WK 6 Assignment
ARTICLE
Qualitative Social Work Copyright ©2007 Sage Publications London, Thousand Oaks, CA and New Delhi, Vol. 6(1): 49–74 www.sagepublications.com DOI:10.1177/1473325007074166
The Role of Self-efficacy in Recovery from Serious Psychiatric Disabilities A Qualitative Study with Fifteen
Psychiatric Survivors
Michael A. Mancini St Louis University, USA
ABSTRACT This qualitative analysis applied the theory of self-efficacy to results from a study that used grounded theory to identify the factors that influenced the recoveries of 15 psychiatric survivors. Participants identified the development of a more competent and efficacious sense of self as a central aspect contributing to their recoveries. Analysis also revealed four factors related to this development: meaningful activities, supportive professional relationships, peer-support and choice among a variety of treatment alternatives. Partici- pants’ description of the recovery process and how they were able to develop a competent sense of self, possessed several parallels with Bandura’s social cognitive theory of self- efficacy. This article argues that self-efficacy may provide practitioners with a useful guide for creating the contexts that facilitate the recovery process. Implications for practice and research will be explored.
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KEY WORDS:
consumer narratives
psychiatric rehabilitation
recovery
self-efficacy
severe and persistent mental illness
INTRODUCTION
Studies have shown that people diagnosed with serious psychiatric disabilities such as schizophrenia are able to recover and live satisfying and productive lives in the community (Anthony, 1993; Anthony et al., 2002; Deegan, 1988; deGirolamo, 1996; Harding et al., 1987a,b; US Department of Health and Human Services [USDHHS], 1999).
The growing use of qualitative methodologies to understand how people recover from serious psychiatric disabilities has taken many forms and has led to numerous important discoveries (Davidson, 2003). For instance, several studies have used personal accounts of psychiatric survivors to develop an in-depth, first person understanding of the recovery process (Barham and Hayward, 1998; Cohen, 2005; Corin and Lauzon, 1992, 1994; Davidson and Strauss, 1992; Estroff, 1989; Jacobson, 2000; Mancini et al., 2005; Ochocka et al., 2005; Ridgway, 2001; Sullivan, 1994). These studies as well as personal testimony from leaders in the psychiatric survivor movement (Chamberlin, 1979; Deegan, 1988) and psychiatric rehabilitation literature (Anthony, 1993; Anthony et al., 2002; Corrigan and Ralph, 2005) have positioned recovery as a complex, subjective and dynamic process dependent upon numerous factors (Davidson and Strauss, 1992; Estroff, 1989; Jacobson, 2000; Jacobson & Greenley, 2001; Ridgway, 2001).
Data from early studies suggests that the development of self-efficacy – a view of the self as competent and agentic – may represent a significant and important contributory factor in helping people with psychiatric disabilities recover (Bandura, 1977, 1986, 2001; Watson and River, 2005). This discovery may hold important practice implications because identifying frameworks that effectively integrate the subjective aspects of the recovery process has been difficult (Kelley and Gamble, 2005).
This study explored the subjective aspects of the recovery process with 15 psychiatric survivors. Participants were consumer providers of mental health services meaning that they were diagnosed with serious psychiatric disabilities (e.g. schizophrenia-spectrum disorders; bipolar disorder, major depression), have utilized mental health services and provided mental health services to other psychiatric survivors. Participants were asked to reflect and describe the key factors that influenced their recoveries from serious psychiatric disabilities. Responses were originally analysed using a grounded theory approach (Glaser and Strauss, 1967) within the framework of symbolic interactionism (Blumer, 1969). Participants indicated that the heart of the recovery process was the trans- formation from an illness-dominated identity to an identity of agency, competence and well-being (see Mancini et al., 2005). Following this initial finding the theory of self-efficacy was used to organize the data post hoc after it was realized that: (1) the data possessed many parallels with the theory of self efficacy; and, (2) this theory could provide useful information for practitioners seeking to understand how they could create contexts that would facilitate
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recovery in their clients. The theory of self-efficacy (Bandura, 1986) will then be explored as a way to make sense of participants’ accounts of recovery and to identify how practitioners may begin to think about how to construct their practice in ways that acknowledge and value the subjective dimensions of the recovery process.
SUBJECTIVE ASPECTS OF THE RECOVERY CONCEPT
Recovery has been conceptualized as a unique and subjective experience. The subjective factors contributing to recovery that have been identified through qualitative analyses include the existence of hope (Ridgway, 2001), choice among recovery oriented treatment strategies (Cohen, 2005; Jacobson and Greenley, 2001; Sullivan, 1994), social support (Cohen, 2005; Jacobson and Greenley, 2001; Mancini et al., 2005), spirituality and religious life apart from one’s psychiatric condition (Barham and Hayward, 1998), meaningful activities such as work, school or activism (Mancini et al., 2005; Ridgway, 2001; Sullivan, 1994), establishment of human rights and elimination of stigma ( Jacobson and Greenley, 2001; Ridgway, 2001), self-help and peer support (Cohen, 2005; Mowbray and Tan, 1993), and self-determination (Fisher, 1994; Ochocka et.al., 2005).
Among the most important factors found to be associated with recovery has been the development of a positive, competent and agentic sense of self (Davidson and Strauss, 1992; Estroff, 1989; Jacobson, 2000; Jacobson & Greenley, 2001; Ochocka et al., 2005; Pettie & Triolo, 1999; Ridgway, 2001). For instance, in a longitudinal, qualitative study using grounded theory to analyze in-depth interviews with 28 people experiencing mental health issues, Ochocka et al. (2005) found that an important part of recovery involved a development of a positive sense of self through a negotiation of internal and external circum- stances. The authors note that taking control and becoming competent in one’s life is a key aspect of recovery from serious psychiatric disabilities. In addition, Cohen (2005) in analyzing oral histories of 36 psychiatric survivors identified self-efficacy and the development of an empowered sense of self as key components of the recovery process.
Quantitative methodologies have also been used to examine the sub- jective aspects of the recovery process. Resnick et al. (2005) have recently attempted to develop an empirical understanding of the subjective experience of recovery. Applying principle components and confirmatory factor analyses with a dataset from a large study of schizophrenia, they identified four main factors associated with the development of a ‘recovery orientation’ or ‘recovery attitude’: empowerment, hope and optimism, knowledge and life satisfaction. They propose that clinical interventions should focus on helping individuals develop recovery attitudes and suggest that recovery attitudes and positive outcomes may influence each other bi-directionally (Resnick et al., 2005).
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It is clear that empowerment is also important in the recovery process (Linhorst, 2006). Although the term empowerment can have different meanings in different contexts the subjective experience of empowerment includes a sense of perceived agency, control and self esteem (Linhorst, 2006). Therefore, understanding the contexts and conditions necessary for the development of self-efficacy, the belief in one’s own competence and agency, may hold important insights into how practitioners can facilitate the recovery process in their clients.
SOCIAL COGNITIVE THEORY AND SELF-EFFICACY
Bandura (1966) first defined self-efficacy as an individual’s personal assessment of their competence to perform tasks. Self-efficacy refers to a person’s belief in their ability to, ‘organize and execute the courses of action required to attain designated types of performances’ (Bandura, 1986: 391). Self-efficacy is a concept rooted in the idea that what one believes about their abilities in a given situ- ation are just as, if not more important than, their actual ability. This concept states that people’s behavior, performance, motivation, and emotions are based heavily on what people believe about themselves. In addition, how efficacious one believes they are in a given situation influences the choices they make, the risks they take, the motivation they have to engage in that situation and their overall performance. It has also proven to be a very good predictor of success on given tasks. For example, it has been shown that people who possess high self-efficacy on a given task do better on that task than people who have low self-efficacy on the same task (Bandura, 2001). Individuals with a high sense of competence in a given area are more likely to perceive difficult situations as challenges rather than risks, set more challenging goals, possess a high degree of perseverance in the face of obstacles, and are more resilient after failures (Bandura, 1986).
Therefore, self-efficacy has also been theorized to be a central component to human agency. That is, the extent to which people believe that they are in control of their own lives will determine the types of choices they will make and how they will behave (Bandura, 1986, 2001).
Self-efficacy develops from four main sources. One source of self-efficacy is ‘social persuasion’ defined as support and encouragement from important others. That is, self-efficacy is shown to improve if an individual is exposed to sustained and genuine encouragement from other individuals whom the person values or respects (Bandura, 1986).
Another source of self-efficacy is ‘vicarious experiences’. This refers to observing others successfully performing tasks. The effects of role-modeling become important here. If individuals who are uncertain about their own abilities in performing a specific task see similar others performing the task
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successfully, they are more likely to develop positive self-efficacy beliefs about their own abilities regarding that task (Bandura, 1986, 2000).
Third, the development of ‘mastery experiences’ is important in the development of a competent sense of self (Bandura, 1986). Perceived success on tasks can influence the creation of positive self-efficacy beliefs and can have a positive influence on an individual’s competence, motivation and persistence on tasks in the future.
Lastly, the ‘somatic and emotional states’ experienced while contemplat- ing and engaging in a certain task can influence how one perceives his or her competency regarding that task (Bandura, 1986). Experiencing a high level of anxiety, fear or negative thoughts can lead to the development of negative self-efficacy beliefs about a particular task (Bandura, 1986, 2000). Conversely, experiencing excitement, positive thoughts or joy when performing a particu- lar task is likely to increase self-efficacy (Bandura, 1986).
Since its development four decades ago (Bandura, 1966), the concept of self-efficacy has been used to analyze, understand and predict human behavior and cognition in a number areas including tobacco use (Colleti, 1985) and academic performance (D’Amico and Cardaci, 2003). This theory has also been used to examine and explain psychosocial well-being in children (Bandura et al., 2003) and in the areas of clinical depression (Stanley and Maddux, 1986) and substance abuse (DiClemente et al., 1995).
Self-efficacy has been less often utilized in research examining recovery from severe and persistent psychiatric disabilities and its effects are less clear. There is some weak empirical support for the relationship of self-efficacy and increased psychosocial functioning. Ventura et al. (2004) found that self-efficacy was related to better psychosocial coping responses in individuals with recent onset schizophrenia when faced with negative life events. Mueser et al. (1997) also found a relationship between self-efficacy and increased coping among individuals diagnosed with schizophrenia.
In addition, Pratt et al. (2005) recently found that self-efficacy was positively associated with psychosocial functioning in a sample of 85 adults diagnosed with schizophrenia or schizoaffective disorder. However, the nature of this relationship was less clear. For instance, when compared to other pre- dictors of psychosocial functioning such as premorbid functioning, negative symptoms and cognitive functioning it was found that negative symptoms were the most critical determinant of psychosocial functioning and not self-efficacy (Pratt et al., 2005). Therefore, early evidence suggests that the influence of self- efficacy on psychosocial functioning for people with schizophrenia spectrum disorders may be indirect and contingent on and mediated by other important factors (Pratt et al., 2005).
Although questions remain regarding the nature of self-efficacy’s role in the recovery of people diagnosed with serious psychiatric disabilities evidence
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does suggest that self-efficacy is in some way associated with improved outcomes. Understanding how practitioners can construct the contexts necessary for the successful development of self-efficacy is thus important for helping practitioners facilitate the recovery process in their clients.
This analysis will apply the theory of self-efficacy to results from a study that used grounded theory to identify the factors that influenced the recoveries of 15 psychiatric survivors who provide consumer-based services. Results indi- cated that environmental resources such as meaningful activities, professional and peer support, and choice among a variety of treatment alternatives played a key role in facilitating participants’ recoveries (Mancini et al., 2005). It was also discovered that these environmental resources were associated with an identity transformation that involved the development of a positive sense of self marked by agency, competence, and well-being (Mancini et al., 2005). The question that emerged from these original findings was: What frameworks exist that can be used to translate these findings into ways that could help mental health practitioners create the contexts necessary to facilitate this transformation?. The author utilized self-efficacy theory in order to answer this question because the personal and environmental factors participants identified as influencing their recoveries possessed several parallels with the concept of self-efficacy just described. These parallels will be outlined and discussed in the following sections along with suggestions and implications for social work practice with individuals diagnosed with psychiatric disabilities.
METHODOLOGY
Data Collection This study utilized in-depth, semi-structured interviews with 15 psychiatric survivors active in the survivor movement and the consumer provision of mental health services. An interview guide was constructed for this study. It emerged from the psychiatric rehabilitation, community mental health and consumer literature and through consultations and piloting with key informants within the psychiatric survivor movement. These informants reviewed the structure, content and language of the guide and provided insights into appropriate questions and question-wording in relation to their personal understanding of recovery, thus helping to contribute to the credibility and authenticity of the guide. For instance, key informants reviewed the language of the interview guide in order to ensure that it was clear, relevant and non-offensive. This information was triangulated with information from the literature on recovery from psychiatric disabilities. In order to further test the interview guide for relevance, clarity and usefulness it was piloted with two additional consumer-providers.
In interviews lasting 1.5 to 2.5 hours, participants were asked to discuss the experiences that helped and hindered their recoveries. For instance,
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participants were asked to discuss the people and experiences that facilitated their recovery as well as to identify and discuss setbacks or obstacles in their recovery. They were then asked to reflect on how their view of themselves as individuals has changed throughout the recovery process (if at all).
Sampling Participants were recruited through convenience and purposive sampling methods. Eligible participants (psychiatric survivors) in the study were defined as persons diagnosed with a psychiatric disability; were users of mental health services; currently provided services to other survivors in the form of advocacy, self-help, counseling, training, and/or research; and, self identified as being in recovery. As leaders in their field, the psychiatric survivors in this study had a working knowledge and understanding of what helps people recover and were able to apply that understanding in their current work. As a result, these indi- viduals were viewed as a particularly rich and untapped source of information regarding the recovery process.
Through a working relationship with consumer advocates within a Statewide Department of Mental Health in the Northeastern part of the USA, the author was able to identify and gain access to appropriate participants for this study.
Participants were members of a statewide consumer advocacy advisory panel. These individuals, by virtue of their position, had experienced serious psychiatric disability and recovery. These experts were actively involved in providing services to current mental health consumers and in promoting statewide recovery-oriented services, practices, and policies.
Participant criteria for the purposes of this study were threefold. First, participants had to be current or former consumers of psychiatric services and experienced serious psychiatric disability. Second, participants had to have experienced their own recovery from psychiatric disability via self-definition. Third, participants in the study were consumer-providers of mental health services. The author’s rationale for selecting participants diagnosed with serious psychiatric disability and who had experienced recovery is self-evident and contributes to the credibility of the sample. To discuss a personal account of illness and recovery, one must have experienced both of these phenomena. Persons who have experienced the phenomenon of recovery are best able to explicate and communicate the nuances of the experience.
The rationale for selecting only consumer-providers was to gather expert perspectives on the recovery experience. Consumer-providers are individuals who possess vast knowledge and experience with the concept of recovery. A key role of the peer advocate is to engage and assist other consumers in their own recovery and act as a role model to the recovery process. In other words, as a function of their position, they must have a working knowledge and
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understanding of what helps people recover and be able to apply that under- standing in their work. In order to do this they may routinely draw upon their own experiences and as a result, represent a rich source of information regard- ing the recovery process.
With the help of a key informant, eligible participants were identified and recruited by telephone and asked to participate in an interview study that would examine how they initiated, developed and maintained their recovery. All participants enthusiastically agreed to participate during the initial phone call. Because of scheduling constraints, one individual could not be interviewed resulting in an additional participant being scheduled.
Participants were interviewed in four urban centers located throughout the state. Two participants were interviewed in a large urban center in the western part of the state. Two other participants were interviewed in a semi- urban area in the central part of the state. Seven participants were interviewed in an urban center in the eastern part of the state and four participants were interviewed in a large metropolitan city in the southern part of the state.
Sample Characteristics Participants ranged in age from approximately 40–55 years old. Six participants held administrative positions in community agencies, while six participants engaged in direct service provision. Three were involved in program develop- ment, policy, training and/or research. Nine participants were women and 13 were Caucasian. One participant was an African American woman and one was a Latino woman.
Participants voluntarily reported diagnoses of schizophrenia, schizo- affective disorder, major depression, and bipolar disorder. Many stated that they received several diagnoses over the course of their treatment histories. In addition, all participants reported at least one hospitalization, while the majority reported more than one such incident. A decision was made not to formally ask participants their diagnosis after key informants had warned that this might be considered offensive and jeopardize the research relationship as many partici- pants rejected the relevance and validity of these diagnoses.
Analysis Commonalities in participant responses were identified and explored using a grounded theory approach (Charmaz, 2000; Glaser and Strauss, 1967; Miles and Huberman, 1994; Strauss, 1987; Strauss and Corbin, 1990). Grounded theory is an inductive method of cross-comparative analysis ideal for providing a ‘thick’ description of subjective and complex phenomena (Glaser and Strauss, 1967; Miles and Huberman, 1994; Strauss, 1987; Strauss and Corbin, 1990). Analysis using a grounded theory approach is also a credible means for understanding how individuals perceive themselves within a particular context (Charmaz, 2000).
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In short, grounded theory allows for the inductive and systematic exploration of the processes individuals engage in to develop meaning and action from their experiences (Charmaz, 2000).
Therefore, themes and categories from interviews were not defined beforehand and emerged from the data through a process of ‘open-coding’ and were refined through a process of ‘memo-writing’ and ‘theoretical sampling’ (Charmaz, 2000). The analysis process consisted of the investigator reading each interview three to four times prior to coding. During this immersion the in- vestigator took memo notes based on observations of the data. Memo notes were taken during the coding process as well. Interviews were audio-recorded, transcribed and coded by hand. Codes and themes emerged inductively from the data itself and did not originate from other outside sources (Charmaz, 2000; Glaser and Strauss, 1967). As the codes developed, sensitizing concepts emerged through the background literature and theoretical frameworks that informed the study. These sensitizing concepts were used to develop interpretations and organize an understanding of the data (Charmaz, 2000).
Common codes were then collapsed into broader categories and sub- categories through a constant comparison method within and between cases (Miles and Huberman, 1994). The memo notes taken during this process assisted in the identification and interpretation of these categories. Based on these observations, case summaries of each interview were constructed. These summaries were then used to make comparison both within and between cases. Categories and subcategories were then constructed and reconstructed through this process.
Through these comparisons, individual codes eventually developed into larger categories. These categories then developed into the analytic frameworks that help to better understand or describe the larger phenomenon under study (Charmaz, 2000; Glaser and Strauss, 1967). In this study, four main categories emerged: recovery definitions; recovery turning points; recovery barriers; and, recovery facilitators. There were approximately 102 initial codes across all inter- views, which were further grouped and collapsed. Following this initial analysis the categories and sub-categories were then re-synthesized using the theoreti- cal framework of social cognitive theory of self-efficacy as a guide.
The analysis in this study followed the grounded theory approach with some modifications. Grounded theory is distinctive in that data analysis and collection occur simultaneously (Charmaz, 2000). As data are refined through the coding and memo writing process, gaps or holes in the data often emerge. When this occurs the researcher then returns to his or her data sources and asks focused and specific questions that are limited to addressing these gaps. This allows researchers to further their understanding of the phenomena they are studying, refine ideas, and develop more valid understandings of their data (Charmaz, 2000; Strauss and Corbin, 1990).
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In this study interviews were conducted close in time to one another due to the feasibility constraints of time, travel costs and the schedules of the participants. For instance, interviews often had to be scheduled in clusters through all parts of the state in order to accommodate participants’ schedules since they often traveled extensively. This left narrow windows of time to schedule and complete interviews resulting in interviews being scheduled close in time to one another. This often prevented analysis of interviews to be conducted simultaneously with data collection. This limited the ability of the investigator to identify themes within each interview and to ask questions related to these emerging themes in subsequent interviews. As a result, data was formally analyzed subsequent to completion of all interviews. This may have limited the richness of the data. The notion and impact of self-efficacy could have been identified sooner and better explored in subsequent interviews had they been formally analyzed simultaneous with data collection.
However, extensive piloting of the interview instrument resulted in extremely rich interviews that provided voluminous amounts of data directly related to the research questions guiding this study. Therefore, the data gathered provided an enormous amount of information related to these questions. In addition, extensive field notes consisting of observations, thoughts and per- ceptions of the investigator were taken during and following each interview. These field notes were then analyzed and used to inform subsequent interviews. The researcher performed theoretical sampling during analysis by repeatedly asking questions of the data and then conducted analysis of the data based on these questions. The researcher then returned to the data in order to address the emerging questions. In addition, an outside reviewer was used in order to triangulate codes and categories and to debrief with the investigator about analysis issues. This outside reviewer analyzed codes developed from transcripts and cross compared these codes with case summaries and field notes in order to establish that codes adequately and exhaustively represented participants’ stories of recovery and that saturation of concepts relevant to recovery had been achieved in relation to the number of participants interviewed. It was concluded that saturation had been achieved as no new themes or ‘surprises’ had emerged in the participants’ stories.
LIMITATIONS
Due to the exploratory nature of this study, important limitations exist. First, the participants in this study represent a small and highly specialized group of recovered individuals. Their responses, beliefs and experiences may not be repre- sentative of the general population of individuals diagnosed with psychiatric disabilities. In addition, convenience sampling will prohibit the results from being generalized outside of this study’s data set, as responses may have been influenced by gender, geography, culture, age and a host of other characteristics.
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Second, the elicitation of narratives from individuals carries with it methodological caveats. Responses from participants may be influenced in a variety of ways. For instance, participants may have selective recall or gaps in their memory of events. Participants may also be motivated to frame their responses in a way that represents them in a favorable light. They may be moti- vated to frame their responses in ways that furthers their own socio-political goals regarding the recovery concept. And, they may have been influenced by cues from the researcher and have altered their responses to either comply with or contradict perceived cues.
Third, time constraints and restrictions in participants’ schedules resulted in some modifications to the grounded theory methodology. Although analysis of field notes and the development of case studies occurred after each inter- view and guided subsequent interviews via theoretical sampling procedures, formal analysis and data collection were not completely integrated as stipulated by the grounded theory methodology. This limitation could have limited the researchers ability to identify and explore issues in interviews as they emerged.
In addition, although the investigator took steps to assure the trust- worthiness of the results including using key informants in the construction and piloting of the interview instrument, and consultation with an outside debriefer to triangulate codes and categories, this study’s findings are limited because the investigator acted as the sole interviewer and main coder in this study. Because inter-rater reliability statistics were not generated and because outside interviewers and coders were not used, this study’s findings may be biased due to the subjectivity of the investigator.
Finally, this study did not originally seek to examine the role of self- efficacy in the recovery process. Rather, this theory was used to organize the data post hoc after it was realized that: (1) the data possessed many parallels with the theory of self-efficacy; and, (2) this theory could provide useful infor- mation for practitioners seeking to understand how they could create contexts that would facilitate recovery in their clients. As a result of this post hoc appli- cation, the data does not always display a ‘tight fit’ with the theory of self- efficacy. However, it is believed that the parallels that do exist provide important insights into how practitioners can create contexts that may facilitate recovery and are sufficient to warrant further discussion and explication in future research.
RESULTS
A significant theme in participants’ responses with regard to the factors that hindered and facilitated their recovery was that their recovery hinged on the development of competent and agentic identities. The factors that participants stated facilitated those identities will be presented via the lens of self-efficacy theory. Specifically, all participants reported four factors that helped facilitate
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their recoveries: supportive and egalitarian relationships; self-help peer role models; meaningful activities; and, choice among a variety of traditional and alternative treatments. These factors will be categorized according to their simi- larity with the four sources of self-efficacy described earlier: social persuasion, vicarious learning, mastery experiences and somatic and emotional well-being. Participants’ voices will be used to illustrate each concept. These concepts will then be synthesized into an overall framework for helping practitioners create the contexts conducive to the development of self-efficacious identities in their clients.
Social Persuasion via Supportive and Egalitarian Relationships Supportive relationships helped foster hope by communicating the expectation that participants could live productive and satisfying lives. Vincent described supportive relationships as a ‘cornerstone’ to his recovery.
I was given a message early on by everybody around me that I could get better . . . that recovery is possible . . . (Vincent)
Participants described relationships with supportive professionals as collaborative partnerships characterized by trust and respect rather than paternalism and coercion. Self-efficacy beliefs have been shown to develop through genuine support and encouragement from respected individuals (Bandura, 1986). Social persuasion has been identified as a main contributing source for self-efficacy. All participants attributed all or at least part of their recovery to the existence of at least one person who believed in them and provided unwavering interpersonal support over an extended period of time. Indeed, the recovery concept as described by participants was an extremely social process nurtured by egalitarian, collaborative partnerships with professionals. In contrast, participants were in agreement with other published personal accounts and testimony from psychiatric consumer-survivors that have concluded that coercion and force present significant barriers to recovery (Chamberlin, 1997; Deegan, 1988, 1996; Fisher, 1994).
Participants repeatedly described effective professionals in terms of their ability to develop positive relationships through active listening, understanding, support and warmth. These qualities were unanimously viewed as the most important factors in determining effective practitioners – even more so than specific interventions or treatment approaches. In fact, every participant stated they continued to utilize professionals either continuously or intermittently. Kelly provided a poignant example of a psychiatrist who provided her with warmth and compassion.
[She would say] ‘Kelly, I know in my heart of hearts you’re going to recover . . . you’ve got so much love of life and so many talents . . . borrow my belief in you until you can feel it again in yourself.’ . . . (Kelly)
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Therefore, participants’ stories indicate that the process of developing positive, supportive relationships, a cornerstone of effective social work practice and an essential ingredient in the development of self-efficacy, may represent a necessary ingredient in assisting individuals diagnosed with serious psychiatric disabilities in moving forward in their recoveries (Mead and Copeland, 2000).
Vicarious Learning via Self-Help Peer Role Models Another source for contributing to the development of positive self-efficacy beliefs is having access to respected and successful role models. Hope for the future has been found to be a vital part of recovery (Resnick et al., 2005; Ridgway, 2001). Likewise, when individuals diagnosed with serious psychiatric disabilities believe that recovery is impossible they are likely to fall into despair (Deegan, 1988). However, according to the self-efficacy model, if people have access to recovery role models – individuals with similar diagnoses who have recovered – they are more likely to develop positive self-efficacy beliefs about their own abilities regarding recovery (Bandura, 1986, 2001).
A substantial proportion of participants stated that the existence of peer support was a key factor in their recovery. They stated that being exposed to individuals who had similar experiences and had achieved recovery provided them with hope that recovery was possible. This realization motivated them to engage in activities that would help them move forward in their recovery. For instance, after attending a consumer-run conference, Cheryl described how she felt after meeting others who shared her experiences.
I felt transformed . . . I mean like a light bulb went off . . . I knew that it would be a continued struggle, but I had hope that there’s something more to me, there’s something more in my life that I can do. (Cheryl)
Through contact with other peers she learned that there were oppor- tunities to develop as a person. She learned that she could be ‘something more’ than a patient and could do many activities she was told were not possible. Self- help and peer support has also been cited in the literature as extremely useful in helping clients move forward in their lives and in their recovery (Cohen, 2005; Mead and Copeland, 2000; Mowbray and Tan, 1993; USDHHS, 1999).
Participants stated they often encountered an overall lack of understand- ing from their families and professionals and that this translated to further confusion and despair. Self-help groups provided participants with a sense of shared understanding and acceptance as evidenced by the following quote from Paul describing his first experience of a self-help meeting:
People were talking about their experiences . . . what was going on with them . . . what helped and what didn’t help . . . I consider that the turning point of my life . . . moving from an extremely dark, lonely isolated place to finding an environment where people weren’t going to judge me or tell me that I was lazy and they understood some of the things that I was going through. (Paul)
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Self-help provided Paul with hope and with information about how to achieve recovery. Peers provided undeniable proof that recovery was possible. Acting as recovery consultants or role models, they offered acceptance and ideas about how to best set and achieve recovery goals. As a result, participants were offered a road map for how to navigate their recovery journeys. The develop- ment of a collaborative and communal network of support provided partici- pants with a sense of agency and purpose that they stated was important in their recovery processes. The importance of self-help in the recovery process, both in this study and in the literature, suggests that helping clients access peer support networks may represent a useful practice in facilitating recovery.
Mastery Experiences via Challenging and Meaningful Activities An important source of self-efficacy is having an opportunity to develop a sense of mastery over a challenging or meaningful task (Bandura, 1986). Individuals who are able to engage successfully in particular tasks develop positive self- efficacy beliefs and can have a positive influence on an individual’s competence, motivation and persistence when undertaking tasks in the future. Participants indicated that engaging in meaningful and challenging activities such as work, school, volunteering, hobbies, self-help, activism or other pursuits provided them an opportunity to develop a sense of competence in their abilities and helped them grow and develop. For example, Sarah, now a consumer advocate, was discouraged by many mental health professionals from working due to their fear she would fail and exacerbate her symptoms. With the support of her mother and friends, Sarah began to work part time and then, later, full time. She also enrolled in computer classes and volunteered at a local prison. Eventually, she developed a career working for the Department of Mental Health as an advocate. She attributes part of her success to her early decision to resist the low expectations of her providers and find employment. When asked about what facilitates recovery she said the following:
Everything comes out of choice . . . I think when you are making your own choices and you’re determined that they’re yours and you’re doing what feels right for you then even when you’re in a lousy job that’s stressing you out making you symptomatic it’s the right way to go . . . (Sarah)
Participants stated that taking risks and engaging in growth-oriented experiences was one of the most important aspects of the recovery process. In the following quote Robert described his experience as a graduate psychology intern. He had recently been discharged from a six-month hospitalization. Follow- ing a recuperation period, he decided to resume his graduate studies and was accepted for an internship at a local psychiatric hospital. Robert was terrified at first because at the time, due to insulin coma treatments and psychiatric drugs,
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he states, ‘my mind was shot’. Despite this, Robert accepted the internship and over time became successful. Robert describes the confidence he was able to build through his successful negotiation of his internship.
[I] started to pick up on the stuff that I needed to learn and started to make some friends there and I was pretty well accepted among the other interns so that that success allowed me to build . . . and [I] sort of learned that I could do a lot and at the same time I was getting sharper mentally and feeling fairly normal . . . it was succeeding in a sense I was doin’ it as well or better than most. (Robert)
Taking risks, struggling and being successful were important themes generated by participants. Participants noted that the ability to take risks and learn from successes (and failures) was a key aspect of their recovery process because taking risks often led to building confidence in themselves and their abilities.
Participants were also unanimous in stating that professional paternalism was a barrier to recovery. They advocated for assisting and supporting clients in taking risks and suggested that overprotection and paternalism reinforced the message in them that they were incompetent, sick and fragile. They claimed that over time, these messages could solidify and result in an intractable sense of incompetence too often labeled as ‘lack of motivation’. Data from this study suggests that taking risks through challenging activities actually led to a better sense of mastery and self-efficacy in participants, and was one of the building blocks of their development toward a successful and satisfying life.
Emotional and Somatic Well-being via a Variety of Wellness Enhancing Tools Healthy and positive emotional and somatic states are vital in the development of efficacy (Bandura, 1986). Experiencing severe emotional or cognitive distress due to psychiatric symptoms, treatment effects, fear or negative thoughts can lead to the development of negative self-efficacy beliefs (Bandura, 1986). Therefore, reducing emotional and cognitive distress may help facilitate the development of self-efficacy. Participants relied on a wide variety of approaches to maintain a sense of stability in their thoughts, feelings and behaviors and that once they were able to think and feel more clearly, they were then able to effectively reflect on their lives, formulate plans and engage in activities designed to achieve recovery related goals. Whether through the use of medications, therapy or alternative approaches, all participants agreed that ‘self-determination and informed choice’ was of primary importance. This finding is also supported else- where (Cohen, 2005; Jacobson and Greenley, 2001; Mead and Copeland, 2000).
The strategies or tools that participants utilized were unique and often developed over many years of trial and error. Professional interventions such as counseling or medication were used in combination with self-help, meditation,
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exercise, hobbies, leisure, nutrition and lifestyle adjustments such as getting the right amount of sleep or limiting alcohol consumption to establish and maintain recovery.
Many participants described alternative ways in which they maintained their well-being. Kelly, in the following quote, described the ways she main- tains her well-being through alternative approaches:
A lot of us have explored and utilized the alternative therapies in our recovery. I have studied Tai Chi and studied Chi Quong and that really just gave me the awareness of subtle energy and just really learning to be able to kind of manipu- late that energy, to utilize that energy, to draw in that energy, to release energy really become conscious of the mind-body-spirit connection. (Kelly)
Some participants stated that getting the right type and dosage of medi- cation(s), sometimes after years of trial and error, had a major impact on initiating and maintaining their recovery. Nancy, a consumer-provider and rights activist, described her experience with medication and the impact it had on her recovery:
I went from crazy to pretty much remission due to medication . . . clearly if I didn’t take it I went crazy [and] if I did take it I was fine. (Nancy)
Nancy’s point illustrated some participants’ recoveries were facilitated by medications that allowed them to think more clearly, feel better, be more in control of their lives, and achieve a level of stability not possible prior to taking them.
However, other participants stated that medication was detrimental to their recoveries because of severe and persistent side effects. Terry, for example, described a situation in which she attempted to get off medications entirely. After a long search she stated that she had finally found a doctor who agreed to help her.
I brought a shoe box full of medication I think I was taking seventeen different things I was taking stuff for pain I was takin’ stuff for my depression they were given me stuff to go to sleep they were given me stuff to get me up in the morning I mean just it was craziness/I was a freakin’ zombie. (Terry)
Terry, and other participants, reported that her psychiatric medications hindered her recovery rather than facilitated it. These medications were often described as keeping participants in a state of confusion and lethargy that inter- rupted their ability to be productive and adequately perform normal adult roles. The role of medication in participants’ recovery was a key tension point in the study.
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However, those that did rely on medications stated that what was important was that their practitioners worked closely with them in helping ensure that they were fully educated about the various aspects of their medi- cations including side effects and their management, long-term effects, inter- actions, contraindications, dosages and alternative medications. Participants were therefore, well informed and supported in their decisions regarding their treat- ment regimen, a key factor in recovery advocated elsewhere (Mead and Copeland, 2000). Likewise, all participants in this study reported that taking responsibility for their health was a key factor in helping facilitate and maintain their recovery. They advocated that mental health clients should not be overtly or covertly encouraged to maintain a passive stance in their treatment. Rather, clients, presumably with the help of their practitioners should learn strategies designed to help them understand their diagnosis, realize what helps and hinders their well-being, learn how to recognize when symptoms may be returning or escalating and develop a crisis plan for action.
DISCUSSION
The development of self-efficacy played a key role in participants’ recoveries. Explicating how practitioners can enhance recovery in people diagnosed with serious psychiatric disabilities has been difficult and the exact nature and magni- tude of self-efficacy’s relationship with improved psychosocial functioning and recovery for people with serious psychiatric disabilities remains unclear and requires further study.
However, evidence from this study demonstrates that understanding the contexts that facilitate self-efficacy development may provide social workers and other mental health practitioners with valuable information regarding how professionals can positively influence the recovery process in people diagnosed with serious psychiatric disabilities. This study suggests that contexts that facili- tate self-efficacy beliefs are those in which clients: (1) are encouraged to take risks and engage in meaningful and challenging activities; (2) have warm and egalitarian professional relationships; (3) have access to self-help and peer- support networks; and, (4) can make informed choices among a variety of formal and alternative treatments. The following discussion will frame what partici- pants said helped their recovery within the context of self-efficacy and position these findings as preliminary suggestions for how social workers might facili- tate the recovery process in their clients.
Implications for Practice Developing competence through mastery experiences represents a key source of self-efficacy (Bandura, 1986). This may be important for people diagnosed with schizophrenia as mastery has also been found to be negatively associated
Mancini The Role of Self-efficacy in Recovery ■ 65
with psychopathology in schizophrenia patients (Bengtsson-Tops, 2004). Partici- pants’ stories suggest that engaging in meaningful activities such as work as well as other activities such as school, activism and volunteering helped them develop a sense of competence and agency. The important role of work in building a positive sense of self is established in the literature (Provencher et al., 2002). Participants also stated that meaningful activities such as work and school gave them the opportunity to develop skills and confidence. Providing opportunities to engage in mastery experiences such as employment or school represent important ways practitioners can help enhance clients’ self-efficacy and improve recovery outcomes.
Practitioners and agencies can create contexts for recovery by infusing the expectation that clients can engage in meaningful activities. This may sound self-evident, however, participants indicated in their stories that they were often discouraged from participating in work or other meaningful activities by practitioners because they feared that the stress of these activities would cause participants to relapse. Social workers concerns of liability and the pervasive conception of relapse as a failure of the client, worker or system may fuel a tendency to overprotect clients and discourage clients’ attempts to take mean- ingful, growth-oriented risks. Paternalism was described as a key barrier in participants’ recoveries (see Mancini et al., 2005). It may be a natural response for practitioners to feel protective of clients. However, it is important for practitioners and their clinical supervisors to recognize when these good in- tentions begin to interfere with a client’s sense of competence and recovery. Clients take risks by engaging in meaningful activities. Clients should be encouraged and supported in taking these types of risks and have opportunities to be successful, thus enhancing their self-efficacy. It should be noted that clients might fail. However, with support, practitioners can help their clients learn from their mistakes and move forward.
The evidence-based practice models of supported employment (Bond and Jones, 2005), supported education (Sullivan-Soydan, 2005) and supported housing (Carling, 1995) may assist practitioners in supporting their clients as they work toward their goals and also develop a sense of personal self-efficacy. These models have been proven to improve employment, education and housing outcomes for individuals with serious psychiatric disabilities. Supported employment and supported education models allows people with psychiatric disabilities to chose from a wide range of competitive employment positions or education programs and then provides them with professional support tailored to meet their needs and ensure continued success (Bond and Jones, 2005; Sullivan-Soydan, 2005). Likewise, supported housing helps people with psychiatric disabilities to attain mainstream community housing and provides structured and ongoing supports that help them to be successful as they live independently (Carling, 1995). These models of practice possess the potential to enhance self-efficacy because they
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give people the opportunity to develop mastery experiences in a number of life domains. More research is needed in order to understand if and how these models affect self-efficacy.
Participants in this study were unanimous in their identification of supportive professionals as vital to the recovery process. Participants defined supportive professionals as warm, respectful, caring and steadfast in their support. Participants stated that the professionals that supported them believed in their ability to recover and provided them with hope and strength. Social persuasion has been identified as another important source of self-efficacy (Bandura, 1986). Individuals develop self-efficacy through the encouragement and support of respected others. Although empathic understanding and relationship building are taught as hallmarks of social work practice it is often the case that the importance of relationship building is overlooked in real-world practice settings. Professional codes of ethics often promote ‘professional boundaries’ and the idea of ‘professional distance’, and may inadvertently inhibit practitioners’ abilities to form deep, warm and supportive relationships with clients by reinforcing hierarchical relationship structures. In addition, huge caseloads, decreased funding and high turnover rates prohibit practitioners from investing the time and energy it takes to form these relationships. Finally, the increased focus on the importance of compliance with psychiatric medication and the rise of forced inpatient and outpatient commitment laws may again restrict practitioners’ abilities to form egalitarian and trusting relationships, and may enhance the development of coercive treatment settings – identified as a key barrier to recovery (Mancini et al., 2005). These factors inhibit social workers and other practitioners from developing empowering relationships with their clients (Linhorst, 2006).
It is important for clinical supervisors to recognize the inherent importance of supportive professional relationships in helping individuals diagnosed with serious psychiatric disabilities in their recoveries. These relation- ships can provide the sense of agency and competence necessary for recovery. Social work training programs must also recognize that supportive, trusting and egalitarian relationships are the cornerstone to helping people develop self- efficacy and emphasize to students that supportive relationships are necessary in developing contexts conducive to recovery.
A third area that participants agreed was important to recovery was having access to self-help and peer support. Self-help and peer support provided many participants with mutual support and recovery role models. Once isolated, participants stated that when they were able to access peer support services they realized that they were not alone in their struggles and that recovery was possible. Self-efficacy is known to emerge from vicarious learning experiences (Bandura, 1986). That is, when an individual sees similar others performing tasks success- fully, their belief in their own abilities improves. Therefore, having access to
Mancini The Role of Self-efficacy in Recovery ■ 67
individuals who have experienced recovery provides people with psychiatric disabilities with hope that recovery is possible and a blueprint for achieving recovery.
Self-help and peer-provided services have shown positive clinical outcomes (Solomon and Draine, 1995a,b, 2001). Self-help programs have outcomes similar to professional therapists (Christensen and Jacobson, 1994; Gould and Clum, 1993) and have been shown to improve psychiatric symptoms and quality of life (Davidson et. al., 1999). They also show decreases in hospitalizations, improved daily functioning and an improved ability to manage one’s condition(s) (Kurtz, 1988; Powell, et. al., 2001). Less is known about how self-help and peer support effects self-efficacy and is an area of future research.
Practitioners can create contexts for clients that may help enhance their own self-efficacy and facilitate recovery by helping client’s access self-help and peer supports in the community. Social work practitioners can do this in a number of ways. Linhorst (2006) provides a review of the ways in which agencies and practitioners can help clients to access peer support networks. First, practitioners can become knowledgeable of the self-help and peer support resources in their particular community and help clients access these networks through referral (Segal et al., 2002). Second, social work practitioners and agencies can develop collaborative peer-partnerships with peer-support agencies in which each agency can share knowledge, training, services and resources in ways that are mutually beneficial (Solomon, 2004). Finally, social work agencies can recruit and hire paid peer providers to their teams. Agencies can then have a built in access point to self-help peer services for their clients (Solomon, 2004). By utilizing peer support networks, practitioners and agencies can help clients have access to vicarious learning experiences and role models that can help build self-efficacy and hope in the possibility of recovery. These networks can also help professional staff learn the importance of developing the supportive and egalitarian relationships that have already been shown to be important.
Participants also stated that choice among a variety of traditional and alternative mental health treatments was important in their overall recovery. Participants stated that traditional approaches such as medication and psycho- therapy and non-traditional approaches such as yoga and sports were vital to establishing emotional, physical and cognitive well-being. Participants stated that emotional and cognitive distress from both psychiatric symptoms and iatrogenic treatment effects were barriers to their recovery. A fourth source of self-efficacy is positive somatic and emotional states (Bandura, 1986). Individuals are better able to build self-efficacy and are better motivated if they are able to associate tasks with positive feelings such as exhilaration or joy. Feelings of anxiety, depression and fear interfere with the development of self-efficacy. In addition, Shahar et al. (2004) found that efficacy predicted a reduction in depressive symptoms over time.
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Participants stated that they were able to achieve states of well-being using a variety of approaches. Prior to their recoveries participants stated that they often did not have access to information about treatment options and associated part of their recovery with making informed choices about the approaches that worked best for them.
Being able to choose from a variety of options has also been identified as a key condition for empowerment (Linhorst, 2006) and recovery (Chamberlin, 1997; Jacobson and Greenley, 2001; Tenney, 2000). In this study, having access to a variety of treatment options and having the ability to choose from those treatments, enhanced participants’ self-efficacy and recovery. Practitioners can help enhance their clients’ self-efficacy and recovery if they are able to create treatment contexts defined by informed choice (Mead and Copeland, 2000).
Evidence suggests that helping clients diagnosed with serious psychiatric disabilities manage their own conditions through a structured psychoeducation program can lead to better symptom management and lower rates of relapse (Mueser et al., 2002). Practitioners must take the time to educate clients about the range of treatment options available to them. In addition, clients must be fully educated about the benefits, risks and drawbacks of all treatment options, particularly psychiatric medication. In addition, clients after being fully informed should have the right to choose which approaches they wish to pursue. This may be difficult if clients make choices that the practitioner believes to be unwise. However, the right to self-determination is a guiding principle in social work’s code of ethics and denying clients’ right to choose carries its own negative consequences such as apathy, despair and hopelessness.
Implications for Research Several implications for research exist. This study sought to apply the theory of self-efficacy to findings that emerged from a grounded theory analysis of consumer-providers’ stories about the factors that facilitate and hinder the recovery process (Mancini et al., 2005). This study did not originally seek to examine the role of self-efficacy in the recovery process. As a result of this post hoc application, the data does not always fit with the theory of self-efficacy. This is a limitation, and future research should explicitly and systematically seek to explore and define the connections between self-efficacy and recovery. Quali- tative studies that examine personal narratives of recovery should specifically explore how self-efficacy influences recovery and the contexts that facilitate its development. In addition, this study used an extremely limited sample. Partici- pants in this study were providers of peer services, middle class, educated and many possessed a high level of functioning prior to experiencing psychiatric disability. Participants were also similar in age and most were white. These factors may influence the importance self-efficacy plays in the recovery process. More
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research is needed that explores the contexts that facilitate recovery and self- efficacy in diverse populations.
Quantitative methodologies should continue to explore the causal pathways of recovery and establish whether self-efficacy has a direct effect or is mediated by other factors. Pratt et al. (2005) recently found that although self-efficacy was associated with higher levels of psychosocial functioning, this association was influenced by other factors, namely, the presence of negative symptoms and premorbid functioning. Further research is needed in this area as few studies have examined the role of self-efficacy in the recovery process. Doing so will better explicate how self-efficacy influences recovery and may lead to the discovery of other important factors associated with recovery.
In addition, there appears to be much overlap and confusion regarding concepts such as empowerment, self-efficacy, self-esteem and agency when discussing recovery. Further research that untangles these concepts and deciphers their individual influences may be especially important in further developing and explicating a recovery model. Likewise, developing more precise models of recovery will assist in the development of interventions that are complimentary to the contexts that facilitate recovery. For instance, Resnick et al. (2005) have recently proposed that interventions should be designed that enhance ‘recovery attitudes’ identified as consisting of: empowerment, hope and optimism, knowl- edge and life satisfaction.
Research on recovery should embrace a bio-psychosocial approach as it is becoming clear that psychological factors such as self perception and person- ality may be as important as biological (e.g. genetics, vulnerability) or social (income, housing, healthcare access) factors in determining outcomes for people diagnosed with serious psychiatric disorders (Shahar et. al, 2004). Further research that explores recovery contexts should be linked with intervention research in order to develop interventions that facilitate, compliment or enhance the bio-psychosocial factors found to facilitate recovery. Integrating objective, outcome oriented intervention research with what is known about the sub- jective aspects of recovery may help move beyond interventions that simply improve concrete research-oriented outcomes such as a reduction in hospital- ization days or number of symptoms, to interventions that help people with psychiatric disabilities become active citizens living fuller, more satisfying and productive lives.
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Michael A. Mancini is assistant professor in the School of Social Work at St Louis University. His teaching and research specializes in community mental health practices, qualitative methods, severe and persistent psychiatric dis- abilities, psychiatric rehabilitation and recovery. Address: Assistant Professor, St Louis University, School of Social Work, 302 Tegeler Hall, 3550 Lindell Blvd, St Louis, MO 63139, USA. [email: mancinim@slu.edu]