of the Recovery Process From Psychiatric Disabilities
LeRoy Spaniol, Ph.D. is a psychiatric rehabilitation consultant and
Consulting Editor of the Psychiatric Rehabilitation Journal, Boston University, Boston, MA.
Address: 159 Selden Hill Drive, West Hartford, CT 06107.
Nancy J. Wewiorski, PhD
Nancy J. Wewiorski, PhD is a Research Associate at the Mental Illness Research Education
and Clinical Center (MIRECC), Bedford VA Medical Center, Bedford, MA 01730
Citation:Spaniol & Wewiorski (2012). Phases of the Recovery Process From Psychiatric Disabilities International Journal of
Psychosocial Rehabilitation. Vol 17(1)
purpose of this paper is to describe the phases of recovery from psychiatric
disabilities and their implications for interventions. The
paper identifies the many variables at work in recovery, including phases that occur
over time, areas of development within which people change, developmental tasks
and processes, and turning points that represent important shifts within the
phases and within the developmental dimensions.
Key Words: psychiatric rehabilitation,
recovery, mental health
article describes recovery as a neurobiological, psychosocial,
spiritual, and developmental process. Through these complementary
perspectives, we can understand how people with psychiatric
disabilities change, and how positive or negative internal and external
factors influence these changes. These new perspectives of how people
are impacted by a wide variety of life situations and how they recover
(Davidson, Harding, & Spaniol, 2005 & 2006; Moller &
Zauszniewski, 2010; Spaniol, Wewiorski, Gagne, & Anthony, 2002) can
enhance the more traditional medical and symptom focus of many mental
The findings of recent research on people
who self-described themselves as recovered identifies the recovery
process as taking place in phases (Spaniol, Wewiorski, Dunn, &
Chamberlin, draft paper, 2011). This current perspective is consistent
with the authors’ previous five-year study of people who were in the
early phases of their recovery process (Spaniol et al., 2002). The
concept of phases is reinforced by these two studies, as well as by
some of the earliest research on recovery conducted by Davidson and
Strauss (1992); Harding et al., (1987); and Strauss, Hafez, Liberman,
and Harding, (1985). The phases tend to be overlapping and cyclical,
representing the general flow of the recovery process. As these
phases are described in the present article, they are integrated with
self-reports of the recovery process as reported by people with
psychiatric disabilities and by the large body of research literature
on recovery. The four phases described in this article are:
• Phase 1: Overwhelmed
• Phase 2: Struggling
• Phase 3: Living with
• Phase 4: Living beyond
article describes each phase of recovery. Personal quotes by
participants in our most recent study are followed by suggestions for
useful interventions that have been developed by the authors, based on
research literature and self-reports. Turning points in all the phases
represent important positive or negative shifts in attitudes and
behavior by people in recovery (Estroff, 1989; Davidson & Strauss,
1992; Rakfeldt & Strauss, 1989; Topor, Svensson, Borg, Bjerke,
& Kufas, 2000; Table 1). These turning points are influenced by a
variety of internal and external factors (Lucksted, 1997). People may
also remain in a particular phase without moving forward for a variety
of reasons, including inadequate medication or treatment, lack of
opportunities, negative attitudes of people in their lives, need for
time to integrate important experiences, and untreated substance abuse
or trauma experienced prior to or after the onset of the disability
(Kramer & Gagne, 1997; Onken, et al, 2007).
Phase 1: Overwhelmed
1 begins at the time of onset of people’s symptoms and can last for
many months or even years. During this phase daily life often
becomes a mental and physical struggle as people try to understand and
manage what is happening, yet feel confused, disconnected from
themselves and others, out of control, and powerless over their
lives. People also often lack self-confidence because they fear
becoming overwhelmed by internal or external experiences.
are four major turning points of this phase of the recovery
process. The first is the onset of the early stage, sometimes
called the prodromal stage, which can continue for many years before an
actual breakdown occurs (Cornblatt, Heinssen, Cannon, & Lencz,
2003). The second is the breakdown itself, when people finally become
overwhelmed by symptoms and the accumulated loss of functioning across
the developmental dimensions (described in Table 1). The third turning
point is the stabilization of symptoms. The fourth entails moving
beyond feeling overwhelmed and beginning to reclaim a sense of self and
successful functioning (Estroff, 1989; Davidson& Strauss, 1992;
Moller & Zauszniewski, 2010).
Early Phase (prodromal)
an intense struggle begins long before the formal diagnosis (Corcoran,
et al., 2003). This struggle may include any of the following
experiences: increasing distress, problems with school or work,
difficulties in relationships, lack of a direction in life, mood
swings, low self-esteem, loss of a sense of self, anxiety, substance
abuse, and a gradual decrease in people’s ability to manage their
lives. At some point, they may experience a shift toward positive
symptoms, such as hallucinations or delusions. Both the behavioral
disturbances and the psychiatric symptoms are often rationalized or
denied by people and those in their environments. However, these
distressing experiences continue to accumulate over time, becoming more
and more difficult to deal with. Confusion and disbelief often develop,
intensifying people’s levels of distress. The experience of the
prodromal phase, and subsequent breakdown, may leave emotional scars
and behavioral adaptations (Post Traumatic Stress Disorder and
interrupted development) that cannot be reduced directly by medication
alone. A 53-year-old white woman, with a diagnosis of depression which
began quite early in her life, stated:
... I think I always suffered
from depression... My mother... would talk about, once I was an
adult,... she would talk about how I would go DAYS as an infant without
eating anything, and she would call the doctor, and say “What should I
do?” And he’d say, “Oh, don’t worry. When she’s hungry
she’ll eat.” … So, I think there were signs that if, if today, you
know, a parent said, “My baby’s not eating, hasn’t been eating for
days...,” they would, you know, look more into that.
As people become overwhelmed by their symptoms, a serious breakdown or
downward shift in functioning occurs. They lose control of their
thoughts, actions, and feelings. If they do not seek help, it is often
forced upon them. Daily life becomes a mental and physical struggle.
People often feel confused, disconnected from themselves and others,
out of control, and powerless to control their lives. They lack
self-confidence and fear becoming overwhelmed by their emotions and
their experiences. They may become suicidal as they despair of healing
their pain and frustration. Established relationships with family and
others often become fragile or broken, heightened by the distress and
confusion everyone feels. New relationships can be difficult to
establish and are often transient. They are often unable to articulate
clear goals or they have goals that are not well anchored in reality.
Many people adopt the strategy of withdrawal in a desperate attempt to
survive. They are inevitably confronted with the reality that something
is happening or are forcibly hospitalized. For example, a 42-year-old
white man, who struggled alone with early manic symptoms and was
eventually hospitalized, stated:
it was in my second semester of my freshman year that I first became
seriously ill, and I, I, I went into a depression. It’s a long
story as to how the depression came about, but... uh, and then, um… I,
um, I became ill, and I stopped going to classes, and I was put on
academic suspension and I left (College), and I joined the Navy, and
then, then I became manic, and left the Navy and hitchhiked... went
AWOL from boot camp and hitchhiked to, um, Montreal from... from...
just off of Chicago. And then, uh, for... then I went back into
the Navy, and, um... I, um... took some LSD and I was hospitalized for
the first time, that was in ‘74. … All I knew was that I was falling
Stabilization. Stabilization through
medication and support takes time. The stabilization process can be
very emotional because people’s feelings about themselves often
fluctuate widely. Even when medication is working, people may
discontinue it four or five times over several years, relapsing
repeatedly. Accepting that what one is experiencing is overpowering and
extended is a difficult process. Self-blame, prejudice, and
discrimination are barriers to acceptance. They lead to disbelief or
even denial because it is hard to accept aspects of their lives that
they and others devalue. As the disability continues and the reality of
the experience begins to become real, acceptance becomes possible.
Acceptance involves people acknowledging and framing what is happening,
from their perspectives, in a way that helps them to move on with their
lives. Acceptance involves both emotional as well as cognitive aspects
of people’s experiences. For most, acceptance is not simply a matter of
making a decision. It involves resolving this decision on an emotional
level and acting on it over time.
Stabilization is not a
linear process. While people are becoming more stable they may become
more vulnerable to relapsing (McCrory et al., 1980). In general, this
vulnerability intensifies during a change process. A 34-year-old black
woman, with a diagnosis of schizophrenia and a long history of
struggling to stabilize her symptoms, stated:
I think I... I sat
down with the psychiatrist and talked with him and my social worker, at
separate times... about my wanting to get out, and my acknowledging
that I had a mental illness, and the only way out was to cooperate.
Again, I was hearing “cooperate.” And the medication was to help
me, and to try it out and see if it actually helped and see if it made
me feel better. And to try it out to see if... it showed any
improvement to the professionals. …And within a month’s time... within
a month’s time, everything had turned around for me. My, I had a
quick... uh, reaction, turnaround reaction, response to the
medication. Really quick [snaps fingers], like, within a month’s
time I was so... mentally and, um... mentally clear...
Moving Beyond the Overwhelmed Phase.
this turning point people develop confidence in their ability to act in
their own interest. They begin to develop a preliminary explanatory
framework for understanding their experience, often using medical or
psychosocial terms. Framing the experience helps people move on with
their lives (Spaniol, Wewiorski, Dunn, and Chamberlin, draft paper,
2011). They recognize the need for coping strategies to develop lives
that are satisfying and stable. At this stage, people often accept
medication, even when it does not completely manage their symptoms.
Some are unable to work, while others can work even when they are
highly symptomatic. The disability is still a very present and
persistent reality, so the fear of relapse or failure often remains
intense. People may not feel fully confident in managing their
disabilities or building lives for themselves. They may continue to
define themselves as patients and see the disability as controlling
their lives. They may even question whether a life is possible with
this disability. However, as people recover, their disabilities become
less important than other aspects of their lives. A 34-year-old white
man describes his experience of “moving beyond the overwhelmed phase”
when he states:
just couldn’t function, I couldn’t think right. Um, so at first,
I was in a very bad state. But as the weeks went by there,
I was put on Lithium, and it seemed to help a great deal. And by
the time I was discharged, I was feeling pretty much normal... um,
whatever normal means. So, I was functioning much better.
So... so then, um... I came back, I went back to school, and this time
I lived at home and that worked out better. I would take one or
two classes at a time …
Useful Interventions by Phase and by Developmental Dimension: Phase 1
foci of interventions for this phase include stabilization, education
for people with the disabilities and their families, conveying hope and
an expectation for recovery, building trust and confidence through
human connection and activities, treating co-occurring disorders such
as substance abuse or trauma, connecting people with their peers, and
helping them to become successfully established in the community (for
further evidence-based interventions see APA/CAPP task force on serious
mental illnesses and severe emotional disturbance practice grid, 2005).
• Provide rapid involvement in treatment and rehabilitation.
• Provide access to ongoing comprehensive, coordinated, and continuous treatment and rehabilitation.
Encourage adherence to treatment. Failure to take medication can hamper
short- and long-term stabilization (Liberman, Kopelowicz, Ventura,
& Gutkin, 2002).
treatment for co-occurring substance abuse, if present. People who use
drugs or alcohol have been found to be more symptomatic while
hospitalized, relapse more frequently, have poorer psychosocial
functioning, and poorer prognosis for recovery. Active abuse affects
more areas of life than just the psychiatric disability. It often leads
to the loss of important resources and supports for coping with the
psychiatric disability such as stable housing and supportive
relationships with family, friends, and providers. Effective management
of a dual disability requires integrated treatment, more resources from
the for¬mal service sector, a stronger informal support net¬work, and
greater resilience and stamina within the individual. Integrated
treatment of psychiatric disabilities and substance abuse has been
shown to be more successful than parallel systems of treatment.
Integrated treatment means treatment within the same facility,
cross-training of staff, rehabilitation interventions, and a long-term
commitment to people (Mueser, Drake, & Noordsy, 1998).
Provide treatment for co-occurring trauma, past or present. Many people
have experienced physical or emotional trauma either prior to or after
the onset of the illness. Untreated trauma is a major barrier to moving
on in one’s recovery (Spaniol, et al., 2002).
Provide or refer to family education. Early referrals to family
education should be considered by all mental health professionals.
Family education that includes the family member with the disability
shows reductions in relapse rates, symptom relief, improving the
well-being of the family member with a disability, and increasing
participation in vocational rehabilitation. Research also shows that
people with psychiatric disabilities who are involved in family
education have better social functioning and require less overall
medication (Dixon, McFarlane et al., 2001; Spaniol, 2010). The
Family-to-Family educational program of NAMI, for example, has been
highly successful in reducing family stress and increasing coping
capacity of family members without a disability (Dixon, Stewart, et
Provide ongoing support, acceptance, warmth, understanding,
encouragement, expectations for improvement, a sense of hope, and
abundant reinforcement for the gradual progress of recovery (Liberman
et al., 2003).
• Providers should
respond constantly and actively to the healthy aspects of people
Spaniol, Gagne, & Koehler, 1997).
Provide opportunities for expressive therapies and rehabilitation
interventions that focus on strengths and build self-esteem and
confidence. Encouraging the natural creative and healing process can
build hope and confidence (Malchiodi, 2012).
Encourage involvement with peers throughout treatment including during
the process of deciding on hospitalization, treatment, rehabilitation,
discharge planning, and rehabilitation in the community (Mead &
Copeland, 2000; Mead & Hilton, 2003). Peers who have experienced
recovery can instill hope in the possibility of recovery for those who
are just beginning their recovery process.
Phase 2: Struggling
phase is characterized by a continuing struggle with the disability,
prejudice, discrimination, and feelings of hopelessness and
loneliness,. However, these barriers may be balanced by treatment and
rehabilitation interventions along one or more of the developmental
dimensions, i.e., emotional, social, vocational, physical, cognitive,
and spiritual (Table 1). During this phase people may find themselves
spiraling up or down in their recovery. Spiraling means that as
successful experiences occur, more will likely occur. And, when
unsuccessful experiences occur, more unsuccessful experiences are
likely to occur. Thus, people often experience significant spurts of
growth or decline in functioning at various periods during this phase.
These shifts represent important turning points in their recovery.
At this phase, people have reached a point where they accept that what
is happening to them requires help. They frame what is happening in
various ways. The most common construct is to view their condition as
an illness that requires medication. Others may see it as a life force
or energy that requires modification. For some, the condition is
perceived as a spiritual crisis (Jacobson, 2001). It is important that
people frame their experiences in ways that help them to move on with
their lives. For example, a 34-year-old white man who decided,
after much struggle, to accept his need for medication, stated:
‘92, it was in the summer, in July when I was at the … hospital.
I wouldn’t take my medication for about, I think it was four or five
days, and finally, I started getting paranoid that the staff there
were... that were, they were out to get me, and so I had to do
something and I said, “Okay. Maybe I need this medication.”
So I tried, and I decided I would take it, and I... as soon as I took
it, I felt much better, I felt much more relaxed, um... it was, it was
like I finally realized that I needed medication. I was one of
those people that needed it. I don’t think EVERYONE needs it, but
I need it.Prejudice and Discrimination.
two socio-cultural factors, often described as stigma, make it
especially difficult for people to accept their disabilities. These
factors can come from within people with the disabilities as they begin
to accept what is happening, for example, people may feel uncomfortable
identifying with other people with psychiatric disabilities. Or, the
prejudice and discrimination may come from other people in their
environments who lack a sense of hopefulness and are unaware of the
possibilities of recovery. In addition, people with disabilities may
question their ability to rebuild their own lives, wondering “Can I
have a life with this disability?” Knowledgeable and caring
professionals, family members, and peers are important sources of
connections and hope at this phase of the process. For example, a
34-year-old white man struggling with his new identity, stated:
didn’t want to be with the people at the... peer support center, well,
that wasn’t in existence, but the mental health center people would
gather around there. I didn’t want to be with THOSE kind of
people. Little did I know that... they were just like me.
‘Cause I was prejudiced against them, which was amazing because, uh...
you know, that’s a form of pride. You know? That’s no
And, a 49-year-old white man with a long experience of coping with his disability in the community, stated:
discriminate against me, they’re prejudiced against me... they treat me
unhanded... uh, unjustly…Um... they patronize me. …These are the forms
of stigma that I see and experience. …And that are written about... in
the press. And, uh, and at times, especially when I’m feeling
low, I feel rather poignantly. …And, uh, sometimes it’ll take I don’t
know what before this lets up! And often, talking to people,
my... especially my peers, will reorient my morale to the point where
I’m thinking, “Well, I’m really not the scum that people think I am...”
Moving Back Into Life
people are cautious about starting new activities because they fear
losing their tenuous stability. They must develop sufficient confidence
to manage their symptoms and the complexities of living their lives.
Coping strategies can be useful for managing symptoms such as
confusion, hallucinations, depression, and anxiety. These strategies
include: activities such as taking medication as directed, connecting
with peers and providers, work, exercise, sleeping, talking to a
friend, or conversely, reducing activities, avoiding stress, or
changing medication. Medication can be very helpful, but usually it is
not sufficient for progressing beyond this phase. If people have
experienced trauma, either prior to the onset of the illness or during
its treatment, people will need to address this. Untreated trauma can
be a major barrier to recovery (Cusack, Frueh, & Brady, 2004).
Substance abuse and serious health conditions can also hinder recovery
(Hutchinson, Skrinar, & Cross, 1999; Mueser et al., 1998; Skrinar,
et al., 2005). Some people continue to struggle with distressing
side-effects of medication or experience acute symptoms that are not
fully relieved by medication. If they have not yet developed
confi¬dence in being able to manage their symptoms, prejudice and
discrimination, or the general stresses of building their lives, they
may avoid helpful actions because the fear of risk may outweigh
potential benefits. For example, a 49-year-old white woman, who was
struggling to maintain her achievements in her community, reported:
when I first started my job, I relapsed on, on drugs. And after a
couple of months, I crashed really bad and I told my board what was
going on, and they supported --- I went into the hospital for three
weeks --- they supported me on that, and then I had like a... I think a
month off, after that, and they supported me, they paid me, and
everything. .... because that’s part of this industry, you know, is
that you have to work with people who have issues like that. So
they were great. I mean, they stuck by me, and now they say
they’re glad they did. But, um... you know, again, that’s SO
important... to have people there, willing to work with you.
this phase many people begin to actively develop peer supports,
especially helpful relationships with other people who have a
psychiatric disability. Peer support, mentoring, and modeling can
be important factors in helping people to frame what is happening to
them, to remind them that they are not alone, and to develop coping
strategies. Peers can be effective in helping them to manage prejudice
and discrimination, develop friends and acquaintances, find meaningful
work and problem-solve the daily struggles of life. Connecting with
peers can also provide an opportunity to share with other people with
psychiatric disabilities what they have learned from their own
experiences (Chamberlin & Rogers, 1996). A 53-year-old white man,
who had received peer support and now worked in peer support, stated:
I found help in peer support. I’ve always found help in peers...
you know, other sick people. …We always rallied together, and I’d get
jokin’ around, and people’d be laughin’ and havin’ a good time.
You know? And we’d... sort of auspicious thing... always felt
comfortable with my peers.
Developing Meaningful Roles
people slowly develop meaningful and consistent roles in their lives.
Assuming typical societal roles enhances their self-esteem and
confidence and is very helpful for maintaining a sense of hope.
Opportunities to become involved in life help people build confidence
and competency. Lack of opportunity to assume a role presents a
significant barrier to moving on. For example, a 47-year-old white man
with a dual diagnosis, who was strongly motivated to work and proud of
his ability to care for his stepmother, stated:
worked six days a week, six hours a day in a restaurant, uh... took
care of this big house that had like five or six bedrooms in it, and a
formal dining room and library. Uh, did all the grocery shopping,
and uh, I think my step-mother and I sort of took care of each other.Accepting Responsibility
turning point occurs when people develop strength and confidence in
their ability to act in their own interest. They gradually become aware
that they can have an impact on their lives, accept responsibility for
their decisions and actions, and take charge of their lives. For
example, a 49-year-old white woman, who originally depended on the
mental health system to cure her, reported:
I remember saying, “WHAT???” (Chuckles) I’m like, “NO!
That’s your job. You have to fix me.” He said, “I’m
sorry.” He said, “I can’t do that.” And I was...
floored! I was just like, “What? I have to do
something?” And, that, again was another turning point when, you
know, I realized that... I had to do it, you know? And I had to
make the changes.
Useful Interventions by Phase and by Developmental Dimension: Phase 2
foci of interventions for this phase include some of the same
interventions as Phase 1, as well as additional actions. These
interventions include education for the people with disabilities and
their families concerning mental illnesses and coping skills, conveying
hope and an expectation for recovery, building trust and confidence
through human connection and activities, treating co-occurring
disorders such as substance abuse, trauma, or physical illnesses,
connecting with peers, acquiring skills to manage symptoms and to cope
with the many barriers to recovery, and building skills across the
various dimensions of recovery based on self-determined need (Table 1).
1: Turning Points: Developmental
Dimensions, Tasks, and Processes
Turning Points: Emotional
Dimension: Developmental Tasks and Processes
- Developing a sense of efficacy and taking charge
- Developing a sense of self and identity
- Developing hope
- Coping with the effects of physical or sexual trauma
- Accepting the illness or what is happening
- Developing confidence and self-esteem
- Dealing with prior trauma
- Developing active coping skills
- Developing meaningful, satisfying, and contributing roles
- Taking risks
- Finding a comfort zone
- Pride in accomplishments
- Having fun
- Realizing one is not alone in how one feels
Turning Points: Social Dimension:
Developmental Tasks and Processes
- Developing sustaining friendships
- Developing intimacy
- Contributing to others
- Developing family relationships
- Coping with prejudice and discrimination
- Coping with the system
- Developing peer relationships
- Developing relationships with providers
- Feeling a valued member of my community
Turning Points: Vocational
Dimension: Developmental Tasks and Processes
- Developing job skills
- Developing and actively completing educational goals
- Finding work
- Developing a career
- Making a career change
- Returning to a desired career
Turning Points: Physical
Dimension: Developmental Tasks and Processes
- Coping with the illness
- Developing physical health and fitness
- Coping with symptoms
- Developing a crises plan
- Developing stress management skills
- Managing substance use
- Coping with medications
- Finding the right combination of medications
- Healthy lifestyle
- Having the “things” of life
Turning Points: Cognitive
Dimension: Developmental Tasks and Processes
· Developing new beliefs and ways of thinking
- Challenging self-defeating thoughts
- Acquiring new knowledge
- Developing an explanatory framework
- Developing personal advocacy skills
- Weighing the benefits and costs
- Trying to understand what is happening
Turning Points: Spiritual
Dimension: Developmental Tasks and Processes
- Developing meaning and purpose
- Practicing within a religious faith
- Connecting with someone or some thing beyond oneself
• Provide assistance for setting personal goals and develop steps to achieve them.
• Provide opportunities for building confidence and self-esteem through development of meaningful roles.
• Provide opportunities for taking risks, developing advocacy skills, and having fun.
Provide ongoing support, acceptance, warmth, understanding,
encouragement, expectations for improvement, a sense of hope, and
abundant reinforcement of gradual progress.
Encourage choice as a personal value with opportunities to express it.
Choices empower people because choice gives them a sense of control
over their lives. However, meaningful choice without options,
resources, and support may not feel very real to people.
Professionals need to resist the urge to take over while providing
people with useful options.
continued outreach to people and their families, using a direct yet
empathic approach, self-disclosure, and encouragement of education
about the illness and its impact. Many studies have corroborated the
value of supportive therapy in reducing relapse and improving social
lives (Coursey, Keller, & Farrell, 1995; Ruocchio, 1989).
Encourage self-determination and assuming responsibility for one’s
life. Many people reach a turning point in their recovery where they
acknowledge that if they are going to recover, they are going to have
to make the effort to change (Caswell, 2003; Deegan, 1996).
Provide skills and opportunities for developing satisfying friendships
and intimacy, contributing to others, developing family relationships,
coping with prejudice and discrimination, and coping with the system.
Provide skills in areas of self-determined need. People with
psychiatric disabilities can learn skills despite their symptoms.
Learning skills increases rehabilitation outcome. A person’s level of
skills is actually a better predictor of rehabilitation outcome than
diagnostic variables (Anthony, Cohen, Farkas, & Gagne, 2001).
Refer to self-help opportunities. The active presence of other people
who have recovered is very motivating. There is much research
supporting the value of self-help across all disability groups
(Chamberlin & Rogers, 1996). Referral to self-help programs should
be a routine procedure in mental health facilities. Peers should also
be available at all points of the treatment and rehabilitation
process—from initial intake, to hospital stay, to discharge planning,
to treatment, and to rehabilitation in the community. Have qualified
people with psychiatric disabilities on staff at all levels of the
• Involve family members in
the treatment and rehabilitation process. There is much research
supporting family involvement as useful to recovery (Clark, 2001;
Bogart & Solomon, 1999; Mueser & Fox, 1998; Spaniol, Zipple,
& Lockwood, 1992).
Provide skills and opportunities for developing job skills, finding
work, maintaining work, developing a career, and continuing education.
People with psychiatric disabilities have been found to be working at
all levels of employment (Russinova, Wewiorski, Lyass, & Rogers,
Provide skills and opportunities for developing physical health and
fitness, coping with symptoms, developing a crises plan, developing
stress management skills, managing substances, dealing with trauma,
addressing physical illnesses, and coping with medications.
• Provide ongoing, long-term, integrated treatment of substance abuse and psychiatric disability.
Provide active involvement in wellness programs such as nutrition,
weight management, regular exercise, and good physical health care
(Hutchinson, et al., 1999; Skrinar et al., 2005).
Provide ongoing treatment of trauma related symptoms—trauma that has
occurred prior to or after onset of the mental illness. Untreated
trauma is a major barrier to recovery. Rosenberg et al. (2001) have
stated that “Exposure to trauma, particularly violent victimization, is
endemic among clients with severe mental illness.” A large percentage
of the most difficult to reach women have had a history of sexual or
physical abuse (Gearon, Kaltman, Brown, & Bellack, 2003). This is
also not uncommon among men.
Provide skills and opportunities that help people develop new beliefs
and ways of thinking, challenging self-defeating thoughts, acquiring
new knowledge, developing an explanatory framework, developing personal
advocacy skills, weighing the benefits and costs of actions, and
understanding what is happening.
Provide training in writing a relapse management plan, and advanced
directives. Also, the Wellness Action Recovery Plan (Copeland, 2002),
the Recovery Workbook (Spaniol, Koehler, & Hutchinson, 2009), and
other interventions (see APA/CAPP task force on serious mental
illnesses and severe emotional disturbance practice grid, 2002) have
been found to be very helpful.
Provide education in self-monitoring. Self-monitoring includes
side-effects and medication but also becoming an observer of one’s own
positive and negative thoughts and actions, e.g., recognizing them,
experiencing them without responding to negative thoughts and actions
(Siegel, 1999; 2010). When people become curious about the validity of
their perceptions and can observe them without acting on them, then,
they have more choices for responding to their perceptions (Podvoll,
1990). Having a friend or family member serve as an additional
monitor and “check step” can also be very helpful.
Provide skills and opportunities for developing explanatory framework,
e.g., medical, psychosocial, political, spiritual, or some combination,
and for developing meaning and purpose. While developing larger meaning
and purpose is helpful, people also need to identify their own personal
purpose in life. A personal purpose often involves activities or
relationships which make people feel useful and valued.
Phase 3: Living With
this phase of recovery people come to terms with their disabilities and
feel confident about managing them. While they may still feel limited
by their disabilities, they have found niche in their worlds. They
report a strong sense of self and a feeling of confidence in having
some control over their lives. They have learned that a satisfying life
is possible despite having a disability. People utilize effective
coping strategies to deal with their disabilities and assume a number
of meaningful roles. They experience more consistency and security in
the people, roles, and environments in their lives. Over time, people
tend to accumulate possessions such as housing items, clothing,
housing, and cars. This ownership helps them to feel like members of
society, builds their self-esteem, and increases their sense of being
part of their community. People who had been cut off or distant from
their families frequently reconnect with them during Phase 3. Although,
some may have previously cut off relationships with family because of
stress or disagreements, connection with family remains a very deep
longing, even when relationships have not gone well. In some instances
reconnection is not possible or possible only with some family members.
Finding a Niche. During this phase people come to accept their
disabilities, feel confident about managing them, and realize that
although some of their medications may reduce their symptoms, this does
not by itself create happiness or satisfaction with life. People accept
responsibility for developing their lives because they have gained a
deeper awareness of their abilities to control their lives. They
continue to grow across the developmental dimensions, although growth
along one or more dimensions may dominate their attention at any given
time. While many may still feel limited by their disabilities, they
have found a place in the world that feels appropriate to them. For
example, a 34-year-old white man with a diagnosis of paranoid
schizophrenia and a strong spiritual focus, stated:
a path. A spiritual path. You know? I feel like,
sometimes I feel like an urban monk. It’s like, you know, all of
life is a path, but... to have peace, to have peace -- that’s what it’s
brought me. It’s brought me peace.
Phase 3 most people in this phase are working at least part-time. The
role most frequently sought since early recovery is that of “worker.”
Work has a powerful meaning to people. Working builds self-esteem and
helps people to feel a part of their community. Other roles that are
valued include parent, friend, student, caretaker, spouse, homeowner,
and renter. The acquisition of these roles does not seem to be
especially influenced by level of symptoms, but by people’s ability to
manage their symptoms well enough to carry out their new roles
successfully. Active participation in various rolls in the community is
very predictive of positive recovery (Kaplan, Salzer, Brusilovskiy,
2012). For example, a 34-year-old white man with a diagnosis of
paranoid schizophrenia responded:
had my own business for three years, now, which has been... I didn’t
think it would last this long. You know, I work with
computers. I train people in software... with the software titles.
Having a Life
discover that having a satisfying life is possible. They learn to
utilize effective coping strategies consistently. They adopt meaningful
living, learning, and working roles. People become increasingly
self-confident as their experiences of the people, roles, and
environments in their lives become more consistent. Unlike Phases 1 and
2, in Phase 3 people’s disabilities interfere much less with their
ability to have satisfying and contributing lives. They feel connected
to self, to others, and to various living, learning, and working
environments in their communities. As a consequence, they attain a
sense of meaning and purpose. For example, a 49-year-old white woman
described the meaning of her experience of disability by stating:
know. But... how can I say this .... I feel very strongly
that one of the reasons that I have this illness -- and I’ve gone
through this -- is to help other people. You know? And I
consider myself very lucky to have gotten, you know, to where I am
because I think THIS is what I was meant to do.
Useful Interventions by Phase and by Developmental Dimension: Phase 3
foci of interventions for this phase include some of the same
interventions as Phase 1 and Phase 2, depending on a person’s need or
request. One important turning point occurs when people assume control
over their own treatment by using the mental health system and
medication as a resource in their recovery rather than feeling
dependent on them. Also, while people during Phase 2 will often accept
any job to build their confidence and self-esteem, during Phase 3 they
focus more on finding work that fits their unique skills and interest.
Provide ongoing support, acceptance, warmth, understanding,
encouragement, and abundant reinforcement for gradual progress.Phase 4: Living Beyond
• Encourage people to surround themselves with positive people and environments that support their growth.
• Continue building support and skills along the developmental dimensions.
this phase of recovery the disability is a much smaller part of
people’s experience and does not significantly interfere with their
having a satisfying and contributing life. They feel
well-connected to themselves; to others; to various living, learning,
and working environments, and to a sense of meaning and purpose in
Functioning well in multiple dimensions of life.
People have moved beyond struggling with building meaningful lives to
focusing on their present and plans for their future. They experience
significant growth along all the developmental dimensions. For example,
in describing their current lives, people talk about working, enjoying
friendships, and satisfying living arrangements. In general, their
lives appear to be well-balanced and stable (Spaniol, Wewiorski, Dunn
and Chamberlin, draft paper, 2011). For example, a 41-year-old black
man who struggled with both schizophrenia and substance abuse for many
years related with a sense of pride:
had difficult, some difficulties, and rose above, and rose above them
to be living in an adequate, normal life, is what I would say about
sense of empowerment often helps people feel in control of their lives.
People who feel empowered typically have a sense of responsibility,
active coping mechanisms, and an ability to set limits. They have good
self-esteem, a personal purpose and meaning, and enjoy contributing to
the lives of others. They also have the ability to solve daily problems
and stresses successfully. While they may depend on others at times,
they see themselves as capable of making important decisions by
themselves. For example, a 45-year-old black man with a diagnosis of
paranoid schizophrenia and alcoholism described the importance of
assuming responsibility for himself by stating:
I found out in recovery that I wasn’t unique, and MY difficulties could
be handled if I stopped doing a few things and alleviated some
problems, and... basically, was more responsible for myself than just
letting it be put off on somebody else..
Contributing to life
Phase 3 people typically want to share what they have learned from
their experiences. Some join self-help or peer-support programs. Some
may also want to be contributing members of their broader communities,
for example, by volunteering, becoming part of a religious belief,
taking academic classes, or joining a bowling league. A 49-year-old
white woman with a diagnosis of manic-depression who described her
interest in teaching others, by stating:
really, you know, I’m here for a reason. You know, and I have
plenty to share, and I have these gifts, and that’s very important to
share now, and you know, whatever the pain or the stigma is, or...
that’s just never gonna outweigh... you know...
to meet life’s challenges. People have a willingness to take risks
because they know they have the internal and external resources
required to meet them and to cope with the stresses they may encounter.
Resources described include confidence, effective medications, family,
friends, peers, a significant relationship, professionals, and
spirituality. Practical problem-solving skills have been
developed and are available. Relationships are often enjoyable and
enduring. People value others and work in various ways to improve,
support, and have fun with them. Although some continue to use
disability income as a financial resource, they are able to build a
satisfying life at the same time. They may remain vulnerable to
emotional stress but also retain the ability to continue developing
satisfying lives. A 33-year-old black woman with a diagnosis of
schizophrenia and a strong religious belief responded:
think so. I think it makes you stronger, 'cause you have that
foundation of belief in God, and a belief that you’re not alone, even
in the hardest of the times.
come to terms with their disabilities and feel confident about managing
them. The disability does not significantly interfere with their having
satisfying and contributing lives. People realize that they are
not defied by their disabilities because they have developed their own
unique strengths and limitations. They describe themselves in terms of
their personhood and not their illnesses. Those who remain connected to
the mental health system use it for their own advantage. A 49-year-old
white woman with a diagnosis of manic-depression described the
importance of being knowledgeable about her medications for her
you gotta learn about meds. I mean, I just think it’s very
important to learn as much as you can rather than just take their word
for it. Um, sometimes information is a BAD thing (chuckles)...
you know, ‘cause it confuses you, or you might not have good
information. But I think it’s important for people to educate
themselves about their illness. I am not one -- I hate
documenting, I hate journaling -- but I think it’s very valuable if
someone’s learning about their triggers and all that?Community integration
People now have roles, interests, activities, work, and long-term
relationships. Work has become an important aspect of their
self-esteem. Most have work they enjoy, and jobs that meet their skills
and interests. Many actively participate in community activities, such
as theaters, movies, parties, religion, and volunteer activities
(Kaplan, Salzer, Brusilovskiy, 2012). For some, their primary community
consists of other people with psychiatric disabilities. For
example, a 34-year-old white man with schizophrenia who was developing
a small business responded:
had my own business for three years, now, which has been... I didn’t
think it would last this long. You know, I work with computers. I train
people in software... with the software titles.
the experience of their mental illness. People accept and frame their
disability in a variety of ways that allow them to move on with their
lives. Most attribute it to a neurobiological disorder. Yet, some have
never adopted the identity of a "mental patient.” They perceive their
experience in other ways, such as one young man who could not identify
what had happened to him, but described "it" as now gone. Others
experience their disability as more psychosocially based. Some view it
as a spiritual experience or a natural transition in their lives. For
example a 59-year-old white woman with a diagnosis of schizophrenia,
who had a strong spiritual orientation, described her experience as:
what am I seeing it as? A chance for people WITH mental illness to
understand that they’re not too something or they’re not defective, or
they’re not lacking something, they’re shamans in disguise.
have goals, determination, resilience, and actively endeavor to create
their lives. They have a sense of inner strength and can recognize and
are confident about meeting their own needs. They are self-motivated
and want to contribute to society. Many people engage in personal or
political advocacy. A 49-year-old white woman, who felt very good about
her determination to survive and succeed, reported:
just... I’m happy that... that I stuck with it, and that I trusted
people, and I had faith, and it came out exactly the way I had
hoped. You know? But I also know that I’ve got enough
strength that, no matter how it turned out, I’d be... I’d survive
and hopefulness about the future fuel ambition and goals. People
describe a sense of potential and anticipate further opportunities for
progress in their lives. They report personal goals they believe they
can achieve with reasonable effort. They regularly associate with
people who care about them and give them hope. For example, a
33-year-old black woman with a diagnosis of paranoid schizophrenia,
whose life was steadily moving forward in a direction she chose,
making plans...in 2007; I'd like to be back in California. That's the
one goal that I made for myself. ...And between now and then, I plan to
get another job...which, very likely, may be just this one job at
Logan, and pay off my student loan....
Satisfaction with current life
report their current life as fulfilling and satisfying, recognizing
that they have found a niche in their communities. They describe using
effective coping strategies consistently and adopting successful
living, learning, and working roles that make their lives meaningful.
They also describe feeling more secure and becoming consistent in their
various roles and environments. They have aspirations and goals for the
future, and feel pride in their accomplishments. A 27-year-old white
man with a diagnosis of paranoid schizophrenia, who described his
happiness with his current place in life, responded:
all I can say is, I'm happy. And, uh.. You know. And I think I'm
actually trying to find a way that can help other people, um... through
my experiences, 'cause I really feel like, you know... they didn't give
us any hope, but somehow it just all worked out from somewhere...
Useful Interventions by Phase and by Developmental Dimension: Phase 4
this phase interventions are absent or minimal. People may want
continued monitoring of medication, involvement with a therapist, or
peer support groups. However, they are dealing successfully with the
ordinary problems of living a life. They are likely to be having fun.
involves growth across the developmental dimensions. This growth can be
represented by phases and turning points in the recovery process.
Understanding the developmental dimensions, phases, and turning points
of recovery can give hope to people with psychiatric disabilities,
their loved ones, and those who care about them.
W. A., Cohen, M., Farkas, M., & Gagne, C. (2001). Psychiatric
rehabilitation. Boston: Center for Psychiatric Rehabilitation, Boston
APA/CAPP task force on serious mental illness and
severe emotional disturbance practice grid. (2005). Washington, DC:
American Psychological Association.
Bogart, T., & Solomon,
P. (1999). Procedures to share treatment information among mental
health providers, consumers, and families. Psychiatric Services, 50,
Caswell, J. (2003). Coping with open doors. Psychiatric Rehabilitation Journal, 27(2), 191–197.
J., & Rogers, S. (1996). Self-help programs: A description of their
characteristics and their members. Psychiatric Rehabilitation Journal,
Clark, R. (2001). Family support and substance use
outcomes for persons with mental illness and substance use disorders.
Schizophrenia Bulletin, 27(l), 93–101.
Copeland, M. (2002). Wellness recovery action plan.
B. A., Heinssen, R. K., Cannon, T. D., & Lencz, T. (2003). Editors’
introduction: New frontiers in prodromal research. Schizophrenia
Bulletin, 29(4), 621–625. (Special issue on prodromal research).
C., Davidson, L., Sills-Shahar, R., Nickou, C., Malaspina, D., Miller,
T., McGlashan, T. (2003). A qualitative research study of the evolution
of symptoms in individuals identified as prodromal to psychosis.
Psychiatric Quarterly,74(4), 313–332.
Coursey, R. D., Keller,
A., B., & Farrell, E. W. (1995). Individual psychotherapy and
persons with serious mental illness. Schizophrenia Bulletin, 21(2),
Cusack, K. J., Frueh, B. C., & Brady, K. T. (2004).
Trauma history screening in a community mental health center.
Psychiatric Services, Feb. (55), 157–162.
Harding, C. M., & Spaniol, L. (2006). Recovery from severe mental
illnesses: Research evidence and implications for practice, Volume II.
Boston, MA: Center for Psychiatric Rehabilitation.
Harding, C. M. , & Spaniol, L. (2005). Recovery from severe mental
illnesses: Research evidence and implications for practice, Volume I.
Boston, MA: Center for Psychiatric Rehabilitation.
& Strauss, J.S. (1992). Sense of self in recovery from severe
mental illness. British Journal of Medical Psychology, 65, 131–145.
Deegan, P. (1996). Recovery as a journey of the heart. Psychiatric Rehabilitation Journal, 19(3), 91–97.
L., McFarlane, W. R., Lefley, H., Lucksted, A., Cohen, M., Falloon, I.,
Mueser, K., Miklowitz, D., Solomon, P., & Sondheimer, D. (2001).
Evidence-based practices for services to families of people with
psychiatric disabilities. Psychiatric Services, 52(July), 903–910.
L., Stewart, B., Burland, J., Delahanty, J., Lucksted, A., &
Hoffman, M. (2001). Pilot study of the effectiveness of the
Family to Family education program. Psychiatric Services, 52(7), 965–967
S. E. (1989). Self, identity, and subjective experiences of
schizophrenia: In search of the subject. Schizophrenia Bulletin, 15(2),
Gearon, J. S., Kaltman, S. I., Brown, C., &
Bellack, A. S. (2003). Traumatic life events and PTSD among women with
substance use disorders and schizophrenia. Psychiatric Services, April,
Harding, C. M., Brooks, G. W., Ashikaga, T.,
Strauss, J. S., & Breier, A. (1987). Review of the Vermont
longitudinal study of persons with severe mental illness, I:
Methodology, study sample, and overall status 32 years later. American
Journal of Psychiatry, 144, 718–726.
Hutchinson, D. S., Skrinar,
G. S., & Cross, C. (1999). The role of improved physical fitness in
rehabilitation and recovery. Psychiatric Rehabilitation Journal, 22(4),
Jacobson, N. (2001). Experiencing recovery: A dimensional
analysis of consumers’ recovery narratives. Psychiatric Rehabilitation
Journal, 24(3). 248–256.
Kaplan, K., Salzer, M. S., &
Brusilovskiy, E. (2012). Community participation as a predictor of
recovery-oriented outcomes among emerging and mature adults with mental
illnesses. Psychiatric Rehabilitation Journal, 35(3), 219–229.
P., & Gagne, C. Barriers to recovery/empowerment for people with
psychiatric disabilities. (1997). In L. Spaniol, C. Gagne, & M.
Koehler, The Psychological and Social Aspects of Psychiatric Disability
(467–476). Boston: Center for Psychiatric Rehabilitation, Boston
Liberman, R. P., Kopelowicz, A., Ventura, J., &
Gutkin, D. (2002). Operational criteria and factors related to
recovery from schizophrenia. International Review of Psychiatry 2002,
Lucksted, A. A. (1997). Empowerment and positive
turning points in the lives of people with serious mental illnesses.
University of Maryland, Department of Psychology, unpublished
Malchiodi, C. A. (2012). Expressive therapies. NY: Guilford.
Mead, S., & Hilton, D. (2003). Crisis and connection. Psychiatric Rehabilitation Journal, 27(1),
S., & Copeland, M. E. (2000). What recovery means to us. Consumer’s
perspectives. Community Health Journal, 2000, 36(3), 315–328.
D. J., Connolly, P. S., Hanson-Mayer, T. P., Sheridan Landolfi, J. M.,
Barone, F. C., Blood, A. H., & Gilson, A. B. (1980). The
rehabilitation crisis: The impact of growth. Journal of Applied
Rehabilitation Counseling, 11(3), 136–139.
Moller, M. D. &
Zauszniewski, J. A. (2010). Psychophenomenology of the postpsychotic
adjustment process. Archives of Psychiatric Nursing, 26(4), 253–268.
K. T., Drake, R. E., & Noordsy. D. L. (1998). Integrated mental
health and substance abuse treatment for severe psychiatric disorders.
Journal of Practice in Psychiatry and Behavioral Health, May 1988, 4,
Mueser, K. T, & Fox, L. (1998). Dual diagnosis:
How families can help. Journal of the California Alliance for the
Mentally Ill, 9, 53–55.
Onken, S. J., Ridgway, P.,
Ralph, R. O., & Cook, J. A. (2007). An analysis of the definitions
and elements of recovery: A review of the literature. Psychiatric
Rehabilitation Journal, 31(1), 9–22.
Podvoll, E. M. (1990). Recovering sanity. A comprehensive approach to understanding and treating psychosis. Boston: Shambala.
J., & Strauss, J. (1989). The low turning point: A control
mechanism in the course of mental disorder. The Journal of Nervous and
Mental Disorders, 177(1), 32–37.
Rosenberg, S. D., Mueser, K.
T., Friedman, M. J., Gorman, P. G., Drake, R., Vidaver, R. M., Torrey,
W. C., & Jankowski, M. K. (2001). Developing effective treatments
for posttraumatic disorders among people with severe mental illness.
Psychiatric Services, 52, 1453–1461.
Ruocchio, P. J. (1989). How psychotherapy can help the schizophrenic patient. Hospital and Community Psychiatry, 40, 180–190.
Z., Wewiorski, N., Lyass, A., Rogers, E. S. (2003). Correlates of
vocational recovery for persons with schizophrenia. International
Review of Psychiatry, 14(4), 303–311
Siegel, D. J. (2010). Mindsight. New York: Bantam Books.
D. J. (1999). The developing mind: How relationships and the brain
interact to shape who we are. New York: Guilford Press.
G. S., Huxley, N. A., Hutchinson, D. S., Menninger, E., & Glew, P.
(2005). The role of a fitness intervention on people with serious
psychiatric disabilities. Psychiatric Rehabilitation Journal, 29(2),
Spaniol, L. (2010). The pain and the possibility: The family recovery process. Community Mental Health Journal, 46(5), 482–485.
L., Wewiorski, N., Dunn, E, & Chamberlin, J. (draft, 2011).
Characteristics of people who self-report as more fully recovered. West
Hartford, Ct: email@example.com.
Spaniol, L., Wewiorski,
N., Cagne, C., & Anthony, W. (2002). The process of recovery from
schizophrenia. International Review of Psychiatry, 14, 327–336.
L., Gagne, C., & Koehler, M (1997). Psychological and social
aspects of psychiatric disability. Boston: Center for Psychiatric
Rehabilitation, Boston University.
Spaniol, L., Koehler, M.
& Hutchinson, D. (2009, Revised Edition). The recovery workbook.
Center for Psychiatric Rehabilitation. Boston, MA 02215.
L., Zipple, A. M., & Lockwood, D. (1992). The role of the
family in psychiatric rehabilitation. Schizophrenia Bulletin, 18(3),
Strauss, J. S., Hafez, H., Liberman, P. & Harding,
C. M. (1985). The course of psychiatric disorder, III: Longitudinal
principles. American Journal of Psychiatry, 142(3), 289–296.
A., Svensson, J., Borg, M., Bjerke, C., & Kufas, E. (2000).
Recovery from severe mental disorders: A study of turning points.
(Unpublished manuscript). Beckomberga Hospital, Sweden.