Introduction
Schizophrenia, a severe mental illness, affects more than 21 million people worldwide.1 The persistent negative symptoms and cognitive impairment associated with schizophrenia have led to its classification among the top 25 leading causes of disability worldwide and the top 11 leading causes of reduced years lived with disability in 2013.2 The WHO’s Mental Health Action Plan 2013–2020 highlights the steps required to provide appropriate services for people with schizophrenia.3
Cognitive–behavioural therapy (CBT) is the primarily recommended psychological treatment for schizophrenia according to major guidelines.4 5 Abundant studies have proven that the effects of CBT on reducing positive symptoms,6 improving negative symptoms,7 conferring functional improvement,8 reducing the time of relapse9 and reducing suicidal ideation10 in patients with schizophrenia are significant. However, the remission of clinical symptoms does not meet the criterion for rehabilitation, and patient organisations have emphasised that recovery can occur even when psychotic symptoms are persistent.11 Recovery is an ongoing, complex and multidimensional process. According to different perspectives, schizophrenia recovery can be classified as clinical and personal.12 In the treatment of patients with schizophrenia, the primary goal traditionally is the clinical recovery. Clinical recovery includes remission of symptoms and functional improvement, which is the premise of other non-pharmacological treatments and rehabilitations. The relationship between the clinical and personal recovery is somewhat correlated, and both should be considered when monitoring the treatments and outcomes of patients with schizophrenia.13 The term ‘personal recovery’, which based on the perspective of individuals who have experienced mental illness,14 has been widely used in the literature to describe the patient-based definition of recovery.15 The most frequently cited patient-based definition is ‘the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.’16
Personal recovery varies from person to person, and it is difficult to define common characteristics. Different researchers also have their own definitions of personal recovery. Andresen et al 17 concluded that personal recovery included four key points: finding hope; re-establishing identity; finding meaning in life; and taking responsibility for recovery. Leamy et al 18 posited that the categories of personal recovery encompass connectedness, hope, identity, meaning and empowerment. Based on a cluster analysis of self-reported personal recovery-related variables, Rossi et al 19 identified resilience, self-esteem, coping strategies, stigma and personal strength. Furthermore, quality of life (QoL),20 21 taking control of one’s life,22 23 personal confidence and reliance on others24 have been found to be important components of personal recovery.
According to a review of the abundant literature on personal recovery, which have most consistently identified connectedness, hope and empowerment as relevant categories,13 and discussions by our research team, we decided to use the CHIME personal recovery model defined by Leamy et al 18: Connectedness–Hope–Identity–Meaning–Empowerment. In addition, this model is consistent with the context of recovery defined by the WHO.25 Based on the progress of pharmacological treatment of acute psychiatric symptoms of schizophrenia, QoL measurement has become an important indicator for evaluating clinical outcomes in patients with schizophrenia.26 Furthermore, QoL is one of the most commonly used outcome assessments. To better address the concept of personal recovery, we have also considered QoL in the assessment of personal recovery.
The concept of recovery is multidimensional; why, then, should personal recovery be the primary focus? Personal recovery pertains to patients’ ability to live a favourable, dignified and meaningful life. It is the core element of recovery from the patient perspective, and it is the ultimate aim of mental illness treatment. Moreover, some components of personal recovery, such as hope, are the foundations and preconditions of treatment and other outcomes.27 In addition, Jahn et al’s28 finding suggests that personal recovery is a protective factor against suicidal ideation in individuals with schizophrenia. However, existing knowledge about the role of CBT in personal recovery is highly limited, and the current meta-analyses focused only on clinical outcomes;29 30 therefore, the aim of this study was to determine the effectiveness of CBT for personal recovery in patients with schizophrenia. This research has been registered at PROSPERO (CRD: 42018085643), and the study protocol can be obtained via the following website: https://www.crd.york.ac.uk/PROSPERO/%23recordDetails.