DO WEEKLY SOCIAL ACTIVITY AND/OR PHYSICAL ACTIVITIES REDUCE
SYMPTOMS OF DEPRESSION IN COMMUNITY DWELLING OLDER ADULTS
WHO ARE AT-RISK FOR INSTITUTIONALIZATION?
Lorrine Suzzette Thomas Bell
B.S., California State University, Sacramento, 2003
M.A., San Francisco State University, 2005
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2011
DO WEEKLY SOCIAL ACTIVITY AND/OR PHYSICAL ACTIVITIES REDUCE
SYMPTOMS OF DEPRESSION IN COMMUNITY DWELLING OLDER ADULTS
WHO ARE AT-RISK FOR INSTITUTIONALIZATION?
A Project
by
Lorrine Suzzette Thomas Bell
Approved by:
__________________________________, Committee Chair
Joyce Burris, Ph.D.
Date
ii
Student: Lorrine Suzzette Thomas Bell
I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.
, Graduate Coordinator
Teiahsha Bankhead, Ph.D., L.C.S.W.
Date
Division of Social Work
iii
Abstract
of
DO WEEKLY SOCIAL ACTIVITY AND/OR PHYSICAL ACTIVITIES REDUCE
SYMPTOMS OF DEPRESSION IN COMMUNITY DWELLING OLDER ADULTS
WHO ARE AT-RISK FOR INSTITUTIONALIZATION?
by
Lorrine Suzzette Thomas Bell
Depression can be a major mental health concern for older adults. Depression frequently
amplifies physical symptoms, which can be a distraction and can contribute to undertreatment of depression in male and female older adults. The purpose of this study is to
explore the effects of daily activities and how these activities influence the mood level.
This qualitative study examined group progress notes from an outpatient treatment
setting. Recorded in this secondary data source are older adult participants, who have a
mental health diagnosis, and participate in daily/weekly therapeutic group activities at the
treatment center. A single case design examined 15 participants who attend morning and
afternoon group activities in a therapeutic program for older adults who experience
variable mood level. The focus of the study was to see whether participants’ mood stayed
positive or improved at the end of two group activity sessions in a single day. The
findings of the study indicate that active involvement in social activities improved
participants’ mood level.
iv
__________________________________, Committee Chair
Joyce Burris, Ph.D.
____________________________
Date
v
ACKNOWLEDGMENTS
This culminating experience has been a life changing journey in which I have
many to thank.
First and foremost, I would like to thank my wonderful partner Larry who is
always supportive of me and is equally dedicated to my career success. I appreciate your
love, patience, encouragement, and understanding of my time spent studying, so that I
could make this experience a reality.
To Renee and Janeen thank you for your encouraging words and patience. I am
truly blessed to have two daughters who inspire me to be the best I can be.
To my amazing grandson’s Noah and Harry who have the unique ability to lift my
spirit and make me laugh.
I would like to extend my sincere appreciation to Dr. Barbara Gillogly, my friend
and mentor as well as Dr. Darlene Yee, San Francisco State University, and Dr. Cheryl
Osborne, Sacramento State University for their letters of recommendation, which made
this journey possible.
vi
TABLE OF CONTENTS
Page
Acknowledgments.............................................................................................................. vi
List of Tables .......................................................................................................................x
Chapter
1. THE PROBLEM .............................................................................................................1
Introduction ..............................................................................................................1
Background of the Problem .....................................................................................2
Statement of the Research Problem .........................................................................3
Purpose of the Study ................................................................................................4
Theoretical Framework ............................................................................................4
Assumptions.............................................................................................................6
Justification ..............................................................................................................7
Delimitations ............................................................................................................8
Definitions of Terms ................................................................................................8
Summary ..................................................................................................................8
2. LITERATURE REVIEW ..............................................................................................10
Mental Health.........................................................................................................10
History of Mental Health Services .........................................................................10
Depression Types ...................................................................................................12
Barriers to Diagnosis and Treatment .....................................................................15
vii
Theories of Aging ..................................................................................................16
Activities ................................................................................................................18
Resilience ...............................................................................................................22
Depression and Activities ......................................................................................24
Summary ................................................................................................................26
3. METHODS ....................................................................................................................27
Introduction ............................................................................................................27
Research Design.....................................................................................................27
Research Question .................................................................................................28
Secondary Data ......................................................................................................28
Instrumentation ......................................................................................................31
Protection of Human Subjects ...............................................................................32
Validity and Reliability ..........................................................................................33
Data Analysis .........................................................................................................34
Summary ................................................................................................................34
4. FINDINGS ....................................................................................................................35
Introduction ............................................................................................................35
Analysis Strategy ...................................................................................................35
Impact of Activities on Mood ................................................................................37
Comparison of Month 1 to Month 3 ......................................................................38
Combination of Month 1 and Month 3 ..................................................................40
viii
Summary ................................................................................................................44
5. CONCLUSIONS AND IMPLICATIONS FOR SOCIAL WORK ...............................45
Introduction ............................................................................................................45
Limitations .............................................................................................................45
Implications............................................................................................................45
Summary ................................................................................................................47
Appendix A. Participant Rating Tables .............................................................................49
Appendix B. Letter of Permission .....................................................................................80
References ..........................................................................................................................81
ix
LIST OF TABLES
Page
1.
Table 1 Participants’ rated “feeling words” that describes their mood level .........36
2.
Table 2 September Activity Sessions ....................................................................39
3.
Table 3 November Group Activity Sessions .........................................................40
4.
Table 4 September and November .........................................................................43
x
1
Chapter 1
THE PROBLEM
Introduction
This writer working in the field of gerontology has worked with many older adult
clients who throughout their lifetimes have lived productive lives. The elder population
has a desire to remain independent and to maintain a sense of positive self, control, and
autonomy. However, due to their significant life changes and losses many have
experienced depression which leads to loneliness and isolation. According to the National
Association of Chronic Disease (2010), older adults may experience a sequence of losses
such as: a reduced sense of purpose, health problems, medication complexities, the death
of a loved one or spouse, and the lack of family support. The Geriatric Mental Health
Foundation (2009), states, the older adult population may be more prone to depression
than any other life stage. In addition, depression in older adults is often times over looked
by professionals and family members. The focus of this study is to examine the
relationship between daily activities and the level of depression in older adults.
Many times the assumption is made that older adults have every right to be
depressed, and therefore depression is a part of aging. In recent research studies inactivity
has been linked as a modifiable risk factor for depression and other chronic diseases such
as cardiovascular disease, hypertension, and diabetes. In recent years there has been
considerable attention to the concept of successful aging. In 1998, research was
conducted for the MacArthur Foundation study of aging in the United States. Gutgeil and
2
Congress (2000) explain that from this study the term “aging well” was developed. The
research team Rowe and Kahn identified three main components to aging well; “avoiding
disease and disability, maintain physical functioning and continuing engagement with
life” (p. 46). The third component, continuing engagement with life, is seen as
encompassing both social relationships and productive activity while prevention and
adaptation play a critical role in the effectiveness of all three components. Gutgeil and
Congress (2000) state, that much of successful aging may be attributed to good genes,
good sense, and good resources, but for many older people avoiding disability and
maintaining physical functioning may become increasingly difficult, if not impossible.
This does not mean they have not aged successfully; it does mean that their experience of
aging involves negotiating difficult circumstances. Gutgeil and Congress (2000) contend
that to acknowledge and account for the capacity of these older people to cope with major
stressors, a broader definition of successful aging, which draws on the resilience literature
to provide the paradigm is necessary.
Background of the Problem
Depression is associated with distress and suffering and can lead to impairment in
physical, mental, and social functioning. The rate of depression of older adults with
depressive symptoms tends to increase with age. The average life span in the 1900s was
approximately 47 years. In contrast, by the mid-1990s the life expectancy is more than 75
years (Surgeon General, 1999). Normal aging is a gradual process with some physical
decline, decreased pulmonary and immune function, and certain changes in mental
3
functioning occurring slowly over many years. The Surgeon General (1999) reports, that
during the normal aging process, important aspects of good mental health include stable
intellectual function, capacity for change, and productive engagement with life. Many
times older adults face difficult challenges such as the death of a spouse or physical
decline, and without a strong support system they may find it difficult to cope with their
losses which can lead to depression.
The National Institutes of Health (2009), reports there are 35 million Americans
age from 65 years or older, and about 2 million within that age group suffer from fullblown depression. There are 5 million older adults who suffer from less severe forms of
the illness. A research conducted by Dupuis and Smale (1996), indicated that
participation in hobbies, crafts and visiting friends was positively related to greater
psychological well-being. The study showed lower levels of depressive symptoms among
the older adult participants regardless of sex, age, and marital status. Overall, the findings
suggest that leisure activities with qualities that are able to provide opportunities for
freedom of choice, self-expression, and creativity are most likely to bring about higher
psychological levels of well-being and lower levels of depression among older adults.
Statement of the Research Problem
The goal of this research is to understand the relationship between activities in
older adult’s daily living and depression. The objectives of the research are to identify
depression in older adults, and examine how activities may enhance their quality of life.
4
Does weekly social activities and/or physical activities reduce symptoms of depression in
older adults?
Purpose of the Study
The primary purpose of this study is to do a qualitative descriptive analysis within
a treatment agency on the overall affects of daily activities and depression in the lives of
older adult 60 years and older. This study will increase awareness, and acquire new
knowledge of the importance of lowering depression through daily activities that will
enhance opportunities for an optimal quality of life.
Theoretical Framework
This writer has chosen two theoretical frameworks Cognitive Behavioral Theory
(CBT) and Strengths-Based Engagement (SBE). Cognitive Behavioral Theory (CBT) is a
combination of Cognitive and behavioral treatment approach for depression, and it has
generated more empirical research than any other psychotherapy model (Corey, 2009).
Cognitive Behavioral Theory places emphasis on helping clients discover and identify
their misconceptions for themselves. The attributes of the Cognitive Behavioral Theory
are: 1) there is a collaborative relationship between client and therapist, 2) the assumption
that psychological distress is largely a function of disturbances in cognitive processes, 3)
there is a focus on changing cognitions to produce desired changes in affect and behavior,
and 4) there is a time-limited and educational treatment focusing on specific and
structured target problems (Corey, 2009).
5
Aaron Beck developed Cognitive Behavioral Theory as a practicing
psychoanalytic therapist. Corey (2009) states that Aaron Beck grew interested in his
client’s automatic thoughts - personalized notions that are triggered by particular stimuli
that can lead to certain emotional responses. As part of Aaron Beck study about dream
content of depressed clients with anger, he discovered that his clients in the study were
turning the anger back on themselves. The Cognitive Behavior Therapist operates on the
assumption that the most direct way to change dysfunctional emotions and behaviors is to
modify inaccurate and dysfunctional thinking. The therapist functions as a catalyst and a
guide to help clients understand how their beliefs and attitudes influence the way they
feel and act.
This writer chose Cognitive Behavioral Therapy as a theoretical framework to
guide the research which will show a significant correlation between activities and
depression in older adults. The National Alliance on Mental Illness (NAMI; 2010) states,
Cognitive-Behavioral Therapy has been shown to be as useful as antidepressant
medication for individuals with depression and is superior in preventing relapse. Patients
receiving CBT for depression are encouraged to schedule activities in order to increase
the amount of pleasure they experience. In addition, depressed patients learn how to
restructure negative thoughts patterns in order to interpret their environment in a less
biased way.
The Strengths-Based Engagement practice focuses on capabilities, assets, and
positive attributes rather than problems and pathologies. The assumption is that clients
6
have within themselves the qualities and resources necessary to grow and develop. The
focus of the Strengths Perspective practice is empowering the individual. According to
Bertolino (2010),
Strength-Based Engagement practice has six core elements that form the
foundation: 1) client contributions (client’s internal strength and external
resources), 2) therapeutic relationship and alliance (collaborative client-therapist
partnership), 3) cultural competence (creating safe, nurturing, and respectful
context that encourage and facilitate growth and change), 4) change as a process
(emphasizes present and future change), 5) expectancy and hope (therapy must
honor, respect, and accommodate clients expectations, beliefs and ideas), 6)
method and factor of fit (therapist select methods that are respectful, culturally
sensitive, and fit within clients beliefs). (p. 35)
The strengths-based approach to recovery complies with the National Association
of Social Work (NASW) Code of Ethics, to up hold the individual rights of self
determination to exercise clients own choices and make their own decisions. The
Strengths-Based model encourages older adults to obtain and maintain as much control
over their lives as possible by focusing on their ability to make choices, and to develop
skills that will help them to adapt in the context of their ever-changing environment.
Assumptions
Mental health is fundamental to health as it is necessary for personal well-being,
quality of life, healthy family relationships, and successful contributions to society.
7
Research on depression reports an acknowledgement that older adults can experience
episodes of depression late in life which are closely associated with dependency and
disability. Societal stereotypes about aging can hamper efforts to identify and diagnose
depression in older adults. This research is a reminder to the helping professions whether
counselors, social workers, doctors, or educators who work with older adults that they are
in a unique position to develop an understanding of quality of life for older adults who
have varying levels of depression and physical limitations through social supports and
daily activities.
Justification
It is this writer’s opinion that non-activity plays a negative part in an older adult’s
physical and psychological well being. Therefore, this research paper will examine the
effects of daily activities within a treatment center, and the level of depression in adults
60 years and older. Indigent older adults are grossly understudied, and current knowledge
is limited in understanding the relationship between weekly group activities and level of
depression. It is hoped that this research will increase awareness and stimulate future
research on the importance of lowering depression through daily/weekly activities to
enhance opportunities for an optimal quality of life for indigent older adults.
This study will be useful to social workers who work with the elderly. It will offer
insight into the importance of daily activities for their client’s psychological well-being
and encourage their clients to construct daily routines to help maintain or improve their
8
mental health. It is hoped that the rich diversity of the older adult participants in this
study will add depth to the study, and can later be used for future studies.
Delimitations
For the purpose of this study the researcher chose a population sample that
reflects a small population range of indigent older adults, with higher needs who have a
diagnosis of a mood disorder. In addition, the researcher does not focus on situational
circumstances in an older person’s life that may contribute to depression, but only zeros
in on participation rates within a particular treatment center. Findings cannot be
generalized beyond this particular population and this particular setting.
Definitions of Terms
Indigent: Without the means of subsistence: improvised, needy (Merriam-Webster,
1976).
Mood: A conscious state of mind or predominant emotion. Mood refers to sustained
emotional states that color the way we view life (Morrison, 2006).
Quality of Life (QOL): The overall joy of a person’s life. Quality of life can be
understood as life satisfaction, trust in others, meaning and purpose in life, and life
engagement and interest. The presence of positive emotion, and the absence of negative
emotions (Diener & Tov, 2010).
Summary
This chapter introduced the general area of interest for the research with a
discussion on the background of the problem which stresses the rate of depression of
9
older adults with depressive symptoms tends to increase with age. A discussion of the
statement of the problem to be researched, as well as, an explanation on the purpose of
the study which is to increase awareness of depression in older adults 60 years and older,
and to gain new knowledge of the importance of daily activities to reduce depressive
symptoms. In addition, this chapter gives an in depth explanation of the theoretical
framework that supports Cognitive Behavioral Therapy (CBT) and Strength Based
Engagement (SBE). Chapter 2 is a review of related literature with sections covering
types of depression, types of activities, resilience, and gaps in the literature.
10
Chapter 2
LITERATURE REVIEW
This literature review will be organized in six sections. The first section will
provide history of mental health. The second section will describe different types of
depression. The third section will discuss the social theories of aging. The fourth section
will describe different types of activities. The fifth section explains resilience in older
adults. The sixth section will discuss depression and activities among older adults.
Mental Health
Mental Health can be explained in terms of how a person copes with the
challenges of daily life. It can be defined in different phrases as “state of mind” or being
content with life, and feeling good about yourself. However a person chooses to define
mental health it remains an important common element in everyone’s life. Mental Health
of America (2010) explains that when a person’s mental health is good, he or she can
deal better with what comes their way at home, at work, in life. When a person’s mental
health is poor it can be difficult to function in day-to-day living. Mental Health is a fluid
state with disability and untreated illness at one end, and recovery and complete wellness
at the other end.
History of Mental Health Services
The origins of the modern Mental Health Service Systems can be traced back to
the colonial settlement of the United States. During the colonial times individuals with
mental illness were cared for at home. The Surgeon General (2010) reports the “State
11
Care Acts” were passed between 1894 and during World War I. These acts centralized
financial responsibility for the care of individuals with mental illness in every state
government. This act gave local governments the opportunity to send everyone with a
mental illness, including dependent older citizens, to the state asylums.
According to the Surgeon General (2010), in 1975 the “community support”
reform was put in place to call for an end to viewing and responding to an individual with
a chronic mental disorder as the object of neglect. The community support reform
legislation called for acute treatment and prevention. The emphasis favored the view that
individuals could once again become citizens of their community if given support and
access to mainstream resources such as housing and vocational opportunities. Service
users and consumers began to take an active role in their own care and policymaking.
Family organizations such as the National Alliance for the Mentally Ill, and the
Federation of Families began to advocate for services with an emphasis on recovery. In
1979, a grassroots nonprofit organization called the National Alliance on Mental Illness
(NAMI) was established to improve the lives of individuals and families affected by
mental illness. Through their dedication and community efforts profound changes have
been made in services, mental health support, education, advocacy, and research (NAMI,
2010).
The Mental Health Service Act (proposition 63) passed in 2004, provided the
California Department of Mental Health (DMH) with increased funding, personnel and
other resources to support county mental health programs and to monitor progress toward
12
statewide goals. The act addresses a broad continuum of prevention, early intervention
and service needs as well as the necessary infrastructure, technology and training
elements that will effectively support this system according to the California Department
of Mental Health (2010). Prevention and early intervention are the key components that
will prevent mental illness from becoming severe and disabling. The Diagnostic and
Statistical Manual of Mental Disorders (DSM; American Psychiatric Association [APA],
2000) was first published by the American Psychiatric Association in 1952. Throughout
the years, the DSM has been revised five times. The DSM provides a common language
and standard criteria for the classification of mental disorders. The Diagnostic and
Statistical Manual of Mental Disorders evolved from systems for collecting census and
psychiatric hospital statistics (pre-World War II), and from a manual developed by the
U.S. Army (post World War II). The DSM provides a common language and standard
criteria for the classification of mental disorders. It is used by clinicians, researchers,
policy maker, health insurance companies, pharmaceutical companies, and drug
regulation agencies in varying ways.
Depression Types
Depression affects 35 million Americans, aged 65 years or older (NAMI, 2010).
Some people experience episodes of depression throughout their lives. However,
depression can have a first onset in late life. Depression in older persons is closely
associated with dependency and disability. Boston Children’s Hospital (2010), there is
three types of depression: 1) Dysthymic Disorder (mild depression), 3) Major Depression
13
(clinical depression), and 3) Manic Depression (bipolar disorder). Dysthymic patients are
chronically depressed. They have many of the same symptoms that are found in major
depression episodes, including low mood, fatigue, hopelessness, trouble concentrating,
and problems with appetite and sleep. These symptoms strongly affect the quality of life
for the individuals experiencing them. Because many people suffer quietly and are not
severely disabled, such individuals often go undiagnosed until major depressive episode
supervenes (Morrison, 2006). In the Diagnostic and Statistical Manual of Mental
Disorders (2000), depression is characterized as a disorder that has disturbances in a
person’s mood as the predominant feature.
A Major Depression Episode, according to DSM (2000), is a period of at least two
weeks during which there is either depressed mood or the loss of interest or pleasure in
nearly all activities. The individual must also experience at least four additional
symptoms drawn from a list that includes, decreased energy, feelings of worthlessness or
guilt, difficulty thinking, concentrating or making decisions, changes in appetite or
weight, disturbed sleep patterns, or recurrent thoughts of death or suicidal ideation, plans
or attempts. Mood disorders can occur in people from any race or social class, but are
more common among people who are single, have no significant other, or family
connections. Mood refers to sustained emotional states that color the way we view life
(Morrison, 2000). According to the American Psychiatric Association (2000), culture can
influence the experience of and communication of symptoms of depression.
14
Clinicians can reduce the patients’ suffering or add to lengths of suffering by
under diagnosis or misdiagnosis of depression. Cultural competence is required by
medical professionals because the ethic and cultural specificity in the presenting
complaints may differ according to the client’s socialization and his or her cultural
support systems. Some cultures may be experienced in expressing discomfort in somatic
complaints, rather than with sadness or guilt. For instance, people from Latino and
Mediterranean cultures may have complaints of “nerves” and headaches. Individuals
from Chinese and Asian cultures may express problems with the heart. Those from
Middle Eastern cultures may speak of being heartbroken (APA, 2000).
A research conducted by Smith (2009) explored the influence of resilience on the
willingness of African Americans, aged 65 and over, to seek mental health care for
depressive symptoms. The study examined relationships between personal resilience and
willingness of undiagnosed, community-dwelling older adults to seek mental health care
for depressive symptoms.
A cross-sectional, correlation, causal modeling design was used to study older
African Americans 121 women and 37 men recruited from churches, retirement
organizations and senior nutrition centers. Participants completed study instruments to
measure depressive symptoms, resilience, willingness to seek mental health care, and
general demographics information. Descriptive statistics and multiple regression analyses
were preformed. Depressive symptoms and resilience accounted for 15.4% of the
willingness to seek mental health care variance; extraction of resilience lowered variance
15
to 0.9%. A direct, predictive relationship between resilience and willingness to seek
mental health care was documented.
A report from the Surgeon General (2010) points out research findings has shown
that “minor depression” is more frequent than “major depression” in older adults. The
studies show that older patients with symptoms of depression often do not meet the full
criteria for major depression. The diagnostic entity to the DSM of major depression has
been proposed to characterize “minor depression” as a sub-syndrome form of depression
with a diagnosis of fewer symptoms and less impairment. However, minor depression is
not yet recognized as an official disorder, and DSM-IV proposes further research on it.
Barriers to Diagnosis and Treatment
Societal stereotypes about aging can hamper efforts to identify and diagnose
depression in older adults. Many people believe that depression is an inevitable part of
aging in response to increased physical limitation, loss of a loved one, and/or the
changing of societal roles. In comparison, the Surgeon General (2010) reports that those
three quarters of physicians believe that depression “is understandable” in older adults,
and suicidal thoughts are sometimes considered a normal facet of old age. Depression
frequently amplifies physical symptoms, distracting both the patient’s and provider’s
attention from the underlying depression. In addition, many older adults may deny
psychological symptoms of depression or refuse to accept the diagnosis, because of the
stigma attached to being diagnosed with depression. Studies show that the under
diagnosis and under treatment of depression of older adults in primary care settings
16
represent a serious health problem. One study found that only 11% of elderly depressed
patients in primary care settings received adequate antidepressant treatment (in terms of
dose and duration of pharmacotherapy), while 34% received inadequate treatment and
55% received no treatment. Lastly, older adults are less likely to report symptoms of
dysphoria and worthlessness, which are often considered the hallmarks of the diagnosis
of depression (Surgeon General, 2010).
Theories of Aging
The field of social gerontology, which studies aging, offers several theoretical
perspectives that explain the aging process. These selected theories are intended to
explain social psychological changes that take place as a person ages. Cockerham (1991)
explains that theories specify relationships between concepts and provide a framework
for explaining why certain things happen the way they do. The social gerontology field is
a new field beginning around 1940. Cocerham further states that in the 1960s the
development and testing of theoretical statements provided the social field with a variety
of theories and a solid foundation to explain the relationship between society and the
aging process. There are three theories of importance to this study: 1) disengagement
theory, 2) activity theory, and 3) continuity theory. Disengagement theory is an
application of functionalism to the study of aging. Cockerham (1991) explains that in
1961, Elaine Cumming and William Henry, proponents of the disengagement theory, had
three basic propositions: 1) a process of mutual withdrawal of aging individuals and
society from each other is natural; 2) this process of withdrawal is inevitable; and 3) it is
17
also necessary for “successful” aging. Disengagement theory tells us that although all
people eventually die, society’s institutions need to survive if they are to maintain social
stability. However, disengagement theory assumes that older people will desire to be
disengaged in order to pursue their own interests, and does not explain what happens if
this is not the case.
The Activity Theory is another important theory. Cockerham (1991) explains that
the Activity Theory was formulated by Robert Havighurst in 1963. The Activity Theory
is an action theory for successful aging. It has three basic premises: 1) that the majority of
normally aging people will maintain fairly constant levels of activity; 2) that the amount
of engagement or disengagement will be influenced by previous lifestyles and
socioeconomic factors, rather than by some inevitable process; and 3) that it is necessary
to maintain or develop substantial levels of social, physical, and mental activity if the
aging experience is to be successful. Activity Theory does not account for the manner in
which some older adults (perhaps a majority) cope with aging through activity, and, like
disengagement theory, it cannot explain the behavior of all older adults.
Hooyman and Kiyak (1996) report that neither Activity theory nor
Disengagement theory fully explain well-adjusted aging. Neither theory adequately
addresses the social, cultural nor historical contexts in which the aging process occurs.
The evident shortcomings and skepticism about disengagement and activity theories led
to the emergence of a third social-psychological theory of adaption in old age.
Cockerham (1991) explains that in 1964 Bernice Neugarten established the Continuity
18
Theory which holds that the individual develops rather stable values, attitudes, norms,
and habits that become an integral part of his or her personality. Neugarten, who was
associated with the Kansas City Studies, urged that gerontologists examine the entire life
course in addressing the processes of aging to take account of different pathways to old
age. The Continuity Theory is based on the premise that people retain a high degree of
consistency in their personality over the various stages of the life cycle. Successful aging
is thought to occur when people are able to maintain or continue having the traits,
interests, and behaviors they have always had while aging.
The Continuity Theory is based on two central propositions: 1) people tend to
maintain their own particular personality over time; and 2) the only major internal
dimension of the personality that changes with age is the tendency to experience greater
introversion by turning one’s attention and interest inward on the self. In contrast
Hutchison (2008) suggests that people who were active earlier in life stay active in later
life, whereas those who adopted a more passive lifestyle continue to do so as older adults.
Basically the Continuity Theory states that with age we become more of what we already
were when younger. Central personality characteristics become even more pronounced
and core values even more salient with age.
Activities
Human motivation is based on people seeking fulfillment and change through
personal growth. Hagerty (1999), states that Abraham Maslow hierarchical theory of
human motivation describes how individuals develop and improve their quality of life.
19
He suggests Maslow’s hierarchy of needs theory is used to predict development of
quality of life overtime. The theory classifies all of human striving as an attempt to fill
one of five needs. The first need is physiological, and is the strongest need; which
consists of the need for oxygen, food, water, and a relatively constant body temperature.
The second need is safety; such as safety from assault, rioting, and chaos. The third need
is belongingness and love, including friends, a family, a community, and “having roots”.
The fourth need is esteem; where a person is valued as a wise decision-maker, and has a
certain status and confidence. The fifth need is self-actualization; where each individual
makes maximum use of his or her individual gifts and interests “to become everything
that a person is capable of becoming” (Hagerty, 1999, p. 46).
Cornwell and Waite (2009) conducted a study on social disconnectedness,
perceived isolation, and health among older adults using population-based data from the
National Social Life, Health, and Aging Project. In their study, they examine the extent
which social disconnectedness and perceived isolation have distinct associations with
physical and mental health among older adults. The results indicate that social
disconnectedness and perceived isolation are independently associated with lower levels
of self-rated physical health. However, the association between disconnectedness and
mental health may operate through the strong relationship between isolation and mental
health.
Exercise can change a person’s mood, increase self-esteem, and maintain better
physical health. It can be a distraction from life problems, and be a social interaction.
20
Exercise improves physical strength, flexibility and posture, which in turn will help a
person’s balance, coordination, and will reduce the risk of falls (Senior Fitness, 2010). A
study by Tingjian, Wilber, Aguirre, and Trejo (2009) assessed the effectiveness of Active
Start, a community-based behavior change and fitness program, designed to promote
physical activity among sedentary community-dwelling older adults. Their results
showed significant improvement was found on all performance measures (strength,
flexibility, and balance) for the intervention group as a whole. Similar improvements
were found among subgroups (Whites, African Americans, and Hispanics). No
significant changes were found in the comparison group when they were in the control
condition. However, they significantly improved on all measures after completing the
intervention. This study suggests that a community-based physical activity program
benefits sedentary, racially, and ethnically diverse older adults by coupling a behavioral
change support group and fitness classes.
Volunteerism creates interaction with others, and develops friendships.
Volunteerism brings opportunities to learn new skills or to teach skills. Larkin, Sadler,
and Mahler (2005) did a multiple-case study to explore the benefits for older adult
volunteers who are mentoring at-risk youth in one-on-one pairings, with in schools or
family environments. They wanted to learn more about the specific outcomes of working
in these programs for the older adult volunteers, since research has shown that younger
generations benefit from mentoring. This study adds to that knowledge base by showing
21
that benefits are mutual. The mentoring experiences allow opportunities for older adults
to renew positive emotions and reinforce meaning in their lives.
Greenfield and Marks (2004) conducted a study on formal volunteering as a
protective factor for older adult’s psychological well-being. This study aimed to
investigate whether formal volunteering protects older adults with more role-identity
absences in major life domains (partner, employment, and parental) from poorer
psychological well-being. Their results showed participants with a greater number of
major role-identity absences, reported more negative affect, less positive affect and less
purpose in life. Being a formal volunteer was associated with more positive affect and
moderated the negative effect of having more major role-identity absences on
respondent’s feelings of purpose in life. Langer and Tirrito (2004) report that Dr. Neona
Chappell, gerontologist and director of the center on aging at the University of Victoria,
Canada, enumerates some of the benefits both physical and psychological that older
volunteers can derive from their altruistic endeavors. New social networks and structure
bring opportunities to continue to grow and learn. Dr. Chappell’s research affirms that
seniors have reported increased mental and physical vigor and positive outlook due in no
small part to their increased sense of continued self worth.
Reminiscence allows people the opportunity to review their life, to make meaning
of it, and it provides them with the opportunity to rectify any wrong-doing. Research
shows that older adults who participate in extensive reminiscence of their past may find it
to be beneficial to their well-being. According to Alea, Vick, and Hyatt (2009), the
22
majority of the research has investigated the beneficial outcomes of reminiscence groups,
like guided autobiography groups. However, few have assessed whether the content of
the autobiography memories shared during these group predicts beneficial outcomes.
Alea et al. (2009), conducted a research to explore whether the content of the
autobiographical memories shared with others would predict beneficial outcomes. The
research involved sixteen community-dwelling older adults. The study modeled the
reminiscence group after Dr. Birren and Dr. Cochran’s guided autobiography program (as
cited in Alea et al., 2009). The result of the research indicated that group participation
decreased depression, lowered fear and avoidance of death, and improved death
acceptance. The results of the study indicate that when individuals participate in
reminiscence groups the narratives that they write and share are more positive than
negative.
Resilience
Norman (2000) explains resiliency as having the ability to bounce back from, or
to successfully adapt to adverse conditions. Resiliency combines the interaction of two
conditions: 1) risk factors such as stressful life events, and 2) adverse environmental
conditions that increase the vulnerability of individuals and the presence of personal,
familial, and community protective factors that buffer, moderate, and protect against
those vulnerabilities.
Traditionally, resilience has been a concept used that refers to successful
adaptation among at-risk children and adolescents despite adversity. Fuller-Iglesias,
23
Sellars, and Antonucci (2008) suggest that there is cohort and life-stage-specific
environmental influences that affect an individual’s development trajectory, and the
challenges and adversities they face. As people age they are increasingly likely to face
adversities that are cumulative or lifelong as well as age specific events, such as adversity
due to life-threatening disease or death of a spouse becomes increasingly common in late
life. They further state in child resiliency studies are conducted to generally focus on
addressing or reversing the effects of internal and external adversity such as poverty and
abuse. In contrast, older adults may experience similar external and/or significant internal
adversities as well. However, in some situations, it may not be possible for the older adult
to overcome internal adversities, such as declining health. In these cases, resilience might
better be described as successfully coping with adversities rather than reversing or
overcoming them.
In reviewing a study conducted in 2001, about “Spousal Relationship Quality”
Fuller-Iglesias et al. (2008) found that depressive symptomatology and life satisfaction
were significantly affected by the quality of the spousal relationship. Thus, spousal
relationship appear to have an especially, significant effect on an individual’s well being,
and perhaps by extension on his or her ability to cope with adversity. Older adults could
be resiliency role models because of their constant lifetime challenges to adapt to change,
and multiple losses (2008). It is essential to look beyond the stereotypes that older people
are needy and frail or that those who have experienced successful aging processes are
24
free from disease or disability. Resiliency can be found within this diverse cohort
regardless of their level of care.
Gutgeil and Congress (2009) suggest three resources older people use to deal with
stress: 1.coping (draw strength and comfort from faith and trust in God), 2. mastery
(drawn from past experience or from having small successes in negotiating tasks of daily
living that have become difficult), and 3. social support (research has found quality of life
is enhanced by social interaction and/or support). Because many of the stressors faced in
late life are not easily controlled. Older adults are more likely than younger adults to use
coping strategies that manage the meaning of stress rather than those focused on problem
solving. By redefining the importance of problematic areas, the power of these problems
can be diminished. Binstock and George (2009) explain that self-efficacy is important
because it serves as a resource that affects people’s ability to cope with problems, and
consequently, influences well-being. Self-efficacy denotes a personal belief about one’s
own control over his or her outcomes, synonymous with instrumentalism mastery and
internal locus of control in contrast to fatalism, helplessness or powerlessness. High selfefficacy predicts more positive outcomes, such as satisfaction and well-being whereas
fatalism and powerlessness contribute to more negative outcomes including distress and
depression.
Depression and Activities
According to Thomas (2004), old age maybe a time of loss and decline, but it is
also accompanied by a countervailing and equally significant increase in the power of
25
adaptation. The development of this capability is one of the most important and least
acknowledged virtues of aging. An older adult wakes up to a new body with new
demands and limitations not once but many times. These changes require older adults to
develop enterprising strategies and subtle adaptations. While it is true that muscles
weaken in late life, it is also true that older adults are less likely to report symptoms of
depression than younger people. Thomas further states that old age has richness and
complexity that, when appreciated, provides a powerful counterweight to the measurable,
progressive, steady decline in bodily functions. The body instructs the mind in patience
and forbearance, while the mind tutors the body in creativity and flexibility.
This eight-year follow-up study conducted by Heikkinen and Heikkinen (2006)
examines the roles of physical and leisure activity as predictors of mental well-being
among older adults born in 1904-1923 as part of the Evergreen project: 1224 (80%
persons aged 65-84 years were interviewed at baseline (1988), and 663 (90%) persons in
the follow-up (1996). Mental well-being factors including depressive symptoms, anxiety,
loneliness, self-rated mental vigor and meaning in life were constructed using factor
analysis. The predictors of mental well-being included physical and leisure activity,
mobility status and number of chronic illnesses.
They used a path analysis model to examine the predictors of mental well-being.
At baseline, low number of chronic illnesses, better mobility status and leisure activity
was associated with mental well-being. Baseline mental well-being, better mobility status
and younger age predicted mental well-being in the follow-up. These findings suggest
26
that mental well-being in later life is associated with activity, better health and mobility
status, which should become targets for preventive measures.
Summary
The pervious discussion contained background information in regard to the
benefits for older adults to engage in daily activities for physical, emotional well being,
and to lower depressed symptoms. The literature review was completed utilizing the
following themes: 1) history of mental health services; 2) depression types; 3) activities;
4) resilience; 5) depression and activities. In terms of depression and activities it has been
noted that mental well-being in later life is associated with activity, better health and
mobility status, which should become targets for preventive measures. Chapter three
introduces and discusses the research design.
27
Chapter 3
METHODS
Introduction
The primary purpose of this study is to explore the effects of daily activities and
how these activities influence the level of depression on the day that the activities are
engaged in by older adults 60 years and older in an outpatient treatment setting who may
be at risk for institutionalization. As a social work professional it is important to become
familiar with current research that offers insight into older adults with mental illness. This
research describes the level of daily/weekly activities with levels of depression in those
with a mental health diagnosis on the days of participation in support services. This
chapter represents the methods employed in conducting this study. The information
discussed in the study design includes the research question, secondary data,
instrumentation, validity/reliability, data gathered, protection of human subjects, and data
analysis.
Research Design
The researcher chose a qualitative, descriptive analysis of secondary data, in
which the researcher analyzed daily activities and mood levels in older adults who
participated in group activities. The level of knowledge generated in this study is
exploratory. The exploratory research was chosen to establish base line data on an outpatient clinic population of indigent older adults with mood disorders. The older adult
participants reside in board and care or assisted living facilities. The participants who
28
utilize the Sierra Elder Wellness services are either on conservatorship or have a payee
service to prevent homelessness. The study utilized a small data sample of 15 male and
female participants, specific to the treatment setting, who may experience variable mood
levels due to mental health and/or substance disorders. A single case design was used to
evaluate each participant’s presence in group activities, and individual mood levels. The
focus of the study was to see whether participant’s mood stayed positive or improved at
the end of a two group activity sessions in a single day. The researcher compared activity
levels and mood improvement from the first month of each person’s participation to the
third month of their participation to see if there was cumulative gain overtime.
Research Question
Do weekly social activities and/or physical activities reduce symptoms of
depression in community dwelling older adults who are at risk of institutionalization?
Secondary Data
The data collected for this project was based on 15 client record files of the El
Hogar Sierra Elder Wellness Program (SEWP). The Sierra Wellness Program is a full
wrap-around service partnership. A full service partnership is the collaborative
relationship between county funded programs and the client to address the total needs of
the client who is experiencing significant emotional, psychological or behavioral
problems that are interfering with their well-being (Campos, 2009). The Sierra Elder
Wellness Program provides specialized outpatient mental health services that fit the
needs of the growing older adult population (age 60+) as well as transition age adults
29
(age 55-59) in Sacramento County. Participants in this study met the criteria for mental
health services which are: being diagnosed with a mental illness; being within the
targeted age group; and, being on or below the poverty level. Sierra Elder Wellness
Program serves older adults, both males and female, of different ethnic backgrounds, who
participate in program activities. The Sierra Elder Wellness program offers two 60minute therapeutic group activities in the morning and afternoon Monday through Friday.
These groups are not a requirement for services, and participants can choose which group
to participate in. The secondary data is collected from group progress notes written by
staff members who facilitate the group activity. The staff facilitator is trained in
providing therapeutic group leadership and is responsible for documentation of each
group participant. Each group progress note is written and submitted and audited by at
least two staff members before being placed in the participants file. The notes contain
evaluation of participation in group activities and mood levels affecting the quality of life
for people with depression. The objective of the therapeutic group activities is to create a
safe environment where older adults who experience variation in mood levels can
participate in daily/weekly activities which provide skill-building techniques, selfexpression, self-esteem, and peer support. The focus of the therapeutic groups is to
enhance the participant’s quality of life. The groups that are offered are required to have
these basic themes, and each group is required to have two facilitators. Having both male
and female facilitators adds balance to the group. This helps the participant (both
genders) to be more comfortable and increases the opportunity for participant to identify
30
with the facilitators. The exception to this rule is if the group is small and consists of two
people or less, one facilitator may be used.
The program activities include creative self-expression such as:

Creative Self-Expression: This is an ongoing group that meets weekly to
provide participants with the opportunity to express their thoughts and feelings
using art, music and creativity through self-expression. This group provides
participants with an opportunity to decrease isolation through socialization and
interaction with others while building positive self-esteem through art and
creativity.

Leisure Exploration: The focus of this group is to provide participants the
opportunity to create self-expression in a group setting through activities and
games. Specific goals and skills are practiced and incorporated according to the
activities chosen, such as communication, relaxation, coping skills, leisure
education, teamwork, creativity, reminiscence, and self awareness.

Peer Support: The focus of this group is to provide participants the opportunity
to share their feelings and experiences with their peers. The group focus is on
respect and support toward one another. Discussions are incorporated to help
the group find solutions to their problems and experience a sense of comfort
and ease.

Mindfulness Meditation: This helps the participant decrease isolation through
socialization and interaction with others. The focus of this group is to help
31
participants decrease symptoms of anxiety and depression through mindfulness
meditation. Participants will be able to apply techniques they can use in their
daily life to help reduce mental stressors.

Mingle and Jingle: This is a socialization and special event group. The focus of
this group is to provide participants the opportunity for social interaction, create
friendships with peers, and promote social recreation which decrease isolation
and depression.
Instrumentation
The researcher is the instrument used in gathering this data. The researcher holds
a BS and MS in Gerontology with 15 years of experience facilitating similar groups. The
key strength of qualitative research is the comprehensive perspective it gives the
researcher. By going directly to the social phenomenon under study, and observing a
deeper understanding is realized (Rubin & Babbie, 2008). Systematic sampling was used
to pull samples by hand from secondary data. The researcher was able to initiate research
more effectively using systematic sampling due to the small sample size and geographic
location chosen for the study. The systematic sampling process for this study is used in
the collection of the group progress notes by selecting every fourth file of participant’s
group progress notes from the agency.
The researcher organized the group progress notes to be analyzed by creating a
table with: 1) the start date (first week in September 2010); 2) the first and third month
(September and November); 3) applying a letter of “A” through “O” in exchange for the
32
participant’s names; 4) differentiating morning group activity by the letter “A.M.” and
afternoon group activity by the letter “P.M”; 5) chart the mood number and the mood
feeling word. Participant Rating Tables are located in Appendix A.
The case notes include a self-reporting “feeling word” that measures each group
participant’s mood level. Each participant is encouraged to describe their mood with a
feeling word such as “happy,” “angry,” “sad,” etc. The self-report “feeling word” from
the group participants is subjective. Therefore, because the study measures changes in the
participants over time, the researcher chose to conduct an interrater reliability
measurement for consistency and stability.
The researcher chose two mental health group facilitators to rate the participant
“feeling word” on a scale by number “1” being in the low mood range, number “2 “ being
in the medium mood range, and number “3” being in the high mood range. The two
facilitators were given a randomized list of participants “feeling words” and were asked
to independently rate the mood as low, medium, and high. If there were any discrepancy
in rating the words the majority prevailed.
Protection of Human Subjects
The protocol taken to obtain this information was to request permission from El
Hogar, Inc. to allow the researcher access to the Sierra Elder Wellness group activity
progress notes (see Appendix B). The Protection of Human Subjects application was
submitted to the Committee for the Protection of Human Subjects and was approved as
33
posing “no risk to human subjects” from the Division of Social work at California State
University Sacramento. The approval number is 10-11-090.
The researcher had no direct contact with participants in collecting any
information for this study. The names and/or identities of the participants and/or El Hogar
staff were not used in the study to ensure no breach of confidentiality to participants or to
El Hogar Inc. The collected data was stored in a locked file cabinet at El Hogar with no
other person having access. The data was analyzed in the privacy of the researcher’s
home, and, at all times, the collected data was locked in a secured safe with no other
person having access to the combination. The collected data was destroyed upon
completion of the research study.
Validity and Reliability
Secondary data collection can involve some limitation in terms of the validity.
When collecting unique data that comes from participant charts, which are housed at the
Sierra Elder Wellness facility this researcher records exactly what is written in the chart.
The researcher cannot speak to the validity of the notes. The researcher analyzed the
collected data objectively without interjecting personal feelings or biases. Limits to
reliability are that: 1) this a small sample; 2) it is a one-time only study; 3) it is done in
only one agency and results cannot be generalized beyond the population used in this
study.
34
Data Analysis
The secondary data analyzed in this study consisted of an inductive approach.
Group progress notes were reviewed and analyzed for commonalities and themes using
open-coding and grounded theory techniques. Elo and Kyngas (2008) state that if there is
not enough former knowledge about the phenomenon, or if this knowledge is fragmented,
the inductive approach is recommended. Additionally, an approach based on inductive
data moves from the specific to the general, so that particular instances are observed and
then combined into a larger whole or general statement. Individual group progress notes
were assessed by the researcher to identify major descriptions of therapeutic group
activities, and how the participant’s mood level is assessed by the group facilitator. The
findings were reviewed and coded for common themes.
Summary
The researcher chose a qualitative descriptive analysis of secondary data to
explore the effects of daily/weekly activities and how activities influence the level of
depression in older adults in an outpatient treatment setting. This chapter discussed the
methods used in conducting this study including the Protection of Human Subjects
approval as posing “no risk.” It is the hope that the researcher will gain reliable data that
will help to expand psychosocial support to older indigent adults who are at risk of
institutionalization.
35
Chapter 4
FINDINGS
Introduction
The purpose of this chapter is to present the findings of the qualitative study. The
study was conducted to explore the effects of daily/weekly activities and how these
activities influence the level of depression in older adults. The data used for this study
was based on secondary data taken from the group activity progress notes of participants
who utilize services from the Sierra Elder Wellness Program in Sacramento California.
The data consisted of a small sample of fifteen male and female older adult group
participants who may experience variable mood levels due to mental health disorders.
The systematic sampling process was used to collect the data. The researcher organized
the group progress notes by creating a table for each participant as described in Chapter
3. The raw data is located in Appendix A.
Analysis Strategy
This study involves a self-reporting “feeling word” that measures each group
participant’s mood level. The self-report “feeling word” from the group participants is
subjective. Therefore, because the study will measure mood changes in the participants
over time the researcher chose to conduct an interrater reliability measurement for
consistency and stability. The researcher chose two mental health group facilitators to
rate the participant “feeling word” on a scale by number “1” being in the low mood
range, number “2 “ being in the medium mood range, and number “3” being in the high
36
mood range. The two facilitators were given a randomized list of participants “feeling
words” and were asked to independently rate the mood as low, medium, and high. If there
were any discrepancy in rating the words the majority prevailed.
Table 1
Participants’ rated “feeling words” that describes their mood level
Low Range =1
Medium Range = 2
High Range =3
Sad
Okay
Happy
Down
Fine
Good
Poorly
Better
Positive
Pain
Glad
Excited
Frustrated
Just Right
Accomplished
Anxious
So-so
Satisfied
Irritable
Friendly
Relieved
Tired
Comfortable
Fun
Uncomfortable
All-right
Great
Sleepy
Doing-well
Wonderful
Nervous
Hopeful
Healthy
Depressed
Peaceful
Spiritual-High
Not doing well
Relaxed
Fantastic
blah
Calm
Optimistic
Proud
Content
Medium
Rich
Pretty Good
Proud
37
Single case design method was used in evaluating the small sample of data. Rubin
and Babbie (2008) report that single case design evaluations are recognized as the most
rigorous way that practitioners can implement the final stage of evidence-based practice
process assessing whether the intervention they have provided to an individual client
appears to be effective in helping that client achieve his or her treatment.
Impact of Activities on Mood
The research study examines group activity sessions of fifteen male and female
older adult participants’ for significant similarities in the effects of weekly/daily group
activities and mood. The researcher did not consider participation when participant
attended only one group activity session in a day when evaluating for mood levels.
Identifying gender differences was not specific to this study. The activity sessions for the
week of Thanksgiving were not included in the study. November had an extra week in the
month. Participants attended various community activities and many celebrated the
holiday with family and friends. The researcher evaluated the data of individual
participants for improved mood level measurements by comparing the first month with
third month as well as combing the two months September and November together for an
overall comparison of mood improvement. The following themes were utilized:

Days participants attended sessions

A.M. and P.M. sessions attended

Number of days mood improved

Number of sessions positive mood level stayed the same
38

Improved Mood Percentage
Comparison of Month 1 to Month 3
In the first month the number of day’s participant’s mood level stayed positive
throughout the end of two sessions of activities was 12 days compared to 8 days in the
third month. In this instance the participant’s mood level was measured after first activity
and remained at the same level throughout the second activity.
There was a significant difference in participants “G” and “F” showing both
participants with a higher level of improved mood level in the first month compared to
the third month. Both participants attended more group day activities in the first month
than in the third month. In addition, four other participants (B, I, J, and K) showed an
improved level of mood in the first month compared to the third month with higher group
attendance in the first month. This indicates that the more days a person attended and
participated in the group activities their mood level improved. The data shows that
participants experience an improved mood level of 50% or higher when attending
morning and afternoon activity sessions.
The first month participants participated in 71 A.M. and P.M. activity sessions,
and experienced mood level improvements 51 times, a total improvement of 71%.
During the third month participants who attended 57 activity sessions experienced with
mood level improvement of forty-three times, a total improvement of 81%.
39
Table 2
September Activity Sessions
Participants
Days
A.M. –P.M.
Number of Days
Number of
Attended
Sessions Attended
Mood Improved
Days Stayed
Percentages
Positive Mood
A
9
7
4
1
57
B
4
3
2
1
66
C
5
3
2
1
66
D
4
4
2
2
50
E
4
4
3
1
75
F
6
3
3
100
G
6
5
4
80
H
10
6
3
2
50
I
13
9
8
1
88
J
12
9
8
K
5
4
3
1
75
L
6
4
2
2
50
M
6
4
3
1
75
N
5
3
2
1
66
O
7
3
2
1
66
88
40
Table 3
November Group Activity Sessions
Days
A.M. –P.M.
Number of Days
Number of Days
Attended
Sessions Attended
Mood Improved
Stayed Positive
Participants
Percentages
Mood
A
11
9
8
88
B
2
2
1
1
50
C
6
6
4
2
66
D
4
3
2
1
66
E
8
6
5
1
83
F
4
1
G
2
1
H
10
9
I
7
J
0
1
0
6
2
66
4
3
1
75
5
4
3
K
3
3
2
L
3
1
1
100
M
5
2
2
100
N
7
4
4
100
O
3
2
2
100
75
1
66
Combination of Month 1 and Month 3
Participant A
Participant attended 20 days of group activity sessions: utilizing 16 days of
A.M./P.M activity sessions. Twelve of the sixteen, mood level improved, by 75%.
41
Participant B
Participant attended six days of group activity sessions: utilizing five days of
A.M./P.M. activity sessions. Three of the five days, mood level improved, by 60%.
Participant C
Participant attended eleven days of group activity sessions: utilizing nine days of
A.M./P.M. activity sessions. Six of the nine days, mood level improved, 67%.
Participant D
Participant attended eight days of group activity sessions: utilizing seven days of
A.M./P.M. activity sessions. Four of the seven days, mood level improved, by 57%.
Participant E
Participant attended 12 days of group activity sessions: utilizing 10 days of
A.M./P.M. activity session. Eight of the ten days, mood level improved, 80%.
Participant F
Participant attended 10 days of group activity sessions: utilizing six days of
A.M./P.M. activity sessions. Four of the six days, mood level improved, 75%.
Participant G
Participant attended eight days of group activity sessions: utilizing six days of
A.M./P.M. activity sessions. Four of six days, mood level improved, by 66%.
Participant H
Participant attended 20 days of group activity sessions: utilizing 15 days of
A.M./P.M. activity sessions. Nine of the fifteen days, mood level improved, by 60%.
42
Participant I
Participant attended 20 days of group activity sessions: utilizing 13 days of
A.M./P.M. activity sessions. Eleven of the thirteen days, mood level improved, 84%.
Participant J
Participant attended 17 days of group activity sessions: utilizing 13 days of
A.M./P.M. activity sessions. Ten of the thirteen days, mood level improved, 76%.
Participant K
Participant attended eight days of group activity sessions: utilizing seven days of
A.M./P.M. activity sessions. Five of the seven days, mood level improved, 71%.
Participant L
Participant attended nine days of group activity sessions: utilizing five days of
A.M./P.M. activity sessions. Three of the five days, mood level improved, 60%.
Participant M
Participant attended eleven days of group activity sessions: utilizing six days of
A.M./P.M. activity sessions. Five of the six days, mood level improved, by 83%.
Participant N
Participant attended 12 days of group activity sessions: utilizing seven days of
A.M./P.M. activity sessions. Six of the seven days, mood level improved, 85%.
Participant O
Participant attended 10 days of group activity sessions: utilizing five days of
A.M./P.M. activity sessions. Four of the five days, mood level improved, by 80%.
43
Table 4
September and November
Participants
Days
A.M. –P.M.
Number of Days
Number of
Percentages
Attended
Sessions Attended
Mood Improved
Sessions Positive
Improved
Mood
Mood
A
20
16
12
75%
B
6
5
3
2
60%
C
11
9
6
3
67%
D
8
7
4
3
57%
E
12
10
8
2
80%
F
10
4
3
75%
G
8
6
4
66%
H
20
15
9
5
60%
I
20
13
11
2
84%
J
17
13
10
K
8
7
5
2
71%
L
9
5
3
2
60%
M
11
6
5
1
83%
N
12
7
6
1
85%
O
10
5
4
1
80%
76%
The findings show that all 15 participants overall had improved mood levels when
attending two therapeutic group activity sessions in a day: one in the morning, and on in
the afternoon. There were uncontrolled factors relating to the study which pertains to the
descriptive words used by participants at the end of each group activity which they are
encouraged to describe a “feeling word” used to measure their mood level. The “feeling
word” can be subjective depending on how the participants view his or her position in the
world.
44
Personality traits (negative, and positive attitudes), and life experiences can also
be considered. Cockerham (1991) explains the continuity theory, which holds that the
individual develops rather stable values, attitudes, norms and habits that become an
integral part of his or her personality. People retain a high degree of consistency in their
personality over various stages of the life cycle. Notes written by group facilitators did
not contain consistent language, which made it difficult at times to extract the
information. Interrater reliability measurement was used as previously mentioned for
consistency.
Summary
The findings of the study indicate that participation in daily/ weekly group
activity sessions improved mood levels of the participants. It is hoped that this small
study will be an inspiration for future studies of indigent older adults with mental health
diagnosis who may experience a better quality of life by utilizing programs such as Sierra
Elder Wellness Program.
45
Chapter 5
CONCLUSIONS AND IMPLICATIONS FOR SOCIAL WORK
Introduction
The purpose of this chapter is to discuss the answers to the research question
which is: Does weekly social activities and/or physical activities reduce symptoms of
depression in older adults? The results of this qualitative exploratory study suggest that
daily/ weekly activities had a positive effect on the older adult’s level of mood when
attending daily/weekly therapeutic group activities.
Limitations
One of the limitations of this study, stemmed from the use of secondary data
collected from one agency. Therefore, the findings of this study cannot be generalized
beyond the older adult participants outside of the Sierra Elder Wellness Center. Other
limitations to this study were the inconsistencies of the language written in the progress
notes to describe participant’s level of mood. It is important to note the limitation of only
measuring the participant’s mood level after the activity brings up some speculation on
the accuracy of the measurement. Further, the descriptive words participants used to
describe mood level were subjective. Since the purpose of recording their mood level is
to establish a base line a more concrete method could be utilized.
Implications
Despite the small sample size of the study and limitations the findings can be a
pathway to future studies. The single sample size allows the researcher to know the
46
unique responses of each participant, and understand their needs. It is hoped that this
small sample size study may be used in other single case experiments to replicate this
study in another context. In addition this study could be replicated
in larger-scale experiments which uses control groups, and which can be tested for
generalizability. To increase reliability the general principle of the study could be
replicated on a larger scale such as a larger group of participants and over a period of six
months.
Overall the Sierra Elder Wellness Program provides quality services to its
participants. Although this project was not intended to evaluate the SEWP program some
suggestions are recommended in providing and documenting adequate group progress
notes: participants level of mood could be measured at the beginning of the activity
group session and at the end of the activity group session for a more accurate mood level;
progress notes could be written with precision utilizing a in a more concise structure for
easier interpretation.
The importance of this study is that mental health social work professionals will
recognize each individual’s innate potential and work to enhance resiliency by expanding
the opportunities for clients to take control of their lives and to participate as much as
possible in daily social and/or physical activities. A physical activity program, for an
older adult with depression, should be individualized to include forms of activity that the
person is physically able to attain (e.g., low-intensity activities).
47
Summary
This study provided evidence that people who have a mental health diagnosis and
participate in therapeutic group activities experience improved mood level. When
participants utilized both morning and afternoon group sessions they had the best results
in improved mood level. This study correlates with other statistical studies of older adults
in the literature review chapter. In conclusion, when a person’s mood level improves they
experience better quality of life.
48
APPENDICES
49
APPENDIX A
Participant Rating Tables
Participant’s rated “feeling words” that describes their mood level:
Low Range =1
Medium Range = 2
High Range =3
Sad
Okay
Happy
Down
Fine
Good
Poorly
Better
Positive
Pain
Glad
Excited
Frustrated
Just Right
Accomplished
Anxious
So-so
Satisfied
Irritable
Friendly
Relieved
Tired
Comfortable
Fun
Uncomfortable
All-right
Great
Sleepy
Doing-well
Wonderful
Nervous
Hopeful
Healthy
Depressed
Peaceful
Spiritual-High
Not doing well
Relaxed
Fantastic
blah
Calm
Optimistic
Proud
Content
Medium
Rich
Pretty Good
Proud
50
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant A
September
Week – 1
Monday
Tuesday
Wednesday
Thursday
Friday
A.M.
A.M.
A.M.
“happy” =3
“sad” =1
“calm” = 2
P.M
P.M. – N/A P.M.
“happy” =3
Week – 2
“good” =3
A.M.
A.M.
“down” =1
“sad” =1
P.M.
P.M.
“down” =1
“happy”
=3
Week – 3
Week – 4
A.M.
“good” =3
P.M.- N/A
A.M.
A.M.
A.M.
“down” =1
“sad”=1
“calm” =2
P.M.
P.M.
P.M.
“good” = 3
“sad” =1
“happy” =3
51
Participant A
November
Monday
Tuesday
Week – 1
Wednesday
A.M.
“calm” = 2
P.M.
“good” -3
Week – 2
Thursday
A.M.
“relaxed = 2
P.M.
“happy” =3
A.M.
“calm” = 2
P.M.- N/A
Week – 3
Week - 4
A.M.
A.M.
A.M. -N/A
A.M.
“down”=1
“down” =1
P.M.
P.M.
P.M.
P.M.
“good”= 3
“good” =3
“good” = 3
“happy” - 3
A.M.
A.M.
“calm” =2
“good” =3
“relaxed” =
2
P.M.
P.M.
“good” =3
“happy” =3
“calm” =2
P.M.
“ happy” =3
Friday
A.M.
“calm” =2
P.M.
“happy”
=3
52
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant B
September
Monday
Week – 1
Tuesday
Wednesday
Thursday
A.M.
“sad” =1
P.M.
“better” =2
Week - 2
A.M.
“good” =3
P.M.- N/A
Week - 3
A.M.
“okay” = 2
P.M.
“good” =3
Week - 4
A.M.
“good” = 3
P.M.
“happy" =3
Friday
53
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant B
November
Monday
Tuesday
Wednesday
Thursday
Week – 1
Week - 2
Week - 3
Week - 4
A.M.
A.M.
“good” = 2
“happy” =3
P.M.
P.M.
“happy” =3
“happy” =3
Friday
54
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant C
September
Monday
Tuesday
Wednesday
Thursday
Week – 1
Week - 2
Week - 3
A.M.
A.M.
A.M.
“good” =3
“fine” =2
“fine” =2
P.M. - N/A
P.M.
P.M.
“good” =3
“good” =3
A.M.
“happy” =3
P.M.
“happy” =3
Week - 4
A.M.
“good” =3
P.M. - N/A
Friday
55
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant C
November
Week – 1
Week - 2
Monday
Tuesday
Wednesday
A.M.
A.M.
“okay” = 2
“fine” =2
P.M.
P.M.
“good” =3
“happy” =3
A.M.
“good” =3
P.M.
“positive” =
3
Week - 3
A.M.
“fine” =2
P.M.
“good” =3
Week - 4
A.M.
A.M.
“okay” =2
“fine” = 2
P.M.
P.M.
“positive”= 3
“okay” = 2
Thursday
Friday
56
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant D
September
Monday
Tuesday
Wednesday
Week - 1
Thursday
Friday
A.M.
“fine” =2
P.M.
“happy” =3
Week - 2
A.M.
“good”= 3
P.M.
“happy” =3
Week - 3
A.M.
A.M.
“happy” =3
“okay” =2
P.M.
P.M.
“excited” =3
“happy” = 3
Week - 4
57
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant D
November
Monday
Tuesday
Wednesday
Thursday
Friday
Week - 1
Week - 2
A.M.
“sad”=1
P.M.
“better” =
2
Week - 3
A.M.
A.M.
“okay” =2
“good” =3
P.M.
P.M.- N/A
“happy”= 3
Week - 4
A.M.
“good” =3
P.M.
“happy” = 3
58
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant E
September
Monday
Week - 1
Tuesday
A.M.
“good” = 2
P.M.
“happy” =3
Week - 2
A.M.
“okay” =2
P.M.
“hopeful” = 2
Week - 3
A.M.
“pain” =1
P.M.
“good” =3
Week - 4
A.M.
“relaxed” =2
P.M.
“good” =3
Wednesday
Thursday
Friday
59
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant E
Novembe
r
Monday
Week - 1
Tuesday
A.M.
“happy” =3
P.M. - N/A
Wednesday
A.M.
“good”= 2
P.M.
“accomplished
” =3
Week - 2
Week - 3
Week - 4
A.M.
“pretty good”
=2
P.M.
“great” =3
A.M.
“good” =3
P.M.
“happy” =3
A.M.
“medium”=2
P.M. - N/A
A.M.
“doing well”
=2
P.M.
“happy” =3
Thursday
Friday
A.M.
“medium”
=2
P.M.
“rich” =3
A.M.
“medium”
=2
P.M.
“happy”
=3
60
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant F
September
Monday
Week - 1
Week - 2
Tuesday
Wednesday
Thursday
Friday
A.M.
A.M.
“okay” =2
“excited” =3
P.M. - N/A
P.M. - N/A
A.M.
A.M.
“pretty good”
=2
“happy” =3
P.M. - N/A
P.M.
“proud” =3
Week - 3
A.M.
“pretty
good” = 2
P.M.
“happy” =3
Week - 4
A.M.
“hopeful” =2
P.M.
“happy” =3
61
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant F
November
Week - 1
Monday
Tuesday
Wednesday
Thursday
A.M.
A.M.
“Blue” =1
“great” =3
P.M.
P.M. -N/A
“frustrated”=1
Week - 2
A.M.
“okay” = 2
P.M. - N/A
Week - 3
A.M.
“happy” =3
P.M. - N/A
Week - 4
Friday
62
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant G
September
Monday
Tuesday
Week - 1
Wednesday
Thursday
A.M.
“anxious”= 1
P.M.
“good” =3
Week - 2
A.M.
“irritable” =1
P.M.
“good” =3
Week - 3
Week - 4
A.M.
A.M.
“okay”=2
“fine” 2
P.M.
P.M.
“had fun” = 3
“happy” =3
A.M.
A.M.
“good” =3
“good” =3
P.M.
P.M. -N/A
“fine” =2
Friday
63
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant G
November
Monday
Tuesday
Wednesday
Thursday
Week - 1
Week - 2
Week - 3
Week - 4
A.M.
A.M.
“little
tired”=1
“happy” =3
P.M.
“tired” =1
P.M.- N/A
Friday
64
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant H
September
Monday
Tuesday
Week - 1
Week - 2
A.M.
A.M.
“good” = 3
“good”=3
P.M.
P.M.
“good” =3
“good” = 3
Week - 3
Thursday
Friday
A.M.
A.M.
A.M.
“good” = 3
“excited”=3
“fine” = 2
P.M. -N/A
P.M. - N/A
P.M. - N/A
A.M.
A.M.
A.M.
A.M.
“friendly” =
2
“alright” =2
“happy” =3
“glad” =2
P.M.
P.M.
P.M.
“great” =3
“happy” =3
“content”
=3
P.M.
“positive”=3
Week - 4
Wednesday
A.M.
“good” =3
P.M. - N/A
65
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant H
November
Week - 1
Monday
Tuesday
A.M.
A.M.
“wonderful”= 3
1. “good”=3
P.M.
P.M.- N/A
Wednesday Thursday
Friday
“healthy”=3
Week - 2
Week - 3
A.M.
A.M.
A.M.
“fine”= 2
“alright” =2
“great” = 3
P.M.
P.M.
P.M.
“good” =3
“happy” =3
“happy” =3
A.M.
A.M.
“alright” =2
“pretty good”
P.M.
=2
“positive” =3
P.M.
“good” =3
Week - 4
A.M.
A.M.
A.M.
“pretty good” =
“pretty good”
“just
2
2
right”=2
P.M. “spiritual-
P.M. “pretty
P.M.
high”= 3
good” =2
“fun” = 3
66
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant I
September
Monday
Week – 1
Tuesday
Wednesday
Thursday
Friday
A.M.
A.M.
A.M.
“fun” =3
“happy” =
“better” =2
P.M. – N/A
3
P.M.
P.M. – N/A “excited” =3
Week – 2
Week – 3
Week – 4
A.M.
A.M.
A.M.
“okay”=2
“okay” =2
“sad” =1
P.M.
P.M.
P.M.
“happy”=3
“happy” =3
“great” =3
A.M.
A.M.
A.M.
“okay” =2
“down” =1
“okay” =2
P.M.
P.M.=3
P.M.
“okay” =2
“unco-
“excited”
mfortable”
=3
A.M.
A.M.
A.M.
A.M.
“okay” =2
“happy”=3
“okay” =2
“okay” =2
P.M.
P.M. – N/A
P.M.
P.M. – N/A
“great” =3
“great” =3
67
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant I
November
Monday
Tuesday
Week – 1
Wednesday
A. M.
“sleepy”=1
P.M. – N/A
Week – 2
A.M.
“so-so” =2
P.M.
“good” =3
Week – 3
A.M
“okay”=2
P.M.
“so-so”=2
Week – 4
A.M
A.M
“okay” =2
“good”=2
P.M.
P.M.
“fantastic”=3
“happy” =3
Thursday
A.M
“okay”=2
P.M. – N/A
A.M.
“excited” =3
P.M. –N/A
Friday
68
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant J
September
Monday
Tuesday
Week - 1
Wednesday
Thursday
Friday
A.M.
A.M.
“nervous” =1
“nervous”=1
P.M - N/A
P.M.
“okay” =2
Week - 2
A.M.
A.M.
A.M.
“good” =3
“down”=1
“fine” =2
P.M.
P.M.
P.M.
“pretty-
“good”=3
“good “ =3
A.M.
A.M.
A.M.
A.M.
“good”=3
“better” =2
“happy” =3
“sad”=1
P.M. -N/A
P.M.
P.M. - N/A
P.M.
good” =2
Week - 3
“happy” =3
Week - 4
“good”=3
A.M.
A.M.
A.M.
“okay” =2
“pretty
“relaxed”=2
P.M.
good”=2
P.M.
“good
P.M.
“happy” =2
day”=3
“happy”=3
69
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant J
November
Monday
Tuesday
Wednesday
Week - 1
Thursday
A.M.
“friendly” =2
P.M.
“optimistic”=3
Week - 2
A.M.
A.M.
“not doing
“sad” =1
well”= 1
P.M. -N/A
P.M.
“relaxed” =2
Week - 3
A.M.
“good”=3
P.M.
“relaxed”=2
Week - 4
A.M.
“pretty
good”=2
P.M.
“happy”=3
Friday
70
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant K
September
Monday
Week - 1
Tuesday
Wednesday
A.M.
“so-so” =2
P.M.
“happy”=3
Week - 2
A.M.
A.M.
A.M.
“pain” =1
“so-so”=2
“happy”=3
P.M.
P.M.
P.M. - N/A
“happy” =3
“having
Fun” =3
Week - 3
A.M.
“okay” =2
P.M.
“so-so”=2
Week - 4
Thursday
Friday
71
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant K
November
Week - 1
Monday
Wednesday
A.M.
A.M.
“so-so”=2
“happy” =3
P.M.
P.M.
“good”=3
“having fun”
=3
Week - 2
Week - 3
Week - 4
Tuesday
A.M.
“pain”=1
P.M.
“happy”=3
Thursday
Friday
72
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant L
September
Monday
Tuesday
Week - 1
Wednesday
Thursday
A.M.
“glad” =3
P.M.
“happy” =3
Week - 2
A.M.
“glad”=2
P.M.
“content”=3
Week - 3
A.M.
A.M.
“happy”=3
“satisfied”=3
P.M.
P.M.
“wonderful”=3
“glad”=2
Week - 4
A.M.
A.M.
“excited”=3 “okay” =2
P.M.
P.M.= -N/A
“wonderful” =3
Friday
73
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant L
November
Monday
Week - 1
Tuesday
Wednesday
Thursday
Friday
A.M.
“comfortable”=2
P.M.
“happy” =3
Week - 2
A.M.
“okay”=2
P.M. -N/A
Week - 3
A.M.
“okay”=2
P.M. -N/A
Week - 4
74
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant M
September
Monday
Week - 1
Tuesday
Wednesday
Thursday
Friday
A.M.
A.M.
“relaxed”=2
“prettygood”=2
P.M.
P.M.
“happy”=3
“positive”=3
Week - 2
Week - 3
Week - 4
A.M.
A.M.
“alright”=2
“relaxed”=2
P.M.
P.M.
“relaxed”
=2
“happy” =3
A.M.
A.M.
“optimistic” =3 “alright” =2
P.M. -N/A
P.M. -N/A
75
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant M
November
Monday
Tuesday
Wednesday
Week - 1
Thursday
A.M.
“relaxed”=2
P.M.
“happy”=3
Week - 2
Week - 3
Week - 4
A.M.
A.M.
A.M.
“good”=3
“good”=3
“happy” -3
P.M. - N/A
P.M. -N/A
P.M. -N/A
A.M.
“hopeful”=2
P.M. “real
good”=3
Friday
76
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant N
September
Week - 1
Monday
Tuesday
Wednesday
Thursday
A.M.
“down” =1
P.M.
“good”=3
Week - 2
Week - 3
A.M.
A.M.
“relaxed”=2
“low” =1
P.M.
P.M.- N/A
” good” =3
Week - 4
A.M.
A.M.
1. “fine” =2
“happy” =3
P.M.
P.M. –N/A
“so-so” =2
Friday
77
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant N
November
Monday
Week - 1
Week - 2
Tuesday
Wednesday
Thursday
A.M.
A.M.
“fine” =2
“blah” =1
P.M.
“happy” =3
P.M. -N/A
A.M.
“fine” =2
P.M. - N/A
Week - 3
Week – 4
A.M.
A.M.
“good” =3
“depressed”=1
P.M. –N/A
P.M. “feeling
–better”=2
A.M.
A.M.
“doing well”
good”=2
“just right
great”=2
P.M.
“positive”=3
P.M.
Happy =3
Friday
78
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant O
September
Monday
Tuesday
Wednesday
Week - 1
Thursday
A.M.
“alright” =2
P.M. -N/A
Week - 2
A.M.
A.M.
“alright”=2
“okay” =2
P.M.
P.M. -N/A
“good” =3
Week - 3
Week - 4
A.M.
A.M.
A.M.
“happy” =3
“fine” =2
“down”=1
P.M.
“happy” =3
P.M. -N/A
P.M.
A.M.
“ good” =3
P.M. - N/A
“alright” =2
Friday
79
The participant is encouraged to check-in with the activity facilitator by using a
“descriptive word” that describes his or her mood on a scale of 1-10. Rating scale of the
mood level is: “1” being in the low range; “2” being in the medium range; and “3” being
in the high range.
Participant O
November
Week - 1
Monday
Tuesday
Wednesday
Thursday
Friday
A.M.
“fine”= 2
P.M.
“happy” =3
Week - 2
A.M.
“alright”=2
P.M- N/A
Week - 3
Week - 4
A.M.
“alright”=2
P.M.
“happy”=3
80
APPENDIX B
Letter of Permission
81
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