As mentioned before, the vision of recovery as an outcome corresponds to the traditional or clinical view of this phenomenon and falls under the umbrella of scientific-oriented definitions (Silverstein and Bellack 2008). Outcomes of recovery here are defined from a pathogenic perspective which views mental health as improvements in typical indicators of mental illness, such as psychiatric symptoms and impairments in cognitive, role, and social functioning. However, there is still an ongoing debate about the requirements for declaring someone recovered. Some authors (Andreasen et al. 2005) have proposed that the full remission of symptoms and the return to premorbid levels of function are necessary, whereas others (Liberman and Kopelowicz 2005; Torgalsboen 2005) have suggested that partial remission of symptoms and role restoration that are sustained over two consecutive years are sufficient.

The pathogenic view of recovery is also represented in the literature that focuses on key dimensions, or process elements, that are involved in the minimization of mental illness and that have been particularly documented in consumer-oriented definitions (Silverstein and Bellack 2008). More specifically, this side of the recovery experience targets the building of protective factors against relapse, functional deterioration, and handicap, which has been traditionally addressed in the field psychiatric rehabilitation (Anthony et al. 2002). Those protective elements refer to personal and environmental resources that contribute to the reduction of mental illness and its negative social consequences (e.g., stigma, discrimination). At the individual level, they involve the restoration of skills that had been altered by the illness and the learning of illness management strategies, such as strategies for preventing relapse or coping with enduring symptoms, as well as advocacy skills for getting needed services (Mueser et al. 2006; Salyers et al. 2009). At the environmental level, they include the provision of accommodations for supporting the performance of social roles, such as parents, students, or workers (e.g., later start times or flexible break times as work adjustments). They also rely on the use of community interventions for restoring civil rights and reducing barriers to social exclusion, such as educating potential employers and other members of the community about mental illness (Corrigan et al. 2008). In addition, several subjective changes take place throughout this process, such as the development of a positive identity based on restored abilities (Brown and Kandirikirira 2007), a renewed sense of hope for better prevention of illness relapses, or the development of a sense of empowerment, which encompasses increased self-efficacy in coping with mental illness, active participation in the planning of individualized services (Adams and Drake 2006; Drake et al. 2009), and advocacy for defending rights as consumers (Onken et al. 2007). In short, the building of protective factors against mental illness and their related subjective processes are aligned with a pathogenic view of recovery and with the use of mental illness indicators as outcomes.

In addition to the pathogenic view, consumer-oriented definitions emphasize another side of the recovery experience in which the pursuit of positive emotions (e.g., happiness, life satisfaction) and the engagement in fulfilling activities are highlighted despite the presence of mental illness. Positive mental health is at the center of this view of recovery and underlies a salutogenic conception of mental health, although never recognized as such. The dimensions of flourishing (see Table 13.1) are used as a framework to propose linkages between recovery and positive mental health, drawing on three lines of literature.

First, qualitative research and personal accounts (Ridgway 2001; Spaniol and Koehler 1994) call attention to consumers’ experiences and aspirations that are aligned with positive mental health (see Table 13.1). Brown and Kandirikirira (2007), for instance, found that persons in recovery require and strive for a positive identity, which reflects self-acceptance. Individuals also said they require and seek to engage in meaningful activities and to develop positive relationships with other people and with their environments, which reflect purpose in life, positive relations with others, and social acceptance. Narratives of persons in recovery also reveal their need and aspiration for living in communities where they are seen as more than their illness and where their contributions are valued, which are signs of positive mental health called social integration and social contribution. Persons in recovery also need and strive to manage their lives, stay healthy, and be resilient to setbacks, which reflect environmental mastery and, to some extent, autonomy (i.e., confidence to express personal opinions, needs).

Several dimensions of positive mental health are indeed targeted in recovery interventions. Consistent with hedonic well-being, having pleasure, fun, and happiness in life through involvement in leisure and social activities is promoted in supported socialization (Davidson et al. 2003, 2004, 2006). With regard to positive functioning, psychological well-being is enhanced in a self-development program (Oades 2008) and other treatment programs, for example, Well-Being Therapy (WBT) (Fava and Ruini 2003) for persons with recurrent depression or functional Cognitive Behavioural Therapy (fCBT) (Cather et al. 2005) for those with schizophrenia. In line with social well-being, peer support encourages those individuals who want to contribute to social changes and to engage in pro-social behaviors, such as using political strategies to increase access to resources (e.g., housing, paid work) (Mead et al. 2001). In this vein, capabilities approaches (Nussbaum 2000; Sen 1999) are increasingly used as guides to promote measures of social inclusion, such as securing access to participatory structures in local organizations in order to join collective efforts oriented toward the welfare of the whole community (Ware et al. 2007).

Finally, several dimensions that are assessed in recovery instruments strongly resemble the dimensions of subjective well-being that make up the assessment and diagnosis of positive mental health. For instance, subjective quality of life, as indexed by life satisfaction, reflects hedonic well-being and has been widely used in clinical practice and evaluation research. The Recovery Assessment Scale (Corrigan et al. 2004) is a self-report questionnaire that is widely used and relies on five dimensions—personal confidence and hope, willingness to ask for help, goal and success orientation, reliance on others, and no domination by symptoms—which all somewhat overlap with purpose in life, environmental mastery, autonomy, and positive relations with others. The RAS reflects psychological well-being, for the most part (see Table 13.1), and is even stronger for post-traumatic growth. This latter concept refers to positive shifts in personality schema and assumptive worlds following significant life crises (e.g., bereavement, chronic disability) (Tedeschi et al. 1998) and captures the process of thriving in recovery or becoming better off than before mental illness (Onken et al. 2007). The three dimensions of post-traumatic growth overlap with those of psychological well-being: changes in philosophy are aligned with the dimensions of purpose in life and with autonomy; changes in perceptions reflect those of environmental mastery, personal growth, and self-acceptance; and changes in relationships mirror the dimension of positive relationships with others (see Table 13.1). In this vein, the evaluation of psychological well-being (Ryff and Singer 1996) has been particularly recommended for tracking changes in growth in longitudinal studies (Joseph and Linley 2008). However, it should be emphasized that flourishing implies thriving and also directs attention to other meaningful experiences, such as positive emotions and a sense of fulfillment in social life. Finally, a special focus has been recently placed on the need for a better understanding of changes in self-experience over the recovery process, and the Scale to Assess Narrative Coherence (STAND) (Lysaker et al. 2006) has been developed to measure the extent of a coherent story about self-experience based on personal narratives of persons with schizophrenia. Four specific dimensions of self-experience are evaluated, namely, social worth, connectedness with others, agency, and illness conception. Social worth concerns a positive view about oneself in private and public life, reflecting the dimensions of self-acceptance and social contribution. Connectedness with others refers to a fulfilling and intimate relationship with at least one person, in line with the dimension of positive relationships with others. Agency corresponds to the perceived ability to affect one’s own destiny and to engage meaningfully with others and reflects the dimensions of mastery and positive relationships with others. Finally, illness conception refers to the ability to address and face diverse personal challenges, including those related to the management of schizophrenia, and overlaps with the dimensions of mastery and personal growth. Those four aspects of self-experience are thus aligned with several dimensions of positive functioning (see Table 13.1).

In summary, personal and environmental changes contributing to the improvement of psychiatric symptoms and illness impairments represent an important side of recovery and underlie a pathogenic view of this experience. A salutogenic perspective is also represented, as other transformations target the achievement of optimal levels of emotional well-being and positive functioning. The ability to function well in a life, toward which one also feels good, is the sine qua non of good mental health (i.e., flourishing) and, therefore, of complete recovery.