Psychiatric Rehabilitation Journal

2013, Vol. 36, No. 2, 80 85

2013 American Psychological Association

1095-158X/13/$12.00 DOI: 10.1037/h0094975

Recovery of People With Psychiatric Disabilities Living in the Community

and Associated Factors
Yen-Ching Chang

Tamar Heller and Susan Pickett

I-Shou University

University of Illinois at Chicago

Ming-De Chen
Kaohsiung Medical University
Objective: Consumer-oriented recovery has been discussed for more than two decades in the mental
health field. Although there some qualitative recovery studies have shown important findings, few
quantitative studies of this concept currently exist. This study examined the relationship between
recovery and associated socialenvironmental and individual factors. Method: A total of 159 people
with psychiatric disabilities receiving services from a large community mental health agency participated
in the study. Participants completed a self-report survey that assessed individual recovery status, social
support, perceived recovery-oriented service quality, psychiatric symptoms, and demographics. One
hundred twenty-four surveys were analyzed. Hierarchical multiple regression analysis was conducted to
examine the relationship between recovery and associated factors. Results: Social support and perceived
recovery-oriented service quality had significant positive relationships with recovery; psychiatric symptoms had a significant negative relationship with recovery. The final regression model accounted for 58%
of the variance in recovery, F(9, 114) 17.72, p .001. Conclusion and Implications for Practice:
Socialenvironmental factors play an important role in peoples recovery, even after taking into account
psychiatric symptoms. Namely, people with psychiatric disabilities can pursue recovery with symptoms
as long as they receive appropriate support and services. Mental health professionals should provide
services adhering to recovery principles in order to help their clients achieve personal recovery.
Keywords: recovery, psychiatric disability, recovery-oriented care, social support

ery components include hope, empowerment, taking personal responsibility, self-redefinition, and participating in meaningful activities (Davidson, OConnell, Tondora, Lawless, & Evans, 2005;
Ridgway, 2001; Young & Ensing, 1999). This consumer-oriented
recovery concept has been regarded as a guiding vision of the
future of mental health services (Anthony, 1993). More and more
agencies provide recovery-oriented services.
Social support and mental health services, which belong to
socialenvironmental factors, have been discussed in much of the
recovery literature, and are regarded as important facilitators of the
recovery process (Jacobson & Greenley, 2001; Spaniol, Wewiorski, Gagne, & Anthony, 2002). Recovery advocates believe that,
with appropriate support and services, people with psychiatric
disabilities can experience a better recovery process and improve
their quality of life (Davidson, OConnell, Tondora, Styron, &
Kangas, 2006; Spaniol et al., 2002).
Furthermore, advocates have also stated that people with psychiatric disabilities can pursue recovery even though symptoms
exist (Anthony, 1993; Davidson et al., 2005). Psychiatric symptoms, which have commonly been regarded as individual problems, are simply viewed as one attribute of psychiatric disabilities
in the consumer-oriented recovery perspective. Although some
studies have found an inverse relationship between psychiatric
symptoms and recovery (Brown, Rempfer, & Hamera, 2008;
Resnick, Rosenheck, & Lehman, 2004), these advocates believe
that symptoms do not necessarily prevent recovery. While people

Consumer-oriented recovery principles were used as the conceptual framework for this study. Unlike the traditional scientific
view on recovery, which focuses on cure and symptom reduction,
this consumer-oriented recovery model was developed by people
with psychiatric disabilities and emphasizes personal goals and
potential (Bellack, 2006; Young & Ensing, 1999). It endeavors to
improve the lives of people with psychiatric disabilities and to
redesign service delivery methods. Under this concept, people with
psychiatric disabilities are treated as independent individuals
rather than as dependent patients; mental health professionals are
helpers rather than controllers. Common consumer-oriented recov-

This article was published Online First May 6, 2013.

Yen-Ching Chang, PhD, OT, Department of Healthcare Administration
and Department of Occupational Therapy, I-Shou University, Kaohsiung
City, Taiwan; Tamar Heller, PhD, Department of Disability and Human
Development, University of Illinois at Chicago; Susan Pickett, PhD, Department of Psychiatry, University of Illinois at Chicago; Ming-De Chen,
PhD, OT, Department of Occupational Therapy, Kaohsiung Medical University, Kaohsiung City, Taiwan.
Supported by the Provosts Award of University of Illinois at Chicago.
Correspondence concerning this article should be addressed to YenChing Chang, PhD, OT, Department of Healthcare Administration and
Department of Occupational Therapy, I-Shou University, 8 Yida Road,
Yanchao District, Kaohsiung City 82445, Taiwan. E-mail: ychang@
isu.edu.tw
80

RECOVERY OF PEOPLE WITH PSYCHIATRIC DISABILITIES

with physical disabilities are not expected to regain their mobility

in order to live successfully in the community, similarly, people
with psychiatric disabilities are not expected to eliminate their
symptoms in order to pursue their recovery (Davidson et al., 2006;
Davidson et al., 2005).
Many studies have examined factors related to traditional scientific definition of recovery, but few studies have investigated
factors associated with consumer-oriented recovery (Resnick et al.,
2004). Some qualitative recovery studies have found common
recovery components and statements (Ridgway, 2001; Smith,
2000; Spaniol et al., 2002). However, these results have been
limited by small sample sizes (i.e., n 20). The above statements
supported by advocates have not been examined by quantitative
studies with a large sample size.
Therefore, this study aimed to investigate the relationship between recovery and socialenvironmental and individual factors
(i.e., social support, perceived recovery-oriented service quality,
and psychiatric symptoms) through a self-report survey. We used
hierarchical multiple regression to examine whether socialenvironmental factors have a significant relationship with recovery
after taking into account psychiatric symptoms, and controlling for
demographic characteristics (i.e., age, illness length, sex, race, and
education). Although few consumer-oriented recovery studies
have discussed the influence of demographic characteristics, it is
possible that these factors impact consumer-oriented recovery. For
example, people of different ages tend to have various personal
goals, and may exhibit different recovery perspectives. Sex difference may also influence recovery expectations. Because demographic factors were not the focus of this study, they were controlled to examine accurately the relationship between recovery
and associated factors.

Method
Participants and Data Collection
Study participants were recruited from a large community mental health agency located in metropolitan Chicago, Illinois. The
agency provides a wide range of services, including case management, housing, vocational rehabilitation, and social skills training,
to people with psychiatric disabilities, regardless of their diagnosis
on the Diagnostic and Statistical Manual of Mental Disorders.
Because the inpatient population is relatively unstable and the
consumer-oriented recovery model may be inapplicable (Frese,
Stanley, Kress, & Vogel-Scibilia, 2001), only the community
sample was considered for inclusion in this study.
Study participants had to meet the following inclusion criteria:
having a diagnosis of mental illness, being age 18 years or older,
living in the community, receiving services from the study site
(i.e., the collaborating agency), and being able to fill out the study
survey independently. People who were actively symptomatic or
could not understand the survey content were not enrolled.
With assistance of program staff, the first author convened
meetings in several community programs of the agency and explained the studys purpose and procedures to potential participants. During these recruitment meetings, program staff helped to
identify individuals who were actively symptomatic or had limited
literacy. These individuals were not allowed to complete surveys
and were excluded from the study. After informed consent was

81

obtained, participants completed the self-report survey. They received a $5 gift card as a reimbursement for their time and
participation. This study was approved by the institutional review
boards of the University of Illinois at Chicago and the study site.
Data collection occurred from June 2010 through August 2010.
A total of 159 participants filled out the survey. After removing
35 surveys with significant missing data (i.e., the individual answered 70% of scale items; n 32) and inattentive response
sets (i.e., the individual responded to the whole survey with a
specific answer or a pattern; n 3), 124 surveys were included in
the regression analysis. A summary of characteristics of both
analyzed and excluded participants is shown in Table 1. Except for
race and ethnicity, there were no significant differences between
the analyzed sample and the excluded sample. Sixty-seven percent
of participants in the analyzed sample were men. Most participants
were single (73%). Nearly equal percentages of Blacks (40%) and
Whites (42%) completed surveys. Regarding education level, 53%
of participants had a high school degree or lower while 47% of
participants reported some college or higher. Most participants
were unemployed or not in the workforce (83%). The majority of
participants (71%) lived in a private residence or household. Four
diagnoses were reported most often: bipolar disorder (37%),
schizophrenia (24%), major depression (19%), and schizoaffective
disorder (15%). The average age of the analyzed sample was 47.10
years (range: 2068, Mdn 47.96) and the average illness length
was 23.82 years (range: 056, Mdn 24.41).

Instruments
The self-report survey included two parts. The first part collected personal information, such as age, sex, and education. The
second part included a battery of self-report scales. First, the
revised Mental Health Recovery Measure (MHRM-R) was used to
measure the individual recovery status. The original MHRM (Bullock, 2005; Young & Bullock, 2003) was developed according to
the recovery process model of Young and Ensing (1999). Chang,
Ailey, Heller, and Chen (in press) evaluated the MHRM using
Rasch analysis. Four items inappropriate for the measured recovery concept were removed from the scale to improve its validity.
The revised scale (MHRM-R) has 26 items and uses a 4-point
Likert scale, ranging from 0 (strongly disagree) to 3 (strongly
agree). It assesses comprehensive recovery content, including
overcoming stuckness, self-empowerment, learning and selfredefinition, basic functioning, overall well-being, new potentials,
and advocacy/enrichment. It showed high internal consistency in
the present study (Cronbachs alpha .95). Higher total scores
represent a better recovery status.
The 19-item Social Support Survey (SSS; Sherbourne & Stewart, 1991) measures five types of social support: emotional support, informational support, tangible support, positive social interaction, and affectionate support. Respondents were asked how
often the support is available if they need it. Response choices
include: none of the time, a little of the time, some of the time, most
of the time, and all of the time. The SSS showed high internal
consistency (Cronbachs alpha .97). Higher total scores represent greater receipt of social support.
The revised version of the Recovery Self-Assessment
(OConnell, Tondora, Croog, Evans, & Davidson, 2005) was used

CHANG, HELLER, PICKETT, AND CHEN

82
Table 1
Characteristics of Participants

Total samplea

Characteristics

Total sample values are n (%) or M (SD).

Excluded samplea
(n 35)

Test statistic

50 (31%)
109 (69%)

41 (33%)
83 (67%)

9 (26%)
26 (74%)

114 (72%)
13 (8%)
32 (20%)

91 (73%)
7 (6%)
26 (21%)

23 (66%)
6 (17%)
6 (17%)

70 (45%)
56 (36%)
29 (19%)

49 (40%)
52 (42%)
23 (19%)

21 (68%)
4 (13%)
6 (19%)

86 (55%)
71 (45%)

66 (53%)
58 (47%)

20 (61%)
13 (39%)

25 (16%)
129 (84%)

21 (17%)
102 (83%)

4 (13%)
27 (87%)

110 (71%)
40 (26%)
5 (3%)

87 (71%)
32 (26%)
4 (3%)

23 (72%)
8 (25%)
1 (3%)

61 (40%)
27 (20%)
54 (36%)
9 (6%)
47.04 (11.12)
24.07 (12.18)
b

47 (38%)
23 (19%)
46 (37%)
7 (6%)
47.10 (10.81)
23.82 (12.17)

14 (50%)
4 (14%)
8 (29%)
2 (7%)
46.77 (12.73)
27.93 (12.41)

df

0.68

2 4.84

2 10.17

2 0.57

2 0.32

2 0.02

2 1.61

t 0.14
t 0.92

148
130

Sex
Female
Male
Marital status
Single
Married/partner
Other
Race and ethnicityb
Black
White
Other
Education
High school or lower
College or higher
Employment
Work
Not work
Living environment
Private Residence/household
Supportive/transitional housing
Other
Diagnosis
Schizophrenia/schizoaffective disorder
Major depression
Bipolar disorder
Other
Age (years)
Illness length (years)
a

Analyzed samplea
(n 124)

p .006.

to assess perceived recovery-oriented service quality, defined in

this study as participants perceptions of the degree to which the
services they received follow recovery principles. This 32-item
scale assesses life goals, involvement, diversity of treatment options, choice, individually tailored services, and inviting space. It
uses a 5-point Likert scale, ranging from 1 (strongly disagree) to
5 (strongly agree), and includes an N/A (not applicable) option; it
showed high internal consistency in this study (Cronbachs
alpha .97). A higher item average indicates better perceived
recovery-oriented service quality.
Finally, psychiatric symptoms were measured by the Brief
Symptom Inventory (BSI; Derogatis & Melisaratos, 1983). The
BSI is a 53-item self-report symptom scale, and has nine
dimensions: somatization, obsessive compulsive, interpersonal
sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Respondents were asked to
rate the presence and severity of their symptoms in the past 7
days. Each item is rated on a 5-point scale, ranging from not at
all, a little bit, moderately, quite a bit, to extremely. The BSI
uses three global indices of distress to describe the individuals
condition, including the General Severity Index (GSI), the
Positive Symptom Distress Index, and the Positive Symptom
Total. This study used the GSI to represent the severity of
psychiatric symptoms. The BSI showed high internal consistency (Cronbachs alpha .98). Higher GSI scores indicate
greater symptom severity.

Data Analysis
In addition to descriptive statistics, which explored data distributions and characteristics of participants, a hierarchical multiple
regression analysis was conducted to further examine the relationship between recovery and associated factors. Demographics (i.e.,
age, illness length, sex, race, and education) were entered first
because they were regarded as control variables. Then, the psychiatric symptom variable (i.e., GSI score) was entered in the
second block, and socialenvironmental factors (i.e., social support and perceived recovery-oriented service quality), which were
the focus of this study, were entered in the third block. This
regression model explored whether the socialenvironmental factors had a significant relationship with the individual recovery
status, after taking into account other variables.
Missing data are common in self-report surveys, and they occurred in this study. Hawthorne and Elliott (2005) found that if at
least half the items of the scale are present, person mean substitution is a better choice because it has simpler computation and its
efficiency is as good as hot deck imputation. Hence, this study
used person mean imputation to handle missing data in each scale.
To maintain each survey scale, person mean imputation was used
if the individual answered 7099% of the scale items. As noted
above, the 32 surveys that had significant missing data (i.e.,
individuals failed to answer at least 70% of scale items) were
removed from the analysis. SPSS, Version 17.0, for Windows was
used for data analysis.

RECOVERY OF PEOPLE WITH PSYCHIATRIC DISABILITIES

83

an important support for people with psychiatric disabilities (Mead

& Copeland, 2000; Substance Abuse and Mental Health Services
Administration, 2005), adding peer support groups to existing
programs may facilitate peoples recovery process.
Perceived recovery-oriented service quality also showed a significant positive relationship with recovery. In this study, perceived recovery-oriented service quality was assessed by participants perceptions of whether the services they received were
recovery-oriented. Although recovery-oriented services have not
been clearly identified, they have several characteristics in common, including offering services that are consumer-centered and
that assist individuals in achieving personal goals (Anthony, 2000;
Noordsy et al., 2002). In addition, attitudinal changes in mental
health professionals are the key of recovery-oriented services.
Mental health professionals need to believe that recovery is possible, to respect clients decisions, and to provide different suggestions and options for people in different recovery levels (Anthony, 1993; Mead & Copeland, 2000; Smith, 2000). Although all
study participants were from the same mental health agency, they
may have had different experiences in receiving services due to
various attitudes or behaviors of designated service providers and
variability in the quality of the specific programs provided. The
research finding indirectly confirms the effectiveness of services
that are perceived as recovery oriented. Namely, people who
receive services that are viewed as adhering more to recovery
principles tend to have better recovery statuses. Therefore, it is
recommended that mental health professionals, administrators, and
policy-makers implement recovery principles in their work.
Greater adaptation of recovery-oriented services is likely to lead to
greater recovery among people with psychiatric disabilities.
Moreover, psychiatric symptoms had a significant negative relationship with recovery. Using the MHRM-R, this study had
findings similar to other previous studies, which assessed recovery
with recovery-related measures, such as hope and empowerment
scales (Brown et al., 2008; Resnick et al., 2004). The result is not
surprising. Symptom reduction has been the main focus of the
traditional scientific recovery paradigm and has been discussed by

Results
The hierarchical multiple regression results are presented in
Table 2. The first regression model was not significant,
F(6, 117) 0.63, p .71. After entering psychiatric symptoms,
the second model, F(7, 116) 4.85, p .001, accounted for 23%
of variance in recovery, and R2 change was significant, F(1,
116) 29.29, p .001. When socialenvironmental factors
were entered, the third model, F(9, 114) 17.72, p .001,
accounted for 58% of variance in recovery, and R2 change was
significant as well, F(2, 114) 48.79, p .001.
Social support, perceived recovery-oriented service quality, psychiatric symptoms, and illness length were significantly associated
with recovery status in the third model. Participants with greater
social support, better perceived recovery-oriented service quality,
lower symptom severity, and longer illness lengths tended to have
higher recovery scores.

Discussion
This study provided preliminary findings on the factors significantly associated with consumer-oriented recovery. Results of the
hierarchical multiple regression analysis found that social support,
perceived recovery-oriented service quality, psychiatric symptoms, and illness length had significant relationships with individual recovery status and accounted for a significant amount of
variance in recovery. These findings have several implications for
mental health providers who seek to enhance clients recovery.
Social support had the positive and highest standardized coefficient in the final regression model (see Table 2), which indicates
that it had the most impact in the model. People with more social
support tend to have a better recovery status. This result is similar
to that of previous research findings (Corrigan & Phelan, 2004;
Hendryx, Green, & Perrin, 2009; Pernice-Duca & Onaga, 2009),
and indicates the importance of social support for people in recovery. It also suggests that programs that facilitate connections
among people with psychiatric disabilities may enhance their
recovery. For example, because peer support has been regarded as

Table 2
The Hierarchical Regression Model for Recovery (n 124)
First model
Block
Block 1
Age
Illness length
Female
Black
White
High school or lower
Block 2
Psychiatric symptoms
Block 3
Social support
Perceived recovery-oriented service quality
R2a
F for change in R2
a

Unadjusted R2.
p .05. p .01.

p .001.

Second model

Third model

0.01
0.06
0.13
0.07
0.03
0.12

0.05
0.58
1.39
0.57
0.20
1.28

0.09
0.11
0.13
0.01
0.05
0.13

0.88
1.12
1.57
0.10
0.48
1.55

0.11
0.16
0.02
0.07
0.12
0.10

1.61
2.24
0.37
0.80
1.36
1.48

0.46

5.41

0.27

4.15

0.49
0.22

6.23
2.85

0.03
0.63

0.23
29.29

0.58
48.79

84

CHANG, HELLER, PICKETT, AND CHEN

numerous researchers and professionals (Harrow, Grossman, Jobe,

& Herbener, 2005; Whitehorn, Brown, Richard, Rui, & Kopala,
2002). However, besides investigating the effectiveness of certain
medication and interventions, researchers often overlook that it is
hard for people with psychiatric disabilities to cope with symptoms
without a good relationship with their service providers. In fact,
many of them have unpleasant experiences with mental health
professionals (Mead & Copeland, 2000). To better assist this
population, mental health professionals should learn how to work
with their clients and to help them find better medication or coping
strategies (Sowers & Quality Management Committee of the
American Association of Community Psychiatrists, 2005). Treating clients with respect and support is one of the critical principles
of recovery-oriented services (Jacobson & Greenley, 2001). When
people with psychiatric disabilities are treated appropriately, it is
more likely that they can handle their symptoms and make good
progress in their recovery.
In terms of demographics, only illness length showed a significant positive relationship with recovery in the final model. People
with longer illness lengths tend to have a better recovery status.
This result corresponds with previous qualitative findings (Deegan, 1988; Smith, 2000; Spaniol et al., 2002). Recovery does not
happen suddenly, and it is not an easy process. It takes time for
people with psychiatric disabilities to accept their illness, have a
desire to change their lives, and to seek help. People with psychiatric disabilities are likely to enter their recovery journey when
they get to know themselves and the illness better.
Overall, the research findings are encouraging. Socialenvironmental factors had a significant contribution to the final regression
model, which supports the assertion of recovery advocates: people
with psychiatric disabilities can experience a better recovery process and pursue better quality of life if they receive appropriate
support and services (Davidson et al., 2006; Spaniol et al., 2002).
Although psychiatric symptoms seem to have a negative impact
on peoples recovery, the positive relationships between recovery and social support as well as perceived recovery-oriented
service quality after taking into account psychiatric symptoms
were evident. This finding advances another advocates assertion: people with psychiatric disabilities can pursue recovery
even though symptoms persist (Anthony, 1993; Davidson et al.,
2005). Namely, even though they have symptoms, as long as the
socialenvironmental support is available, people with psychiatric disabilities can gradually improve their lives and pursue
their recovery.

Study Limitations
Several limitations exist in this study. First, cross-sectional data
cannot determine the causal direction of these relationships between recovery and associated factors. It is unclear whether the
improvement in social support, perceived recovery-oriented service quality, and psychiatric symptoms influences recovery and/or
whether the enhancement of recovery helps people with psychiatric disabilities to receive social support, better services, and control
their symptoms.
Second, several factors limit the generalization of this study.
The present study sample is limited to people with psychiatric
disabilities served in one recovery-oriented mental health agency.
The results may not reflect experiences of people without services

or receiving no recovery-oriented services. From their demographics and responses to the survey, this sample tended to represent a
population that had relatively stable conditions, both in regard to
symptoms and to the environmental support system. Moreover,
because participants were required to fill out the survey independently, the experiences of people with limited literacy were excluded from this study.
Finally, the use of a self-report survey also resulted in several
study limitations. Social desirability (Huang, Liao, & Chang,
1998) and missing data are common in self-report surveys. Participants might answer items in a way that matches social desirability and could skip items that they did not want to answer. These
may cause an overestimation or underestimation of the results.
However, the self-report survey is valuable for appropriately reflecting the respondents perceptions. This study used anonymous
participation to decrease the influence of social desirability, and
used person mean substitution to better estimate participants
responses, hence increasing the reliability of the findings.
Although the study participants may not represent all people
with psychiatric disabilities living in the community, our study
results contribute important quantitative evidence for the
consumer-oriented recovery concept. Future research should collect data from various mental health agencies and attempt to reach
people with limited services. People with low literacy may be
included by face-to-face interviews. A larger and diverse sample
can expand the generalization of study findings. Moreover, although these associated factors may truly have significant contributions, it will be beneficial to have more empirical studies to
reconfirm these results.

Conclusion and Implications for Practice

The study explored the relationship between recovery and socialenvironmental and individual factors. We found that social
support and perceived recovery-oriented service quality had significant positive relationships with recovery; psychiatric symptoms had a significant negative relationship with recovery. The
final regression model accounted for 58% of variance in recovery.
These findings support the statements of recovery advocates. Socialenvironmental factors do play an important role in peoples
recovery, even after taking into account psychiatric symptoms. It
indicates that people with psychiatric disabilities can pursue recovery with symptoms as long as they receive appropriate support
and services. In addition to symptom control, people with psychiatric disabilities who live in the community also need adequate
support and services to improve their lives and achieve their
personal goals.
The results of this study are useful for mental health service
designs and mental health policy-making. Mental health professionals can have more confidence to follow the consumeroriented recovery paradigm, and they are encouraged to adopt
and provide recovery-oriented services to help their clients
achieve personal recovery. These research results expand the
knowledge base of the consumer-oriented recovery concept, and
they are beneficial for further follow-up or randomized controlled
studies, which can provide stronger evidence to verify the relationship between recovery and associated factors.

RECOVERY OF PEOPLE WITH PSYCHIATRIC DISABILITIES

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