Skip to main content Accesibility Help


  • Access
  • Open access
  • Cited by 59
  • Cited by
    This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

    Galbusera, Laura Fellin, Lisa and Fuchs, Thomas 2019. Towards the recovery of a sense of self: An interpretative phenomenological analysis of patients’ experience of body-oriented psychotherapy for schizophrenia. Psychotherapy Research, Vol. 29, Issue. 2, p. 234.

    Bradstreet, Simon Dodd, Alyson and Jones, Steven 2018. Internalised stigma in mental health: An investigation of the role of attachment style. Psychiatry Research, Vol. 270, Issue. , p. 1001.

    Gola, Sueanne M. and Burton, Lorelle J. 2018. Social Capital and Enterprise in the Modern State. p. 239.

    Rochefort, David A. 2018. The Affordable Care Act and the Faltering Revolution in Behavioral Health Care. International Journal of Health Services, Vol. 48, Issue. 2, p. 223.

    Ramon, Shulamit 2018. The Place of Social Recovery in Mental Health and Related Services. International Journal of Environmental Research and Public Health, Vol. 15, Issue. 6, p. 1052.

    Wu, Harry Yi-Jui 2018. Six domains to develop critical medical humanities. The Clinical Teacher, Vol. 15, Issue. 2, p. 93.

    IsHak, Waguih William Bonifay, Wes Collison, Katherine Reid, Mark Youssef, Haidy Parisi, Thomas Cohen, Robert M. and Cai, Li 2017. The recovery index: A novel approach to measuring recovery and predicting remission in major depressive disorder. Journal of Affective Disorders, Vol. 208, Issue. , p. 369.

    Slemon, Allie Jenkins, Emily and Bungay, Vicky 2017. Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice. Nursing Inquiry, Vol. 24, Issue. 4, p. e12199.

    Alguera-Lara, Victoria Dowsey, Michelle M Ride, Jemimah Kinder, Skye and Castle, David 2017. Shared decision making in mental health: the importance for current clinical practice. Australasian Psychiatry, Vol. 25, Issue. 6, p. 578.

    Stuart, Simon Robertson Tansey, Louise and Quayle, Ethel 2017. What we talk about when we talk about recovery: a systematic review and best-fit framework synthesis of qualitative literature. Journal of Mental Health, Vol. 26, Issue. 3, p. 291.

    Samuelsen, Silje S. Moljord, Inger Elise Opheim and Eriksen, Lasse 2016. Re-establishing and preserving hope of recovery through user participation in patients with a severe mental disorder: the self-referral-to-inpatient-treatment project. Nursing Open, Vol. 3, Issue. 4, p. 222.

    Stratford, Anthony Brophy, Lisa Castle, David Harvey, Carol Robertson, Joanne Corlett, Philip Davidson, Larry and Everall, Ian 2016. Embedding a Recovery Orientation into Neuroscience Research: Involving People with a Lived Experience in Research Activity. Psychiatric Quarterly, Vol. 87, Issue. 1, p. 75.

    Phillips, Jeff 2016. Handbook of Recovery in Inpatient Psychiatry. p. 227.

    Davidson, Gavin Brophy, Lisa and Campbell, Jim 2016. Risk, Recovery and Capacity: Competing or Complementary Approaches to Mental Health Social Work. Australian Social Work, Vol. 69, Issue. 2, p. 158.

    Harrison, Amy Al-Khairulla, Hind and Kikoler, Maxim 2016. The feasibility, acceptability and possible benefit of a positive psychology intervention group in an adolescent inpatient eating disorder service. The Journal of Positive Psychology, Vol. 11, Issue. 5, p. 449.

    Whybrow, Dean New, Chris Coetzee, Rik and Bickerstaffe, Paul 2016. Meeting the healthcare needs of transgender people within the armed forces: putting UK military policy into practice. Journal of Clinical Nursing, Vol. 25, Issue. 23-24, p. 3743.

    O’Keeffe, D. Hickey, D. Lane, A. McCormack, M. Lawlor, E. Kinsella, A. Donoghue, O. and Clarke, M. 2016. Mental illness self-management: a randomised controlled trial of the Wellness Recovery Action Planning intervention for inpatients and outpatients with psychiatric illness. Irish Journal of Psychological Medicine, Vol. 33, Issue. 02, p. 81.

    Niebieszczanski, Rebecca J. Dent, Helen and McGowan, Amanda 2016. 'Your personality is the intervention': a grounded theory of mental health nurses’ beliefs about hope and experiences of fostering hope within a secure setting. The Journal of Forensic Psychiatry & Psychology, Vol. 27, Issue. 3, p. 419.

    Byrne, Louise Roper, Cath Happell, Brenda and Reid-Searl, Kerry 2016. The stigma of identifying as having a lived experience runs before me: challenges for lived experience roles. Journal of Mental Health, p. 1.

    Barnao, Mary Ward, Tony and Casey, Sharon 2015. Looking Beyond the Illness. Journal of Interpersonal Violence, Vol. 30, Issue. 6, p. 1025.



      • Send article to Kindle

        To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

        Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

        Find out more about the Kindle Personal Document Service.

        Does the scientific evidence support the recovery model?
        Available formats
        Send article to Dropbox

        To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

        Does the scientific evidence support the recovery model?
        Available formats
        Send article to Google Drive

        To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

        Does the scientific evidence support the recovery model?
        Available formats
Export citation


This editorial addresses the question of whether some of the basic tenets of the recovery model – optimism about outcome, the value of work, the importance of empowerment of patients and the utility of user-run programmes – are supported by the scientific research.


Declaration of interest


Recovery model

The recovery model is a social movement that is influencing mental health service development around the world. It refers to the subjective experience of optimism about outcome from psychosis, to a belief in the value of the empowerment of people with mental illness, and to a focus on services in which decisions about treatment are taken collaboratively with the user and which aim to find productive roles for people with mental illness. 13 Flowing from this model is a renewed interest in educating users about illness management, in tackling stigma and in the creation of service user-run services that offer advocacy, mentoring and peer support via such mechanisms as user-run drop-in centres. Collaborative models, like the psychosocial clubhouse and educational programmes that involve both professionals and clients as teachers, are seen as important elements of recovery-oriented services. 13

A social movement is a form of social action based on shared values and aspirations, and it is not necessarily founded upon scientific evidence. Do the research data, in fact, support optimism about outcome from serious mental illness, the value of work, the importance of empowerment and other tenets of the recovery model?

Recovery from schizophrenia

A large body of data, including several recent studies, suggest that optimism about outcome from schizophrenia is justified. A meta-analysis of over a hundred outcome studies in schizophrenia conducted in high-income countries throughout the 20th century 4 assessed whether individuals had achieved ‘social recovery’ (economic and residential independence and low social disruption) or ‘complete recovery’ (loss of psychotic symptoms and return to the pre-illness level of functioning). The analysis revealed a substantial rate of recovery from schizophrenia throughout the century – around 20% complete recovery and 40% social recovery (which includes those who achieved complete recovery). Recent support for this level of recovery comes from various sources. Lambert and colleagues 5 in Hamburg, Germany, found that 17% of nearly 400 patients with never previously treated schizophrenia achieved complete recovery after a 3-year follow-up. A Chicago-based 15-year prospective follow-up study of 64 people with schizophrenia, conducted by Harrow & Jobe, 6 found 19% to be in complete recovery. An 8-year follow-up of 67 individuals with non-affective psychosis in Dublin found 39% to be in social recovery. 7 These recent results are closely in line with the results of the 20th-century meta-analysis. 4 It emerges that one of the most robust findings about schizophrenia is that a substantial proportion of those who present with the illness will recover completely or with good functional capacity.

Another recent publication, the International Study of Schizophrenia, offers a comparison of outcome from schizophrenia in high-income and low- and middle-income countries. 8 The study pulls together data from several multinational studies of long-term outcome from schizophrenia-incidence cohorts from two World Health Organization (WHO) studies and two studies in Chennai and Hong Kong. Also included are data from prevalence cohorts in the WHO International Pilot Study of Schizophrenia and another study conducted in Beijing. The resulting analysis includes over 1000 individuals from 16 centres around the world followed up after 12–26 years. From this amalgam of studies, conducted in a variety of settings around the world and spanning the last quarter of the 20th century, we learn that the course and outcome of schizophrenia are superior in low- and middle-income countries. Five of the ten centres with the highest proportion of clients rated ‘recovered’ on the Bleuler symptom scale were in low- and middle-income countries. Kraepelin's view that a deteriorating course is a hallmark of the illness proves not to be true; heterogeneity of outcome, both in terms of symptoms and functioning, is the signature feature.

Work and outcome from schizophrenia

The belief that working helps people recover from psychosis is supported by macroeconomic and individual level data. At the macroeconomic level, outcome from schizophrenia worsens during economic downturns 4 and hospital admissions for working-age individuals with psychosis increase. 9 At an individual level, numerous controlled studies conducted since the early 1990s have identified improved non-vocational outcomes for individuals with serious mental illness who are working. Participation in an effective vocational programme or having paid employment is associated with reduced psychiatric hospital admissions, reduced healthcare costs and less intensive positive and negative symptoms of psychosis. Successful work programmes lead to increased quality of life, improved self-esteem, enhanced functioning, and an expanded social network. 3,10,11 These controlled studies of the non-vocational benefits of work only became feasible in the 1990s with the development of an effective vocational intervention for people with mental illness – supported employment. A series of randomised controlled trials, two meta-analyses 12,13 and a recent review 14 have demonstrated the effectiveness of this model in the USA. Recent studies have confirmed that this American model is also effective outside the USA. 11,15,16


A central tenet of the recovery model is that empowerment of the user is important in achieving good outcome in serious mental illness. To understand why this may be so, it is important to appreciate that people with mental illness may feel disempowered, not only as a result of involuntary confinement or paternalistic treatment, but also by their own acceptance of the stereotype of a person with mental illness. People who accept that they have mental illness may feel driven to conform to an image of incapacity and worthlessness, becoming more socially withdrawn and adopting a disabled role. As a result, their symptoms may persist and they may become dependent on treatment providers and others. Thus, insight into one's illness may be rewarded with poor outcome. 4

This view is supported by an early study of people with serious mental illness which found that those who accept that they are mentally ill and have a sense of mastery over their lives (an internal locus of control) have the best outcomes. However, those who accept the label of mental illness tend to have lower self-esteem and an external locus of control, and those who find the mental illness label to be most stigmatising have the weakest sense of mastery. Thus, internalised stigma undermines the possibility that insight will lead to good outcome. 17

Similarly, in a recent cluster analysis of 75 people with schizophrenia, Lysaker and colleagues 18 found that individuals who demonstrated high levels of insight and low levels of internalised stigma demonstrated the highest functioning, but those with high insight and high internalised stigma experienced the lowest levels of hope and self-esteem. The 15-year naturalistic follow-up study of people with schizophrenia by Harrow & Jobe, cited earlier, provides further evidence that empowerment is an aid to recovery. 6 The participants who were no longer taking antipsychotic medication, many of whom were in a sustained period of recovery, were more likely to have had an internal locus of control when evaluated 5–10 years earlier. Another recent study of over 100 people with schizophrenia, applying path analysis, demonstrated that an internalised sense of stigma is associated with avoidant coping (similar to an external locus of control), social avoidance and depression: these relationships were mediated by the effect of internalised stigma on hope and self-esteem. 19 In a similar study applying structural equation modelling to data gathered from 172 out-patients with schizophrenia, Vauth and colleagues 20 found that a large proportion of depression and decreased quality of life could be explained by eroded empowerment and that much of the decreased empowerment was explained by high levels of anticipatory stigma. The conclusion we may draw from this body of research is that the empowerment of people with mental illness and helping them reduce their internalised sense of stigma are as important as helping them find insight into their illnesses. Until now, however, more effort has been expended on the last than on the former two factors.

An important means of empowering patients is to involve them in decisions about their illness. A recent northern Italian study, however, indicates that psychiatrists (in an excellent service system) rate poorly in practising this approach; 21 psychiatrists in the Netherlands performed better. 22

Another route to empowerment is to offer patients peer support (via user-operated services), which benefits both the recipient of services, who is exposed to a positive role model, and the user provider of services, who gains confidence by being of assistance to others. Corrigan, 23 in a survey of over 1800 people with psychiatric disability, found that participation in peer support was significantly associated with enhanced outcome and recovery. Sells and colleagues 24 found that peer service providers were perceived by clients to be more validating but that they were able to achieve improved short-term outcomes when they found it necessary to challenge clients' attitudes and behaviours. Resnick & Rosenhan, 25 in a Veterans Affairs study, found that people with severe mental illness who participated in a vet-to-vet peer education and support programme scored significantly higher on measures of empowerment, functioning and well-being than an earlier cohort who were not exposed to the programme.


The recovery model refers both to subjective experiences of optimism, empowerment and interpersonal support, and to the creation of positive, recovery-oriented services. Optimism about outcome from schizophrenia is supported by the research data. One of the most robust findings in schizophrenia research is that a substantial proportion of those with the illness will recover completely and many more will regain good social functioning. Much recent research suggests that working helps people recover from schizophrenia and advances in vocational rehabilitation have made this more feasible. A growing body of research supports the concept that empowerment is an important component of the recovery process and that user-driven services and a focus on reducing internalised stigma are valuable in empowering the person with schizophrenia and improving the outcome from illness. Further controlled studies of empowerment-oriented interventions are required to demonstrate convincingly that a focus on this factor will yield better outcomes in psychosis.


1 Liberman, RP. Recovery from Disability: Manual of Psychiatric Rehabilitation. American Psychiatric Publishing, 2008.
2 Shepherd, G, Boardman, J, Slade, M. Making Recovery a Reality. Sainsbury Centre for Mental Health, 2008.
3 Leff, J, Warner, R. Social Inclusion of People with Mental Illness. Cambridge University Press, 2006.
4 Warner, R. Recovery from Schizophrenia: Psychiatry and Political Economy (3rd edn). Brunner-Routledge, 2004.
5 Lambert, M, Naber, D, Schacht, A, Wagner, T, Hundemer, HP, Karow, A, et al. Rates and predictors of remission and recovery during 3 years in 393 never-treated patients with schizophrenia. Acta Psychiatr Scand 2008; 118: 220–9.
6 Harrow, M, Jobe, TH. Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multi follow-up study. J Nerv Ment Dis 2007; 195: 406–14.
7 Crumlish, N, Whitty, P, Clarke, M, Browne, S, Kamali, M, Gervin, M, et al. Beyond the critical period: longitudinal study of 8-year outcome in first-episode non-affective psychosis. Br J Psychiatry 2009; 194: 1824.
8 Hopper, K, Harrison, G, Janca, A, Sartorius, N (eds). Recovery from Schizophrenia: An International Perspective. A Report of the WHO Collaborative Project, the International Study of Schizophrenia. Oxford University Press, 2007.
9 Brenner, MH. Mental Illness and the Economy. Harvard University Press, 1973.
10 Bond, GR, Resnick, SG, Drake, RE, Xie, H, McHugo, GJ, Bebout, RR. Does competitive employment improve non-vocational outcomes for people with severe mental illness? J Consult Clin Psychol 2001; 69: 489501.
11 Burns, T, Catty, J, Becker, T, Drake, RE, Fioritti, A, Knapp, M, et al. The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial. Lancet 2007; 370: 1146–52.
12 Crowther, RE, Marshall, M, Bond, GR, Huxley, P. Helping people with severe mental illness to obtain work: systematic review. BMJ 2001; 322: 204–8.
13 Twamley, EW, Jeste, DV, Lehman, AF. Vocational rehabilitation in schizophrenia and other psychotic disorders: a literature review and meta-analysis of randomized controlled trials. J Nerv Ment Dis 2003; 191: 515–23.
14 Bond, GR. An update on randomized controlled trials of evidence-based supported employment. Psychiatr Rehabil J 2008; 31: 280–90.
15 Killackey, E, Jackson, HJ, McGorry, PD. Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual. Br J Psychiatry 2008; 193: 114–20.
16 Latimer, EA, Lecomte, T, Becker, DR, Drake, RE, Duclos, I, Piat, M, et al. Generalisability of the individual placement and support model of supported employment: results of a Canadian randomised controlled trial. Br J Psychiatry 2006; 189: 6573.
17 Warner, R, Taylor, D, Powers, M, Hyman, J. Acceptance of the mental illness label by psychotic patients: effects on functioning. Am J Orthopsychiatry 1989; 59: 398409.
18 Lysaker, PH, Davis, LW, Warman, DM, Strasburger, A, Beattie, N. Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: associations across six months. Psychiatry Res 2007; 149: 8995.
19 Yanos, PT, Roe, D, Marus, K, Lysaker, PH. Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatr Serv 2008; 59: 1437–42.
20 Vauth, R, Kleim, B, Wirtz, M, Corrigan, PW. Self-efficacy and empowerment as outcomes of self-stigmatizing and coping in schizophrenia. Psychiatry Res 2007; 150: 7180.
21 Goss, C, Moretti, F, Mazzi, MA, Del Piccolo, L, Rimondini, M, Zimmermann, C. Involving patients in decisions during psychiatric consultations. Br J Psychiatry 2008; 193: 416–21.
22 Goossensen, A, Zijlstra, P, Koopmanschap, M. Measuring shared decision making processes in psychiatry: skills versus patient satisfaction. Patient Educ Couns 2007; 67: 50–6.
23 Corrigan, PW. Impact of consumer-operated services on empowerment and recovery of people with psychiatric disorders. Psychiatr Serv 2006; 57: 1493–6.
24 Sells, D, Black, R, Davidson, L, Rowe, M. Beyond generic support: incidence and impact of invalidation in peer services for clients with severe mental illness. Psychiatr Serv 2008; 59: 1322–7.
25 Resnick, SG, Rosenheck, RA. Integrating peer-provided services: a quasi-experimental study of recovery orientation, confidence and empowerment. Psychiatr Serv 2008; 59: 1307–14.