INTRODUCTION
The recovery of people with schizophrenia has a subjective dimension which is the ability to live life at the desired level, both in terms of family and professional circumstances, as well as social interactions. The so-called ‘consumer model of recovery’, as opposed to the ‘biomedical model’, assumes that recovery is a process in which a sick person gradually overcomes the effects of the disease, including loss of hope, stigmatization and rejection [1-4].
The stigma of a mental illness such as schizophrenia may be an obstacle to recovery. A negative assessment goes hand in hand with a hostile attitude and translates into impaired functioning of a mentally ill person in many areas, such as social, psychological, economic, political, etc. [5]. The situation of a mentally ill person internalizing, self-referring and accepting negative social attitudes creates the phenomenon of self-stigma. Both stigmatizing and self-stigmatizing attitudes contribute to withdrawal from social contacts and translate into poorer adherence to pharmacological treatment [5, 6]. One of the key challenges in the recovery process of almost every mentally ill person is overcoming self-stigmatization and stigmatization [3]. Other challenges that, according to researchers, a mentally ill person in recovery faces are renewing commitment as well as hope, redefining oneself, accepting the illness and its effects, engaging in meaningful activities, combating stigmatization and self-stigma, taking control over one’s own life (including medical treatment), coping with symptoms, being able to ask for and use support from other people, and empowerment [5, 6]. The definition of recovery emphasizes that it is a process understood in subjective terms, which includes managing the symptoms of the disease and engaging in everyday functioning. It is not about returning to life before the symptoms but learning to look for its meaning despite their presence [7]. Recovery is a process that is based on four dimensions observed in the functioning of patients. These are internal factors (e.g., awareness of the impact that the disease has on the patient’s life), external factors (e.g., receiving support from loved ones and from professionals), self-help (e.g., coping with adversities caused by the disease), consolidating (e.g., caring about what will happen to the patient in the community) [8]. The progress of the recovery process in a person with schizophrenia is not as linear as in other chronic diseases. This may apply not only to schizophrenia, but more generally to mental diseases and disorders that significantly impair functioning, the so-called serious mental illness (SMI). In tracing the lives of people experiencing SMI, it has been noted that they often follow unexpected trajectories. Patients with low-level symptoms may not be as advanced in the recovery process as might have been expected, while others with multiple symptoms, incomplete remissions, experiences of stigmatization and trauma may achieve high levels of recovery. As part of this journey, they may develop subjectivity, hope, and a sense of coherence [9]. Researchers indicate that these outcomes depend on personal resources, of which only some are directly related to the disease, and most are linked to other aspects of the patient’s life [10].
The recovery process is accompanied by a sense of mental well-being [7], which involves two elements. Firstly, it is one of the variables that correlate positively with gratitude that is often called one of the key elements of well-being [11]. Secondly, achieving well-being may be profitable to patients not only because it is associated with a model of mental health in which there is a place for the healing process and not only for the elimination of psychopathology. Additionally, well-being plays a potential protective role against the recurrence of mental illness [12]. The healing process may involve more complex aspects, such as existential anxiety coexisting with insight into one’s psychological situation and life circumstances [10]. In line with the above, it can be assumed that gratitude may be one of the factors modifying the levels of healing.
Women and men differ in their experience of schizophrenia. Firstly, the difference may be caused by a varied time of the onset of illness. Secondly, they have a different way of experiencing and expressing gratitude. Thirdly, the correlations and course of the recovery process also vary in the two groups. The literature indicates that gratitude can be understood as a positive element of the recovery process, i.e., an element of positive psychology that may strengthen recovery or facilitate the process [13]. Considering the above considerations, the following research questions were posed:
Do women and men with schizophrenia differ in terms of experiencing gratitude, going through the recovery process and the general level of functioning in the disease?
Do gratitude, the recovery process and general functioning coexist in women and men with schizophrenia?
Data from the psychological literature provide grounds for assuming that internal dispositions, such as feeling gratitude, influence the functioning of an individual, which in turn partially determines their coping with mental illness. Referring to the theoretical considerations discussed earlier and research results, it can be assumed that high-level gratitude co-occurs with a better level of recovery, whereas low-level gratitude may co-occur with a lower assessment of general functioning.
METHODS
Subjects
Fifty patients took part in the study – 25 women aged 23 to 72 (M = 51.52; SD = 13.52) and 25 men aged 21 to 69 (M = 42.92; SD = 12.73) – all diagnosed with schizophrenia. They were treated in the Psychiatric Rehabilitation Day Ward of the Institute of Psychiatry and Neurology in Warsaw, the Ex CORDIS Day Rehabilitation Ward in Lublin, the Ex CORDIS General Psychiatric Day Ward in Lublin or the Community Self-Help Home at Grochowska Street in Warsaw.
The following tools were used in the study:
A questionnaire designed for the purposes of the study, collecting socio-demographic data (such as gender, age, education, professional situation, family situation) and basic information on the course of the disease (such as year of onset, number of hospitalizations, whether a person holds a disability certificate related to illness).
GQ6 – Gratitude Questionnaire, by M.E. McCullough, R.A. Emmons, J. Tsang (Kossakowska, Kwiatek, 2014) [14]. The tool intends to examine the level of gratitude understood as a disposition and consists of six statements. The examinee’s task is to respond to them on a 7-point scale. The scale has good psychometric properties [14]. The reliability analysis of this scale using Cronbach’s α for six test items was 0.71. In the study below, the coefficient was 0.79 for women and 0.46 for men, respectively. Item 6 was therefore removed, as it is also described in the literature as the weakest, and satisfactory Cronbach’s α results were obtained, adding up to 0.83 for the group of women and 0.67 for the group of men.
RAS-24 (PL) – shortened Recovery Assessment Scale [8], adapted by Anczewska. The tool examines recovery as a subjective process in 24 statements and consists of five subscales: sense of self-confidence and hope, ability to use help, sense of purpose and success orientation, reliance on others, and not being dominated by symptoms. In the present study, Cronbach’s α is 0.87 for women and 0.89 for men, and these are satisfactory results. The ‘reliance on others’ subscale has much lower reliability than other scales, which occurred in both study groups. It was therefore decided to remove the scale from our statistical inferences.
GAF – Global Assessment of Functioning Scale. This tool is used to measure the functioning of a person at various levels, i.e., mental, social and professional (or educational). This is a scale that is not completed by examinees, but by a specialist who knows the situation of the person examined. The scale contains 10 segments, each containing 10 items. The GAF scale covers functioning from severe psychopathology to full mental health [15].
Procedure
The research questionnaires were filled out individually, at facilities in Warsaw or Lublin, from September 2020 to July 2021. People who reported co-existing intellectual disability, alcohol and psychoactive substance addiction, as well as those with neurodegenerative brain processes (e.g., developing Alzheimer’s disease) were excluded from the study.
RESULTS
Statistical analysis was performed using IBM SPSS Statistics version 26, with an overall significance level of 0.05. The first step in data mining was to calculate descriptive statistics for all the variables studied.
The measurement result of the studied variables
The basic statistical parameters of the distribution of results concerning socio-demographic variables and information about the course of treatment were examined.
The analysis with the Shapiro-Wilk normality test for women W(25) = 0.97, p = 0.61 and men W(25) = 0.97, p > 0.05 allowed for the analysis with the Student’s t-test for independent groups, which showed that no statistically significant differences between the examined women (M = 51.52; SD = 13.52) and men (M = 42.92; SD = 12.73) were found in terms of age, t(48) = 2.32, p > 0.05. Twenty four percent of women and 8% of men declared having children. The analysis using the Mann-Whitney U rank test showed that the differences between the groups were not statistically significant U = 262.50, p > 0.05 (two-sided asymptotic significance). The analysis carried out using the Mann-Whitney U rank test showed no statistically significant differences between the education of women and men, U = 293.50, p > 0.05 (two-sided asymptotic significance). Women who were studying, employed or retired constituted 32% of the surveyed group whereas 68% were unemployed. Unemployed men constituted 96% of the surveyed group. The analysis using the Mann-Whitney U rank test showed that these were statistically significant differences between these groups U = 225.00, p < 0.05 (two-sided asymptotic significance).
Among the surveyed patients 76% of women and 76% of men had a disability certificate. The analysis using the Mann-Whitney U rank test showed no statistically significant differences between the assessed degrees of disability (mild, moderate, severe), U = 171.50, p > 0.05 (two-sided asymptotic significance) between women and men. All women and all men admitted that they were diagnosed with schizophrenia. In most women, the onset of the disease was observed in 2001 and in men in 2003, which, taking into account other collected socio-demographics, means that the age of onset in women was on average 32 and in men 25. The analysis with the Mann-Whitney U test showed a statistically significant difference between the examined women and men, U = 186.00, p < 0.05 (two-sided asymptotic significance). The analysis using the Mann-Whitney U rank test also showed that in terms of the number of hospitalizations, the examined women and men do not differ statistically significantly, U = 286.00, p > 0.05 (two-sided asymptotic significance).
Socio-demographic variables and their relationships with the sense of gratitude, functioning, and the recovery process
The strength and direction of correlations were checked between age, age of onset, number of hospitalizations and feeling gratitude, assessment of general functioning, recovery process and its four subscales, i.e., self-confidence and sense of hope subscale, ability to use help subscale, sense of purpose and success orientation, and not being dominated by symptoms subscale. The normal distribution of some of the above variables allowed for the use of the Pearson r correlation coefficient, which was used to compare age with the advancement of the recovery process and its three scales, such as the ability to use help, the subscale sense of purpose and success orientation, as well as the subscale of not being dominated by symptoms (Table 1). Due to the fact that the rest of the data did not meet the assumptions needed to apply a parametric coefficient, a non-parametric equivalent, Spearman’s rho correlation coefficient, was later also used to check for co-occurrence.
Table 1
Co-occurrence of age, the recovery process and its three subscales, i.e. the ability to use help subscale, the sense of purpose and success orientation subscale, and the subscale of not being dominated by symptoms in women and men, respectively – correlations
| Recovery process | Subscale: Ability to use help | Subscale: sense of purpose and success orientation | Subscale: Not being dominated by symptoms | |
|---|---|---|---|---|
| Women’s age | –0.14 | 0.22 | –0.28 | 0.08 |
| Men’s age | 0.07 | 0.05 | –0.11 | 0.14 |
The results of the above analysis using the Pearson r correlation coefficient are not statistically significant either in the group of the examined women or in the group of the examined men with schizophrenia.
Another coefficient was used to search for further correlations in the two study groups, i.e., Spearman’s rho. We looked for correlations in terms of age, age of onset, number of hospitalizations and the main variables studied. The details are presented in Table 2.
Table 2
Co-occurrence of age, age of onset, number of hospitalizations and sense of gratitude, assessment of general functioning and the recovery process with its four subscales: self-confidence and sense of hope subscale, ability to use help subscale, sense of purpose and success orientation subscale, and not being dominated by symptoms in women subscale
Using Spearman’s rho correlation coefficient, four correlations were found in the group of women with schizophrenia – one being moderately strong positive correlation, i.e., between age and the age of onset, and three moderately strong negative correlations, i.e., between age and sense of gratitude, age at onset and the number of hospitalizations, and age at onset and the subscale of the recovery process not being dominated by symptoms.
The next step was to analyze the correlation between these analogous variables in the group of men (Table 3).
Table 3
Co-occurrence of age, age of onset, number of hospitalizations and gratitude, assessment of general functioning and the recovery process with its four subscales: self-confidence and sense of hope subscale, ability to use help subscale, sense of purpose and success orientation subscale, and not being dominated by symptoms in men subscale
| W | 1 | 0.28 | 0.22 | 0.12 | 0.40* (p = 0.049) | 0.22 | 0.31 | 0.08 | –0.09 | 0.17 |
|---|---|---|---|---|---|---|---|---|---|---|
| WZ | 0.28 | 1 | –0.15 | –0.26 | 0.09 | –0.06 | 0.09 | –0.05 | –0.17 | 0.18 |
| lh | 0.22 | –0.15 | 1 | –0.07 | 0.23 | 0.23 | 0.17 | 0.15 | –0.02 | 0.13 |
In the group of men with schizophrenia, only one correlation was found between the variables and it is a moderate positive correlation.
Moreover, the analysis using the non-parametric Mann-Whitney U test the differences between women with and without children in terms of the recovery process U = 25.00, p < 0.05, as well as in one of the subscales, i.e., of sense of purpose and success orientation U = 24.50, p < 0.05. No statistically significant differences were found in the group of men.
The non-parametric Mann-Whitney U rank test also compared other data, such as having or not having a disability certificate, professional circumstances, education and gratitude, general level of functioning, the recovery process and its subscales in both groups of women and men, however, the results were not statistically significant.
Sense of gratitude, recovery and overall functioning
In the case of the assessment of general functioning, as well as the subscale of the recovery process of self- confidence and sense of hope, the assumptions about the normality of the distribution of the results were not met, however, the assumptions about the homogeneity of variance and the equality of groups were met, and in these cases parametric tests were used. The remaining variables meet all assumptions for parametric tests. The details are presented in Table 4.
Table 4
Gratitude, general functioning, level of the recovery process – average values and differences between them in the group of women and men with schizophrenia (N = 50)
| Women (n = 25) | Men (n= 25) | t | d | |||
|---|---|---|---|---|---|---|
| M | SD | M | SD | |||
| Grattitude | 25.32 | 7.14 | 25.40 | 5.32 | NS | NS |
| General functioning | 60.52 | 9.40 | 58.32 | 8.47 | NS | NS |
| Recovery process | 87.16 | 12.53 | 80.88 | 14.00 | NS | NS |
The statistical analyses performed show that the group of women does not differ statistically significantly from the group of men in terms of the variables examined, such as sense of gratitude, assessment of general functioning and overall recovery process (Table 5).
Table 5
The recovery process – average values and differences between groups of women and men with schizophrenia (N = 50)
We also compared the statistical parameters of the four subscales of the recovery process in the two sexes, looking for differences, except for the subscale ‘reliance on others’, which was excluded from the analyses prior to the statistical analysis.
The statistical analyses performed show that the group of women does not differ statistically significantly from the group of men in terms of the variables examined, such as gratitude, assessment of general functioning and overall recovery process.
We also compared the statistical parameters of the four subscales of the recovery process in the two sexes, looking for differences, except for the subscale ‘reliance on others’, which was excluded from the analyses at the beginning.
The above results showed that men and women differ statistically significantly in terms of the ability to use help subscale.
Relationships between the sense of gratitude, general functioning, and subscales of the recovery process in women and men with schizophrenia
The results of statistical analyses examining the co- occurrence of gratitude with subscales of the recovery process, and the effects of searching for connections between the recovery scales themselves are presented below. The results of the respondents on the GAF General Functioning Scale do not correlate statistically significantly with any subscale of the recovery process, neither in the case of women nor men with schizophrenia, therefore they were not included in the investigations to follow.
In women, correlations were noted between sense of gratitude and two recovery scales, i.e., the self-confidence and sense of hope subscale and the sense of purpose and success orientation subscale. Two associations within the recovery scale were also reported; one is the correlation between self-confidence and sense of hope subscale and the sense of purpose and success orientation subscale. The second link is between the ability to use help subscale and the subscale of not being dominated by symptoms. The above correlations are moderate and strong.
Four correlations were noted in both men and women, but they concern different variables in each of the studied groups. In the group of men, there are four connections between the recovery scales, in the group of women there are two. In the group of men, gratitude does not correlate with the subscales of the recovery process. In the group of women, it occurs twice. Three strong correlations and one moderate correlation were found.
DISCUSSION
Gratitude is experienced differently by women and men. Many studies confirm the assumption that women experience a higher level of gratitude than men. This happens both when biological sex is considered and when the analysis is made from a socio-cultural perspective [16, 17]. This could be due to the fact that some people associate the concept of gratitude with a certain type of dependence, which in turn may be understood as synonymous with sensitivity and seen as weakness. This, in turn, may be threatening to the socio-cultural understanding of masculinity and therefore make men reluctant to show or even experience gratitude. A difference in values is often demonstrated between women and men to the effect that men rate power or hedonism higher, while women value qualities related to interpersonal relationships or, for example, tolerance [18]. Women may therefore attach greater importance to the experience of gratitude in connection to values. When analyzing the concept of gratitude, it should be noted that it is not only associated with positive experiences. For some people, experiencing gratitude may evoke pleasant emotions, while for others, it may be mixed emotions, pleasant and unpleasant [19]. At the same time, it should be noted that gratitude is an important element of the recovery process in the case of mentally ill people.
Table 6
Co-occurrence of gratitude and four subscales of the recovery process and internal correlations between the subscales of the recovery process in women
Table 7
Co-occurrence of gratitude and four subscales of the recovery process and internal correlations between the subscales of the recovery process in men
In fact, gratitude and its relation to recovery were central to our analysis. However, considering these variables could not be done without describing the two groups compared, because their non-clinical properties may constitute an important background for the development of the recovery process and the level of experienced gratitude. The results obtained in the study show that women and men with experience of mental illness who participated in the study did not constitute a homogeneous group in terms of socio-demographic variables, differing from one another in a number of areas significant to the recovery process and experienced gratitude. Women differed statistically significantly from men when it came to the age of onset, 32 in women and 25 in men. The difference in the age of onset is not surprising as it is consistent with the earlier research [20]. The correlation between age and age of onset in women was also examined. The older the women, the later their age of onset of schizophrenia. In men, there was no correlation in these ranges. A correlation was also noted between the age of onset and the number of hospitalizations in women. The earlier the age at which the disease occurred, the more hospitalizations occurred. No such correlation was found in men.
Noticeable differences were found between the groups in terms of professional circumstances. Women were more often working or retired, and men were more often unemployed or professionally inactive o on benefits. Although no statistically significant differences were found between the groups in terms of having or not having a disability certificate, or the differences between the level of the assessed disability, it is worth noticing that among the surveyed women and men there was the same number of people with different degrees of disability. It can be assumed that both women and men obtained such certificate for professional purposes, e.g., to take advantage of the extensive offer of the State Fund for the Rehabilitation of Disabled Persons [21].
Interestingly, for women who participated in the study, the earlier they got sick, the better they coped with the symptoms at a later stage. This correlation did not apply to men. Perhaps this is related to women’s more willing, longer participation in various forms of rehabilitation and community support systems. It is estimated that the participants in these interactions are mostly women who constitute approximately 60% of all patients [22].
In turn, it can be said about the men participating in the study that their age correlated with the assessment of general functioning. The older the man was, the higher his overall functioning was upon assessment. No such co-occurrence was demonstrated in women. This may be due to the fact that of two people – a woman and a man – of the same age, the man, due to the earlier average age of onset, suffered from schizophrenia longer than the woman. Perhaps, over a longer period of illness and a longer stay in the medical care system, men have learned to cope better with the symptoms of the disease and thus function better in various fields [23].
Differences were noted between women with and without children in terms of the assessment of the recovery process, as well as in the assessment of one of its subscales, i.e., the sense of purpose and success orientation subscale. In the group of men, no statistically significant differences were found in this regard. It seems that the topic of parenting is much more difficult for women than for men with mental illness. It should be remembered that medical knowledge is much more extensive nowadays when it comes to our understanding of pregnancy in women with mental illness and the use of antipsychotic drugs in this sensitive period. Women, especially older, often reported that in their youth, doctors recommended that they did not become pregnant or refused treatment. Based on this, it can be concluded that parenthood is more emotionally complex for women with schizophrenia than for men. And if women attribute greater value to having or not having a child, there is nothing surprising in the fact that the situation of childlessness or parenthood has a completely different gravity for women and for men.
Studies show that women are more effective than men in using help. They are more likely to take advantage of community support systems [22], and more often take part in such therapeutic interventions as neurocognitive training, social skills training, social cognition training, self-service training, relapse recognition training and conversation training. Participants in this type of training have the opportunity to improve communication methods, understand social situations better, and show overall higher functioning.
Gratitude is a strong element of recovery process, but the present study has demonstrated that it is only in case of the women surveyed. In the case of men, no relationship was shown between gratitude and recovery process. As Kashdan et al. [18] assert, men often represent different values than women and gratitude, which for women may be positively associated with sensitivity, for men may have negative associations related to weakness. This will translate into reluctance to experience and show gratitude, as well as having mixed or negative emotions about it. Since it is known that gratitude is strongly anchored in the process of women’s recovery, its components should also be analyzed. Thus, in women, gratitude correlates with two subscales of the recovery process, such as the sense of purpose and success orientation subscale and the self-confidence and hope subscale. This shows how integral gratitude is to women’s recovery.
The analyses of socio-demographic variables showed that gratitude is also associated with this type of indicators, and in women it correlates with age. There is nothing surprising in this, as examined by Chopik et al. [24], gratitude is experienced more intensely by older and less so by younger people.
In addition, the study showed several interesting relationships between recovery subscales and gratitude, different in each group. Although the same number of correlations in each group was found, only one correlation was shared. In both women and men, self-confidence and a sense of hope correlated with a sense of purpose and success orientation. Moreover, in women, the use of help correlates with not being dominated by symptoms. This may be related to the use of community support systems, which is more common in this group. In the group of men, self-confidence and a sense of hope also coexisted with using help and not being dominated by symptoms. In addition, the use of help correlates with a sense of purpose and orientation to success. It can therefore be assumed that recovery is a process in which there are many interdependencies in both women and men, but in men it seems to be more complex and does not involve gratitude as it does in women.
CONCLUSIONS
The study involved 50 people with schizophrenia, in symptomatic remission, who used various types of psychiatric rehabilitation and support systems. In the investigated group, the analyses concerned women and men separately and the results are as follows:
The study did not show any statistically significant differences between women and men in terms of experienced gratitude.
The compared groups differ in terms of their ability to use help, which is one of the elements supporting the recovery process. Women outperform men in this respect.
Experiencing gratitude is associated with the healing process only in women in such areas as a sense of self-confidence and hope and a sense of purpose and success orientation.
The age of the women participating in the study has been linked to the level of gratitude they experience and the progress of their healing process.
