Nowak et al.

BMC Psychiatry (2016) 16:228

DOI 10.1186/s12888-016-0912-8

RESEARCH ARTICLE Open Access

Disability and recovery in schizophrenia:

a systematic review of cognitive behavioral
therapy interventions
Izabela Nowak1*, Carla Sabariego2, Piotr Świtaj1 and Marta Anczewska1

Abstract
Background: Schizophrenia is a disabling disease that impacts all major life areas. There is a growing need for
meeting the challenge of disability from a perspective that extends symptomatic reduction. Therefore, this study
aimed to systematically review the extent to which traditional and “third wave” cognitive – behavioral (CBT)
interventions address the whole scope of disabilities experienced by people with lived experience of schizophrenia
using the WHO’s International Classification of Functioning, Disability and Health (ICF) as a frame of reference. It also
explores if current CBT interventions focus on recovery and what is their impact on disability domains.
Methods: Medline and PsycINFO databases were searched for studies published in English between January 2009
and December 2015. Abstracts and full papers were screened against pre-defined selection criteria by two reviewers.
Methodological quality of included studies was assessed by two independent raters using the Effective Public Health
Practice Project Quality assessment tool for quantitative studies (EPHPP) guidelines.
Results: A total of 50 studies were included, 35 studies evaluating traditional CBT interventions and 15 evaluating
“third wave” approaches. Overall, traditional CBT interventions addressed more disability domains than “third wave”
approaches and mostly focused on mental functions reflecting schizophrenia psychopathology. Seven studies met the
inclusion criteria of recovery-oriented interventions. The majority of studies evaluating these interventions had however
a high risk of bias, therefore evidence on their effectiveness is inconclusive.
Conclusions: Traditional CBT interventions address more disability domains than “third wave” therapies, however
both approaches focus mostly on mental functions that reflect schizophrenia psychopathology. There are also
few interventions that focus on recovery. These results indicate that CBT interventions going beyond symptom
reduction are still needed. Recovery-focused CBT interventions seem to be a promising treatment approach as
they target disability from a broader perspective including activity and participation domains. Although their
effectiveness is inconclusive, they reflect users’ views of recovery and trends towards improvement of mood,
negative symptoms and functioning are shown.
Keywords: Schizophrenia, Disability, International Classification of Functioning, Disability and Health (ICF),
Personal recovery, Cognitive-behavioral therapy

* Correspondence: [email protected]
1
First Department of Psychiatry, Institute of Psychiatry and Neurology,
Sobieskiego 9, 02-957 Warsaw, Poland
Full list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Nowak et al. BMC Psychiatry (2016) 16:228 Page 2 of 15

Background (CBTp) has gained large empirical support, however

Schizophrenia is a psychotic disorder that affects about results obtained in meta-analytic reviews [16–19], have
26 million people around the world [1]. It is typically been mixed leading to a debate over the effectiveness of
diagnosed in early adulthood, and mostly persists through- CBTp and pointing the need of its further development.
out peoples’ lives [2]. Several long-term follow-up studies One way of improving the outcomes of traditional CBT
have challenged the view about schizophrenia poor out- approaches is the inclusion of “third wave” CBT or more
come and proved that varying degrees of improvement are recently called “contextual” approaches to the theory and
possible [3–5], however schizophrenia is still one of the practice. Traditional CBT interventions actively focus on
main causes of disability worldwide [6]. identifying and changing the thought content in specific
The World Health Organization International disorders, whereas “third wave” approaches focus on modi-
Classification of Functioning, Disability and Health – fying the context and function of thoughts [20]. A number
ICF [7] provides a unified and standard language for of interventions represent “third wave” oriented CBT e.g.
the description of health, functioning and disability. mindfulness-based cognitive therapy (MBCT) [21], meta-
According to the ICF disability encompasses impairments cognitive therapy (MCT) [22], acceptance and commit-
of body functions, activity limitations or participation re- ment therapy (ACT) [23], dialectical behavior therapy
strictions, arising as a result of interaction between a health (DBT) [24], functional analytic psychotherapy (FAP) [25],
condition and contextual factors (i.e. personal and environ- integrative behavioral couple therapy (IBCT) [26] or
mental factors). An individual with lived experience of person-based cognitive therapy for psychosis [27]. There is
schizophrenia, might experience disability due to impair- a growing evidence supporting “third wave” interventions
ments of thought or perceptual functions (mental in schizophrenia indicating moderate effect sizes in redu-
functions) as well as difficulties in family relationships and cing negative symptoms [28].
interpersonal interactions or in acquiring and keeping a Current systematic reviews on CBT interventions in
job (activities and participation). Environmental factors schizophrenia mostly focus on symptomatic recovery,
such as accessibility to health services and appropriate i.e. on mental functions, as a primary treatment target
treatment, systems and policies of a country, or stigmatiz- [18, 19]. Although symptom reduction is undeniably
ing societal attitudes as well as personal factors e.g. low important in schizophrenia it is less clear the extent to
self-esteem impact the level of disability experienced. which traditional and “third wave” CBT interventions
Results of a systematic review by Świtaj et al. [8] indeed address the whole scope of disabilities experienced by
revealed that disability in schizophrenia does not only refer people with lived experience of schizophrenia. Consid-
to impairments of mental functions but also to several ering service users definitions of recovery it is also im-
activities and participation domains. This is in line with the portant to explore, whether current CBT interventions
recently developed ICF Core Set for Schizophrenia, which focus on recovery and what is their impact on disability
in addition to the above mentioned domains also includes domains. This information would be useful in the de-
various environmental factors [9]. As a result, there has velopment of CBT interventions that aim to support
been a growing need on the part of clinicians and re- people with lived experience of schizophrenia in over-
searchers to meet the challenge of reducing disability faced coming disabilities experienced in daily life through a
by people with schizophrenia from a broader perspective. process that is in line with the personal recovery ap-
Key elements of the broader perspective are service users’ proach. The objective of this systematic review is there-
views on personal recovery understood as the achievement fore threefold:
of a valued, meaningful life, rather than clinical recovery
[10, 11]. Elements of personal recovery have been recap- 1. to provide a comprehensive overview on disability
tured in the systematic review carried out by Leamy et al. domains considered by traditional and “third wave”
[12] who identified them as: connectedness; hope and opti- CBT interventions in schizophrenia using the ICF as
mism about the future; identity; meaning in life; and em- a frame of reference;
powerment (giving the acronym CHIME). Lloyd et al. [13] 2. to examine whether there are CBT interventions
revealed that subjective indicators of recovery such as focusing on personal recovery;
empowerment are associated with more objective recovery 3. to examine if recovery-oriented interventions effectively
dimensions such as level of participation in the community impact targeted disability domains.
and income from employment.
From the perspective of treatment various forms of The review specifically answers the following questions:
psychosocial interventions have been recommended as
an adjunct to medications, with cognitive-behavioral a) which disability domains are being addressed by
therapy (CBT) being one of the acknowledged interven- current CBT approaches?
tions [14, 15]. Cognitive behavioral therapy for psychosis b) are there CBT interventions that focus on recovery?
Nowak et al. BMC Psychiatry (2016) 16:228 Page 3 of 15

c) what is the effectiveness of CBT interventions focusing to personal recovery oriented intervention formulation
on recovery? or inclusion of personal recovery aspects in the interven-
tion conceptualization. Personal recovery was defined
Methods according the CHIME framework [12].
We adhered to the PRISMA guidelines for conducting Studies were excluded if:
and reporting systematic reviews for evaluating health
care interventions [29]. (a) included participants with active drug or alcohol
dependence, organic brain disease, severe cognitive
Search strategy deficits or documented mental retardation,
A systematic search was conducted using Medline and (b)considered primary prevention studies, phase I and
PsycINFO databases. Keywords, MeSH and Index terms II study, ecologic studies, case reports, case series,
for the search strategy were identified through reviewing cross-sectional studies, qualitative studies, economic
systematic reviews [16, 30] and studies relevant to the evaluations,
pre-established diagnosis, intervention and study design. (c) the primary target of interventions was not
The full search strategy is presented in Additional file 1. effectiveness,
The reference lists of previously published reviews were (d)CBT forming part of broader interventions,
also screened in order to identify papers that might have (e) hybrid forms of existing cognitive therapy,
been omitted in the systematic search. (f ) considered unpublished studies, book chapters,
dissertations, commentaries, letters to the editors,
Selection criteria editorials, conference reports.
Studies were included if:
Eligibility assessment
(a) published in English between January 2009 and Abstracts retrieved from databases were examined against
December 2015, the selection criteria by a trained reviewer. To increase re-
(b)considered adults (18–65 years), at least 50 % of the liability of this process 20 % of randomly selected abstracts
sample under the study with schizophrenia spectrum were double checked by a second reviewer, who was blind
disorders diagnosed by the International Classification to the decision of the first researcher. Papers considered
of Diseases, tenth edition (ICD-10) [31] or Diagnostic eligible were retrieved and examined by two researchers.
and Statistical Manual of Mental Disorders, fourth
edition (DSM-IV) [32]. We also included studies in Data extraction and data synthesis
which schizophrenia diagnosis was confirmed on the One reviewer extracted the following data from the in-
basis of medical records or the diagnostic criteria have cluded papers: the objectives of the study; study design;
not been explicitly specified but the study considered study population; outcome variables and questionnaires
people with spectrum of schizophrenia disorders. used; disability aspects; recovery orientation; and results.
(c) study design was Randomized Controlled Trial Extracted information about interventions involved the
(RCT), Clinical Controlled Trial (CCT), name, number of sessions, duration and frequency, inter-
observational study with/without control group, vention description and manual used. A matrix of trad-
(d)schizophrenia disability dimension was an outcome, itional and “third wave” CBT interventions was provided
(e) referred to traditional or “third wave” CBT with regards to conceptually or thematically-related cat-
interventions. egories of disability based on the ICF using the linking rules
described by Cieza et al. [33]. A separate categorization of
With regards to traditional approaches we selected stud- interventions focusing on recovery was also performed.
ies with intervention description including reference to (a)
establishing links between outcomes, thoughts and beliefs, Methodological assessment
distress or problem behavior (b) included re-evaluation of Included studies were independently assessed by two
perceptions, beliefs or reasoning [16] relating to the target researchers using the Effective Public Health Practice
outcomes. Regarding “third wave” interventions we in- Project (EPHPP) quality assessment tool [34]. This in-
cluded all acceptance-based, compassion-based, and strument permits quality evaluation of a wide range of
mindfulness-based approaches and interventions using study designs such as RCTs, CCTs, and observational
“third wave” strategies as one of the central compo- studies with and without control groups. Assessed quality
nents of the treatment conceptualization. In order to components included: selection bias, study design, con-
assess whether interventions focused on recovery, we founders, blinding, data collection methods, withdrawals
set the following criteria: indication by authors that the and drop-outs. Strong rating is given to a study if there is
intervention refers to recovery, which is further linked no weak component score. Moderate rating is given with
Nowak et al. BMC Psychiatry (2016) 16:228 Page 4 of 15

one weak component score. Weak rating is given with two eight controlled clinical trials (CCT), and sixteen cohort
or more component rating scores. studies. According to the EPHPP quality assessment tool
two studies (4 %) were qualified as strong, nineteen as
Results moderate (38 %), and twenty nine (58 %) as weak. The
Study selection most common reasons for the low quality of rating were
Study selection process is presented in Fig. 1. Fifty missing or insufficient information regarding the selection
articles were included in the review. of the study population as well as control of confounders.
Thirty-five studies considered traditional CBT interven-
Characteristics of included studies tions whereas fifteen referred to “third wave” approaches.
Included studies were mostly carried out in Europe Among these seven interventions were considered as meet-
(n = 31), predominantly in the UK (n = 21) and involved ing the established recovery criteria. Traditional CBT inter-
3213 participants who were recruited from in-patient and ventions were grouped according to their treatment focus,
out-patient settings. Forty-four papers reported partici- that is generic interventions (n = 15) or focusing on specific
pants’ gender, with men being in majority (58.9 %). Mean aspects such as hallucinations (n = 4), delusions (n = 3),
age of participants ranged between 23.48 and 47.12 years. negative symptoms (n = 2), emotions (n = 3), recovery
Only 14 studies reported participants’ duration of illness, (n = 5), suicide (n = 1), sleep (n = 1), and work (n = 1). Many
the mean ranged between 3.1 and 17.7 years. Eight studies interventions did not make a clear reference to change in
reported the number of participants’ hospitalizations, the beliefs, cognitive restructuring or re-evaluation of the sub-
mean ranged from 1.69 to 7.9 times. The selected studies jective meaning of the intervention targets. Some interven-
included twenty six randomized controlled trials (RCT), tions emphasized coping strategies instead [35] and others

Fig. 1 Flow diagram of the study selection process

Nowak et al. BMC Psychiatry (2016) 16:228 Page 5 of 15

combined CBT with other treatment approaches [36–38] Selected interventions varied with regards to the recovery
but overall were described as cognitive-behavioral. The in- concept. It ranged from interventions explicitly referring to
terventions were delivered on an individual, group or mixed the Recovery Movement [41] or recovery definitions that
basis, or using media-delivery modes such as a computer resemble the spirit and goals of the recovery paradigm
program, mobile SMS or internet. As regards the “third [42, 43] to other concepts such as social recovery [36]
wave” interventions they were grouped into generic (n = 1), or functional recovery [37]. Interventions also differed
mindfulness-based (n = 7), compassion-based (n = 1), and with regards to their content as many studies integrated
acceptance-based (n = 2) approaches, as well as person- recovery approach with a wide variety of already existing
based cognitive therapy (n = 1), metacognitive therapy therapeutic concepts and strategies. Identifying and work-
(n = 1) and recovery focused approaches (n = 2). Most in- ing towards meaningful personal goals seemed to be a core
terventions were delivered on a group basis. Some of the element of many recovery-focused approaches.
included “third wave” studies also used traditional CBT
techniques in their treatment conceptualization [39, 40]. What is the effectiveness of CBT interventions focusing on
recovery?
The impact of recovery-focused interventions on disability
Which disability domains are being addressed by current
domains was mostly pronounced in mental functions,
CBT approaches?
namely emotional functions – depression [37, 43, 44] anx-
Considering conceptualization of schizophrenia disability
iety [43], mood [42], affective flattening, and anhedonia
traditional approaches focus on changing the thought con-
[43]. Improvements were also reported in the domain of
tent whereas “third wave” therapies focus on modifying the
energy and drive functions (avolition) [41, 43], perceptual
context and function of thoughts. We assumed that the
functions (hallucinations), thought functions (delusions),
outcomes measuring the impact of the interventions on
language functions (alogia) and interpersonal problems
schizophrenia disability may also differ and the results were
[43]. Global scores related to disability also showed im-
presented separately. Outcomes measured in traditional
provements in aspects such as global psychopathology [36],
CBT interventions are displayed in Table 1.
general psychopathology [44], and positive symptoms [41].
Disability aspects addressed in “third wave” approaches
Regarding the domain of activity and participation
are presented in Table 2.
improvements were reported in work functioning at
It becomes evident that both traditional and “third
follow-up and participation in extended social network
wave” CBT approaches measured domains of mental
relationships across the trial [37]. Global scores of dis-
functions, however only studies evaluating traditional
ability and functioning showed improved functioning
CBT interventions addressed activity and participation
[37, 41, 42] as well as hours spent on economic and
domains. In traditional CBT approaches measured mental
structured activity [36].
functions mostly referred to thought functions (n = 18),
The above results have to be interpreted with caution as
perceptual functions (n = 16), followed by emotional func-
four of the studies [37, 42, 44, 45] were rated as weak with
tions such as depressive mood (n = 14) and anxiety (n = 8).
regards to the risk of bias, whereas three [36, 41, 43] were
“Third wave” interventions focused more on emotional
given a moderate rating.
functions such as depression (n = 7) rather than perceptual
(n = 4) or thought functions (n = 3). In the domain of
Discussion
activity and participation traditional CBT addressed em-
In the present systematic review we provide a compre-
ployment (n = 4), relationships with others (n = 4) and
hensive overview on disability domains considered by
treatment adherence (n = 2). There was also a number of
CBT interventions in schizophrenia using the ICF as
outcomes in both traditional and “third wave” CBT inter-
reference framework. We also examined whether there
ventions that we could not directly link to the ICF categor-
are any CBT interventions focusing on personal recovery
ies, therefore they were grouped under personal factors,
and the impact of these interventions on disability do-
global scores related to disability and others category. Re-
mains. We included 35 studies evaluating traditional CBT
sults considering these categorizations also show a high
interventions and 15 evaluating “third wave” approaches,
number of studies measuring the impact of interventions
7 of them met our inclusion criteria of personal recovery.
on schizophrenia psychopathology, which was followed by
Traditional CBT interventions addressed more disability
global disability and global functioning scores.
domains than “third wave” therapies, however in both ap-
proaches there was a strong emphasis on mental functions
Are there CBT interventions that focus on personal reflecting schizophrenia symptoms. Recovery-focused
recovery? interventions differed in the degree of clarity with regards
Seven studies were considered as focusing on personal to the recovery concept. These studies show significant
recovery (Table 3). impact on emotional functions, negative symptoms,
Nowak et al. BMC Psychiatry (2016) 16:228 Page 6 of 15

Table 1 Disability dimensions addressed by traditional CBT interventions

ICF categories n Traditional CBT Brief ICF
Core Set
Generic Hallucinations Delusions Negative Emotions Recovery Suicide Sleep Work
(n = 25)
(n = 15) (n = 4) (n = 3) symptoms (n = 3) (n = 5) (n = 1) (n = 1) (n = 1)
(n = 2)
Mental functions
Global psychosocial functions (b122) x
Temperament and personality 3 x x
functions (b126)
Worry (b1263) 3 x x
Energy and drive (b130) x
Apathy (b130) 4 x x x
Sleep functions (b134) 1 x
Attention (b140) 3 x x x x
Psychomotor function (b147) 1 x
Emotional functions (b152) x
Depression (b1522) 14 x x x x x
Anxiety (b152) 8 x x x x x
Anhedonia (b1520) 4 x x x
Hostility (b1522) 2 x x
Flat affect (b1522) 4 x x x
In general (b152) 4 x x x
Anger (b152) 1 x
Perceptual function (b156) 16 x x x x x x x
Thought functions (b160) 18 x x x x x x x x
Suicidal ideation (b1602) 3 x x
Higher-level cognitive functions (b164) 2 x x x
Cognitive flexibility (b1643) 2 x x
Insight (b1644) 7 x x x
Alogia (b167) 4 x x x
Experience of self and time x
functions (b180)
Activities and participation
Acquiring skills (d155) x
Solving problems (d175) x
Carrying out daily routine (d230) x
Handling stress and other psychological x
demands (d240)
Looking after one’s health (d570) x
Treatment adherence (d5702) 2 x
Interpersonal interactions and 2 x x
Relationships in general (d7)
Basic interpersonal interactions (d710) x
Complex interpersonal x
interactions (d720)
Aggressive behaviour (d7202) 2 x x
Family relationships (d760) x
Employment in general (d850) 2 x x
Nowak et al. BMC Psychiatry (2016) 16:228 Page 7 of 15

Table 1 Disability dimensions addressed by traditional CBT interventions (Continued)

Work efficiency (d850) 2 x x
Acquiring, keeping and x
terminating a job (d845)
Community life (d910) x
Personal factors
Satisfaction in general 1 x
Self-perception: self esteem 6 x x x x
Believes/awareness 4 x x x x
Social skills 1 x
General interpersonal skills 1 x
Living independently 2 x x
Global scores related to disability
Negative symptoms 18 x x x x x
Positive symptoms 16 x x x x x
Global symptomatology 18 x x x x x x x x
General psychopathology 7 x x x x x x x x
Global disability or global 10 x x x x x x
functioning
Social functioning 3 x x x
Others
Quality of life 7 x x x x
Wellbeing 3 x x x
n the number of articles addressing the disability dimension, x considered disability dimension

schizophrenia psychopathology, work functioning, partici- the illness and exacerbation of deficits in psychosocial
pation in extended social network relationships, global functioning often preceding attempted and completed
disability, functioning and hours spent on economic and suicide [46, 47].
structured activities. However, only three recovery-focused With regards to activity and participation the impact of
studies were rated as fair regarding the risk of bias. traditional CBT interventions mostly revolved around the
All studies included in this review have a strong focus area of relationships with others and employment which is
on mental functions, especially perceptual functions, also in line with Świtaj et al. [8] results. In studies evaluat-
thought functions and depressive mood, and fail to meas- ing “third wave” CBT no activity and participation domain
ure the impact of their interventions on a broad range of was included as an outcome but studies reported on global
activity and participation domains. However, in a recently scores related to disability, functioning and social function-
published systematic review on psychosocial difficulties in ing. In terms of treatment conceptualization “third wave”
schizophrenia [8] the proportion of reported mental func- approaches differ from the traditional CBT interventions by
tions against the activity and participation domain is com- deemphasizing the importance of changing the content and
parable. Results refereeing to mental functions are in line frequency of cognition while focusing on mindfulness and
with those reported by Świtaj et al. [8] where the most acceptance processes [48]. However as indicated by Khoury
extensively studied were cognitive (27 %) and emotional et al. [28] targeting these processes among people diag-
functions (27 %). This resembles the core aim of many nosed with schizophrenia spectrum disorders later trans-
CBT interventions, i.e. targeting the distress resulting lates into improvement of symptoms, functioning and
from psychotic symptoms. As reported by Jones et al. [16] quality of life. This might explain why the area of activ-
outcomes in CBT for psychosis are often defined in terms ity and participation was not the target of “third wave”
of the reduction in hallucinatory and delusional experi- approaches.
ence instead of eliciting emotional and behavioral changes, Our results indicate a mismatch between what is targeted
however our findings also indicate the strong emphasis in CBT for schizophrenia and the scope of disabilities expe-
on outcomes related to depressive mood. This supports rienced by persons with schizophrenia in daily life. In a
the stance on commonality of affective disorders in recent qualitative study it was shown that users’ perception
psychosis and its contribution to the suffering caused by of psychosocial difficulties or disability domains, revolve
Nowak et al. BMC Psychiatry (2016) 16:228 Page 8 of 15

Table 2 Disability dimensions addressed by “third wave” CBT

ICF codes n Third wave CBT Brief ICF
Core Set
Generic Mindfulness Compassion Acceptance Person-based Metacognitive Recovery
(n = 25)
(n = 1) based based based cognitive therapy therapy (n = 2)
(n = 7) (n = 1) (n = 2) (n = 1) (n = 1)
Mental functions
Global psychosocial functions (b122) x
Temperament and personality
functions (b126)
Mood (b1263) 1 x
Optimism (b1265) 1 x
Energy and drive functions (b130) x
Attention functions (b140) x
Emotional functions (b152) x
Depression (b1522) 7 x x x x x x
Anxiety (b152) 3 x x x
Anhedonia (b1520) 1 x
Hostility (b1522) 1 x
In general 3 x x
Mania (b152) 1 x
Emotional regulation (b1521) 1 x
Perceptual function (b156) 4 x x x x x
Thought functions (b160) 3 x x
Higher-level cognitive functions (b164) x
Insight (b1644) 3 x x x
Sleep functions (b134)
In general (b134) 2 x
Experience of self and time x
functions (b180)
Activities and participation
Acquiring skills (d155) x
Solving problems (d175) x
Carrying out daily routine (d230) x
Handling stress and other psychological x
demands (d240)
Looking after one’s health (d570) x
Basic interpersonal interactions (d710) x
Complex interpersonal interactions (d720) x
Family relationships (d760) x
Acquiring, keeping and terminating x
a job (d845)
Community life (d910) x
Personal factors
Perception and experience of 1 x
social support
Satisfaction in general 2 x x
Self-perception (in general) 1 x
Self-perception: self esteem 1 x
Nowak et al. BMC Psychiatry (2016) 16:228 Page 9 of 15

Table 2 Disability dimensions addressed by “third wave” CBT (Continued)

Self-perception: self-image 1 x
Self-efficacy 1 x
Believes/awareness 2 x x
Related to disability
Negative symptoms 8 x x x x x
Positive symptoms 7 x x x x x
Global psychopathology 4 x x x
General psychopathology 5 x x x x
Global disability or global 4 x x x x
functioning
Social functioning 1 x
Others
Quality of life 2 x x
Wellbeing 2 x x
Mindfulness 6 x x x
Acceptance 1 x
Self-compassion 2 x x
Experiential avoidance 3 x x x
Cognitive fusion 1 x
n the number of articles addressing the disability dimension, x considered disability dimension

around the activity and participation areas such problems of traditional CBT interventions included in this review
in relationships or finding and keeping work and place to targeted a wide spectrum of symptoms including negative
live. Many of the indicated psychosocial difficulties also symptoms and mood while “third wave” interventions
considered personal factors such as problems with self- targeted emotional distress arising from psychotic symp-
esteem or environmental factors e.g. experience of stigma toms. Having in mind the recent works shading light on
or frustrations with mental health services. Interestingly the activity and participation outcomes important for per-
users’ views of the domain of mental functions refer to sons with schizophrenia, it would be highly relevant if
emotional functions for example feeling fear or despair but studies would indeed examine the effectiveness of their
not to impairments of thought or perceptual functions [49]. interventions in these areas.
This may indicate that when human experience is consid- Although expectations of people with lived experience
ered these areas of functioning seem to be less prominent. of schizophrenia revolve around the recovery paradigm,
Several reasons might explain the strong focus on men- we have identified few CBT interventions focusing on
tal functions. The focus of traditional CBT interventions is personal recovery. Studies included in our review reflect
mostly on symptoms alleviation rather than functioning, the diversity of existing recovery definitions. They also
whether by directly targeting the psychotic symptoms or varied in their scope, however identifying and working
distress related with them. The underlying hypothesis towards meaningful personal goals seemed to be a core
behind that is the assumption that symptom alleviation element of many recovery-focused approaches. With
will automatically translate in improvement in functioning regards to the targeted disability dimensions the included
in general, what might explain why measures of global recovery interventions addressed relatively wide scope of
disability, functioning or social functioning are included both mental functions and activity and participation
while specific functioning domains related to activity and domains. Interestingly they did not extensively focused
participation are missing. However, as shown by Wykes on perceptual or thought functions but targeted dis-
et al. [17] improvements in positive symptoms were corre- ability aspects that mostly revolve around negative
lated with improvements in negative symptoms but did symptoms and emotional functions. In the area of ac-
not quite reach significance with regards to improved tivity and participation they targeted relationships, and
global functioning among people with schizophrenia employment. This points out that these interventions
spectrum disorders. Instead improvements in negative come closer to the desired broad perspective than
symptoms were indeed significantly correlated with traditional CBT interventions due to targeting personal
better functioning and improved mood. The majority recovery process but also using objectives measures of
 Nowak et al. BMC Psychiatry (2016) 16:228
Table 3 Characteristics of recovery focused interventions
Study Recovery Study design n Intervention group Control Follow up Outcome measures Impact on disability Quality of
(country) group rating
Farhall et al., Recovery concept: recovery. RCT 94 total Recovery therapy TAU 9 months Primary measures: No statistically significant Weak
2009 Australia Main content: the recovery 45 intervention (CBTp) + TAU PANSS; HADS. differences between
therapy intervention is a form 49 control Individual Secondary measures: CBTp + TAU and TAU.
of CBTp, which focuses on 12–24 sessions RSE; Self Report
agreed recovery goals using Insight Scale; LSP.
one or more recovery
therapy components such as
everyday coping, working
with symptoms,
understanding experience of
psychosis, strengthening
adaptive view of self,
personal/emotional issues or
comorbid disorders, relapse
prevention, and family or
social reintegration.
Fowler et al., Recovery concept: social CCT* 77 total Social Recovery TAU No follow Primary measures: No main effects of CBT Moderate
2009 The UK recovery. 35 intervention Cognitive Behaviour up Time Use Survey treatment for any of the
Main content: stage one 42 control Therapy (SRCBT) + Secondary measures: outcome variables for the
involved formulation of the TAU PANSS; BHS; QLS; total sample.
person in social recovery as Mean of 12 sessions Tertiary assessments: Global scores:
well as identifying day-to-day BDI-II; BAI; SOFAS; Non-affective psychosis
meaningful personal goals to CAN. group improved on
address motivation and PANSS.
hopelessness. Stage two Non-affective psychosis
involved identifying and group improved on
working towards medium- constructive economic
to long-term goals and activity and structured
promotion of a sense of activity (Time Use Survey).
agency and addressing
hopelessness, feelings of
stigma and negative beliefs
about self and others. Stage
three involved the active
promotion of social activity,
work, education and leisure
linked to meaningful goals,
while managing symptoms
of anxiety and low-level
psychotic symptoms.
Grant et al., Recovery concept: the RCT 60 total Cognitive Therapy Standard 6 months; Primary measures: Mental functions: Moderate
2012 Recovery Movement with 31 intervention plus standard treatment 12 months; GAS. Avolition-apathy (SANS)
The USA central features referring to 29 control treatment (ST) (ST) 18 months. Secondary measures: across the trial
goal-directed framework, Flexible SANS, SAPS. Global scores:

Page 10 of 15
personalized and person- Positive symptoms (SAPS)
oriented therapeutic across the trial.
approach highlighting the Global functioning (GAS)
across the trial.
 Nowak et al. BMC Psychiatry (2016) 16:228
Table 3 Characteristics of recovery focused interventions (Continued)
patients’ interests, assets, and
strengths.
Main content: initial sessions
focused on enhancing the
therapeutic relationship and
stimulating patients’ interest
and motivation to focus
respectively on achievable
goals. Impediments to goals
achievement were also
addressed in the later phases
of the intervention.
Johns et al., Recovery concept: recovery Pre + post 89 total Acceptance and No control 20 weeks The Sheehan Mental functions: Weak
2015 referred to as “living a Commitment Therapy group Disability Scales, Mood over time (HADS)
The UK satisfying, hopeful and Group HADS, AAQ-II, CFQ, Global scores:
contributing life even with 4 sessions, SMQ. Functioning over time
limitations caused by the one optional (The Sheehan Disability
illness” and “having a sense telephone session Scales)
of purpose and direction”. Other:
Main content: the authors Processes targeted by the
described the interventions intervention (AAQ-II, CFQ,
as compatible with SMQ).
conceptualizations of
recovery. The intervention
promoted psychological
flexibility (a more accepting,
mindful, and de-fused
approach) in response to
symptoms of psychosis and
associated emotions/
thoughts, in order to help
the person act in accordance
with their personal values.
Laithwaite Recovery concept: recovery. Pre + post 19 total Compassionate mind No control 6 weeks Primary measures: Mental functions: Weak
et al., 2009 Main content: a recovery training (CMT) group SCS, OAS, SeCS, BDI-II, Depression (BDI-II)
The UK intervention was based on Group RSE, SIP-AD. Second- Global scores:
the compassionate mind 20 sessions ary measures: PANSS. General psychopathology
training. During the first (PANSS)
module of the intervention Personal factors:
participants were encouraged Comparisons to others
to think about their recovery (SCS), self-esteem (RSE),
beyond symptom reduction external shame (OAS).
and as a journey of
experience. Further modules
targeted compassion with
reference to working on

Page 11 of 15
strength, acceptance,
forgiveness as well as
developing the ideal friend.
The last module focused on
 Nowak et al. BMC Psychiatry (2016) 16:228
Table 3 Characteristics of recovery focused interventions (Continued)
developing plans for recovery
after psychosis.
Study Recovery Study design n Intervention group Control Follow up Outcome measures Impact on disability Quality of
(country) group rating
Penn et al., Recovery concept: illness RCT 46 total Graduated Recovery TAU 3 months Primary outcomes: Activity and participation Weak
2011 management and functional 23 intervention Intervention Program QLS; RFS, MCAS; SSPA. domain: Work functioning
The USA recovery. 23 control (GRIP) (CBT) + TAU Secondary outcomes: at follow-up (RFS)
Main content: the program Individual the PANSS; CDSS; Within-group analysis
placed an emphasis on 36 sessions subscales from the Mental functions:
personal goal pursuit to Scales of Depression (CDSS) across
foster optimism and self- Psychological Well- the trial
esteem, targeted malleable Being; MSPSS; AUS; Activity and participation
factors that may enhance DUS; BEMIB. domain:
recovery such as residual Extended social network
symptoms and substance (RFS) across the trial
use, and enlists external Global scores:
social support to maximize Total role functioning
therapeutic gains and (RFS) across the trial
engagement. The intervention Personal factors:
consisted of four phases: Social competence
engagement and wellness (MCAS) across the trial
management; substance use;
persistent symptoms; and
functional recovery.
Williams et al., Recovery concept: the CCT 47 total Cognitive-behavioural TAU No follow SAPS, SANS, PSYRATS, Mental functions: Moderate
2014 recovery model described as 30 intervention therapy up DASS, IIP. Delusions (SAPS)
The UK building a meaningful and 17 control Individual and group Hallucinations (SAPS)
satisfying life defined by the 35 planned sessions Affective flattening (SANS)
person themselves, focusing Alogia (SANS)
upon strengths and wellness Anhedonia (SANS)
not illness and pathology, a Avolition (SANS)
sense of hope, and possibility Depression (DASS)
of change, promotion of self- Anxiety (DASS)
management and personal Overall interpersonal
identity (not patient identity), problems (social
the therapeutic relationship inhibition and self-
being one of partnership sacrifice) (IIP)
not “expert-patient”; and
encouragement of group
members to help each other
in recovery.
Main content: The
intervention was delivered in
five modules. The first one
focused on engagement and

Page 12 of 15
treatment preparation,
module two on individual
analysis of the person and
schizophrenia, module three
understanding and managing
 Nowak et al. BMC Psychiatry (2016) 16:228
Table 3 Characteristics of recovery focused interventions (Continued)
positive symptoms, module
four maximizing mental
health and module five
reviews of personal aims and
goals, reinforcement of
protective factors,
development of a detailed
relapse recognition and
staying well plan as well as
discussion of future
directions.
CCT Clinical Controlled Trial, CCT* Clinical Controlled Trial (EPHPP criteria regarding RCTs where the allocation method is not described or allocation is transparent before assignment), Pre + post Cohort (one group pre + post
(before and after)), RCT Randomized Controlled Trial, TAU Treatment as usual, n number of participants, PANSS Positive and Negative Syndrome scale, HADS The Hospital Anxiety and Depression Scale, RSE Rosenberg Self-
Esteem scale, LSP the Life Skills Profile, BHS Beck Hopelessness Scale, QLS Quality of Life Scale, BDI-II the Beck Depression Inventory, BAI the Beck Anxiety Inventory, SOFAS the Social and Occupational Functioning Assessment
Scale, CAN the Camberwell Assessment of Needs, GAS The Global Assessment Scale, SANS Scale for the Assessment of Negative Symptoms, SAPS The Scale for the Assessment of Positive Symptoms, AAQ-II The Acceptance and
Action Questionnaire, CFQ The Cognitive Fusion Questionnaire, SMQ The Southampton Mindfulness Questionnaire, SCS Social Comparison Scale, OAS The Other as Shamer Scale, SeCS Self-Compassion Scale, SIP-AD The Self-
Image Profile for Adults, RFS The Role Functioning Scale, MCAS The Multnomah Community Ability Scale, SSPA The Social Skills Performance Assessment, CDSS the Calgary Depression Scale for Schizophrenia,
MSPSS The Multidimensional Scale of Perceived Social Support, AUS the Alcohol Use Scale, DUS Drug Use Scale, BEMIB The Brief Evaluation of Medication Influence and Beliefs, PSYRATS the Psychotic Symptom
Rating Scales, DASS Depression Anxiety Stress Scale, IIP The Inventory of Interpersonal Problems

Page 13 of 15
Nowak et al. BMC Psychiatry (2016) 16:228 Page 14 of 15

negative symptoms which were shown to be related Additional file

with increased functioning and mood.
The evidence on effectiveness of these interventions is Additional file 1: Search strategies for MEDLINE and PsycINFO. (DOCX 14 kb)
inconclusive, due to the fact that many addressed out-
comes considered global scores of disability and func- Abbreviations
ACT, acceptance and commitment therapy; CBT, cognitive – behavioral
tioning and that four of the seven included studies had interventions/therapy; CBTp, cognitive-behavioral therapy for psychosis; CCT,
weak rating regarding study quality. Studies of good Clinical Controlled Trial; CHIME, connectedness, hope and optimism about the
methodological quality including as outcomes not global future, identity, meaning in life, empowerment; DBT, dialectical behavior therapy;
DSM-IV, American Psychiatric Association Diagnostic and Statistical Manual of
functioning but the specific functioning domains rele- Mental Disorders, fourth edition; EPHPP, Effective Public Health Practice Project
vant to persons with schizophrenia are therefore needed. Quality assessment tool for quantitative studies; FAP, functional analytic psycho-
This review should be interpreted considering several therapy; IBCT, integrative couple therapy; ICD-10, the International Classification of
Diseases, tenth edition; ICF, International Classification of Functioning, Disability
limitations. Firstly, we only analyzed papers that were pub- and Health; MBCT, mindfulness-based cognitive therapy; MCT, metacognitive ther-
lished in English and used two databases. Nevertheless, to apy; RCT, Randomized Controlled Trial
complement the search we checked reference lists of other
Acknowledgements
systematic reviews. Secondly, we set the time limit 2009– We wish to thank the reviewers for their insightful comments on earlier
2015 for the selected studies, therefore it is possible we did versions of this manuscript.
not consider some relevant papers that were published be-
fore this time frame. Thirdly, we cannot generalize the Funding
The research leading to these results has received funding from the People
findings as majority of studies came from high income Programme (Marie Curie Actions) of the European Union’s Seventh Framework
countries and disabilities in schizophrenia may depend on Programme FP7/2007 – 2013 under REA grant agreement n° 316795.
the economic, political and cultural context [8]. Fourthly,
Availability of data and materials
despite the existence of guidelines for developing recovery- The data and materials used in this review are available on request.
oriented services we felt that the implications for clinical
practice were not clear [50, 51]. Therefore, we used the Authors’ contributions
IN carried out the search of literature, reviewed the abstracts and full texts,
CHIME personal recovery framework as it provides useful evaluated the study quality, and drafted the manuscript. PŚ reviewed the
information regarding the key recovery process to be po- abstracts, full texts as well as assessed independently the quality of studies
tentially targeted by the interventions [12, 52]. Another as a second reviewer. CS and MA made important contributions to the study
design and data interpretation. The final manuscript was critically revised
limitation of the study is that integrative metacognitive and approved by all authors.
models [53, 54], which have been specifically designed to
target subjective recovery were not considered in our re- Competing interests
The authors declare that they have no competing interests.
view. Further studies should evaluate the impact of such
interventions on schizophrenia disability. Consent for publication
Not applicable.
Conclusions
Ethics approval and consent to participate
Despite the growing need of shifting the focus from Not applicable.
symptom-oriented approaches to treatment conceptual-
izations that support real-world functioning of service Author details
1
First Department of Psychiatry, Institute of Psychiatry and Neurology,
users, our study indicate that traditional and “third Sobieskiego 9, 02-957 Warsaw, Poland. 2Department of Medical Informatics,
wave” CBT interventions mostly focus on aspects of Biometry and Epidemiology – IBE, Chair for Public Health and Health Services
disability that relate to mental functions. There are also Research, Research Unit for Biopsychosocial Health,
Ludwig-Maximilians-Universität München, Munich, Germany.
few interventions that focus on personal recovery, how-
ever they seem to be a promising treatment approach Received: 31 July 2015 Accepted: 7 June 2016
as they target disability from a broader perspective in-
cluding activity and participation domains. Despite the References
limited evidence of their effectiveness it might be valu- 1. World Health Organization. The global burden of disease: 2004 update.
able to explore further possibilities of developing 2008. http://www.who.int/healthinfo/global_burden_disease/2004_report_
update/en/. Accessed 25 July 2015.
recovery-oriented CBT interventions as they reflect 2. Tandon R, Nasrallah HA, Keshavan MS. Schizophrenia, “just the facts” 4.
users’ views of recovery and target disability outcomes Clinical features and conceptualization. Schizophr Res. 2009;110:1–23.
that in previous studies have been shown to improve 3. Bleuler M. The Schizophrenia Disorders. Long-Term Patient and Family
Studies. New Haven and London: Yale University Press; 1978.
mood and functioning. Perhaps the best practices from 4. Harding CM, Brooks GW, Ashikaga T, Strauss JS, Breier A. The Vermont
both traditional and “third wave” approaches could be longitudinal study of persons with severe mental illness. I. Methodology,
combined in order to maximize their therapeutic po- study samples, and overall status 32 years later. Am J Psychiatry.
1987;144:718–26.
tential in terms of what matters to persons with 5. Jobe TH, Harrow M. Long-term outcome of patients with schizophrenia: a
schizophrenia. review. Can J Psychiatry. 2005;50:892–900.
Nowak et al. BMC Psychiatry (2016) 16:228 Page 15 of 15

6. World Health Organization. World report on disability 2011. http://www. 31. World Health Organization. International statistical classification of diseases
who.int/disabilities/world_report/2011/report.pdf. Accessed 25 July 2015. and related health problems, tenth revision. Geneva: World Health
7. World Health Organization. International Classification of Functioning, Organization; 1992.
Disability and Health-ICF. Geneva: World Health Organization; 2001. 32. American Psychiatric Association. Diagnostic and Statistical Manual of
8. Świtaj P, Anczewska M, Chrostek A, Sabariego C, Cieza A, Bickenbach J, et al. Mental. Disorders. 4th ed. Washington, DC: American Psychiatric
Disability and schizophrenia: a systematic review of experienced Association; 1994.
psychosocial difficulties. BMC Psychiatry. 2012;12:193. 33. Cieza A, Geyh S, Chatterji S, Kostanjsek N, Üstün B, Stucki G. ICF linking rules:
9. Brief ICF Core Set for Schizophrenia. http://www.icf-research-branch.org/ an update based on lessons learned. J Rehabil Med. 2005;37:212–8.
download/send/9-mentalhealth/255-brief-icf-core-set-for-schizophrenia. 34. Thomas BH, Ciliska D, Dobbin M, Micucci S. A process for systematically
Accessed 26 July 2015. reviewing the literature: providing the research evidence for public health
10. Deegan PE. Recovery: the lived experience of rehabilitation. Psychosoc nursing interventions. Worldviews Evid Based Nurs. 2004;1:176–84.
Rehabil J. 1988;11:11–9. 35. Penn DL, Meyer PS, Evans E, Wirth RJ, Cai K, Burchinal M. A randomized
11. Andresen R, Oades L, Caputi P. Psychological recovery: beyond mental controlled trial of group cognitive-behavioral therapy vs. enhanced
illness. Chichester, West Sussex: Wiley-Blackwell; 2011. supportive therapy for auditory hallucinations. Schizophr Res.
12. Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework 2009;109:52–9.
for personal recovery in mental health: systematic review and narrative 36. Fowler D, Hodgekins J, Painter M, Reilly T, Crane C, Macmillan I. Cognitive
synthesis. Br J Psychiatry. 2011;199:445–52. behaviour therapy for improving social recovery in psychosis: a report from
13. Lloyd C, King R, Moore L. Subjective and objective indicators of recovery in the ISREP MRC Trial Platform study (Improving Social Recovery in Early
severe mental illness: a cross-sectional study. Int J Soc Psychiatry. 2010;56: Psychosis). Psychol Med. 2009;39:1627–36.
220–9. 37. Penn DL, Uzenoff SR, Perkins D, Mueser KT, Hamer R, Waldheter E. A pilot
14. Dixon LB, Dickerson F, Bellack AS, Bennett M, Dickinson D, Goldberg RW, investigation of the Graduated Recovery Intervention Program (GRIP) for
et al. The 2009 schizophrenia PORT psychosocial treatment recommendations first episode psychosis. Schizophr Res. 2011;125:247–56.
and summary statements. Schizophr Bull. 2010;36:48–70. 38. Waller H, Emsley R, Freeman D, Bebbington P, Dunn G, Fowler D, et al.
15. National Collaborating Centre for Mental Health. Psychosis and Thinking Well: a randomised controlled feasibility study of a new CBT
schizophrenia in adults. National Clinical Guideline Number 178. London: therapy targeting reasoning biases in people with distressing persecutory
National Institute for Health and Clinical Excellence; 2014. delusional beliefs. J Behav Ther Exp Psychiatry. 2015;48:82–9.
16. Jones C, Hacker D, Cormac I, Meaden A, Irving CB. Cognitive behaviour 39. Dannahy L, Hayward M, Strauss C, Turton W, Harding E, Chadwick P. Group
therapy versus other psychosocial treatments for schizophrenia. Cochrane person-based cognitive therapy for distressing voices: pilot data from nine
Database of Systematic Reviews 2012, Issue 4. Art No.: CD008712. doi:10. groups. J Behav Ther Exp Psychiatry. 2011;42:111–6.
1002/14651858.CD008712.pub2. 40. Shawyer F, Farhall J, Mackinnon A, Trauer T, Sims E, Ratcliff K, et al. A randomised
17. Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapy for controlled trial of acceptance-based cognitive behavioural therapy for command
schizophrenia: effect sizes, clinical models, and methodological rigor. hallucinations in psychotic disorders. Behav Res Ther. 2012;50:110–12.
Schizophr Bull. 2008;34:523–37. 41. Grant PM, Huh GA, Perivoliotis D, Stolar NM, Beck AT. Randomized trial to
18. Jauhar S, McKenna PJ, Radua J, Fung E, Salvador R, Laws KR. Cognitive- evaluate the efficacy of cognitive therapy for low-functioning patients with
behavioural therapy for the symptoms of schizophrenia: systematic review schizophrenia. Arch Gen Psychiatry. 2012;69:121–7.
and meta-analysis with examination of potential bias. Br J Psychiatry. 42. Johns LC, Oliver JE, Khondoker M, Byrne M, Jolley S, Wykes T, et al. The
2014;204:20–9. feasibility and acceptability of a brief Acceptance and Commitment Therapy
19. van der Gaag M, Valmaggia LR, Smit F. The effects of individually tailored (ACT) group intervention for people with psychosis: the ‘ACT for life’ study.
formulation-based cognitive behavioural therapy in auditory hallucinations J Behav Ther Exp Psychiatry. 2016;50:257–63.
and delusions: a meta-analysis. Schizophr Res. 2014;156:30–7. 43. Williams E, Ferrito M, Tapp J. Cognitive-behavioural therapy for schizophrenia
20. Hayes SC, Villatte M, Levin M, Hildebrandt M. Open, aware, and active: in a forensic mental health setting. J Forensic Pract. 2014;16:68–77.
contextual approaches as an emerging trend in the behavioral and 44. Laithwaite H, O’Hanlon M, Collins P, Doyle P, Abraham L, Porter S, et al. Recovery
cognitive therapies. Annu Rev Clin Psychol. 2011;7:141–68. after psychosis (RAP): a compassion focused programme for individuals residing
21. Teasdale JD, Segal Z, Williams JMG. How does cognitive therapy prevent in high security settings. Behav Cogn Psychother. 2009;37:511–26.
depressive relapse and why should attentional control (mindfulness) 45. Farhall J, Freeman NC, Shawyer F, Trauer T. An effectiveness trial of cognitive
training help? Behav Res Ther. 1995;33:25–39. behaviour therapy in a representative sample of outpatients with psychosis. Br
J Clin Psychol. 2009;48:47–62.
22. Wells A. Emotional disorders and metacognition: Innovative cognitive
46. Birchwood M, Trower P. The future of cognitive–behavioural therapy for
therapy. Chichester: John Wiley & Sons; 2002.
psychosis: not a quasi-neuroleptic. Br J Psychiatry. 2006;188:107–8.
23. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: An
47. Mulholland C, Cooper S. The symptom of depression in schizophrenia and
Experiential Approach to Behavior Change. New York: Guilford Press; 1999.
its management. Adv Psychiatr Treat. 2006;6:169–77.
24. Linehan MM. Dialectical behavioral therapy: a cognitive behavioral approach
48. Morris EM, Johns LC, Oliver JE. Acceptance and commitment therapy and
to parasuicide. J Pers Disord. 1987;1:328–33.
mindfulness for psychosis. Hoboken, NJ: John Wiley & Sons; 2013.
25. Tsai M, Kohlenberg RJ, Kanter JW, Kohlenberg B, Follette WC, Callaghan GM.
49. Hartley S, McArthur M, Coenen M, Cabello M, Covelli V, Roszczynska-Michta J,
A guide to functional analytic psychotherapy: awareness, courage, love and
et al. Narratives reflecting the lived experiences of people with brain
behaviorism. New York: Springer; 2008.
disorders: common psychosocial difficulties and determinants. PLoS
26. Jacobson NS, Margolin G. Marital Therapy: strategies based on social
One. 2014;9(5):e96890.
learning and behavior exchange principles. New York: Brunner/Mazel;
50. Davidson L, Tondora J, Lawless MS, O'Connell M, Rowe M. A practical guide
1979.
to recovery-oriented tools for transforming mental health care. New York:
27. Chadwick P. Person-based cognitive therapy for distressing psychosis. Oxford University Press; 2009.
Chichester: John Wiley & Sons; 2006.
51. Slade M. Personal Recovery and mental illness. A guide for mental health
28. Khoury B, Lecomte T, Gaudiano BA, Paquin K. Mindfulness interventions for professionals. New York: Cambridge University Press; 2009.
psychosis: a meta-analysis. Schizophr Res. 2013;150:176–84. 52. Slade M, Amering M, Farkas M, Hamilton B, O’Hagan M, Panther G, et al.
29. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. Uses and abuses of recovery: implementing recovery-oriented practices in
The PRISMA statement for reporting systematic reviews and meta-analyses mental health systems. World Psychiatry. 2014;13:12–20.
of studies that evaluate health care interventions: explanation and 53. Lysaker PH, Dimaggio G. Metacognitive capacities for reflection in
elaboration. PLoS Med. 2009;6:e1000100. schizophrenia: implications for developing treatments. Schizophr Bull.
30. Churchill R, Moore THM, Furukawa TA, Caldwell DM, Davies P, Jones H, 2014;40:487–91.
Shinohana K, Imai H, Lewis G, Hunot V. 'Third wave' cognitive 54. Bargenquast R, Schweitzer RD. Enhancing sense of recovery and self‐reflectivity in
andbehavioural therapies versus treatment as usual for depression. people with schizophrenia: a pilot study of metacognitive narrative
Cochrane Database of Systematic Reviews 2013, Issue 10. Art.No.: CD008705. psychotherapy. Psychol Psychother. 2014;87:338–56.
doi:10.1002/14651858.CD008705.pub2.