This project is a study of the use of mindfulness in a psychosocial rehabilitation setting (PSR). This paper explores ten published articles, a book, and a personal interview as it relates to mindfulness and the treatment of severe mental illness (SMI). In an interview done with the head of a (PSR) program, Evelyn Sanders (2018) who defined PSR as a place to assist persons diagnosed with a severe mental illness (SMI) with decreasing psychiatric hospitalizations, gaining social support and insight into their illnesses. Walsan et al (2018) defined severe mental illness (SMI) as any person in an impaired psychological state where the brain is functioning improperly lasting long in duration. All the articles describe the effects mindfulness meditation and mindfulness-based interventions have on persons diagnosed with a (SMI). The researchers will utilize a mindfulness community intervention created by Norwood & Merritt (2017) which includes three practices from the published book, “A Journey to Spiritual Health”.  The three practices include the practice of meditation and utilizing mantras and gratitude journaling in which the researcher defined in this paper.

Mindfulness is an evidenced based practice that is effective for people with severe mental illness (SMI). Severe mental illness is defined as psychological disorders, consistent with an onset of symptoms lasting for a duration producing the brains inability to function properly (i.e. Schizophrenia, Schizoaffective, Bipolar) (Walsan, Bonney, Mayne, Pai, Feng, & Toms, 2018). The researchers conducted an interview with the owner of the psychosocial rehabilitation (PSR) adult day center at Southeastern Healthcare of NC, Evelyn Sanders. Essentially, Mrs. Sanders reported the goal of PSR treatment is to assist people who have extensive histories of inpatient mental health hospitalizations, difficulties complying with mental health treatment, or obstacles to functioning independently in the community due to mental health issues with achieving their personal goals and decreasing institutionalization (Sanders, 2018). The member’s ages range from 18 to 60 years old. Sanders reported at Southeastern Healthcare of NC the PSR program has designed units for daily activities. These units are different areas where the members diagnosed with SMI are assigned by choice if they have the capacity; or, given a unit to participate in if they do not have the capacity to choose. The five units include culinary, engineering (inside and outside work refinement), clerical, social media (art and design enterprise) and volunteer work. The units are designed to assist the members with increasing vocational skills as well as functioning independently within the community. Members also do social activities in the morning where they converse about their thoughts and feelings or current events in an open forum setting in order to increase social functioning. Members also get a chance to speak out free of marginalization where their opinions and perspectives can be heard as they share their personal experiences, and/or talk about current events (i.e. voting rights). Somedays, instead of having an open forum setting the members participate in a fun dancing exercise with music (i.e. Zumba) in order to increase physical health functioning. The program also includes community outings designed to assist the members with acclimating to social settings outside of institutional settings (Sanders, 2018). The members that carry the diagnoses of a SMI feel more important, happy, free of marginalization, gain social support from staff and like-minded individuals who carry the same diagnoses.

Sanders (2018), reported clients are referred to Southeastern Healthcare of NC to prevent psychiatric hospitalizations due to noncompliance with previous treatment, lack of insight into their mental illnesses as well as inadequate social support. The researcher will create a community mindfulness intervention to assist the members of the day program at Southeastern Healthcare that are diagnosed with severe mental illness (SMI) with decreasing problematic behavior patterns, increasing compliance with treatment, and reporting of an overall increase in functioning. There is little research involving SMI and mindfulness especially in a day program setting.

The researcher has an interest in mindfulness due to the natural effects it has on healing. Studies show a reduction in indicators of physiological arousal such as oxygen consumption, carbon dioxide elimination, and respiratory rate as a result of transcendental meditation (Keng, Smoski, & Robins, 2011, p. 3). The aspects of mindfulness the researcher will use are meditation, mantras, and gratitude journaling.

Meditation involves a calm space where one would practice deep breathing exercises (Norwood & Merritt). Deep breathing is the goal as one will start by taking a deep breath through their nose, bring the air into the body and one should feel and see their stomach fill with air and expand. After the stomach is filled with air one should then release the air through their mouth (Norwood & Merritt, 2017). Essentially, meditation is deep breathing through the nose and released through the mouth. One could meditate for seconds, minutes or hours depending on the person.

A mantra can be any word, sound, phrase, or sentence that brings power and positive energy to that person (i.e. I am at peace, I am loved) (Merritt & Norwood, 2017). The goal is using positive affirmations to incorporate one’s mantra to his or her meditation methods. For example, “I can overcome any obstacle”, “I will succeed”. This is important to all clients in all mental health settings due to the increasing of one coping skills. Using positive affirmations and mantras will redirect negative thoughts and feelings into positive thoughts and feelings. Gratitude Journaling is the free-thinking space that allows one to write down their thoughts and feelings in a positive manner (Norwood & Merritt, 2017). It could be formal or informal meaning, it does not have to be a journal. One can write in a note pad, journal, or a piece of paper, if the person is writing something, he or she feels grateful about. Gratitude Journaling could be goal oriented or simply something good that happened (Norwood & Merritt, 2017). The researcher will use these three components to justify an increase in positive behaviors and to find a correlation in mindfulness and increase in functioning for those diagnosed with SMI.

Comprehensive Lit Review

Mindfulness has been utilized in many clinical settings with various populations. DiGiacomo, Moll, MacDermid, & Law (2016), defined Mindfulness as an evidence-based psychotherapy method. The authors described mindfulness as the “ability for one to be aware of the present moment without judgement” (p. 19).  Mindfulness stems from Eastern philosophies and spiritual platforms, mainly Buddhism. The practice is commonly cultivated through meditation. According to DiGiacomo, Moll, MacDermid, & Law (2016), mindfulness and meditation can be found in almost all the world’s religions (p. 19). Grecucci et al. (2015), described mindfulness in these various religious practices: “yogic meditation in the Hindu tradition, kabbalah meditation in Judaism, contemplative prayer in Christianity, and Sufi meditation in Islam” (p. 1-2). So, mindfulness originated in religious practices, but the benefits have since been adapted to clinical treatment settings.

Furthermore, Neuroimaging is the process that can be used clinically to produce images for brain activity (i.e. magnetic resonance imaging (MRI) or computerized tomography) and can be helpful with seeing the impacts of mindfulness-based interventions (Dormont, Seidenwurm, Galanaud, Cornu, Yelnik, & Bardinet, 2010). Additionally, neuroimaging techniques have allowed researchers to discover the neural mechanisms found in the attentional and body awareness processes (Grecucci, Pappaianni, Siugzdaite, Theuninck, & Job, 2015). Holzel and colleagues said that mindfulness is supported by several interconnected neural mechanisms as hypothesized by Kabat-Zinn. According to Grecucci et al. (2015),

“Scientifically, parts of the brain are stimulated in mindfulness meditation. The cingulate cortex plays a vital role in the merging of attention, motivation, and motor control. The rostral (ACC) part is activated in tasks with an emotional overload, whereas the dorsal (dmPFC) part is triggered by cognitive control tasks” (p. 3).

Therefore, mindfulness has been shown to change the brain physically in ways that support positive psychological functioning.

Mindfulness Meditation

Meditation is a major component of mindfulness. DiGiacomo et al. (2016) defined meditation as “a family of self-regulation practices that focus on training attention and awareness” (p. 19). Meditation practitioners spend a designated amount of time learning to focus their attention on the present moment. Davis, Strasburger, & Brown (2007) said that people educated in mindfulness are taught to note their mental states, but not to get stuck on them or to judge them with aversion. Practitioners are taught to accept and welcome the feelings and thoughts they experience. Mindfulness allows for practitioners to examine emotional and thought patterns for effectiveness and to choose more constructive choices (p.24). They are taught to let go of maladaptive cognitive, behavioral, and emotional patterns that may have been causing the practitioners difficulties functioning in their everyday lives.

The introduction of mindfulness meditation in scholarly treatment started in the medical field. Grecucci et al. (2015), reported that MBSR was developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center to “facilitate adaptation to medical illness that provides systematic training in mindfulness as a self-regulation approach to stress reduction and emotion management” (p. 1-2). According to the authors, over the past twenty years there has been a drastic increase in the amount of clinical interventions based on mindfulness meditation (p. 19). DiGiacomo et al. (2016) said that more than 240 hospitals and international clinics utilized mindfulness-based stress reduction (MBSR) programs (p.20).  The use of mindfulness practice to treat mental health issues is on the rise and more and more programs and researchers are collecting data on the effectiveness of mindfulness with various populations.

Treating Schizophrenia.

Schizophrenia is one of the serious mental illnesses (SMI) which largely consists of psychosis and has a long history of difficulty treating. According to DiGiacomo et al. (2016), “Regardless of factors such as gender, race, culture, religion, or socioeconomic status, 3% of the world’s population experience symptoms of psychosis” (p. 19).  The authors stated that the average person’s psychotic symptoms go untreated for about two years and these individuals will attempt to engage in treatment 2.3 times before finding successful treatment (p. 19). Psychotic symptoms may also exist in other health disorders ranging from mood disorders to substance use disorders. However, psychosis is most prominent in Schizophrenia (p. 19). DiGiacomo et al. (2016) asserted that mindfulness could be useful with treating Schizophrenia in regard to assisting participants with accepting psychotic symptoms “without resisting or redirecting, and not judging themselves because of their experience” (p. 21). Therefore, mindfulness and meditation have a role with treating SMI, specifically Schizophrenia and psychosis.

Mindfulness meditation has been shown to have specific impacts on participants with Schizophrenia. Davis, Strasburger, & Brown (2007) stated that mindfulness can be successfully adapted for use with individuals with psychosis or schizophrenia diagnoses to decrease negative emotional states (p. 24).  Hussien & Rayan (2017) suggested that mindfulness might have a positive impact on symptom severity and number of mental health hospitalizations and increase in overall functioning for participants with Schizophrenia. The researchers also found positive outcomes in suicidality, quality of life, emotional regulation, level of mindfulness, compliance with medication and coping ability (p. 42). These impacts are sorely needed when it comes to treating Schizophrenia.

The impacts of mindfulness meditation that have been shown in research thus far are important because these are impacts that medication alone cannot produce, and medication has been the major avenue for treating SMI historically. According to Lam & Chien (2016), the use of medication with treating Schizophrenia and psychotic symptoms has side effects (p. 210). This often leads to noncompliance with treatment and medication management. Side effects include metabolic symptoms and weight gain, prolonged QT interval sedation and sexual dysfunction. (Lin et al., 2014, p. 678).  There is a need for a variety in treatment for psychosis as noncompliance with current treatment regimens is high. Davis, Strasburger, & Brown (2007) claimed to have the first study adapting mindfulness practice to “help those with schizophrenia manage worry and stress” (p. 23). There is a need for further study and research on the matter.

Mindfulness-Based Interventions

Mindfulness-based interventions describe the actual techniques that are being used to treat mental health disorders. DiGiacomo et al. (2016) described mindfulness-based interventions (MBI) as any “psychotherapeutic intervention with a mindfulness element” (p. 21). Hussien & Rayan (2017) described examples of MBI programs as mindfulness-based stress reduction mindfulness-based cognitive therapy and acceptance and commitment therapy (p. 41). The researchers reported findings that suggest that MBI indicate a promising approach to the treatment of Depression Schizophrenia (p. 41). Emerging research supports the use of MBI to manage stress and anxiety among patients with various mental health disorders. MBI has been shown to address negative symptoms among participants with schizophrenia, depression, anxiety, and emotion regulation (p. 41-42). There is a need in research to identify more MBI’s.

Theoretical Framework

Maslow’s Hierarchy of Needs is the theory chosen by the researcher to determine the impact mindfulness practices will have on the participants functioning, and quality of life as defined by Maslow. Hall & Goodenough (2017) created a needs analysis scaling tool for Maslow’s hierarchy (p 6). Maslow’s Hierarchy of needs have five levels (pyramid-type).

“The First level involves Physiological/Survival Needs: breathing, food, water shelter, clothing, sex, sleep, homeostasis, money procreative. The Second level are Safety/Security Needs: physical, employment, resources, mortality, order, structure, control, the family, health, property.

The Third level are Social Needs: love, affection, connection, bonding, part of a group, approval, friendship, family, sexual intimacy. The Fourth level are Esteem/Self Needs: self-esteem, confidence, importance, achievement, dignity, value, respect of others, respect by others, status, honor. The Fifth level are Self-Actualization Needs: morality, creativity, excellence, exploration, spontaneity, contribution, legacy, and problem-solving, lack of prejudice, acceptance of facts, justice, fairness, and democracy” (Hall & Goodenough, 2017, p. 7).

Furthermore, Maslow’s theory will be used as a measuring tool for the participants at the adult day program at Southeastern Healthcare of NC who have a severe mental illness. This tool is important to the participants with (SMI) mainly due to the inadequate social support and stigma of their (SMI). The Self-Actualization Scale for Needs Assessment (SASNA) instrument tool will be used as a survey for the participants after completing the mindfulness community intervention (Hall, & Goodenough, 2017). The assessment tool will indicate which level of functioning participants are in at the beginning of the intervention and which level they are in at the end of the intervention. For example, one of the questions from the SASNA scaling tool asks participants, do you live in the Red Zone mostly or in the Green Zone mostly? (Hall & Goodenough, 2017) (See Appendix A). The red zone means the participant is experiencing dissatisfaction and is not getting by well, and the green zone indicates the participants is feeling good and is getting by well (Hall & Goodenough, 2017, p. 6) (See Appendix A). Hall & Goodenough (2017) uses the SASNA scaling tool to measure the red zone and the green based of Maslow’s Hierarchy of Needs (p. 6). For example, the scale as it pertains to Maslow’s Hierarchy starts at Survival, Safety, Social, Self and ends at Meta needs (Hall & Goodenough, 2017, p. 6).

The researchers also discussed incorporating mantras (words or phrases) inside of their journals to use for the meditation activity. The mantra’s chosen by the participants can either be used for mantra meditation, replacing negative thoughts with positive thoughts, or for other personal use to increase their coping skills and practices. Additionally, the researcher explained if the group prefers to do the intervention one and one on a micro level then accommodations will be made.

Implications for Social Work

Treating the SMI population has been a longstanding challenge for social work practitioners as evidenced by the difficulties with engaging the population and the difficulties with maintaining compliance with treatment. The SMI population is heavily treated with medication and evidenced-based therapeutic interventions lag. More research should be done to increase evidenced-based therapeutic interventions regarding treating SMI.  Mindfulness -based interventions have started to gain momentum and this study further supports mindfulness practices in use with the SMI population. Moreover, in regards to assisting individuals with a SMI diagnosis, after basic needs are met, the use of mindfulness-based intervention could be used to assist the individuals with high-level functioning. The intervention can increase overall quality of life.