The International Journal of Psychosocial Rehabilitation.

Exploring Hope in Individuals
with Schizophrenia

Janet Landeen, RN, PhD
Assistant Professor, School of Nursing
McMaster University

Mary V. Seeman, MD
Professor of Psychiatry
University of Toronto
 

Citation:
Landeen, J. & Seeman, M.V. (2000)  Exploring hope in individuals with
Schizophrenia. International Journal of Psychosocial Rehabilitation. 5, 45-52


Acknowledgments:
This study was support by a grant from the Bertha Rosenstadt Fund, University of Toronto, 1996.
Abstract
The purpose of this study was to assess the stability of hope, measured over a three-month period and to assess the effectiveness of a short-term intervention for individuals with long-standing schizophrenia. A before-after study design was used. The level of hopefulness was measured in thirty subjects, using the Miller Hope Scale. Eleven subjects self-selected to attend an inspirational lecture delivered by an individual who was coping well with schizophrenia. All 30 were tested again 2 and 6 weeks after the lecture. Subject bias was tested on each occasion using the Social Desirability Scale. The entire group had no significant change in hopefulness over time (F=1.86, df=2, p=.165). At the two post-test times, no significant difference was found between attenders and non-attenders on their level of hopefulness (F=.03, df=2, p=.968). The study group (x=142.30, SD=26.74) was 20 points lower on the Miller Hope Scale than the norms for healthy, normal adults (x=164.46, SD=17.65), but with larger variation in scores. This pilot study found that hope is a relatively stable phenomenon in individuals with long-standing schizophrenia. The relatively large variations in hopefulness indicates the need for future studies examining factors that influence this variation. The evaluation of the one time inspirational lecture found no long-term effect on hopefulness.

Introduction
The outlook for individuals with schizophrenia has changed dramatically over the years, partially due to changes in diagnostic criteria (Hegerty, Baldessarini, Tohen, Waternaux, & Oepen, 1994). It has also changed as a result of the findings of very long-term follow-up studies which demonstrate better outcomes than were previously thought possible (Harding, Zubin, & Strauss, 1987). However, the new view of prognosis is not necessarily communicated in the treatment settings of individuals with schizophrenia (Deegan, 1988; Harding & Zahniser, 1994; Leete, 1993).
Psychosocial rehabilitation is an approach aimed at improving the outcome (or induction of recovery) for individuals with schizophrenia. Promoting a hopeful attitude is one of its basic principles (Anthony, Cohen & Farkas, 1990). Some first person accounts of schizophrenia describe regaining hope as a turning point in recovery (see for example, Deegan, 1988 and Lovejoy, 1984).

The past decade has witnessed a dramatic rise in the number of individuals with schizophrenia coming forward to share their stories. Consumers and professionals alike have been inspired by the stories of individuals reclaiming their lives despite serious obstacles (Hatfield & Lefley, 1993). What is the actual impact of this increased openness? Many believe that it challenges the conventional wisdom of the outcomes of schizophrenia and brings hope to individuals living with the illness.

Most of the research on hope in various populations has been cross sectional in nature (Farran, Herth, & Popovich, 1995; Fehring, Miller, & Shaw, 1997) and there has been virtually no research on the natural variance of hope over time in individuals with schizophrenia. Existing literature on hope suggests that supportive relationships and positive role models could serve as hope-inspiring interventions (Farran, Herth, & Popovich, 1995; Dufault & Martocchio, 1985; Kirkpatrick, et al., 1995). One study of homeless veterans found increased levels of hope among participants following a hope-inspiring group strategy when compared to a control group (Tollett & Thomas, 1995).

There is limited research on hope and individuals with schizophrenia. Hopelessness, conceptualized as low self-concept, depression and external locus of control, was associated with poor rehabilitation outcome in a study of 46 individuals with schizophrenia (Hoffmann, Kupper, & Kunz, 2000). A study on hope in individuals who were hospitalized for schizophrenia demonstrated that hope improved in 14 suicidal individuals using a combination of medication and psychosocial treatment (Littrell, Herth, & Hinte, 1996). In a cross-sectional study of individuals with schizophrenia, Landeen, Pawlick, Woodside, Kirkpatrick, and Byrne (2000) found significant correlations between hopefulness and a subjective sense of health. To date, there has also been virtually no research into the effectiveness of particular hope-inspiring strategies in schizophrenia.

While definitions of hope vary, nearly all include the idea of a positive, future orientation. For the purposes of this study, Millerís (1986) operational definition of hope has been used:

Hope is a state of being characterized by an anticipation for a continued good state, an improved state or a release from a perceived entrapment. The anticipation may or may not be founded on concrete, real world evidence. Hope is an anticipation of a future which is good and based upon: mutuality (relationships with others), a sense of personal competence, coping ability, psychological well-being, purpose and meaning in life, as well as a sense of 'the possible' (p. 52). The purpose of this pilot project is to determine the stability of hope in individuals with long-standing schizophrenia over a three-month time period and to assess the effectiveness of a short-term intervention of their levels of hopefulness.

Operating hypotheses are as follows. 1) Levels of hope in individuals with long-standing schizophrenia, as measured by the Miller Hope Scale (MHS) (Miller & Powers, 1988), will differ significantly over time. 2) Individuals with schizophrenia who self-select to attend an inspirational speech given by an individual who is coping well with schizophrenia are more hopeful at baseline than their non-attending counter-parts. 3) A positive change on the MHS will be related to attendance at an inspirational speech and this change will be sustained over time. 4) Individuals who are more hopeful are no more likely than the general public to answer questionnaires in a manner they think the researchers expect, as measured by the Social Desirability Scale (SDS) (Crowne & Marlowe, 1960).

Methods
The study uses a before-after design, with subjects completing questionnaires prior to the lecture and at two follow-ups, approximately one month apart. One of the researchers was present during test administration to ensure that participants answered all questions thoughtfully. The study received Ethics approval from the Review Committee on the Use of Human Subjects, University of Toronto.

Sample
Individuals who were clients of the Continuing Care Division of Centre for Addictions and Mental Health, Clarke Site were invited to participate in the study. Inclusion criteria were: a diagnosis of schizophrenia as defined by a SCID-determined DSM-IV diagnosis of schizophrenia (American Psychiatric Association, 1994) and the ability to read and understand English at a Grade 5 level or higher.

The Intervention
The existing research and theoretical literatures on hope identify relationships as being key ingredients in promoting hopefulness (eg. Farran, Herth, & Popovich, 1995; Dufault, & Martocchio, 1985; Byrne, et al., 1994; Frank, 1968). Many authors discuss the contagious effects of both hopefulness and hopelessness (Farran, Herth, & Popovich, 1995; Landeen, et al., 1996). Schizophrenia can challenge the individual's ability to form and maintain reality-based, hopeful relationships both due to the illness itself (Seeman & Greben, 1990) and to the isolating stigma, which occurs in relation to the illness (Deegan, 1988; Leete, 1993). As identified earlier, one strategy that has been identified by staff working with individuals with schizophrenia for enhancing or supporting hope is connecting individuals to positive role models (Kirkpatrick, et al., 1995). One way to facilitate this connection is through a one-time lecture delivered by an individual who is coping well with schizophrenia.

Mr. William McPhee, publisher of Schizophrenia Digest and the 1997 recipient of a Schizophrenia Society of Canada award, is a Canadian consumer who gives public addresses about his personal experiences of schizophrenia and his story of recovery. He has talked to family and consumer groups and is currently being sponsored to deliver talks across Canada. Mr. McPhee was a Bertha Rosenstadt Lecturer at the Clarke on March 6, 1996. Consumers, family, and staff were invited to attend the lecture. Notices were posted and included in publications consumers were likely to read. Pizza was served after the lecture to encourage attendance. Staff at the Day Centre, from which most of the study participants had been recruited, encouraged members to attend the lecture. However, neither staff nor consumers knew that the lecture was part of the research design.

Measurement
All subjects were aware that they were volunteering in a study that measures hope, and this, in itself, might have influenced the level of hopefulness of the subjects. However, subjects were blind to the inclusion of the inspirational talk as part of the study, thus reducing the sampling bias for impact of the intervention. In addition, all subjects completed the Marlowe-Crowne Social Desirability Scale (SDS) to determine if the subject group is more likely than the general public to respond in a manner they believe the researchers want (Crowne & Marlowe, 1960). The SDS has established reliability and validity and is used extensively in research.

All subjects completed a Miller Hope Scale (MHS), which measures multidimensional aspects of hope, and has established reliability and validity in handicapped and non-handicapped samples (Miller & Powers, 1988) and has been used in psychiatrically ill populations (Holdcraft & Williamson, 1991; Landeen, et al., 2000).

Data were analyzed using repeated measures ANOVA to test for variability over three points in time and to compare the attenders and non-attenders. Z tests were used to compare the means of the subjects to published norms for healthy adults on the two scales (MHS and SDS). Pearson correlations were used to analyze the relationship between subjects' scores on the two scales (MHS and SDS).

Results
Forty five individuals volunteered to participate in the study. Six subjects were excluded because they did not meet a DSM-IV criteria for schizophrenia as measured by the SCID. Nine individuals dropped out of the study. A comparison at baseline of included and excluded subjects and drop-outs using two-way ANOVA did not reveal statistically significance differences on either measure (Miller Hope=F Ratio 2.380, p =.11 and Social Desirability=F Ratio .089, p=.915). However, the differences approached significance for level of hope, with the drop-outs being least hopeful.

A total of 30 subjects met all of the inclusion criteria and completed all of the measures. The average age of the group was 38, with 73% of the sample being male. (See Figure 1.)

Figure 1
Demographics for Total Group (n=30)
Gender
Male 

Female

 
22 (73.3%) 
8 (26.7%)
Age
x =38.47 
SD = 8.73
Marital Status
Single 

Married 

Sep/Div

 
25 (83.3%) 
2 (6.7%) 
3 (10%)
Years Ill
x = 17.03 
SD = 8.51
The entire group had no significant change in hopefulness over time (F=1.86, df=2, p=.165) using repeated measures ANOVA. This pilot study found that hope is a relatively stable phenomenon in individuals with schizophrenia.

No significant differences were found from published scores of healthy, normal adults on either scale (p = .20 for MHS and p >.20 on SDS) using two-tailed t-tests. The study group (x=142.30, SD=26.74) was 20 points lower on the Miller Hope Scale than the norms (x=164.46, SD=17.65) which would lead one to suspect significance. This was not achieved probably due to the large variation in individuals with schizophrenia. This high degree of variability is, in itself, an interesting finding as the fluctuations in hope among individuals with schizophrenia has not been established. The lack of difference on the Social Desirability Scale was in the predicted direction, indicating that study subjects were no more likely than the general public to tell the researchers what they wanted to hear.

Both the MHS and SDS were administered at each testing point. On the first occasion there was a moderate correlation (r=.365) using Pearson correlation. This correlation disappeared by the second testing point (Time 2 r=.160 and Time 3 r=.269).

No statistically significant differences were found between the attenders (n=11) and non-attenders (n=19) on demographic data or on the level of hopefulness or desire to please the researchers at baseline using t-tests. (See Figure 2). At the two post-test times, no significant difference was found between attenders and non-attenders on their level of hopefulness (F=.03, df=2, p=.968) using repeated measures ANOVA. Thus, this pilot study found no effect of the inspirational talk on level of hopefulness.

Figure 2

Comparison of Attenders and Non-Attenders

  Attenders

n=11

Non-Attenders

n=19

Total

n=30

Gender Male

Female

7 (63.6%)

4 (36.4%)

15 (78.9%)

4 (21.1%)

22 (73.3%)

8 (26.7%)

Age x = 41.36

SD = 8.21

x = 36.79

SD = 8.79

x = 38.47

SD = 8.73

Marital Status Single

Married

Sep/Div

9 (81.8%)

0

2 (18.2%)

16 (84.2%)

2 (10.5%)

1 (5.3%)

25 (83.3%)

2 (6.7%)

3 (10%)

Years Ill x = 20.36

SD = 8.95

x = 15.11

SD = 7.84

x = 17.03

SD = 8.51

Baseline Comparisons Hope  x = 140.53

SD = 28.28

x = 138.36

SD = 28.84

p=.51
Social Desirability x = 14.91

SD = 4.23

x = 17.53

SD = 4.93

p=.66
Discussion
There was no significant change in hope over time for the entire group, with all of the multivariate tests of significance producing the same results. The time period of approximately three months may have been insufficient for there to be any change, indicating that levels of hope are relatively enduring in individuals with long-standing schizophrenia. Alternately, the instrument may be insensitive to minor fluctuations in hopefulness, although minor fluctuations would be of little clinical significance.

The relatively large variation in hope in the group with schizophrenia (x=142.30, SD=26.74) compared to the published norms (x=164.46, SD=17.65) indicates that there is more to uncover in investigating hope in individuals with schizophrenia. Identifying factors that influence that large variation is of great clinical significance, particularly because the suicide rate is approximately 10% among individuals with schizophrenia (Seeman & Greben, 1990) and hopelessness and depressions have been previously correlated with higher rates of suicide in individuals with schizophrenia (Caldwell & Gottesman, 1990; Tanney, 1992).

The lack of a demonstrated effect of the lecture on the attenders' levels of hope was disappointing. This may be due to a number of factors. First, it was projected that a minimum sample size of 16 per group was required to allow for statistical significance using a standard formula for calculation (Streiner, 1990) and projecting an effect size of 1 standard deviation on the Miller Hope Scale (MHS) following attendance at the inspirational lecture. This projected effect size on the MHS is consistent with the findings of Holdcraft and Williamson (1991) for a mentally ill population comparing initial and post hospitalization rates. Despite an original sample size of 45 and aggressive advertising of the lecture, only 11 study participants attended the lecture. Thus, the impact of the lecture would have had to been quite large for statistical significance to be reached. The very nature of any one-time lecture would be unlikely to produce such dramatic effects given the complex nature of hope. Also, this research was conducted with subjects with long-standing schizophrenia (x=17.03 years). These individuals may have reached a level of acceptance of their illness, or at a minimum, have developed a relatively stable coping pattern, which includes their levels of hopefulness. Future research on hope in schizophrenia should explore variations in hope in individuals with differing durations of illness in order to explore the stability of hope and to identify optimal timing for interventions. It makes clinical sense that individuals with different illness trajectories will require interventions of varying lengths and strategies, of which a hope-inspiring lecture might be one component.

The timing of the follow-ups was designed to capture long-term effects of attending an inspirational speech, and no attempt was made to evaluate hopefulness immediately following the lecture. It may be that the effects of such an intervention are short term and that there may be a short-term window of opportunity in which to clinically intervene to bolster the effect of such a speaker. Thus, the future research should include immediate as well as longer-term follow-ups.

The low correlations between the MHS and the SDS and the similarity of the participants scores with those of healthy adults indicate that there were no discernable patterns between level of hopefulness and desire to tell the researchers what they thought the researchers wanted to hear. Thus, future research evaluating hope-inspiring interventions can have a more open design, allowing for evaluation of hopefulness immediately following interventions.

Conclusion
This pilot study demonstrated that hope is relatively stable in individuals with long-standing schizophrenia. A direction for future research is to establish the stability of hope in populations with differing durations of illness. The study also found relatively large variations in hopefulness among the participants, indicating the need for future studies examining factors that influence this variation. The evaluation of the inspirational lecture found no long-term effect on hopefulness. However, this type of intervention remains promising for inclusion in longer-term, hope-inspiring interventions that are tailored to individuals with varying degrees of experience in living with schizophrenia. This pilot study does begin to unravel some of the basic understanding of hope in individuals with schizophrenia.

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