Background
The concept of recovery in mental health has been re-examined, and recent developments have revealed two non-synonymous recovery constructs: clinical recovery (objective state, i.e., symptoms, functioning) and personal recovery (subjective process, i.e., attitude or life orientation) [
1‐
4]. Findings from a previous study with 381 service users substantiate the importance of personal recovery, as it was found that the highest level of consensus on the definition of recovery was “recovery is the achievement of a personally acceptable quality of life” and “recovery is feeling better about yourself” [
5]. Therefore, this angle of recovery may only be assessable by the individuals themselves and may approximate us to a more holistic definition of recovery. Moreover, personal recovery impacts the quality of life of individuals with schizophrenia [
6], and a reduction in psychiatric symptoms alone does not necessarily translate into higher personal recovery [
7,
8]. Hence, it may be essential to consider personal recovery in the evaluation of overall recovery in people with psychosis.
Although it may be understood in clinical practice that some form of clinical recovery is essential for personal recovery to take place, the recovery movement has contested that personal recovery can take place without clinical recovery [
9]. In a recent study, Macpherson et al. [
10] administered a series of measures and found that these measures eventually clustered into three factors (termed patient-rated personal recovery, patient-rated clinical recovery, and staff-rated clinical recovery). Although only patient-rated personal recovery (consisting of measures of personal recovery (QPR), empowerment, well-being and hope) had improved over the course of 1 year, closer examination shows that the change in patient-rated personal recovery scores was significantly correlated with the change in symptom scores. This finding suggested that clinical factors should not be forsaken, as they can affect personal recovery. There were other similar findings in the literature, as certain clinical factors were found to be correlated with [
3] and predictive of [
11] personal recovery as well as of recovery orientation [
7]. Clarifying the relationship between these two forms of recovery is essential for appropriate subsequent interventions, as we could promote synergy between the two [
12] instead of having a trade-off based on their relative importance.
While it remains challenging to quantify personal recovery, several reviews have uncovered broad themes that are common in these subjective accounts of recovery [
13‐
16]. Accordingly, several scales that aim to measure personal recovery have been developed, and these scales have been comprehensively reviewed within the previous two decades [
17‐
22]. In 2011, Leamy and colleagues [
23] adopted a systematic review and narrative synthesis approach to identify a conceptual framework that describes the process of recovery: connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (CHIME). In contrast, with other frameworks that have been developed from limited samples or types of data, this framework was derived from 97 studies that consist of wider data sources, providing an empirical basis for related future work. Since then, the Questionnaire about the Process of Recovery (QPR) has been identified as the personal recovery measure that most closely maps to the CHIME framework [
24].
To date, six studies have evaluated the psychometric properties of the QPR and have shown that it has good internal consistency, construct validity and test-retest reliability [
25‐
30]. However, Williams and colleagues [
27] found that the interpersonal subscale underperforms in terms of its psychometric properties and that the intrapersonal subscale overlaps substantially with the 15-item version (see methods for information on the QPR). Hence, they have recommended the 15-item version, as it is more robust and less burdensome. Two other studies had similar findings. Law and colleagues [
28] found that the original 2-factor solution fit their data poorly and that the internal consistency could be improved by the removal of seven items. Similarly, Argentzell et al. [
25] found that the psychometric properties of a brief Swedish QPR-16 version were better supported, where the items of factor 2 (interpersonal) had underperformed. With these findings, the shorter QPR-15 version may be a better choice in terms of psychometric properties and feasibility for clinical use.
The six existing QPR studies, however, have not been able to confirm the conclusion of Shanks and colleagues that the QPR maps to the CHIME framework most closely, as the CHIME framework has not been completely represented in these studies. Given that the current literature has not been comprehensive in its empirical method of testing, it remains uncertain if the QPR encompasses the CHIME framework, let alone the QPR-15 (shortened version).
Moreover, no studies on personal recovery from mental illnesses have been conducted in Singapore, as it is a relatively new concept in Asia [
31]. However, it was reported that Western concepts of personal recovery were applicable in Hong Kong [
32‐
34], an Asian socio-cultural setting. Singapore is a country with a multi-ethnic and predominantly Asian society, with English as the main language of communication. Before the move towards recovery-oriented mental health services can occur, the applicability of valid personal recovery measures in our socio-cultural setting is one of the steps required. Furthermore, more recovery research has been encouraged in culturally dissimilar societies [
35].
Therefore, one of the aims of the current study is to evaluate the psychometric properties of the QPR-15 in Singapore. We aim to test its validity using the CHIME framework and to examine its initial factor structure and its reliability in terms of internal consistency and test-retest reliability. In addition, we aim to examine the associations of personal recovery with clinical and psychological factors, as it remains unclear how the two forms of recovery should be viewed and applied clinically. Although two QPR studies [
8,
28] have included clinical factors, the authors did not enter them into a single model to represent clinical recovery in the analysis. We hypothesise that compared to psychological factors, clinical factors will have significant but lower associations with personal recovery.
Discussion
The current study examined the psychometric properties of the QPR-15 in Singapore, as well as the association between clinical and personal recovery. Our results demonstrate that the QPR-15 has adequate psychometric properties in our socio-cultural setting, possessing CHIME-consistent convergent validity, internal consistency, test-retest reliability and a one-factor structure. To our knowledge, this is the first study that has found empirical evidence for the QPR-15 to represent the CHIME personal recovery framework, as prior QPR studies had excluded the connectedness component and internalized stigma as a subcomponent of identity. Our data also revealed that clinical factors had significant little to moderate (mostly low) correlations with the QPR-15 and explained a significant proportion of variance of the QPR-15; however, this association was no longer statistically significant when all the CHIME-related psychological factors were added into the hierarchical multiple linear regression model. This finding suggested that although psychological factors have a larger contribution to personal recovery than clinical factors, clinical factors still have a complementary role in personal recovery.
The psychometric properties of the QPR-15 obtained from our study are comparable to those found in previous QPR studies. We report an initial factor structure of one factor, which is consistent with the findings of prior QPR studies [
25,
27,
28] that had recommended the briefer version of the QPR (15–16 items) but not with the findings of studies providing support for the full version [
26,
29,
30]. With regards to convergent validity, the QPR-15 in our study had moderately significant correlation coefficients with subjective scales of psychological factors. This finding is in line with those of other QPR studies (r
s = 0.5–0.7). However, it should be noted that among the psychological factors in our study, only the correlation of WHOQOL-BREF item 6 with the QPR-15 (r
s = 0.472) was low. Using a single item (item 6) of the WHOQOL-BREF to represent meaning in life might not have been suitable because a more comprehensive measure would have been more valid. The use of a single item could have limited the strength of the correlation between meaning in life and the QPR-15. Nonetheless, Leamy and colleagues [
23] reported that 65% of the studies they reviewed had endorsed quality of life as important to the recovery process, categorised under the domain of meaning in life (66% of studies endorsed meaning in life itself). The fact that the QPR-15 showed a moderate correlation with the total WHOQOL-BREF (quality of life) (r
s = 0.669) in the current study thus supports its convergent validity with the CHIME domain of meaning in life. Overall, our results provide preliminary evidence for the validity and reliability of the QPR-15 in our socio-cultural setting.
Our results demonstrated that the main clinical predictor of the QPR-15 was depressive symptoms, which is consistent with several studies [
3,
7,
8,
11,
60] that examined the relationship between clinical and personal recovery. A recent meta-analysis investigating the association between clinical and personal recovery found a higher mean weighted effect size for affective symptoms compared to symptoms and functioning [
60]. Jørgensen et al. [
11] also found that the only symptom index that was consistently linked with overall personal recovery over four time points (baseline, 3 months, 6 months and 12 months) was the emotional discomfort factor (depression, anxiety and guilt) of the PANSS. Using the QPR-15, Law et al. [
8] found that the QPR-15 scores at time point 2 were predicted by negative emotion (CDSS and negative self-esteem), positive self-esteem, hopelessness and, to a lesser extent, symptoms and functioning. Indeed, our results (Model 1 of both time points in Table
5) suggested that depressive symptoms were the clinical factor with the largest impact on personal recovery. Although depressive symptoms (CDSS) were not significant in the final model (time point 2) of our study, we postulate that the WHOQOL-BREF, through its evaluation of negative feelings, might have captured self-reported depressive symptoms. The results of Roe et al. [
3] may also shed some light on how depressive symptoms can affect personal recovery. They found that although the total symptom score did not correlate with subjective recovery (Recovery Assessment Scale; RAS), the dimensions of mood were correlated with the hope domain of the RAS. Therefore, a greater severity of depressive symptoms may reduce one’s level of hope and hence affect one’s personal recovery.
Although our results suggested that psychological factors contributed more to personal recovery than did clinical factors, the relationships between psychological and clinical factors and their effects on personal recovery may be complex. We selected one psychological factor to be entered at stage 2 of the model due to collinearity among the factors. However, we found that inserting different psychological factors into the model produced different effects that clinical factors had on personal recovery. This finding suggests some indirect or interactional relationship amongst the variables, which is congruent with the results of a number of studies [
6,
61‐
64]. For instance, Rossi et al. [
61] found that in patients with schizophrenia, avolition (part of negative symptoms) has direct effects on depression, while it also has indirect effects on depression through internalised stigma and resilience. Internalized stigma was related to depression through the mediation of resilience. In addition, Jørgensen et al. [
11] found that in addition to depressive symptoms, the relationship of symptom severity with personal recovery did not appear to be generally stable. Negative symptoms were linked to personal recovery at three time points but not one time point, while positive symptoms were linked to subjective recovery at one time point but not three time points. Similarly, we found that negative symptoms were predictive of subjective recovery at one time point (baseline, model 1) but not at time point two of our study. Jørgensen et al. proposed that the result may suggest influence from other factors, such that personal recovery may not be directly impacted by the immediate clinical state. This could also explain why Law et al. found functioning to be of higher significance than depressive symptoms in a cross-sectional study [
28] but not in a longitudinal study [
8]. Thus, the result of the previously mentioned robust clinical predictor should also be interpreted with caution, as there may be indirect effects from other variables. The role of other clinical factors should not be dismissed. Future longitudinal research should take into account complex indirect or interactional relationships because these relationships can fluctuate due to interrelationships during the time period. This approach will further inform future clinical practice.
Nevertheless, consistent with our hypothesis, our current results showed that compared to psychological factors, clinical factors had lower but significant associations with personal recovery. The size of the correlation for clinical factors was little to moderate (mostly low except for the CDSS, which was moderate; the PANSS excitement correlation was none to little, and the PANSS cognition correlation was none). In contrast, the size of the correlations with psychological factors was moderate (except for WHOQOL-BREF item 6, which had a low correlation). Similarly, the hierarchical multiple linear regression models demonstrated that clinical factors explained a significant proportion of model variance of the QPR-15, albeit a lower proportion than that explained by psychological factors, before psychological factors were entered into the model. This finding is consistent with several studies that have stated that clinical recovery is not synonymous with personal recovery but rather is complementary to it [
3,
7,
10,
11,
60]. Therefore, the present results suggest that clinical recovery does play a role in personal recovery.
There were two additional observations made from our results. We found that the HHI (i.e., hope) could explain more of the QPR-15 variance than the clinical factors combined. Perhaps hope is the cornerstone of personal recovery, fuelling one’s motivation to rebuild one’s life and self. It is also noted that self-rated measures of psychological factors can predict self-rated personal recovery compared to objective measures (rated by clinician or trained raters). This finding affirms that there is an aspect of recovery in people with psychosis that is subjective and not assessable by others’ judgement. This is also consistent with the study of Karow et al. [
2] that found that service users’ rated remission was only predicted by their self-rated subjective well-being scores but not by objective measures of symptoms and functioning, as rated by psychiatrists.
There are several limitations in this study. The sample size was relatively small; nevertheless, the validation results obtained were consistent with published literature. In addition, a post hoc power analysis revealed that the hierarchical multiple linear regression analysis was adequately powered to detect the observed effects. However, it is advisable to explore the validity of the QPR using its original 22 items in future studies in a larger sample. We recognise that our small sample size was not suitable for factor analysis and hence consider it an initial factor structure using the dimension reduction method (PCA), in which the factor structure may change with larger sample sizes or with factor analysis. Because factor analysis takes into account the underlying structure caused by latent variables, it is a recommended method compared to dimension reduction methods. This approach could answer whether personal recovery is a latent structure that causes the manifest variables (CHIME-related psychological factors) to co-vary. As mentioned above, the usage of a single item (item 6) of the WHOQOL-BREF might not have been valid to represent meaning in life. Hence, future research is recommended to use a more comprehensive measure. Our clinical sample was limited to stable outpatients; therefore, the results might not be generalisable to inpatients or to those who are seriously ill. Our sample was also limited to people with psychosis and might not generalise to other clinical populations. Criterion validity in terms of predictive validity and sensitivity to change could not be examined given the cross-sectional nature of the study. This is an important consideration; as personal recovery measures should be employed as outcome measures to evaluate interventions. Future longitudinal interventional studies would allow for such investigations. Finally, due to the cross-sectional nature of the study, causal inferences cannot be made.
We have identified several future directions. First, there is a need to view recovery within an ecological framework. Although personal recovery is viewed as an individual construct, we need to recognise that individuals exist in a web of relationships with the family, the community and larger socio-political units [
65]. Hence, it is necessary to understand the interactions between individual characteristics and environmental factors (such as choice) [
23]. Second, as suggested by Leamy et al. [
23], we need a deeper understanding of how these individual characteristics of hope, resilience, and empowerment are operating, i.e., how they are ignited and sustained. We have utilised the CHIME framework to guide us in conceptualising personal recovery. However, it remains uncertain if it applies the same way in our population as it did in other socio-cultural settings. Studies have shown or noted that culture and socio-political systems can mediate the operationalisation of the subcomponents of the CHIME framework [
66,
67]. Thus, future research is required to evaluate the conceptualisation of personal recovery in Asian socio-cultural settings, the relevance of personal recovery, and the operationalisation of it. Qualitative work has been recommended for these purposes [
68]. As mentioned previously, the inter-relationships between clinical and psychological factors and their effect on personal recovery also warrant further work. More research is required before we can effectively capture personal recovery in our socio-cultural setting, hence establishing if the QPR-15 can be used for this purpose and to understand the relationship between personal recovery and clinical recovery. However, it is certain that clinical services will be better informed and thus will improve, both in their delivery and support (psychotherapeutic interventions and rehabilitation), if evaluations of recovery move beyond symptoms and functioning. The evaluation of personal recovery will help provide an index of how service users experience their social environments and themselves as individuals as they make sense of their strengths and challenges [
3], since personal recovery is related to personal well-being and social inclusion, which may not be directly captured by clinical recovery [
69].
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