be better off dead? Have you ever felt like
ending it all?"

[If individual reports suicidal ideation, ask the following]:

"How often have you thought about [use individual's description]?"

"Did you (Do you) have a specific plan?"

5. Guilt
Overconcern or remorse for past behavior. Rate only individual's statements, do not infer guilt
feelings from depression, anxiety, or neurotic defenses. Note: if the individual rates 6 or 7 due to
delusions of guilt, then you must rate Unusual Thought Content at least 4 or above, depending on
level of preoccupation and impairment.

2 Very mild Concerned about having failed someone, or at something, but not preoccupied. Can
shift thoughts to other matters easily.

3 Mild Concerned about having failed someone, or at something, with some preoccupation.
Tends to voice guilt to others.

4 Moderate Disproportionate preoccupation with guilt, having done wrong, injured others by
doing or failing to do something, but can readily turn attention to other things.

5 Moderately Severe Preoccupation with guilt, having failed someone or at something, can turn
attention to other things, but only with great effort. Not delusional.

6 Severe Delusional guilt OR unreasonable self-reproach very out of proportion to

circumstances. Moderate preoccupation present.

7 Extremely Severe Delusional guilt OR unreasonable self-reproach grossly out of proportion to

circumstances. Individual is very preoccupied with guilt and is likely to disclose to others or act
on delusions.

"Is there anything you feel guilty about? Have you been thinking about past problems?"

"Do you tend to blame yourself for things that have happened?"

"Have you done anything you're still ashamed of?"

[If individual reports guilt/remorse/delusions, ask the following]:

"How often have you been thinking about [use individual's description]?"

"Have you disclosed your feelings of guilt to others?"

 113

6. Hostility
Animosity, contempt, belligerence, threats, arguments, tantrums, property destruction, fights, and
any other expression of hostile attitudes or actions. Do not infer hostility from neurotic defenses,
anxiety or somatic complaints. Do not include incidents of appropriate anger or obvious self-
defense.

2 Very mild Irritable or grumpy, but not overtly expressed.

3 Mild Argumentative or sarcastic.

4 Moderate Overtly angry on several occasions OR yelled at others excessively.

5 Moderately Severe Has threatened, slammed about or thrown things.

6 Severe Has assaulted others but with no harm likely, e.g., slapped or pushed, OR destroyed
property, e.g., knocked over furniture, broken windows.

7 Extremely Severe Has attacked others with definite possibility of harming them or with actual
harm, e.g., assault with hammer or weapon.

"How have you been getting along with people (family, co-workers, etc.)?"

"Have you been irritable or grumpy lately? (How do you show it? Do you keep it to yourself?"

"Were you ever so irritable that you would shout at people or start fights or arguments?

(Have you found yourself yelling at people you didn't know?)"

"Have you hit anyone recently?"

7. Elevated Mood
A pervasive, sustained and exaggerated feeling of well-being, cheerfulness, euphoria (implying a
pathological mood), optimism that is out of proportion to the circumstances. Do not infer elation
from increased activity or from grandiose statements alone.

2 Very mild Seems to be very happy, cheerful without much reason.

3 Mild Some unaccountable feelings of well-being that persist.

4 Moderate Reports excessive or unrealistic feelings of well-being, cheerfulness, confidence or

optimism inappropriate to circumstances, some of the time. May frequently joke, smile, be
giddy, or overly enthusiastic OR few instances of marked elevated mood with euphoria.

5 Moderately Severe Reports excessive or unrealistic feelings of well-being, confidence or

optimism inappropriate to circumstances, much of the time. May describe feeling `on
top of the world', `like everything is falling into place', or `better than ever before', OR several
instances of marked elevated mood with euphoria.
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6 Severe Reports many instances of marked elevated mood with euphoria OR mood definitely
elevated almost constantly throughout interview and inappropriate to content.

7 Extremely Severe Individual reports being elated or appears almost intoxicated, laughing,
joking, giggling, constantly euphoric, feeling invulnerable, all inappropriate to immediate
circumstances.

"Have you felt so good or high that other people thought that you were not your normal
self?" "Have you been feeling cheerful and `on top of the world' without any reason?"

[If individual reports elevated mood/euphoria, ask the following]:

"Did it seem like more than just feeling good?"

"How long did that last?"

8. Grandiosity
Exaggerated self-opinion, self-enhancing conviction of special abilities or powers or identity as
someone rich or famous. Rate only individual's statements about himself, not his/her demeanor.
Note: if the individual rates 6 or 7 due to grandiose delusions, you must rate Unusual Thought
Content at least 4 or above.

2 Very mild Feels great and denies obvious problems, but not unrealistic.

3 Mild Exaggerated self-opinion beyond abilities and training.

4 Moderate Inappropriate boastfulness, e.g., claims to be brilliant, insightful or gifted beyond

realistic proportions, but rarely self-discloses or acts on these inflated selfconcepts. Does not
claim that grandiose accomplishments have actually occurred.

5 Moderately Severe Same as 4 but often self-discloses and acts on these grandiose ideas. May
have doubts about the reality of the grandiose ideas. Not delusional.

6 Severe Delusional - claims to have special powers like ESP, to have millions of dollars,
invented new machines, worked at jobs when it is known that he/she was never employed in
these capacities, be Jesus Christ, or the Prime Minister. Individual may not be very preoccupied.

7 Extremely Severe Delusional - same as 6 but individual seems very preoccupied and
tends to disclose or act on grandiose delusions.

"Is there anything special about you? Do you have any special abilities or powers? Have
you thought that you might be somebody rich or famous?"

[If the individual reports any grandiose ideas/delusions, ask the following]:
"How often have you been thinking about [use individuals description]?”
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“Have you told anyone about what you have been thinking? Have you acted on any of these
ideas?"

9. Suspiciousness
Expressed or apparent belief that other persons have acted maliciously or with discriminatory
intent. Include persecution by supernatural or other non-human agencies (e.g., the devil). Note:
ratings of 3 or above should also be rated under Unusual Thought Content.

2 Very mild Seems on guard. Reluctant to respond to some `personal' questions. Reports being
overly self-conscious in public.

3 Mild Describes incidents in which others have harmed or wanted to harm him/her that sound
plausible. Individual feels as if others are watching, laughing or criticizing him/her in public, but
this occurs only occasionally or rarely. Little or no preoccupation.

4 Moderate Says other persons are talking about him/her maliciously, have negative intentions
or may harm him/her. Beyond the likelihood of plausibility, but not delusional. Incidents of
suspected persecution occur occasionally (less than once per week) with some preoccupation.

5 Moderately Severe Same as 4, but incidents occur frequently, such as more than once per
week. Individual is moderately preoccupied with ideas of persecution OR individual reports
persecutory delusions expressed with much doubt (e.g., partial delusion).

6 Severe Delusional - speaks of Mafia plots, the FBI or others poisoning his/her food,
persecution by supernatural forces.

7 Extremely Severe Same as 6, but the beliefs are bizarre or more preoccupying. Individual
tends to disclose or act on persecutory delusions.

"Do you ever feel uncomfortable in public? Does it seem as though others are watching
you? Are you concerned about anyone's intentions toward you? Is anyone going out of
their way to give you a hard time, or trying to hurt you? Do you feel in any danger?"

[If individual reports any persecutory ideas/delusions, ask the following]:

"How often have you been concerned that [use individual's description]? Have you told anyone
about these experiences?"

10. Hallucinations
Reports of perceptual experiences in the absence of relevant external stimuli. When rating degree
to which functioning is disrupted by hallucinations, include preoccupation with the content and
experience of the hallucinations, as well as functioning disrupted by acting out on the
hallucinatory content (e.g., engaging in deviant behavior due to command hallucinations).
Include thoughts aloud (`gedenkenlautwerden') or pseudohallucinations (e.g., hears a voice
inside head) if a voice quality is present.

2 Very mild While resting or going to sleep, sees visions, smells odors or hears voices, sounds,
or whispers in the absence of external stimulation, but no impairment in functioning.
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3 Mild While in a clear state of consciousness, hears a voice calling the individual's name,
experiences non-verbal auditory hallucinations (e.g., sounds or whispers), formless visual
hallucinations or has sensory experiences in the presence of a modality-relevant stimulus (e.g.,
visual illusions) infrequently (e.g., 1-2 times per week) and with no functional impairment.

4 Moderate Occasional verbal, visual, gustatory, olfactory or tactile hallucinations with no

functional impairment OR non-verbal auditory hallucinations/visual illusions more than
infrequently or with impairment.

5 Moderately Severe Experiences daily hallucinations OR some areas of functioning are

disrupted by hallucinations.

6 Severe Experiences verbal or visual hallucinations several times a day OR many areas of
functioning are disrupted by these hallucinations.

7 Extremely Severe Persistent verbal or visual hallucinations throughout the day OR most areas
of functioning are disrupted by these hallucinations.

"Do you ever seem to hear your name being called?"

"Have you heard any sounds or people talking to you or about you when there has been nobody
around?

[If hears voices]:

"What does the voice/voices say? Did it have a voice quality?"

"Do you ever have visions or see things that others do not see? What about smell odors that
others do not smell?"

[If the individual reports hallucinations, ask the following]:

"Have these experiences interfered with your ability to perform your usual activities/work? How
do you explain them? How often do they occur?"

11. Unusual thought content

Unusual, odd, strange, or bizarre thought content. Rate the degree of unusualness, not the degree
of disorganization of speech. Delusions are patently absurd, clearly false or bizarre ideas that are
expressed with full conviction. Consider the individual to have full conviction if he/she has acted
as though the delusional belief was true. Ideas of reference/persecution can be differentiated
from delusions in that ideas are expressed with much doubt and contain more elements of reality.
Include thought insertion, withdrawal and broadcast. Include grandiose, somatic and persecutory
delusions even if rated elsewhere. Note: if Somatic Concern, Guilt, Suspiciousness or
Grandiosity are rated 6 or 7 due to delusions, then Unusual Thought Content must be rated 4 or
above.
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2 Very mild Ideas of reference (people may stare or may laugh at him), ideas of persecution
(people may mistreat him). Unusual beliefs in psychic powers, spirits, UFOs, or unrealistic
beliefs in one's own abilities. Not strongly held. Some doubt.

3 Mild Same as 2, but degree of reality distortion is more severe as indicated by highly unusual
ideas or greater conviction. Content may be typical of delusions (even bizarre), but without full
conviction. The delusion does not seem to have fully formed, but is considered as one possible
explanation for an unusual experience.

4 Moderate Delusion present but no preoccupation or functional impairment. May be an

encapsulated delusion or a firmly endorsed absurd belief about past delusional circumstances.

5 Moderately Severe Full delusion(s) present with some preoccupation OR some areas of
functioning disrupted by delusional thinking.

6 Severe Full delusion(s) present with much preoccupation OR many areas of functioning are
disrupted by delusional thinking.

7 Extremely Severe Full delusion(s) present with almost total preoccupation OR most areas of
functioning disrupted by delusional thinking.

"Have you been receiving any special messages from people or from the way things are arranged
around you? Have you seen any references to yourself on TV or in the newspapers?"

"Can anyone read your mind?"

"Do you have a special relationship with God?"

"Is anything like electricity, X-rays, or radio waves affecting you?"

"Are thoughts put into your head that are not your own?"

"Have you felt that you were under the control of another person or force?"

[If individual reports any odd ideas/delusions, ask the following]:

"How often do you think about [use individual's description]?"

"Have you told anyone about these experiences? How do you explain the things that have been
happening [specify]?"

Rate items 12-13 on the basis of individual's self-report and observed behavior.

12. Bizarre behavior

Reports of behaviors which are odd, unusual, or psychotically criminal. Not limited to interview
period. Include inappropriate sexual behavior and inappropriate affect.
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2 Very mild Slightly odd or eccentric public behavior, e.g., occasionally giggles to self, fails to
make appropriate eye contact, that does not seem to attract the attention of others OR unusual
behavior conducted in private, e.g., innocuous rituals, that would not attract the attention of
others.

3 Mild Noticeably peculiar public behavior, e.g., inappropriately loud talking, makes
inappropriate eye contact, OR private behavior that occasionally, but not always, attracts the
attention of others, e.g., hoards food, conducts unusual rituals, wears gloves indoors.

4 Moderate Clearly bizarre behavior that attracts or would attract (if done privately) the
attention or concern of others, but with no corrective intervention necessary. Behavior occurs
occasionally, e.g., fixated staring into space for several minutes, talks back to voices once,
inappropriate giggling/laughter on 1-2 occasions, talking loudly to self.

5 Moderately Severe Clearly bizarre behavior that attracts or would attract (if done privately)
the attention of others or the authorities, e.g., fixated staring in a socially disruptive way,
frequent inappropriate giggling/laughter, occasionally responds to voices, or eats non-foods.

6 Severe Bizarre behavior that attracts attention of others and intervention by authorities, e.g.,
directing traffic, public nudity, staring into space for long periods, carrying on a conversation
with hallucinations, frequent inappropriate giggling/laughter.

7 Extremely Severe Serious crimes committed in a bizarre way that attract the attention of
others and the control of authorities, e.g., sets fires and stares at flames OR almost constant
bizarre behavior, e.g., inappropriate giggling/laughter, responds only to hallucinations and
cannot be engaged in interaction.

"Have you done anything that has attracted the attention of others?"

"Have you done anything that could have gotten you into trouble with the police?"

"Have you done anything that seemed unusual or disturbing to others?"

13. Self-neglect
Hygiene, appearance, or eating behavior below usual expectations, below socially acceptable
standards or lifethreatening.

2 Very mild Hygiene/appearance slightly below usual community standards, e.g., shirt out of
pants, buttons unbuttoned, shoe laces untied, but no social or medical consequences.

3 Mild Hygiene/appearance occasionally below usual community standards, e.g., irregular

bathing, clothing is stained, hair uncombed, occasionally skips an important meal. No social or
medical consequences.

4 Moderate Hygiene/appearance is noticeably below usual community standards, e.g., fails to

bathe or change clothes, clothing very soiled, hair unkempt, needs prompting, noticeable by
others OR irregular eating and drinking with minimal medical concerns and consequences.
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5 Moderately Severe Several areas of hygiene/appearance are below usual community standards
OR poor grooming draws criticism by others and requires regular prompting. Eating or hydration
are irregular and poor, causing some medical problems.

6 Severe Many areas of hygiene/appearance are below usual community standards, does not
always bathe or change clothes even if prompted. Poor grooming has caused social ostracism at
school/residence/work, or required intervention. Eating erratic and poor, may require medical
intervention.

7 Extremely Severe Most areas of hygiene/appearance/nutrition are extremely poor and easily
noticed as below usual community standards OR hygiene/appearance/nutrition require urgent
and immediate medical intervention.

"How has your grooming been lately? How often do you change your clothes? How often do you
take showers? Has anyone (parents/staff) complained about your grooming or dress? Do you eat
regular meals?"

14. Disorientation
Does not comprehend situations or communications, such as questions asked during the entire
BPRS interview. Confusion regarding person, place, or time. Do not rate if incorrect responses
are due to delusions.

2 Very mild Seems muddled or mildly confused 1-2 times during interview. Oriented to person,
place and time.

3 Mild Occasionally muddled or mildly confused 3-4 times during interview. Minor inaccuracies
in person, place, or time, e.g., date off by more than 2 days, or gives wrong division of hospital
or community centre.

4 Moderate Frequently confused during interview. Minor inaccuracies in person, place, or time
are noted, as in 3 above. In addition, may have difficulty remembering general information, e.g.,
name of Prime Minister.

5 Moderately Severe Markedly confused during interview, or to person, place, or time.

Significant inaccuracies are noted, e.g., date off by more than one week, or cannot give correct
name of hospital. Has difficulty remembering personal information, e.g., where he/she was born
or recognizing familiar people.

6 Severe Disoriented as to person, place, or time, e.g., cannot give correct month and year.
Disoriented in 2 out of 3 spheres.

7 Extremely Severe Grossly disoriented as to person, place, or time, e.g., cannot give name or
age. Disoriented in all three spheres.

"May I ask you some standard questions we ask everybody?"

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"How old are you? What is the date [allow 2 days]"

"What is this place called? What year were you born? Who is the President?"

Rate items 15-24 on the basis of observed behavior and speech.

15 Conceptual disorganization
Degree to which speech is confused, disconnected, vague or disorganized. Rate tangentiality,
circumstantiality, sudden topic shifts, incoherence, derailment, blocking, neologisms, and other
speech disorders. Do not rate content of speech.

2 Very mild Peculiar use of words or rambling but speech is comprehensible.

3 Mild Speech a bit hard to understand or make sense of due to tangentiality, circumstantiality,
or sudden topic shifts.

4 Moderate Speech difficult to understand due to tangentiality, circumstantiality, idiosyncratic

speech, or topic shifts on many occasions OR 1-2 instances of incoherent phrases.

5 Moderately Severe Speech difficult to understand due to circumstantiality, tangentiality,

neologisms, blocking or topic shifts most of the time, OR 3-5 instances of incoherent phrases.

6 Severe Speech is incomprehensible due to severe impairment most of the time. Many BPRS
items cannot be rated by self-report alone.

7 Extremely Severe Speech is incomprehensible throughout interview.

16. Blunted affect

Restricted range in emotional expressiveness of face, voice, and gestures. Marked indifference or
flatness even when discussing distressing topics. In the case of euphoric or dysphoric
individuals, rate Blunted Affect if a flat quality is also clearly present.

2 Very mild Emotional range is slightly subdued or reserved but displays appropriate facial
expressions and tone of voice that are within normal limits.

3 Mild Emotional range overall is diminished, subdued or reserved, without many spontaneous
and appropriate emotional responses. Voice tone is slightly monotonous.

4 Moderate Emotional range is noticeably diminished, individual doesn't show emotion, smile
or react to distressing topics except infrequently. Voice tone is monotonous or there is noticeable
decrease in spontaneous movements. Displays of emotion or gestures are usually followed by a
return to flattened affect.

5 Moderately Severe Emotional range very diminished, individual doesn't show emotion, smile,
or react to distressing topics except minimally, few gestures, facial expression does not change
very often. Voice tone is monotonous much of the time.
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6 Severe Very little emotional range or expression. Mechanical in speech and gestures most of
the time. Unchanging facial expression. Voice tone is monotonous most of the time.

7 Extremely Severe Virtually no emotional range or expressiveness, stiff movements. Voice

tone is monotonous all of the time.
Use the following probes at end of interview to assess emotional responsivity:

"Have you heard any good jokes lately? Would you like to hear a joke?"

17. Emotional withdrawal

Deficiency in individual's ability to relate emotionally during interview situation. Use your own
feeling as to the presence of an `invisible barrier' between individual and interviewer. Include
withdrawal apparently due to psychotic processes.

2 Very mild Lack of emotional involvement shown by occasional failure to make reciprocal
comments, appearing preoccupied, or smiling in a stilted manner, but spontaneously engages the
interviewer most of the time.

3 Mild Lack of emotional involvement shown by noticeable failure to make reciprocal

comments, appearing preoccupied, or lacking in warmth, but responds to interviewer when
approached.

4 Moderate Emotional contact not present much of the interview because individual does not
elaborate responses, fails to make eye contact, doesn't seem to care if interviewer is listening, or
may be preoccupied with psychotic material.

5 Moderately Severe Same as 4 but emotional contact not present most of the interview.

6 Severe Actively avoids emotional participation. Frequently unresponsive or responds with

yes/no answers (not solely due to persecutory delusions). Responds with only minimal affect.

7 Extremely Severe Consistently avoids emotional participation. Unresponsive or responds with

yes/no answers (not solely due to persecutory delusions). May leave during interview or just not
respond at all.

18. Motor retardation

Reduction in energy level evidenced by slowed movements and speech, reduced body tone,
decreased number of spontaneous body movements. Rate on the basis of observed behavior of
the individual only. Do not rate on the basis of individual's subjective impression of his own
energy level. Rate regardless of medication effects.

2 Very mild Slightly slowed or reduced movements or speech compared to most people.

3 Mild Noticeably slowed or reduced movements or speech compared to most people.

4 Moderate Large reduction or slowness in movements or speech.

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5 Moderately Severe Seldom moves or speaks spontaneously OR very mechanical or stiff

movements

6 Severe Does not move or speak unless prodded or urged.

7 Extremely Severe Frozen, catatonic.

19. Tension
Observable physical and motor manifestations of tension, `nervousness' and agitation. Self-
reported experiences of tension should be rated under the item on anxiety. Do not rate if
restlessness is solely akathisia, but do rate if akathisia is exacerbated by tension.

2 Very mild More fidgety than most but within normal range. A few transient signs of tension,
e.g., picking at fingernails, foot wagging, scratching scalp several times or finger tapping.

3 Mild Same as 2, but with more frequent or exaggerated signs of tension.

4 Moderate Many and frequent signs of motor tension with one or more signs sometimes
occurring simultaneously, e.g., wagging one's foot while wringing hands together. There are
times when no signs of tension are present.

5 Moderately Severe Many and frequent signs of motor tension with one or more signs often
occurring simultaneously. There are still rare times when no signs of tension are present.

6 Severe Same as 5, but signs of tension are continuous.

7 Extremely Severe Multiple motor manifestations of tension are continuously present, e.g.,
continuous pacing and hand wringing.

20. Uncooperativeness
Resistance and lack of willingness to co-operate with the interview. The uncooperativeness
might result from suspiciousness. Rate only uncooperativeness in relation to the interview, not
behaviors involving peers and relatives.

2 Very mild Shows non-verbal signs of reluctance, but does not complain or argue.

3 Mild Gripes or tries to avoid complying, but goes ahead without argument.

4 Moderate Verbally resists but eventually complies after questions are rephrased or repeated.

5 Moderately Severe Same as 4, but some information necessary for accurate ratings is
withheld.

6 Severe Refuses to co-operate with interview, but remains in interview situation.

7 Extremely Severe Same as 6, with active efforts to escape the interview

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21. Excitement
Heightened emotional tone or increased emotional reactivity to interviewer or topics being
discussed, as evidenced by increased intensity of facial expressions, voice tone, expressive
gestures or increase in speech quantity and speed.

2 Very mild Subtle and fleeting or questionable increase in emotional intensity. For example, at
times seems keyed-up or overly alert.

3 Mild Subtle but persistent increase in emotional intensity. For example, lively use of gestures
and variation in voice tone.

4 Moderate Definite but occasional increase in emotional intensity. For example, reacts to
interviewer or topics that are discussed with noticeable emotional intensity. Some pressured
speech.

5 Moderately Severe Definite and persistent increase in emotional intensity. For example, reacts
to many stimuli, whether relevant or not, with considerable emotional intensity. Frequent
pressured speech.

6 Severe Marked increase in emotional intensity. For example, reacts to most stimuli with
inappropriate emotional intensity. Has difficulty settling down or staying on task. Often restless,
impulsive, or speech is often pressured.

7 Extremely Severe Marked and persistent increase in emotional intensity. Reacts to all stimuli
with inappropriate intensity, impulsiveness. Cannot settle down or stay on task. Very restless and
impulsive most of the time. Constant pressured speech.

22. Distractibility
Degree to which observed sequences of speech and actions are interrupted by stimuli unrelated to
the interview. Distractibility is rated when the individual shows a change in the focus of attention
as characterised by a pause in speech or a marked shift in gaze. Individual's attention may be
drawn to noise in adjoining room, books on a shelf, interviewer's clothing, etc. Do not rate
circumstantiality, tangentiality or flight of ideas. Also, do not rate rumination with delusional
material. Rate even if the distracting stimulus cannot be identified.

2 Very mild Generally can focus on interviewer's questions with only 1 distraction or
inappropriate shift of attention of brief duration.

3 Mild Individual shifts focus of attention to matters unrelated to the interview 2-3 times.

4 Moderate Often responsive to irrelevant stimuli in the room, e.g., averts gaze from the
interviewer.

5 Moderately Severe Same as above, but now distractibility clearly interferes with the flow of
the interview.
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6 Severe Extremely difficult to conduct interview or pursue a topic due to preoccupation with
irrelevant stimuli.

7 Extremely Severe Impossible to conduct interview due to preoccupation with irrelevant

stimuli.

23. Motor hyperactivity

Increase in energy level evidenced in more frequent movement and/or rapid speech. Do not rate
if restlessness is due to akathisia.

2 Very mild Some restlessness, difficulty sitting still, lively facial expressions, or somewhat
talkative

3 Mild Occasionally very restless, definite increase in motor activity, lively gestures, 1-3 brief
instances of pressured speech.

4 Moderate Very restless, fidgety, excessive facial expressions, or non-productive and

repetitious motor movements. Much pressured speech, up to one-third of the interview.

5 Moderately Severe Frequently restless, fidgety. Many instances of excessive nonproductive

and repetitious motor movements. On the move most of the time. Frequent pressured speech,
difficult to interrupt. Rises on 1-2 occasions to pace.

6 Severe Excessive motor activity, restlessness, fidgety, loud tapping, noisy, etc., throughout
most of the interview. Speech can only be interrupted with much effort. Rises on 3-4 occasions
to pace.

7 Extremely Severe Constant excessive motor activity throughout entire interview, e.g.,
constant pacing, constant pressured speech with no pauses, individual can only be interrupted
briefly and only small amounts of relevant information can be obtained

24. Mannerisms and posturing

Unusual and bizarre behavior, stylised movements or acts, or any postures which are clearly
uncomfortable or inappropriate. Exclude obvious manifestations of medication side effects. Do
not include nervous mannerisms that are not odd or unusual.

2 Very mild Eccentric or odd mannerisms or activity that ordinary persons would have difficulty
explaining, e.g., grimacing, picking. Observed once for a brief period.

3 Mild Same as 2, but occurring on two occasions of brief duration.

4 Moderate Mannerisms or posturing, e.g., stylised movements or acts, rocking, nodding,

rubbing, or grimacing, observed on several occasions for brief periods or infrequently but very
odd. For example, uncomfortable posture maintained for 5 seconds more than twice.

5 Moderately Severe Same as 4, but occurring often, or several examples of very odd
mannerisms or posturing that are idiosyncratic to the individual.
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6 Severe Frequent stereotyped behavior, assumes and maintains uncomfortable or inappropriate

postures, intense rocking, smearing, strange rituals or fetal posturing. Individual can interact with
people and the environment for brief periods despite these behaviors.

7 Extremely Severe Same as 6, but individual cannot interact with people or the environment
due to these behaviors.
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Brief Psychiatric Rating Scale (BPRS) Scoring

Individual's name:
Date:
Rater's name:

INSTRUCTIONS
This form consists of 24 symptom constructs, each to be rated on a 7-point scale of severity ranging from
'not present' to 'extremely severe'. If a specific symptom is not rated, mark 'NA' (not assessed). Circle the
number headed by the term that best describes the patients present condition.

1 2 3 4 5 6 7

Not present Very Mild Mild Moderate Moderately Severe Extremely

Severe Severe

1. Somatic Concern NA 1 2 3 4 5 6 7
2. Anxiety NA 1 2 3 4 5 6 7
3. Depression NA 1 2 3 4 5 6 7
4. Suicidality NA 1 2 3 4 5 6 7
5. Guilt NA 1 2 3 4 5 6 7
6. Hostility NA 1 2 3 4 5 6 7
7. Elated mood NA 1 2 3 4 5 6 7
8. Grandiosity NA 1 2 3 4 5 6 7
9. Suspiciousness NA 1 2 3 4 5 6 7
10. Hallucinations NA 1 2 3 4 5 6 7
11. Unusual thought content NA 1 2 3 4 5 6 7
12. Bizarre behavior NA 1 2 3 4 5 6 7
13. Self-neglect NA 1 2 3 4 5 6 7
14. Disorientation NA 1 2 3 4 5 6 7
15. Conceptual disorganization NA 1 2 3 4 5 6 7
16. Blunted affect NA 1 2 3 4 5 6 7
17. Emotional withdrawal NA 1 2 3 4 5 6 7
18. Motor retardation NA 1 2 3 4 5 6 7
19. Tension NA 1 2 3 4 5 6 7
20. Uncooperativeness NA 1 2 3 4 5 6 7
21. Excitement NA 1 2 3 4 5 6 7
22. Distractibility NA 1 2 3 4 5 6 7
23. Motor hyperactivity NA 1 2 3 4 5 6 7
24. Mannerisms and posturing NA 1 2 3 4 5 6 7
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APPENDIX G

Demographics Questionnaire

1. Age: _____ Yrs. Ed: _______

2. Diagnosis: ___ Schizophrenia ____Schizoaffective Disorder ____Bipolar Disorder

___ Other (please specify): ___________________________________________________

3. Marital Status: ___ Single ___ Married ____ Divorced ___ Widowed

4. Race/Ethnicity (circle one): ____ White/Caucasian ____ Asian/Pacific Islander

____ Black/African American ____ Hispanic

____ American Indian ____ Other

5. Have you been involved in therapy at the VA? _____YES _____NO

If so, what type? Please check all that apply:

____Individual Therapy ____Support Group _____CAFE ____CBSST Group

____Case Management ____MICM ______ PPH

1. How long have you been in services at VA Hospital? __________________________

2. Have you ever been psychiatrically hospitalized? _____YES _____NO

If so, how many times? _____________________

3. Where do you live?

____Vet’s Home ____Own Residence (house, apartment) _____With Family

____With Friends ____ Group Home Supported Housing

____Other (please specify): ______________________________________________________________

If you live with family, who do you live with? _______________________________

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APPENDIX H

Personal Loss from Mental Illness Scale

Please read the following statements and circle how much you agree with each statement.

1. Chances are good that I will get married and have a family.
Strongly Disagree Disagree Neutral Agree Strongly Agree

2. I will probably never be able to own my own house.

Strongly Disagree Disagree Neutral Agree Strongly Agree

3. It is hard for me to find a good reason to get out of bed.

Strongly Disagree Disagree Neutral Agree Strongly Agree

4. I have things that I like doing everyday.

Strongly Disagree Disagree Neutral Agree Strongly Agree

5. I doubt that I will have the same future as others my age.

Strongly Disagree Disagree Neutral Agree Strongly Agree

6. The plans I make for each day often do not get done.
Strongly Disagree Disagree Neutral Agree Strongly Agree

7. Having a mental illness might stop me from getting/keeping a good job.

Strongly Disagree Disagree Neutral Agree Strongly Agree

8. I miss the friends that I had before I became ill.

Strongly Disagree Disagree Neutral Agree Strongly Agree

9. I have lost a lot of friends because of being mentally ill.

Strongly Disagree Disagree Neutral Agree Strongly Agree

10. Having a mental illness has kept me from being an important member of my family.
Strongly Disagree Disagree Neutral Agree Strongly Agree

11. I liked myself better before I became mentally ill.

Strongly Disagree Disagree Neutral Agree Strongly Agree

12. People who knew me before would hardly recognize me now.

Strongly Disagree Disagree Neutral Agree Strongly Agree
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13. I don’t enjoy being around other people who have a mental illness.
Strongly Disagree Disagree Neutral Agree Strongly Agree

14. I haven’t really changed very much because of having a mental illness.
Strongly Disagree Disagree Neutral Agree Strongly Agree

15. Having a mental illness has really changed who I am.

Strongly Disagree Disagree Neutral Agree Strongly Agree

16. Having a mental illness has taken away my normal daily routine.
Strongly Disagree Disagree Neutral Agree Strongly Agree

17. I feel that I don’t have the kind of friends that other people my age have.
Strongly Disagree Disagree Neutral Agree Strongly Agree

18. I don’t plan for the future, but I do have hopes for what I would like to happen.
Strongly Disagree Disagree Neutral Agree Strongly Agree

19. Other people often tell me not to plan too far into the future.
Strongly Disagree Disagree Neutral Agree Strongly Agree

20. My future is as bright now as it was before becoming ill.

Strongly Disagree Disagree Neutral Agree Strongly Agree
 130

APPENDIX I

QUALITY OF LIFE INTERVIEW

Section A: General Life Satisfaction

Please look at this card. (HAND SUBJECT THE DELIGHTED-TERRIBLE SCALE).

This is called the Delighted-Terrible Scale (D/T Scale). The scale goes from terrible, which is the
lowest ranking of 1, to delighted, which is the highest ranking of 7. There are also points 2
through 6 with descriptions below them. (READ POINTS ON THE SCALE).

During the interview we'll be using this scale from time to time to help you tell me how you feel
about different things in your life. All you have to do is tell me what on the scale best describes
how you feel. For example, if I ask, "how do you feel about chocolate ice cream" and you are
someone who loves chocolate ice cream, you might point to "delighted." On the other hand, if
you hate chocolate ice cream, you might point to "terrible." If you feel about equally satisfied
and dissatisfied with chocolate ice cream, then you would point to the middle of the scale.

Do you have any questions about the scale?

Please show me how you feel about chocolate ice cream.

Let's begin. The first question is a very general one.

1. How do you feel about your lifein general?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

Now, set the scale aside. I'll let you know when we need it again.

Section B: Living Situation

Now I am going to ask you some questions about your living situation.

1. What is your current living situation?

(USE CODES BELOW)
(IF RESPONDENT IS CURRENTLY IN THE HOSPITAL, AND THIS HOSPITALIZATION
HAS LASTED LESS THAN 3 MONTHS, LIVING SITUATION = LIVING SITUATION
JUST PRIOR TO HOSPITALIZATION. IF THE HOSPITALIZATION HAS BEEN FOR 3
MONTHS OR MORE, CODE "HOSPITAL").
01 Hospital
02 Skilled nursing facility: 24 hour nursing service
03 Intermediate care facility: less than 24 hour nursing facility
04 Supervised group living: (generally long term)
05 Transitional group home:(halfway or quarterway house)
06 Family foster care
07 Cooperative apartment, supervised(staff on premises)
08 Cooperative apartment, unsupervised (staff not on premises)
 131

09 Board and care home: (private proprietary home for adults, with program and
supervision)
10 Boarding house:(includes meals, no program or supervision)
11 Rooming or boarding house or hotel: (includes single room occupancy, no meals
are
provided, cooking facilities may be available)
12 Private house or apartment
13 Shelter
14 Jail
15 No current residence (including the streets, bus stations, missions, etc.)
16 Other:__________________
99 No information

2. List in order the places you have lived during the past year, including psychiatric
hospitalizations, beginning with your current living situation. (USE CODES BELOW; CODE
DESCRIPTION)

A.

B.

C.

D.

E.

F.

01 Hospital
02 Skilled nursing facility: 24 hour nursing service
03 Intermediate care facility: less than 24 hour nursing facility
04 Supervised group living: (generally long term)
05 Transitional group home:(halfway or quarterway house)
06 Family foster care
07 Cooperative apartment, supervised(staff on premises)
08 Cooperative apartment, unsupervised (staff not on premises)
09 Board and care home: (private proprietary home for adults, with program and
supervision)
10 Boarding house:(includes meals, no program or supervision)
11 Rooming or boarding house or hotel: (includes single room occupancy, no meals
are
provided, cooking facilities may be available)
12 Private house or apartment
13 Shelter
14 Jail
 132

15 No current residence (including the streets, bus stations, missions, etc.)

16 Other: __________________
99 No information

2G. Total number of different, non-hospital residences, during the past year. (SPECIFY)_____

3. Which of these was your usual residence during the past year? (USE CODES BELOW)

01 Hospital
02 Skilled nursing facility: 24 hour nursing service
03 Intermediate care facility: less than 24 hour nursing facility
04 Supervised group living: (generally long term)
05 Transitional group home:(halfway or quarterway house)
06 Family foster care
07 Cooperative apartment, supervised(staff on premises)
08 Cooperative apartment, unsupervised (staff not on premises)
09 Board and care home: (private proprietary home for adults, with program and
supervision)
10 Boarding house:(includes meals, no program or supervision)
11 Rooming or boarding house or hotel: (includes single room occupancy, no meals
are
provided, cooking facilities may be available)
12 Private house or apartment
13 Shelter
14 Jail
15 No current residence (including the streets, bus stations, missions, etc.)
16 Other:__________________
99 No information

4. Now look at the D-T Scale again and answer the following: (HAND RESPONDENT THE D-
T SCALE. IF RESPONDENT IS CURRENTLY IN THE HOSPITAL FOR LESS THAN 3
MONTHS, USE MORE RECENT RESIDENCE PRIOR TO HOSPITALIZATION. IF
RESPONDENT IS IN THE HOSPITAL 3 MONTHS OR MORE, USE HOSPITAL AS THE
RESIDENCE. SKIP IF HOMELESS).

How do you feel about:

A. The living arrangements where you live?

____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

B. The privacy you have there?

____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

C. The prospect of staying on where you currently live for a long period of time?
_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)
 133

Section C: Daily Activities & Functioning

1. Now let's talk about some of the things you did with your time in the past week. I'm going to
read you a list of things people may do with their free time. For each of these, please tell me if
you did it during the past week. Did you…(READ OPTIONS A-H)

NO 0
YES 1
MISSING 9

A. Go for a walk? _____

B. Go shopping? _____

C. Go to a restaurant or coffee shop? _____

D. Read a book, magazine, or newspaper? _____

E. Go for a ride in a bus or car? _____

F. Work on a hobby? _____

G. Play a sport? _____

H. Go to a park? _____

2. Overall, how would you rate your functioning in home, social, school, and work settings at
the present time? Would you say your functioning in these areas is excellent, good, fair or poor?
(CIRCLE ONE)

Excellent 1
Good 2
Fair 3
Poor 4
Missing 9

3. Now please look at the D-T Scale again. How do you feel about:

A. The way you spend your spare time?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

B. The chance you have to enjoy pleasant or beautiful things?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

C. The amount of fun you have?

 134

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

D. The amount of relaxation in your life?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

Section D: Family
The next few questions are about your relationship with your family including any relatives with
whom you live.

4. In the past year, how often did you talk to a member of your family on the telephone? Would
you say at
least once a day, at least once a week, at least once a month, less than once a month but at least
once during the year, or not at all? (CIRCLE ONE)

At least once a day 5

At least once a week 4
At least once a month 3
Less than once a month 2
Not at all 1
No family (GO TO SECTION E) 0
Missing 9

5. In the past year, how often did you get together with a member of your family--at least once
a day, at
least once a week, at least once a month, less than once a month but at least once during the year,
or not at all? (CIRCLE ONE)

At least once a day 5

At least once a week 4
At least once a month 3
Less than once a month 2
Not at all 1
No family (GO TO SECTION E) 0
Missing 9

6. Please look at the D-T Scale again. How do you feel about (READ OPTIONS A – B):

A. The way you and your family act toward each other?
_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

B. The way things are in general between you and your family?
_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)
 135

Section E: Social Relations

Now I'd like to know about other people in your life, that is, people who are not in your family.

1. About how often do you do the following? Would you say, at least once a day, once a week,
once a month, less than once a month or not at all? (READ OPTIONS A – D):

At least once a day 5

At least once a week 4
At least once a month 3
Less than once a month 2
Not at all 1
Missing 9

A. Visit with someone who does not live with you?_____

B. Telephone someone who does not live with you? _____

C. Do something with another person that you planned ahead of time? _____

D. Spend time with someone you consider more than a friend, like a spouse, a boyfriend
or a
girlfriend? _____

2. Please look at the D-T Scale again. How do you feel about:

A. The things you do with other people?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

B. The amount of time you spend with other people?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

C. The people you see socially?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

Section F: Finances

A few questions about money.

1. In the past year have you had any financial support from the following sources? (READ
OPTIONS A – N)

NO 0
YES 1
MISSING 9
 136

A. Earned Income _____

B. Social Security Benefits (SSA)_____

C. Social Security Disability Income (SSDI) _____

D. Supplemental Security Income (SSI)_____

E. Armed Service connected disability payments _____

F. Other Social Welfare benefits - state or county (general welfare, Aid to Families with
Dependent
Children (AFDC)) _____

G. Vocational program (Comprehensive Employment and Training Act (CETA),

Vocational
Rehabilitation, sheltered workshop)_____

H. Unemployment compensation _____

I. Retirement, investment or savings income _____

J. Rent supplements (including HUD, Section 8 certificates, living programs receiving

public
assistance support) _____

K. Alimony and child support ______

L. Food stamps _____

M. Family and/or spouse contribution _____

N. Other source(s) (SPECIFY BELOW)

2. How much money did you receive during the past month from all of these sources?
(SPECIFY) $ ______ (Missing = 9999 )

3. On the average, how much money did you have to spend on yourself in the past month, not
counting money for room and meals?
(SPECIFY) $ _____ (Missing = 9999)
 137

INTERVIEWER RATING:
HOW RELIABLE DO YOU THINK THE SUBJECT’S RESPONSES WERE TO QUESTION
1?
VERY RELIABLE 4
GENERALLY RELIABLE 3
GENERALLY UNRELIABLE 2
VERY UNRELIABLE 1

7. During the past year, did you generally have enough money each month to cover…(READ
OPTIONS A-F)

NO = 0
YES = 1
MISSING = 9

A. Food? _____

B. Clothing? _____

C. Housing? _____

D. Traveling around the city for things like shopping, medical appointments, or visiting
friends and
relatives? _____

E. Social activities like movies or eating in restaurants? _____

8. Now, I'd like to use the D-T Scale again. In general, how do you feel about:

A. The amount of money you get?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

B. How comfortable and well-off you are financially?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

C. The amount of money you have available to spend for fun?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

SECTION G: Work

1. Have you worked during the past year? that is since (DATE)? Are you working now?

Yes, currently working 1

Yes, worked in the past year but
not currently employed (GO TO
 138

NEXT SECTION) 2
No work in the past year (GO TO
NEXT SECTION) 0
Missing 9

2. What kind of work do you do at the present time?

(IF MORE THAN ONE JOB, USE JOB AT WHICH THE RESPONDENT EARNS THE
HIGHER WEEKLY SALARY)(SPECIFY BELOW)

3. How many hours a week do you usually work? _____ (Missing = 999)

4. How much do you earn per hour/week at this job? (CHOOSE ONE)

$ per hour. $______

$ per week. $______

5. JOB SATISFACTION (USE D-T SCALE) How do you feel about:

A. Your job?
_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

B. What it is like where you work (the physical surroundings)?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

C. The amount you get paid?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

Section H: Legal & Safety Issues

1. In the past year, were you a victim of: (READ OPTIONS A – B)

No 0
Yes 1
Missing 9

A. Any violent crimes such as assault, rape, mugging, or robbery? _____

B. Any nonviolent crimes such as burglary, theft of your property or money, or being
cheated? ____

2. A. In the past year, have you been arrested or picked-up for any crimes? [ No = 0; YES = 1]
 139

B. How many times? _____

3. Please look at the D-T Scale again. How do you feel about:

A. How safe you are on the streets in your neighborhood?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

B. How safe you are where you live?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

C. The protection you have against being robbed or attacked?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

Section I: Health

Now I'd like to ask about your health.

1. In general, would you say your health is excellent, very good, good, fair, or poor?

Excellent 1
Very Good 2
Good 3
Fair 4
Poor 5
Missing 9

2. How do you feel about: (USE THE D/T SCALE)

A. Your health in general?

____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

B. Your physical condition?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

C. Your emotional well-being?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9)

Section J: Global Rating

1. And a very general question again. Using the D-T Scale again, how do you feel about your
lifein general?

_____ (FROM D/T SCALE; IF SUBJECT DOES NOT RESPOND = 9

 140

QUALITY OF LIFE INTERVIEW

THE DELIGHTED-TERRIBLE SCALE

1 2 3 4 5 6 7

Terrible Unhappy Mostly Mixed Mostly Pleased Delighted

Dissatisfied Satisfied
 141

APPENDIX J

RECOVERY ASSESSMENT SCALE (RAS)

Strongly Disagree Not Sure Agree Strongly NANS NASK

Disagree Agree
1. I have a desire to succeed. 1 2 3 4 5 8 9
2. I have my own plan for how to 1 2 3 4 5 8 9
stay or become well.
3. I have goals in life that I want to 1 2 3 4 5 8 9
reach.
4. I believe I can meet my current 1 2 3 4 5 8 9
personal goals.
5. I have a purpose in life. 1 2 3 4 5 8 9

6. Even when I don’t care about 1 2 3 4 5 8 9

myself, other people do.
7. I understand how to control the 1 2 3 4 5 8 9
symptoms of my mental illness.
8. I can handle it if I get sick again. 1 2 3 4 5 8 9

9. I can identify what triggers the 1 2 3 4 5 8 9

symptoms of my mental illness.
10. I can help myself become better. 1 2 3 4 5 8 9

11. Fear doesn’t stop me from 1 2 3 4 5 8 9

living the way I want.
12. I know that there are mental 1 2 3 4 5 8 9
health services that do help me.
13. There are things I can do that 1 2 3 4 5 8 9
help me with unwanted symptoms.
14. I can handle what happens in 1 2 3 4 5 8 9
my life.
15. I like myself. 1 2 3 4 5 8 9

16. If people really knew me, they 1 2 3 4 5 8 9

would like me.
17. I am a better person than before 1 2 3 4 5 8 9
my experience with mental illness.
18. Although my symptoms may 1 2 3 4 5 8 9
get worse, I know I can handle
them.
19. If I keep trying, I will continue 1 2 3 4 5 8 9
to get better.
20. I have an idea of who I want to 1 2 3 4 5 8 9
become.
21. Things happen for a reason. 1 2 3 4 5 8 9

22. Something good will eventually 1 2 3 4 5 8 9

happen.
 142

23.I am the person most responsible 1 2 3 4 5 8 9

for my own improvement.
24. I’m hopeful about my future. 1 2 3 4 5 8 9

25. I continue to have new interests. 1 2 3 4 5 8 9

26. It is important to have fun. 1 2 3 4 5 8 9

27. Coping with my mental illness 1 2 3 4 5 8 9

is no longer the main focus of my
life.
28. My symptoms interfere less and 1 2 3 4 5 8 9
less with my life.
29. My symptoms seem to be a 1 2 3 4 5 8 9
problem for shorter periods of time
each time they occur.
30. I know when to ask for help. 1 2 3 4 5 8 9
31. I am willing to ask for help. 1 2 3 4 5 8 9
32. I ask for help when I need it. 1 2 3 4 5 8 9

33. Being able to work is important 1 2 3 4 5 8 9

to me.
34. I know what helps me get 1 2 3 4 5 8 9
better.
35. I can learn from my mistakes. 1 2 3 4 5 8 9

36. I can handle stress. 1 2 3 4 5 8 9

37. I have people I can count on. 1 2 3 4 5 8 9

38. I can identify the early warning 1 2 3 4 5 8 9

signs of becoming sick.
39. Even when I don’t believe in 1 2 3 4 5 8 9
myself, other people do.
40. It is important to have a variety 1 2 3 4 5 8 9
of friends.
41. It is important to have healthy 1 2 3 4 5 8 9
habits.
 143

APPENDIX K

SUBSCALE ITEMS FOR EACH MEASURE

1. Items on Each Subscale of Beck Cognitive Insight Scale (BCIS)

Self-Reflectiveness
• At times, I have misunderstood other people’s attitudes towards me.
• Other people can understand the cause of my unusual experiences better than I can.
• I have jumped to conclusions too fast.
• Some of my experiences that have seemed very real may have been due to my
imagination.
• Even though I feel strongly that I am right, I could be wrong.
• If somebody points out that my beliefs are wrong, I am willing to consider it.
• There is often more than one possible explanation for why people act the way they do.
• My unusual experiences may be due to my being extremely upset or stressed.

Self-Certainty
• My interpretations of my experiences are definitely right.
• If something feels right, it means that it is right.
• I know better than anyone else what my problems are.
• When people disagree with me, they are generally wrong.
• I cannot trust other people’s opinions about my experiences.
• I can trust my own judgment at all times.
Ratings on Self-Reflectiveness and Self-Certainty were made on a 4-point scale (0 = do not agree
at all, 1 = agree slightly, 2 = agree a lot, 3 = agree completely)

2. Items on Each Subscale of the 4-Factor Model of the Brief Psychiatric Rating
Scale (BPRS).

Positive Symptoms
• Suspiciousness
• Hallucinations
• Unusual Thought Content
• Bizarre Behavior
• Disorientation

Negative Symptoms
• Self-Neglect
• Blunted Affect
• Emotional Withdrawal
• Motor Retardation

Manic-Excitement
• Hostility
• Elevated Mood
• Grandiosity
• Excitement
• Distractibility
• Motor Hyperactivity
 144

Depression-Anxiety
• Anxiety
• Depressed Mood
• Suicidality
• Guilt Feelings

Other Items not Loading on a Subscale

• Somatic Concern
• Conceptual Disorganization
• Tension
• Uncooperativeness
• Mannerisms and Posturing

Ratings were made on a 7-point scale (1 = Not Present, 7 = Extremely Severe).

3. Items on Each Subscale of Personal Loss due to Mental Illness Scale (PLMI).
Loss of Roles and Routines
• Chances are good that I will get married and have a family.
• I will probably never be able to own my own house.
• It is hard for me to find a good reason to get out of bed.
• I have things that I like doing everyday.
• I doubt that I will have the same future as others my age.
• The plans I make for each day often do not get done.
• Having a mental illness might stop me from getting/keeping a good job.

Loss of Former Relationships

• I miss the friends that I had before I became ill.
• I have lost a lot of friends because of being mentally ill.
• Having a mental illness has kept me from being an important member of my family.
• I liked myself better before I became mentally ill.
• People who knew me before would hardly recognize me now.
• I don’t enjoy being around other people who have a mental illness.

Loss of Former Self

• I haven’t really changed much because of having a mental illness.
• Having a mental illness has really changed who I am.
• Having a mental illness has taken away my normal daily routine.

Loss of Future
• I feel that I don’t have the kind of friends that others people my age have.
• I don’t plan for the future, but I do have hopes for what I would like to have happen.
• Other people often tell me not to plan too far into the future.
• My future is as bright now as it was before becoming ill.
Ratings made on 5-point scale (1 = strongly disagree, 2= disagree, 3 = neutral, 4 = agree,
5=strongly agree), therefore, higher scores reflect higher sense of personal loss.
 145

4. Items on Each Subjective Subscale of Quality of Life Interview (QOLI).

General Life Satisfaction
• How do you feel about your life in general?

Living Situation
• How do you feel about the living arrangements where you live?
• How do you feel about the privacy you have there?
• How do you feel about the prospect of staying where you currently live for a long period
of time?

Daily Activities
• How do you feel about the way you spend your spare time?
• How do you feel about the chance you have to enjoy pleasant or beautiful things?
• How do you feel about the amount of fun you have?
• How do you feel about the amount of relaxation in your life?

Family
• How do you feel about the way you and your family act towards each other?
• How do you feel about the way things are in general between you and your family?

Social Relations
• How do you feel about the things you do with other people?
• How do you feel about the amount of time you spend with other people?
• How do you feel about the people you see socially?

Finances
• How do you feel about the amount of money you get?
• How do you feel about how comfortable and well-off you are financially?
• How do you feel about the amount of money you have available to spend for fun?

Employment
• How do you feel about your job?
• How do you feel about what it is like where you work (physical surroundings)?
• How do you feel about the amount you get paid?

Legal and Safety

• How do you feel about how safe you are on the streets in your neighborhood?
• How do you feel about how safe you are where you live?
• How do you feel about the protection you have against being robbed or attacked?

Health
• How do you feel about your health in general?
• How do you feel about your physical condition?
• How do you feel about your emotional well-being?
 146

Global Rating of Quality of Life

• How do you feel about your life in general?

Satisfaction ratings were made on 7-point scale (1 = terrible, 2 = unhappy, 3 = mostly dissatisfied,
4 = mixed, 5 = mostly satisfied, 6 = pleased, 7 = delighted).

5. Items on Each Subscale of Recovery Assessment Scales (RAS).

Personal Confidence and Hope
• Fear doesn’t stop me from living the way I want to.
• I can handle what happens in my life.
• I like myself.
• If people really knew me, they would like me.
• I have an idea of who I want to become.
• Something good will eventually happen.
• I’m hopeful about my future.
• I continue to have new interests.
• I can handle stress.

Willingness to Ask for Help

• I know when to ask for help.
• I am willing to ask for help.
• I ask for help, when I need it.

Goal and Success Orientation

• I have a desire to succeed.
• I have my own plan for how to stay or become well.
• I have goals in life that I want to reach.
• I believe that I can meet my current personal goals.
• I have a purpose in life.

Reliance on Others
• Even when I don’t care about myself, other people do.
• I have people I can count on.
• Even when I don’t believe in myself, other people do.
• It is important to have a variety of friends.

No Domination by Symptoms
• Coping with my mental illness is no longer the main focus of my life.
• My symptoms interfere less and less with my life.
• My symptoms seem to be a problem for shorter periods of time each time they occur.

Ratings made on 5-point scale (1 = strongly disagree, 2= disagree, 3 = neutral, 4 = agree, 5

=strongly agree), therefore, higher scores reflect higher levels of recovery.
 147

APPENDIX L

MEANS, STANDARD DEVIATIONS, AND RANGES FOR EACH MEASURE

1. Means, Standard Deviations, and Ranges of Brief Psychiatric Rating Scale

(BPRS)
_____________________________________________________________________________
Standard
Scale Mean Deviation Range
_____________________________________________________________________________
Positive Symptoms 2.54 1.01 1 – 5.60
Suspiciousness 3.35 1.87 1–7
Hallucinations 2.51 2.12 1–7
Unusual Thought Content 3.69 1.90 1–7
Bizarre Behavior 2.05 1.35 1–6
Disorientation 1.12 0.48 1–3

Negative Symptoms 2.07 0.77 1–4

Self-Neglect 2.25 1.24 1–5
Blunted Affect 2.55 1.45 1–6
Emotional Withdrawal 2.12 1.13 1–6
Motor Retardation 1.37 0.63 1–3

Manic-Excitement 1.73 0.72 1 – 4.33

Hostility 1.97 1.31 1–7
Elevated Mood 1.38 1.06 1–6
Grandiosity 2.12 1.97 1–7
Excitement 1.55 1.06 1–5
Distractibility 1.86 1.01 1–5
Motor Hyperactivity 1.49 0.87 1–4

Depression-Anxiety 2.88 1.00 1.25 – 5.25

Anxiety 4.08 1.59 1–7
Depressed Mood 2.72 1.63 1–6
Suicidality 1.60 1.04 1–5
Guilt Feelings 3.11 1.64 1–7

Other Items
Somatic Concern 3.26 1.46 1–7
Conceptual Disorganization 1.60 1.12 1–5
Tension 1.49 0.81 1–4
Uncooperativeness 1.11 0.44 1–4
Mannerisms and Posturing 1.08 0.51 1–5

Total BPRS Score (average) 2.14 0.48 1.33 – 4

_____________________________________________________________________________

Note. Ratings were made on a 7-point scale (1 = Not Present, 7 = Extremely Severe).
 148

2. Means, Standard Deviations, and Ranges of Beck Cognitive Insight Scale (BCIS)
_____________________________________________________________________________

Scale Mean Standard Deviation Range

_____________________________________________________________________________

Self-Reflectivenessa 13.95 4.87 3 - 24

Self-Certainty b 6.54 3.51 0 - 15
c
Composite Index 7.42 6.98 -7 - 24
_____________________________________________________________________________
Note. Ratings on Self-Reflectiveness and Self-Certainty were made on a 4-point scale (0 = do not
agree at all, 1 = agree slightly, 2 = agree a lot, 3 = agree completely), therefore, higher scores
reflect higher Self-Reflectiveness and Self-Certainty, respectively.
a
Self-Reflectiveness subscale is comprised of 9-items. bSelf-Certainty subscale is comprised of 6-
items. cComposite Index is determined by subtracting the individual’s Self-Certainty score from
his/her Self-Reflectiveness score.

3. Means, Standard Deviations, and Ranges of Subscales of Personal Loss due to

Mental Illness Scale (PLMI)
_____________________________________________________________________________

PLMI Scale Mean Standard Deviation Range

_____________________________________________________________________________

Loss of Roles and Routines a 2.81 0.63 1 – 4.29

b
Loss of Former Relationships 2.97 0.74 1.17 – 4.67
Loss of Former Self c 3.38 0.80 1–5
Loss of Future d 3.13 0.68 1 – 4.75
Overall Loss 3.01 0.50 1.75 – 3.90
_____________________________________________________________________________

Note. Ratings made on 5-point scale (1 = strongly disagree, 2= disagree, 3 = neutral, 4 = agree, 5
=strongly agree), therefore, higher scores reflect higher sense of personal loss.
a
Loss of Roles and Routines subscale is comprised of 7-items. bLoss of Former
Relationships subscale is comprised of 6-items. cLoss of Former Self subscale is
comprised of 3-items. dLoss of Future subscale is comprised of 4-items.
 149

4. Means and Standard Deviations for Quality of Life Interview (QOLI) Scales

_____________________________________________________________________________

QOLI Subscale Mean Standard Deviation

_____________________________________________________________________________

Objective Scales
Daily Activities a 5.00 2.00
Family Contactb 3.61 0.99
Social Contactb 3.05 0.85
Financial Adequacyc 0.90 0.20
Spending Moneyd $397.00 $571.00

Subjective Scale – Satisfaction

General Life 4.62 1.39
Living Situation 5.02 1.32
Daily Activities 4.74 1.04
Family Relations 4.68 1.33
Social Relations 5.04 1.02
Finances 4.42 1.62
Worke 4.96 1.06
Legal and Safety 5.16 1.32
Health 4.62 1.12
Global Rating 4.78 1.34
_____________________________________________________________________________

Note. Satisfaction ratings were made on 7-point scale (1 = terrible, 2 = unhappy, 3 = mostly
dissatisfied, 4 = mixed, 5 = mostly satisfied, 6 = pleased, 7 = delighted).
a Out of a possible total of 8 activities. b Values range from 1 = not at all, 2= less than once per
month, 3= at least once per month, 4= at least once per week, to 5 = at least once per day.
c Values represent percentile out of 5 costs that can be adequately covered by available finances.
d Values represent reported spending money available. Reported for 59 participants. Missing

data from 6 participants who were unable to give an estimate of their available funds. e For this
group (participants currently working), n = 23 (17 with schizophrenia, 6 with schizoaffective
disorder, and none with bipolar disorder).
 150

5. Means, Standard Deviations and Ranges of Subscales of the Recovery Assessment Scale
(RAS)
_____________________________________________________________________________

RAS Scale Mean Standard Deviation Range

_____________________________________________________________________________

Personal Confidence and Hopea 3.77 0.62 1.67 – 5

Willingness to Ask for Help b 4.01 0.90 1–5
Goal and Success Orientation c 3.96 0.78 1–5
d
Reliance on Others 4.00 0.71 1.5 – 5
e
No Domination by Symptoms 3.39 1.02 1–5
Overall Recovery 3.87 0.52 2.17 – 5
_____________________________________________________________________________

Note. Ratings made on 5-point scale (1 = strongly disagree, 2= disagree, 3 = neutral, 4 = agree, 5
=strongly agree), therefore, higher scores reflect higher levels of recovery.
a
Personal Confidence and Hopesubscale is comprised of 9-items. bWillingness to Ask for Help
subscale is comprised of 3-items. cGoal and Success Orientation subscale is comprised of 5-items.
d
Reliance on Others subscale is comprised of 4-items. eNo Domination by Symptoms subscale is
comprised of 3-items.
 151

APPENDIX M

SIGNIFICANT T-TEST FINDINGS

Gender
-Females significantly higher Self-Reflectiveness (BCIS subscale) than Males.
t(63)= - 2.28, p<.05.
-Females significantly higher Loss of Future (PLMI subscale) than Males.
t(63)= - 2.13, p<.05.

Race
-Caucasians have significantly higher Annual Income than non-Caucasians (those who
reported annual income N = 60). t(58) = - 2.04, p<.05.

Employment
-Unemployed significantly older than employed. t(63) = 3.19, p<.01.
-Unemployed significantly higher Self-Certainty (BCIS subscale) than employed.
t(63) = 2.00, p<.05.
-Unemployed significantly higher Loss of Future (PLMI subscale) than employed.
t(63) = 2.30, p<.05.

Disability
- Those on disability take medications from a significantly lower number of categories of
medications than non-disabled. t(63) =2.77, p<.01.
- Those on disability have significantly higher length of treatment than non-disabled.
t(63) = - 2.60, p<.05.
- Those on disability rate their satisfaction with Living Situation (QOLI subjective
subscale) significantly higher than non-disabled. t(63) = - 2.18, p<.05.
- Those on disability rate their satisfaction with Daily Activities (QOLI subjective
subscale) significantly higher than non-disabled. t(63) = - 2.02, p<.05.
- Those on disability rate their satisfaction with Finances (QOLI subjective subscale)
significantly higher than non-disabled. t(63) = - 2.09, p<.05.
- Those on disability have significantly higher General Life Satisfaction (QOLI score)
than non-disabled. t(63) = 2.12, p<.05.
- Those on disability rate their satisfaction with Financial Adequacy (QOLI score)
significantly higher than non-disabled. t(63) = - 3.48, p<.01.
- Those on disability have a significantly higher Global Rating of quality of life (QOLI
score) than non-disabled. t(63) = - 2.45, p<.05.
- Those on disability have significantly higher No Domination by Symptoms (RAS
subscale) than non-disabled. t(63) = - 2.10, p<.05.

Antipsychotic Medication
- Those on antipsychotics take significantly more medications. t(63) = -3.77, p<.001.
- Those on antipsychotics take medications from a significantly higher number of
categories of medications. t(63) = -3.83, p<.001.

Atypical Antipsychotics
- Those on Atypical antipsychotics take significantly more medications.
t(63) = -2.15, p<.05.
 152

Typical Antipsychotics
-Those on Typical antipsychotics have significantly more Overall symptoms (BPRS
Total score). t(63) = -2.07, p<.05.

Mood Stabilizers
- Those on mood stabilizers have significantly higher education. t(63) = -2.00, p<.05.
- Those on mood stabilizers take significantly more medications. t(63) = -2.53, p<.05.
- Those on mood stabilizers take medications from a significantly higher number of
categories of medications. t(63) = -2.16, p<.05.
- Those on mood stabilizers are involved in a significantly higher number of treatment
services. t(63) = -2.47, p<.05.
-Those on mood stabilizers rate their quality of Social Relations (QOLI subjective
subscale) significantly lower. t(63) = 2.15, p<.05.
-Those on mood stabilizers have significantly lower Personal Confidence and Hope(RAS
subscale). t(63) = 2.32, p<.05.

Antiparkinsonian Medications (for extrapyramidal side-effects)

- Those on antiparkinsonian medication take significantly more medications.
t(63) = -2.03, p<.05.
- Those on antiparkinsonian medication take medications from a significantly higher
number of categories of medications. t(63) = -4.72, p<.001.
-Those on antiparkinsonian medication have significantly more Overall symptoms
(BPRS Total score). t(63) = -3.01, p<.01.
-Those on antiparkinsonian medication have significantly more Positive symptoms
(BPRS subscale). t(63) = -2.53, p<.05.
-Those on antiparkinsonian medication have significantly more Manic-Excited
symptoms (BPRS subscale). t(63) = -2.24, p<.05.

Hypnotics
- Those on hypnotics take significantly more medications. t(63) = -3.89, p<.001.
- Those on hypnotics take medications from a significantly higher number of categories
of medications. t(63) = -4.82, p<.001.
- Those on hypnotics take significantly less mood stabilizers. t(63) = 2.33, p<.05.
-Those on hypnotics have significantly more Overall symptoms (BPRS Total score).
t(63) = -3.15, p<.01.
-Those on hypnotics have significantly more Negative symptoms (BPRS subscale).
t(63) = -2.61, p<.05.
-Those on hypnotics have significantly less satisfaction with their Living Situation (QOLI
subjective subscale). t(63) = -3.15, p<.01.
-Those on hypnotics have significantly less satisfaction with their Family Relations
(QOLI subjective subscale). t(63) = 2.46, p<.05.
-Those on hypnotics have significantly less satisfaction with their Health (QOLI
subjective subscale). t(63) = 2.01, p<.05.
-Those on hypnotics have a significantly lower number of Social Contacts (QOLI
subscale). t(63) = 2.14, p<.05.
-Those on hypnotics have significantly lower Self-Reflectiveness (BCIS subscale).
t(63) = 2.18 p<.05.
 153

Anxiolytics
- Those on anxiolytics take significantly more medications. t(63) = -4.48, p<.001.
- Those on anxiolytics take medications from a significantly higher number of categories
of medications. t(63) = -4.93, p<.001.
- Those on anxiolytics are involved in a significantly lower number of treatment services.
t(63) = 2.26, p<.05.
- Those on anxiolytics have significantly less satisfaction with their Jobs (QOLI
subjective subscale; of those who are currently employed N = 23). t(21) = 3.07, p<.01.
- Those on anxiolytics report significantly lower General Life Satisfaction (QOLI score).
t(63) = 2.26, p<.05.
- Those on anxiolytics report significantly more Family Contacts (QOLI score).
t(63) = - 2.05, p<.05.

Antidepressants
- Those on antidepressants take significantly more medications. t(63) = -3.82, p<.01.
- Those on antidepressants take medications from a significantly higher number of
categories of medications. t(63) = -4.80, p<.01.
-Those on antidepressants have significantly more Negative Symptoms (BPRS subscale).
t(63) = -2.49, p<.05.
-Those on antidepressants have significantly more Dep/Anxiety (BPRS subscale).
t(63) = -3.10, p<.01.
-Those on antidepressants have significantly less satisfaction with Family Relations
(QOLI subjective subscale). t(63) = 3.18, p<.01.
-Those on antidepressants report significantly lower Number of Daily Activities (QOLI
score). t(63) = 2.07, p<.05.
-Those on antidepressants have significantly higher Loss of Roles and Routines (PLMI
subscale). t(63) = -2.64, p<.05.
-Those on antidepressants have significantly higher Loss of Former Relationships (PLMI
subscale). t(63) = -2.15, p<.05.
-Those on antidepressants have significantly higher Overall Loss (Total Score form
PLMI). t(63) = -3.06, p<.01.
 154

APPENDIX N

SIGNIFICANT ANOVA FINDINGS

Number Hospitalizations
1. Age
F(4,60) = 5.78, p<.001.
Tukey HSD Post-hoc
-No Hosp significantly younger than 2-5 Hosp, p=.006
-No Hosp significantly younger than 6-10 Hosp, p =.001
-No Hosp significantly younger than > 10 Hosp, p =.046
-One Hosp significantly younger than 6-10 Hosp, p =.026

2. Length of time in treatment

F(4,60) = 6.01, p<.001.
Tukey HSD Post-hoc
-No Hosp significantly less time in treatment than 2-5 Hosp, p =.012
-No Hosp significantly less time in treatment than 6-10 Hosp, p =.000
-No Hosp significantly less time in treatment than > 10 Hosp, p =.004

Diagnosis
1. Number of Mood Stabilizers
F(2,62) = 10.32, p<.001.
Tukey HSD Post-hoc
-Bipolar on significantly more mood stabilizers than schizophrenia, p =.000
-Bipolar on significantly more mood stabilizers than schizoaffective, p =.006

2. Positive Symptoms (BPRS subscale)

F(2,62) = 3.88, p<.05.
Tukey HSD Post-hoc
-Schizophrenia significantly more positive symptoms than Bipolar, p =.016
-Schizoaffective significantly more positive symptoms than Bipolar, p =.043

3. Negative Symptoms (BPRS subscale)

F(2,62) = 3.16, p<.05.
Tukey HSD Post-hoc
-Schizophrenia significantly more negative symptoms than Bipolar, p =.039

4. Depression/Anxiety Symptoms (BPRS subscale)

F(2,62) = 5.85, p<.01.
Tukey HSD Post-hoc
- Schizoaffective significantly more dep/anx symptoms than Schizophrenia, p =.003

5. Legal and Safety (Subjective Subscale from QOLI)

F(2,62) = 3.43, p<.05.
Tukey HSD Post-hoc
-Bipolar significantly higher satisfaction with legal and safety than Schizoaffective,
p =.036
 155

6. General Life Satisfaction (QOLI score)

F(2,62) = 5.03, p<.01.
Tukey HSD Post-hoc
-Schizophrenia significantly higher general life satisfaction than Bipolar, p =.026
-Schizophrenia significantly higher general life satisfaction than Schizoaffective, p =.050

7. Number of Social Contacts (QOLI score)

F(2,62) = 3.26, p<.05.
Tukey HSD Post-hoc
-Schizoaffective significantly more social contacts than Schizophrenia, p =.038

8. Global Rating of QOL (QOLI score)

F(2,62) = 4.57, p<.05.
Tukey HSD Post-hoc
-Schizophrenia significantly higher global rating of QOL than Schizoaffective, p=.014

Marital Status
1. Total Number of Antipsychotics
F(4,60) = 3.06, p<.05.
Tukey HSD Post-hoc
-Married take significantly more antipsychotics than Married x 2, p=.012

2. Daily Activities (Subjective subscale from QOLI)

F(4,60) = 3.12, p<.05.
Tukey HSD Post-hoc
-Single significantly more satisfied with daily activities than divorced, p =.040

3. Family Relations (Subjective subscale from QOLI)

F(4,60) = 2.86, p<.05.
Tukey HSD Post-hoc
-No Significant post-hoc
Married - Married (x2), p =.497
Married – Single, p =.908
Married – Divorced, p =.136
Married – Widowed, p =.109
Single - Married (x2), p=.731
Single – Divorced, p =.258
Single – Widowed, p =.210
Divorced - Married (x2), p =1.00
Divorced – Widowed, p =.897
Married (x2) –Widowed, p =.985
 156

4. Social Relations (Subjective subscale from QOLI)

F(4,60) = 3.26, p<.05.
Tukey HSD Post-hoc
-No Significant post-hoc
Married - Married (x2), p =.944
Married – Single, p=.960
Married – Divorced, p =.065
Married – Widowed, p =.467
Single - Married (x2), p =.752
Single – Divorced, p =.070
Single – Widowed, p =.643
Divorced - Married (x2), p =.112
Divorced – Widowed, p =1.00
Married (x2) –Widowed, p =.326

5. Health (Subjective subscale from QOLI)

F(4,60) = 2.69, p<.05.
Tukey HSD Post-hoc
-No Significant post-hoc
Married - Married(x2), p =1.00
Married – Single, p =.901
Married – Divorced, p =.071
Married – Widowed, p =.344
Single - Married (x2), p =.978
Single – Divorced, p =.131
Single –Widowed, p =.581
Divorced - Married (x2), p=.422
Divorced – Widowed, p =1.00
Married (x2) – Widowed, p =.579

6. Annual Income
F(4,60) = 3.11, p<.05.
Tukey HSD Post-hoc
-Married have significantly higher annual income than Divorced, p=.016
-Married have significantly higher annual income than Single, p=.052

7. Global Rating of QOL (QOLI)

F(4,60) = 3.88, p<.05.
Tukey HSD Post-hoc
-Single significantly higher global rating of QOL than Widowed, p=.044

8. Loss of Roles and Routines (PLMI subscale)

F(4,60) = 3.77, p<.01.
Tukey HSD Post-hoc
-Divorced have significantly more Loss Roles & Routines than Married, p=.004
-Singles have significantly more Loss Roles & Routines than Married, p=.026

Living Arrangements
1. Number of Medications
F(2,62) = 3.90, p<.05.
 157

Tukey HSD Post-hoc

-No Significant post-hoc
Independent - Semi-independent p=.093
Independent - Assisted p=.096
Semi-independent - Assisted p=.995

2. Number of Categories of Medications

F(2,62) =5.43, p<.01.
Tukey HSD Post-hoc
-Assisted significantly more number of categories of meds than Independent p=.009

3. Number of Anxiolytics
F(2,62) =3.54, p<.05.
Tukey HSD Post-hoc
-Semi-independent significantly more anxiolytics than Independent p=.009

5. Negative Symptoms (BPRS)

F(2,62) = 5.70, p<.01.
Tukey HSD Post-hoc
-Assisted significantly more negative symptoms than Independent p=.004

6. Depression/Anxiety Symptoms (BPRS)

F(2,62) = 7.36, p<.01.
Tukey HSD Post-hoc
-Semi-independent significantly more dep/anx symptoms than Independent p=.001
-Semi-independent significantly more dep/anx symptoms than Assisted p=.008

7. Family Relations (Subjective from QOLI)

F(2,62) = 3.85, p<.05.
Tukey HSD Post-hoc
-Independent significantly more satisfied with family relations than Semi-independent
p=.045

8. General Life Satisfaction (QOLI)

F(2,62) = 6.24, p<.01.
Tukey HSD Post-hoc
-Independent significantly higher general life satisfaction than Semi-independent p=.003

9. Number of Activities
F(2,62) = 4.34, p<.05.
Tukey HSD:
-Independent engage in significantly more activities than Semi-independent p=.013

10. Number of Social Contacts

F(2,62) = 4.46, p<.05.
Tukey HSD Post-hoc
-Independent significantly more social contacts than Assisted p=.012
11. Global Rating of QOL (QOLI)
F(2,62) = 4.80, p<.05.
Tukey HSD Post-hoc
 158

-Independent significantly higher global rating QOL than Semi-independent p=.008

12. Loss of Roles and Routines (PLMI)

F(2,62) = 3.70, p<.05.
Tukey HSD Post-hoc
-No Significant post-hoc
Independent - Semi-independent p=.109
Independent - Assisted p=.104
Semi-independent - Assisted p=.998
 159

APPENDIX O

CORRELATION MATRIX FOR ALL CONTINUOUS DEMOGRAPHIC AND CLINICAL VARIABLES

Variable 1 2 3 4 5 6 7 8 9 10 11 12 13

1. Age --

2. Education .07 --

3. Number of Medications -.13 -.01 --

4. Number Categories Medications -.08 -.09 .85** --

5. Number of Antipsychotics -.05 .05 .53** .25* --

6. Number of Antidepressants -.04 -.03 .51** .52** -.06 --

7. Number of Anxiolytics .13 -.16 .52** .51** .16 .03 --

8. Number of Mood Stabilizers -.16 .21 .33** .20 .08 -.01 -.14 --

9. Number of Treatment Services .26* .04 -.01 .02 -.02 .16 -.29* .24 --

10. Length of Treatment .64** .01 -.27* -.15 -.17 -.18 -.02 -.18 .22 --

11. Overall BPRS -.04 -.14 .36** .37** .33** .02 .25* -.07 -.18 -.01 --

12. Positive Symptoms a -.05 -.15 .13 .14 .27* -.19 .17 -.13 -.21 -.01 .77** --

13. Negative Symptoms a .05 -.06 .34** .33** .21 .30* .13 -.14 -.03 -.08 .35** .10 --

14. Manic-Excit Symptoms a -.31 -.12 .08 .10 .19 -.22 .04 .03 -.21 -.04 .65** .39** -.14
 160

Variable 1 2 3 4 5 6 7 8 9 10 11 12 13

15. Dep-Anx Symptomsa .12 -.02 .46** .39** .15 .35** .24 .15 .07 -.01 .57** .20 .21

16. Self-Reflectivenessb -.05 .18 -.10 -.03 -.28* .15 .04 .06 .04 .09 -.13 -.16 -.19

17. Self-Certaintyb .06 -.47** .07 .05 .09 -.01 .14 -.10 -.16 .12 .33* .29* -.01

18. Composite Indexc -.06 .36** -.10 -.05 -.24 .11 -.04 .09 .11 .00 -.25* -.26* -.13

19. Loss of Roles & Routinesd -.11 -.10 .21 .27* -.12 .33** .17 -.02 .01 -.03 .03 .04 .16

20. Loss of Former Relationshipsd -.09 -.24 .04 .17 -.24 .31* -.02 -.12 -.02 -.06 .19 .28* .22

21. Loss of Former Selfd -.12 .02 .06 .10 -.13 .15 .15 -.08 -.14 -.03 .24 .16 .05

22. Loss of Futured -.05 -.23 .17 .20 -.08 .19 .14 .06 .08 -.04 .20 .08 .17

23. Overall Personal Losse -.13 -.21 .17 .27* -.21 .37** .14 -.06 -.01 -.06 .21 .20 .23

24. Personal Confidence and Hopef .09 -.08 -.09 -.11 .10 -.10 -.10 -.17 -.11 .02 -.02 -.05 -.04

25. Willingness to Ask for Helpf .05 -.24* .02 -.06 .07 -.07 -.02 -.01 .08 -.01 -.09 .01 .01

26. Goal and Success Orientationf .07 .08 .03 .02 .04 .01 -.09 .08 .04 -.02 .00 -.02 -.11

27. Reliance on Othersf .08 .05 -.15 -.22 -.08 -.02 .00 -.06 .07 .04 -.23 -.30* -.09

28. No Domination by Symptomsf .25* .08 -.03 -.15 .16 -.11 .01 -.11 -.15 .18 -.25* -.17 -.04

29. Overall Recoveryg .19 -.03 -.08 -.18 .09 -.09 -.08 -.09 .02 .11 -.13 -.16 -.10

30. General Life Satisfaction h .18 .15 -.40** -.32** -.10 -.26* -.28* -.22 -.10 -.02 -.24 -.02 -.19
 161

Variable 1 2 3 4 5 6 7 8 9 10 11 12 13

31. Number Daily Activities h .05 .17 -.11 -.06 -.06 -.28* .06 .00 -.10 .14 .02 .20 -.30*

32. Number Family Contact h -.12 -.09 -.01 .11 -.26* -.13 .26* .08 -.12 .06 -.15 -.21 -.35**

33. Number Social Contact h -.14 .05 -.17 -.22 -.03 -.17 -.05 .11 -.14 .22 -.03 -.10 -.31*

34. Annual Income h -.05 .34** .02 .01 -.12 .19 -.04 .11 .06 -.14 -.12 .00 -.11

35. Financial Adequacy h .11 .10 -.06 -.09 .20 -.15 .07 -.13 .04 .20 -.12 -.11 .16

36. Spending Money h .19 .25 -.14 -.09 -.09 -.09 -.09 -.05 -.04 .26 -.08 -.01 .03

37. Living Situation h (subjective) -.03 .17 -.32** -.35** -.10 -.09 -.16 -.12 .26* .18 -.47** -.37** -.11

38. Daily Activities h (subjective) .15 .20 -.25* -.25* -.06 -.16 -.09 -.08 -.11 .16 -.34** -.18 -.10

39. Family Relations h (subjective) .09 .08 -.37** -.37** .11 -.38** -.19 -.09 -.07 .17 -.32** -.15 -.31*

40. Social Relations h (subjective) -.03 .00 -.31* -.27* -.18 -.10 -.07 -.21 -.19 -.01 -.13 -.11 -.16

41. Finances h (subjective) .11 .06 -.23 -.15 -.03 -.14 -.08 -.11 -.06 .07 -.20 -.06 .06

42. Work h,i (subjective) .46* -.19 -.50* -.20 -.39 -.25 -.55** -.10 .05 .54** -.30 -.23 -.21

43. Legal and Safety h (subjective) .06 .04 -.07 -.05 -.11 -.13 .08 .17 -.06 -.13 -.39** -.27* -.13

44. Health h (subjective) .20 .10 -.32** -.30** -.08 -.17 -.26* -.02 .02 .01 -.37** -.26* -.10

45. Global Rating of QOLh .17 .12 -.34** -.28* -.07 -.27* -.21 -.12 -.11 .01 -.27* -.12 -.08
 162

Variable 14 15 16 17 18 19 20 21 22 23 24 25 26

14. Manic-Excit Symptoms --

15. Dep-Anx Symptoms .16 --

16. Self-Reflectiveness -.14 .15 --

17. Self-Certainty .41** .05 -.38** --

18. Composite Index -.30* .08 .89** -.76** --

19. Loss of Roles & Routines -.30* .20 .09 .01 .06 --

20. Loss of Former Relationships -.11 .22 -.12 .25* -.21 .37** --

21. Loss of Former Self .02 .39** .33** -.07 .26* .16 .32* --

22. Loss of Future -.01 .39** .17 .05 .10 .31* .41** .40** --

23. Overall Personal Loss -.18 .39** .11 .11 .02 .73** .80** .56** .69** --

24. Personal Confidence and Hope .17 -.24 -.11 .11 -.13 -.63** -.30* -.26* -.29* -.56** --

25. Willingness to Ask for Help -.08 -.01 -.16 .04 -.13 -.18 -.05 -.17 -.07 -.16 .25* --

26. Goal and Success Orientation .15 -.11 .01 .10 -.04 -.41** -.02 .05 -.19 -.23 .58** .18 --

27. Reliance on Others -.10 -.03 .30* -.19 .31* -.50** -.33** .06 -.30 -.36** .58** .25* .42**

28. No Domination by Symptoms -.18 -.33** -.06 .03 -.06 -.24 -.30* -.29* -.38** -.41** .58** .05 .29*

29. Overall Recovery .04 -.16 -.04 .07 -.06 -.59** -.32** -.16 -.25* -.51** .88** .47** .68**
 163

Variable 14 15 16 17 18 19 20 21 22 23 24 25 26

30. General Life Satisfaction .00 -.55** .11 -.25* .20 -.46** -.19 -.15 -.34** -.42** .45** -.08 .27*

31. Number Daily Activities .18 -.23 -.02 -.22 .10 -.26* -.12 .03 -.20 -.22 .11 .22 .23

32. Number Family Contact .01 .14 .29* -.03 .22 -.04 -.02 .25* .16 .08 .01 -.03 .27*

33. Number Social Contact .14 .10 .24 -.04 .18 -.29* -.34** .02 -.01 -.28* .18 .06 .02

34. Annual Income -.01 -.13 .21 -.07 .18 -.06 .04 .08 -.09 -.01 -.17 -.05 .06

35. Financial Adequacy -.15 -.19 -.16 .17 -.20 -.11 -.16 -.10 -.29* -.22 .04 .16 -.01

36. Spending Money -.08 -.12 .13 -.04 .11 .23 -.04 .04 -.13 .06 -.13 -.01 -.01

37. Living Situation (subjective) -.34** -.32** .22 -.21 .26* -.20 -.18 -.05 -.14 -.22 .27* .03 .20

38. Daily Activities (subjective) -.08 -.53** .19 -.12 .19 -.40** -.30* -.39** -.40** -.51** .56** .13 .31*

39. Family Relations (subjective) .07 -.57** -.00 .05 -.03 -.38** -.45** -.21 -.38** -.52** .48** -.05 .19

40. Social Relations (subjective) .08 -.24 .28* -.12 .26* -.38** -.14 .10 -.08 -.23 .49** -.02 .31*

41. Finances (subjective) -.16 -.32* .23 -.06 .19 -.21 -.05 -.06 -.31* -.21 .19 .02 .25*

42. Work (subjective) .05 -.44* -.20 .16 -.25 -.31 -.06 -.36 -.23 -.35 .31 .02 .06

43. Legal and Safety (subjective) -.24 -.27* .08 -.14 .13 -.12 -.23 -.13 -.32* -.27* .07 .13 .13

44. Health (subjective) -.03 -.49** .00 -.15 .08 -.51** -.35** -.36** -.49** -.60** .41** .07 .22

45. Global Rating of QOL .06 -.66** .07 -.18 .14 -.52** -.37** -.35** -.44** -.60** .54** .01 .38**
 164

Variable 27 28 29 30 31 32 33 34 35 36 37 38 39

27. Reliance on Others --

28. No Domination by Symptoms .27* --

29. Overall Recovery .69** .61** --

30. General Life Satisfaction .29* .29* .31* --

31. Number Daily Activities .15 -.03 .17 .27* --

32. Number Family Contact .23 -.07 .07 -.06 .16 --

33. Number Social Contact .28* .05 .17 .09 .26* .36** --

34. Annual Income -.10 -.07 -.08 .20 .14 -.04 .04 --

35. Financial Adequacy -.04 .21 .08 .10 -.10 -.15 .06 .11 --

36. Spending Money -.22 -.03 -.10 .06 .08 .01 -.03 .29* .24 --

37. Living Situation (subjective) .45** .22 .33** .32** .06 .11 .30* .01 .36** .09 --

38. Daily Activities (subjective) .47** .40** .48** .63** .22 -.12 .12 .10 .24 .07 .51** --

39. Family Relations (subjective) .37** .38** .36** .49** .08 .01 .30* -.08 .30* .02 .56** .62** --

40. Social Relations (subjective) .61** .20 .40** .49** .22 .19 .40** -.02 .03 -.14 .53** .55** .54**

41. Finances (subjective) .26* .14 .18 .45** -.05 -.05 .02 .21 .36** .26* .36** .51** .32*

42. Work (subjective) -.18 .16 .20 .71** .04 -.03 .04 .01 .25 .03 .17 .50* .38
 165

Variable 27 28 29 30 31 32 33 34 35 36 37 38 39

43. Legal and Safety (subjective) .28* .09 .14 .31* .04 .14 .05 .20 .09 .08 .14 .35** .26*

44. Health (subjective) .36* .36** .38** .58** .11 -.10 .12 .14 .10 -.15 .16 .57** .42**

45. Global Rating of QOL .38** .35** .43** .79** .25* -.07 .08 .13 .16 -.07 .34** .78** .62**
 166

Variable 40 41 42 43 44 45

40. Social Relations (subjective) --

41. Finances (subjective) .32** --

42. Work (subjective) .19 .38 --

43. Legal and Safety (subjective) .28* .46** .29 --

44. Health (subjective) .36** .42** .58** .48** --

45. Global Rating of QOL .53** .52** .72** .37** .76** --

*p < .05, ** p < .01

Note. BPRS=Brief Psychiatric Rating Scale, QOL = Quality of Life
a
Subscale of the Brief Psychiatric Rating Scale
b
Subscale of the Beck Cognitive Insight Scale
c
Composite Index from the Beck Cognitive Insight Scale
d
Subscale of the Personal Loss due to Mental Illness Scale
e
Overall Personal Loss from Personal Loss due to Mental Illness Scale
f
Subscale of the Recovery Assessment Scale
g
Overall Recovery from Recovery Assessment Scale
h
From Quality of Life Interview
i
This rating was only made on those who were currently working, n = 23
 167

APPENDIX P

INTERCORRELATIONS OF CRITERION MEASURES

1. Correlations between Subscales/Other Indicators and General Life Satisfaction

(GLS) and Global Rating (GR) on the Quality of Life Interview (QOLI)
_____________________________________________________________________________
Subscale/Indicator GLS GR
_____________________________________________________________________________

Objective

Daily Activities .27* .25*

Family Contact -.06 -.07

Social Contact .09 .08

Financial Adequacy .10 .16

Spending Money .06 -.07

Subjective – Satisfaction

Living Situation .32** .34**

Daily Activities .63** .78**

Family Relations .49** .62**

Social Relations .49** .53**

Finances .45** .52**

Worka .71** .72**

Legal and Safety .31* .37**

Health .57** .75**

Global Life Satisfaction 1.00 .79**

Global Rating .79** 1.00

_____________________________________________________________________________

*p < .05. **p < .01.

a For this group (those who are currently working), n = 23.
 168

2. Correlations between Subscales and Total Score on the Recovery Assessment

Scale (RAS).
_____________________________________________________________________________
Subscale Total Recovery Score
_____________________________________________________________________________

Personal Confidence and Hope .88**

Willingness to Ask for Help .47**

Goal and Success Orientation .68**

Reliance on Others .69**

No Domination by Symptoms .61**

_____________________________________________________________________________

*p < .05. **p < .01.

 169

Table 1

Demographic and Clinical Characteristics: Frequency and Percentage of Participants

_____________________________________________________________________________

Number of Percentage
Characteristic Participants of Participants
_____________________________________________________________________________

Gender
Male 54 83.1
Female 11 16.9
Race
Caucasian 56 86.2
African American 6 9.2
Native American 2 3.1
Hispanic 1 1.5
Marital Status
Single, never married 32 49.2
Married, once 11 16.9
Married, twice 3 4.6
Divorced 15 23.1
Widowed 4 6.2
Living Arrangements
Independent 48 73.8
Semi-independent 8 12.3
With parents 6 9.2
Co-op Apartment 1 1.5
Boarding House 1 1.5
Assisted 9 13.8
Board and Care Home 4 6.2
Skilled nursing facility (VA) 5 7.7
Diagnosis
Schizophrenia 34 52.3
Schizoaffective Disorder 22 33.8
Bipolar Disorder 9 13.8
a
Patient Reported Accurate Diagnosis
Yes 40 61.5
No 4 6.2
Partial 21 32.3
b
Number of Hospitalizations
None 6 9.2
1 6 9.2
2 -5 28 43.1
6 -10 13 20.0
More than 10 12 18.5
Employment Status
Currently Employed 23 35.4
Schizophrenia 17 73.9
Schizoaffective Disorder 6 26.1
Bipolar Disorder 0 0.00
Employed within Past Year 31 47.7
Working full-time 5 7.7
Working part-time 18 27.7
 170

Not Working 42 64.6

Legal and Safety, Past Year
Victim of Violent Crime 1 1.5
Victim of Non-Violent Crime 13 20.0
Arrested 2 3.1
c
Disability Status
Disability 62 95.4
SSDI 45 69.2
VA Service Connection 48 73.8
No Disability 3 4.6
d
Annual Income
Under $10,000 5 7.7
$10-20,000 22 33.8
$20-30,000 7 10.8
$30-40,000 11 16.9
$40-50,000 9 13.8
$50-60,000 3 4.6
$60-70,000 1 1.5
$70-80,000 0 0.0
$80-90,000 1 1.5
Over $100,000 1 1.5
e
Services Utilized
Medication 63 95.4
Case Management 64 98.5
Intensive Case Management 8 12.3
Individual Therapy 49 75.4
Support Group 32 49.2
CBSST Skills Group 13 20.0
Recreational Therapy 7 10.8
Educational Group 18 27.7
Partial Hospitalization 20 30.8
_____________________________________________________________________________
a
Partially correct diagnosis reflects when participants report having schizophrenia when they
have schizoaffective disorder, or vice versa.
b
Number of hospitalizations data collected only in these ranges, so averages are not available.
c
Some participants have both SSDI and VA service connection, so totals are greater than 100%.
d
Incomes reported for 60 participants. Missing data from 5 participants with money conservators,
who therefore did not know their income level.
e
Numerous participants were involved in multiple treatments, so totals are greater than 100%.
 171

Table 2
Demographic and Clinical Characteristics: Means, Standard Deviations, and Ranges

_____________________________________________________________________________

Characteristic Mean Standard Range

Deviation
_____________________________________________________________________________

Age 51.43 9.81 28 – 69

Years of Education 14.12 1.82 11 – 19
Monthly Income $2,470.13 $1,603.41 $40 – $9000
Annual Income $29,641.60 $19.240.96 $480 – $108,000
Number of Medications 2.74 1.31 0–6
Number of Treatment Services 3.25 1.59 1–8
Length of Treatment (months) 240.25 140.40 4 – 480
_____________________________________________________________________________
 172

Table 3

Medications: Frequency and Percentage of Participants

Number of Percentage
Characteristic Participants of Participants
_____________________________________________________________________________
a
Current Medications
Antipsychotics 60 92.3
Antidepressants 32 49.2
Anxiolytics 20 30.8
Mood Stabilizers 25 38.5
Hypnotics 18 27.7
Antipartkinsonians 12 18.5

Total Number Medications

0 3 4.6
1 9 13.8
2 13 20.0
3 24 36.9
4 10 15.4
5 5 7.7
6 1 1.5

Number Classes of Medications

No medications
Meds from 1 class
Meds from 2 classes
Meds from 3 classes
Meds from 4 classes
Meds from 5 classes
Meds from 6 classes
3 4.6
9 13.8
21 32.3
25 38.5
6 9.2
1 1.5
0 0.0

Antipsychotics
Typicals 7 10.8
Atypicals 56 86.2
Both 3 4.6

Number Antipsychotics
None 5 7.7
1 48 73.8
2 11 4.6
3 3 4.6

Number Antidepressants
None 33 50.8
1 29 44.6
2 3 4.6
 173

Number Anxiolytics
None 45 69.2
1 17 26.2
2 2 4.6

Number Mood Stabilizers

None 40 61.5
1 22 33.8
2 2 4.6
_____________________________________________________________________________
a
Numerous participants were prescribed multiple medications, so totals are greater than 100%.
 174

Table 4
Means, Standard Deviations and Ranges for Overall Scores of each Measure
_____________________________________________________________________________

Standard
Scale Mean Deviation Range
_____________________________________________________________________________

Total BPRS Score 2.14 0.48 1.33 – 4

Composite Index (BCIS) 7.42 6.98 -7 – 24
Overall Personal Loss 3.01 0.50 1.75 – 3.90
General Life Satisfaction (QOLI) 4.62 1.39 1-7
Global Rating of Quality of Life 4.78 1.34 2-7
Overall Recovery 3.87 0.52 2.17 – 5
_____________________________________________________________________________

Note. For BPRS, ratings were made on a 7-point scale (1 = Not Present, 7 = Extremely Severe).

For BCIS, ratings on Self-Reflectiveness and Self-Certainty were made on a 4-point scale (0 = do

not agree at all, 1 = agree slightly, 2 = agree a lot, 3 = agree completely), therefore, higher scores

reflect higher Self-Reflectiveness and Self-Certainty, respectively. Composite Index is

determined by subtracting the individual’s Self-Certainty score from his/her Self-Reflectiveness

score. For Personal Loss, ratings made on 5-point scale (1 = strongly disagree, 2= disagree, 3 =

neutral, 4 = agree, 5 =strongly agree), therefore, higher scores reflect higher sense of personal

loss. For QOLI, satisfaction ratings were made on 7-point scale (1 = terrible, 2 = unhappy, 3 =

mostly dissatisfied, 4 = mixed, 5 = mostly satisfied, 6 = pleased, 7 = delighted). For recovery,

ratings made on 5-point scale (1 = strongly disagree, 2= disagree, 3 = neutral, 4 = agree, 5

=strongly agree), therefore, higher scores reflect higher levels of recovery.

 175

Table 5

Hierarchical Regression of Variables Predicting Participants’ Overall Recovery from Serious Mental Illness (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .01 .01 .17 .01 .01 .17 .01 .01 .17 .01 .01 .14
Education -.03 .04 -.12 -.04 .04 -.13 -.03 .04 -.10 -.06 .04 -.19
Diagnosisa -.03 .22 -.02 -.05 .22 -.04 -.09 .22 -.06 -.10 .20 -.07
Diagnosisb .01 .16 .00 .04 .16 .03 .03 .16 .03 .09 .14 .08
c
Living -.11 .21 -.07 -.11 .22 -.07 -.10 .22 -.06 -.01 .19 -.00
d
Living -.32 .21 -.21 -.28 .21 -.19 -.30 .21 -.20 -.24 .19 -.16
Disabilitye -.21 .35 -.09 -.20 .35 -.08 -.16 .36 -.07 .03 .32 .01
BPRS Total -.14 .15 -.13 -.16 .15 -.15 -.06 .13 -.06
BCIS – CI -.01 .01 -.10 -.00 .01 -.03
PLMI – Total -.54 .13 -.52***
Note. R2 = .09 for Block 1 (p > .05); ΔR2 = .01 for Block 2 (p > .05); ΔR2 = .01 for Block 3 (p > .05); ΔR2 = .23 for Block 4 (p < .001).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Recovery is the total score from Recovery Assessment Scale.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 176

Table 6

Hierarchical Regression of Variables Predicting Participants’ Personal Confidence and Hope (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .01 .01 .08 .01 .01 .08 .00 .01 .07 .00 .01 .04
Education -.05 .05 -.14 -.05 .05 -.14 -.03 .05 -.08 -.07 .04 -.19
Diagnosisa -.30 .26 -.17 -.31 .26 -.17 -.38 .27 -.21 -.39 .22 -.22
Diagnosisb -.07 .19 -.05 -.06 .19 -.05 -.07 .19 -.05 .01 .16 .00
c
Living -.19 .25 -.10 -.19 .26 -.10 -.17 .26 -.09 -.04 .21 -.02
d
Living -.40 .25 -.22 -.39 .25 -.22 -.42 .25 -.24 -.34 .21 -.19
Disabilitye -.07 .42 -.02 -.07 .42 -.02 .01 .43 .00 .27 .35 .09
BPRS Total -.03 .18 -.02 -.08 .18 -.06 .06 .15 .04
BCIS – CI -.02 .01 -.18 -.01 .01 -.10
PLMI – Total -.75 .14 -.60***
Note. R2 = .09 for Block 1 (p > .05); ΔR2 = .00 for Block 2 (p > .05); ΔR2 = .02 for Block 3 (p > .05); ΔR2 = .31 for Block 4 (p < .001).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Personal Confidence and Hopeis one subscale from Recovery Assessment Scale.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 177

Table 7

Hierarchical Regression of Variables Predicting Participants’ Willingness to Ask for Help (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .01 .01 .07 .01 .01 .07 .01 .01 .06 .00 .01 .05
Education -.13 .07 -.26 -.14 .07 -.28 -.12 .07 -.25 -.14 .07 -.29
Diagnosisa .10 .37 .04 .05 .37 .02 .00 .39 .00 -.01 .38 -.00
Diagnosisb .18 .27 .10 .25 .28 .13 .24 .28 .13 .28 .28 .15
c
Living .13 .37 .05 .14 .37 .05 .15 .37 .06 .22 .37 .08
d
Living .16 .36 .06 .24 .36 .09 .22 .37 .09 .26 .36 .10
Disabilitye -.23 .61 -.06 -.20 .61 -.05 -.15 .62 -.04 -.01 .62 -.00
BPRS Total -.30 .25 -.16 -.33 .26 -.18 -.25 .26 -.14
BCIS – CI -.01 .02 -.07 -.01 .02 -.04
PLMI – Total -.41 .25 -.23
Note. R2 = .08 for Block 1 (p > .05); ΔR2 = .02 for Block 2 (p > .05); ΔR2 = .00 for Block 3 (p > .05); ΔR2 = .04 for Block 4 (p > .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Willingness to Ask for Help is one subscale from Recovery Assessment Scale.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 178

Table 8

Hierarchical Regression of Variables Predicting Participants’ Goal and Success Orientation (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .00 .01 .05 .00 .01 .05 .00 .01 .04 .00 .01 .03
Education .00 .06 -.00 .00 .06 .00 .01 .07 .03 -.00 .07 -.01
Diagnosisa .06 .33 .03 .07 .33 .03 .02 .34 .01 .02 .34 .01
Diagnosisb .10 .24 .06 .08 .25 .05 .08 .25 .05 .11 .25 .07
c
Living -.49 .32 -.21 -.50 .33 -.21 -.48 .33 -.21 -.43 .33 -.18
d
Living -.38 .31 -.17 -.40 .32 -.18 -.41 .32 -.19 -.38 .32 -.17
Disabilitye -.01 .53 -.00 -.02 .54 -.01 .02 .55 .01 .13 .55 .04
BPRS Total .06 .22 .03 .03 .23 .02 .08 .23 .05
BCIS – CI -.01 .02 -.08 -.01 .02 -.05
PLMI – Total -.32 .22 -.20
Note. R2 = .07 for Block 1 (p > .05); ΔR2 = .00 for Block 2 (p > .05); ΔR2 = .01 for Block 3 (p > .05); ΔR2 = .03 for Block 4 (p > .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Goal and Success Orientation is one subscale from Recovery Assessment Scale.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 179

Table 9

Hierarchical Regression of Variables Predicting Participants’ Reliance on Others (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .01 .01 .10 .01 .01 .09 .01 .01 .11 .01 .01 .09
Education .02 .06 .06 .01 .06 .03 -.03 .06 -.07 -.06 .05 -.14
Diagnosisa -.23 .30 -.11 -.29 .30 -.14 -.15 .30 -.07 -.16 .28 -.08
Diagnosisb -.13 .22 -.09 -.05 .22 -.03 -.03 .22 -.02 .03 .20 .02
c
Living -.11 .30 -.05 -.10 .30 -.05 -.14 .29 -.06 -.04 .27 -.02
d
Living -.25 .29 -.12 -.16 .29 -.08 -.10 .29 -.05 -.04 .27 -.02
Disabilitye .45 .50 .13 .49 .49 .15 .36 .48 .11 .56 .45 .17
BPRS Total -.35 .20 -.23 -.25 .20 -.17 -.15 .19 -.10
BCIS – CI .03 .02 .28 .03 .01 .33*
PLMI – Total -.58 .18 -.40**
Note. R2 = .04 for Block 1 (p > .05); ΔR2 = .05 for Block 2 (p > .05); ΔR2 = .06 for Block 3 (p > .05); ΔR2 = .14 for Block 4 (p < .01).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Reliance on Others is one subscale from Recovery Assessment Scale.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 180

Table 10

Hierarchical Regression of Variables Predicting Participants’ No Domination by Symptoms (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .02 .01 .22 .02 .01 .21 .02 .01 .20 .02 .01 .18
Education .01 .07 .01 -.01 .07 -.01 .03 .08 .06 -.00 .07 -.00
Diagnosisa -.36 .40 -.13 -.43 .40 -.15 -.56 .40 -.19 -.57 .38 -.20
Diagnosisb -.50 .29 -.24 -.41 .30 -.19 -.43 .29 -.20 -.36 .28 -.17
c
Living .16 .40 .05 .17 .39 .06 .21 .39 .07 .32 .37 .10
d
Living -.74 .38 -.25 -.64 .38 -.22 -.69 .38 -.24 -.62 .37 -.21
Disabilitye -.84 .65 -.17 -.79 .65 -.16 -.66 .65 -.14 -.43 .62 -.09
BPRS Total -.42 .27 -.20 -.51 .27 -.24 -.39 .26 -.18
BCIS – CI -.03 .02 -.19 -.02 .02 -.14
PLMI – Total -.65 .25 -.32*
Note. R2 = .19 for Block 1 (p > .05); ΔR2 = .04 for Block 2 (p > .05); ΔR2 = .03 for Block 3 (p > .05); ΔR2 = .08 for Block 4 (p < .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of No Domination by Symptoms is one subscale from Recovery Assessment Scale.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 181

Table 11

Hierarchical Regression of Variables Predicting Participants’ General Life Satisfaction (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .01 .02 .09 .01 .02 .09 .01 .02 .09 .01 .02 .08
Education .08 .09 .11 .07 .09 .09 .03 .10 .04 -.01 .09 -.01
Diagnosisa -1.08 .50 -.27* -1.18 .50 -.30* -1.07 .51 -.27* -1.08 .48 -.27*
Diagnosisb -.91 .37 -.31* -.79 .37 -.27* -.77 .37 -.26* -.68 .35 -.24
c
Living -1.10 .50 -.26* -1.09 .49 -.26* -1.12 .49 -.27* -.97 .47 -.23*
d
Living -.86 .48 -.22 -.72 .48 -.18 -.68 .48 -.17 -.58 .46 -.15
Disabilitye -.71 .82 -.11 -.64 .81 -.10 -.75 .82 -.11 -.46 .78 -.07
BPRS Total -.55 .33 -.19 -.47 .34 -.16 -.32 .33 -.11
BCIS – CI .02 .03 .11 .03 .02 .15
PLMI – Total -.85 .31 -.31**
Note. R2 = .31 for Block 1 (p < .01); ΔR2 = .03 for Block 2 (p > .05); ΔR2 = .01 for Block 3 (p > .05); ΔR2 = .08 for Block 4 (p < .01).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of General Life Satisfaction is a single score from the Quality of Life Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05 **p<.01 ***p<.001.
 182

Table 12

Hierarchical Regression of Variables Predicting Participants’ Number of Daily Activities (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age -.00 .02 -.01 -.00 .02 -.01 .00 .02 -.01 -.00 .02 -.02
Education .09 .11 .10 .09 .11 .10 .06 .12 .07 .03 .12 .03
Diagnosisa .31 .61 .07 .33 .62 .07 .43 .64 .10 .42 .63 .09
Diagnosisb .67 .45 .21 .64 .46 .20 .66 .46 .20 .72 .46 .22
c
Living -1.82 .61 -.39** -1.82 .61 -.39** -1.85 .62 -.40** -1.75 .61 -.38**
d
Living .00 .59 .00 -.02 .60 -.01 .02 .61 .01 .09 .60 .02
Disabilitye .02 1.00 .00 .01 1.01 .00 -.09 1.02 -.01 .11 1.02 .02
BPRS Total .10 .42 .03 .17 .43 .05 .28 .43 .09
BCIS – CI .02 .03 .09 .03 .03 .12
PLMI – Total -.59 .41 -.19
Note. R2 = .17 for Block 1 (p > .05); ΔR2 = .00 for Block 2 (p > .05); ΔR2 = .01 for Block 3 (p > .05); ΔR2 = .03 for Block 4 (p > .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Number of Daily Activities is the average number of activities engaged in during the past week from the Quality of Life
Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 183

Table 13

Hierarchical Regression of Variables Predicting Participants’ Number of Family Contacts (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age -.01 .01 -.05 -.01 .01 -.05 -.00 .01 -.04 -.00 .01 -.04
Education -.05 .07 -.09 -.06 .07 -.11 -.10 .08 -.19 -.10 .08 -.18
Diagnosisa .01 .41 .00 -.04 .41 -.01 .11 .41 .04 .12 .42 .04
Diagnosisb -.10 .30 -.05 -.03 .30 -.02 -.01 .30 -.01 -.02 .30 -.01
c
Living .27 .40 .09 .28 .40 .09 .24 .40 .08 .23 .41 .08
d
Living -.57 .39 -.20 -.50 .40 -.18 -.43 .39 -.15 -.43 .40 -.15
Disabilitye .80 .67 .17 .84 .67 .18 .69 .66 .15 .67 .68 .14
BPRS Total -.31 .28 -.15 -.20 .28 -.10 -.21 .29 -.10
BCIS – CI .03 .02 .23 .03 .02 .23
PLMI – Total .05 .27 .03
Note. R2 = .10 for Block 1 (p > .05); ΔR2 = .02 for Block 2 (p > .05); ΔR2 = .04 for Block 3 (p > .05); ΔR2 = .00 for Block 4 (p > .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Number of Family Contacts is the average number of family contacts during the past year from the Quality of Life
Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 184

Table 14

Hierarchical Regression of Variables Predicting Participants’ Number of Social Contacts (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age -.01 .01 -.14 -.01 .01 -.14 -.01 .01 -.13 -.01 .01 -.15
Education -.05 .06 -.11 -.05 .06 -.11 -.09 .06 -.18 -.11 .06 -.24
Diagnosisa .43 .33 .18 .43 .33 .17 .54 .34 .22 .53 .32 .22
Diagnosisb .51 .24 .28* .52 .25 .29* .54 .25 .30* .59 .23 .33*
c
Living -.51 .33 -.20 -.51 .33 -.20 -.55 .33 -.21 -.45 .31 -.18
d
Living -.72 .31 -.29* -.71 .32 -.29* -.66 .32 -.27* -.60 .30 -.24
Disabilitye -.34 .54 -.09 -.34 .54 -.08 -.46 .54 -.11 -.26 .52 -.07
BPRS Total -.04 .22 -.02 .04 .23 .03 .15 .22 .08
BCIS – CI .03 .02 .20 .03 .02 .25
PLMI – Total -.56 .21 -.33**
Note. R2 = .22 for Block 1 (p < .05); ΔR2 = .00 for Block 2 (p > .05); ΔR2 = .03 for Block 3 (p > .05); ΔR2 = .09 for Block 4 (p < .01).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Number of Social Contacts is the average number of social contacts during the past year from the Quality of Life
Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 185

Table 15

Hierarchical Regression of Variables Predicting Participants’ Financial Adequacy (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .00 .00 .03 .00 .00 .03 .00 .00 .01 .00 .00 .00
Education .00 .041 .03 .00 .01 .02 .01 .01 .13 .01 .02 .10
Diagnosisa .02 .08 .04 .02 .08 .03 -.02 .08 -.04 -.02 .08 -.04
Diagnosisb -.01 .06 -.02 .00 .06 .01 -.00 .06 -.01 .00 .06 .00
c
Living .09 .08 .16 .09 .08 .16 .10 .07 .18 .11 .07 .19
d
Living .03 .07 .05 .04 .07 .07 .02 .07 .04 .03 .07 .05
Disabilitye -.40 .12 -.43** -.39 .12 -.43** -.35 .12 -.39** -.34 .12 -.37**
BPRS Total -.05 .05 -.11 -.07 .05 -.18 -.06 .05 -.16
BCIS – CI -.01 .00 -.29* -.01 .00 -.27*
PLMI – Total -.05 .05 -.12
Note. R2 = .19 for Block 1 (p > .05); ΔR2 = .01 for Block 2 (p > .05); ΔR2 = .06 for Block 3 (p < .05); ΔR2 = .01 for Block 4 (p > .05). BPRS =
Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness Scale.
Criterion variable of Financial Adequacy is a percentile out of 5 costs that can be adequately covered by available finances from the Quality of Life
Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 186

Table 16

Hierarchical Regression of Variables Predicting Participants’ Spending Money (N=59).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age 10.68 7.65 .19 10.57 7.73 .19 10.63 7.84 .19 11.19 7.86 .20
Education 65.60 43.46 .21 64.27 44.19 .21 62.52 48.83 .20 70.64 49.44 .23
Diagnosisa 34.61 236.68 .02 30.52 239.44 .02 35.58 248.59 .02 35.90 248.44 .02
Diagnosisb 19.30 181.98 .02 33.02 191.67 .03 32.65 193.65 .03 4.71 195.42 .00
c
Living -215.17 233.60 .13 215.62 235.79 .13 214.35 238.60 .13 189.14 239.71 .11
d
Living -93.68 227.86 -.06 -80.29 236.13 -.05 -78.82 239.09 -.05 -102.31 240.03 -.07
Disabilitye -174.69 382.72 -.07 -170.18 386.71 -.07 -175.96 396.08 -.07 -235.42 400.03 -.09
BPRS Total -42.51 169.81 -.04 -38.13 178.60 -.03 -62.38 180.04 -.05
BCIS – CI 1.13 12.79 .01 -.31 12.86 -.00
PLMI – Total 165.69 160.96 .15
Note. R2 = .12 for Block 1 (p > .05); ΔR2 = .00 for Block 2 (p > .05); ΔR2 = .00 for Block 3 (p > .05); ΔR2 = .02 for Block 4 (p > .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Spending Money is a single score from the Quality of Life Interview. For this group, n = 59. Missing data from six
participants who were unable to give an estimate of their available monthly funds.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 187

Table 17

Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Living Situation (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age -.01 .02 -.11 -.02 .02 -.12 -.02 .02 -.11 -.02 .02 -.12
Education .07 .10 .09 .03 .08 .04 -.01 .09 -.01 -.02 .09 -.03
Diagnosisa -.20 .53 -.05 -.44 .46 -.12 -.33 .47 -.09 -.34 .47 -.09
Diagnosisb .21 .39 .08 .53 .34 .19 .54 .35 .20 .57 .35 .21
c
Living -.75 .53 -.19 -.72 .46 -.18 -.75 .46 -.19 -.70 .46 -.18
d
Living -.27 .51 -.07 .08 .45 .02 .13 .45 .03 .16 .45 .04
Disabilitye -1.28 .87 -.21 -1.11 .75 -.18 -1.21 .76 -.20 -1.12 .77 -.18
BPRS Total -1.41 .31 -.51*** -1.34 .32 -.49*** -1.29 .33 -.47***
BCIS – CI .02 .02 .12 .03 .02 .13
PLMI – Total -.27 .31 -.10
Note. R2 = .13 for Block 1 (p > .05); ΔR2 = .23 for Block 2 (p < .001); ΔR2 = .01 for Block 3 (p > .05); ΔR2 = .01 for Block 4 (p > .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Satisfaction with Living Situation is a subscale from the Quality of Life Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 188

Table 18

Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Daily Activities (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .01 .01 .06 .01 .01 .05 .01 .01 .06 .00 .01 .04
Education .11 .08 .19 .09 .07 .16 .07 .08 .12 .02 .07 .04
Diagnosisa -.21 .41 -.07 -.32 .40 -.11 -.25 .41 -.08 -.26 .37 -.09
Diagnosisb -.53 .30 -.24 -.39 .30 -.18 -.38 .30 -.17 -.29 .27 -.13
c
Living -.43 .41 -.14 -.41 .39 -.13 -.43 .39 -.14 -.28 .36 -.09
d
Living -.06 .39 -.02 .10 .38 .04 .13 .39 .05 .23 .35 .08
Disabilitye -.92 .67 -.19 -.84 .65 -.17 -.91 .66 -.18 -.61 .60 -.12
BPRS Total -.64 .27 -.29* -.59 .28 -.27* -.43 .25 -.20
BCIS – CI .01 .02 .10 .02 .02 .15
PLMI – Total -.87 .24 -.42***
Note. R2 = .18 for Block 1 (p > .05); ΔR2 = .08 for Block 2 (p < .05); ΔR2 = .01 for Block 3 (p > .05); ΔR2 = .15 for Block 4 (p < .001).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Satisfaction with Daily Activities is a subscale from the Quality of Life Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 189

Table 19

Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Family Relations (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .01 .02 .04 .00 .02 .03 .00 .02 .02 .00 .02 .00
Education .00 .10 .00 -.02 .10 -.03 .02 .10 .03 -.04 .09 -.06
Diagnosisa .13 .53 .03 .00 .52 .00 -.12 .54 -.03 -.14 .48 -.04
Diagnosisb -.45 .39 -.16 -.28 .39 -.10 -.30 .39 -.11 -.18 .35 -.07
c
Living -1.01 .53 -.25 -1.00 .52 -.25 -.96 .52 -.24 -.76 .47 -.19
d
Living -.89 .51 -.23 -.70 .51 -.18 -.76 .251 -.20 -.63 .46 -.17
Disabilitye -.48 .87 -.08 -.39 .85 -.06 -.27 .86 -.04 .13 .78 .02
BPRS Total -.74 .35 -.27* -.83 .36 -.30* -.61 .33 -.22
BCIS – CI -.03 .03 -.14 -.02 .02 -.08
PLMI – Total -1.16 .31 -.43***
Note. R2 = .14 for Block 1 (p > .05); ΔR2 = .06 for Block 2 (p < .05); ΔR2 = .02 for Block 3 (p > .05); ΔR2 = .16 for Block 4 (p < .001).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Satisfaction with Family Relations is a subscale from the Quality of Life Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 190

Table 20

Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Social Relations (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age -.01 .01 -.06 -.01 .01 -.06 -.00 .01 -.04 -.01 .01 -.05
Education -.01 .08 -.02 -.02 .08 -.03 -.08 .08 -.14 -.10 .08 -.18
Diagnosisa -.19 .43 -.06 -.23 .44 -.08 -.04 .44 -.01 -.05 .43 -.02
Diagnosisb -.08 .32 -.04 -.02 .33 -.01 .01 .32 .01 .06 .31 .03
c
Living -.56 .43 -.18 -.55 .43 -.18 -.61 .42 -.20 -.52 .42 -.17
d
Living -.27 .42 -.09 -.20 .42 -.07 -.11 .41 -.04 -.06 .41 -.02
Disabilitye .13 .71 .03 .16 .71 .03 -.04 .70 -.01 .14 .69 .03
BPRS Total -.28 .29 -.13 -.14 .30 -.07 -.05 .29 -.02
BCIS – CI .04 .02 .28 .05 .02 .32*
PLMI – Total -.52 .28 -.25
Note. R2 = .04 for Block 1 (p > .05); ΔR2 = .02 for Block 2 (p > .05); ΔR2 = .06 for Block 3 (p > .05); ΔR2 = .05 for Block 4 (p > .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Satisfaction with Social Relations is a subscale from the Quality of Life Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 191

Table 21

Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Finances (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .01 .02 .05 .01 .02 .05 .01 .02 .06 .01 .02 .05
Education .06 .12 .06 .04 .12 .04 -.02 .13 -.03 -.05 .13 -.06
Diagnosisa -.65 .66 -.14 -.77 .66 -.17 -.58 .67 -.12 -.59 .67 -.13
Diagnosisb -.55 .49 -.16 -.39 .49 -.11 -.36 .49 -.11 -.30 .49 -.09
c
Living .48 .66 .10 .49 .65 .10 .44 .65 .09 .53 .65 .11
d
Living .27 .64 .06 .45 .64 .10 .53 .64 .12 .60 .64 .13
Disabilitye -1.75 1.09 -.23 -1.66 1.08 -.22 -1.86 1.08 -.24 -1.66 1.08 -.22
BPRS Total -.73 .44 -.21 -.59 .46 -.18 -.49 .46 -.14
BCIS – CI .04 .03 .18 .05 .03 .20
PLMI – Total -.56 .43 -.17
Note. R2 = .10 for Block 1 (p > .05); ΔR2 = .04 for Block 2 (p > .05); ΔR2 = .02 for Block 3 (p > .05); ΔR2 = .03 for Block 4 (p > .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Satisfaction with Finances is a subscale from the Quality of Life Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 192

Table 22

Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Employment (N=23).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .05 .03 .47 .04 .03 .38 .04 .03 .38 .03 .03 .30
Education -.12 .17 -.17 -.08 .18 -.11 -.08 .19 -.12 -.07 .19 -.11
Diagnosisa -.44 .60 -.19 -.41 .60 -.17 -.40 .64 -.17 -.41 .66 -.18
Livingc .06 .72 .02 .07 .72 .02 .03 .82 .01 -.00 .84 .00
d
Living .28 .56 .11 .64 .66 .26 .68 .77 .27 .69 .78 .28
e
Disability -.11 1.20 -.02 .35 1.28 .07 .38 1.36 .08 .35 1.38 .07
BPRS Total -.67 .67 -.28 -.70 .76 -.29 -.66 .77 -.27
BCIS – CI .01 .07 .03 .01 .07 .03
PLMI – Total -.40 .57 -.17
2 2 2 2
Note. R = .34 for Block 1 (p > .05); ΔR = .04 for Block 2 (p > .05); ΔR = .00 for Block 3 (p > .05); ΔR = .02 for Block 4 (p > .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Satisfaction with Work is the average subjective rating of Work from the Quality of Life Interview. For this group (those
who are currently working), n = 23.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. Since there were no individuals with bipolar disorder diagnosis who were currently employed, the first dummy-coded variable was
omitted from this analysis. The dummy-coded diagnosis variable shown here corresponds to the Diagnosis variable “b” shown on all other
b
regression model tables. As a categorical variable with three groups, living arrangement was dummy-coded across two variables, with the largest
c d
group, independent living, serving as the reference group. The second of the two dummy coded variables for living arrangement. As a categorical
variable with two groups, disability status was dummy-coded, with the largest group, disability, serving as the reference group. *p<.05. **p<.01.
***p<.001.
 193

Table 23

Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Legal and Safety (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .01 .02 .08 .01 .02 .07 .01 .02 .07 .01 .02 .06
Education .08 .10 .11 .05 .09 .07 .03 .10 .04 -.01 .10 -.01
Diagnosisa .58 .54 .15 .41 .51 .11 .49 .52 .13 .47 .51 .13
Diagnosisb -.55 .39 -.20 -.32 .38 -.12 -.31 .38 -.11 -.24 .37 -.09
c
Living .09 .53 .02 .11 .50 .03 .09 .51 .02 .20 .50 .05
d
Living .28 .52 .07 .53 .49 .14 .56 .50 .15 .63 .49 .17
Disabilitye .66 .88 .11 .78 .83 .13 .71 .84 .11 .94 .83 .15
BPRS Total -1.01 .34 -.37** -.96 .35 -.35** -.83 .35 -.30*
BCIS – CI .02 .03 .08 .02 .03 .12
PLMI – Total -.66 .33 -.25*
Note. R2 = .12 for Block 1 (p > .05); ΔR2 = .12 for Block 2 (p < .01); ΔR2 = .01 for Block 3 (p > .05); ΔR2 = .05 for Block 4 (p < .05).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Satisfaction with Legal and Safety is a subscale from the Quality of Life Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 194

Table 24

Hierarchical Regression of Variables Predicting Participants’ Satisfaction with Health (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .02 .02 .16 .02 .01 .16 .02 .01 .16 .01 .01 .13
Education .06 .08 .09 .04 .08 .06 .04 .09 .07 -.02 .07 -.03
Diagnosisa -.15 .45 -.05 -.27 .43 -.09 -.30 .45 -.09 -.32 .37 -.10
Diagnosisb -.68 .33 -.29* -.52 .32 -.22 -.52 .32 -.22 -.40 .27 -.17
c
Living -.36 .45 -.11 -.35 .43 -.10 -.34 .43 -.10 -.13 .36 -.04
d
Living -.43 .43 -.13 -.25 .42 -.08 -.26 .42 -.08 -.13 .35 -.04
Disabilitye -.10 .73 -.02 -.01 .70 -.00 .01 .72 .00 .43 .60 .08
BPRS Total -.74 .29 -.32* -.75 .30 -.32* -.53 .26 -.23*
BCIS – CI -.01 .02 -.03 .01 .02 .04
PLMI – Total -1.21 .24 -.54***
Note. R2 = .14 for Block 1 (p > .05); ΔR2 = .09 for Block 2 (p < .05); ΔR2 = .00 for Block 3 (p > .05); ΔR2 = .24 for Block 4 (p < .001).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Satisfaction with Health is a subscale from the Quality of Life Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.
 195

Table 25

Hierarchical Regression of Variables Predicting Participants’ Global Rating of Quality of Life (N=65).

Block 1 Block 2 Block 3 Block 4

Variable
B SE B β B SE B β B SE B β B SE B β

Age .01 .02 .05 .01 .02 .05 .01 .02 .05 .00 .01 .03
Education .06 .09 .08 .05 .09 .06 .02 .10 .03 -.05 .08 -.07
Diagnosisa -.37 .49 -.10 -.46 .48 -.12 -.38 .50 -.10 -.40 .42 -.10
Diagnosisb -.98 .36 -.35** -.86 .36 -.31* -.85 .36 -.30* -.71 .30 -.25*
c
Living -.95 .49 -.24 -.94 .48 -.23 -.97 .48 -.24* -.74 .40 -.18
d
Living -.35 .47 -.09 -.21 .47 -.06 -.17 .47 -.05 -.03 .40 -.01
Disabilitye -1.54 .80 -.24 -1.48 .79 -.23 -1.56 .80 -.25 -1.10 .67 -.17
BPRS Total -.55 .33 -.20 -.49 .34 -.18 -.24 .29 -.09
BCIS – CI .02 .02 .10 .03 .02 .17
PLMI – Total -1.35 .27 -.50***
Note. R2 = .29 for Block 1 (p < .01); ΔR2 = .04 for Block 2 (p > .05); ΔR2 = .01 for Block 3 (p > .05); ΔR2 = .21 for Block 4 (p < .001).
BPRS = Brief Psychiatric Rating Scale, BCIS – CI=Composite Index from Beck Cognitive Insight Scale, PLMI=Personal Loss due to Mental Illness
Scale. Criterion variable of Global Rating of Quality of Life is a single score from the Quality of Life Interview.
a
As a categorical variable with three groups, diagnosis was dummy-coded across two variables, with the largest group, schizophrenia, serving as the
reference group. bThe second of the two dummy coded variables for diagnosis. cAs a categorical variable with three groups, living arrangement was
dummy-coded across two variables, with the largest group, independent living, serving as the reference group. dThe second of the two dummy coded
variables for living arrangement. eAs a categorical variable with two groups, disability status was dummy-coded, with the largest group, disability,
serving as the reference group. *p<.05. **p<.01. ***p<.001.