Identifying and describing the stages of psychological recovery
The focus of these research projects varied: Davidson and Strauss (1992) focused on the role of the sense of self in recovery; Baxter and Diehl (1998) were interested in the emotional stages of recovery; Pettie and Triolo (1999) used case studies to describe the relationship between the meaning of the illness and identity; Young and Ensing (1999) conducted structured interviews and focus groups to identify components of the recovery process; and Spaniol et al. (2002) conducted a longitudinal study to investigate the processes of recovery. Although there was no consensus on the exact delineation of the stages, a pattern emerged that provided a model for further empirical investigation. A brief description of the research and the findings of each of these studies follows.
Davidson and Strauss (1992) conducted a series of interviews over a two to three year period. Participants were 66 people who had been hospitalized with serious mental disorders, 25 of whom had a diagnosis of schizophrenia. Participants were interviewed at bi-monthly intervals for one year and then at yearly intervals.
Although the interview protocols were comprehensive, Davidson and Strauss focused their report on the theme of the sense of self in personal narratives.
Nearly all of these individuals described themes of redefining or rediscovering an agentic sense of self over the course of their illness. Davidson and Strauss presented four aspects of this process, which they described as related and overlapping. These four aspects were:
. Discovering the possibility of a more agentic sense of self. This involves the awareness of latent aspects of the self, either through the rediscovery of parts of the self which remain unaffected by the illness, or the discovery of previously unrealized parts of the self. It may involve acceptance of the illness as separate from the self, allowing an identity separate from the illness, or a reawakening after a period of passivity and withdrawal.
. Taking stock of one’s strengths and limitations. Once the person has gained renewed hope for a more active role in life, they need to determine whether they have the personal resources to pursue whatever goal they have in mind. This can be a cognitive appraisal of the individual’s abilities and limitations, or a more intuitive sense of what is right for the person. Taking stock can involve step-bystep accumulation of the skills required to achieve a goal. It may also involve changing the goal to fit the person.
. Putting aspects of the self into action. Having acquired the skills considered necessary, the person attempts to achieve their desired goal. If successful, the person’s strengths are affirmed, and his or her sense of self is enhanced.
The focus of these research projects varied: Davidson and Strauss (1992) focused on the role of the sense of self in recovery; Baxter and Diehl (1998) were interested in the emotional stages of recovery; Pettie and Triolo (1999) used case studies to describe the relationship between the meaning of the illness and identity; Young and Ensing (1999) conducted structured interviews and focus groups to identify components of the recovery process; and Spaniol et al. (2002) conducted a longitudinal study to investigate the processes of recovery. Although there was no consensus on the exact delineation of the stages, a pattern emerged that provided a model for further empirical investigation. A brief description of the research and the findings of each of these studies follows.
Davidson and Strauss (1992) conducted a series of interviews over a two to three year period. Participants were 66 people who had been hospitalized with serious mental disorders, 25 of whom had a diagnosis of schizophrenia. Participants were interviewed at bi-monthly intervals for one year and then at yearly intervals.
Although the interview protocols were comprehensive, Davidson and Strauss focused their report on the theme of the sense of self in personal narratives.
Nearly all of these individuals described themes of redefining or rediscovering an agentic sense of self over the course of their illness. Davidson and Strauss presented four aspects of this process, which they described as related and overlapping. These four aspects were:
. Discovering the possibility of a more agentic sense of self. This involves the awareness of latent aspects of the self, either through the rediscovery of parts of the self which remain unaffected by the illness, or the discovery of previously unrealized parts of the self. It may involve acceptance of the illness as separate from the self, allowing an identity separate from the illness, or a reawakening after a period of passivity and withdrawal.
. Taking stock of one’s strengths and limitations. Once the person has gained renewed hope for a more active role in life, they need to determine whether they have the personal resources to pursue whatever goal they have in mind. This can be a cognitive appraisal of the individual’s abilities and limitations, or a more intuitive sense of what is right for the person. Taking stock can involve step-bystep accumulation of the skills required to achieve a goal. It may also involve changing the goal to fit the person.
. Putting aspects of the self into action. Having acquired the skills considered necessary, the person attempts to achieve their desired goal. If successful, the person’s strengths are affirmed, and his or her sense of self is enhanced.
If unsuccessful, the person needs to reflect and integrate this into his or her sense of self. The important aspect of this process is that the goals must originate from the individual and the action must be taken by the individual, in order to establish a sense of agency, and the ability to take further steps.
. Appealing to the self. The enhanced sense of self separate from the illness can serve as a refuge from the effects of the illness such as stress and stigma. The agentic self can now be used as a resource in coping with the illness. There is a sense of a self that can be responsible for managing the illness and taking charge of one’s life. The self can now monitor, manage and compensate for the illness in a social context.
(Davidson and Strauss, 1992)
Davidson and Strauss (1992) stress that a person may not progress through these phases in an orderly fashion; they describe the four aspects as related, overlapping and possibly interactive. However, they appear to have a logical sequence as presented.
Baxter and Diehl (1998) developed a semi-structured interview, based on constructs in the recovery literature. Content analysis was conducted on the responses from 40 mental health consumers, and the emotional stages of recovery were identified. Baxter and Diehl’s model consists of three overarching psychological events, each of which are followed by a stage of recovery. These are:
. Crisis – followed by a stage of recuperation. The crisis may be psychosis, a suicide attempt, panic attack, manic episode or some other trauma accompanied by confusion. The Recuperation phase is a stage of dependence.
Emotions include denial, negative feelings about the self and others, despair and/or anger. The person in this stage needs safety, food, rest, care and probably medication.
. Decision – followed by a stage of rebuilding independence. The decision to get going
can occur from a few days to years after the crisis. This is followed by rebuilding the ability to take care of oneself and resume normal life roles. The person experiences successes and setbacks. Perseverance through this stage results in the development of a more integrated sense of self. During this stage, the person needs to be heard and accepted, needs to learn about mental illness, and develop recovery skills.
. Awakening – followed by building healthy interdependence. Awakening to a restructured personhood is followed by the stage of recovery and discovery involving rebuilding healthy interdependence. This stage is characterized by acceptance of self and others, confidence, helpfulness to others and anger at injustice. In this stage, the person needs a dream to strive for, good relationships, meaningful work, fun and may also advocate for self and others.
The three psychological events and emotional stages described by Baxter and Diehl (1998) are presented as ordinal in nature. Even so, the second stage involves times of success and setbacks, illustrating the sense in which consumers have described their recovery as non-linear.
Pettie and Triolo (1999) drew on the experiences of people with psychiatric disabilities to examine the effects of illness on identity. They used two case examples to illustrate the process of reconstructing identity, and the role of meaning in this process. They described two steps to the recovery process:
. Why me? This is a stage of identity confusion. The person struggles to reconcile his or her pre-illness identity with their new identity as a person with a mental illness. The person seeks the meaning of the illness. There are two main chosen meanings of the illness – illness as evolution, in which dealing with the illness results in personal growth; and illness personified, in which the illness is seen as a separate entity to the healthy self.
. What now? This is a stage of identity reconstruction. The person has found a meaning for the illness and moves on to the task of developing a new identity and positive sense of self. This may involve some changes to lifestyle and new values.
Pettie and Triolo (1999) concluded that the psychological response to illness is progressive; first the person must find an acceptable meaning for the illness, they can then use this meaning as a foundation on which to build a self which he or she can respect.
Young and Ensing (1999) used themes from a literature review and information from consumers and professionals to develop a protocol for individual interviews and focus groups to explore the meaning of recovery. Grounded Theory Analysis was used to analyse the data from 18 people, and three overarching phases of recovery, each involving a number of subcategories were described:
. Initiating recovery – overcoming ‘stuckness’. This phase involves: (i) acknowledging and accepting the illness; (ii) having the desire and motivation to change; and (iii) finding a source of hope or inspiration, such as role models, other people or spirituality.
. Middle phase – regaining what was lost and moving forward. This includes: (i) discovering and fostering self-empowerment, including taking control and responsibility for one’s life and developing empowering attitudes; (ii) learning and self re-redefinition, involving discovering new or lost parts of the self, insight of one’s relationship with the illness and insight about living in the world; (iii) returning to basic functioning, involving taking care of self, being active and connecting with others.
. Later phase – improving quality of life. This includes: (i) striving for an overall sense of well-being, involving self-esteem, feeling at peace, feeling ‘normal’, caring about things; and (ii) striving to reach new potentials of higher functioning, involving finding meaning and purpose in life, improving standard of living, increased independence, maintaining a positive focus and symptom reduction.
Within each of the subcategories of these three phases are a number of tasks, themes or subprocesses. Young and Ensing (1999) point out that although each person follows a unique path to recovery, the results of their study highlighted the commonalities amongst consumers’ experiences. Their labelling of the three main phases implies that they are conceptually sequential in nature.
Spaniol et al. (2002) conducted a longitudinal qualitative study. Participants were 12 people with schizophrenia who had previously been involved in a vocational skills programme. They were interviewed at four to eight-monthly intervals over four years. Themes and patterns were identified in the data and constructs were developed inductively. Three broad phases of recovery were identified from the interviews. A fourth phase, which was identified from the recovery literature, was not evident in the interviews:
. Overwhelmed by the disability. In this early phase, the person struggles with daily life. The person feels confused, out of control of his or her life, lacking in selfconfidence and lacking connection with others. The person may fear becoming verwhelmed and is unable to articulate his or her goals. . Struggling with the disability. In this stage the person formulates an explanation for his or her experiences, and accepts that they have a long-term problem. The person realizes the need to develop ways of coping with the illness, and managing symptoms. There is a fear of failure on new activities, and a focus on building strengths.
. Living with the disability. The person has accepted the disability and is confident in managing it. There is a stronger sense of self, and some control over life. The person has meaningful roles and realizes the possibility of a satisfying life within the limitations of the disability.
. Living beyond the disability (conceptualized from the literature). In this phase, the disability is a much smaller part of the person’s life, and does not interfere with having a satisfying and contributing life. The person feels well connected to self and others and has a sense of meaning and purpose to life.
Spaniol et al. (2002) described recovery as a developmental process. They found that while some participants made steady fast or slow progress, others fluctuated. Sometimes periods of progress were followed by plateau periods of consolidation and integration.
. Appealing to the self. The enhanced sense of self separate from the illness can serve as a refuge from the effects of the illness such as stress and stigma. The agentic self can now be used as a resource in coping with the illness. There is a sense of a self that can be responsible for managing the illness and taking charge of one’s life. The self can now monitor, manage and compensate for the illness in a social context.
(Davidson and Strauss, 1992)
Davidson and Strauss (1992) stress that a person may not progress through these phases in an orderly fashion; they describe the four aspects as related, overlapping and possibly interactive. However, they appear to have a logical sequence as presented.
Baxter and Diehl (1998) developed a semi-structured interview, based on constructs in the recovery literature. Content analysis was conducted on the responses from 40 mental health consumers, and the emotional stages of recovery were identified. Baxter and Diehl’s model consists of three overarching psychological events, each of which are followed by a stage of recovery. These are:
. Crisis – followed by a stage of recuperation. The crisis may be psychosis, a suicide attempt, panic attack, manic episode or some other trauma accompanied by confusion. The Recuperation phase is a stage of dependence.
Emotions include denial, negative feelings about the self and others, despair and/or anger. The person in this stage needs safety, food, rest, care and probably medication.
. Decision – followed by a stage of rebuilding independence. The decision to get going
can occur from a few days to years after the crisis. This is followed by rebuilding the ability to take care of oneself and resume normal life roles. The person experiences successes and setbacks. Perseverance through this stage results in the development of a more integrated sense of self. During this stage, the person needs to be heard and accepted, needs to learn about mental illness, and develop recovery skills.
. Awakening – followed by building healthy interdependence. Awakening to a restructured personhood is followed by the stage of recovery and discovery involving rebuilding healthy interdependence. This stage is characterized by acceptance of self and others, confidence, helpfulness to others and anger at injustice. In this stage, the person needs a dream to strive for, good relationships, meaningful work, fun and may also advocate for self and others.
The three psychological events and emotional stages described by Baxter and Diehl (1998) are presented as ordinal in nature. Even so, the second stage involves times of success and setbacks, illustrating the sense in which consumers have described their recovery as non-linear.
Pettie and Triolo (1999) drew on the experiences of people with psychiatric disabilities to examine the effects of illness on identity. They used two case examples to illustrate the process of reconstructing identity, and the role of meaning in this process. They described two steps to the recovery process:
. Why me? This is a stage of identity confusion. The person struggles to reconcile his or her pre-illness identity with their new identity as a person with a mental illness. The person seeks the meaning of the illness. There are two main chosen meanings of the illness – illness as evolution, in which dealing with the illness results in personal growth; and illness personified, in which the illness is seen as a separate entity to the healthy self.
. What now? This is a stage of identity reconstruction. The person has found a meaning for the illness and moves on to the task of developing a new identity and positive sense of self. This may involve some changes to lifestyle and new values.
Pettie and Triolo (1999) concluded that the psychological response to illness is progressive; first the person must find an acceptable meaning for the illness, they can then use this meaning as a foundation on which to build a self which he or she can respect.
Young and Ensing (1999) used themes from a literature review and information from consumers and professionals to develop a protocol for individual interviews and focus groups to explore the meaning of recovery. Grounded Theory Analysis was used to analyse the data from 18 people, and three overarching phases of recovery, each involving a number of subcategories were described:
. Initiating recovery – overcoming ‘stuckness’. This phase involves: (i) acknowledging and accepting the illness; (ii) having the desire and motivation to change; and (iii) finding a source of hope or inspiration, such as role models, other people or spirituality.
. Middle phase – regaining what was lost and moving forward. This includes: (i) discovering and fostering self-empowerment, including taking control and responsibility for one’s life and developing empowering attitudes; (ii) learning and self re-redefinition, involving discovering new or lost parts of the self, insight of one’s relationship with the illness and insight about living in the world; (iii) returning to basic functioning, involving taking care of self, being active and connecting with others.
. Later phase – improving quality of life. This includes: (i) striving for an overall sense of well-being, involving self-esteem, feeling at peace, feeling ‘normal’, caring about things; and (ii) striving to reach new potentials of higher functioning, involving finding meaning and purpose in life, improving standard of living, increased independence, maintaining a positive focus and symptom reduction.
Within each of the subcategories of these three phases are a number of tasks, themes or subprocesses. Young and Ensing (1999) point out that although each person follows a unique path to recovery, the results of their study highlighted the commonalities amongst consumers’ experiences. Their labelling of the three main phases implies that they are conceptually sequential in nature.
Spaniol et al. (2002) conducted a longitudinal qualitative study. Participants were 12 people with schizophrenia who had previously been involved in a vocational skills programme. They were interviewed at four to eight-monthly intervals over four years. Themes and patterns were identified in the data and constructs were developed inductively. Three broad phases of recovery were identified from the interviews. A fourth phase, which was identified from the recovery literature, was not evident in the interviews:
. Overwhelmed by the disability. In this early phase, the person struggles with daily life. The person feels confused, out of control of his or her life, lacking in selfconfidence and lacking connection with others. The person may fear becoming verwhelmed and is unable to articulate his or her goals. . Struggling with the disability. In this stage the person formulates an explanation for his or her experiences, and accepts that they have a long-term problem. The person realizes the need to develop ways of coping with the illness, and managing symptoms. There is a fear of failure on new activities, and a focus on building strengths.
. Living with the disability. The person has accepted the disability and is confident in managing it. There is a stronger sense of self, and some control over life. The person has meaningful roles and realizes the possibility of a satisfying life within the limitations of the disability.
. Living beyond the disability (conceptualized from the literature). In this phase, the disability is a much smaller part of the person’s life, and does not interfere with having a satisfying and contributing life. The person feels well connected to self and others and has a sense of meaning and purpose to life.
Spaniol et al. (2002) described recovery as a developmental process. They found that while some participants made steady fast or slow progress, others fluctuated. Sometimes periods of progress were followed by plateau periods of consolidation and integration.
