Elsevier

Schizophrenia Research

Volume 131, Issues 1–3, September 2011, Pages 133-138
Schizophrenia Research

The relation between objective and subjective domains of recovery among persons with schizophrenia-related disorders

https://doi.org/10.1016/j.schres.2011.05.023Get rights and content

Abstract

In recent years, growing emphasis has been placed on the vision of recovery, which is broadly organized into two types: clinical objective versus personal subjective. The purpose of the present study was to investigate the relation between objective clinical recovery as defined by symptom severity and level of functioning, and subjective personal recovery as defined by quality of life, domains of personal confidence and hope, willingness to ask for help, reliance on others and no domination by symptoms. One hundred and fifty-nine persons diagnosed with schizophrenia or schizoaffective disorder completed measures of recovery, quality of life, perceived social support and emotional loneliness. Clinicians used the Modified Brief Psychiatric Rating Scale and the Global Assessment Functioning Scale to assess the severity of symptoms and level of functioning. Results revealed no direct correlation between total score of observer ratings of symptoms and total score of subjective self-report of being in recovery. The relationship between total score of symptoms and total score of subjective self-report of recovery was moderated by the age of onset. Magnitude of the self-report of subjective recovery was related to higher levels of reported social support and lower levels of reported loneliness. Finally, analyses suggested that the impact of social support and loneliness upon self-reported recovery was mediated by quality of life. Taken together, results are consistent with literature suggesting that clinical objective recovery is not synonymous with personal subjective recovery yet can be conceptualized as complementary.

Introduction

The introduction of the vision of recovery to mental health care has been inspiring and influential. It has drawn attention to the fact that many people with serious mental illness (SMI) can live personally meaningful lives as integral members of their communities, despite and beyond the limits of their psychiatric disorder. Even though recovery has been widely embraced by state and federal authorities in several countries (Slade, 2009), it is still an evolving concept, the definitions and dimensions of which require further development (Noordsy et al., 2002, Liberman and Kopelowicz, 2005, Roe et al., 2007). At present, definitions of recovery can be broadly organized into two types, which have been labeled as objective versus subjective (Lysaker et al., 2006) or clinical versus personal (Slade, 2009). The former refers to the more scientific–professional view of recovery as an outcome based on whether operationally defined criteria are met. The latter alludes to the more consumer-experience-based approach that views recovery as an ongoing process of identity change, including a broadening of self-concept (Silverstein and Bellack, 2008). Generally speaking, many in the scientific community view recovery as an outcome defined by emphasis on reduction of clinical symptoms (e.g., psychosis, negative symptoms, cognitive disorganization, depression and anxiety) and more commonly as improved everyday functioning (role and social functioning, self-care and independent living skills). A recently proposed consensus definition of “clinical remission” (Andreasen et al., 2005) has included definitions for remission of a set of specific clinical symptoms. Similar attempts have been made to develop a remission criterion for functional disability (Harvey and Bellack, 2009). Such attempts have focused on role functioning, which includes major social roles that involve some form of productive activity that are impaired by SMI. Although few would argue against the importance of defining and studying the intensity of symptoms and level of functioning, these efforts clearly fall short of representing a broader picture of what one would hope for in life. “Subjective” or “personal” recovery is about reclaiming autonomy and self-determination regardless of whether one does or does not clinically recover from the illness. In this respect, people with SMI can be “in recovery” depending on how they define what recovery means to them. Similarly, being “in recovery” refers to the process of pursuing one's personal hopes and aspirations, despite the person's presumed vulnerability to relapse. Thus, “being in recovery” (Davidson and Roe, 2007) does not necessarily require a cure, remission of one's psychiatric disorder, or a return to a pre-existing state of health. Instead, it involves changes in unique and deeply subjective domains of human experience. In this sense, recovery involves redefinition of one's illness as only one aspect of a multidimensional sense of self and connotes the process of trying to identify, choose and pursue personally meaningful aspirations (Roe and Davidson, 2005, Lysaker et al., 2010a).

Some have suggested that clinical and objective versus personal and subjective conceptualizations of recovery should be viewed as complementary rather than incompatible (Silverstein and Bellack, 2008). Each definition contributes to portraying and understanding key aspects of living with SMI, helps evaluate a person's progress along the multidimensional course of illness and recovery and guide the tailoring of individualized care. Although both of these forms of recovery offer a range of possible recovery elements, the relationship among these elements remains unclear (Slade and Hayward, 2007). Are these, for example, semi-autonomous phenomena, some of which can be achieved but not others, or is the achievement of some dependent upon the attainment of others? Several recent empirical studies have directed efforts toward identifying different aspects of recovery and investigating their relationship to one another. One such effort is that of Resnick et al. (2004), based on the analysis of data derived from a total sample of 1076 participants from two sources: the original PORT study and a VA extension of that study. Findings from this study revealed that the components of recovery are comprised of two distinct sets of phenomena, one which reflects the reduction of objective problems linked to illness and another which reflects changes in subjective experiences. The more objective set involves the absence of features of illness (e.g. symptoms), whereas the second, more subjective, category involves attitudes and life orientation (e.g. hopefulness). It is interesting to note that whereas symptom severity was inversely associated with a recovery orientation, symptom reduction was not always linked to personal recovery. For example, symptom severity was not related to hope. In another study (Clarke et al., 2009), the relationship between baseline levels of symptom distress and recovery constructs such as hope, self-confidence, sense of purpose and positive identity was mediated by goal attainment. Based on data collected from a sample of 161 persons with SMI, Lloyd et al. (2009) found that although the association between subjective and objective measures of recovery was greater than might be expected by chance, it was variable with respect to strength. On the other hand, Lysaker et al. (2006) reported that persons with more impoverished narratives of recovery appeared to experience higher levels of cognitive symptoms.

Andresen et al. (2010) compared three measures of consumer-defined recovery using four conventional clinical measures with a sample of 110 participants with a psychiatric disorder of at least six months duration. Although correlational analyses supported the convergent validity of the recovery measures, little relationship was found between consumer-defined recovery and the clinical measures, suggesting the latter measure to be a unique construct that is not comprehensively assessed by conventional clinical measures. Lysaker et al. (2010a) found that the quality of social connection among 103 adults with schizophrenia spectrum disorders was closely related to the richness of their personal narratives, even after controlling for symptoms and premorbid intellectual functioning. The authors suggest that, consistent with other studies, it is the deeply subjective aspects of recovery that enable meaningful integration within one's community. Finally, other studies have also suggested that changes in objective aspects of recovery are not synonymous with changes in subjective aspects or with one another (Drake et al., 2006, San et al., 2007, Leung et al., 2008). The review of studies on the relation between subjective aspects of personal recovery and more objective aspects of clinical recovery provide mixed findings, which together seem to provide some support for the notion that these domains are related but semi-independent.

To explore this issue further, the present study has sought to investigate the relation between objective clinical recovery as defined by symptom severity and level of functioning, and subjective personal recovery as defined by domains of personal confidence and hope, willingness to ask for help, reliance on others and no domination by symptoms. To study this issue while taking into consideration the experience of one's social environment we also assessed social support and loneliness.

Specifically, the study attempted to address four research questions:

  • 1)

    Is there a relationship between objective clinical recovery (observer ratings of symptom severity and level of functioning) and subjective personal recovery (self-report of recovery and quality of life)?

  • 2)

    Do demographic variables moderate the relation between objective clinical recovery (observer-rated symptom severity and level of functioning) and subjective personal recovery (self-report of recovery and subjective quality of life)?

  • 3)

    Is there a relationship between social support and loneliness and subjective personal recovery (self-report of recovery and subjective quality of life)?

  • 4)

    Does subjective quality of life mediate the relationship between social support and loneliness and self-report of recovery?

Section snippets

Research setting

The study was conducted at psychiatric rehabilitation residential centers in six large cities in Israel: Haifa, Tiberias, Tel Aviv, Jerusalem, Beer Sheba and Ashkelon. Approval for the study was obtained from a committee of representatives of the University of Haifa after reviewing the ethical implications of the research. Data were collected between April 2007 and December 2008.

Participants

One hundred and fifty-nine persons, whose age ranged from 19 to 66 years (M = 43.2, SD = 10.7) and were diagnosed with

Relationship between objective clinical recovery and subjective personal recovery

Correlations between objective clinical recovery (BPRS and GAF) and subjective personal recovery (RAS and QoL) were explored and are reported in Table 1. As can be seen in Table 1, there is no significant correlation between the total score of symptoms (BPRS Total) and the total score of recovery (RAS Total) and between functioning (GAF) and the total score of recovery (RAS Total). Analysis of the subscales revealed a significant negative correlation between mood (on the BPRS) and hope (on the

Discussion

Although the construct of recovery is receiving growing attention, the conceptualization of its components and the relationships between them remain unclear. With an eye to examining this larger issue, the purpose of the present study was to explore the relationships between objective and subjective aspects of recovery and between social support and loneliness and subjective elements of recovery. Results of this study did not reveal a relationship between the global symptom severity and global

Role of funding source

The study sponsors had no involvement in the study design, data collection, analysis or writing the manuscript.

Contributors

Roe and Lysaker were involved in literature searches. Mashiach-Eizenberg undertook the statistical analyses. Roe wrote the complete first draft and all authors subsequently made meaningful contributions to the writing. All authors contributed to and have approved the final manuscript.

Conflict of interest

All other authors declare that they have no conflicts of interest

Acknowledgements

The authors wish to thank Vered Baloush-Kleinman and Batya Leidner from the Ministry of Health for their help in carrying out this study and Shira Alfiah, Galit Greenshtein, Revital Ordan and Adi Weiner for their assistance with data collection.

References (37)

  • P.W. Corrigan et al.

    Social support and recovery in people with serious mental illnesses

    Community Ment. Health J.

    (2004)
  • N. Dangoor et al.

    Women with chronic physical disabilities: correlates of their long-term psychosocial adoption

    Int. J. Rehabil. Res.

    (1994)
  • L. Davidson et al.

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

    JMH

    (2007)
  • R.E. Drake et al.

    Ten year recovery outcomes for clients with co-occurring schizophrenia and substance use disorders

    Schizophr. Bull.

    (2006)
  • J. Endicott et al.

    The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance

    Arch. Gen. Psychiatry

    (1976)
  • P.D. Harvey et al.

    Toward a terminology for functional recovery in schizophrenia: is functional remission a viable concept?

    Schizophr. Bull.

    (2009)
  • J. Jaccard et al.

    Interaction Effects in Multiple Regression

    (1990)
  • Y. Kao et al.

    Effects of age of onset on clinical characteristics in schizophrenia spectrum disorders

    BMC Psychiatry

    (2010)
  • Cited by (173)

    View all citing articles on Scopus
    View full text