Content uploaded by Mark S Salzer
Author content
All content in this area was uploaded by Mark S Salzer on Jul 05, 2014
Content may be subject to copyright.
This article was downloaded by: [Temple University Libraries]
On: 27 June 2014, At: 05:23
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954
Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,
UK
American Journal of
Psychiatric Rehabilitation
Publication details, including instructions for
authors and subscription information:
http://www.tandfonline.com/loi/uapr20
Role of Leisure in Recovery
From Mental Illness
Yoshitaka Iwasaki a , Catherine Coyle b , John Shank
b , Emily Messina c , Heather Porter b , Mark Salzer
b , David Baron d , Gretchen Kishbauch b , Rocio
Naveiras-Cabello b , Lynda Mitchell b , Andera Ryan b
& Glenn Koons b
a Faculty of Extension , University of Alberta ,
Edmonton , Alberta , Canada
b Department of Rehabilitation Sciences , Temple
University , Philadelphia , Pennsylvania , USA
c Department of Physical Education, Health, and
Recreation , Eastern Washington University ,
Cheney , Washington , USA
d Department of Psychiatry , University of Southern
California , Los Angeles , California , USA
Published online: 28 May 2014.
To cite this article: Yoshitaka Iwasaki , Catherine Coyle , John Shank , Emily Messina ,
Heather Porter , Mark Salzer , David Baron , Gretchen Kishbauch , Rocio Naveiras-
Cabello , Lynda Mitchell , Andera Ryan & Glenn Koons (2014) Role of Leisure in
Recovery From Mental Illness, American Journal of Psychiatric Rehabilitation, 17:2,
147-165, DOI: 10.1080/15487768.2014.909683
To link to this article: http://dx.doi.org/10.1080/15487768.2014.909683
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the
information (the “Content”) contained in the publications on our platform.
However, Taylor & Francis, our agents, and our licensors make no
representations or warranties whatsoever as to the accuracy, completeness,
or suitability for any purpose of the Content. Any opinions and views
expressed in this publication are the opinions and views of the authors, and
are not the views of or endorsed by Taylor & Francis. The accuracy of the
Content should not be relied upon and should be independently verified with
primary sources of information. Taylor and Francis shall not be liable for any
losses, actions, claims, proceedings, demands, costs, expenses, damages,
and other liabilities whatsoever or howsoever caused arising directly or
indirectly in connection with, in relation to or arising out of the use of the
Content.
This article may be used for research, teaching, and private study purposes.
Any substantial or systematic reproduction, redistribution, reselling, loan,
sub-licensing, systematic supply, or distribution in any form to anyone is
expressly forbidden. Terms & Conditions of access and use can be found at
http://www.tandfonline.com/page/terms-and-conditions
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
Role of Leisure in Recovery From
Mental Illness
Yoshitaka Iwasaki
Faculty of Extension, University of Alberta, Edmonton,
Alberta, Canada
Catherine Coyle and John Shank
Department of Rehabilitation Sciences, Temple
University, Philadelphia, Pennsylvania, USA
Emily Messina
Department of Physical Education, Health, and
Recreation, Eastern Washington University, Cheney,
Washington, USA
Heather Porter and Mark Salzer
Department of Rehabilitation Sciences, Temple
University, Philadelphia, Pennsylvania, USA
David Baron
Department of Psychiatry, University of Southern
California, Los Angeles, California, USA
Gretchen Kishbauch, Rocio Naveiras-Cabello,
Lynda Mitchell, Andera Ryan, and Glenn Koons
Department of Rehabilitation Sciences, Temple
University, Philadelphia, Pennsylvania, USA
Address correspondence to Yoshitaka Iwasaki, PhD, Professor and Associate Dean, Research,
Faculty of Extension, University of Alberta, 2-281 Enterprise Square, 10230 Jasper Ave.,
Edmonton, Alberta T5J 4P6, Canada. E-mail: iwasaki@ualberta.ca
American Journal of Psychiatric Rehabilitation, 17: 147–165, 2014
Copyright #Taylor & Francis Group, LLC
ISSN: 1548-7768 print=1548-7776 online
DOI: 10.1080/15487768.2014.909683
147
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
Conceptually supported by recovery, positive psychology, and health pro-
motion perspectives, this study explored the role of leisure in recovery and
health among culturally diverse individuals with mental illness. One-on-one
survey interviews were conducted with Black (n ¼35), Hispanic=Latino
(n ¼28), White (n ¼28), and Asian (n ¼8) adults (aged between 23 and 78)
with mental illness (N ¼101). A variety of mental health diagnoses were
represented in the sample (e.g., bipolar disorder, n ¼32; major depression,
n¼23; schizophrenia, n ¼22). Regression analyses were performed to esti-
mate the predictive effects of leisure variables on recovery, health, and psychi-
atric symptoms. The findings emphasize the importance of: (a) meanings that
persons with mental illness gain from leisure (e.g., connection=belonging,
identity, freedom=autonomy) (i.e., meaning making via leisure) and (b) leisure
opportunities to fight against or reduce perceptions of boredom (i.e., boredom
reduction in leisure) as both of these were significant predictors of recovery.
Also, a greater perception of being actively engaged=involved (i.e., perceived
active living) was a significant predictor of recovery and overall physical and
mental health and less frequent psychiatric symptoms, whereby leisure poten-
tially provides a key context for the pursuit of active living. Furthermore, the
use of leisure both for coping with stress (i.e., stress coping via leisure) and
reducing boredom significantly predicted fewer psychiatric symptoms. The
findings highlight the need to consider the experiences, feelings=emotions,
and meanings that people with mental illness gain from leisure beyond sim-
ply behavioral forms of leisure (i.e., leisure activities) per se by respectfully
appreciating the cultural diversity of people with mental illness.
Keywords:Leisure; Recreation; Recovery; Health; Mental illness; Culture; Race; Ethnicity;
Active living; Meaning; Coping
The promotion of recovery is the central goal of the public mental
health system (Power, 2009; Segal, Silverman, & Temkin, 2010;
Whitley & Drake, 2010). This recovery orientation requires greater
attention to established, but understudied, interventions (e.g., peer
support), new interventions (e.g., wellness recovery action plans,
supported education and employment), and new concepts applied
to the promotion of recovery. Recovery is defined as ‘‘a journey of
healing and transformation enabling a person with a mental health
problem to live a meaningful life in a community of his or her
choice while striving to achieve his or her full potential’’ (U.S.
Department of Health and Human Services, 2006) from a holistic=
ecological, person-centered, and strength-based perspective
(National Alliance on Mental Illness Policy Research Institute,
2004; Sells, Borg, & Marin, 2006).
As a key contributor to recovery, the pursuit of active living
(Cabassa, Ezell, & Lewis-Ferna
´ndez, 2010; Richardson, Faulkner,
148 Y. Iwasaki et al.
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
McDevitt, et al., 2005) has been discussed in relation to counteract-
ing inactive, sedentary lifestyles, and obesity among people with
mental illness that present substantial health risks including dia-
betes and heart disease (Brown, Leith, Dickerson, et al., 2010; Gal-
letly & Murray, 2009; Wheeler, Harrison, Mohini, et al., 2010).
However, it is plausible that recovery, in addition to health pro-
motion, may also be strengthened in persons with serious mental
illness if efforts to promote active living include enjoyable, express-
ive, and meaningful leisure experiences (Fullagar, 2008, pp. 14–16;
Iwasaki, Coyle, & Shank, 2010; Rudnick, 2005). Leisure refers to a
relatively freely chosen activity and its accompanying experiences
and emotions (e.g., enjoyment, satisfaction, happiness, excitement)
that can make one’s life enriched and meaningful (Blackshaw,
2010; Kelly & Freysinger, 2000; Mannell & Kleiber, 1997).
A number of previous studies have shown that leisure-related
concepts are associated with recovery-oriented outcomes. For
example, some qualitative research suggests that leisure opportu-
nities (e.g., at recreation centers, in peer-run programs) can promote
recovery from mental illness (Clay, Schell, Corrigan, & Ralph, 2005;
Swarbrick & Brice, 2006). Additionally, Babiss’s (2002) study of
women with mental illness found that expressive leisure activities
(e.g., art, music, writing=journaling, dance) facilitate recovery,
while salient themes of recovery in the study of Davidson, Borg,
and Mann (2005) included going out and engaging in normal
activities and having meaningful social roles and positive relation-
ships outside the formal mental health system. Leisure and its
related, more organized and purposeful form, recreation, provide
opportunities for these meaningful personal and social activities
(Henderson & Bialeschki, 2005; Kleiber, Hutchinson, & Williams,
2002; Iwasaki, MacKay, Mactavish, Ristock, & Bartlett, 2006). Also,
leisure was found to be an antidote to depressive symptomotology
in Fullagar’s (2008) study of 48 Australian women with depression.
Fullagar found that creative (e.g., art=craft, gardening, music,
community theatre), actively embodied (e.g., martial arts, walking,
dance, yoga, tai chi, swimming, bowling), and social (e.g., cafes,
friend=support groups, church, pets, helping others) leisure acted
as a counterdepressant to facilitate recovery and transformation
through the facilitation of the hope that there is life beyond
depression.
Furthermore, Lehman’s study with persons living with mental
illness (n ¼278) reported leisure’s (a subjective quality-of-life
Role of Leisure in Recovery From Mental Illness 149
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
indicator) strong association with global well-being (r ¼.59)
(Lehman, 1983), which is consistent with the Trauer et al. (1998)
study of 55 patients with serious mental illness reporting that one’s
satisfaction with leisure had the strongest association with global
well-being (r ¼.76) (greater than any other life-domain measures
such as health, family, and social relations). Also, the study of
Lloyd, King, and McCarthy (2007) of 44 clubhouse members living
with mental illness found that their motivation to engage in leisure
was significantly correlated with recovery (r¼.35). Finally, Lecomte,
Corbie
`re, and The
´roux (2010) found that high capacity for leisure
activities was a significant factor explaining optimism as a key
element of recovery among 150 patients with early psychosis.
A focus on leisure and active living is consistent with positive
psychology (Seligman & Csikszentmihalyi, 2000), which has been
suggested as an important theoretical framework for promoting
recovery (Resnick & Rosenheck, 2006; Slade, 2010). Positive psy-
chology is ‘‘the science of what is needed for a good life’’ (Seligman
& Csikszentmihalyi) and is defined at subjective (e.g., well-being,
satisfaction), individual (e.g., courage, perseverance, spirituality),
and group (e.g., citizenship) levels (Seligman, 2002).
This study furthers our understanding of the role of leisure in
recovery and health of individuals with mental illness by focusing
on the contributions of leisure to meaning making, stress coping,
and satisfaction production. The role of leisure in coping with stress
represents a humanistic and strengths-oriented approach to dealing
with challenges in life via leisure that may help people gain valued
meanings of life and make their lives enjoyable (Kleiber et al., 2002;
Iwasaki et al., 2006; Kleiber & Hutchinson, 2010; Chun & Lee, 2010;
Pressman, Matthews, Cohen, et al., 2009). On the other hand, poten-
tially negative or dark sides of leisure should be recognized because
leisure may not be exclusively positive (Rojek, 1999; Rojek, Shaw, &
Veal, 2006). Thus, another concept explored in this study includes
leisure boredom (i.e., individual differences in perceptions of bore-
dom in leisure) (Iso-Ahola & Weissinger, 1990) because some per-
sons with mental illness may have difficulty in using their free or
leisure time constructively.
In addition to further developing a theoretical framework for
how leisure facilitates recovery, this study is also among the first
to address the gap in knowledge about the leisure experiences of
culturally diverse groups of individuals with serious mental illness.
It also addresses the serious underrepresentation of racial=ethnic
150 Y. Iwasaki et al.
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
minorities in lifestyle intervention studies among people with
mental illness and a lack of attention to cultural factors in this area
of research (Hwang, Myers, Abe-Kim, & Ting, 2008; Ida, 2007;
Mendenhall, 2008; Warren, 2007; Graham, 2011; Smith, Stinson,
Dawson, et al., 2006). This approach has important implications,
considering the mental health disparities being faced by non-White
persons with mental illness (e.g., the double jeopardy of having
mental illness and racial=ethnic minority status, leading to great
risk of stigma, isolation=exclusion, inaccessibility, and limited
opportunities in life) (Piatt, 2011).
Built on the above conceptual perspectives, this paper examines
the following primary research questions: Do leisure-related con-
cepts, including leisure-generated meanings, leisure stress coping,
leisure satisfaction, leisure boredom, and perceived active living,
significantly predict recovery among culturally diverse individuals
having mental illness? If so, to what extent?
METHODS
Guided by the principles of community-based participatory
research (e.g., mutual respect and trust, colearning and collective
capacity building, power sharing, and coownership of research)
(Israel, Eng, Schulz, & Parker, 2005; Minkler & Wallerstein, 2008;
Wallerstein & Duran, 2006), we worked collaboratively with five
community mental health agencies (offering education, advocacy,
and community outreach programs and mental health services) in
Philadelphia, Pennsylvania, to recruit study participants. Members
of our research team held information sessions to describe this
study for potential participants at partner agency sites. Partner
agency staff assembled diverse consumers from different programs
that represented each agency’s consumer base for these information
sessions. After attending the informational session, interested indi-
viduals who met inclusion criteria (i.e., community-dwelling adults
with a DSM-IV diagnosis confirmed by psychiatric case managers)
voluntarily listed their contact information so that face-to-face sur-
vey interviews could be scheduled at their convenience.
The interviewers were three graduate research assistants (RAs)
(including one doctoral and two master’s students) with extensive
experience in working with our target population. As key members
of our research team, the RAs gained sufficient knowledge about
Role of Leisure in Recovery From Mental Illness 151
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
our research methodology including interview procedures (in
addition to its conceptualization), informed by the coprincipal
investigators of this project via a series of team meetings. The inter-
view protocol and procedures developed by our research team
went through a series of iterations to ensure that the measures, for-
mats, and implementation process were appropriate. The instruc-
tions and introductory script for the interviewer were developed,
along with the use of a coding sheet. Within each section of the
questionnaire, a note to an interviewer was provided (e.g., ‘‘Use
green cards. Review each response while pointing to each card.
Associate the numbers with the verbal prompts.’’). Following a ser-
ies of training sessions using this interview protocol with the RA,
the interview procedure was implemented by the RA via a pilot test
with two individuals (one male with bipolar disorder and one
female with schizophrenia) from our target population who
worked with our team as knowledgeable consumer representatives.
Based on feedback from these two interviewees, the interview pro-
cess was deemed appropriate, including the RAs’ implementation
techniques, the measures, and the interview’s relevance to our tar-
get population, although minor wording refinement was made as
suggested by the interviewees.
Conducted by these RAs, the interview process followed an
IRB-approved protocol including voluntary participation, informed
consent, and confidentiality and anonymity of data. Each one-on-
one interview (1.5 to 2 hours) followed the same structured
sequence and included the standardized measures listed below.
At the completion of the interview, each participant was paid $20.
Participants
Fifty-five men and 46 women were enrolled in the study (N ¼101).
The average age was 48 years, with a range of 23 to 78. As intended,
we enrolled an ethnically diverse group of participants: Black
(n ¼35), Hispanic=Latino (n ¼28), White (n ¼30), and Asian
(n ¼8). Diagnoses reported and confirmed by case managers
include bipolar disorder (n ¼32), major depression (n ¼23), schizo-
phrenia (n ¼22), bipolar=schizophrenic (n ¼10), schizoaffective dis-
order (n ¼8), substance abuse (n ¼3), panic disorder (n ¼1),
posttraumatic stress disorder (n ¼1), and borderline personality
disorder (n ¼1). Of the 101 participants, 81 were unemployed
152 Y. Iwasaki et al.
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
TABLE 1. Characteristics of study sample (N¼101)
Categories n
Gender Men 55
Women 46
Race=Ethnicity Black 35
White 30
Hispanic=Latino 28
Asian 8
Age 20–29 6
30–39 10
40–49 36
50–59 39
60–69 8
70–79 2
Primary diagnosis Bipolar disorder 32
Major depression 23
Schizophrenia 22
Bipolar=Schizophrenic 10
Schizoaffective disorder 8
Substance abuse 3
Panic disorder 1
Posttraumatic stress disorder 1
Borderline personality disorder 1
Relationship status Single, not married, not in a relationship 43
Married 11
Divorced 16
Separated 7
Widowed 6
Not married, in a relationship 13
Not married, cohabiting 3
Other 2
Education Less than 9 years of school 14
9–12 years of school (not graduated) 23
High school graduate or GED 33
Some college, vocational, trade, or business school 16
Associate or vocational graduate 6
College graduate 5
Some graduate school 2
Master’s degree or equivalent 3
Current job status Full-time (32 þhours weekly) 7
Part-time 7
Irregular work 1
Retired 4
Unemployed not on disability 34
Unemployed on disability 47
Other 1
(Continued)
Role of Leisure in Recovery From Mental Illness 153
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
(n ¼47 on disability, n ¼34 not on disability), 43 were single (not
married, not in a relationship), and 79 reported yearly income of
less than $10,000 (n ¼28, less than $5,000; n ¼51, $5,000– $10,000)
(see Table 1).
Measures
The Recovery Assessment Scale (RAS; Corrigan, Salzer, & Ralph, 2004) is
a measure of subjective experience of recovery. The measure consists
of 24 items using a 5-point Likert-type scale (1 ¼‘‘strongly disagree’’ to
5¼‘‘strongly agree’’) with five factors: personal confidence and hope,
willingness to ask for help, goal and success orientation, reliance on
others, and no domination by symptoms. Sample items include: ‘‘I
have a desire to succeed,’’ ‘‘I have a purpose in life,’’ and ‘‘I like
myself.’’ Very good psychometric properties of the RAS have been
reported (Andresen, Caputi, & Oades, 2010; Barbic, Krupa, &
Armstrong,2009;Jerrell,Cousins,&Roberts,2006;Lloydetal.,
2007). Recently, the Cavelti, Kvrgic, Beck, Kossowsky, and Vauth
(2012) review of 13 self-report instruments to assess recovery from
schizophrenia rated RAS as the best currently available measure of
personal recovery based on their assessments on validity (content
and construct validity), reliability (internal consistency and test-retest
reliability), user friendliness, and administrator friendliness.
The SF-12 Health Survey (Ware, Kosinski, & Keller, 1996; 12
items) assesses physical and mental health, yielding two summary
scores: the Mental Component Summary and Physical Component
Summary, whereas the combined scores represent an overall physi-
cal and mental health indicator. Sample items include ‘‘During the
past 4 weeks how much did pain interfere with your normal
work?’’ (0 ¼‘‘not at all’’ to 4 ¼‘‘extremely’’), and ‘‘During the past
4 weeks did you have a lot of energy? (0 ¼‘‘none of the time’’ to
TABLE 1. Continued
Categories n
Yearly income Less than $5,000 28
$5,000–$10,000 51
$10,000–$15,000 8
$15,000–$20,000 5
$20,000–$30,000 5
$30,000–$40,000 3
Missing 1
154 Y. Iwasaki et al.
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
5¼‘‘all of the time’’). The SF-12 has been used effectively with per-
sons living with mental illness (Salyers, Bosworth, Swanson, et al.,
2000; Teh, Kilbourne, McCarthy, et al., 2008).
The Colorado Symptom Index (CSI) (Shern, Wilson, & Coen, 1994)
is a self-report measure (with 10 items) of psychiatric symptoms, in
which people indicate the frequency of various psychiatric symp-
toms they have experienced during the past month, using a 5-point
Likert-type scale: 1 ¼‘‘At least every day,’’ 2 ¼‘‘Several times a
week,’’ 3 ¼‘‘Several times during the month,’’ 4 ¼‘‘Once during
the month,’’ and 5 ¼‘‘Not at all.’’ Boothroyd and Chen’s (2008)
study (N ¼3,874) provided strong evidence of the CSI’s psycho-
metric properties including excellent internal consistency (.92),
test-retest reliability (.71), and strong validity (e.g., CSI scores
distinguished among individuals with and without mental health
services needs and were significantly correlated with functioning).
The Leisure Meanings Gained Scale (LMGS) (Porter, 2009) mea-
sures leisure-generated meanings people gain, while leisure meaning
is defined as ‘‘a socially and contextually grounded psychological=
emotional experience that holds inner significance for an individual
that evolves from, or within, the context of leisure.’’ Porter’s
literature-informed synthesis (including positive psychology frame-
work) and psychometric testing including factor analysis (N ¼163)
(Porter) supported the dimensionality of this scale including con-
nection=belonging, identity, freedom=autonomy, power=control,
and competence=mastery with a total Cronbach alpha of .97. This
scale asks a person to list his or her most favorite leisure activities,
then, while thinking about the ways he or she participates in these
activities, respond to each item such as ‘‘It makes me feel at peace
within myself,’’ ‘‘It lets me express who I am,’’ and ‘‘It makes me
feel a sense of wholeness; more together.’’ The measure consists
of 24 items with a Likert-type scale (1 ¼‘‘never’’ to 5 ¼‘‘always’’).
The Leisure Coping Scale (Iwasaki & Mannell, 2000) measures peo-
ple’s use of leisure as a way of coping with stress, consisting of two
versions: (a) the Leisure Coping Belief Scale (LCBS, dispositional
measure) to assess people’s beliefs that their leisure contributes to
coping with stress, and (b) the Leisure Coping Strategy Scale (LCSS,
situation-specific measure) to assess the extent to which leisure pur-
suits specifically help people cope with stress. The LCBS asks the
subject to report how he or she engages in leisure for stress coping
in general, whereas the LCSS asks the person to think back to
stressful events encountered in the past month and then recall
Role of Leisure in Recovery From Mental Illness 155
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
how he or she coped with these events. Sample items include ‘‘I
gain feelings of personal control in leisure’’ (LCBS) and ‘‘Leisure
helped me manage my negative feeling’’ (LCSS). The measure con-
sists of 21 items with a Likert-type scale (1 ¼‘‘very strongly dis-
agree’’ to 7 ¼‘‘very strongly agree’’). Iwasaki and Mannell’s
(2000) study (N ¼247) reported internal consistency (.91 and .93
for the LCBS and LCSS, respectively) and construct validity includ-
ing the dimensionality and factor structures of the two scales based
on confirmatory factor analysis. The usefulness of the Iwasaki and
Mannell framework has been demonstrated both in the leisure
research literature (e.g., Heintzman & Mannell, 2003) and in the
health research literature (e.g., Iwasaki, Mannell, Smale, & Butcher,
2005).
The Leisure Satisfaction Scale (Beard & Ragheb, 1980) assesses the
extent to which individuals feel that their needs are met through
their leisure activities. Di Bona (2000) and Trottier et al. (2002)
showed good validity and reliability of the scale. Sample items
include ‘‘My leisure activities are very interesting to me,’’ ‘‘I engage
in leisure activities simply because I like doing them,’’ ‘‘I use many
different skills and abilities in my leisure activities,’’ and ‘‘My
leisure activities give me a sense of accomplishment.’’ The measure
consists of 24 items with a Likert-type scale (1 ¼‘‘almost never
true’’ to 5 ¼‘‘almost always true’’).
The Leisure Boredom Scale (Iso-Ahola & Weissinger, 1990) mea-
sures individual differences in perceptions of boredom in leisure.
Sample items include ‘‘Leisure time is boring,’’ ‘‘During my leisure
time, I become highly involved in what I do’’ (reverse item), ‘‘I
waste too much of my leisure time sleeping,’’ ‘‘For me, leisure time
just drags on and on,’’ and ‘‘I am excited about leisure time’’
(reverse item). The measure consists of 12 items with a Likert-type
scale (1 ¼‘‘strongly disagree’’ to 5 ¼‘‘strongly agree’’). Besides
Iso-Ahola and Weissinger, Gordon and Caltabiano (1996) and
Wegner, Flisher, Muller et al. (2002) reported very good psycho-
metric properties of this scale.
The Perceived Active Living Scale has been developed and used in
this study to assess the extent to which people feel involved and
actively engaged in various parts of life including personal, family,
social, community, and cultural life domains (six items including
life in general=overall), using a Likert-type 5-point scale (1 ¼‘‘not
active at all’’ to 5 ¼‘‘very active’’). As stated in its instructions,
‘‘By ‘active’ or ‘actively engaged’ we mean having things to think
156 Y. Iwasaki et al.
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
about, places to go, things to do, and people to be with in various
parts of your life.’’ The measure’s Cronbach alpha in this study
was .83, and all the Cronbach alpha reliability scores for the mea-
sures used in the study are reported in Table 2.
RESULTS
As shown in Table 2, each of the leisure variables except leisure
boredom was positively and significantly correlated with recovery,
overall health (SF-12), and psychiatric symptom scores (CSI in
which higher scores indicate lower psychiatric symptoms). In con-
trast, leisure boredom was negatively and significantly correlated
with recovery, SF-12, and CSI. Also, perceived active living had sig-
nificant positive correlations with leisure-generated meanings, lei-
sure coping, leisure satisfaction, recovery, SF-12, and CSI, and
significant negative correlations with leisure boredom.
TABLE 2. Zero-order correlation coefficients among variables
Variables 1 2 3 4 5 6 7 8 Mean SD Alpha
1. Leisure-
generated
Meanings
—.68.79.68.61.75.33.413.84 .78 .94
2. Leisure
coping
—.77.73.55.66.36.545.23 1.02 .95
3. Leisure
satisfac-
tion
—.76.59.68.43.483.79 .78 .94
4. Leisure
boredom
—.57.69.42.562.31 .67 .85
5. Perceived
active
living
—.66.57.543.32 .93 .83
6. Recovery —.48.503.98 .69 .93
7. SF-12
Overall
health
—.632.90 1.02 .87
8. Colorado
Symptom
Index
—3.52 .97 .90
p<.001; all measures use 5-point scales except for leisure coping, which uses a
7-point scale. Higher Colorado Symptom Index scores indicate lower psychiatric
symptoms.
Role of Leisure in Recovery From Mental Illness 157
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
We performed hierarchical regression by entering gender and
race=ethnicity at step 1 and then entered predictor variables of
interest at step 2. Our findings (see Table 3) showed that 65%
(R2
change ¼:65, F
change
¼63.6, p <.001) of the variance in recovery
was significantly and uniquely accounted for by leisure-generated
meanings (b¼.43, p <.001), perceived active living (b¼.25,
p<.001), and leisure boredom (b¼.26, p <.001). Another
regression (Table 4) estimated that 31%(R2
change ¼:31, F
change
¼46.5,
46.5, p <.001) of the variance of SF-12 overall health was signifi-
cantly and uniquely accounted for by perceived active living
(b¼.56, p <.001). In addition, we found that 38%(R2
change ¼:38,
F
change
¼20.3, p <.001) of the variance in psychiatric symptoms
was significantly and uniquely accounted for by leisure stress
coping (b¼.22, p <.05), perceived active living (b¼.28, p <.01),
and leisure boredom (b¼.22, p <.001) (Table 5).
TABLE 4. Hierarchical regression (dependent variable: SF-12 overall health): total
sample (N¼101)
Predictors R2
total R2
adjusted R2
change F
change
btp
Step 1: .05 .03 .05 2.59 n.s.
Gender .19 1.95 n.s.
Race=Ethnicity .12 1.26 n.s.
Step 2: .36 .34 .31 46.58 .00
Perceived active living .56 6.82 .00
Note: Gender (1 ¼woman, 0 ¼man), Race=Ethnicity (1 ¼Non-White, 0 ¼White),
n.s. ¼statistically nonsignificant.
TABLE 3. Hierarchical regression (dependent variable: recovery): total sample
(N¼101)
Predictors R2
total R2
adjusted R2
change F
change
btp
Step 1: .02 .01 .02 .70 n.s.
Gender .02 .23 n.s.
Race=Ethnicity .12 1.17 n.s.
Step 2: .67 .65 .65 63.63 .00
Leisure-generated meanings .43 4.98 .00
Leisure boredom .26 3.05 .00
Perceived active living .25 3.19 .00
Note: Gender (1 ¼woman, 0 ¼man), Race=Ethnicity (1 ¼Non-White, 0 ¼White),
n.s. ¼statistically nonsignificant.
158 Y. Iwasaki et al.
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
DISCUSSION
Overall, the findings highlight the potentially significant role of
leisure in recovery of culturally diverse individuals with mental
illness. In particular, the use of leisure for both promoting meaning
making and reducing boredom significantly predicted recovery
from mental illness. Also, greater perceptions of being actively
engaged and involved in life (i.e., perceived active living) signifi-
cantly predicted recovery and overall health, as well as lower psy-
chiatric symptoms. Furthermore, the use of leisure for both coping
with stress and reducing boredom significantly predicted lower
psychiatric symptoms. The findings add to and give new insights
into the knowledge in the recovery literature, given that the role
of leisure in recovery from mental illness has seemed to be largely
neglected (and perhaps undervalued) and seldom studied directly
(Clay et al, 2005; Davidson et al., 2005; Iwasaki et al., 2010).
These findings suggest the importance of giving attention to the
experiences, feelings, and meanings that people with mental illness
gain from leisure activity, beyond simply behavioral forms of lei-
sure (i.e., leisure activities) per se. Specifically emphasized are the
meanings that these persons value, search for, and obtain from lei-
sure pursuits, as well as leisure opportunities to fight against and
reduce a perception of boredom, so that they can find interest,
enjoyment, and excitement from leisure activity. It seems important
to consider the role of leisure in promoting a sense of connection=
belonging, identity, freedom=autonomy, control, and competence=
mastery as different ways to facilitate meaning making via leisure
TABLE 5. Hierarchical regression (dependent variable: Colorado Symptom Index):
total sample (N¼101)
Predictors R2
total R2
adjusted R2
change F
change
btp
Step 1: .02 .01 .02 .96 n.s.
Gender .03 .30 n.s.
Race=Ethnicity .14 1.36 n.s.
Step 2: .40 .37 .38 20.34 .00
Leisure stress coping .22 1.87 .04
Leisure boredom .22 1.88 .04
Perceived active living .28 2.77 .01
Note: Gender (1 ¼woman, 0 ¼man), Race=Ethnicity (1 ¼Non-White, 0 ¼White),
n.s. ¼statistically nonsignificant; higher Colorado Symptom Index scores indicate
lower psychiatric symptoms.
Role of Leisure in Recovery From Mental Illness 159
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
because these are identified as the key dimensions of leisure-
generated meanings in the LMGS (see Methods).
This notion seems consistent with past studies (Arai, Griffin,
Miatello, et al., 2008; Hood & Carruthers, 2007; Pedlar, Yuen, & For-
tune, 2008). For example, Hood and Carruthers’ Leisure and
Well-being Model, which is supported by both positive psychology
and leisure research literature, describes the roles of leisure (as a
therapeutic device, e.g., for persons with disabilities) in promoting
well-being: (a) savoring leisure (to generate positive emotions), (b)
authentic leisure (to promote positive identity), (c) leisure gratifi-
cation (in promoting have highly engaged experiences), (d) mindful
leisure (to cope well in life), and (e) virtuous leisure (to mobilize
strengths), all of which emphasize the pursuit of actively engaged,
enjoyable, and meaningful life.
It is, however, important to note that examining psychosocial
benefits of leisure that has implications for the concept of leisure-
generated meanings has a long tradition in the leisure research
field. For example, Tinsley and colleagues’ paragraphs about
leisure (PAL; Tinsley & Kass, 1980; Tinsley, Colbs, Teaff, &
Kaufman, 1987) and Driver and colleagues’ (1978, 1987) recreation
experiences preferences (REP) have shown its utility, especially in
outdoor recreation settings. The PAL consist of 27 paragraphs
measuring 27 leisure-activity-specific, need-satisfier dimensions
(e.g., affiliation, self-esteem, achievement), whereas REP scales,
representing 19 motivation domains (Manfredo, Driver, & Tarrant,
1996) are grounded in motivation theory, which posits that indivi-
duals recreate to attain certain psychological and physical goals
(Driver & Brown, 1978; Driver, Brown, Stankey, & Gregoire, 1987;
Manfredo et al., 1996). Although we acknowledge the significance
of their work, including its implications for leisure meaning-based
research, the concept of meanings gained from leisure or recreation
is not explicitly focused on in these measures. On the other hand,
the LMGS used in our study is designed to more directly measure
this concept, with integrating relevant contemporary knowledge
from the literature (Porter, 2009).
Furthermore, the findings suggest that the extent to which per-
sons with mental illness feel involved and actively engaged in life
(i.e., perceived active living) seems to be a critical predictor of
recovery and overall health. Because this study reported a strong,
significant correlation of perceived active living with several leisure
variables (r ¼.61, .59, .55, .58 for leisure generated meanings,
160 Y. Iwasaki et al.
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
leisure satisfaction, leisure coping, and leisure boredom, respect-
ively), leisure can provide a key context for the pursuit of active liv-
ing. In addition, the role of leisure in coping with stress appears to
be important in its potential association with lower psychiatric
symptoms for culturally diverse individuals with mental illness.
Because of the cross-sectional data, however, causal interpretations
of the findings should be avoided, along with the use of a
partnership-based sampling method (as opposed to random sam-
pling) and the sample size (N ¼101) as the limitations of the study.
CONCLUSION
The mental health system should be further expanded to more appro-
priately meet the unique needs of culturally diverse individuals with
mental illness from a more holistic, humanistic, and strengths-based
perspective (Ida, 2007; Iwasaki et al., 2010; Resnick & Rosenheck,
2006; Slade, 2010; Young, Chinman, Forquer, et al., 2005). Consistent
with both recovery and positive psychology frameworks that support
such perspective, it is important to give more serious attention to the
role of actively engaged, enjoyable, and meaningful leisure (e.g., for
meaning making, stress coping, and boredom reduction) in recovery
and health promotion in mental health services. As explicitly
intended in this study, acknowledging the cultural diversity of the
population with mental illness (of the total of 101, 71 participants
were non-White, including Black, Hispanic, and Asian) is a must
from both conceptual (e.g., knowledge advancement) and practical
(e.g., service provision, policy-making) perspectives.
FUNDING
The research project on which this paper is based was supported by
the National Institutes of Health=National Institute of Mental
Health (Award No.: R21MH086136).
REFERENCES
Andresen, R., Caputi, P., & Oades, L. G. (2010). Do clinical outcome measures assess
consumer-defined recovery? Psychiatry Research,177, 309–317.
Arai, S. M., Griffin, J., Miatello, A., & Greig, C. L. (2008). Leisure and recreation
involvement in the context of healing from trauma. Therapeutic Recreation Journal,
42(1), 37–55.
Role of Leisure in Recovery From Mental Illness 161
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
Babiss, F. (2002). An ethnographic study of mental health treatment and outcomes:
Doing what works. Occupational Therapy in Mental Health,18(3=4), 1–146.
Barbic, S., Krupa, T., & Armstrong, I. (2009). A randomized controlled trial of the
effectiveness of a modified recovery workbook program: Preliminary findings.
Psychiatric Services,60, 491–497.
Beard, J., & Ragheb, M. (1980). Measuring leisure satisfaction. Journal of Leisure
Research,12(1), 20–33.
Blackshaw, T. (2010). Leisure. New York: Routledge=Taylor & Francis Group.
Boothroyd, R. A., & Chen, H. J. (2008). The psychometric properties of the Colorado
Symptom Index. Administration and Policy in Mental Health and Mental Health
Services Research,35, 370–378.
Brown, C., Leith, J., Dickerson, F., et al. (2010). Predictors of mortality in patients with
serious mental illness and co-occurring type 2 diabetes. Psychiatry Research,177,
250–254.
Cabassa, L. J., Ezell, J. M., & Lewis-Ferna
´ndez, R. (2010). Lifestyle interventions for
adults with serious mental illness: A systematic literature review. Psychiatric Ser-
vices,61, 774–782.
Cavelti, M., Kvrgic, S., Beck, E. M, Kossowsky, J, & Vauth, R. (2012). Assessing recov-
ery from schizophrenia as an individual process. A review of self-report instru-
ments. European Psychiatry,27(1), 19–32.
Chun, S., & Lee, Y. (2010). The role of leisure in the experience of posttraumatic
growth for people with spinal cord injury. Journal of Leisure Research,42, 393–415.
Clay, S., Schell, B., Corrigan, P. W., & Ralph, R. O. (2005). On our own, together: Peer
programs for people with mental illness. Nashville, TN: Vanderbilt University Press.
Corrigan, P. W., Salzer, M., & Ralph, R. O. (2004). Examining the factor structure of
the recovery assessment scale. Schizophrenia Bulletin,30(4), 1035–1041.
Davidson, L., Borg, M., & Mann, I. (2005). Processes of recovery in serious mental ill-
ness: Findings from a multinational study. American Journal of Psychiatric Rehabili-
tation,8(3), 177–201.
Di Bona, L. (2000). What are the benefits of leisure? An exploration using the Leisure
Satisfaction Scale. British Journal of Occupational Therapy,63, 50–58.
Driver, B. L., & Brown, P. (1978). The opportunity spectrum concept in outdoor recreation
supply inventories: A rationale. Proceedings of the integrated renewable resource
inventories workshop.USDA Forest Service General Technical Report RM-55, 24–31.
Driver, B. L., Brown, P. J., Stankey, G. H., & Gregoire, T. G. (1987). The ROS planning
system: Evolution, basic concepts, and research needed. Leisure Sciences,9, 201–212.
Fullagar, S. (2008). Leisure practices as counter-depressants: Emotion—work and
emotion—play within women’s recovery from depression. Leisure Sciences,30,
35–52.
Galletly, C. L., & Murray, L. E. (2009). Managing weight in persons living with severe
mental illness in community settings: A review of strategies used in community
interventions. Issues in Mental Health Nursing,30, 660–668.
Gordon, W. R., & Caltabiano, M. L. (1996). Urban-rural differences in adolescent
self-esteem, leisure boredom, and sensation seeking as predictors of leisure-time
usage and satisfaction. Adolescence,31, 883–901.
Graham, S. (2011). School racial=ethnic diversity and disparities in mental health and
academic outcomes. In G. Carlo, L. J. Crockett, & M. A. Carranza (Eds.), Health dis-
parities in youth and families: Research and applications. New York: Springer Science &
Business Media.
162 Y. Iwasaki et al.
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
Heintzman, P., & Mannell, R. C. (2003). Spiritual functions of leisure and spiritual
well-being: Coping with time pressure. Leisure Sciences,25, 207–230.
Henderson, K. A., & Bialeschki, M. D. (2005). Leisure and active lifestyles: Research
reflections. Leisure Sciences,27, 355–365.
Hood, C. D., & Carruthers, C. (2007). Enhancing leisure experience and developing
resources: The Leisure and Well-Being Model, part II. Therapeutic Recreation Journal,
41(4), 298–325.
Hwang, W. C., Myers, H. F., Abe-Kim, J., & Ting, J. Y. (2008). A conceptual paradigm
for understanding culture’s impact on mental health: The cultural influences on
mental health (CIMH) model. Clinical Psychology Review,28(2), 211–227.
Ida, D. J. (2007). Cultural competency and recovery within diverse populations. Psy-
chiatric Rehabilitation Journal,31(1), 49–53.
Iso-Ahola, S. E., & Weissinger, E. (1990). Perceptions of boredom in leisure: Concep-
tualization, reliability, and validity of the leisure boredom scale. Journal of Leisure
Research,22, 1–17.
Israel, B. A., Eng, E., Schulz, A. J., & Parker, E. A. (Eds.) (2005). Methods in
community-based participatory research for health. San Francisco: Jossey-Bass.
Iwasaki, Y., Coyle, C., & Shank, J. (2010). Leisure as a context for active living, recov-
ery, health, and life quality for persons with mental illness in a global context.
Health Promotion International,25, 483–494.
Iwasaki, Y., MacKay, K., Mactavish, J., Ristock, J., & Bartlett, J. (2006). Voices from the
margins: Stress, active living, and leisure as a contributor to coping with stress. Lei-
sure Sciences,28, 163–180.
Iwasaki, Y., & Mannell, R. C. (2000). Hierarchical dimensions of leisure stress coping.
Leisure Sciences,22, 163–181.
Iwasaki, Y., Mannell, R. C., Smale, B. J. A., & Butcher, J. (2002). A short-term longi-
tudinal analysis of leisure coping used by employees of police and emergency
response service workers. Journal of Leisure Research,34, 311–339.
Jerrell, J. M., Cousins, V. C., & Roberts, K. M. (2006). Psychometrics of the recovery
process inventory. Journal of Behavioral Health Services & Research,33, 464–473.
Kelly, J. R., & Freysinger, V. J. (2000). 21st century leisure: Current issues. Boston: Allyn
& Bacon.
Kleiber, D. A., & Hutchinson, S. L. (2010). Making the best of bad situations: The
value of leisure in coping with negative life events. In L. Payne, B. Ainsworth, &
G. Godbey (Eds.), Leisure, health, and wellness: Making the connections. State College,
PA: Venture.
Kleiber, D., Hutchinson, S., & Williams, R. (2002). Leisure as a resource in transcend-
ing negative life events: Self-protection, self-restoration, and personal transform-
ation. Leisure Sciences,24, 219–236.
Lecomte, T., Corbie
`re, M., & The
´roux, L. (2010). Correlates and predictors of opti-
mism in individuals with early psychosis or severe mental illness. Psychosis:
Psychological, social and integrative approaches,2(2), 122–133.
Lehman, A. F. (1983). The well-being of chronic mental patients: Assessing their qual-
ity of life. Archives of General Psychiatry,10, 369–374.
Lloyd, C., King, R., & McCarthy, M. (2007). The association between leisure motiv-
ation and recovery: A pilot study. Australian Occupational Therapy Journal,54, 33–41.
Manfredo, M. J., Driver, B., & Tarrant, M. A. (1996). Measuring leisure motivation: A
meta-analysis of the recreation experience preference scales. Journal of Leisure
Research,28(3), 188–213.
Role of Leisure in Recovery From Mental Illness 163
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
Mannell, R. C., & Kleiber, D. A. (1997). A social psychology of leisure. State College, PA:
Venture.
Mendenhall, M. (2008). Factoring culture into outcomes measurement in mental
health. In S. Loue & M. Sajatovic (Eds.), Diversity issues in the diagnosis, treatment
and research of mood disorders. New York: Oxford University Press.
Minkler, M., & Wallerstein, N. (Eds.) (2008). Community-based participatory research for
health: From process to outcomes (2nd ed.). San Francisco: Jossey-Bass.
National Alliance on Mental Illness (NAMI) Policy Research Institute (2004). Road-
map to recovery and cure: Final report of the NAMI policy research institute task force
on serious mental illness research. Arlington, VA: Author.
Pedlar, A., Yuen, F., & Fortune, D. (2008). Incarcerated women and leisure: Making
good girls out of bad? Therapeutic Recreation Journal,42(1), 24–36.
Piatt, E. E. (2011). Race, mental illness, and premature mortality: Double jeopardy?
Psychiatric Services,62, 223–224.
Porter, H. R. (2009). Developing a Leisure Meanings Gained and Outcomes Scale
(LMGOS) and exploring associations of leisure meanings to leisure time physical
activity (LTPA) adherence among adults with type 2 diabetes. Dissertation Abstracts
International: Section B: The Sciences and Engineering,70(6-B), 3469.
Power, A. K. (2009). A public health model of mental health for the 21st century. Psy-
chiatric Services,60, 580–584.
Pressman, S. D., Matthews, K. A., Cohen, S., et al. (2009). Association of enjoyable
leisure activities with psychological and physical well-being. Psychosomatic
Medicine,71, 725–732.
Resnick, S. G., & Rosenheck, R. (2006). Recovery and positive psychology: Parallel
themes and potential synergies. Psychiatric Services,57, 120–122.
Richardson, C. R., Faulkner, G., McDevitt, J., et al. (2005). Integrating physical activity
into mental health services for persons with serious mental illness. Psychiatric Ser-
vices,5=.,k6, 324–331.
Rojek, C. (1999). Deviant leisure: The dark side of free-time activity. In E. L. Jackson
& T. L. Burton (Eds.), Leisure studies: Prospects for the twenty-first century. State Col-
lege, PA: Venture.
Rojek, C., Shaw, S. M., & Veal, A. J. (Eds.) (2006). A handbook of leisure studies. Basing-
stoke, UK: Palgrave Macmillan.
Rudnick, A. (2005). Psychiatric leisure rehabilitation: Conceptualization and illus-
tration. Psychiatric Rehabilitation Journal,29, 63–65.
Salyers, M. P., Bosworth, H. B., Swanson, J. W., et al. (2000). Reliability and validity of
the SF-12 health survey among people with severe mental illness. Medical Care,38,
1141–1150.
Segal, S. P., Silverman, C. J., & Temkin, T. L. (2010). Self-help and community mental
health agency outcomes: A recovery-focused randomized controlled trial. Psychi-
atric Services,61, 905–910.
Seligman, M. P. (2002). Authentic happiness: Using the new positive psychology to realize
your potential for lasting fulfillment. New York: Free Press.
Seligman, M. P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduc-
tion. American Psychologist,55(1), 5–14.
Sells, D., Borg, M., & Marin, I. (2006). Arenas of recovery for persons with severe
mental illness. American Journal of Psychiatric Rehabilitation, Special issue: Process
and contexts of recovery, Part II.9(1), 3–16.
164 Y. Iwasaki et al.
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
Shern, D. L., Wilson, N. Z., & Coen, A. S. (1994). Client outcomes II. Longitudinal cli-
ent data from the Colorado Treatment Outcome Study. The Milbank Quarterly,72,
123–149.
Slade, M. (2010). Mental illness and well-being: The central importance of positive
psychology and recovery approaches. BioMed Central Health Services Research,
10(26), 1–14.
Smith, S. M., Stinson, F. S., Dawson, D. A., et al. (2006). Race=ethnic differences in the
prevalence and co-occurrence of substance use disorders and independent mood
and anxiety disorders: Results from the National Epidemiologic Survey on Alcohol
and Related Conditions. Psychological Medicine,36, 987–998.
Swarbrick, M., & Brice, G. H. Jr. (2006). Sharing the message of hope, wellness, and
recovery with consumers psychiatric hospitals. American Journal of Psychiatric
Rehabilitation,9(2), 101–109.
Teh, C. F., Kilbourne, A. M., McCarthy, J. F., et al. (2008). Gender differences in
health-related quality of life for veterans with serious mental illness. Psychiatric
Services,59, 663–669.
Tinsley, H. E. A., Colbs, S. L., Teaff, J. D., & Kaufman, N. (1987). The relationship of
age, gender, health and economic status to the psychological benefits older persons
report from participation in leisure activities. Leisure Sciences,9(1), 53–65.
Tinsley, H. E. A., & Kass, R. A. (1980). Construct-validity of the leisure activities
questionnaire and of the paragraphs about leisure. Educational & Psychological
Measurement,40(1), 219–226.
Trauer, T., Duckmanton, R. A., & Chiu, E. (1998). A study of the quality of life of the
severely mentally ill. International Journal of Social Psychiatry,44, 79–91.
Trottier, A. N., Brown, G. T., Hobson, S. J. G., et al. (2002). Reliability and validity of
the Leisure Satisfaction Scale (LSS-short form) and the Adolescent Leisure Interest
Profile (ALIP). Occupational Therapy International,9, 131–144.
U.S. Department of Health and Human Services. (2006). Transforming mental health
care in America, federal action agenda: First steps. Rockville, MD: Author.
Wallerstein, N. B., & Duran, B. (2006). Using community-based participatory
research to address health disparities. Health Promotion Practice,7(3), 312–323.
Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12- item short-form health survey:
Construction of scales and preliminary tests of reliability and validity. Medical
Care,34, 220–233.
Warren, B. J. (2007). Cultural aspects of bipolar disorder: Interpersonal meaning for
clients & psychiatric nurses. Journal of Psychosocial Nursing & Mental Health Services,
45(7), 32–37.
Wegner, L., Flisher, A. J., Muller, M., et al. (2002). Reliability of the Leisure Boredom
Scale for use with high school learners in Cape Town, South Africa. Journal of Lei-
sure Research,34, 340–350.
Wheeler, A. J., Harrison, J., Mohini, P., et al. (2010). Cardiovascular risk assessment
and management in mental health clients: Whose role is it anyway? Community
Mental Health Journal,46, 531–539.
Whitley, R., & Drake, R. E. (2010). Recovery: A dimensional approach. Psychiatric Ser-
vices,61, 1248–1250.
Young, A. S., Chinman, M., Forquer, S. L., et al. (2005). Use of a consumer-led inter-
vention to improve provider competencies. Psychiatric Services,56, 967–975.
Role of Leisure in Recovery From Mental Illness 165
Downloaded by [Temple University Libraries] at 05:23 27 June 2014
