Community Mental Health Journal

https://doi.org/10.1007/s10597-020-00616-5

ORIGINAL PAPER

Subjective Recovery in Patients with Schizophrenia and Related

Factors
Kübra İpçi1 · Mustafa Yildiz1,2 · Aysel İncedere1 · Fatma Kiras2 · Duygu Esen2 · Mehmet B. Gürcan2

Received: 5 November 2019 / Accepted: 6 April 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Subjective recovery is a personally perceived recovery involving other factors beyond clinical recovery. This study aims at
investigating the factors related to subjective recovery in patients with schizophrenia living in Turkey. This study assessed
120 clinically stable outpatients with schizophrenia or schizoaffective disorder using the clinical and psychosocial scales.
Gender, type of the diagnosis of disease, and age of the illness onset were found to be correlated with the subjective recovery.
Subjective recovery was significantly correlated with CGI-S (r = − 0.25), total PANSS score (r = − 0.29), global assessment
of functioning (r = 0.27), social functioning (r = 0.43), internalized stigma (r = − 0.38), self-esteem (r = 0.56), depression
(r = − 0.59), and hopelessness (r = − 0.55). Hopelessness and self-esteem were found to be predictive of the subjective
recovery explaining 52% of the variance. It can be argued that efforts to promote hope and self-esteem contribute to the
subjective recovery.

Keywords  Schizophrenia · Subjective recovery · Functioning · Psychopathology · Self-stigmatization · Hope · Self-esteem

Introduction and the continuation of this state for a period of 6 months

(Andreasen et al. 2005; van Os et al. 2006) whereas func-
Recovery in schizophrenia is a complex and multidimen- tional recovery is defined as the ability of a person with
sional concept defined in several different ways (Schrank stabilized symptoms to live independently for a long time
and Slade 2007; Henderson 2011; Drake and Whitley 2014). (at least 2 years) without any recurrence, to engage in social
Clinical recovery is defined as remission of core symptoms relationships, and to maintain professional/academic func-
of schizophrenia to a degree to not impair functioning tioning (Liberman et al. 2002; Novick et al. 2009). Another
definition of recovery emphasizes the subjective recovery
process of an individual and calls it subjective/personal
* Mustafa Yildiz
myildiz60@yahoo.com recovery (Deegan 1988; Anthony 1993). This definition
has originated from individuals who experience the illness
Kübra İpçi
kubraipci@gmail.com and service users and differs from a clinician’s definition
(Mead and Copeland 2000; Bellack 2006; Henderson 2011).
Aysel İncedere
ayselyazici@gmail.com It underlines the fact that recovery is different for each indi-
vidual and needs to be perceived as a process, not just an
Fatma Kiras
fatma_kiras@hotmail.com endpoint or outcome (Davidson et al. 2005a; Pitt et al. 2007).
Regardless of the severity of psychopathology, subjective
Duygu Esen
duyguesen47@gmail.com recovery focuses on areas of personal development such as
empowerment, having a sense of hope, having confidence for
Mehmet B. Gürcan
mbgurcan@gmail.com future, redefining self, overcoming stigma, establishing sup-
portive relationships, taking responsibility, making sense of
1
Department of Psychosocial Rehabilitation, Kocaeli life, and leading a satisfactory life (Anthony 1993; Andresen
University Institute of Health Science, Izmit, Kocaeli, et al. 2003; Resnick et al. 2005; Leamy et al. 2011; Cavelti
Turkey
et al. 2012). This understanding assumes that although the
2
Department of Psychiatry, Kocaeli University School illness may prevail at various levels, the person continues
of Medicine, Umuttepe, 41001 Izmit, Kocaeli, Turkey

13
Vol.:(0123456789)

with his/her journey to recovery (Anthony 1993; Pitt et al.
2007). While the first two definitions of recovery focus on
the outcome, the third definition focuses on the process and
is evaluated based on self-reports of patients (Law et al.
2012; Cavelti et al. 2012). These definitions of recovery
emphasize different dimensions of the same phenomenon
and are complementary to each other (Davidson et al. 2005b;
Bellack 2006; Essock and Sederer 2009; Roe et al. 2011).
In other words, clinical recovery relates to biochemical
improvement, functional recovery to social improvement,
and subjective recovery to psychological strengthening, and
it is agreed that a patient can achieve improvements in every
dimension at various levels at any time (Whitley and Drake
2010; Henderson 2011).
Approaches targeting recovery beyond solely stabilizing
symptoms in the treatment of schizophrenia have become
popular recently (Schrank and Slade 2007; Warner 2009;
Drake and Whitley 2014; Vita and Barlati 2018). Psycho-
social therapies and rehabilitation have important contribu-
tions to achieving functional recovery beyond symptom sta-
bilization (Liberman 2008). This understanding emphasizes
patient participation in treatment processes and personal
development. A recovery-oriented service approach is one
that takes account of subjective recovery as perceived by
the patient and related factors (Whitley 2014; Chan et al.
2017). Subjective evaluations of patients concerning recov-
ery may differ from the clinician’s point of view; therefore,
the inclusion of assessments on subjective recovery in clini-
cal interviews is being debated recently (Essock and Sederer
2009; Jaeger and Hoff 2012; Law et al. 2012; Macpherson
et al. 2016).
Studies show that a relationship exists between clinical
recovery and subjective recovery (Resnick et al. 2004; Corri-
gan et al. 2004; Roe et al. 2011; Kukla et al. 2014; Jørgensen
et al. 2015; Wciorka et al. 2015; Macpherson et al. 2016;
Chan et al. 2017). The extent of such a relationship can vary
depending on the scales used in studies and the heterogene-
ity of patient groups. A meta-analysis has shown that there is
a weak or moderate correlation between subjective recovery
and positive symptoms, negative symptoms, and emotional
symptoms (van Eck et al. 2018b). Reduced psychopathology
is usually found to be associated with improved subjective
recovery (Resnick et al. 2004; Jørgensen et al. 2015; Rossi
et al. 2018). Depression or negative affectivity is reported
to be more associated with subjective recovery than posi-
tive and negative symptoms (Resnick et al. 2004; Law et al.
2016; van Eck et al. 2018a; Lim et al. 2019). Similarly, it is
argued that while depression and negative self-esteem have
a direct effect on subjective recovery, positive symptoms
and impaired insight have an indirect effect (Morrison et al.
2013). However, few they may be, there are also studies
showing that psychopathology is not associated with per-
ceived subjective recovery (Roe et al. 2011; Kukla et al.
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Community Mental Health Journal
2014; Giusti et al. 2015). Even if there is a direct relation-
ship between subjective recovery and clinical recovery, other
factors such as social support, economic status, helplessness,
and stigma are known to contribute to subjective recovery
(Roe et al. 2011; Schrank et al. 2014; Vass et al. 2015).
Another obstacle to recovery is self-stigmatization (Kvrgic
et al. 2013). Stemming from the internalization of stigmatiz-
ing and discriminating attitudes of the society, self-stigmati-
zation can affect perceived recovery negatively by lowering
self-esteem and aggravating hopelessness and depression
(Schulze and Angermeyer 2003; Law and Morrison 2014).
Since subjective recovery is rather a personal phenom-
enon, it is argued that there is not any gold standard scale
for its assessment and the most accurate measurement
would be through scales developed within a distinct cul-
ture (Essock and Sederer 2009; Law et al. 2012). Factors
included in the subjective recovery scales used frequently
in studies are mostly empowerment (self-confidence), hope,
awareness (understanding), goal orientation, relationships
with others, and peer support (Leamy et al. 2011; Law et al.
2012). The number of factors in such scales may vary and
there are also single-factor scales (Shanks et al. 2013; Law
and Morrison 2014; Argentzell et al. 2017). The Subjective
Recovery Assessment Scale (SubRAS) developed in Turkey
for patients with schizophrenia has a single-factor structure
(Yıldız et al. 2018a). This scale has shown a high correla-
tion with functioning, psychopathology, and quality of life
scales in the group of patients with schizophrenia for which
it was developed. However, it has not been studied in any
other patient group. This study investigates the relationships
between subjective recovery and psychopathology, self-stig-
matization, and social functioning in patients with schizo-
phrenia using SubRAS, which is a suitable scale for culture.
Methods
Participants
The study was conducted with 120 patients aged between 18
and 65 years who were graduates of at least primary school
and were diagnosed with schizophrenia or schizoaffective
disorder according to DSM-5 (APA 2013) at the Psychia-
try Outpatient Clinic of Kocaeli University Medical School
and were in their maintenance therapy period. Patients
who received electroconvulsive therapy (ECT) within the
last 6 months, had a chronic neurological disease such as
epilepsy and Parkinson, mental retardation, communica-
tion problems, or alcohol/substance dependence were not
included in the study. The participants were informed about
the purpose and method of the study and their consents were
obtained. Permission for the study was obtained from the
Community Mental Health Journal
Non-Interventional Clinical Trials Ethics Committee of
Kocaeli University (KÜ GOKAEK 2017/2.14).
Assessment Tools
Demographic and Clinical Information Form
A patient registry form to collect data on age, gender, mari-
tal status, education situation, economic status (financial
income in Turkish Lira found by dividing monthly total
household income by the number of persons living in the
house), diagnosis of the psychiatric disorder, age at the onset
of psychotic disorder, duration of the illness (from the first
psychotic breakdown to the present), number of hospitaliza-
tions related to psychotic disorder, etc.
Positive and Negative Syndrome Scale (PANSS)
A 30-item semi-structured interview scale developed by Kay
et al. (1987). The Turkish version of the scale was tested for
validity and reliability by Kostakoğlu et al. (1999). Psycho-
pathology was examined in this study using the five-factor
model of PANSS as proposed by Gaag et al. (2006) (posi-
tive, negative, disorganized/cognitive, excitement/hostility,
and emotional distress).
Clinical Global Impression‑Severity (CGI‑S)
A measurement tool to assess the severity of any disease and
improvements in disease symptoms in general terms (Guy
1976). Based on his/her knowledge and experience on the
disease in question, the clinician rates the severity of the
disease on a Likert-type scale ranging from 1 to 7.
Global Assessment of Functioning (GAF)
A measurement tool to assess psychological, social and
occupational functioning, excluding impairments caused by
physical or environmental factors. Scoring is based on the
selection of a single number between 0 and 100 by a trained
expert. Higher scores obtained from the scale indicate higher
levels of functioning (APA 1994).
Subjective Recovery Assessment Scale (SubRAS)
A 17-item Likert-type self-report scale to determine subjec-
tive recovery as perceived by individuals with schizophrenia.
Each item is scored from 1 to 5 and the assessment is based
on the total score. Higher scores indicate higher levels of
perceived recovery. The Cronbach alpha coefficient of the
scale is 0.98 (Yıldız et al. 2018a).
Internalized Stigma of Mental Illness (ISMI) Scale
A self-report scale consisting of 29 items and 5 subscales
(Ritsher et al. 2003). Higher scores obtained from the scale
indicate more severe internalized stigma. The Cronbach
alpha coefficient of the scale was found to be 0.93 in the
validity and reliability study of the scale in Turkish (Ersoy
and Varan 2007).
Rosenberg Self‑Esteem Scale (RSES)
A self-report scale consisting of 12 subscales and 63 items
to determine the level of self-esteem (Rosenberg 1965). The
scale’s first 10-item subscale to measure self-esteem directly
was used in the study. Higher scores obtained from this
subscale consisting of 5 positive and 5 negative-weighted
statements indicate higher levels of self-esteem. The Cron-
bach alpha coefficient of the scale was found to be 0.89
in the validity and reliability study of the scale in Turkish
(Çuhadaroğlu 1986).
Beck Hopelessness Scale (BHS)
A 20-item self-report scale developed to determine the level
of hopelessness in people in risk groups (Beck et al. 1974).
Higher total scores indicate increased levels of hopelessness.
The Cronbach alpha coefficient was found to be 0.86 in the
validity and reliability study of the scale in Turkish (Seber
et al. 1993).
Beck Depression Inventory (BDI)
A 21-item self-rated scale to measure the affective, cogni-
tive, somatic, and motivational components of depression
(Beck 1961). Higher scores obtained from the inventory
indicate increased severity of depression. The Cronbach
alpha coefficient was found to be 0.80 in the validity and
reliability study of the inventory in Turkish (Hisli 1989).
Social Functioning Assessment Scale (SFAS)
Developed in Turkey to assess social functioning in patients
with schizophrenia, this 19-item scale consists of 4 factors,
self-care, interpersonal relationships/recreation, independ-
ent living, and occupational status. Higher scores obtained
from the scale indicate higher levels of social functioning.
The Cronbach alpha coefficient of the scale is 0.84 (Yıldız
et al. 2018b).
Statistical Analysis
The statistical analyses of the study were performed
using the SPSS 22 (Armonk, New York, ABD) package
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 Community Mental Health Journal

program. The demographic and clinical characteristics
of the patients were evaluated in percentages and means.
Since the scale scores other than that of SFAS did not have
a normal distribution, the Man-Whitney U test and Spear-
man correlation analysis were used to assess relationships
between the demographic and clinical characteristics and
the scores obtained from SubRAS. Correlations were
rated in three categories: weak (≥ 0.1– < 0.3), moderate
(≥ 0.3– < 0.5) and strong (≥ 0.5) (Cohen 1988). Consider-
ing that the subjective recovery score had a normal dis-
tribution for being within the ± 2 limits of the skewness
and kurtosis coefficient indexes (Tabachnick and Fidell
2013), the variables that had significant correlations in
paired comparisons were made subject to multiple linear
regression analysis using the enter method to identify fac-
tors predicting subjective recovery.
Correlations Between Subjective Recovery
and Psychopathology, Internalized Stigma, Social
Functioning
The results of the correlation analysis made between sub-
jective recovery and the other psychometric measures are
shown in Table 2. Subjective recovery was found to have a
moderately significant correlation with self-esteem, hope-
lessness, depression, and social functioning, and a weak sig-
nificant correlation with internalized stigma, PANSS, clini-
cal global impression, and global assessment of functioning.
To identify factors predicting subjective recovery, gen-
der, diagnosis, age of illness onset, depression, hopeless-
ness, self-esteem, internalized stigma, social functioning,
and PANSS subscale (5-factor) scores, which showed sig-
nificant correlation with the total SubRAS score, were made
subject to multiple linear regression analysis. The results
of the analysis are shown in Table 3. Hopelessness and

Results

Demographic Characteristics Table 2  Results of correlations between subjective recovery and the

other psychometric measures

Data of all participating patients (n = 120) were evalu- Variables Mean ± SD rs

ated. The patients’ mean age was 37 and mean years of
Subjective recovery 64.4 ± 1.7 1.00
education 11. Most of the patients were male, single and
Self-esteem 28.9 ± 5.7 .56**
unemployed. The relationships between demographic/clin-
Hopelessness 4.8 ± 4.5 − .55**
ical characteristics and subjective recovery are shown in
Depression 10.8 ± 10.1 − .60**
Table 1. Gender, diagnosis, and age of illness onset were
ISMI1 total 60.4 ± 17.2 − .39**
found significantly correlated with the subjective recovery.
 Stigma resistance 11.2 ± 3.6 − .37**
 Alienation 12.4 ± 5.2 − .37**
 Stereotype endorsement 13.3 ± 4.2 − .25**
 Discrimination experience 10.2 ± 4.3 − .29**
 Social withdrawal 13.0 ± 4.6 − .22*
Global assessment of functioning 61.9 ± 9.5 .27**
Table 1  Correlations between the patients’ demographic and clinical
SFAS2 total 40.8 ± 6.8 .43**
characteristics, and subjective recovery (n = 120)
 Interpersonal relations/recreation 14.3 ± 3.6 .43**
Variables Mean ± SD SubRAS P value  Independent living 9.9 ± 2.2 .17
Number (%) Statistics
 Self-care 14.9 ± 2.8 .30**
Age 36.6 ± 8.4 rs = 0.006 .948  Occupational status 1.7 ± 0.9 .12
Gender/male 92 (76.7) z = − 2.697 .007 Clinical global impression-severity 4.1 ± 0.9 − .25**
Marital status/single 96 (80.0) z = − 0.876 .381 PANSS3 total 68.7 ± 20.3 − .28**
Education year 10.9 ± 3.3 rs = − 0.072 .437  Positive 13.3 ± 5.2 − .19*
Unemployment 92 (76.7) z = − 0.701 .483  Negative 18.4 ± 6.6 − .34**
Income per c­ apitaa 1036.52 ± 815.79 rs = 0.105 .253  Disorganized/cognitive 19.8 ± 6.4 − .16
Diagnosis/schizophrenia 99 (82.5) z = − 2.505 .012  Excitement/hostility 6.8 ± 3.2 − .16
Age of onset 23.1 ± 6.6 rs = − 0.211 .021  Emotional distress 10.5 ± 4.0 − .29**
Duration of illness/year 13.6 ± 7.8 rs = 0.176 .054  Insight 3.07 ± 1.5 − .16
Number of hospitaliz 2.3 ± 2.1 rs = 0.077 .404 *
 p < 0.05, **p < 0.01
1
Statistically significant values are given in bold  Internalized Stigma of Mental Illness Scale
2
rs Spearman correlation analysis, Z Mann Whitney U test  Social Functioning Assessment Scale
a 3
 Per capita income in the household  Positive and Negative Syndrome Scale

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Community Mental Health Journal

Table 3  Factors predicting subjective recovery, results of multiple subjective recovery is agreed to start occurring with the
linear regression analysis alleviation of the symptoms and a partial or full remission
Variables Β t P (Wciorka et al. 2015). Although associated with it, the per-
sisting psychopathology does not appear to be predictive of
Gender (female) 0.143 1.973 0.051
subjective recovery. Having hopes, making plans for future,
Diagnosis (schizoaffective disorder) 0.006 0.086 0.932
adding meaning to life, and improving self-esteem, without
Age of onset − 0.105 − 1.455 0.149
being concerned about the limitations of psychopathology
Depression − 0.185 − 1.838 0.069
are the subjective aspects of recovery for a patient. This
Hopelessness − 0.232 − 2.473 0.015
dimension of recovery is influenced also by other factors
Self-esteem 0.315 3.241 0.002
alongside psychopathology.
Internalized stigma 0.069 0760 0.449
In assessing the relationship between subjective recov-
Social functioning 0.086 0.891 0.375
ery and social functioning, a weak correlation was found
PANSS positive − 0.023 − 0.170 0.866
with the GAF score ­(rs = 0.27) and a moderate correlation
PANSS negative − 0.193 − 1.963 0.052
with the functioning score as assessed by SFAS ­(rs = 0.43),
PANSS disorganized/cognitive 0.250 1.831 0.070
which allows for a detailed assessment. Other studies have
PANSS excitement/hostility − 0.166 − 1.693 0.093
also found similar correlation coefficients (Drapalski et al.
PANSS emotional distress 0.075 0.777 0.439
2016; Law et al. 2016; Chan et al. 2017; Lim et al. 2019) and
Global F(13,106) = 8,693; p < 0,001; ­R2(95% CI) = 0.516 reported higher correlations with more detailed social func-
Statistically significant values are given in bold tioning scales (SFS) than with general functioning scales
PANSS Positive and Negative Syndrome Scale (GAF, PSP, SOFAS). The reason for this may be that general
functioning scales evaluate psychopathology and function-
ing in combination. While general functioning assessments
self-esteem were found to be predictive of subjective recov- reflect the judgment of clinicians (APA 1994), SFAS used in
ery [F(13,106) = 8693; p < 0,001; ­R2(95% CI) = 0.516]. our study reflects using 19 items the assessments in 4 areas
(self-care, interpersonal relationships/recreation, independ-
ent living, and occupational status) based on concrete data
Discussion (Yıldız et al. 2018b). Therefore, it was found meaningful
that the SFAS score had a moderate correlation with subjec-
The results of the study showed that subjective recovery tive recovery. The higher correlation seen between interper-
had a weak negative correlation with psychopathology and sonal relationships/recreation and subjective recovery in the
a moderate positive correlation with functioning, which were functioning domain points out the significant relationship
alike to those of other studies in this area. Subjective recov- between perceived recovery and socialization. However,
ery was predicted by hopelessness and self-esteem in a way social functioning did not turn out to be predictive of sub-
to explain 52% of the variance. jective recovery in our study. Social functioning would be
Both cross-sectional (Giusti et  al. 2015; Rossi et  al. expected to have a strong correlation with subjective recov-
2018; Lim et al. 2019) and longitudinal studies (Jørgensen ery as it reflects the level of individual activities. Even in
et al. 2015) have revealed that there is a weak or moder- the presence of positive symptoms, subjective recovery can
ate negative correlation between subjective recovery and be found associated with quality of life (Kukla et al. 2014).
psychopathology in schizophrenia. In our study group, both We think that the relationship between functioning and sub-
CGI-S and PANSS total scores had also a weak correlation jective recovery should be reassessed in further studies to
­(rs < − 0.30) with the SubRAS score concerning psychopa- be conducted with samples including a larger number of
thology. Only the negative symptoms subscale of PANSS patients.
showed a moderate correlation ­(rs = − 0.34). Although there The study showing the relationships between hope,
was a negative correlation in the cognitive/disorganized and depression, and self-stigmatization in schizophrenia
excitement/hostility subscales in the 5-factor PANSS, no (Schrank et al. 2014) has argued that negative symptoms
significant relationship was found, and this was consistent influence hopelessness, depression, and self-stigmatiza-
with other studies (Jørgensen et al. 2015; Lim et al. 2019). tion directly and positive symptoms indirectly by reduc-
Some studies have reported that the relationship between ing insight. Another study (Vass et al. 2015) has found that
insight and subjective recovery is paradoxical (Rossi et al. self-stigmatization is predictive of clinical and subjective
2018; Lysaker et  al. 2007), but no significant relation- recovery after a period of 6 months. The authors who found
ship was found in our study in both the PANSS (GP = 12) that self-esteem and hopelessness had a mediating role
insight score alone and the mean cognitive/disorganized in self-stigmatization reported that to reduce the effect of
score, which also includes insight item. The perception of stigma, self-esteem and hope had to be promoted. Our study

13

assessed self-stigmatization using the internalized stigma
scale. The total score of this scale had a moderate correla-
tion ­(rs = − 0.39) with subjective recovery comparable to the
study of Vass et al. (2015) (rs = − 0.41) and self-stigmati-
zation was not found to be a predictive factor for subjec-
tive recovery. Although not found to be predictive in our
cross-sectional study, self-stigmatization constitutes a major
obstacle to perceived subjective recovery. Hopelessness and
self-esteem were found to be predictive of subjective recov-
ery in our study. It can be argued that self-stigmatization
influences subjective recovery in an indirect way by increas-
ing hopelessness (Schulze and Angermeyer 2003; Law et al.
2014; Vass et al. 2015; Wood et al. 2017).
Hope, empowerment and a high level of self-esteem are
among the basic components of subjective recovery (Pitt
et al. 2007; Leamy et al. 2011). Depression, which reflects
negative emotions, has been found predictive of subjective
recovery in both self-rated scales and clinician-completed
scales (van Eck et al. 2018a; Law et al. 2016; Lim et al.
2019). Longitudinal studies have also shown a continuation
of the relationship between subjective recovery and hope,
self-esteem, and depression (Law et al. 2016). In our study,
depression, hopelessness, and self-esteem had a strong cor-
relation with subjective recovery, but depression was not
predictive of subjective recovery.
Efforts to alleviate clinical symptoms and promote func-
tioning in the treatment of schizophrenia should also include
the provision of support to improve the subjective recovery
of patients. Subjective recovery is not a separate phenome-
non independent of objective recovery but is complementary
to it (Schrank and Slade 2007; Jørgensen et al. 2015; van
Eck et al. 2018a; Lim et al. 2019). As there are fluctuations
in the level of objective recovery, subjective recovery may
also have variations. The criterion of objective recovery may
not always align with the subjective recovery. Treatment and
rehabilitation in schizophrenia should involve approaches
and interventions to improve the feeling and perception of
personal/subjective recovery in addition to the elimination
of symptoms (Liberman and Kopelowicz 2005; Leamy et al.
2011). What do the patients think about themselves? What
is their perception of self? What is their perception of recov-
ery? How would they feel happier? What are their plans for
future? How would they lead a more meaningful life? Deal-
ing with questions like these during interviews and deter-
mining the treatment goals accordingly would be a human-
istic approach taking recovery beyond clinical recovery.
Limitations
Most of the participating patients were male. Therefore, it
would be advisable to repeat this type of study with a sam-
ple where female/male proportion is balanced. Assessing
depression, which is a clinical condition, using a self-report
13
Community Mental Health Journal
scale may have prevented an accurate rating of depres-
sion in the participants. Inclusion of a depression scale to
be assessed by psychiatry specialists in the data collecting
instruments would enable testing of the predictive value
of depression. Drug side effects (Resnick et al. 2004) that
may influence subjective recovery were not dealt with in the
study. Similarly, metacognitive capacity (Kukla et al. 2013;
Lysaker et al. 2018) that may be associated with subjective
recovery was also not considered. All participants were out-
patients with stable symptoms and exclusion of those who
fail to come to treatment and those who had alcohol-sub-
stance dependence makes it difficult to generalize the results
to all patients with schizophrenia. Since subjective recov-
ery was assessed in a cross-sectional study, data relating to
changes in subjective recovery in time were not available. It
would be advisable for further studies to assess subjective
recovery in a longitudinal study design also including other
psychosocial variables on a sample of patients with schizo-
phrenia who are at different stages of the illness.
Funding  The author/s received no financial support for the research,
authorship, and/or publication of this article.
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