Elsevier

Clinical Psychology Review

Volume 28, Issue 7, October 2008, Pages 1108-1124
Clinical Psychology Review

A scientific agenda for the concept of recovery as it applies to schizophrenia

https://doi.org/10.1016/j.cpr.2008.03.004Get rights and content

Abstract

Recovery is now a widely discussed concept in the field of research, treatment, and public policy regarding schizophrenia. As it has increasingly become a focus in mainstream psychiatry, however, it has also become clear both that the concept is often used in multiple ways, and that it lacks a strong scientific basis. In this review, we argue that such a scientific basis is necessary for the concept of recovery to have a significant long-term impact on the way that schizophrenia is understood and treated. The discussion focuses on key issues necessary to establish this scientific agenda, including: 1) differences in definitions of recovery and their implications for studying recovery processes and outcomes; 2) key research questions; 3) the implications of data from outcome studies for understanding what is possible for people diagnosed with schizophrenia; 4) factors that facilitate recovery processes and outcomes, and methods for studying these issues; and 5) recovery-oriented treatment, including issues raised by peer support. Additional conceptual issues that have not received sufficient attention in the literature are then noted, including the role of evidence-based practices in recovery-oriented care, recovery-oriented care for elderly people with schizophrenia, trauma treatment and trauma-informed care, and the role of hospitals in recovery-oriented treatment. Consideration of these issues may help to organize approaches to the study of recovery, and in doing so, improve the impact of recovery-based initiatives.

Introduction

With publication of the Surgeon General's Report on Mental Health (Department of Health and Human Services, 1999) and the President's New Freedom Commission on Mental Health's Final Report (2003), the concept of “recovery,” which had evolved through the consumer advocacy movement since the first half of the 20th century (Frese, 1998, Tomes, 2006), became a significant consideration for treatment providers and policy makers. Recovery is now routinely a subject of presentations and publications by consumers, clinicians, administrators, researchers, and policy makers, and many states are developing plans to transform their mental health systems in accordance with recovery-oriented care, as recommended by the reports noted above and other publications. At the same time that the groundswell of advocacy for recovery-oriented care continues to increase, however, it has been noted that there is still a lack of a consensual definition of what recovery is or involves. Indeed, as Davidson, O'Connell, Tondora, Straeheli, and Evans (2005) noted, “the only thing about which most involved parties seem to be able to agree is that the notion of recovery has become the focus of a considerable amount of confusion, dialogue and debate between and among various constituencies within the mental health community” (p. 6). Davidson et al. (2005) further noted that as a result of the variety of uses of the word, recovery is in danger of becoming the latest in a line of terms that are used frequently to connote insider status in the mental health community, but without having any meaningful content or implications. Similarly, Liberman and Kopelowicz (2005) noted that lack of agreement on how to define recovery may lead to its loss of credibility as a meaningful construct, a concern also voiced by Roe, Rudnick, and Gill (2007). Jacobson and Greenly (2001) also noted that without consensual agreement on what recovery is, it is likely that currently available treatments and delivery systems will be repackaged in non-significant ways, with the claim that they are now recovery-oriented. Finally, Davidson et al. (2005) argued that the elusive nature of the concept has led to an inconsistency in the degree to which recovery principles are translated into actual practice, and the degree to which the extent that this is occurring can even be assessed. All of these scenarios imply that, despite the current enthusiasm regarding transforming mental health care in a more recovery-oriented direction, unless agreement can be reached on one or more ways to understand recovery in terms that can be measured and studied, there will ultimately be a less than desired impact on the types of services and supports that are made available to consumers of mental health services. These issues are in addition to the complex set of issues that have been raised involving implementation of a recovery model even after agreement on concepts has occurred at the local level (Davidson, O'Connell, Tondora, Styron, & Kangas, 2006).

As a remedy for this situation, Bellack (2006), Liberman and Kopelowicz (2005), and Slade and Hayward (2007) called for efforts to ground the concept of recovery in a scientific base. This would include operational definitions of recovery, reliable measurement of phenomena considered to be core features of recovery, the generation of research data on factors that facilitate or impede attainment of recovery criteria sets, and factors related to the effectiveness of recovery-oriented care. As Liberman (2002) pointed out, in addition to accelerating our understandings of recovery and of how to help people recover, such research can also help improve the differentiation of schizophrenia as a heterogeneous set of disabilities rather than a unitary disease.

In this paper, we review what we believe to be the major research questions facing the field of schizophrenia treatment with regards to the various uses of the concept of recovery. We also note the data, where available, that led us to formulate what we see as the major questions and issues. While we acknowledge at the outset that many more questions are asked than answered in this paper, our hope is that the questions asked, and the rationale behind their generation, will serve to organize research efforts on recovery so that it moves from being an often ambiguous term to one that has concrete meaning and benefit for people suffering from the effects of schizophrenia. We should also note that while our narrower focus is on schizophrenia, much of the discussion has broader applicability to people with serious mental illness in general. We have chosen to focus on schizophrenia, however, because this condition has traditionally been associated with the poorest outcomes, and because response to even recovery-oriented interventions such as supported employment is often poorest among people with this diagnosis (see below, section on interventions). Therefore, we believe it is important to raise the issues of the extent to which current discourse around recovery applies to this population, and the practical issues that a recovery orientation raises for the treatment and lives of this heterogeneous group of people.

Section snippets

Defining recovery

The concept of recovery has been defined in multiple ways. These different definitions can be roughly organized into two types: those that reflect recovery as an outcome based on whether operationally defined criteria in one or more domains are met, and those that reflect recovery as an ongoing process of identity change including a broadening of self concept wherein the role of consumer of psychiatric services becomes less pronounced. As Bellack (2006) noted, the former type of definition

Defining a research agenda for recovery

Answering the key definitional questions posed above will allow for a more productive focus on other questions relevant to recovery that are in need of further study. These research questions include: 1) how are the outcome and process aspects of recovery related, and to what extent do these relationships vary across individuals? 2) what research designs are most appropriate to study the type of long-term change implied by the process-oriented concept of recovery? 3) how does the recovery

Conceptual issues related to recovery-oriented treatment

In this final section, we address some remaining issues that are relevant to both conceptualization and treatment, and therefore to research as well. One of these involves what can be seen as an apparent incompatibility between evidence-based practices (EBPs) and recovery-oriented care. Some authors have raised concerns about a fundamental incompatibility between these approaches (Essock et al., 2003), while others have demonstrated that the approaches are compatible (Bond et al., 2004, Tracy,

References (158)

  • AnthonyW.A.

    Recovery from mental illness: The guiding vision of the mental health service system in the 1990s

    Psychosocial Rehabilitation Journal

    (1993)
  • BallR.A. et al.

    Expressed emotion in community care staff. A comparison of patient outcome in a nine month follow-up of two hostels

    Social Psychiatry and Psychiatric Epidemiology

    (1992)
  • BaumeisterR.F. et al.

    Does high-self esteem cause better performance, interpersonal success, happiness or healthier lifestyles?

    Psychological Science in the Public Interest

    (2003)
  • BeckA.T. et al.

    Manual for the Beck Hopelessness Scale

    (1988)
  • BellM.D. et al.

    Integrated versus sealed-over recovery in schizophrenia: BORRTI and executive function

    Journal of Nervous and Mental Disease

    (2005)
  • BellackA.S.

    Scientific and consumer models of recovery in schizophrenia: Concordance, contrasts, and implications

    Schizophrenia Bulletin

    (2006)
  • BellamyC.D. et al.

    An analysis of groups in consumer-centered programs

    American Journal of Psychiatric Rehabilitation

    (2006)
  • BerkowitzR. et al.

    The management of schizophrenic patients: The nurses view

    Journal of Advanced Nursing

    (1984)
  • BleulerM.

    The Schizophrenic Disorders: Longterm Patient and Family Studies (trans. S. M Clemens)

    (1978)
  • BondG.R. et al.

    Does competitive employment improve nonvocational outcomes for people with severe mental illness?

    Journal of Consulting and Clinical Psychology

    (2001)
  • BondG.R. et al.

    How evidence-based practices contribute to community integration

    Community Mental Health Journal

    (2004)
  • Campbell-OrdeT. et al.

    Measuring the promise: A compendium of recovery measures, Volume II

    (2005)
  • ChampagneT. et al.

    Sensory approaches in inpatient psychiatric settings: Innovative alternatives to seclusion & restraint

    Psychosocial Nursing and Mental Health Services

    (2004)
  • CiompiL.

    Catamnestic long-term study on the course of life and aging of schizophrenics

    Schizophrenia Bulletin

    (1980)
  • CopelandM.E.

    Wellness Recovery Action Plan

    (2002)
  • CournosF.

    The impact of environmental factors on outcome in residential programs

    Hospital and Community Psychiatry

    (1987)
  • CourseyR.D. et al.

    Competencies for direct service staff members who work with adults with severe mental illnesses: Specific knowledge, attitudes, skills, and bibliography

    Psychiatric Rehabilitation Journal

    (2000)
  • CourseyR.D. et al.

    Competencies for direct service staff members who work with adults with severe mental illnesses in outpatient public mental health/managed care systems

    Psychiatric Rehabilitation Journal

    (2000)
  • CroweT.P. et al.

    Effectiveness of a collaborative recovery training program in Australia in promoting positive views about recovery

    Psychiatric Services

    (2006)
  • CruzM. et al.

    Research on the influence that communication in psychiatric encounters has on treatment

    Psychiatric Services

    (2002)
  • DavidsonL. et al.

    Peer support among adults with serious mental illness: A report from the field

    Schizophrenia Bulletin

    (2006)
  • DavidsonL. et al.

    Recovery in serious mental illness: Paradigm shift or shibboleth?

  • DavidsonL. et al.

    The top ten concerns about recovery encountered in mental health system transformation

    Psychiatric Services

    (2006)
  • DavidsonL. et al.

    Recovery from versus recovery in serious mental illness: one strategy for lessening confusion plaguing recovery

    Journal of Mental Health

    (2007)
  • DavidsonL. et al.

    Supported socialization for people with psychiatric disabilities: Lessons from a randomized controlled trial

    Journal of Community Psychology

    (2004)
  • DeeganP.

    Recovery and empowerment for people with psychiatric disabilities

    Social Work Health Care

    (1997)
  • DeeganP.E.

    The lived experience of using psychiatric medication in the recovery process and a shared decision-making program to support it

    Psychiatric Rehabilitation Journal

    (2007)
  • DeeganP.E. et al.

    Shared decision making and medication management in the recovery process

    Psychiatric Services

    (2006)
  • Department of Health and Human Services

    Mental Health: A report of the Surgeon General

    (1999)
  • DeSistoM. et al.

    The Maine and Vermont three-decade studies of serious mental illness. II. Longitudinal course comparisons

    British Journal of Psychiatry

    (1995)
  • DeSistoM.J. et al.

    The Maine and Vermont three-decade studies of serious mental illness. I. Matched comparison of cross-sectional outcome

    British Journal of Psychiatry

    (1995)
  • DrakeR.E. et al.

    Psychiatric rehabilitation

  • EdwardsJ. et al.

    Prolonged recovery in first-episode psychosis

    British Journal of Psychiatry (Suppl.)

    (1998)
  • EkstromS.R.

    A cacophony of theories: Contributions towards a story-based understanding of analytic treatments

    Journal of Analaytic Psychology

    (2002)
  • FeeneyT.J. et al.

    Context-sensitive behavioral supports for young children with TBI: Short-term effects and long-term outcome

    Journal of Head Trauma Rehabilitation

    (2003)
  • FisherD.

    A new vision of recovery: People can fully recovery from mental illness, it is not a life long process

    (2006)
  • FreseF.J. et al.

    Integrating evidence-based practices and the recovery model

    Psychiatric Services

    (2001)
  • GitlinM. et al.

    Clinical outcome following neuroleptic discontinuation in patients with remitted recent-onset schizophrenia

    American Journal of Psychiatry

    (2001)
  • GreenM.F.

    What are the functional consequences of cognitive deficits in schizophrenia?

    American Journal of Psychiatry

    (1996)
  • Cited by (267)

    • Recovery beyond clinical improvement - Recovery outcomes measured for people with bipolar disorder between 1980 and 2020

      2022, Journal of Affective Disorders
      Citation Excerpt :

      For instance, employment status was assessed as a potential influential factor in SFR by several studies, while in ORR studies, occupational status was an operational definition of recovery. Other reviews on the recovery concept in severe mental health problems also identified that the key barrier to studying recovery was the diversity in recovery concepts and definitions (Leonhardt et al., 2017; Silverstein and Bellack, 2008). Therefore, this categorisation was used as an attempt to organise the data coherently and reflect key differences in emphasis across studies.

    View all citing articles on Scopus
    View full text