Personal recovery suits us all: A study in patients with non-affective psychosis, unaffected siblings and healthy controls

are hope, meaning, and rebuilding oneself. Here we aim to investigate whether factors associated with personal recovery in patients with non-affective psychosis, unaffected siblings and healthy controls are similar. We investigated the association between personal recovery and resilience, social support, socio-demographic and illness-related variables in 580 patients, 630 siblings, and 351 healthy controls who participated in the Genetic Risk and Outcome of Psychosis (GROUP) study. Bi-variate associations between personal recovery and individual variables were assessed and multiple linear regression analyses were performed to estimate the proportion of variance in personal recovery that could be accounted for by the predictors and to investigate which predictors independently added to the model. Positive self was significantly and independently associated with personal recovery in all three groups. Pro-active action taking also seems to be important. Social functioning significantly contributed to explained variance in patients and siblings. Regarding illness-related factors, depressive symptoms had impact on personal recovery in both patients and siblings, whereas positive symptoms only did in siblings. The findings imply that not only personal recovery itself, but also some associated factors are universally human and suit us all. This means that patients and non-patients share supportive factors of personal recovery which may help to reach mutual understanding. Recovery-oriented practices and mental health services might be more effective when focusing also on improving self-image, functional coping styles and generating social interaction, next to the reduction of affective symptoms.


Introduction
Recovery and subjective wellbeing of patients with schizophrenia spectrum disorders have increasingly become the focus of mental health services. The concept of recovery is complex and different types are defined (Best et al., 2020;Castelein et al., 2021;Macpherson et al., 2015). At least two main categories of recovery are distinguished: clinical and personal recovery (Slade et al., 2008). Clinical recovery is described as long-term reduction or resolution of symptomatology (Andreasen et al., 2005;Torgalsbøen, 2013). Personal recovery is defined as "a deeply personal, unique process of changing one 's attitudes, values, feelings, goals, skills and roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness" (Anthony, 1993). This definition emphasizes the ability to live a good life irrespective of ongoing symptoms and conceptualizes recovery as a unique process with essential themes including hope, meaning, and rebuilding oneself (Bellack, 2006;Law and Morrison, 2014). Effective ways to facilitate personal recovery have become a central topic in mental health care (Liberman et al., 2002).
The word recovery suggests that it is about returning to a pre-existing state. Following the definition of Anthony mentioned above, the word 'to overcome' might suit better what this process is about: not about a complete return, but about rebuilding and going on after an impactful life-event. Because this event does not necessarily have to be a mental disease, the process of recovery (or overcoming) might also be applicable to the general population and not only to patients. Anthony states: "Recovery transcends illness and the disability field itself. Recovery is a truly unifying human experience. Because all people (helpers included) experience the catastrophes of life (death of a loved one, divorce, the threat of severe physical illness, and disability), the challenge of recovery must be faced" (Anthony, 1993). The general applicability is also illustrated by the fact that personal recovery is closely related to concepts such as well-being (Chan et al., 2017) and quality of life (Eack and Newhill, 2007). In a systematic review five core recovery processes were identified: connectedness, hope and optimism about the future, identity, meaning in life and empowerment (CHIME) (Leamy et al., 2011). Law and Morrison interviewed individuals who had experienced psychotic symptoms and asked them to rate statements essential or important for their recovery. Particularly, environmental factors such as having a place to live or work, social support and having a good understanding of mental health problems were endorsed (Law and Morrison, 2014). Similarly, a review of qualitative studies found that patients with mental disorders reported contribution from others, participating in social activity and individual processes such as accepting and finding an identity or using coping strategies to contribute to their recovery (Salzmann-Erikson, 2013). Accordingly, a review of qualitative studies in patients with psychosis found similar themes, i.e. faith and spiritualty, social support, personal agency and hope, environmental resources and positive support from services (Wood and Alsawy, 2018). Which factors correlate with or influence personal recovery has been investigated in qualitative, as well as in quantitative research. In a metaanalysis concerning patients with psychotic disorders, only modest associations between clinical and personal recovery measures were found. Affective symptoms were found to have more impact on personal recovery than psychotic symptoms (Van Eck et al., 2018b). In line with these findings, a large prospective study of first episode patients did not find symptoms of psychosis to be a relevant predictor of personal recovery, but a primary affective disorder predicted lower recovery scores 20 years later (iHOPE study) (O'Keeffe et al., 2019). These results imply that exclusively aiming at reducing psychotic symptoms might not result in improved personal recovery (Van Eck et al., 2018a). Song et al. investigated associations between personal recovery and five groups of independent variables: sociodemographic variables, illness-related variables, resilience, formal support and informal support in a Taiwanese sample of patients with a severe mental illness (Song, 2017). Their findings revealed that resilience, family support and the extent of rehabilitation service use showed the strongest correlations with personal recovery.
To the best of our knowledge, research into the possible predictors of personal recovery has only been done in patients, not in healthy siblings of patients, nor in healthy controls. Assuming that personal recovery (in terms of overcoming a life event) is also relevant to non-patients, like Anthony (1993) stated, we expect that there are similar factors that influence personal recovery.
In the current study, we aim to investigate which individual and environmental factors influence personal recovery in patients with nonaffective psychosis, their unaffected siblings and healthy controls. If the same factors are applicable for patients and non-patients, this may imply that the road to recovery has universal components.
Based on the findings in the former study of Song, we expect to find good functioning (e.g. having work, being in a relationship, having friends) and individual factors of resilience (e.g. positive beliefs about self and others and functional coping strategies) to be positively associated with personal recovery across all groups (patients, siblings and controls) (Song, 2017). Based on our own previous research (Van Eck et al., 2018a;Van Eck et al., 2018b), we expect that illness-related factors have limited association with personal recovery. We anticipate that [subclinical] affective symptoms have more impact on personal recovery than [subclinical] psychotic symptoms in patients, siblings and healthy controls.

Methods
For this study, data from a naturalistic longitudinal cohort study, Genetic Risk and Outcome of Psychosis (GROUP), were used (Korver et al., 2012). GROUP participants were included by a consortium of four university psychiatric centers (Amsterdam, Groningen, Utrecht and Maastricht) and their affiliated mental health care institutions in the Netherlands and Belgium, covering >7.5 million inhabitants. Extensive assessment of genetic factors, environmental factors, (endo)phenotypes, and outcome variables were conducted.

Participants
Inclusion criteria were: aged 16 to 50 years; good command of the Dutch language; able and willing to give written informed consent. For patients an additional criterion was: a diagnosis of a non-affective psychotic disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria (APA, 2000). For healthy controls additional criteria were: no lifetime psychotic disorder and no first-degree family member with a lifetime psychotic disorder.
For detailed information regarding recruitment and procedure we refer to (Korver et al., 2012). For the current study, we only used crosssectional data assessed at 6-year follow-up (conducted between May 2011 and March 2014), because personal recovery, coping, core schemas and life events, were only measured at that time point.

Procedure
The assessments were administered by trained research assistants. If participants were unable to visit the institute, home assessments were being offered. The assessment of the questionnaires (containing different measurements) lasted on average four hours for patients and three hours for other participants. To account for fatigue effects, the four-hour assessment for patients was divided over two separate assessments of two hours each, within a week from each other. All participants provided informed consent and the GROUP study was approved by the Medical Ethical Committee (protocol number 04/003-O). Release 7.0 of the GROUP database was used for all analyses.

Personal recovery
Personal recovery was evaluated with the Dutch version of the 24item, self-report Recovery Assessment Scale (RAS) (Giffort et al., 1995; van der Krieke et al., 2019). Items are scored on a 5-point Likert scale (1; strongly disagree, 5; strongly agree). The scale comprises of 5 subscales of personal recovery (confidence and hope, willingness to ask for help, goal and success, reliance on others and the degree to which a person is dominated by symptoms). Items include a variety of statements regarding life goals and purpose, hope, symptoms, asking for help, and general outlook and attitudes. Examples are: 'I believe that I am capable of reaching my current personal goals' and 'I can handle what happens in my life'. Higher scores are an indication for greater recovery. Testretest reliability for this instrument is satisfactory, as is evidence for internal consistency. Studies have also shown good evidence of validity (Corrigan et al., 2004;Salzer and Brusilovskiy, 2014). In accordance with earlier studies, we use the mean total RAS score for analyses in patients, but excluded the last subscale 'no domination by symptoms' from the total score for the sibling and control group as this domain was considered inapplicable to these groups (van der Krieke et al., 2019).
We selected the following sociodemographic variables, illness variables, resilience and support variables from GROUP.

Sociodemographic and illness variables
Several sociodemographic factors have been collected: age, gender, ethnicity, relationship and employment status, and IQ.
The following illness variables were assessed: diagnosis, illness duration, age of onset, hospitalization in the past 3 years, current antipsychotic and cannabis use, and symptoms. The Dutch version of the Community Assessment of Psychic Experiences (CAPE) (Stefanis et al., 2002) was used to assess self-reported (subclinical) positive, negative and depressive symptoms in patients, siblings and healthy controls. Participants answered 42 items on a 4-point Likert scale (0; never to 3; nearly always) regarding the presence of symptoms and related experienced distress over the last 3 years. The present study used frequency scores as outcome measures. The CAPE proved to be reliable, valid and stable in the general population (Konings et al., 2006).

Resilience
Resilience was assessed by measuring coping strategies, using the Dutch questionnaire Utrechtse Coping Lijst (UCL) (Schreurs et al., 1993). This instrument consists of 47 self-report items on a 4-point Likert scale (0; hardly or never, 3; very often). The items are divided over seven subscales, three of which can be regarded as functional coping mechanisms; these three were included in the current study. The subscales active approach, seeking social support, and reassuring/ calming thoughts contain functional coping mechanisms. Studies have shown that the reliability and validity are satisfactory (Sanderman and Ormel, 1992).
Furthermore, schemas were measured with the Brief Core Schema Scales (BCSS) (Fowler et al., 2006). Twenty-four items concerning attitudes towards oneself and others were assessed both dichotomous (0; no, 1; yes) and on a 4-point Likert scale (1; slightly agree, 4; totally agree) if the participant agreed with the statement. This instrument measures schemas of participants on four subscales: positive self, positive other, negative self, and negative other. In the current study, positive self and positive other were included. According to Fowler et al. (2006), the BCSS has good psychometric properties.

Social functioning
Social functioning was assessed using the self-report Social Functioning Scale (SFS) (Birchwood et al., 1990) over the past three months, in seven subscales, namely withdrawal, interpersonal behavior/interaction, prosocial activities, recreation, independence-performance, independence-competence, and employment/occupation. The current study included two of the subscales, namely amount of interpersonal interaction and prosocial activities. Higher scores on the subscales indicate better social functioning. Studies show that the SFS is reliable, valid, sensitive and responsive to change (Birchwood et al., 1990).

Satisfaction with care
Only in patients, satisfaction with care was measured with the validated Dutch translation of the short version of the self-report Client Satisfaction Questionnaire (CSQ-8) (Attkisson and Zwick, 1982;de Brey, 1983). The questionnaire consists of eight items scored on a scale from 1 (poor) to 4 (excellent) resulting in a total score between 8 and 32.

Life events
The number of "positive and negative life events" was measured using the interview for recent life events (IRLE; (Paykel, 1997)) This questionnaire states 61 positive and negative life events in which the participant can indicate whether or not he or she has experienced it in the three years before the interview. Examples of life events are: death of a loved one, physical disease, marriage, birth of a child. For every experienced event the impact was rated on a 5-point Likert scale varying from 1 (very unpleasant) to 5 (very pleasant). Sum scores for negative events with an appraisal as (very) unpleasant (i.e. a score of 1 or 2) and positive events with an appraisal as (very) pleasant (i.e. a score of 4 or 5) were calculated.

Statistical analysis
Sociodemographic and outcome variables were compared between groups applying analysis of variance and chi-squared tests. To investigate which variables were individually associated with personal recovery, bi-variate associations between personal recovery and all individual variables were assessed across all groups using t-test, ANOVA or nonparametric correlations applying Bonferroni correction of α = 0.05/ 25 = 0.002 in the patient sample and α = 0.05/19 = 0.003 in siblings and healthy controls. Multiple linear regression analyses were then performed to estimate the proportion of variance in personal recovery that could be accounted for by relevant predictors and to investigate which predictors independently added to the model. Analyses were done per group separately to be able to compare findings between patients, siblings and healthy controls. Prior to analyses, assumptions of multivariate normality, homoscedasticity and no multicollinearity were investigated by q-q plots, scatterplots of the residuals and variance inflation factor, respectively. Data analysis was conducted with IBM SPSS Statistics 24.

Sample characteristics
For the current study, data on personal recovery was available from 580 patients, 630 siblings, and 351 healthy controls. Table 1 presents descriptive statistics of the variables included. Differences between patients, siblings and healthy controls were significant across all characteristics.

Associations between variables of interest and personal recovery in patients, siblings and healthy controls
Bi-variate associations are presented in Table 2. In all three groups, symptom dimensions, aspects of resilience (positive schemata and functional coping strategies), aspects of social functioning, as well as the experience of positive life events showed significant correlations with personal recovery. No other illness-related variables (e.g. antipsychotic use or illness duration) were significantly associated with personal recovery in the subsample of patients.

Multiple regression analyses
When investigating the assumption of the multiple linear regression analyses, q-q plots of standardized residuals showed no significant deviation from normality and scatterplots of residuals versus predicted values showed no clear pattern in the distribution implying homoscedasticity. Finally, no serious multicollinearity existed among the independent variables, with the highest variance inflation factor of 3.25 for depressive symptoms in siblings.
In some cases, data of independent variables were missing (see Table 2). To analyze the full, incomplete data set, maximum likelihood estimation was used in multiple regression analyses. Variables showing significant bi-variate associations with personal recovery were entered on bloc to the model.
Results in patients with psychotic disorders revealed a significant equation F = 22,368, p < .001, with an overall explained variance of 48.2 % (R = 0.695, SE 0.383). As shown in Table 3, depressive symptoms, positive self, social interaction and pro-social behavior were the four variables significantly associated with personal recovery in patients. Proactive coping and positive life events additionally contributed on a trend level.
In siblings, independent variables explained 37.5 % of the variance (R = 0.612, SE 0.367, F = 18.311, p < .001). Age, positive and depressive symptoms, positive self, positive others and social interaction were significantly associated with personal recovery. Pro-active action taking and pro-social behavior additionally contributed on a trend level (see Table 4).
Finally, in healthy controls independent variables explained 39.7 % of the variance in personal recovery (R = 0.630, SE 0.373, F = 11.979, p < .001). Positive self and pro-active action taking significantly contributed to the model (see Table 5).

Main findings
To the best of our knowledge, this is the first study investigating whether similar factors are associated with personal recovery in patients with non-affective psychosis, unaffected siblings and healthy controls. The schema of positive self was significantly and independently associated with personal recovery in all three groups. Pro-active action taking also seems to be important. Social functioning significantly contributed to explained variance of personal recovery in patients and siblings. Regarding illness-related factors, depressive symptoms were associated with personal recovery in both patients and siblings, whereas positive symptoms were only associated in siblings and not in patients.

Interpretation and comparison with existing literature
Because there is no existing literature on factors associated with personal recovery of siblings or controls, our findings can only be compared with studies in patients.
The link between resilience factors, specifically positive self-image Song reported that resilience, family support and symptom severity were associated with personal recovery (Song, 2017). Broyd et al. found that poorer coping was associated with reduced subjective well-being, which is closely related to personal recovery (Broyd et al., 2016). Roosenschoon et al. also showed that coping is a determinant of recovery and mentioned the relevance of improving coping skills (Roosenschoon et al., 2019). Our findings that social interaction and functioning is associated  with personal recovery is in line with previous research (Law and Morrison, 2014;Wood and Alsawy, 2018). It is known that patients with severe mental illness unfortunately often lose important social relationships and have difficulties in developing new relationships (Palumbo et al., 2015). Also, carers of people with psychosis experience a high rate of social isolation (Poon et al., 2017). This may explain that differences in social functioning in siblings are associated with personal recovery, as it is in patients. Furthermore, it is probable that most healthy controls have social contacts, which means that other factors, such as coping strategies, are more important in their personal recovery than social interaction. Regarding (sub)clinical symptoms in patients and siblings, the more prominent impact of affective symptoms (compared to positive or negative symptoms) on personal recovery, has also been shown in previous research (O'Keeffe et al., 2019;Van Eck et al., 2018a;Van Eck et al., 2018b). Affective symptoms are obviously linked to hope and optimism about the future, which are vital for achieving personal recovery (Landeen et al., 2000). A possible explanation of the impact of affective and positive symptoms on personal recovery in siblings is that they might perceive subclinical expressions as more alarming given the illness of their sibling.

Implications
Resilience factors as positive self-schema and pro-active coping strategies are robustly associated with personal recovery in patients, siblings and healthy controls. Irrespective of illness or vulnerability status, promoting positive schemas and coping strategies may result in better personal recovery. Changing a person's attitudes and adopting more adaptive schemas have already been shown to have a positive impact on mental strength and well-being: treatments to increase selfesteem and improve functional coping show effect, such as a 24-session group module in which participants work on the sense of security, identity, belonging, purpose and competence (Borras et al., 2009;Lecomte et al., 1999;Turkington and Siddle, 2000). Treating dysfunctional beliefs by cognitive behavioural therapy can contribute to better functioning in patients with psychosis (Grant et al., 2012;Staring et al., 2013).
Social interaction is associated with personal recovery in patients and siblings. Possibly, initiatives to support social interaction may lead to better personal recovery. In patients, promoting social interactions, for instance by peer support, individual placement and support (IPS), wellness recovery action planning, and recovery colleges could promote personal recovery (Castelein et al., 2015;Slade et al., 2014;Vogel et al., 2019). Future research might take a closer look at which particular components of social support are most important for personal recovery. One can imagine that reducing (self) stigma, promoting openness about illness and efforts to maintain existing social contacts can also help.
The fact that illness-related factors, especially in patients, show less predictive value for personal recovery, supports the statement of Anthony (1993) that personal recovery transcends illness. As found in earlier research, this suggests that focusing on illness-related factors might not be the key to personal recovery of patients (Van Eck et al., 2018b). Nevertheless, it is apparent that treating symptoms is important, especially affective symptoms, and to a lesser extent psychotic symptoms, but a strict focus on symptom reduction only might not result in improving personal recovery (Slade et al., 2014).

Strengths and limitations
Strengths of the current study include the relatively large sample size, the fact that not only patients, but also siblings and healthy controls participated, and the multitude of self-report measures that highlights the individual experience of recovery.
We need to acknowledge some limitations. Personal recovery was measured only at one time point, even though it has been defined by many as an active process with different recovery stages (Anthony, 1993;Law and Morrison, 2014;Leamy et al., 2011). Having a score of how recovery may change over time is therefore more useful than a single measurement. The current cross-sectional design also precludes causal inferences. From our findings it is unclear whether promoting coping styles and social interaction or treatment of affective symptoms facilitate personal recovery, or the other way around. Longitudinal evaluation is needed to clarify causal interrelations.
Furthermore, in the current research the Social Functioning Scale (SFS) (Birchwood et al., 1990) was used to determine to what extent participants are undertaking social and occupational activities. To gain more insight in which specific factors of support contribute most, one could use more detailed measures for informal support (i.e. for family, partner and religious support) and formal support (professional relationship and support and work support) (Russinova et al., 2006).
Although we were able to explain a substantial part of the variation in personal recovery of patients, siblings and healthy controls, still 50-60 % of the variance of personal recovery is not explained by the factors mentioned above. More research is needed to find which other factors are important.

Conclusion
The current study was the first to examine whether similar factors are associated with personal recovery in patients with non-affective psychosis, their unaffected siblings and healthy controls. Resilience (positive self-image, schemas and functional coping strategies) was found to be the strongest predictor of personal recovery in all three groups and good social functioning and interaction had added value in patients and siblings. Psychotic symptoms, like in previous studies, were found to be less important for personal recovery. Also, in line with earlier research, affective symptoms have more impact on recovery than psychotic symptoms.
These findings support the statement of (Anthony, 1993) that not only personal recovery itself, but also associated factors are universally human and suit us all. This is good news, since it means that patients and non-patients share possibly supportive factors of personal recovery which may help to reach mutual understanding. Own experiences of rebuilding and going on after a life event of professionals, experts by experience and family members and friends may help them to better understand the need of patients. Besides that, if the factors found in the current study prove to be relevant in longitudinal and intervention studies, recovery-oriented practices and mental health services might be more effective when focusing also on improving self-image or schemas, teaching functional coping styles and generating social interaction next to the reduction of symptoms. Moreover, reducing affective symptoms may improve personal recovery.

Funding
The infrastructure for the GROUP study is funded through the Geestkracht programme of the Dutch Health Research Council (Zon-Mw, grant number 10-000-1001), and matching funds from participating pharmaceutical companies (Lundbeck, AstraZeneca, Eli Lilly, Janssen Cilag) and universities and mental health care organizations (Amsterdam: Academic Psychiatric Centre of the Academic Medical Center and the mental health institutions: GGZ Ingeest, Arkin, Dijk en Duin, GGZ Rivierduinen, Erasmus Medical Centre, GGZ Noord Holland Noord. CRediT authorship contribution statement RE, JV, AV, FS and LH contributed to the conception and design of the study. JV and FS contributed to data analyses. RE, JV, AV, FS and LH contributed to data interpretation. RE, JV and FS drafted the article while the other authors critically appraised it and revised it. All authors approved the final version of manuscript for submission and publication.

Declaration of competing interest
The authors have declared that there are no conflicts of interest in relation to the subject of this study.
Robin Michael Van Eck works as a psychiatrist at an outpatient clinic of Focus GGZ, a mental health institution in Amsterdam, the Netherlands. Besides that, he performs a PhD research into the relationship between clinical and personal recovery at the Amsterdam University Medical Centre in collaboration with Arkin/Mentrum.
Judith van Velden has been working as a psychologist at the day-patient treatment and inpatient clinic of Jellinek (substance abuse and addiction) in Utrecht, The Netherlands. She has been involved in the GROUP-project in connection with her master thesis, under the supervision of Frederike Schirmbeck, while interning at Zorglijn Vroege Psychose, Amsterdam UMC, The Netherlands.
Astrid Vellinga works as a psychiatrist, medical director, and senior researcher at Arkin Institute for Mental Health in Amsterdam, the Netherlands. Her research is focused on personal recovery of patients with severe mental illness, as well as competence and decision making capacity.
Lian van der Krieke works as a senior researcher and a health care psychologist in training to become a specialist at the University Center for Psychiatry at the University Medical Center Groningen. Over the last ten years, her research has focused on psychosis and psychosis care in which she combines quantitative with qualitative approaches.