The recovery movement differentiated clinical, which is related to disorder’s symptoms, from personal recovery, which is outlined by a subjectively defined wellness state, characterised by hope and self-management. Schizophrenia research has long focused on risk factors and symptoms. The recovery movement triggered a focus shift from psychopathology towards better adjustment and growth despite living with schizophrenia.

The recovery movement flourished parallel with positive psychology, the scientific study of ordinary human strengths and virtues investigating human motives and potentials. Understanding of human strengths could contribute to prevention or lessening of psychiatric disorders’ devastating consequences, since optimism, sense of personal control and many other positive processes promote psychological health.

Lately, the concepts of positive psychology have been implemented in schizophrenia research. Positive self-appraisals moderated suicidal ideation, even when patients experienced high levels of hopelessness.¹ Additionally, among other factors, better self-images, internal locus of control (i.e. the perception that events in one’s life relate to one’s actions) and emphasis on personal efforts predicted a more favourable outcome in functioning of unmedicated patients.²

The concept of “resilience” is closely related to positive psychology. The American Psychological Association defines resilience as ‘‘the process of adapting well in the face of adversity, trauma, threats or significant sources of stress’’. The concept of resilience includes rebound from adversity.³

Determinants of resilience include biological, psychological, social and cultural factors that interact in a complex manner. The major manifestations of personal resilience are social competence, problem solving, autonomy and sense of purpose.5 Personality strengths that relate to resilience include high self-esteem, extroversion and optimism. Internal assets and personal competencies comprise the so called “phenomenological resilience” that can be measured by scales.^4,5

Originally, research focused on resilience in relation to post-traumatic stress disorder and depression. Recently, resilience was proven a significant predictor of depressive episode recurrence in bipolar disorder.⁶ Low resilience levels were also established in individuals at clinical high risk state for development of psychosis. Interestingly, individuals at high risk that developed a full-blown psychosis had shown significantly lower resilience levels compared with non-converters. Additionally, high resilience levels in individuals at high risk for psychosis related to less severe negative, anxiety and depressive symptoms, as well as higher social functioning.^7,8 Schizophrenia patients with higher resilience levels and optimism showed higher levels of happiness that associated in turn with lower perceived stress and higher personal mastery,⁹ while resilience was a significant predictor of functioning in a subgroup of non-medicated schizophrenia patients.¹⁰

In light of evidence supporting a positive association between resilience and schizophrenia outcome and based on the fact that resilience is modifiable and could improve with treatment,⁵ resilience studies are particularly meaningful, specifically within the first 3–5 years after schizophrenia onset,¹¹ and could lead to interventions that aim at harnessing resilience during this “critical period”. Diverse positive psychology interventions aim at improving psychological well-being by developing and nourishing positive feelings, behaviours and cognitions. Lately, positive psychotherapy was adapted for schizophrenia patients and was proven a feasible intervention that might contribute to improvement in functioning.¹²

Conclusively, sustained improvement in social and occupational functioning remains the most important indicator of recovery from schizophrenia. Still, such an improvement may not be accomplished in all patients by currently available pharmacological treatment alone. Studies that implement resilience and other positive psychology concepts reinforce schizophrenia research shift from risk to protective factors, reverse the question “which factors associate with relapse and chronicity” to “which factors promote recovery” and are promising for the development of additional therapeutic approaches.

Vasilis P. Bozikas
Associate Professor of Psychiatry, 1st Department of Psychiatry
Aristotle University of Thessaloniki

Eleni Parlapani
Assistant Professor of Psychiatry, 1st Department of Psychiatry
Aristotle University of Thessaloniki

References

1. Johnson J, Gooding PA, Wood AM, Taylor PJ, Pratt D, Tarrier N. Resilience to suicidal ideation in psychosis: Positive self-appraisals buffer the impact of hopelessness. Behav Res Ther 2010, 4:883–889
2. Harrow M, Jobe TH. Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study. J Nerv Ment Dis 2007, 195:406–414
3. Southwick SM, Bonanno GA, Masten AS, Panter-Brick C, Yehuda R. Resilience definitions, theory, and challenges: interdisciplinary perspectives. Eur J Psychotraumatol 2014, doi: 10.3402/ejpt.v5.25338
4. Bernard B. Resilience Outcomes: Personal Strengths. Resiliency: What we have learned. West Ed, San Francisco, 2004:13–35
5. Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety 2003, 18:76–82
6. Choi JW, Cha B, Jang J, Park CS, Kim BJ et al. Resilience and impulsivity in euthymic patients with bipolar disorder. J Affect Disord 2015, 170:172–177
7. Kim KR, Song YY, Park JY, Lee EH, Lee M et al. The relationship between psychosocial functioning and resilience and negative symptoms in individuals at ultra-high risk for psychosis. Aust N Z J Psychiatry 2013, 47:762–771
8. Marulanda S, Addington J. Resilience in individuals at clinical high risk for psychosis. Early Interv Psychiatry 2014, doi: 10.1111/eip.12174
9. Palmer BW, Martin AS, Depp CA, Glorioso DK, Jeste DV. Wellness within illness: happiness in schizophrenia. Schizophr Res 2014, 159:151–156
10. Torgalsbøen AK. Sustaining full recovery in schizophrenia after 15 years: does resilience matter? Clin Schizophr Relat Psychoses 2012, 5:193–200
11. Bozikas VP, Parlapani E, Holeva V, Skemperi E, Bargiota SI, Kirla D, Rera E, Garyfallos G. Resilience in patients with recent diagnosis of a schizophrenia spectrum disorder. J Nerv Ment Dis 2015, under review
12. Meyer PS, Johnson DP, Parks A, Iwanski C, Penn DL. Positive living: A pilot study of group positive psychotherapy for people with schizophrenia. The Journal of Positive Psychology: Dedicated to furthering research and promoting good practice 2012, doi:10.108 0/17439760.2012.677467

Full Article in pdf