Extrinsic and Intrinsic Factors related to Recovery Process
in People with Schizophrenia
1) Fernandez, Aaron*¹ (Masters in Medicine, Psychiatry)
2) Kit-Aun, Tan¹ (PhD)
3) Masiran, Ruziana¹ (Masters in Medicine, Psychiatry)
4) Abdul Rahim, Riana² (Masters in Medicine, Psychiatry)
1) Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia
2) Department of Psychiatry and Mental Health, Kuala Lumpur Hospital, Malaysia
Fernandez A, Kit-Aun T, Masiran R & Abdul Rahim
Extrinsic and Intrinsic Factors related to Recovery
Process in People with Schizophrenia . International Journal of Psychosocial Rehabilitation. Vol 22 (1) 114-124
Dr. Aaron Fernandez
Psychiatrist & Lecturer
Department of Psychiatry
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia, Serdang
objective of this study was to examine the associations between
recovery processes, recovery-oriented practices, and symptom severity
in people with schizophrenia attending clinics at Hospital Kuala
Lumpur. Psychiatric diagnosis was established using the Mini
international neuro-psychiatric interview. Participants completed the
RSA, measures of extrinsic enablers of recovery and the RAS, measures
of internal recovery characteristics. Clinicians provided ratings using
the PANSS, measures of symptom severity, and the M.I.N.I., measures of
psychiatric diagnosis. Recovery orientation in individuals with
schizophrenia was found to be positively correlated with the presence
of recovery-oriented practices in the mental health system and
negatively correlated with their symptoms. Recovery-oriented practices
in the mental health system as rated by participants was negatively
correlated with their symptom severity. The findings of this study
suggest that a recovery-oriented mental health system or milieu is
positively associated with the presence of internal recovery values in
people with schizophrenia and negatively related to symptom
a lifetime prevalence rates range from 1.1% to 4% (Bhugra, 2005),
schizophrenia is a serious mental illness characterized by
hallucinations, delusions, disorganized thought, and disorganized
behavior accompanied by impairment in psychosocial functioning
(American Psychiatric Association.2013. Diagnostic and statistical
manual of mental disorders (5th Ed.). Perceptual and thought
disorders can provide interferences in realms of interpersonal
functioning, employment, self-care, and ability to live independently
(Galletly et al., 2016).
From the beginning of the 20th century, when the term schizophrenia was
coined, the common notion prevalent at the time was that schizophrenia
was both a neurodevelopmental (i.e. the presence of aberrant genes
which manifest later as the brain develops into the clinical
presentation of schizophrenia) and neurodegenerative illness (i.e.
emotional and environmental factors precipitate noxious
neurodegenerative changes in the adolescent or adult brain that results
in an inevitably deteriorating course (DeLisi, 2008) (Frese, Knight
& Saks, 2009) which results in an inevitably deteriorating course
and unfavorable outcome associated with a precocious cognitive decline
as seen in schizophrenia (Jablensky, 2007). Remission of symptoms was
not commonly anticipated. This did not only make the outlook for
schizophrenia bleak but resulted in management approaches that had as
its endpoints control of disruptive behavior, symptomatic response, and
History of Prognostication of Schizophrenia: Remission vs. Recovery
With the advent of the discovery of antipsychotics in the early 1950’s
(Shen, 1999), the new goal of psychiatric management in schizophrenia
was to minimize or ameliorate psychopathology i.e. hallucinations,
delusions, abnormal behavior etc. which were collectively referred to
as impairment and thus the beginning of the impairment-oriented
paradigm. In this paradigm, a person with schizophrenia was said to
demonstrate a response to psychiatric management when at least fifty
percent of the symptomatology had decreased. Remission is the
continuation of the gains made in response phase with mild symptom
intensity level, and not influencing an individual’s behavior
(Andreasen et al., 2005). The symptom criteria are combined with
a time threshold of 6 months. While attaining remission is most
definitely a desirable milestone in the management of this disorder,
remission does not predate recovery from schizophrenia (Leucht &
Lasser, 2006) as dysfunction, disability, and discrimination continues
to account for the major morbidity of people with schizophrenia
(Jablensky, 2000). Unlike other illnesses, be they of physical or
mental in nature, the term recovery in schizophrenia continues to be a
highly contentious one and is sparingly used by psychiatrists due to
the inherent pessimism about the illness. The field of psychiatry
dictates that only the strictest of research-based criteria had to be
fulfilled before one was pronounced as recovered from schizophrenia.
Mental health professionals define recovery as long-term reduction or
absence of symptomology along with functional improvement (Hopper,
Harrison, Janca & Sartorius, 2007). One such set of criteria
required the following: sustained presence (of at least two years) of
the following abilities in people diagnosed to have schizophrenia; that
they spend at least fifty percent of their time on meaningful
educational and/or vocational pursuits; that they could have autonomous
control of finances and medication; and that they could have regular
contact with their social networks ((Liberman & Kopelowicz, 2002).
Recovery was hence dichotomized as an all or nothing endpoint based on
the absence or presence of clinical symptomatology, the pronouncement
of which lay solely with the treating psychiatrists. No doubt,
the inherent conceptual understanding of schizophrenia as a
neuro-developmental and/or neuro-degenerative mental illness with an
inevitable deteriorating course negatively influences prognostication
of this disorder. Emerging evidence from multiple longitudinal studies
and meta-analysis of the same however indicates a more optimistic
prognosis for schizophrenia. To quote just one, the landmark Vermont
longitudinal study which studied 262 patients for 32 years found that
at the end of the study period, 50-66% of patients achieved
‘considerable improvement or recovery’ (Harding, Brooks, Ashikaga,
Strauss, & Breier, 1987).
The heterogeneity of Schizophrenia
As opposed to the dictums and assumptions made about it, schizophrenia
is neither a homogenous illness with an inevitably deteriorating course
(Shepherd, Watt, Falloon, & Smeeton, 1989) nor is it characterized
by non-recovery (Harrow, Grossman, Jobe & Herbener, 2005).
Moreover, with respect to episodes of illness, symptomatology, and
social impairment, longitudinal data collected over recent decades have
convincingly demonstrated that schizophrenia exhibits marked
heterogeneity of outcomes in terms of symptoms and functioning
(Davidson & McGlashan, 1997). This heterogeneity in outcome is not
merely a reflection of the variation of the natural course of the
illness (Warner, 2007), dependent on the previously recognized DSM-IV
schizophrenia subtypes, or the use of newer antipsychotics. Recent
longitudinal cohort studies indicate that the rates of achieving
remission in schizophrenia seems much higher than previously thought.
What more, people with schizophrenia in remission have corresponding
improved outcomes in other domains such as better social and
occupational functioning (Eberhard, Levander, & Lindström, 2009).
People with schizophrenia in remission are also more likely to favor
utilizing medications and have fewer relapses (Emsley, Rabinowitz &
With regards to recovery in schizophrenia, the variance in outcomes of
schizophrenia is strongly influenced and determined in part by a
recovery-oriented approach that promotes an optimum environment
(Martens, 2004). An optimum environment is one in which an active
treatment approach with the goal of attaining remission is complemented
by evidence-based psychotherapy and individualized psychosocial
interventions from day one of engagement with psychiatric services.
Psychosocial interventions that have proven to be effective include
family intervention, coping skills training, emotional regulation and
social skills training. In fact, a nation-wide initiative by mental
health professionals in the United States to identify empirically
supported interventions with proven effectiveness have produced six (6)
evidenced-based practices (EBP’s) for people with severe mental illness
(Harrison et al, 2001). These EBP’s are: 1) collaborative
psychopharmacology; 2) assertive community treatment; 3) family
psychoeducation; 4) supported employment; 5) illness management and
recovery skills, and 6) integrated dual disorders treatment.
To summarize this in a cautiously optimistic manner, we now have
evidence that the prognosis of schizophrenia can be improved by
recognizing and managing the disorder early by providing evidence-based
practices that promote recovery. Recovery can best be understood as
both an outcome and a process. Corrigan (2006) argues that it is by
combining these two concepts that a holistic account of recovery truly
An impairment or disability -oriented paradigm that has dominated much
of the later part of the 20th century has an overt focus on
psychopathology and had as its main goal the reduction of impairment.
In this paradigm, people with schizophrenia were merely recipients of
services instead of active empowered participants of the same. They
were told not to be overly optimistic about their chances of living a
productive and independent life but instead to have realistic goals.
Recovery in schizophrenia was simply not a prognosis (or outcome)
entertained except under the occasional but rare strict scrutiny of
psychiatrists (Martens, 2004).
As the reader would have probably inferred by now, recovery from
schizophrenia was conceptualized by psychiatrists using clinical
parameters where the outcome was dichotomized to either recovered or
non-recovered. In an apparent contradiction to the psychiatrist-defined
recovery, personal accounts of people with schizophrenia in recovery
were also beginning to emerge circa three decades ago, describing
recovery as a process beyond the mere absence of symptoms and
functional impairment and can even take place despite persistent and
Consumer-defined Recovery: Recovery as a Process Characterized by Salient Features
Beginning in the 1980’s, existent literature has challenged the
recovered-not recovered dichotomy dictum imposed by psychiatrist by
demonstration of the nature of recovery i.e., being a process on a
continuum rather than an endpoint (Davidson & Strauss, 1992)
(Deegan, 1998). Consumers of psychiatric services report that recovery
can and does occur despite the persistence of symptoms and difficulties
in functional and social domains. This is what is termed as personal
recovery and is best surmised to be a deeply personal, unique process
of changing one’s attitudes, values, feelings, goals, skills, and roles
(Anthony, 1993). 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 purposes in one’s life as
one grows beyond the catastrophic effects of mental illness. The
recovery process entails the development of cogent attitudes. Such
attitudes are positively related to personal responsibility (Andresen,
Oades & Caputi, 2003), empowerment (Schrank & Slade, 2007), and
hope (Leamy, Bird, Le Boutillier, Williams & Slade, 2011). These
facts seemed to be supported by rich empirical data about schizophrenia
that has accrued over the recent decades which have somewhat challenged
the old paradigm of schizophrenia.
Internal Factors Facilitating the Recovery Process within People with Schizophrenia
Recovery is a process characterized by empowering consumers of
psychiatric services with positive attributes, developing one’s skills
necessary to cope with stigma, managing one’s problematic
symptomatology, accepting one’s personal responsibility for his or her
own actions, and keeping one’s hope for recovery alive (Andresen, Oades
& Caputi, 2003) (Schrank & Slade, 2007). The presence of such
characteristics and attitudes within people with schizophrenia is
collectively known as intrinsic factors of recovery. Among the many
psychometric tools used to measure intrinsic factors of recovery, the
Recovery Assessment Scale or RAS (Giffort, Schmook, Woody, Vollendorf
& Gervain, 1995) stands out for ease of use. The RAS captures
personal recovery characteristics in people with severe mental illness
as well as the deeply personal, unique process of changing one’s
attitudes, values, feelings, goals, skills, and roles. The RAS has been
found to be associated with individual recovery characteristics, the
provision of recovery-oriented services as well as good social support
(Chang, Heller, Pickett, and Chen, 2013).
External Factors Facilitating the Recovery Process within People with Schizophrenia
As opposed to intrinsic factors of recovery found within people
recovering from SMI, recovery from mental illness can also be greatly
influenced by extrinsic factors i.e., the recovery orientation of
mental health care systems and other systems serving people with
serious mental illnesses. Extrinsic factors of recovery are those
factors that are in the person’s environment that serve to ignite,
encourage and bring to fulfilment all the positive factors required
towards one’s journey to recovery (Shepherd, Boardman, Rinaldi &
Extrinsic factors are typically a supportive family or community, a
recovery-oriented treatment milieu, a multidisciplinary team that does
not only provide crisis intervention, case management, and
rehabilitation services but also promote self-actualization, rights
protection, and basic support (Cohen, Cohen, Nemec, Farkas, &
Extrinsic factors also refer to policies and practices of the clinic
delivering mental health services (Jacobson & Greenly, 2001) and
these contribute to part of what is the optimum environment as
discussed above. In it, patients can initiate, pursue, and sustain
their life aims. A recovery-oriented healthcare system would encourage
patients’ active involvement in formulating and deciding their own
wellness plans by offering a diversity of treatment options such as
individually tailored services (Le Boutillier, Leamy, Bird, Davidson,
Williams, & Slade, 2011). In one study examining factors associated
with a recovery-oriented program found that individual recovery status
was predicted by the provision of recovery-oriented services, low
psychiatric symptomatology and good social support (Chang, Heller,
Pickett & Chen, 2013). Of equal importance are community-based
recovery-oriented services that focus on early intervention and relapse
prevention. In the UK, these types of recovery-oriented community-based
early intervention and relapse prevention are very effective for both
service users and providers in that they are highly accessible to
people in crisis or early relapse and as for the service provider and
mental health system, avoiding inpatient admissions translates to
millions of British £s saved (Knapp et al., 2014).
Assessing consumers’ perception of recovery-orientation of the systems serving their needs.
Individual consumer perception of recovery-oriented service was found
to be positively correlated with recovery from schizophrenia (Noordsy,
Torrey, Mueser, Mead, O’Keefe, & Fox, 2002).
Among the various psychometric tools used to measure extrinsic factors
of recovery, the Recovery Self-Assessment Scale (O’Connell, Tondora,
Croog, Evans, & Davidson, 2005) is widely used and was chosen for
this study. The RSA captures the recovery orientation of the mental
health system where people with schizophrenia receive services from.
The RSA measures extrinsic recovery-supporting practices in five
domains i.e., Life Goals, Involvement, Diversity of Treatment Options
and Choice, and Individually-Tailored Services
The Present Study
With the gradual accumulated hard data on the improvement in
prognostication of schizophrenia and determination of encouraging
recovery rates along with the discovery of intrinsic recovery processes
and external environmental recovery-oriented practices, it was
inevitable indeed necessary that a paradigmatic shift occurred which
gradually came to be known as the recovery-oriented paradigm.
In line with the Malaysian Ministry of Health Medical Development
Division’s (2011) policy paper, there is a need to establish and
develop rehabilitation and recovery-orientated services. Hence, the
present study meets this timely need by examining both intrinsic and
extrinsic correlates of symptom severity via a recovery-oriented
paradigm. Based on previous findings, we formulated three research
H1: Recovery is positively related to recovery-oriented mental health treatment.
H2: Recovery is negatively related to symptom severity.
H3: Recovery oriented-treatment are negatively related to symptom severity.
Participants for this study were drawn from the Malaysian Study of
Recovery in People with Schizophrenia (MSRPS). The sample
characteristics and the design for MSRPS have been described in
previous publications (Tan & Fernandez, 2018). The study was
approved by the National Medical Research Register and the Ethics
Committee for Research Involving Human Subjects, Universti Putra
This cross-sectional study was conducted at the psychiatric clinic of
Hospital Kuala Lumpur. Sample size calculation was based on a previous
study by Lloyd, C., King, R., & Moore, L.
Following medical research ethical clearance, we performed data
collection from October 2014 to April 2015. Participants aged between
18 and 65 years old were included in the present study if they had
diagnosed with schizophrenia based on DSM IV-TR and had consented to
participate the study They were selected via systematic random sampling
technique. The informed consent procedure was as such. Those patients
who were selected via systematic random sampling from the sampling
frame (people with schizophrenia attending clinic on that particular
day). The researchers (who were either one of the four psychiatrists
participating in this study) then invited the potential participant
into a consulting room and debriefed them (and their significant others
where applicable) as to the nature of the research and invited them to
participate. The psychiatrists strongly emphasized the autonomy of
participation and that the participants could opt out of the study at
any time with no consequence to them. The researchers ensured that all
potential participants, irrespective of symptom severity, were only
eligible to participate in the study if they fully understood the
nature of the study and were able to give a valid informed consent.
Psychiatric patients were excluded if they had 1) high suicidal
tendency as assessed during intake interview during data collection and
2) had no diagnosis of schizophrenia. Those who were too
psychiatrically ill or were unable to understand, receive and carry out
instructions were similarly excluded from the study, as were those who
for whatever reason declined to participate. Psychiatrists trained in
using the Mini-International Neuropsychiatric Interview (M.I.N.I)
confirmed the psychiatric diagnosis. To this end, we recruited 118
participants. Gender was equally distributed (age; M = 39.89, SD =
11.377). Of 118 participants, 36.4 % were employed full-time.
In the present study, three psychological instruments were chosen: The
Recovery Self-Assessment (RSA) to assess the presence of extrinsic
enablers of recovery, the Recovery Assessment Scale (RAS) to measure
internal recovery characteristics and process in people with
schizophrenia, and the Positive and Negative Symptoms Scale in
Schizophrenia (PANSS) to measure symptom severity.
The Recovery Self-Assessment (RSA) self-report scale (O’Connell,
Tondora, Croog, Evans, & Davidson, 2005) (O’Connell, 2005) was used
to assess the external measure of recovery from the perspective of
service users. The RSA was developed to assess the degree to which
mental health care systems and their personnel provided
recovery-supporting practices as determined from the perspective of
their service users through a 36-item self-report scale. Individual
items are rated using the same 5-point Likert scale that ranges from
strongly disagree to strongly agree. It consists of five-subscales for
five domains of extrinsic recovery process: Life Goals, Involvement,
Diversity of Treatment Options and Choice, and Individually-Tailored
Services. A total score on the RSA could be obtained. The RSA subscales
have demonstrated good reliability (Tan & Fernandez, 2018).
Cronbach’s alpha for the RSA total score in the present sample was .97.
The intrinsic measure of recovery was assessed using the Recovery
Assessment Scale or RAS (Schrank & Slade, 2007), a self-report
scale developed to assess internal components of recovery in people
with serious mental illness. The RAS has five domain subscales. The
subscales are as follows: Personal Confidence and Hope; Willingness to
Ask for Help; Goal and Success Orientation; Reliance on Others and
finally No Domination by Symptoms. A total score on the RAS could be
obtained. Cronbach’s alpha for the RSA total score in the present
sample was .87.
Participants’ scores on symptom severity were obtained via use of the
Positive and Negative Symptoms Scale in Schizophrenia (PANSS). The
PANSS is an interviewer-rated scale used to measure symptom type and
severity in people with schizophrenia (Kay, Fiszbein, & Opler,
1987). The Positive and Negative Scales consists of seven (7)
items each and the General Psychopathology Scale consists of 16 items.
The minimum score on each item is 1 and the maximum score is 7.
Cronbach’s alpha estimates for the present study were as follows: Total
PANSS (.94), PANSS Positive (.80), PANSS Negative (.92), and PANSS
Participants’ Perception on Mental Health Services
We used Cohen, Cohen, West, and Aiken’s recommendations (2013) to
categorize the RSA scores into low, moderate, and high levels. A total
of 82.5% participants reported that psychiatric services they received
had only low to moderate levels of recovery orientation.
Participants’ Recovery Process
We also used Cohen et al.’s recommendations (2013) to categorize the
RAS scores into low, moderate, and high levels. When this was done, our
findings showed that 15.1, 63.5, and 16.7% of the participants had low,
moderate, and high levels of recovery process characteristics
Participants’ Symptom Severity
Following standard procedures for categorization using the PANSS, our
findings showed that participants’ severity of symptoms was mildly ill.
Correlations among Study Variables
As expected, recovery process of individuals with schizophrenia was
positively correlated with recovery-oriented practices (r = .62, p <
.05, Cohen’s d = 1.58). It is reported that recovery process of
individuals with schizophrenia was negatively correlated with their
symptom severity (r = -.55, p < .05, Cohen’s d = 1.32). Our findings
also showed that recovery-oriented practices as rated by participants
was negatively correlated with their symptom severity (r = -.72, p <
.05, Cohen’s d = 2.08).
The present study examined intrinsic and extrinsic correlates of
symptom severity via a recovery-oriented paradigm. Our findings
reported that 82.5% of the participants rated their mental care
services were not supportive in their recovery endeavors. In other
words, clinic services they received were deemed as not adequately
helpful in cultivating hope, overcoming stigma, and connecting to
others. An even larger proportion of the respondents (86%) reported
only low to moderate characteristics of personal recovery within
themselves. Our sample generally showed a mild level of
psychopathology. The low scores on the PANSS is similar to what was
found in a cross-sectional study on outpatient population in Asia
(Shanker et al, 2014) and is possibly explained by the reasoning that
people with schizophrenia treated on an outpatient basis are more
likely to be in symptomatic remission as compared to those requiring
Despite mild clinical symptoms of schizophrenia, 86% of these patients
reported only low to moderate characteristics of personal recovery
within themselves. Findings of this study lends credence to the
argument that symptomatic remission is only a means to the end i.e.,
recovery. Despite being relatively symptom free, the patients in this
study still lacked personal confidence, were not optimistic about
recovering, set low goals for themselves and lacked a drive to
succeed. This is consistent with previous studies which indicate
the presence of ongoing functional deficits and residual disability
even when symptomatic remission has been reached (Liberman, &
In this study, symptom severity was found to be negatively and
significantly correlated to participants’ recovery process. These
finding replicates that of several other studies done elsewhere (Chang,
Heller, Pickett & Chen, 2013), (Norman, Windell, Lynch &
Manchanda, 2012) & (Resnick, Rosenheck, Lehman, 2004). Here the
authors would like to attempt to postulate a possible explanation for
this finding. When psychotic symptoms and thought disorganization are
florid in the acute phase of schizophrenia, they cause marked
disruption to the patients’ ability to think, feel and behave in a
normal manner. In this acute state, intrinsic factors of recovery are
unlikely to be present in any meaningful degree in the person. However,
as demonstrated in the preceding paragraph, even when symptoms are
absent or mildly present, intrinsic factors of recovery are still
Given that the recovery orientation of the system was positively
correlated to participants’ own recovery process, it can be argued that
a more supportive recovery-oriented clinical service would help ignite
some flicker of hope and facilitate the recovery process. An
impairment-oriented mental health service focuses on symptom reduction
and remission. While these goals are desirable, such a system takes
little account the dysfunction, disability and discrimination faced by
people with schizophrenia, what more address the demoralizing impact of
mental illness on the personhood, esteem, and social networks. It is no
surprise then that psychiatric services have been criticized as being a
hindrance (Deegan, 1990) rather than facilitating to recovery. An
impairment-oriented mental health service is largely disempowering as
patients are recipients of services instead of participating actively
in their own recovery, have no autonomy with regards to treatment
options, are discouraged from taking risks and not given
responsibilities commensurate with their strengths and skills (Tew et
al., 2011). Instead of serving as a reservoir of hope, such
patients’ optimism is tempered with the declaration of prognosis and
realistic goals. Relapses and setbacks in management are seen almost
exclusively due to patient non-adherence to medications or other
Practical Implications for Malaysian Mental Health Services
Our recent findings have practical implications for Malaysian health
services in three ways. Firstly, we recommend that mental health
services in Malaysia make attaining and sustaining symptomatic and
functional remission a priority in all people with schizophrenia to
prevent chronicity of illness and development of disability.
Furthermore, it must be kept in mind that in accordance with recent
evidence-based practice principals, the pursuit of symptomatic and
functional remission is only a means to the end goal, which is
Secondly, we recommend the routine use of standardized instruments
translated for local needs of external and internal recovery i.e., the
RSA and the RAS as part of a new recovery-oriented paradigm that the
mental health system must embrace. This is in line with recommendations
of a large systematic review encompassing 7431 studies (Slade et al,
2012). A system that is recovery-oriented is immensely therapeutic and
conducive to the recovery processes of its service consumers
(Avdibegović & Hasanović, 2017)
Thirdly, a recovery-oriented paradigm is one where people with
schizophrenia are not merely pathologically impaired individuals whose
impairments are deemed the most important target goals. The mental
health staff, system and policies acknowledge people with schizophrenia
as people with unique strengths, values and interests whose life’s
goals and pursuits are interrupted by an illness that is known to have
potentially debilitating effects on functioning and abilities. A
recovery-oriented paradigm’s objectives are not only setting goals to
attaining response, remission and recovery but concomitantly to
minimize the impact of such an illness on a person’s academic,
vocational and employment. People with schizophrenia are assisted in
planning for their recovery by identifying skills and resources to
reach these goals and linking them to them. By doing so, recovery
orientation (or rather lack of thereof) can be identified early and
appropriate remedial measures can be taken to improve the service
delivery of mental health systems as well as address the lack of
recovery orientation in people with schizophrenia. A recovery-oriented
mental health system goes beyond just remission to encourage and
nurture recovery-oriented attitudes and behavior in people with
schizophrenia towards their journey towards achieving recovery.
The validity of our current findings should be interpreted within the
issue of social desirability in that most of the respondents filled up
the RSA with the help of the four interviewers who were psychiatrists.
In the presence of psychiatrists, the respondents were inclined and had
tendency to give positive remarks with regards to the clinical services
provided at the clinic. The Hawthorne effect therefore could have
resulted in respondents giving more favorable answers about the
services and result in artificially higher scores on the RSA. This is
also consistent with the theory of social desirability where people on
self-report surveys tend to report what they think others may want them
to hear and not report what they actually think and feel.
In order for mental health services to be pertinent and effective, it
must embrace a recovery-oriented paradigm. In accord to recommendations
of international practice guidelines, the Malaysian mental health
system can support recovery by promoting community integration and
equality, supporting patient-defined recovery and relationship goals,
and most critical perhaps is having a clearly defined organizational
commitment towards facilitating recovery (Le Boutillier et al., 2011).
Clinical remission is not an end to itself but a means to the end of
individually tailored recovery plans through the process of psychiatric
rehabilitation. This requires a shift away from the erroneous
presumption that increasing spending on newer, novel atypical
antipsychotics could perhaps alter the course or progression of
schizophrenia. As surmised by Liberman and Kopelowisc (2002), if
recovery is the desired clinical outcome, management must extend beyond
symptomatic remission and include individually tailored psychosocial
interventions provided by a recovery-oriented mental health system that
helps consumers develop goals and overcome barriers according to their
strengths, interests and values. This is consistent with providing of
an optimum environment, as postulated by Harrison et al. (2001), to
facilitate recovery. As driven by the present findings, we recommend a
recovery-oriented paradigm that supports both the intrinsic recovery
process and an attempt to promote the provision of an extrinsic
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