Advances in Psychology Research: Volume 97 9781626188044, 9781626188051

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ADVANCES IN PSYCHOLOGY RESEARCH

ADVANCES IN PSYCHOLOGY RESEARCH VOLUME 97

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ADVANCES IN PSYCHOLOGY RESEARCH

ADVANCES IN PSYCHOLOGY RESEARCH VOLUME 97

ALEXANDRA M. COLUMBUS EDITOR

New York

Copyright © 2013 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data

ISSN: 1532-723X ISBN:  (eBook)

Published by Nova Science Publishers, Inc. † New York

CONTENTS Preface Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

vii Advances in Cognitive Therapy for Voice Hearers:The Introduction of Cognitive Behavioural Relating Therapy (CBRT) Georgie Paulik, Mark Hayward and Helen J. Stain Beer Consumption and Alcohol Abuse Related Problems in Italian Adolescents: Risk and Protective Factors Elena Cattelino, Manuela Bina, Federica Graziano, Tatiana Begotti, Gabriella Borca and Emanuela Calandri Organizational Diversity Management: A Look at the Benefits, Challenges, Solutions, and Beyond Seth Ayim Gyekye Chronic Fatigue in People with Neurological Injuries and Its Influence on Wellbeing Ashley Craig, Yvonne Tran, James Middleton and Ian Cameron Stressors as Antecedents to Sports Injuries: A Psychological Perspective Urban Johnson and Andreas Ivarsson

1

25

47

65

83

Chapter 6

President’s Violence in Sports Competition: Fiction or Reality? Sébastien Guilbert

Chapter 7

Cognitive Behavioral Case Management (CBCM) for Early Psychosis: A Hong Kong Experience Wendy Wy. Tam and Eric Yh. Chen

117

Enhancing Regularity in Meditation Using the Social Cognitive Theory Manoj Sharma

131

Chapter 8

Chapter 9

The Old Me/New Me Model and the Process of Change Lino Faccini

103

139

vi Chapter 10 Index

Contents Money Transfer Offers Made by E-Mails Uwe Hentschel

145 153

PREFACE This continuing series presents original research results on the leading edge of psychology. Each article has been carefully selected in an attempt to present substantial results across a broad spectrum. This book reviews research on Cognitive Behavioral Relating Therapy (CBRT); beer consumption and alcohol abuse related problems in Italian adolescents; the psychopathological effects of cochlear implants; organizational diversity management; chronic fatigue in people with neurological injury and its influence on wellbeing; stressors as antecedents to sports injuries; violence in sports competition; Cognitive Behavioral Case Management (CBCM) for early psychosis; enhancing regularity in meditation using social cognitive therapy; the identity change process and the serially depraved offender; and e-mail scam perpetrators. Chapter 1 - Cognitive behavioural models of voice hearing suggest that the affective and behavioural responses to voices can be explained by the hearer’s beliefs about the voice, such as perceived voice intent, omnipotence/power, omniscience, and control (Chadwick & Birchwood, 1994). Recent evidence suggests that these responses, and the beliefs that contribute to them, are at least partially mediated by perceptions of the self in relation to social others. Specifically, empirical studies have investigated how the social processes (or schemata) that govern everyday social interactions also influence styles of relating to a voice. Two interpersonal theories have been utilized to develop these ideas: social rank theory and relating theory. These two complimentary theories have led to the development of somewhat dissimilar therapy approaches, Cognitive Therapy of Command Hallucinations (CTCH; Trower et al., 2004) and Relating Therapy (Hayward et al., 2009), respectively. The Chadwick and Birchwood cognitive behavioural model of voice hearing has since been adapted to incorporate the findings from the social rank and social relating literature to provide an expanded understanding of the cognitive and social processes contributing to the voice hearing experience (Paulik, 2012). This chapter will further provide a rationale for the integration of CTCH and Relating Therapy to strengthen the critical components for therapeutic change. This combined approach has been named Cognitive Behavioural Relating Therapy (CBRT) and has been piloted within individual therapy and in a group setting. These therapeutic explorations will be described and illustrated using clinical case studies. Chapter 2 - Alcohol consumption, above all wine drinking, is deeply rooted in the Italian culture. However, national and European statistics (ISTISAN, 2010; ESPAD, 2011) emphasize that beer is the preferred and most widespread alcoholic beverage of 16-20 yearold Italian adolescents. This is consistent with a progressive change in young drinking

viii

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models, from the traditional “Mediterranean” style (prevalent consumption of wine during meals or on special occasions) to the “Northern” style, (occasional and heavy consumption of beer and spirits) (Bonino, Cattelino, 2012). Starting from the Problem Behavior Theory proposed by Jessor (Jessor, Donovan, Costa 1991), the present study analyzes young beer consumption in the context of adolescents’ risk behaviors and in relation to a complex system that includes variables related to individual values, opinions and feelings and to the peer and family contexts (distinguishing both individual and contextual proximal and distal factors). The aims of the study were to investigate: a) different styles of beer consumption (moderate or heavy) and their relations with alcohol abuse and problems related to alcohol abuse; b) the relation between beer abuse, problems related to alcohol abuse and different externalizing (substances use, risky driving, antisocial behavior) and internalizing problems (depression and feelings of alienation); c) protective and risk factors with reference to beer consumption, beer abuse and problems related to alcohol abuse. In particular, both individual and social (concerning family and peer context) factors, divided in proximal and distal variables were considered. Gender differences were also investigated. Data were collected through an anonymous self-report questionnaire (Italian version of the Health Behavior Questionnaire of R. Jessor by Cattelino, Begotti, Bonino, 1999). The study involved 1173 adolescents, boys (43%) and girls, ages 14 to 18, attending different high schools in North-western Italy. Correlations and hierarchical multiple regressions were carried out, respondent age and gender were controlled for, in order to investigate relations between variables. Main results stressed that: 1) 12% of adolescents are heavy drinkers (moderate 57%, nondrinkers 31%) 2) beer abuse is strongly correlated with alcohol abuse problems (health and social problems) and both correlate with involvement in externalizing problem behavior; 3) among proximal contextual factors, beer consumption with friends is the strong predictor for both beer abuse and problems related to alcohol abuse; among both individual and contexual distal factors, regulatory self-efficacy and family variables play a protective role. Cultural aspects of adolescents’ beer drinking in Italy and implications for alcohol abuse prevention were discussed. Chapter 3 - The expected changes in organizational demographics and the growing tendency towards heterogeneity in the workplace have encouraged a great amount of research to be devoted to the analysis of diversity management in organizations. Despite researchers’ intensive efforts to measure diversity and predict its outcomes, the literature offers few conclusive findings about the effects of diversity in the workplace. The academic debate on what should be done and how it should be done has therefore been a topical issue in the applied social psychology and organizational literature. This paper engages with this debate by examining the tangible outcomes of diversity management, the challenges it poses and how they can be addressed. It focuses primarily on diversity management practices and their consequences. It includes a summary on the reviews of the consequences of diversity in the literature, the business case for the introduction of diversity initiatives, hindrances that confront effective organizational diversity strategies and how they can be addressed. Chapter 4 - Chronic fatigue is a state of excessive tiredness in which motivation to function is substantially reduced. It is a common debilitating condition following neurological injuries such as spinal cord injury (SCI) and traumatic brain injury (TBI). The primary aim of this chapter is to present a review concerning current understanding of the nature of chronic

Preface

ix

fatigue, its relationship to negative mood states and quality of life in people with neurological injury, especially in adults with SCI. Results of recent studies are presented that investigate chronic fatigue and its relation to quality of life and negative mood states in adults with SCI living in the community, and comparisons to able-bodied controls of a similar age and sex ratio are made. The clinical consequences of living with chronic fatigue in people with a neurological injury such as SCI are explored. Chapter 5 - Sports injury prediction research has traditionally focused on physiological and demographical variables, for example, please see the work of Bahr and Krosshaug, (2005). However, contemporary research highlights the importance of including psychological variables to understand the complex interaction of factors that impact injury susceptibility. Previous research has especially identified: personality, history of stressors and coping in influencing injury outcome. The aim of the chapter is to provide an overview of psychological factors associated with injury outcome and organized under the general concept Stressors. Furthermore, to conduct a meta-analysis, in order to analyze the joint as well as separate effects of collected studies. The literature review resulted in 49 included articles. Of these 49 articles, 36 provided sufficient information for z-value calculation. In the total sample of selected studies (N = 36) the overall correlational effect size for the relationship between Stressors and injury occurrence were .129 (p 29.08) = 0.004 / V.Test = 2.7.

Total 20 29.3 16 34.7 100

President’s Violence in Sports Competition: Fiction or Reality?

109

Furthermore, the meaning of presidents’ violence differs significantly according to the sport. From looking at the results, basketball, swimming and table tennis presidents express a practical and instrumental nature of violence, compared with shooting and karate presidents, who were less expressive concerning this question. However if violence is used to ‘destabilize’ and ‘win’, for some table tennis and karate presidents it is also seen as a ‘positive’, ‘liberating’, as a relief from a certain pressure or tension accumulated.

Synoptic Diagram of Presidents’ Violence in the Field of Sport To avoid any wrong interpretation, to improve our results, to synthesize them also, an analysis using the main elements was carried out. ‘The existence’, ‘the frequency’ and ‘the degree’ of violence were coded as continuous variables and ‘the sports’, ‘the forms’ and ‘the meanings’ of violence as illustrative nominal variables. The relation between these variables shows that presidents’ violence differentiates sports. From this ‘multivaried’ analysis we can note a correlation between the ‘existence’, the ‘frequency’ and the ‘degree’ of the presidents’ violence. The analysis of the correlation matrix showed that in fact they correlated positively between themselves (0.45 ≤ r ≤ 0.68). Factor 1, which alone condenses 73.1% of the information, shows, on the left of the axis, sports marked by presidents’ violence and on the right, sports less or not at all marked. Here we can see that karate and swimming stand out positively, followed by basketball and table tennis and then by shooting, in particular, which appears less or is not at all concerned by presidents’ violence. As for factor 2, which represents 18.3% of the information, it shows a significant difference according to the degree of violence. Thus the intensity of the violence seems lower in sports where presidents’ violence exists contrary to basketball and table tennis where violence seems to appear less but with a higher intensity when it does.

Figure 1. the violence of presidents in the sporting field.

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Thus, the analysis used as a main element shows that not only the disparity of sports is correlated with the disparity of presidents’ violence in the sporting field but tends to show three groups positioned differently according to the presidents’ violence.

Group 1: Sports with ‘Violent’ Presidents This group is characterized by the presence of swimming and karate. Two sports with apparently different rationale: on the one hand karate is a combat sport with intermittent contact15, socially, culturally and economically ‘poor’16, symbolically considered a ‘sport of brutes’.17 On the other hand there is swimming, an individual sport without contact18, social, cultural or otherwise economical ‘average’19, symbolically considered an ‘upper-middle class sport’.20 All of this appears to divide them except for the existence of presidents’ violence. This result may seem surprising. However, whatever may be said pools and tatamis are places of rivalry, competition and violence. In swimming, the presidents of some clubs mentioned that certain presidents cheat with the licences, tamper with qualifying times, decimate swimmers’ clubs, protest verbally against their coaches and swimmers and don’t hesitate to humiliate themselves in front of other managers to express their violence.21 Likewise in karate, it seems apparently natural to see violent presidents or presidents who encourage violence in karate. As an example, a karate president, also trainer, after having been a competitor, clearly told us that if a trainee happened to complain of violence, his method was, in his own words: ‘to take his partner and to tell him, now you can give it and the other guy understood immediately. Because I can really hit hard’.22 In short this president’s answer to violence is to use violence too. And not just any violence, but the one he belongs to. In swimming, club presidents cultivate symbolic violence, whereas in karate presidents cultivate physical violence. So if the existence of violence seems shared between these two sports, their forms of expression or communication prove to be radically different.

Group 2: Sports with ‘Non Violent’ Presidents This group is characterized by the presence of one sport only, shooting. It is an individual sport practised from a distance, without a direct opponent. Nothing comparable with the extreme violence and physical deaths of the past centuries.23 During the ‘process of civilisation’ shooting has become a regulated, controlled and secure sport.24 Any form of violence is impossible and banned in such a structured sport. Moreover, there are no real regulations concerning violence in shooting, and this speaks for itself. A firearm is itself a safeguard against violence for the discipline as well as for the participants and managers. Indeed, presidents have mentioned the possibility of occasional self-intended moody outbursts following high tension matches. However, the general speech still shows a propensity for reassurance, self control, morality, common sense in the behaviour of the presidents of shooting clubs.25

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Group 3: The Intermediates This group is characterized by basketball and table tennis. Two sports, one a team sport, the other an individual sport, both with an ultimate objective of aiming with a ball or putting the ball in a material net, either the table or the basket. In theory physical contact between opponents is not favoured or authorised.26 Admittedly, if the president’s violence appears less in these sports, however with a higher degree in basketball compared to table tennis, verbal violence seems to characterise them both. Moreover, the interviews concerning this point are revealing. A basketball club president told us: ‘Some are terrible; I don’t know if at X you saw the president, to this question he can’t say he doesn’t know any violent presidents because he’s the first, he’s violence himself, he’s a horrible guy. He’s a guy capable of insulting the opponents, threatening the referees, all from his front row seat. X is a public hazard and he was so as a player’.27 In table tennis also, some presidents cannot control their language: ‘I realise I can set a bad example. I can become very violent verbally. A player who shows me a fist, when I’m outside the sports arena it exasperates me and I become very virulent and I can lose control’.28 So, if from our comparative study we can see that the president’s violence in basketball and table tennis is less perceptible than in swimming and karate, it is still present. There are presidents who ‘get carried away’ who let certain words slip out, who forget their ‘role’ even in disciplines in which there is very little violence.29

DISCUSSION The results of this study show that the presidents’ violence is a phenomenon to be taken into account in the sporting field. It is certainly not excessive but it does exist, as 16% of presidents admit the presence of violent presidents and of presidents who encourage violence in their sport. Whereas 60% of sportspeople declare that the violence in their sport is mainly directed at them30, 40% of coaches recognize that they can behave in a violent way from the substitutes’ bench31, there is no choice but to say that the ‘sports personnel’ relation to violence decreases according to the distance from the field. The closer to the field we are, the more present violence is and the further away we are the less present it is. As ‘position property’ to use Bourdieu’s classification32, violence seems to be more the property of sportspeople rather than one of instructors or managers; this is also confirmed by certain studies.33 The presidents’ violence is not mainstream, however it varies according to the sports. The ‘multivaried’ analysis reveals a diversified distribution of sports according to the presidents’ violence. Three groups appear: sports where presidents’ violence is truly real, here karate and swimming, sports where the presidents’ violence is more a myth, shooting, and the so-called ‘intermediate’ sports where the presidents’ violence is average, here basketball and table tennis. Whether it be about the existence, the level of the presidents’ violence etc. sports reveal differences: between the swimming presidents and the shooting presidents, and between those of karate and those of table tennis, between those of basketball and those of shooting. The disparity of the sports is correlative with the disparity of the presidents’ violence.

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If the results show an adequacy in the distribution of sports according to violence and the position occupied34, they also show an ‘outstanding position’ in one discipline, basketball. If this discipline seems to be the most affected by violence, according to the players and coaches, compared with other sports, sportspeople, coaches and presidents, on the other hand it seems to recede when it comes to the violence of their presidents. Should we conclude that basketball presidents are ‘cats’ and their sportspeople and coaches ‘dogs’? Or should we see in this a strategy on the part of the presidents to hide a reality which could go against them and their sport? Probably, because we know that basketball is a violent team sport35 where stakes are high and that, where they are important, violence is important.36 We also know that it is a ‘popular’, ‘virile’ sport37, identified as a ‘sport of brutes’ and ‘working class’ sport.38 Even if this distribution is to be perceived as a temporary, imperfect formalisation, it nonetheless remains useful. It gives a vision, admittedly limited, of the presidents’ violence in the sporting field but it enables to inform on the weight and nature in sports, to give information and to increase presidents’ awareness of the violence they express but are not always aware of and to remind them of their duty as president: set an example, give a sense of responsibility to their sports instructors and sports people, promote the values of sport, respect, education, socialisation and non-violence. By behaving negatively presidents cause themselves a lot of harm and have a bad influence on their environment: coaches, players, parents and supporters. Moreover this distribution reveals the dangers of violence to which presidents expose themselves to and commit in certain sports, but which could also guide them in their choice of sport according to their position concerning violence. On the other hand, this distribution also shows that swimming and karate are sports where the violence of presidents appears most. This result can be surprising, as violence is often said to be linked with team sports involving physical contact.39 The results of this study breach the rules and show that on the one hand the violence of presidents can touch sports reputed for their non violence and on the other hand that the violence of presidents is not limited to brutal force, physical violence, which affects people’s physical integrity, in this case, karate, but that it can take on other forms, more underhand, more intelligent, softer forms, more symbolic and can therefore affect people’s moral integrity, here swimming.40 Moreover, the violence represented and practised by presidents appears to conform to the properties of the violence of each sector they belong to.41 Regarding this point, we have already shown the compatibility between the violence of areas and that of the sportspeople.42 This homology of positions, presidents, coaches and sportspeople confirms Bourdieu’s theory, according to which the agents are determined, whatever their position, by their practising areas and their properties of violence, especially the forms that characterize them.43 If the distribution of sports according to the violence of their presidents tends to show the pertinence of the chosen identifying variables, this study also shows its limits of a methodological nature. Firstly, the sports practices are limited in number and do not cover all sports’ families. Secondly, we only took into account institutionalized sports areas. Yet, the behaviour of the presidents towards violence can vary considerably depending on whether we are in a ‘self-organized sports area’ or a federal sports area.44 Finally, even if we know that violence in sport is more a male problem than a female one, the sample didn’t include women and the other positions held in the sporting field, parents, referees, supporters... who are also concerned by the problem. All of this confirms the limits of the work presented and the necessity to complete it in the above-mentioned registers.

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Lastly, the problem of the violence of presidents was considered from a comparative angle. This relational and comparative perspective appeared as one of the solutions to address the violence of presidents, as according to the principles of social determinisms the violence of presidents in a given sport cannot be understood independently from that of other sports, it can only take on a meaning within the whole system.45 This way of approaching the problem is however one of many, but we think it can bring solutions to violence. To see that such a sport is besieged by such a form of violence and that this is transmitted through training to its agents (presidents, coaches, sportspeople), the ‘transposition’ or ‘transfer’ of these agents in other areas reputed ‘peaceful’ could modify their ‘habitus’. In schools, do we not use a strategy which involves putting disturbing, violent elements in classes with a peaceful reputation? It seems the answer is positive and the results rather conclusive.

CONCLUSION This study has shown that presidents’ violence exists and that it is not characterized in the same way in the field of various competitive sports. The definition of presidents’ violence, in terms of existence, level and form varies according to the sport. This proves that these are particularly ‘cleaved’ variables. The ‘multivaried’ analysis has shown that the disparity of the sports is correlated to the disparity of the presidents’ violence. Finally three groups with diverse relations to presidents’ violence have been highlighted showing that violence is a classed and ‘classifying’ property.

End Notes 1

Colinon, Histoire des jeux olympiques, 25-28; Mossé, les jeux de l’antiquité, 5-7. Dorozynski, ‘Les JO de l’antiquité n’étaient pas si «purs» que ça’, 1. 3 Brohm, Le mythe olympique, 267. 4 Elias and Dunning, Sport et civilisation, 205-38, 309-34; Elias, La civilisation des mœurs, 279-97. 5 Brohm, Critiques du sport, 243-244. 6 Pefferkorn, ‘L’avenir des jeux olympiques’, 170-75; Brohm, Sociologie politique du sport, 241-78. 7 Simson and Jennings, Main basse sur les jeux olympiques, 170-85. 8 Meynaud, Sport et politique, 235. 9 Bourdieu, ‘L’habitus et l’espace des styles de vie’, 189-248. 10 Guilbert, Sports et violences, 269-73, 417-41. 11 Bourdieu, Choses dites, 203. 12 Parlebas, Eléments de sociologie du sport, 67-96; Pociello, ‘La force, l’énergie, la grâce et les réflexes. Le jeu complexe des dispositions culturelles et sportives’, 171-237. 13 Guilbert, Sports et violences, 98-106. 14 Lassalle, La violence dans le sport, 91; Brohm, Les meutes sportives, 465-498. 15 Parlebas, Eléments de sociologie du sport, 67-96. 16 Guilbert, ‘Violences sportives, milieux sociaux et niveaux scolaires. Distribution socioculturelle des formes de violence dans le champ des pratiques sportives de terrain’, 33-4. 17 Guilbert, ‘Violence et capital symbolique: l’exemple du sport’, 26-7. 18 Parlebas, Eléments de sociologie du sport, 67-96. 19 Pociello, ‘La force, l’énergie, la grâce et les réflexes. Le jeu complexe des dispositions culturelles et sportives’, 171-237. 20 Guilbert, ‘Violence et capital symbolique: l’exemple du sport’, 25-6. 21 Guilbert, Sports et violences, 700-28. 2

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22

Guilbert, Sports et violences, 660. Tavernier, L’art du duel; André, L’art de se défendre dans la rue avec armes ou sans armes. 24 Elias and Dunning, Sport et civilisation, 205-38, 309-34; Elias, La civilisation des mœurs, 279-97. 25 Guilbert, Sports et violences, 729-52. 26 Parlebas, Eléments de sociologie du sport, 67-96. 27 Guilbert, Sports et violences, 630. 28 Guilbert, Sports et violences, 686. 29 Bourdieu, Questions de sociologie, 178. 30 Guilbert, Sports et violences, 128. 31 Guilbert, ‘La violence des entraîneurs: une étude comparative entre 5 disciplines sportives (basket-ball, tennis de table, karaté, natation et tir)’, 6. 32 Bourdieu, ‘L’habitus et l’espace des styles de vie’, 189-248. 33 Lassalle, ‘La violence des sportifs’, 90-108; Thomas, ‘La violence sur le terrain’, 107-12. 34 Guilbert, ‘Violence in Sports and Among Sporstmen’, 231-240; Guilbert, ‘La violence des entraîneurs: une étude comparative entre 5 disciplines sportives (basket-ball, tennis de table, karaté, natation et tir)’, 1-19. 35 Lassalle, La violence dans le sport, 91; Harrel, ‘Aggression by high school basketball players: an observational study of the effects of opponents aggression and frustration inducing factors’, 290-298; Tenenbaum, Kirker and Mattson, ‘An investigation of the dynamics of aggression: direct observations in ice hockey and basketball’, 373-386. 36 Guilbert, ‘L’influence des enjeux sur les violences sportives’, 49-85; Pilz, ‘Performance sport: Education in fairplay?’, 391-403. 37 Bourdieu, ‘L’habitus et l’espace des styles de vie’, 189-248; Pociello, ‘La force, l’énergie, la grâce et les réflexes. Le jeu complexe des dispositions culturelles et sportives’, 171-237. 38 Guilbert, ‘Violence et capital symbolique: l’exemple du sport’, 26-7. 39 Lassalle, La violence dans le sport, 91. 40 Bourdieu, Questions de sociologie, 258-59. 41 Guilbert, ‘Sport and Violence: A Typological Analysis’, 45-55. 42 Guilbert, ‘Violence in Sports and Among Sporstmen’, 231-240. 43 Bourdieu, ‘L’habitus et l’espace des styles de vie’, 189-248. 44 Vieille-Marchiset, ‘Sports urbains auto-organisés et politiques municipales d’équipements sportifs: L’exemple du basket’, 53-75. 45 Bourdieu, ‘L’habitus et l’espace des styles de vie’, 189-248; Pociello, ‘La force, l’énergie, la grâce et les réflexes. Le jeu complexe des dispositions culturelles et sportives’, 171-237. 23

REFERENCES André, E. L’Art de se défendre dans la rue avec armes ou sans armes. Paris: Flammarion, 1906. Bourdieu, P. La distinction, critique sociale du jugement. Paris: Minuit, 1979. Bourdieu, P. Questions de sociologie. Paris: Minuit, 1980. Bourdieu, P. Choses dites. Paris: Minuit, 1987. Brohm, J.M. Critiques du sport. Paris: Bourgois, 1976. Brohm, J.M. Le mythe olympique. Paris: Bourgois, 1981. Brohm, J.M. Sociologie politique du sport. Nancy: Presses universitaires de Nancy, 1992. Brohm, J.M. Les Meutes sportives. Paris: L’Harmattan, 1993. Colinon, M. Histoire des jeux olympiques. Paris: Gedalge, 1960. Dorozynski, A. ‘Les JO de l’antiquité n’étaient pas si purs que ça!’, Sciences et vie, no. 751 (1980): 47-53. Elias, N. La civilisation des moeurs (Translation from German by Pierre Kamnitzer of Über den Prozess der Zivilisation. Sociogenetische und Psychogenetische Untersuchungen [vol 1]) Paris: Calmann-Levy, 1973.

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Elias, N., Dunning, E. Sport et civilisation. La violence maîtrisée. (Translation from English by J. Chicheportiche and F. Duvigneau of Quest for excitement, Sport and Leisure in the Civilizing Process) Paris: Fayard, 1994. Guilbert, S. Sports et violences: Approche sociologique des représentations de la violence en sport. Thèse en Staps. Strasbourg: Université Marc Bloch, 2000. Guilbert, S. ‘L’influence des enjeux sur les violences sportives : Analyse à partir de 5 activités (le tennis de table, le karaté, la natation, le tir, le basket-ball)’, Revue Européenne de Management du Sport no.6 (2001): 49-85. Guilbert, S. ‘Sport and Violence: A Typological Analysis’, International Review for the Sociology of Sport 39, no.1 (2004): 45-55. Guilbert, S. ‘Violence in Sports and Among Sportsmen: A Single or Two-Track Issue?’, Aggressive Behavior 32, no.3 (2006): 231-40. Guilbert, S. ‘Violences sportives, milieux sociaux et niveaux scolaires’, International Journal of Violence and School no.8 (2009): 24-40. Guilbert, S. ‘La violence des entraîneurs: une étude comparative entre 5 disciplines sportives (basket-ball, tennis de table, karaté, natation et tir)’, Esporte e Sociedade, 5, no. 13 (nov 2009/feb 2010): 1-20. Guilbert, S. ‘Violence et capital symbolique: L’exemple du sport’, French Cultural Studies 21, no.1, (2010): 19-30. Harrel, W.A. ‘Aggression by high school basketball players: an observational study of the effects of opponents aggression and frustration inducing factors’, International Journal of Sport Psychology, no.4 (1980): 290-98. Lassalle, J.Y. La violence dans le sport. Paris: PUF, 1997. Meynaud, J. Sport et politique. Paris: Payot, 1966. Mossé, C. Les jeux de l’antiquité. Paris: Dossiers de l’archéologie, 1980. Parlebas, P. Eléments de sociologie du sport. Paris: PUF, 1986. Pilz, G.A. ‘Performance sport: Education in fair-play?’, International Review for the Sociology of Sport 30, no. 3-4 (1995): 391-403. Pociello, C., W. Andreff, J.P. Augustin, M. Berges, M. Bernard, J. Blouin, J.P. Clément, N. Dechavanne, J. Defrance, F. Di Ruzza, J. Durry, P. Falt, C. Fleuridas, B. Gerbier, J. Guillerme, L. Herr, P. Irlinger, C. Louveau, M. Métoudi and G. Vigarello. Sports et société: Approche socioculturelle des pratiques. Paris: Vigot, 1981. Simson, V., Jennings, A. Main basse sur les jeux olympiques. Paris: Flammarion, 1992. Tavernier, A. L’Art du duel. Paris: Marpon and Flammarion, 1880. Tenenbaum, G., Kirker, B., Mattson, J. ‘An investigation of the dynamics of aggression: direct observations in ice hockey and basket-ball’, Research Quaterly for Exercice and Sport, no.71(2000): 373-86. Thomas, R. Sociologie du sport. Paris: PUF, 1993. Vieille-Marchiset, G. ‘Sports urbains auto-organisés et politiques municipales d’équipements sportifs: L’exemple du basket’, Revue Européenne de Management du Sport, no.2 (1999): 53-75.

Author note: Sébastien GUILBERT is a qualified Doctor in Sport Sociology at the University of Strasbourg (EA n°1342). His works deal mainly with a study of the representations of violence in the sports area.

In: Advances in Psychology Research. Volume 97 Editor: Alexandra M. Columbus

ISBN: 978-1-62618-804-4 © 2013 Nova Science Publishers, Inc.

Chapter 7

COGNITIVE BEHAVIORAL CASE MANAGEMENT (CBCM) FOR EARLY PSYCHOSIS: A HONG KONG EXPERIENCE Wendy Wy. Tam* and Eric Yh. Chen† Jockey Club Early Psychosis Project, Department of Psychiatry, The University of Hong Kong, Hong Kong Jockey Club Early Psychosis Project, State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong

ABSTRACT CBT is considered as one of the effective psychological interventions for people with psychosis in reducing their distresses result from psychotic symptoms. A formal or high intensity CBT requires structured sessions for people with psychosis, which can last for up to 16 weeks. However, due to scarce resources in Hong Kong, this is not easily available. In the public mental health care system provided by the Hospital Authority, people with psychosis are provided with medication treatment and case management services. The caseload for case manager in local setting is much higher than in the west, ranging from 50 up to 80 or above. As a result, low intensity CBT may be more appropriate in the local setting. This chapter describes experiences in Jockey Club Early Psychosis (JCEP) project, which is a pioneer project in Hong Kong to provide early psychosis case management for adult onset early psychosis patients. Low intensity (LI) CBT is provided during the course of intervention, aiming to reduce patient’s distress through understanding their cognitive pattern and relationship with symptoms in terms of behavior, cognition and emotions. Some of the key components will also be reviewed: assessment and engagement, formulation, symptoms management, relapse prevention and outcome evaluations. The chapter will also cover background for psychotic disorders in Hong *

Chief Administrative Officer, Jockey Club Early Psychosis Project, Department of Psychiatry, The University of Hong Kong Email: [email protected]. † Head, Department of Psychiatry Director, Psychosis Studies and Intervention Program Director, Jockey Club Early Psychosis Project, State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong Email: [email protected].

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INTRODUCTION CBT is considered as an adjunct to pharmacological treatment for people with psychosis. Existing literature supported the effectiveness of CBT in distress reduction, improvement in positive symptoms, mood and social functioning (Dixon et al, 2010). However, CBT interventions are not easily available to patients as it involves professionals who received formal CBT training and structured time requirement for intervention. LI CBT had been developed in the attempt to address the limitations of traditional CBT. There were evidences suggesting that LI CBT also provides compatible results with traditional CBT on people with schizophrenia (Turkington, 2002 and Tai et al, 2009). This chapter is divided into five sections. In the first section we go through briefly on how we define low-intensity CBT in the Hong Kong setting. In the second section, we provide a brief background on CBT application in Hong Kong in the Jockey Club Early Psychosis (JCEP) Project. In the third section, we present a case from JCEP Project. In the fourth section, we illustrate CBT applications and techniques used in the intervention. In the last section, we summarize intervention experiences and propose future directions.

LOW INTENSITY CBT (LI CBT) LI CBT is a new trend developed in recent years and there is no conclusive definition yet (Bennett-Levy et al, 2010). The term is developed in order to describe the applications of CBT in a less formal structure which aims to deliver similar impacts and effects through increasing the accessibility in a cost effective manners. LI CBT includes CBT in the forms of various technological means, such as phone, SMS, email, internet based interventions, as well as group CBT and or self-help based CBT (Bennett-Levy and Ferrand, 2010). The LI CBT practitioners are not necessarily high intensity CBT therapists (Bennett-Levy et al, 2010). Low intensity CBT in JCEP project refers to the applications of CBT techniques in providing intervention to first episode psychosis patients. Based on the definition of LI CBT intervention by Bennett-Levy et al. (2010), JCEP project applies LI CBT in the following ways: 1. Reduction in time for practitioner in terms of contacting the patients 2. ‘Use of CBT resources whose content is often less intensive’ (p9) 3. Provide more rapid access to early intervention program The keys are to deliver CBT principles to patients in effective and accessible manners. In the JCEP project we also use face-to-face, email, SMS, referral to community and voluntary resources to increase accessibility for patients.

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BACKGROUND ON JCEP PROJECT Cognitive behavioral case management (CBCM) refers to ‘an intervention that provides cognitive-behavioral treatment delivered within a therapeutic case management framework.’ (Nelson, B et al, 2008, p7). JCEP project also adopts case management based on a phase specific approach tailor made for first episode psychosis patient’s need. CBT framework is used for facilitating patient’s understanding on the relationship between cognition, emotion and behavior. This serves as a tool for case manager to build up therapeutic alliance and rapport with patient, making continuous assessments as well as providing patient with an understanding on their illness experiences (Bennett-Levy et al, 2010). Coping strategies are also introduced to facilitate recovery. There are three main goals in applying CBT on people with schizophrenia. They include (Li, 2009): 1. reducing distress and disability associated with residual psychotic symptoms 2. reducing emotional disturbance 3. promoting patient’s participation in relapse prevention Apart from that, some key components were also followed as proposed by Fowler et at 1995 (Li, 2009) 1. 2. 3. 4. 5. 6.

Thorough assessment and rapport building Reduce immediate distress (coping strategy enhancement) Insight enhancement and drug compliance Manage psychotic symptoms Changing dysfunctional core beliefs Consolidation and relapse prevention

Training Two CBCM trainings were conducted by an experienced clinical psychologist in Hong Kong before the project launch and in the third year by collaborators from Australia. Two workshops by local and experienced clinical psychologist and social worker were also conducted on CBT applications on people with psychosis. Two experienced clinical psychologists from United Kingdom also conducted 2 days workshops on same topic. All these workshops were attended by case managers. Besides, weekly supervisions by clinical psychologist and psychiatrist were also conducted for training on case formulation and reviewing of case care plan and management.

BACKGROUND ON HONG KONG Hong Kong is a densely populated city with over 7 millions people. Living environment in general is crowded and mostly 2 or 3 generations live together. About 67% of people aged

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above 18 lived together with their parents (Census & Statistics Department, 2010). Thus for people with psychosis in Hong Kong, family support is more available when compared to the west as adult tends to leave the family and live on their own once they grown up. However, this also complicated stigma issues in Hong Kong which may be related to the idea of ‘face’ in Chinese culture which is similar to fame in the west. If a family member has psychosis, it is considered as a taboo in the family, which family members either ignore the issues or keep it as a secret to prevent ‘losing face’. One of the reasons may be related to general public attitude and understanding of mental illness in Hong Kong. Local media usually report in a high profile and sensational manner when there are violence incidents related to people with mental illnesses. People with mental illness are often perceived as being more violent and unpredictable. Apart from that, Hong Kong also have migrants from China, though also Chinese, the dialects vary which may also result in adjustment issues due to differences in cultures and habits. Early intervention service for people with psychosis was launched in 2001 in Hong Kong. In addition to medication treatment, case management services are also provided to people with young adult aged between 15 to 25 first episode psychosis patients. These include key components such as engagement and assessment, symptoms management, functioning recovery and relapse prevention. The program also provided public education in the general public to increase an awareness of psychosis in the hope to enhance early detection. Jockey Club Early Psychosis (JCEP) Project is the first early intervention program for adult first episode psychosis patient in Hong Kong. The project aims to provide cognitive behavioral case management intervention for people with first episode psychosis. Inclusion criteria fall into those who aged between 26 to 64 years old, with a diagnosis of schizophrenia spectrum disorders and depression with psychotic symptoms. Interventions are provided by social workers and psychologists who received induction training covering knowledge on psychosis and skills training on engagement and assessments. There are also weekly supervision by psychiatrists and clinical psychologist in discussion on case management and formulation. CBT techniques are usually applied to those with mild to moderate psychological disorders (Bennett-Levy et al, 2010). In JCEP project, symptoms management is often the first task when a case manager received the referrals. CBT techniques usually apply when the symptoms subside and when patient’s mental state has the capacity and readiness to make senses of their illness experiences. Key components in CBT model are adopted in JCEP project, including ABC models, 5P principles (see below), engagement and assessment, formulation, symptoms management and normalization.

JCEP LI CBT COMPONENTS The LI CBT components used in JCEP Project include common components used in CBT, including Engagement and assessment. In the JCEP project we use a timeline approach as well as 5P principles. Following that we have the formulation for management and care plan. We also use ABC model in facilitating patients to understand the relationship between cognition, emotion and behavior and how it may relate to the psychotic symptoms. Normalization is also used to assist patients who have a tendency for jumping to conclusion,

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having black and white thinking which are common in people with psychosis. Normalization is also used in the attempt to address stigma issues for people with psychosis. All these will be discussed in the following case illustration.

CASE ILLUSTRATION Presenting Complaint Ann was referred to a psychiatrist from the general outpatient clinic due to presentation of chronic insomnia for 6-7 years, low mood and suicidal ideas. She has paranoid ideas that she was followed by others on the street. She also heard a number of voices, including second and third person voices. Ann’s unstable mood resulted in hitting her 8 years old daughter with a hanger at home once. This was intervened by a social worker who took Ann’s daughter to foster care to prevent happening of harmful event.

Demographic Details Ann is a 33 years old woman born in China and came to Hong Kong at the age of 28 after giving birth of her daughter at 26 years old. She is divorced and living with her 8 years old daughter in a private rented flat. She is unemployed and living on savings. She has limited social support since she seldom contacts her mother or siblings due to distant relationship. She reported no family history of mental illness, non substance or drug abuse user.

Daily Activities Ann is currently unemployed as she needs to take care of her 8 years old daughter. She sends her daughter to school in the morning, follow by performing household chord at home and preparing lunch for herself. After that she shops at the market and picks her daughter up after school. She spends most of the time on her own in the flat and she either idles at home or sleeps when she feels tired. When she feels bored, she listens to radio, surfs on the internet or reads. She seldom goes out unless necessary.

Personal History She was the eldest sister with two younger brothers. She studied up to secondary school in China. She used to be taken care of by her auntie when she was a kid, who she looked upon a lot. She described auntie taught and encouraged her a lot when she was a kid. Unfortunately, this auntie died suddenly due to health reasons when she was about 7 years old. Her family members did not explain in details about this sudden death and as a child she felt very sad and that she considered herself not behaved well when the auntie was still alive. Since then she also took care of her younger brothers as she was the eldest sister and her

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parents were both working to make a living for the family. She started looking after her younger brothers through taking up all household chord as well as looking after their studies and disciplining them. However, she reported having difficulties in looking after her younger brothers as they were disobedient, thus her relationships with her younger brothers were poor and with lots of arguments. She also received little support from her parents who both worked outside most of the time. She considered her parents as providing the basic needs and supports only, without providing enough love and warmth to her. She reported her studies were fine in primary school and got along well with others. She described herself as an introvert and was quiet in the group and denied any bullying or abuse events happening to her when she was a child. She was able to make some friends and maintained in good relationship with them although they would not discuss in-depth issues. She reported that her academic result at secondary school dropped a bit as she had difficulties in catching up with various subjects. However, she was still able to complete her secondary school education with fair results. She reported she also got a few friends at secondary school and she mainly played a listener role in the group. Her friends would seek advice and support from her. On the other hand, she reported herself seldom be able to find friends who listen to her and most of the time she keeps things in her heart without seeking help from others. She also reported herself being pessimistic and would think in a negative way most of the time. After her graduation, she started working at various fields, including education, sales and beauty salon. She reported her job as a kindergarten teacher, which she worked for about 1.5 years with stresses. Ann reported she failed to handle a class of 20-30 kindergarten kids and she would cry at home after work as she felt stressed, failure to control the class discipline and handling of kids. She quitted the job after 1.5 years and changed to working in sales and related items. She encountered similar situation when working in sales related items. She felt stressful to meet sales target and she reported poor relationships with colleagues and seniors. She was scolded by her boss when she failed to meet the target and that her colleagues were neither helpful nor supportive. She was able to maintain most of the jobs for a maximum of 12 years. Ann got married at the age of 25 with a man in Hong Kong introduced by her mother who lived and worked in Hong Kong. Her husband was 13 years older than her and was a construction worker. Ann said she looked for someone who can take care of and listen to her and together to build up a happy family. There was no real dating before marriage as she got pregnant very soon after they started the relationship. She loved her husband as she would like to find someone to rely and depend on. She stayed in China during early pregnancy and only came to Hong Kong when it was almost time for delivery of birth. She described herself as if living in prison when she came to Hong Kong as she needed to live with her family-inlaws. She stayed at home most of the time and was unable to help much of the household chord as she was pregnant. She would not leave home as well since she was not familiar with places in Hong Kong at that time. The family lived in public housing estate, the living environment was not as what she expected and there were frequent conflicts with in-laws who criticized her not helpful or productive. After giving birth of her daughter, she returned to China to take care of herself and her daughter. Her husband would send money back to China to support their living. Although she can take care of her daughter by her own, she developed insomnia since then. Ann came to Hong Kong when her daughter was 2 years old. Originally living together with family-in-laws however due to conflicts with in-laws and crowded living conditions, her

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family moved out when her daughter started attending kindergarten. However, Ann only realized that her husband has the habit of gambling, which not only resulted in losing money but also in debts. When her husband lost money due to gambling, he had bad temper and throw things around at home. Although he would not harm Ann and their daughter, Ann felt fearful and urges to protect daughter from this environment. Subsequently, her husband stopped supporting the family, which resulted in Ann resuming job to support the family. Ann sought help from social worker with the attempt to file divorce in 2006. She received marital counseling with the hope to maintain the family at the initial stage, thus she also helped to pay off the debts on her husband’s behalf by using her own savings. There were periods which her husband’s behaviors improved, but same situations repeated later on, thus Ann was determined to divorce with her husband and the process only completed by 2009. Her insomnia did not improve but worsen and her mood became depressed at that time. Ann started hearing voices and developed idea of reference in 2009. Ann reported herself hearing a number of voices, including from in-law family and colleagues, all with negative content. The voices laughed, criticized and talked about her, which she also received running commentary. She felt distressed about the voices and she would cry and talk back to the voices. She usually heard the voices when she was home alone. She also heard a voice at night which she believed it was from a woman next door seeking for assistance.

CBT TECHNIQUES IN JCEP Engagement and Assessment - Timeline Approach JCEP case manager engaged Ann with empathetic feedbacks and curiosity in understanding her experiences during the initial sessions. A problem list was generated during assessment in the initial stage when exploring Ann’s distressing areas which included symptoms issues such as voices, sleeping problems and practical issues such as divorce status, financial stress. A collaborative goal focus approach was used in order to build up the therapeutic alliance and set as an agenda in forthcoming sessions. Her own illness explanation model was also explored which she considered her onset of illness due to stresses she faced in handling the divorce, financial stress to support living and handling of debts which was left behind by her separated husband. She also considered her negative thinking style as one of the factors in contributing to the onset of illness. During the first few sessions, Ann would still considered the voices as real despite the fact that those people whom she recognized from the voices were not present at her home. Later on, when Ann was able to distinguish voices and symptoms, psycho-education and normalization were provided based on stress-vulnerability model to understand her illness experiences. The ABC (Activating event-belief-consequence) model was used to explain the relationship between event, interpretation and emotional and behavioral consequences. This simple cognitive model was introduced and used repeatedly for maintaining engagement with Ann (Bentall, 2012). Activating event: Ann’s daughter needs to apply for a new tuition class, however the staff’s attitude was poor and not helpful, Ann’s belief that it is a discrimination to her as she was divorced and came from China and the consequent was she did not apply tuition class for

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her daughter but found a private tutor for her daughter. This model was shown to Ann for understanding and increasing awareness on her cognitive pattern and offering an alternative thinking to interpret various events in daily life.

Figure 1. ABC model.

Case Formulation

Figure 2. Timeline Approach.

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Case formulation models were mainly shared with patients after a thorough assessment was made. A time line approach was used after obtaining relevant and salient information from Ann to confirm a clear understanding between case manager and Ann. Apart from that, a historical formulation was also prepared which was shared with Ann in order to understand her illnesses experiences.

Figure 3. Historical formulation.

Her early experiences that sudden death of her auntie who took care of her and later on she took up a key role in looking after her siblings generated the core belief that she was abandon by others and no one love her. These generate thoughts that popped up in her minds at time included she had to be good, responsible and useful. The meanings to Ann were that if she could do that, she would be loved. On the other hand, if she failed, no one would love her. As Ann would like to fulfill this, she coped by providing unconditional love to her exhusband despite his repeated betrayals and that she felt very stressed in taking good care of her daughter so that she can be considered as responsible and good. The purpose of this formulation sharing aided to increase Ann’s understanding of her life story and to increase therapeutic alliance. Another approach is based on the 5P principles adopted from the CBCM model to explain the formation and maintenance of illness in the attempt to draw insight for relapse preventions. The 5P refers to (1) Predisposing factors, such as issues that are specifically to develop a psychotic illness; (2) Precipitating factors, relevant experiences that precede the onset of illness; (3) perpetuating factors which hinder recovery or increase the relapse risk; (4) protective factors which facilitate recovery and (5) premobid functioning. This

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formulation is not shared with Ann but mainly for case manager to guide the formulation and care plan.

Symptom management - understanding and coping with voices Apart from the historical formulation shared with Ann earlier regarding the appearance of voices, ABC model was used again in making sense of the voices.

Figure 4. Cognitive model on voices.

When Ann heard a voice saying ‘You are bad’, she interpreted the voice as being powerful and her emotion reactions were fear, guilt and depressed. As a result, she would cry and attempted to resist from hearing the voices, yet the harder she tried, the more voices appeared. The voice would appear when she was alone and feeling depressed. Interpretation of voices plays an important role in working on hallucinations as that can help to generate a list of alternative thinking in relating to the voices (Bentall, 2012). Inner speech theory was also explained to Ann in providing alternative understanding of voices she heard and how the content might be related to her core belief and schema. Thoughts diary was also introduced to Ann for understanding the frequencies of voices and circumstances that voices appeared. This also provided an opportunity for Ann to understand the relationship between the content of the voices and her emotions and thoughts.

Relapse Prevention – Maintaining Model After understanding the appearance of voices, Ann was also presented with an explanation on how the voices were maintained.

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In relation to the voices dairy she was able to make sense of how voices were maintained and what kind of safety behaviors were adopted by her. Coping strategies were discussed for better control of the voices.

Figure 5. Maintenance model.

Normalization The purposes of normalization are decastrophising the psychotic experiences and making it understandable and normal for patient (Kington and Turkington, 2005). Ann expressed when she idled at home alone, many negative intrusive thoughts came to her minds and she attempted to suppress these thoughts but in vain. White bear suppression thought experiment was introduced to Ann in the attempt to explain the effects of thought suppression. On another occasion, Ann shared that she had hesitation in taking up a domestic helper role due to an intrusive thought that if she climb up to a ladder to clean the windows, she would have an urge to jump from height. This resulted in a safety behavior that she would stop cleaning the windows close to the ceiling in her flat. The idea of intrusive thought was also explained to Ann that this is also a common phenomenon which the majority also experience.

Outcome Evaluation Ongoing assessments and evaluations are used to validate the formulation and management plan. In terms of onset of illness (Figure 2), Ann is also able to identify precipitating factors related to the onset, such as divorce, stresses and worries from handling debts. The historical formulation (Figure 3) facilitates Ann in understanding her emotion responses during the anniversary of her auntie’s death almost annually. Apart from relieving

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her emotion responses, she is also able to understand how her interpretation and understanding of her auntie’s death impact on some of her core beliefs about herself, that she must be responsible, must behave and live well. When these core beliefs interacted with her following life experiences, such as poor job performances and divorce, she started hearing voices with negative comments on her. Figure 4 helped Ann to understand how the voices are maintained and impact on her emotion, cognition and behaviors. Coping strategies were also introduced in handling residual symptoms. The last figure on maintaining model enabled Ann to identify factors which may prevent her from relapse. Presentation of these various figures enable Ann to understand and make sense of her illness experiences, identify factors contributing to her onset of illness as well as factors which can help her to prevent relapse. Apart from that she is able to learn skills in coping with negative cognitions, such as suppression of thoughts. Ann’s symptoms subsided and she is able to distinguish symptoms and voices in times when she was stressful and she learns how to cope with symptoms. She also resumed part-time job and engaged in a wider range of daily activities.

CONCLUSION This chapter summarizes the experience of CBCM in the JCEP project in Hong Kong, with an attempt to define LI CBT used in the project. Early intervention service in HK developed in a unique context, with needs to adapt to the local population. A case illustration on a JCEP patient is used to demonstrate how CBT techniques can be applied in CBCM. The key CBT techniques were used in a simple way for facilitating engagement and assessment, sharing with patients to understanding of illness experiences. Through such understandings, patients’ distresses are relieved and they acquire coping skills in the course of recovery for relapse prevention. Further researches are needed in evaluating the intervention effectiveness specific to LI CBT.

REFERENCE Bennett-Levy, J. and Farrand, P. (2010). Low intensity CBT models and conceptual underpinnings Overview. In Bennett-Levy et al. (Ed.), Oxford Guide to Low Intensity CBT Interventions (pp 1-2). New York: Oxford University Press. Bennett-Levy, J., Richards, D.A. and Farrand, P. (2010). Low Intensity CBT interventions: a revolution in mental health care. In Bennett-Levy et al. (Ed.), Oxford Guide to Low Intensity CBT Interventions (pp 3-18). New York: Oxford University Press. Bentall, R. (2012). Case formulation in CBT and therapeutic engagement. International Symposium and workshop on Cognitive-Behavioral Therapy for psychosis (ThoughtPerception Sensitivity Syndrome) presented. Chonbuk National University Hospital, Jeonju, Korea. Census and Statistics Department (2010). Thematic Household Survey Report No.44 Relationships among Family Members. Hong Kong: Social Survey Section, Census and Statistics Department.

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Dixon, L.B., Dickerson, F., Bellack, A.S., Bennett, M., Dickinson, D., Goldberg, R.W. et al. (2010) Schizophrenia Patient Outcomes Research Team (PORT). The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin 36:48-70 Kington, D.G. and Turkington, D. (2005). Cognitive-behavioral therapy of schizophrenia. New York: Guilford Press. Li, F. (2009) Cognitive Behavioral Case Management: An overview. CBCM training presented. The University of Hong Kong. Nelson, B., Philips L.J., Bechdolf, A. and Francey, S.M. (2008) Cognitive Behavioral Management (CBCM) Manual. Australia: Orygen Youth Health Research Centre. Tai, S. and Turkington, D. (2009). The Evolution of cognitive behavioral therapy for schizophrenia: current practice and recent developments. Schizophrenia Bulletin 35: 865873 Turkington, D., Kingdon, D. and Turner, T. (2002). Effectiveness of a brief cognitivebehavioral therapy intervention in the treatment of schizophrenia. British Journal of Psychiatry 180:523-527

In: Advances in Psychology Research. Volume 97 Editor: Alexandra M. Columbus

ISBN: 978-1-62618-804-4 © 2013 Nova Science Publishers, Inc.

Chapter 8

ENHANCING REGULARITY IN MEDITATION USING THE SOCIAL COGNITIVE THEORY Manoj Sharma Health Promotion and Education, University of Cincinnati, Cincinnati, OH, US

ABSTRACT There are several forms of meditation that are popular in the US: mindfulness meditation, transcendental meditation, Zen meditation, Kundalini yoga meditation, Sahaja yoga meditation and so on. Meditation offers numerous advantages and benefits. Many people initiate meditation but most people are not able to sustain regularity in practicing meditation. There are several barriers in maintaining regularity with practice. This short communication introduces an approach based on social cognitive theory that can help practitioners become regular with meditation. The origins of social cognitive theory, the underpinnings of social cognitive theory, the constructs of social cognitive theory, and application of social cognitive theory in promoting adherence to practice of meditation are discussed in this short communication. The constructs of knowledge, outcome expectations, outcome expectancies, situational perception, environment, selfefficacy for meditation, self-efficacy in overcoming barriers to meditation, goal setting or self-control, and emotional coping are reified to enhance practice of meditation. Examples of meditation program based on this approach for anxiety reduction, management of arthritis, and smoking cessation are presented.

Meditation involves concentration on an object, sound, breath, inner energy, movement, visualization or on awareness itself. The process leads to enhanced awareness of the present moment. Meditation can lead to reduction of stress, relaxation, and improved personal growth. It has its origin from ancient practice of yoga from India. In Patanjali’s Asthangayoga, the seventh limb is dhyana, or meditation (Romas andSharma, 2010). Some popular forms of meditation in the United States are mindfulness meditation (Marchand, 2012), transcendental meditation (Balaji, Varne, and Ali, 2012), Zen meditation (Marchand, Tel: (513) 556-3878. Fax: (513) 556-3898. E-mail: [email protected].

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2012), Kundalini yoga meditation (Shannahoff-Khalsa, 2004), Sahaja yoga meditation (Chung, Brooks, Rai, Balk, and Rai, 2012), Kriya yoga meditation (Schmidt, Wijga, Von Zur Mühlen, Brabant, and Wagner, 1997), and Sudarshan Kriya yoga meditation (Baijal, and Srinivasan 2010). A study by Astin and colleagues (2003) found that there is evidence regarding the efficacy of mind-body therapies including meditation in the treatment of coronary artery disease, headaches, insomnia, incontinence, chronic low back pain, disease and treatment-related symptoms of cancer, for improving postsurgical outcomes, hypertension and arthritis. According to the National Health Interview Survey done in 2007, 9.4% adults in United States were meditating which was higher than 2002 when 7.6% reported practicing meditation (Barnes, Bloom, and Nahin, 2008). Many people initiate the practice of meditation; however they are not able to sustain this practice over a longer period of time. A study by Williams and colleagues (2011) examined this phenomenon of low enrolment and high attrition. Some of the barriers that this study identified were: (a) cannot stop the thoughts, (b) being uncomfortable with silence, (c) cannot sit still long enough to meditate, (d) prefer to be accomplishing something, (e) boring (f) thinking that it is a waste of time doing nothing, (g) not knowing much about meditation, (h) prayer being better, (i) lack of quiet place, (j) not having time, (k) not having alone time, (l) not knowing if doing it right, (m) conflict with religion, (n) family thinks unusual, (o) feel odd, (p) not believing that meditation can help, and (q) potential harm. Many of these barriers can be overcome if meditation instructors use the approach based on social cognitive theory. The following narration will describe the origins of social cognitive theory, the underpinnings of social cognitive theory, the constructs of social cognitive theory as they relate to practice of meditation and applications of this theory in promoting meditation.

ORIGINS OF SOCIAL COGNITIVE THEORY The precursor to social cognitive theory was the social learning theory. Bandura and Walters (1963) proposed the social learning theory which described the role of three important influences on learning of a behavior. The first was imitation. Imitation contributes to learning in three ways: (a) a modeling effect in which the learner directly reproduces the behavior; (b) an inhibitory or disinhibitory effect in which there is an increase or decrease in the behavior due to observation; and (c) an eliciting effect in which imitation serves as a cue for releasing similar responses in the observer. The second influence in learning was that of reinforcements. Positive reinforcement which could be in the form of verbal approval or material rewards helps to reinforce the behavior. Negative reinforcement which could be in the form of verbal or physical punishment by an authority figure inhibits aggression as long as the punitive agent is present. The third influence in learning was that of self-control. Selfcontrol is learned and sustained by direct reinforcement that takes the form of disciplinary interventions, both negative and positive. In 1970s social learning theory was used in designing the Stanford three-community study, which began in three northern California communities for prevention of risk factors associated with heart disease (Farquhar, 1978; Farquhar et al., 1977). In 1977 Bandura refined the original theory and published a book, Social Learning Theory, which formed the basis of the Stanford five-city project, a major cardiovascular disease prevention trial (Farquhar et al., 1985; Young, Haskell, Jatulis, and

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Fortmann, 1993). The theory was renamed as social cognitive theory in the eighties (Bandura, 1986) and is the name by which it is known today. Hundreds of applications of this theory to different health and other behaviors have been applied and tested and it continues to be a popular theory.

UNDERPINNINGS OF SOCIAL COGNITIVE THEORY Social cognitive theory describes five basic capabilities of human beings which help in learning and changing any behavior (Sharma and Romas, 2012). The first capability is the symbolizing capability. This refers to the utilization of symbols in assigning meaning to experiences. It is an essential tool for comprehending, creating, and managing one’s environment. Most environmental events are understood by cognition as opposed to directly. Through use of symbols one gives structure, meaning, and continuity to one’s experiences. This capability also helps in communicating with others at any distance in time and space. Use of written communication is possible only due to this capability. The second capability is the vicarious capability. This refers to the ability to learn from observation of other people’s behavior and the consequences they face as a result of their behaviors. This ability is significant because it enables people to generate and regulate behavior without indulging in tedious trial and error. Some complex skills can be mastered only through modeling. Modeling is not simply a process of response mimicry but entails creativity and innovativeness as well. The third capability is the forethought capability. This refers to the fact that most behavior is purposive and regulated by prior thoughts. Human beings motivate themselves and plan their behaviors based on forethought capability. People imagine future events even when those do not have actual existence and use them as motivators in the present to perform behaviors. The behaviors that are likely to bring positive rewards are easily adopted, while the behaviors that are likely to produce negative consequences are not adopted. The fourth capability is self-regulatory capability. This capability refers to forming internal standards and self-evaluative reactions for one’s behavior. When one meets the desirable standards when gains self-satisfaction while when standards are not met it results in dissatisfaction. Human beings are proactive and constantly form challenging goals for themselves, which also plays an important role in self-regulation. The fifth capability is self-reflective capability. This entails the analysis of experiences and examination of one’s own thought processes. Human beings are not just agents of action but they also self-examine and critique their own actions. They generate ideas, act upon them based on an anticipated outcome, and then in retrospect judge the accuracy and value of the outcomes, finally modifying their thinking as needed.

CONSTRUCTS OF SOCIAL COGNITIVE THEORY The constructs of social cognitive theory have been delineated in different ways in the literature. We will describe the constructs as illustrated by Bandura (2004) and relate them to regularity in meditation.

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The first construct of social cognitive theory is knowledge. In the context of meditation for practicing regularity it is important that correct technique be known to the practitioner. Whichever system of meditation is being followed the steps in doing that technique must be clear. The meditation instructor must provide clear directions regarding the practice of the meditation steps. The second construct is outcome expectations, which is the anticipation of the likely outcomes that would ensue as a result of engaging in practicing meditation regularly. Bandura (2004) has identified three types of outcomes: (1) physical outcomes, which include positive and negative consequences of the behavior; (2) the outcome of social approval or disapproval of engaging or disengaging in the behavior; and (3) positive and negative self-evaluations. For example, some outcome expectations for a person wanting to practice meditation regularly would be stress reduction, attainment of peace, improved relationships, feeling of satisfaction, possible social approval from family and friends, and self-contentment. The meditation instructor can discuss these benefits with the practitioner in order to build this construct. The third construct is outcome expectancies, which refers to the value a person places on the likely outcomes that result from engaging in meditation regularly. The higher the expectancies the greater will be the chance that the individual will engage in the behavior. For example, if a person values the outcome of stress reduction then he or she is likely to engage in practicing meditation. Likewise if a person does not value the outcome of attainment of peace he or she is not likely to practice meditation. In order to modify this construct the meditation instructor must conduct a discussion on the values of anticipatory outcomes. He or she can also use a psychodrama or role play to show the value of the anticipatory outcomes. The fourth construct is situational perception, which refers to how one perceives and interprets the environment. Misperceptions hinder the behavior change. Practice of meditation may be associated with several misperceptions such as development of extrasensory powers as a result of meditation, rituals associated with meditation etc. Such misperceptions must be corrected. Providing correct information and explanation of the truthful benefits of meditation are very important. The fifth construct is environment, which refers to physical and social conditions around a person who is meditating. Creation of a distraction free environment for practice of meditation is very important. Likewise there must be social support of like-minded people around the person who help in sustenance of the practice. Formation of a meditation club or a similar group is also helpful in this regard. The sixth construct is self-efficacy for meditation, which is the confidence a person has in his or her ability to pursue meditation. Self-efficacy is behavior specific and pertains to the present. It is not about the past or future. The first way self-efficacy about meditation can be built is by teaching meditation in small steps so that complete mastery can be gained. The second way is to use credible role models. Examples of celebrities and other well-known people who practice meditation can be used. The third way is to use persuasion and reassurance. People who have not been successful in meditating regularly in the past can be told to attribute their failures to external reasons. Likewise if a person has been successful in maintaining other behaviors successfully then those successes should be attributed to the person. Finally all stress associated with practice of meditation must be removed and it should be made a stress-free activity.

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The seventh construct is self-efficacy in overcoming impediments while practicing meditation, which refers to the confidence that a person has in overcoming barriers while performing meditation. There are several barriers associated with regular practice of meditation such as not finding time, tiredness, not feeling the need to meditate, environmental distractions, job stress, conflicts, anger, anxiety, and so on. Stepwise approach to overcome each barrier must be developed and taught to the practitioners. The eighth construct is goal setting or self-control for meditation, which refers to setting goals and developing plans to accomplish regularity in meditation. Practitioners of meditation must develop daily goals of practicing meditation for a set duration of time. They must selfmonitor their progress and set personal rewards for accomplishing goals. The final construct is emotional coping, which refers to the techniques employed by the person to control the emotional and physiological states associated with acquisition of a new behavior. Meditation by its very nature reduces stress so this construct is not that relevant to this behavior.

APPLICATIONS OF SOCIAL COGNITIVE THEORY IN PROMOTING MEDITATION The first application of social cognitive theory on meditation was published by Sharma (2001) and utilized Kundalini yoga meditation. The study used a pre-test post-test design and consisted of a six week intervention with six weekly classes (n=31). A psychometric scale was developed that measured knowledge, expectations (multiplicative score between outcome expectations and outcome expectancies), self-efficacy for performing meditation, and performance of meditation in the past week. All the constructs were found to be statistically significant with meditation related self-efficacy increasing from 1.19 units to 8.10 units and past week yoga related behaviors increasing from 0.55 units to 6.93 units. Another study by Sharma (2005) was done with patients of arthritis (n=24) that used Kundalini yoga meditation. A pretest posttest design was utilized. A psychometric scale was developed that measured self-reported pain, joint swelling, joint stiffness, functional independence, self-efficacy for performing asanas, pranayama, relaxation, and meditation, and recollection of the frequency of these behaviors performed in the past week. Statistically significant difference was noted for increase in frequency of performing certain yoga behaviors including meditation) (p