Enhancing Wellbeing for Older Adults With Serious Mental Illnesses: Co-Producing a Positive Psychology Course With Certified Older Adult Peer Specialists

Abstract

Compared to peers in the general population, persons aging with serious mental illnesses (SMIs) face physical health disparities, increased isolation, and decreased subjective experiences of quality of life and wellbeing. To date, limited intervention research focuses on addressing specific needs of persons aging with SMIs and no interventions targeted for that population are informed by the theory and science of positive psychology. With the aim of co-producing a positive-psychology-based program to enhance wellbeing for older adults with SMIs, the author held a series of focus groups and individual interviews with six certified older adult peer specialists. Analysis of the data developed in-depth insights into helpful processes, values, and priorities of individuals aging with SMIs, as well as the creation of a wellbeing-enhancing course curriculum.

Keywords

Older adults serious mental illness co-producing research enhancing wellbeing peer specialists focus groups North America

Introduction

Approximately 5% of adults in the United States carry an SMI diagnosis, such as a schizophrenia-spectrum disorder, a bipolar or related disorder, personality disorders, or severe presentations of any number of other diagnoses (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). SMIs are broadly associated with physical health disparities, psychosocial disability, cognitive impairment, problematic alcohol and substance use, relationship and employment problems, medical problems, and social isolation far surpassing that of the general population (Castle & Morgan, 2008; Hafner & Heiden, 2008). Symptomatic and functional recovery across the life course is possible for many persons so diagnosed and the course of an SMI and related recovery processes are diverse and defined by individuals’ subjective experiences and individual psychosocial contexts. Nonetheless, many persons diagnosed with SMI in late adolescence or young adulthood, as is the typical onset, experience a course of illness with symptoms and psychosocial consequences extending past the age of 55 years and into later life (Bankole et al., 2008; Meeks & Jeste, 2008). Psychiatric symptoms, health disparities, and the many psychosocial consequences of SMIs interact with later life challenges to create unique problems in living for this group of older adults, such as poor physical health and limited social and economic resources (Cummings & Kropf, 2011).

Despite marked disparities faced by persons with SMI and a growing evidence-base of psychosocial interventions for the population of persons with SMI in general (see e.g., Rubin et al., 2011), few interventions address aging with SMIs specifically (Cummings & Kropf, 2011; Zechner et al., 2019). Most address social skills deficits and/or use cognitive behavior therapy (CBT), with an eye toward dual health and mental health management (Cummings & Kropf, 2011). Much of the existing research into the needs of older adults with SMIs identifies skills-deficits and lack of full community participation (Cummings & Kropf, 2011), but fail to acknowledge the resilience-promoting skills and strengths that allow the population to survive, which alone can be considered a success in light of life course adversities they face (Henwood et al., 2014). For example, coping appears to increase among older adults with SMIs, especially among those who have participated in rehabilitative programs earlier in life (Cummings & Kropf, 2011). Overall, although this group of older adults by definition must have important sources of resilience, these sources have been under-explored in the scientific literature to-date. Furthermore, understanding and enhancing sources of wellbeing in this population could have important implications for advancing recovery-oriented treatment.

A steadily growing body of research addresses the subjective experience of aging with an SMI and can be used to understand subjective wellbeing, as well as to inform new treatment initiatives. Shibusawa and Padgett (2009) found through thematic analysis of case studies, the experience of aging with SMIs included themes of reflecting on losses, growing older and wiser, struggling with normality, having space and time to reevaluate, and awareness of the future and “time left,” all of which situate these older adults in an experience defined by the intersection of aging and life course experiences of mental illnesses, rather than one or the other. Ogden (2014a) found that in later life, persons with schizophrenia-spectrum disorders experience the challenge of lost or absent interpersonal relationships, and demonstrate wellbeing in their recovery of those relationships as well as in adapting relationships with professionals and/or peers to meet their social and emotional needs. Similarly, Padgett et al. (2020) found for the same population that careful restoration of relationships was an important part of this stage in the life course. While older adults with SMIs are disproportionately represented in the lowest socioeconomic brackets, their self-narratives also indicate later-life strivings toward meaningful work and careers that were thwarted by psychiatric illness in earlier life, demonstrating needs for meaning and purpose in their vocational narratives and narratives of lifelong goals, hopes, and dreams (Ogden, 2018). Overall, research into the lives experience of older adults with SMI finds these individuals express less interest in mental health symptom management and more interest in integrating a satisfying and whole sense of self and belonging, wherein addressing mental health is important only to the extent that it supports that larger goal (Ogden, 2014b; Padgett et al., 2020; Reynolds et al., 2020). Furthermore, expressions of hope and the need to maintain hope are central to narrative understanding of older adults with SMIs (Ogden, 2014b; Padgett et al., 2020).

Person-centered, recovery-oriented research into living with SMIs indicates that recovery from SMI is not the absence of illness or symptoms, but rather the ability to find meaning, purpose, and hope in one’s life regardless of presence or absence of psychiatric symptoms (SAMHSA, 2012). This is also a core concept of wellbeing that emerges in the “positive psychology” approach to mental health. Positive psychology can thus be considered an approach that intersects with SAMHSA’s “recovery-oriented” approach to SMIs (Park & Chen, 2016). Connected to humanistic and cognitive-behavioral psychological theories, positive psychology is the scientific study of positive emotions, character traits, and strengths that enable people to confront challenges and create meaning; and of what factors in life make people feel it is worth living (Seligman, 2002, 2012; Seligman et al., 2005). Rather than focus upon helping the unwell feel less unwell by decreasing psychopathology, positive psychology suggests that psychosocial interventions should focus upon helping people thrive across important areas of their lives by enhancing their inherent sources of strength and resilience that create a subjective sense of wellbeing.

Positive psychology research is informed by the theory of wellbeing, often known by the acronym “PERMA” theory, which proposes that subjective and objective human wellbeing comes from a combination pleasant emotions; full engagement in activities within the major domains of life; positive and healthy interpersonal relationships; a sense of meaning and purpose that leads engagement in meaningful activities; and achievement for the sake of achievement (Seligman, 2012). Pleasant emotions clearly have a role in wellbeing, and can be enhanced through activities such as savoring practices, but are statistically less important to wellbeing than the theory’s other concepts. In particular, positive and healthy relationships and a sense of meaning and purpose appear to have the strongest correlation with wellbeing (Seligman, 2012).

Positive psychology interventions have growing evidence supporting their effectiveness for broad swaths of the general public and for those with specific psychosocial problems (Bolier et al., 2013; Donaldson et al., 2014), for improving mood and building personal resources (Cohn & Fredrickson, 2010), and for enhancing psychosocial interventions to prevent and treat psychopathology in mental health care settings (Duckworth et al., 2005). Although a great deal of positive psychology addresses thriving in later life (e.g., Ho et al., 2014; Melendez Moral et al., 2014) and Slade et al. (2016) have published a book describing an evidence-informed positive psychology intervention to support recovery from psychosis, to date there has been no positive-psychology informed intervention designed to improve the lived experience of aging with SMI (Park & Chen, 2016). According to narrative gerontology, a satisfying and whole sense of belonging is the developmental task of all older adults (Randall, 2011) and it is also a product of positive psychology interventions designed for older adults that use reminiscence as a central tool (Melendez Moral et al., 2014) and for persons with psychotic disorders (Slade et al., 2016). Thus, a positive psychology informed program designed to improve the wellbeing of older adults with SMIs has a strong theoretical and empirical grounding.

The development of empowering, person-centered interventions begins with listening to members of any target population effectively and advancing those insights into novel interventions (Flanagan et al., 2007). The tradition of co-producing social science research comes from an anti-oppressive social constructivist theoretical frame that emphasizes the de-centering of power and sources of knowledge in resource and situating it equally across stakeholders so that problems are formulated accurately and relevant, usable solutions can be created. Co-producing interventions is increasingly viewed as central to fully addressing the unmet needs of individuals with SMIs (Fortuna et al., 2019). Co-producing an intervention is the process that involves all stakeholders in the research process that develops new knowledge, protocols, and/or interventions to increase its relevance and acceptability to the groups who would eventually be served or otherwise affected by them (Hickey et al., 2018).

Certified older adult peer specialists (COAPS) are important stakeholders for co-producing research focused on older adults with SMIs, as they serve as both members of the population and as service providers. COAPS are older adults (aged 50 years and above) who are in recovery from a mental illness according to the SAMHSA (2012) definition of recovery. They have completed a certified peer specialist training and as many as 21 additional hours of training in working as a peer specialist with older adults. COAPS are considered role models of person-centered recovery who may work wherever behavioral health services are delivered and whose training generally includes such skills as active listening, appropriate self-disclosure, inspiring hope, and goal setting (Zubritsky et al., 2015). Connecting with peers in general can decrease self-stigma and increase subjective sense of wellbeing (Corrigan, 2016). In the United States, where the study was conducted, the availability and funding for mental health services provided by COAPS varies by state, but represents a growing initiative in mental health services and research. The direct input of COAPS into the development of an intervention or initiative for older adults with SMI can thus deepen the role of subjective experience into, and thus relevance of, new psychosocial interventions and initiatives.

The aim of the research in the present study was to determine what elements of existing evidence-informed positive psychology interventions were important to older adults with SMIs, and specifically those serving in the role of COAPS, and how such an intervention could be designed and delivered to support and enhance their wellbeing in an empowering way. As such the central research question of this project asked, “What do COAPS think will improve the experience of aging with an SMI?” More specifically, it asked COAPS how a psychosocial intervention should be structured, measured, and delivered, and what the content should look like through engaging in conversations centered on close examination of a proposed positive-psychology-informed wellness-enhancing intervention for older adults with SMIs.

Methodology

To address the research question in the present study I used a series of focus groups and individual interviews with COAPS to identify meaningful outcomes and empowering service delivery methods, and to develop consensus around a proposed positive-psychology informed intervention that aimed to improve the experience of aging with SMI by supporting and enhancing wellbeing. Focus groups were an ideal method for this study, as conversations could develop consensus as well as identify significant areas of diverging opinions to guide and troubleshoot intervention design. After the series of focus groups was complete, I conducted individual interviews for member-checking and to address methodological concerns of social desirability bias within the focus group discussions. I developed understanding of the underlying values and priorities of the group through thematic analysis of the data, as well as using the data to inform development of the proposed intervention.

Sampling and Participants

I used a purposive sampling strategy to identify a clearly defined target population, COAPS, who would be uniquely able to speak to the issues raised in the focus group both from personal experiences and experiences related to their work as peer specialists. Inclusion criteria were that they were older adults (50+, due to premature aging of the population), living with SMIs (any diagnosis, self-disclosed), and trained as older adult peer specialists through the local department of mental health (DMH.) Exclusion criteria included inability to demonstrate capacity to provide informed consent, and non-English language speakers. COAPS were recruited through a series of three emails to a listserv of COAPS, in collaboration with the DMH. COAPS who received the email describing the focus group study were instructed to email the author of this paper for more information and to join the study.

Ethical Considerations

I obtained internal review board permission through the DMH and the author’s host university. Due to the vulnerable nature of the population, I screened potential participants for capacity to provide informed consent, and gathered verbal informed consent during a telephone screening conversation. I gathered written informed consent from participants at the beginning of the first focus group. Participants signed additional informed consents prior to the individual interviews.

Many participants knew one another from COAPS trainings and other events. They were coached and given reminders about keeping one another’s participation in the present study confidential; however, they were not discouraged from having interpersonal relationships with one another beyond the context of the study. Another ethical consideration was disclosure of identifying or very personal information in the interviews, and the implications of so-doing was discussed in the first meeting, with emphasis on confidentiality and safety, to ensure participants were comfortable contributing to the group discussions. At my suggestion, participants gave themselves code names (i.e., Bruce Springsteen, Purple, Daisy), which they wore on name tags so others could refer to them by those names, to avoid being identifiable to the professional transcriber and increase confidentiality.

Because the participants were peer specialists, trained to talk with others about mental health and other life challenges, the likelihood they would become distressed during any of the conversations was low, despite their lived experiences with mental illnesses. If a person had appeared distressed or expressed distress, as a licensed clinical social worker, I am trained to assess distress and determine what steps need to be taken, as well as to mediate conflict in group settings. This problem did not emerge.

Research Design

The project began with a series of five focus groups that lasted for about 2 hours each, with a short break in the middle. Focus groups were held every 2 weeks. I facilitated the focus groups in collaboration with a graduate research assistant. At the beginning of the first focus group, participants were provided with a color-printed and bound guide for the focus group presentations and discussion questions. The outline of the focus group meetings is presented in Supplemental Table 1.

For the first three groups, we focused discussions on the context and conditions in which such an intervention would be useful, with a few specific examples of content provided to contextualize the discussion. In groups 4 and 5, we focused on examining the specific content more directly. In these latter group sessions, I presented and offered brief opportunities to practice skills, strategies, and exercises evidenced for effectiveness in enhancing wellbeing. The content I proposed included evidence-informed positive psychology material created for older adults, which was sourced from Ho et al. (2014); created for persons with SMI and sourced from Slade et al. (2016); and created for the general population, sourced from Duckworth et al. (2005) and Seligman (2012). I had edited and combined this existing content to better meet the aforementioned specific needs of older adults with SMIs. In terms of structure, I based the proposed intervention generally on the illness management and recovery (IMR) session model (see Meyer et al., 2010, p. 37), with variance to allow for weekly positive psychology exercises and the focus on evidence-informed positive psychology material, rather than what is typically included in IMR groups.

The focus group guide, described by Supplemental Table 1, geared conversations, but was used flexibly, and the format of the groups and content of discussion were driven by the participants’ interests and lead in conversations. For example, in the first group I aimed to present the orienting theory of positive psychology, positive psychology measures, and a positive psychology exercise, in which the group would participate if interested. However, the group was interested in getting to know one another, and then became engaged in discussion of the theory and applications of positive psychology, and so the remainder of the material was covered on subsequent weeks. Following participant leads, rather than strictly adhering to the focus group guide, was important to the integrity of the focus group process, wherein as a researcher I served as a facilitator or moderator of discussion between participants, rather than centering my role and conducting a group interview (Parker & Tritter, 2006).

In general, each week began with ice breakers, opportunities for participants to help themselves to snacks and drinks, and a re-cap from the previous week in which I sometimes asked questions based on my process memos of the earlier group. Then, new material was presented and discussed. There were no formal decision-making processes within the focus groups—instead the goal was to generate open discussion wherein all voices were heard. Meetings often closed with a positive psychology exercise and participants typically lingered for informal discussions with each other, me and the graduate student research assistant.

At the end of the fifth group, participants were invited to meet with me for individual member-checking interviews. The meetings offered an opportunity for participants to review and give feedback on the draft curriculum that had emerged from the focus groups, as well as to provide feedback on the focus group process, and also served to reduce some social desirability bias. All participants were invited to join the ongoing project’s advisory board.

Focus groups were held on the host university campus in a private conference room, audio-recorded, and professionally transcribed verbatim. Individual interviews were also audio-recorded and professionally transcribed.

Analysis

Qualitative data analysis was completed using Microsoft Word Software to code the interviews using the comment function, locate texts associated with themes using the text search function, which also was useful in comparative analysis and memo-writing. Existing qualitative software programs are most helpful with large databases and geared toward larger scale studies (Creswell, 2007), and the scope of the present study did not necessitate the use of such software as their central functions could be replicated through Microsoft Word.

Both directed content analysis (Hsieh & Shannon, 2005) and inductive and deductive thematic analysis (Fereday & Muir-Cochrane, 2006) were used to analyze the data. Directive content analysis is typically used to develop or extend existing theoretical frameworks (Hsieh & Shannon, 2005), but in this case, was used to develop the framework for a proposed intervention grounded in wellbeing theory (Seligman, 2012). Key concepts and variables were identified and defined through the guide presented within the focus group, and analysis centered on participants’ response to the material, seeking responses that indicated support or lack of support for the presented material, as well as any novel approaches or ideas introduced by participants. Rather than look at frequency of responses as is traditional in directive content analysis, I used a constant comparison process to examine whether responses conveyed consensus, majority agreement, or disagreements. This analysis informed revisions to the proposed curriculum

Next, in the thematic coding process, I looked again at the material with wellbeing theory (Seligman, 2012) orienting the process, parallel to how it had oriented the focus group guide and discussions. I applied broad codes of pleasant emotion, engagement, relationships, meaning, and achievement, the concepts that make up the structure of wellbeing theory, in the initial round of coding (Fereday & Muir-Cochrane, 2006). I used analytic memos to summarize the results and identify new themes that did not fit with wellbeing theory. Subsequently, I examined the data supporting all codes to determine processes and underlying meanings within the data and used this analysis to identify the most salient themes.

I used the data analysis to draft an outline psychosocial “intervention” to share with the participants in the individual member-checking meetings. I also used the member-checking meetings to check-in about the other meanings and processes I had observed in my analysis.

Results

The project design yielded qualitative data from a total of five 2-hour long focus groups with six COAPS and hour-long individual interviews with four of the COAPS. Two declined individual interviews because of other commitments. In total, there were approximately 14 hours of data and additional data were collected in observation and process memos by myself and the graduate research assistant.

The recruited COAPS group consisted of two men and four women, all identified as White, with an age range of 61–72 years. Participants disclosed they had variously been labeled with and identified as having the psychiatric diagnoses of bipolar disorder types 1 and 2, major depressive disorder with psychotic features, and anxiety disorder. Two COAPS also disclosed co-occurring substance use disorders, now in remission. All COAPS reported they took medications for their psychiatric diagnoses as well as for medical conditions. Our work together to co-produce an intervention to enhance wellbeing for older adults living with SMIs changed the structure and processes of the proposed intervention.

In this section, I first present findings from in-depth analysis of the transcribed data, which yielded insight into values and priorities of older adults with SMIs, contextualized by the evidence-informed positive psychology material presented in the focus groups, and oriented by wellbeing theory in the discussions and the data analysis. I also include a description of processes that the COAPS felt important to include in the psychosocial intervention, to create an empowering and achievement-oriented experience, which is in line with both mental health recovery and positive psychology.

In brief, COAPS agreed that rather than an “intervention” our work together should be designing a “course” to enhance the wellbeing of older adults with SMIs, and that it would ultimately be led by peer specialists and/or staff with “lived experience” of mental health challenges. Although such a course might be suitable for many settings, ultimately a psychosocial clubhouse was agreed upon as ideal, because such settings promote recovery-oriented, empowering approaches to work with persons with SMIs.

The most challenging discussions were about how and when to measure successfulness of the course. Overall, the COAPS agreed a positive psychology informed course is an acceptable approach to enhancing the wellbeing of older adults with SMIs, and their feedback reflected deeper values and priorities. These values and priorities, presented herein, are worth examining outside of the specific course content, as they can easily be applied to other courses or interventions, or to work more broadly with this population.

In the findings presented below, all cases where quotations are used reflect direct words or statements from the COAPS. Grammatical errors or inconsistencies are maintained for authenticity. In-depth thematic analysis of the data yielded categories of findings, which can be summarized as an overview of what matters to COAPS, as organized by wellbeing theory, and in the context of considering how a psychosocial intervention could enhance wellbeing for individuals like themselves and/or their peer-clients.

Pleasant Emotions: All Emotions are Important

The concept of and research on pleasant emotions and their connection to wellbeing was presented to COAPS in the first focus group, and COAPS discussions returned to the topic in several of the subsequent groups and individual interviews. Exercises to enhance pleasant emotions were also examined and discussed, including through a “what-went-well” exercise that asked participants to identify positive experiences in their daily lives and intrapersonal strengths that contributed to them (Seligman, 2012) and savoring activities. However, pleasant emotion for its own sake was not a priority for the COAPS, who were uninterested in merely chasing happy moods.

Instead, a recurring theme was the importance of validating all emotions, including unpleasant ones. As one woman noted, “It’s ok to feel sad also.” Another woman agreed, adding that personality determines what a balanced life looks like for an individual,

I have a friend who’s just gregarious, she’s out all the time, she’s got a million people to phone and when you’re with her she’s getting texts, she’s doing all this stuff, and I don’t do any of that, that’s just not my personality . . . I’ll never be that gregarious. And I think it’s okay, it’s who you are. And you learn to sort of be okay with that.

Pleasant emotion was thus partly found in living life on one’s own terms, and COAPS agreed self-acceptance was important than seeking pleasant emotions.

Pleasant emotions were found in appreciating small moments in life, and the savoring exercises resonated more than the “what-went-well” exercise. One of the men noted, “For me happiness oftentimes is a moment, it’s a blast of some interaction or hearing something that’s amazing for me—closing my eyes and listening to the rush of water. I mean, those are moments of happiness.” Pleasant emotions magnified by savoring activities were reframed through their concept of appreciating small moments. As one participant summarized, “Savoring life—that’s great.”

Rather than focusing on “what-went-well,” the COAPS indicated that “real challenges,” “hardships,” “places where we get stuck,” and “whole experiences” should be validated, and that narrow focus on pleasant emotions would be avoided. The graduate research assistant introduced what is called the “rose-bud-thorn” exercise (see: Gonzalez, 2020), an ice-breaker tool which emphasizes the positive and hope but allows for “thorns,” and it was agreed this would be a good way to begin each class session rather than “what-went-well.” For COAPS, it needed to be ok not to be ok.

Achievement is More Important Than Treatment

The wellbeing enhancing effect of achievement for the sake of achieving, another core tenet of wellbeing theory, was valued by the COAPS. By the third focus group, the COAPS made it clear that designing another intervention was not as interesting to them as designing a class or course (the terms were used interchangeably). The language shift from intervention to class reflected treatment and intervention fatigue they believed older adults with SMI experience, and that some felt in their own lives. Significantly, offering the material as an educational program for older adults with SMI offered an opportunity for achievement, viewed as far more desirable than a new treatment or intervention. They observed that existing behavioral health programs, including psychosocial clubhouses, offered “mental health recovery classes,” and so, a positive psychology class designed to improve the wellbeing of older adults with SMIs fit into the general framework of those classes. A class offered an opportunity to achieve something, rather than to take on a “sick role,” which can be “hard to shake” anyway.

COAPS suggested acknowledging the achievement of completing the course with a certificate at the end, enhancing the wellbeing of program participants one final time. However, they later decided the course should be ongoing to support interpersonal relationship development. Therefore, we agreed the certificates would be delivered after a participant attended 12 class sessions, and again every time the participant attended 12 more. If the participant had perfect attendance for 24 classes in a row, they would receive a certificate for that. There would be no negative consequences for missed classes.

To add empowerment to the certificate process, I proposed an element where classmates would sign each other’s certificates in addition to the instructor and the peer specialist, which was well received by the COAPS. Adding to opportunities for achievement and empowerment, one participant suggested students could eventually become peer instructors, either for one session or for an indefinite period of time, if they had been engaged in the class material and were interested. This suggestion was accepted by the other COAPS and became part of the course design, which I eventually named the “peer-takeover model.”

Until the peer-takeover happened, and if there were times when peers were unavailable, COAPS felt a psychosocial clubhouse staff member with lived experience of mental health challenges could be the instructor, in collaboration with a COAPS, who would be the lead instructor. Staff with lived experience should be on hand to provide support for instrumental needs issues that might be disclosed by students in group discussions (e.g., housing crisis; food stamps crisis; and anything threatening physiological wellbeing or safety). The staff person could also take the lead if peer specialists needed a break and to help handle any conflicts within a group. COAPS agreed that a staff member could be a social worker or a social work student, but more important than a specific profession was that the person understand the role of peers and not interfere with peer leadership. Clearly, being in a group where all members have emic understanding of living with mental health challenges was central: This would avoid othering experiences and contribute to empowerment. Overall, taking a course, earning certificates, and becoming instructors were elements of the course introduced by COAPS that promoted its ability to offer wellbeing enhancing experiences of achievement, within an empowering model.

Small Processes Contribute to Empowerment and Achievement

Throughout the project, COAPS used their dual lived experiences as recipients of mental health services and providers of peer support in mental health to describe processes they would like to see in a wellbeing enhancing course. For those who had experiences running groups and classes considered the following essential processes to support wellbeing: having a clear daily agenda for every class meeting, ensuring homework follow-up, and providing praise and validation for the accomplishment of completing homework. COAPS viewed repetition and predictability throughout the structure within and across sessions as important for increasing familiarity, so students would feel comfortable enough to fully participate in the course. Establishing decision-making processes to create safety within the first few sessions of the course, and reiterating what those processes are frequently, was important for the same reason.

As COAPS considered their experiences with peers with SMIs, they focused on the ordering of the class material, determining it was best to begin with small experiments or tasks and slowly moving to more complex exercises. Complex exercises could be “a little bit too much for them to get” right away. To that end, having “a chat” about the material could be just as useful as multi-media presentations of the positive psychology material.

Engagement With Course Material Is Paramount

The concept of flow or engagement was introduced in the first focus group and referred to by group members throughout subsequent focus group meetings and in one of the individual interviews. In positive psychology engagement is often defined by ability to enter a flow state, wherein one is so fully engaged with an activity that one loses track of time or even place, and other concerns and even feelings are forgotten (Seligman, 2012). However, the concept of flow is complicated for persons with SMIs because symptoms of mental illness and trauma can interfere with concentration and ability to enter a flow state. In applying the concept to their own experiences, COAPS agreed on “the importance of here and now” and felt that breathing exercises at the start of each meeting could effectively marking space for something different as well as “a break” from usual thought patterns.

Engagement was also looked at from another angle—how to engage the students in the course. COAPS considered how older adults with SMIs might engage with the new material and apply it to their lives and experiences, proposing that in initial class sessions group leaders gather expectations from, and share expectations of, the students, as a way to promote engagement. As one COAPS explained,

At the beginning, just sort of striving to let them know what it’s about and what they can get from it, so you have kind of a buy-in. You know? Because I’ve done a lot of groups and . . . some people are just looking to keeping themselves busy. Or some of the therapists will say, “Go to this class. It will be good for you.” They’re not all that committed to doing it, but if there’s some way to sort of get them buy-in about what they’re gonna learn and how it can maybe enhance their day-to-day wellness, I think that might be helpful ‘cause you know, they’re not compelled to come to the course and they’re not necessarily compelled to participate either and you don’t necessarily want that after all the effort that you’ve put out.

While not the favored tool for enhancing pleasant emotions, the “what-went-well” exercise was nonetheless identified as a way to engage older adults with SMI in the material:

I keep on thinking . . . getting them engaged in what they’re doing is really good and [what-went-well] is something that’s very deliberately asking them, and asking them for what it is they do in their life that is a positive outcome.

Group members described that once one was engaged with material, within a class setting one can have flow experiences: “[In] a great class, there’s flow.” Attending an engaging class might therefore be conducive to a flow state.

Connection With People Leads to Engagement With Material

The COAPS found the wellbeing theory concepts of relationships and engagement intertwine, noting that developing strong interpersonal relationships would enhance students’ full engagement with the class. COAPS identified “relatable,” “personal stories” or “vignettes” as central to making positive psychology concepts come to life and retain the attention of older adults with SMI. Envisioning themselves as class co-facilitators, they foresaw the importance of sharing their stories, which was more important than a potential staff instructor’s sharing. As one participant explained, “It’s about the class. It’s not about the instructor imparting knowledge upon people.” When a staff instructor does share stories, the stories should be relatable, based on what they know about the individuals in the class, rather than the points of reference in their own personal lives.

Connection with individuals could also be constructed through interactive processes that build engagement with the material: “I think having different interactive styles, some people like to write, some people don’t. Some people like to talk. Some people don’t. If you vary the exercises, everybody will feel like they’ve been engaged.” Another participant noted, “I think anything that’s gonna get them to chat, to open up, or to share with each other will be really good.”

Flexibility Leads to Engagement

COAPS noted that levels of symptoms and availability of resources of their peer-clients varied. However, even in the face of being very unwell, the COAPS felt older adults with SMIs “deserve a chance to try new things” and that the instructors “can always adjust as needed.” Flexibility with content and delivery was therefore important to creating an engaging course experience. Because the students “will have an open mind,” the format should reflect that as well.

The COAPS identified how flexibility was also needed within class sessions. For example, when gathering discussion responses or engaging in new activities, allowing students time and different mediums for responding was important:

Allow them time and to share their answers. I find that exercises where they get to answer a question, write it down, and then share it, the people who might not be outgoing, to share at a discussion, will read their answer . . . It’s a way to safely participate.

Flexible ways of participating would enhance engagement.

The COAPS emphasis on flexibility merged engagement with opportunities for achievement. Rewarding of (but not punishing) attendance provided acknowledgment that “just showing up” is central to engagement and change and can be an accomplishment for some individuals.

Snacks and Engagement

Initially in the analytic process, I deemed comments about snacks as insignificant. However, through constant comparison I noted each participant discussed the importance of snacks at some point in the research process, and found that providing snacks conveys several important messages connected to engagement: (a) Food is a sign of celebration and therefore, in the spirit of positive psychology and pleasant emotions, uplifts the tone of an event and sense that the experience is worthwhile; (b) Snacks might help address food insecurity for some older adults with SMIs, which could otherwise distract from full engagement; (c) Providing snacks that convey knowledge of group members’ preferences, allergies, and aversions demonstrates respect for the individuals and their belonging in the group. Therefore, providing snacks could be important to the success of a wellbeing course for older adults with SMIs.

Relationships are Central

The importance of productive and healthy relationships, identified as central to subjective experiences of wellbeing in the general population, was apparent in the present study. The majority of discussions within focus groups and individual interviews centered on the theme of relationships: How to build constructive working relationships and what such relationships should look like; how to use working relationships to navigate challenges like classroom power dynamics and completion of pre-and post-test measures; and how language builds relationships and sets the tone for interpersonal dynamics within the classroom.

Authenticity builds relationships

In terms of building constructive working relationships, establishing authenticity and longevity was considered key. COAPS emphasized the need to develop relationships with students before diving into course material. To enhance relational authenticity, all emotions and experiences would need to be validated, as described above. The need for validation of negative experiences would add an element of trust and authenticity to the relationship, so despite the emphasis of the course on “positive psychology,” relationships between the instructors and students should be built on a platform of authenticity and acknowledgment of the whole selves of the students in the course—reiterating the “it’s ok not to be ok” idea. Rapport needs to be built before moving to the solutions implied within the course material.

Another step toward authenticity was acknowledgment of the “power differential” between instructors and students, even peer/COAPS instructors. This was considered important to acknowledge and address, rather than pretending that peer instructors were no different from students. This acknowledgment also validates the role of the peer as an instructor. COAPS believed that with ability for class members to rotate into leadership positions and peers serving as co-facilitators, longer term, authentic relationships were more likely to be established. Long-term relationships with course instructors, whether staff or peers, were essential to authenticity.

Language is the building block of relationships

The theme of being attuned to language and the meaning of words saturated the data. Broadly, COAPS felt “clinical” language was “dehumanizing” and should be avoided, especially in work with older adults with SMI who would likely have had negative experiences in clinical settings across the life course. For example, before the “intervention” became a “class,” the term “intervention” garnered a great deal of discussion. One participant noted, “I don’t like the word intervention either. It’s like ouch. It’s like too clinical . . . so social work-y.” Upon exploration, the opposite of clinical was constructed by COAPS as “making a connection” and “healer.” The term “coaching” was considered problematic because of the many other type of coaches in the mental health and substance use recovery fields. As language moved from “intervention” to “course” and “classes,” COAPS noted that students connected by a classroom experience offered more potential for developing strong interpersonal relationships than being patients connected by an intervention experience.

As such, data went beyond identifying client-first language and into deeper considerations of the meaning and power of language to this particular group of older adults, identifying older adult with SMI-sensitive language. Language would frame classroom experiences, building either healthy relationships and engaged students, or creating boundary issues or uninterested students. As one COAPS explained,

I think all of us whose had experiences, I think, want to make sure that when we’re dealing with clients like this that you’re respectful and that the language is always respectful. I think that we all gave our feedback on that.

Language builds relationships by promoting inclusivity. Perceived pathologizing, “clinical,” and/or academic terms were a no-go: these would lead to a sense of inadequacy or objectification. Mentioning the Diagnostic Statistic Manual was considered unnecessary. COAPS preferred explaining that the class goal was to “enhance your wellness” rather than “improve your life,” because the latter suggests that the person’s life has something wrong with it. However, the word “goal” should be avoided, as it invoked other psychosocial interventions (“what you would like to get out of the experience” was better). Talking about theory and theorists garnered the comment, “I don’t know what a theorist is and I don’t think I want to know.”

Similarly, it was noted that all language that evoked 12-step groups, like Alcoholics Anonymous groups, should be avoided. Although one COAPS described having benefited from being in a 12-step program, others had negative experiences with them or knew of peer-clients with negative experiences with them. So terms used in and beyond 12-step groups like “higher power” and “one day at a time,” as generic as they might seem, could be problematic.

Small changes in wording therefore evoked large changes in meaning and impact. For example, one COAPS challenged use of the word “characterize” when “describe” essentially means the same thing. Asking students to describe “meaningful experiences” rather than “memorable experiences” was better because not all “memorable experiences” for this group of older adults would be meaningfully recalled in a constructive way: Lengthy hospitalizations, managing difficult medication side effects, and life course traumas might be memorable but not particularly meaningful.

There was not always agreement on the best language to use. One participant liked the term “stories” to describe reminiscence processes and another felt it was condescending, and that “experiences” was a more validating term, reflecting that her experiences were “real” and “not just stories.” However, most items gathered consensus. Language was thus an important tool for accessibility that would promote students’ sense of belonging. In sum, language needed to be easily relatable, promote respect, avoid condescension, respect humanity and diverse life experiences, and respect the reality of individuals’ experiences.

Accessibility

Accessibility was a theme that emerged in the way the course was structured: the absence policy, the way opportunities for participation could be diversified, need for flexibility, vocabulary used in course material, and the course material itself. COAPS wanted to ensure the class material would be presented at an accessible reading level with images depicting key points included whenever possible. One man noted the font should be large with color contrast between text and paper, for those with vision problems. Another explained that instructions should be “broken down in a detailed way.” By promoting accessibility, the course material would build belonging rather than estrangement or othering.

Psychometric Measures are Personal

All COAPS came with prior experience of completing psychometric measures and were provided psychometric measures of wellbeing to try within the second focus group. All but two, who had participated in research projects with pre- and post-tests, agreed that “pre-test” measures should not be introduced prior to the second or third class session, and should be presented in the context of conversation and developing relationships, rather than given “like a test.” Furthermore, any measures used to evaluate the effectiveness of enhancing wellbeing should be multi-faceted, using multiple measures. COAPS found standardized measures, such as the PERMA Profiler (Butler & Kern, 2016), un-relatable and challenging. They also emphasized the need for larger fonts. One found the measures so overwhelming that she did not complete any. Only half the group finished them on the day that we looked at them.

Upon discussion, the group agreed psychosocial measures emphasizing the positive would be a better fit. For example, they knew a measure of success for persons with SMI was a low number of days in the hospital over a given period of time, but found that to be a negative measure. They proposed instead that measures of successful outcomes focus on constructive experiences like number of days spent with friends or family, number of days spent doing something meaningful (e.g., going to church or support group), the number of days doing a pleasant activity. COAPS also agreed that personalized, subjective measures (such as reporting on a scale from 1 to 10, where 1 is the worst and 2 is the best, in the past week I have generally felt at number ___) would be more “motivating” rather than something that seemed generic and/or overwhelming.

Meaning in Illness, Wellness, and Reminiscence

Overall, COAPS found that positive psychology material needed to be directly connected to the SAMHSA (2012) approach to recovery. Such a connection would add to the course’s meaning and make it resonate more fully with older adults with SMIs, in addition to assuring material is relatable and inclusive. This was different from connecting material to illness experiences or illness management in that the focus of mental health recovery is recovering hope and what gives meaning to life in the context of mental illness, rather than focusing on symptoms (SAMHSA, 2012). The concept of finding meaning in the “small things,” as discussed above, linked mental health recovery and enhancing wellbeing.

As such, when considering gratitude as meaning-making exercises, discussions about expressing gratitude and “remembering to thank someone who holds the door” or the cashier at the grocery store would be a more useful “small things” starting point than, for example, the empirically validated gratitude letter exercise which involves writing and presenting a long letter to someone who has been helpful but never adequately acknowledged (Seligman et al., 2005).

Reminiscence was another opportunity for meaning-making processes in the material presented and COAPS asked for more opportunities for reminiscence. One man recalled a reminiscence exercise he had completed elsewhere that asked him to consider the title of his memoir, the chapter headings, and what he would want the final chapter to be. He explained the last section was most helpful because, “We can’t change all those other chapters but we can certainly rewrite the ending of our story.” Several of the COAPS wanted more opportunities for reminiscence included in the course generally, as well as opportunities for reminiscence and reflection throughout the weekly course structure. This speaks to the importance of meaning-making processes that consider the full lived experiences of older adults with SMIs.

Discussion

Data analysis from the current project identifies and explores valuable parts of building wellness for older adults living with SMIs. These wellbeing factors connect to and build upon Seligman’s (2012) wellbeing theory as it applies to this population. One such example is in the findings around developing and magnifying pleasant emotion, and the COAPS’ experience that all emotions are valid and need validating. This concept is not new, stemming from the psychoanalytic theoretical concept of emotional holding spaces (Ogden, 2004). Improbable as this origin is, in light of the problematic ways psychoanalysis has been applied to persons with SMIs and their families (Corrigan, 2016), it is important to consider this in the context of the current evidence base. Most psychosocial interventions for older adults with SMIs include elements of illness management, a CBT orientation and/or focus on coping skills (Cummings & Kropf, 2011). Validating feelings and experiences are considered part, but not the focus, of such interventions (Meyer et al., 2010). Therefore, offering an experience that devotes attention to emotional validation and holding might offer something both novel and necessary. Furthermore, the acceptability of savoring exercises to induce and enhance pleasant emotion supports the importance of pleasant emotion to wellbeing for older adults with SMI, if not a central focus, and cements its place in wellbeing programs for the population.

The findings around achievement are profound. While robust research describes the importance of vocational (e.g., Bond, 2004; Bond & Drake, 2014; Dunn et al., 2008; Krupa & Chen, 2013; Modini et al., 2016) and educational (e.g., Krupa & Chen, 2013; Mowbray et al., 2005; Nuechterlein et al., 2008) support and participation for persons living with SMIs, such participation has not been connected with the concept of achievement, or to the connection between achievement and wellbeing. Being able to gear coursework or employment offerings for older adults with SMIs toward the overarching value of achievement for achievements sake might be important to their acceptability in general; to the pride and self-esteem (Dunn et al., 2008) such participation can provide; as well as to added therapeutic value overall.

While wellbeing theory is framed conceptually by each of the “PERMA” concepts, it does not provide clear processes throughout which these concepts can best be developed, at least, not for individuals living with SMIs (Park & Chen, 2016; Seligman, 2012). In this project, processes created for the wellbeing class, ranging from how attendance is considered to how students become instructors, provided insight into which processes would be most valuable for older adults with SMIs. At the center of each was the need for individualization and empowerment—to have opportunities to become the instructor, and to be ensured that instructors will not condescend to or disrespect students in any way. Receiving an age-appropriate intervention might also promote a sense of empowerment and individualization.

The emphasis COAPS put into enhancing engagement with positive psychology informed course material spoke to their receptiveness to it and to the value of a positive classroom experience for persons living with SMI. These findings indicate that such an experience can support focus and create a sense of flow otherwise missing or unattainable in their lives. That engagement is gained through flexibility was important insight gleaned from the data. For one thing, the implementation and adoption of evidence-based practices (EBPs) into the field has been hampered in part by the lack of flexibility many of the models appear to invoke (Okpych & Yu, 2014). Furthermore, in the context of building a class-offering, one needs to consider universal accommodations and the social model of disability, wherein the class flexibly adjusts for the students rather than asking students to adjust to make the class work for them (Kattari et al., 2017). Finally, flexibility enters into what one conceives as belonging in a classroom at all, as exemplified by the consensus around the importance of snacks. The connection between snacks and engagement gives insight into what it means to be working with older adults with SMIs: Small things make a big difference and have greater meaning than at first glance, a theme that connects to prior research on older adults with SMIs (Padgett et al., 2020; Shibusawa & Padgett, 2009).

Further connecting to research on the experience of wellbeing (Duckworth et al., 2005; Seligman, 2012) and the values and priorities of older adults with SMI (Padgett et al., 2020), is the centrality of interpersonal relationships to wellbeing. Informal relationships matter, but so do the relationships with social service and treatment providers, and individuals who might teach a class to enhance wellbeing (Ogden, 2014a). Conversely, loneliness and social support needs emerge across multiple studies of the experience of long-term mental illness (Collier & Grant, 2018). As always, authenticity builds those relationships.

While the COAPS with whom I collaborated undoubtedly would refuse the title of social constructionists, inaccessible and overly complex as it is, they nonetheless saw and named the power of language to construct social realities. Importantly they identified the need for older adult with SMI-centered language, and within it, the need to age-out of “treatment” and “intervention” and age into more meaningful parts of life, such as later life narrative processes. Furthermore, relationships were essential to that meaning, and language could build such relationships. These findings connect to the recovery from social disability of SMIs, and again, the subjective experience of relational recovery (Bradshaw et al., 2007; Davidson, 2003; Gunnmo & Bergman, 2011; Ng et al., 2008; Ogden, 2014a).

While from my perspective as a researcher the psychometric measures I introduced were emotionally neutral, the COAPS felt otherwise. Their insights into psychometric measures further illuminated what is important to enhancing wellbeing in older adults with SMI: Every aspect of an offering, including the outcomes measures, should be oriented by the goal of enhancing wellbeing as defined by the individuals. Focusing on what has been accomplished, what small steps have been made, and what the individual values are as important within the measures as within the rest of the process. No matter how well validated measurements might be, if they do not align with enhancing wellbeing, then they do not belong.

Reminiscence therapies, an EBP for older adults in the general population with strong theoretical underpinnings (Kropf & Cummings, 2017), are also of interest to older adults with SMIs and have not been widely studied with this population (with the exception of older adults experiencing unipolar depression). Opportunities to process, such as through reminiscence, were seen as opportunities to connect and engage in meaning-making processes with peers that can include and also move beyond mental health recovery. This speaks to the desire to live inside and outside of mental health recovery (Davidson, 2003) and the desire for engaging in normative aging processes that support wellbeing, such as reminiscence, rather than continual focus on illness management.

Zechner et al. (2019) review found that wellness research for older adults with SMIs consistently failed to fully address the SAMHSA framework of recovery, focusing on physical and social domains, while overlooking the spiritual and intellectual. The present project focused on enhancing wellbeing as defined by PERMA theory, rather than SAMHSA’s recovery framework, however, the two models intersect significantly. While material examined by this focus group did not address physical health domains of wellbeing and recovery, it addressed several of the others. The course design and activities emphasized social wellbeing and recovery; content included multiple meaning-making processes, addressing the spiritual aspects of wellbeing and recovery; and as a course offering with rich material, it addressed the intellectual aspects of wellbeing and recovery. By addressing the spiritual and intellectual aspects of mental health recovery, this material offers an approach and content that has previously been missing from work with older adults with SMIs. Of note, none of the participants decried (or even commented on) the lack of material on maintaining physical health and or symptom/illness management.

Finally, presenting the positive psychology material as a course offering has significant advantages. The stigma of living with a psychiatric diagnosis extends to treatment for that diagnosis, leading many older adults with SMIs to reject the illness labels (Ogden, 2014b; Reynolds et al., 2020) and be negatively pre-disposed toward treatment (Reynolds et al., 2020). If addressing mental health is prioritized only to the extent that it supports that larger goal (Ogden, 2014b; Padgett et al., 2020) then packaging material as a course rather than treatment may be a useful way to work with this reality. On the other hand, demonstrating transparency and integrity in the presentation of the offering is equally important to establishing trust—no one wants to be tricked into treatment. Therefore, providing clarity that this is a class where a student will learn positive psychology material, and that people benefit from learning this material (Seligman, 2012) and that our aim is that these students too will benefit from learning the material, is an essential piece of ethical communication to engage in around the class. As it was the students who suggested the material be presented as a course offering, adds to the acceptability of the re-frame, a significant contribution of this qualitative investigation (Duggleby et al., 2020).

Strengths and Limitations

While the methods included rigorous processes, such as multiple focus group meetings with participants and an individual member-checking process, there are inevitable limitations. Transferability of findings is limited by the demographic homogeneity of the group: All participants and the author identified as White, non-Latinx, non-immigrant Americans, which likely influenced perceptions of what was valuable and meaningful. Furthermore, COAPS by definition have achieved a higher degree of mental health recovery and lesser degree of psychiatric disability than their peer-clients, and so their perspectives may hold important differences. However, they often contrasted their personal experiences with those of peer-clients, and gave conscious consideration to levels of impairment they had observed in them, thus augmenting that divide. While the age minimum was set at 50+ years, the age range began at over a decade older (61 years), which may limit the age-appropriateness of the findings for other age groups of older adults (Collier & Grant, 2018). Social desirability bias within focus groups was addressed through the use of individual interviews, but may have occurred within individual interviews as well. Finally, confirmation bias may have emerged through who decided to join the project—COAPS with knowledge of or interest in positive psychology might have been more likely to join, and then more likely to confirm acceptability of content. Nonetheless, the thick description within the data, which included disagreements at times, suggests the process made room for multiple viewpoints to emerge.

Supplemental Material

sj-docx-1-qhr-10.1177_1049732321992047 – Supplemental material for Enhancing Wellbeing for Older Adults With Serious Mental Illnesses: Co-Producing a Positive Psychology Course With Certified Older Adult Peer Specialists

Supplemental material, sj-docx-1-qhr-10.1177_1049732321992047 for Enhancing Wellbeing for Older Adults With Serious Mental Illnesses: Co-Producing a Positive Psychology Course With Certified Older Adult Peer Specialists by Lydia P. Ogden in Qualitative Health Research

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding from the Simmons University School of Social Work Director’s Research Initiative.

ORCID iD

Lydia P Ogden

Supplemental Material

Supplemental Material for this article is available online at . Please enter the article’s DOI, located at the top right hand corner of this article in the search bar, and click on the file folder icon to view.

Author Biography

Lydia P. Ogden is an assistant professor at the Simmons University School of Social Work, Boston. Her research focuses on understanding the experiences and developing the potential of persons living with symptoms of serious mental illnesses, especially older adults.

References

Bankole

Cohen

C. I.

Vahia

Diwan

Palekar

Reyes

Sapra

Ramirez

P. M.

(2008). Symptomatic remission in a multi-racial urban population of older adults with schizophrenia. American Journal of Geriatric Psychiatry, 16(12), 966–973. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2777609/

Bolier

Haverman

Westerhof

G. J.

Riper

Smit

Bohgmeijer

(2013). Positive Psychology interventions: A meta-analysis of randomized controlled studies. BMC Public Health, 13, Article 119. https://doi.org/10.1186/1471-2458-13-119

Bond

G. R.

(2004). Supported employment: Evidence for an evidence-based practice. Psychiatric Rehabilitation Journal, 27(4), 345–359. https://doi.org/10.2975/27.2004.345.359

Bond

G. R.

Drake

R. E.

(2014). Making the case for IPS supported employment. Administration and Policy in Mental Health and Mental Health Services Research, 41(1), 69–73. https://doi.org/10.1007/s10488-012-0444-6

Bradshaw

Armour

M. P.

Roseborough

(2007). Finding a place in the world: The experience of recovery from severe mental illness. Qualitative Social Work: Research and Practice, 6, 27–47. https://dx-doi-org.web.bisu.edu.cn/10.1177/1473325007074164

Butler

Kern

M. L.

(2016). The PERMA-Profiler: A brief multidimensional measure of flourishing. International Journal of Wellbeing, 6(3), 1–48. https://doi.org/10.5502/ijw.v6i3.526

Castle

D. J.

Morgan

(2008). Epidemiology. In Mueser

K. T.

Jeste

D. V.

(Eds.), Clinical handbook of schizophrenia (pp. 14–24). Guilford Press.

Cohn

M. A.

Fredrickson

B. L.

(2010). In search of durable positive psychology interventions: Predictors and consequences of long-term positive behavior change. Journal of Positive Psychology, 5(5), 355–366. https://dx-doi-org.web.bisu.edu.cn/10.1080/17439760.2010.508883

Collier

Grant

M. J.

(2018). A literature review on the experience of long-term mental illness. Issues in Mental Health Nursing, 39(6), 506–513. https://doi.org/10.1080/01612840.2017.1404169

10.

Corrigan

P. W.

(2016). Principles and practices of psychiatric rehabilitation: An empirical approach (2nd ed.). Guilford Press.

11.

Creswell

J. W.

(2007). Qualitative inquiry and research design: Choosing among five approaches (2nd ed.). SAGE.

12.

Cummings

S. M.

Kropf

N. P.

(2011). Aging with a severe mental illness: Challenges and treatments. Journal of Gerontological Social Work, 54(2), 175–188. https://doi.org/10.1080/01634372.2010.538815

13.

Davidson

(2003). Living outside mental illness: Qualitative studies of recovery in schizophrenia. New York University Press.

14.

Donaldson

S. I.

Dollwet

Rao

M. A.

(2014). Happiness, excellence, and optimal human functioning revisited: Examining the peer-reviewed literature linked to positive psychology. Journal of Positive Psychology, 10(3), 185–195. https://dx-doi-org.web.bisu.edu.cn/10.1080/17439760.2014.943801

15.

Duckworth

A. L.

Steen

T. A.

Seligman

M. E.

(2005). Positive psychology in clinical practice. Annual Review of Clinical Psychology, 1, 629–651. https://doi.org/10.1146/annurev.clinpsy.1.102803.144154

16.

Duggleby

Peacock

Ploeg

Swindle

Kaewwilai

HeunJung

(2020). Qualitative research and its importance in adapting interventions. Qualitative Health Research, 30(30), 101605–101613. https://doi.org/10.1177/1049732320920229

17.

Dunn

E. C.

Wewiorski

N. J.

Rogers

E. S.

(2008). The meaning and importance of employment to people in recovery from serious mental illness: Results of a qualitative study. Psychiatric Rehabilitation Journal, 32(1), 59–62. https://dx-doi-org.web.bisu.edu.cn/10.2975/32.1.2008.59.62

18.

Fereday

Muir-Cochrane

(2006). Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods, 5(1), 80–92. https://doi.org/10.1177/160940690600500107

19.

Flanagan

E. H.

Davidson

Strauss

J. S.

(2007). Issues for DSM-V: Incorporating patients’ subjective experiences. American Journal of Psychiatry, 164(3), 391–392. https://ajp.psychiatryonline.org/doi/pdfplus/10.1176/ajp.2007.164.3.391

20.

Fortuna

K. L.

Ferron

Pratt

S. I.

Muralidharan

Aschbrenner

K. A.

Williams

A. M.

Deegan

P. E.

Salzer

(2019). Unmet needs of people with serious mental illness: Perspectives from certified peer specialists. Psychiatric Quarterly, 90(3), 579–586. https://doi.org/10.1007/s11126-019-09647-y

21.

Gonzalez

(2020, June 21). A mindful way to reflect: Rose, bud, and thorn. Mindful Schools. https://www.mindfulschools.org/inspiration/mindful-reflection/?gclid=CjwKCAjwq832BRA5EiwACvCWsRnz8LnYpOT1kcqp9MEnu95gSqUuu0fV471XJLHS-_SwtDYMpP-N9hoCHMcQAvD_BwE

22.

Gunnmo

Bergman

H. F.

(2011). What do individuals with schizophrenia need to increase their well-being. International Journal of Qualitative Studies on Health and Well-Being, 6, 1283–1294. https://dx-doi-org.web.bisu.edu.cn/10.3402/qhw.v6i1.5412

23.

Hafner

Heiden

(2008). Course and outcomes. In Mueser

K. T.

Jeste

D. V.

(Eds.), Clinical handbook of schizophrenia (pp. 100–116). Guilford Press.

24.

Henwood

B. F.

Katz

M. L.

Gilmer

T. P.

(2014). Aging in place within permanent supportive housing. International Journal of Geriatric Psychiatry, 30, 80–87. https://doi.org/10.1002/gps.4120

25.

Hickey

Brearley

Coldham

Denegri

Green

Staniszewska

Tembo

Torok

Turner

(2018). Guidance on co-producing a research project. INVOLVE. https://www.invo.org.uk/wp-content/uploads/2019/04/Copro_Guidance_Feb19.pdf

26.

H. C. Y.

Yeung

D. Y.

Kwok

S. Y. C. L.

(2014). Development and evaluation of the positive psychology intervention for older adults. Journal of Positive Psychology, 9(3), 187–197. https://dx-doi-org.web.bisu.edu.cn/10.1080/17439760.2014.888577

27.

Hsieh

H. F.

Shannon

S. E.

(2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. https://doi.org/10.1177/1049732305276687

28.

Kattari

S. K.

Lavery

Hasche

(2017). Applying a social model of disability across the life span. Journal of Human Behavior in the Social Environment, 27(8), 865–880. https://doi.org/10.1080/10911359.2017.1344175

29.

Kropf

Cummings

S. M.

(2017). Evidence-based treatment with older adults: Theory, practice, and research. Oxford University Press.

30.

Krupa

Chen

S. P.

(2013). Psychiatric/psychosocial rehabilitation (PSR) in relation to vocational and educational environments: Work and learning. Current Psychiatry Reviews, 9(3), 195–206. https://doi.org/10.2174/1573400511309030005

31.

Meeks

T. W.

Jeste

D. V.

(2008). Older individuals. In Mueser

K. T.

Jeste

D. V.

(Eds.), Clinical handbook of schizophrenia (pp. 390–397). Guilford Press.

32.

Melendez Moral

J. C.

Fortuna Terrero

F. B.

Sales Galan

Rodriguez

T. M.

(2014). Effect of integrative reminiscence therapy on depression, well-being, integrity, self-esteem, and life satisfaction in older adults. Journal of Positive Psychology, 10.3, 103, 240–247. https://dx-doi-org.web.bisu.edu.cn/10.1080/17439760.2014.936968

33.

Meyer

P. S.

Gingerich

Mueser

K. T.

(2010). A guide to implementation and clinical practice of illness management and recovery for people with schizophrenia. In Rubin

Springer

D. W.

Trawver

(Eds.), Psychosocial treatment of schizophrenia (pp. 23–87). Wiley.

34.

Modini

Tan

Brinchmann

Wang

M. J.

Killackey

Glozier

Mykletun

Harvey

S. B.

(2016). Supported employment for people with severe mental illness: Systematic review and meta-analysis of the international evidence. The British Journal of Psychiatry, 209(1), 14–22. https://doi.org/10.1192/bjp.bp.115.165092

35.

Mowbray

C. T.

Collins

M. E.

Bellamy

C. D.

Megivern

D. A.

Bybee

Szilvagyi

(2005). Supported education for adults with psychiatric disabilities: An innovation for social work and psychosocial rehabilitation practice. Social Work, 50(1), 7–20. https://doi.org/10.1093/sw/50.1.7

36.

R. M.

Pearson

Lam

Law

C. W.

Chiu

C. P.

Chen

E. Y.

(2008). What does recovery from schizophrenia mean? Perceptions of long-term patients. The International Journal of Social Psychiatry, 54, 118–130. https://dx-doi-org.web.bisu.edu.cn/10.1177/0020764007084600

37.

Nuechterlein

K. H.

Subotnik

K. L.

Turner

L. R.

Ventura

Becker

D. R.

Drake

R. E.

(2008). Individual placement and support for individuals with recent-onset schizophrenia: Integrating supported education and supported employment. Psychiatric Rehabilitation Journal, 31(4), 340–349. https://doi.org/10.2975/31.4.2008.340.349

38.

Ogden

L. P.

(2014a). Interpersonal relationship narratives of older adults with schizophrenia-spectrum diagnoses. American Journal of Orthopsychiatry, 84(6), 674–684. https://doi.org/10.1037/ort0000035

39.

Ogden

L. P.

(2014b). “My life as it is has value”: Narrating schizophrenia in later years. Qualitative Health Research, 24(10), 1342–1355. https://doi.org/10.1177/1049732314546752

40.

Ogden

L. P.

(2018). “To fill the emptiness”: The importance of work in life history narratives of older adults with schizophrenia-spectrum diagnoses. Qualitative Social Work: Research and Practice, 17(4), 556–576. https://doi.org/10.1177/1473325016688368

41.

Ogden

T. H.

(2004). On holding and containing, being and dreaming. The International Journal of Psychoanalysis, 85(6), 1349–1364. https://doi.org/10.1516/T41H-DGUX-9JY4-GQC7

42.

Okpych

N. J.

J. L.

(2014). A historical analysis of evidence-based practice in social work: The unfinished journey toward an empirically grounded profession. Social Service Review, 88(1), 3–58. https://doi.org/10.1086/674969

43.

Padgett

D. K.

Bond

Gurdak

Henwood

B. F.

(2020). Eliciting life priorities of older adults living in permanent supportive housing. The Gerontologist, 60(1), 60–68. https://doi.org/10.1093/geront/gnz040

44.

Park

Chen

(2016). Positive psychology and hope as means to recovery from mental illness. Journal of Applied Rehabilitation Counseling, 47(2), 34–42. https://doi.org/10.1891/0047-2220.47.2.34

45.

Parker

Tritter

(2006). Focus group method and methodology: Current practice and recent debate. International Journal of Research & Method in Education, 29(1), 23–37. https://doi.org/10.1080/01406720500537304

46.

Randall

W. L.

(2011). Memory, metaphor and meaning: Reading for wisdom in the stories of our lives. In Kenyon

G. M.

Bohlmeijer

Randall

W. L.

(Eds.), Storying later life: Issues, investigations, and interventions in narrative gerontology (pp. 18–36). Oxford University Press.

47.

Reynolds

Medved

Mackenzie

C. S.

Funk

L. M.

Koven

(2020). Older adults’ narratives of seeking mental health treatment: Making sense of mental health challenges and “muddling through” to care. Qualitative Health Research, 30(10), 1517–1528. https://doi.org/10.1177/1049732320919094

48.

Rubin

Springer

D. W.

Trawver

(2011). Psychosocial treatment of schizophrenia (Vol. 8). John Wiley & Sons.

49.

Seligman

M. E.

(2002). Authentic happiness: Using the new positive psychology’ to realize your potential for lasting fulfillment. Free Press.

50.

Seligman

M. E.

(2012). Flourish: A visionary new understanding of happiness and well-being. Simon and Schuster.

51.

Seligman

M. E.

Steen

T. A.

Park

Peterson

(2005). Positive psychology progress: Empirical validation of interventions. American Psychologist, 60(5), 410–421. https://doi.org/10.1037/0003-066X.60.5.410

52.

Shibusawa

Padgett

(2009). The experiences of “aging” among formerly homeless adults with chronic mental illness: A qualitative study. Journal of Aging Studies, 23(3), 188–196. https://doi.org/10.1016/j.jaging.2007.12.019

53.

Slade

Brownell

Rashid

Schrank

(2016). Positive psychotherapy for psychosis: A clinician’s guide and manual. Taylor & Francis.

54.

Substance Abuse and Mental Health Services Administration [SAMHSA]. (2012). Results from the 2010 national survey on drug use and health: Mental health findings (NSDUH Series H-42, HHS Publication No. (SMA) 11-4667). Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/2k10MH_Findings/2k10MH_Findings/2k10MHResults.htm

55.

Zechner

M. R.

Pratt

C. W.

Barrett

N. M.

Dreker

M. R.

Santos

(2019). Multi-dimensional wellness interventions for older adults with serious mental illness: A systematic literature review. Psychiatric Rehabilitation Journal, 42(4), 382–393. https://dx-doi-org.web.bisu.edu.cn/10.1037/prj0000342

56.

Zubritsky

Keogh

Mastrine

Deppen

Boyer

(2015). Certified older adult peer specialist program. http://164.156.7.185/parecovery/documents/COAPS_Initiative_2015.pdf

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