Evidence That People Recover from Schizophrenia

Long-term research by Harding, Ciompi, Bleuler and others has shown that a majority of people hospitalized for lengthy periods have recovered significantly or completely from schizophrenia.  The researchers defined consumers as completely recovered being without symptoms, off of psychotropic medication, living independently in the community, working, and relating well to others with no behaviors considered odd or unusual. The researchers defined consumers as significantly improved when the consumers fulfilled all but one of the domains. Their findings are summarized in the following table:

Long-term Studies Showing People Recover from Schizophrenia

StudySampleProgram DescriptionMethodResults
Holter, M., Mowbray, C., Bellamy, C., MacFarlane, P. & Dukarski, J. (2004)67 national experts on consumer-run services representing all regions of the country identified fidelity criteria for consumer-operated drop-in centers.Consumer-run drop-in centers offer organized and informal recreational and social activities where members and staff help each other solve daily living problems. Drop-in center activities are conducted within an atmosphere of acceptance and respect. They include providing access to a safe & supporting community for persons with mental illness, utilizing consumers as volunteers, providing a normalized environment, monitoring network for individuals in crisis, and positive role models.Developed and operationalized fidelity criteria for consumer-run mental health services in consumer-run drop-in centers. Critical ingredients identification based on published literature; revised and validated criteria through expert judgments using a modified Delphi method.Respondents rated highest those structural and process components that emphasized the value of consumerism: consumer control, choices and opportunities for decision-making, voluntary participation, and respect for members by program staff.
Corring, D. (2002)18 people with mental illness & 21 family members.Chatham/Kent Consumer/Survivor Network Inc. & Chatham/Kent Family Network commissioned the study of quality of life issues and formed the participant group.Qualitative methods using 3 focus groups which were audiotaped, transcribed & coded, member checks conducted.Results supported the need for continued peer support & advocacy services along with a continued focus on promoting and supporting recovery.
Dumont, J. & Jones, K. (2002)265 participants with a DSM diagnosis.The Crisis Hostel (CH), involving a small 5 bed residence, operated for two years in Tompkins County, NY, as an alternative to psychiatric hospitalization. Throughout the project’s planning and development, ex-patients and other consumers provided the initiative, expertise, concepts and staffing. CH distinguished itself from other crisis services in its consumer/survivor involvement, voluntary non-medical model, self-definition of need, and basis in peer support. CH services included a preparatory hostel training, crisis services, on-going workshops, peer counseling, advocacy and entry to a rage or meditation/massage room. A National Research Demonstration Grant funded by the Center for Mental Health Services was awarded to operate and evaluate the project. Research demonstration project to determine if people with access to a Crisis Hostel would experience greater recovery and increased empowerment, lower use of crisis services and reduced total mental health treatment costs when compared to persons without access. Randomized, experimental design with assessment at baseline, 6 months & 12 months.

Providers were contacted with the consent of participants to provide information concerning volume of service use. Each service category was assigned a unit cost estimate based on accounting data.
At baseline all study participants had experienced substantial hospital stays with a majority having had four or more admissions and a median ‘longest stay’ of over one month. The median annual income of the group was only $8,400. At 12 months, the experimental group had better healing outcomes, greater levels of empowerment, shorter hospital stays and less hospital admissions (which resulted in lower costs than control group).
Magura, S., Laudet, A., Mahmood, D., Rosenblum, A. & Knight, E. (2002)240 members of Double Trouble in Recovery.Double Trouble in Recovery (DTR) is a 12-step self-help organization specifically designed for persons with both mental illness and substance use disorder.A sample of members of DTR was interviewed at baseline and one year later. Correlates of adherence were identified for attendees who had received a prescription for a psychiatric medication.Consistent attendance at DTR meetings was associated with better adherence to medication regimens after baseline variables that were independently associated with adherence were controlled (e.g., living in supported housing, having fewer stressful life events and having a lower severity of psychiatric symptoms). In addition, better adherence was associated with a lower severity of symptoms at one year and no psychiatric hospitalization during the follow-up period.
Trainor, J., Shepherd, M., Boydell, K,. Leff, A. & Crawford, E. (2002)Over 600 consumers from the Consumer/Survivor Development Initiative (CSDI) of Ontario, Canada.CSDI directly funded 36 organizations at the time of the study, including cooperative businesses (6) generic consumer/survivor organizations (28), a provincial business council (1) and a diagnostically focused organization (1).The impact of CSDI membership on the use of Mental Health Services was examined. Also looked at the importance attached to various components of the mental health system.CSDI members used fewer mental health services, noted an increase in community involvement and contacts, found consumer/survivor organizations to be more helpful than traditional mental health services, and found other consumer/survivors as individuals to be more helpful professionals with mental health issues.
Forquer, S. & Knight, E. (2001)Equal partnership between ValueOptions, a national behavioral managed care company, and eight community mental health centers that integrated recovery and self-help into the routine care delivery.Evaluation of the impact of Colorado’s Mental Health Assessment Agencies Under Capitation Financing (FY97-98 to FY 98-99), which included the creation of more than 70 self-help groups & 4 consumer-operated drop-in centers.Number of persons with severe mental illness served by the Colorado managed care capitation project increased significantly; suicide rate and substance abuse decreased significantly, as did hospitalization; social contacts increased significantly, as did participants’ ability to carry out activities of daily living.
Powell, T., Yeaton, W., Hill, E., & Silk, K. (2001)170 adult patients living in the metropolitan Detroit who were hospitalized with unipolar and bipolar disorders in a large teaching hospital, and who were free of medical conditions that might interfere with self-help participation, were selected into experimental (N=65) and control (N=105) groups. 144 provided follow-up data at 12 months.The National Depressive and Manic Depressive Association self-help groups focus on helping people manage their illness by (1) encouraging members to acquire a foundation of information about the diagnosis; (2) challenging the notion of personal responsibility for the development of the illness while stressing the need to be proactive in its management; (3) providing a forum for discussion about effective selection and use of providers; (4) and dissemination of experimentally-based, pragmatic, everyday techniques for managing their illness and maximizing social functioning.The study utilized a two group, partially randomized experimental design to determine whether participation in a self-help group is associated with better management of illness and daily functioning after controlling for severity of illness and social support variables. In the randomized design participants were recruited from the same units for both experimental and control groups; in the non-randomized design participants were recruited from different units. After baseline data was obtained, experimental group participants were assigned a member sponsor who accompanied the study participant to a support group meeting outside the hospital. Follow-up data was collected at 12 months after hospitalization.The study supports the conclusion that the predictors of psychosocial outcomes for persons with mood disorders differ from those that predict symptoms and recurrence outcomes, and self-help involvement may be linked to more favorable psychosocial outcomes. Education and baseline values were significant predictors of daily functioning and management of illness. Self-help involvement predicted management of illness. Daily functioning was positively related to employment and education but not to age, sex, minority status, marital status or severity of illness variables (age of onset and number of hospitalizations).
Yanos, P., Primavera, L. & Knight, E. (2001)60 participants with past or present psychiatric diagnosis.Consumer-run servicesRecruitment from a mental health center and 2 consumer-run programs to determine if involvement in consumer-run services is positively associated with recovery. Random selection from CMHC and screening of self-selected participants from consumer-run programs; selected scales administered face-to-face at one point in time.Participants in consumer-run programs had better social functioning than those in CMHC; psychological variables associated with social functioning & mediated by problem-centered coping strategies.
Campbell, J. (2000), Consumer-Operated Service Programs Multisite Research Initiative1,827 participants with serious mental illness receiving mental health services within the year previous to enrollment. Funded by Substance Abuse and Mental Health Services Administration, HHS.7 study sites and a Coordinating Center funded to study cost-effectiveness of 8 consumer-operated programs when offered as an adjunct to traditional mental health services. Models of consumer-operated service programs included drop-in centers (4), mutual support groups (2), and educational/advocacy programs (2).Randomized, controlled trial with common assessment protocol administered face-to-face at baseline, 4 months, 8 months, & 12 months, along with a fidelity assessment of intervention. Outcomes included: empowerment, social inclusion, well-being, housing, employment, recovery, program satisfaction.Baseline, Outcome, Cost and Fidelity analyses currently underway.
Powell, T., Hill, E., Warner, L., Yeaton, W., & Silk, K. (2000)226 former patients hospitalized for major depression or bipolar disorder.Volunteer sponsors with stabilized illnesses received training on introducing MDDA and accompanying an individual to a mutual support meeting.Participants randomly assigned an MDDA (Manic-Depressive and Depressive Association) sponsor were compared to those who were not assigned a sponsor. Comparisons made after a participant attended an MDDA meeting with his/her sponsor.Individuals with sponsors were almost seven times as likely (6.8) to attend subsequent meetings(s) on their own than those without sponsors. The proportion of individuals attending meetings was greater among persons with sponsors (56%) than those without sponsors (15%).
Van Tosh, L. & del Vecchio, P. (2000)13 demonstration projects of peer-run programs from the Community Support Program, Center for Mental Health Services.Project materials from the projects were examined in order to provide in-depth, cross-program examination of each individual initiative. Documents reviewed were original applications, annual continuation applications, NIMH correspondence, final project reports and evaluation findings.Program elements were explored: project goals & objectives, program description, implementation issues and problems, & evaluation findings.75% of the programs provided mutual support; 85% provided direct services, 50% indicated that empowerment was a major focus, 90% cited public education as a goal, 75% also indicated rights protection was a project goal. Programs served people who were in poverty (30%).as well as veterans (30%). All projects reported their participants showed greater levels of independence, empowerment & self-esteem. Over 60% indicated increased development of social supports.
Roberts, L., Salem, D., Rappaport, J., Toro, P. & Seidman, E. (1999)98 individuals with serious mental illness attending one of 15 different GROW self-help groups.GROW, Inc. is an organization of mutual support groups for persons with serious mental illness or psychiatric hospitalizations.Over a period of 6-13 months (averaging 8 months) of participation in group meetings, members showed improved psychological and social adjustments. Helping others in the group improved members’ social adjustment. Receiving help from those with closely integrated members was also related to positive adjustment; receiving help from less closely associated members was less related to social adjustment. Adjustment of members high in both giving and receiving help did not differ from those with lower levels of giving and receiving.
Klein, R., Cnaan, R. & Whitecraft, J. (1998)10 dually diagnosed clients from a peer social support program & 51 who had been in community care one year prior to the investigation.Friends Connection is a consumer-operated program that provides mutual support for persons with mental illness and a substance use problem.61 dually diagnosed clients who had been receiving ICM services were randomly selected and 10 participants were assigned to Friends Connection for 6 months. Data from pre & post client interviews and case records were compared.Findings suggest that coupling peer support with ICM is associated with positive system outcomes: number of crisis events & hospitalizations of the comparison group was higher. Those in the peer program showed improved quality of life and perceived physical and emotional well-being.
DeMasi, M., Carpinello, S., Knight, E., Videka-Sherman, L., Sofka, C. & Marwokitz, F. (1997)Statewide sample of New York public mental health service recipients.New York Office of Mental Health service recipients.Data from a statewide, two-wave mail survey were analyzed to develop a conceptual model of the recovery process, examined how participation in self-help and traditional services contributes to recovery, investigated ways individuals are referred to self-help groups and identified most persuasive referral sources..Findings on the role of self-help in the recovery process indicated that traditional services have a slight negative impact on self-concept and social outcomes. The relationships among symptoms, self-evaluation and quality of life proved significant. The effects of one’s beliefs about stigma on self concepts varied based upon individual symptoms. There is significant differences between members and non-members of self-help groups in the ways referral sources are used. The most persuasive methods that influenced individuals to join self-help groups came from recommendations made by peers through distribution of printed materials describing self-help groups.
Kessler, R. & Mickelson, K. (1997)3,032 respondents recruited from a random digit dial sampling frame from the US; ages ranged from 25-74; men & older respondents were over-sampled.Data reported came from the Midlife Development in the US survey, a nationally representative telephone-mail survey carried out in 1995-96 under the auspices of McArthur Foundation Network on Successful Midlife DevelopmentSurvey in two phases: telephone interview & self-administered mail questionnaire.18.1% of sample participated in a self-help group at some time in their life & 6.9% did so in the past year. Large proportions of people who use self-help groups for substance (50%) and emotional (76%) problems also see a professional for these problems. Those reporting less support and more conflict in their social networks are more likely to participate than those with more supportive networks. Those with a lower sense of personal control are more likely to participate.
Carpinello, S., Knight, E., Videka-Sherman, L., Sofka,C. & Markowitz, F. (1996)554 persons from mental health service sites (33%) and self-help groups (67%) were assessed.Mental health service sites and self-help groups in western region of New York State.Two sub-studies investigated the decision making process that leads to the use of self-help strategies: a cross-sectional survey and a cohort study.Findings from cross-sectional study indicated that self-help participants tend to be older, white, married, and to have a higher level of education. Diagnosis and symptoms were not related to participation. Participants were less likely than non-participants to have been hospitalized in the last 5 yrs. These findings suggest that self-help programs aid in the recovery process and reduce overall use of mental health services.
Chamberlin, J., Rogers, E.S., & Ellison, M. (1996)271 members of self-help programs were sampled.Geographically diverse self-help programs in the United States.A survey of 6 self-help programs in the U.S. was conducted to collect information about users of such programs, their demographics, quality of life & program satisfaction. Survey data & descriptive data from each of the programs were collected and descriptive results calculated.This sample averaged 4.8 lifetime hospitalization; 34.5% were unemployed at the time of the survey; 48.1% lived in private homes or apartments; used programs 15.3 hours/week; used both self-help and traditional services; 46% indicated that self-help involvement had changed the amount of contact with family in a way they liked; and that it had a salutary effect on QOL.
Kaufmann, C. (1995)146 Clients with serious mental illness were assessed.Self-Help Employment Center in Pennsylvania provided vocational services based on self-help principles.Outcome assessment sought to determine % working, % in new jobs, hours worked, time to present job, and time in present job. Participants were randomly assigned to Experimental and Control groups and were assessed at baseline, 6, and 12 months.Not many significant differences on employment variables; center members were significantly more improved at 12 months on a vocational status scale.
Segal, S., Silverman, C., & Temkin, T. (1995)310 clients who participated for at least 3 months in selected self-help agencies in the San Francisco Bay area were surveyed.Four consumer-run self-help agencies participated.Survey of members of self-help agencies randomly selected from the total population was conducted to characterize service utilization, psychiatric history, functional status, symptoms, diagnosis, and health issues.Typical members were found to be poor, African-American, and homeless and had a serious mental illness.
Kaufmann, C., Schulberg, H., & Schooler, N. (1994)90 individuals from an urban community mental health center were surveyed.Three consumer-run self-help groups participated.Individuals who met criteria for severe mental illness were randomly assigned to either self-help or non-self-help conditions while they continued with their customary care in the community mental health system.Results showed low rates of participation in the self-help groups for the experimental group, as well as cross-overs from the control group, so was discontinued. However, post hoc analysis showed self-help participants to have more severe psychiatric symptoms than either non-participants or current self-help members. Results indicated the need for multi-site studies in self-help group research.
Luke, D., Roberts, L., & Rappaport, J. (1994)861 people attending at least one GROW meeting were surveyed.15 self-help group from GROW, Inc., an organization for people with serious mental illness or psychiatric hospitalizations located in Southern Illinois.This study was part of an assessment of GROW, Inc. conducted during a 27 month period by trained observers/participants who collected data as members attended 527 meetings.Participants ranged in age from 15 to 85 and tended to be single, Caucasian, and female and to have some education beyond high school; participation of the member can be influenced by the "fit" between the member and the particular self-help group (e.g., self-help group/specific person, characteristics of the first meeting attended by the individual, and individual/other group members). Participants most likely to drop out were: (1) younger, less educated, currently or previously married, and high functioning; (2) members who attend meetings that are more than 2:1 female; (3) members who attended group with persons who had different hospitalization history, different marital status.
Kaufmann, C., Ward-Colasante, M., & Farmer, M. (1993)478 consumers (psychiatric patients, excluding substance abusers, homeless) across nine self-help centers during a 6-month period.Self-help centers provided social support and employment services.Conducted interviews and focus groups with members and tracked attendance to evaluate Centers.Members liked the “relaxed atmosphere”, being with similar people, having a place to go; clients wanted more equitable enforcement of rules, support, and expanded hours of activities. Components of a successful center were identified as: participatory management, strong volunteers, relationships with other provider systems, resources, social activities, special events and ongoing recruitment.
Mowbray, C. & Tan, C. (1993)120 consumers attending self-help centers in the Justice in Mental Health Organization.Six self-help centers in Justice in Mental Health Organization.Study conducted structured interviews using the Group Environment scale, Community Oriented Program Environment scale, and the Client Satisfaction Questionnaire.Most consumers believed they had input into center operations, felt supported, learned from one another, were encouraged to be independent, and participated more in positive activities and less in negative activities; 80% reported being more confident in several life domains; 75% perceived the centers more positively than other mental health services in the area.
Carpinello, S., Knight, E., & Janis, L. (1992)25 adults sampled from self-help groups (10 group leaders, 11 group members, 4 parents).48 self-help groups representing 7 classes of self-help: advocacy & legal, educational & technical, information & referral, drop-in centers, group support, service provider, and alternative therapy.Qualitative research methods including focus group and key informant interviews, member checking and negotiation discussions.Participants reported positive outcomes related to self-help membership such as empowerment, and felt that self-help worked. Self-help success related to creation of a social network, change in role from helpee to helper, sharing of coping behaviors, presence of role model, and existence of a meaningful group structure.
Emerick, R. (1990)104 self help groups participated.The social movement groups offered legal advocacy, public education, technical assistance, and information-referral networking. The individual therapy groups offered more “inner-focused” individual change through group support meetings.By conducting key informant interviews, classified groups based on structure, affiliation, and service model along an ideological continuum from radical, separatist to conservative groups that allowed professionals to act as leaders in partnership with consumers/survivors.Social movement and individual therapy were found to be the two major service models. Two-thirds of the groups were identified as social movement groups and of these more than 70% were found to have little to no interaction with mental health professionals; 43% held anti-professional attitudes.
Kennedy, M. (1990)31 members of GROW and 31 former psychiatric patients of similar age, race, sex, marital status, number of previous hospitalizations and other factors.GROW is a mutual support organization for people with psychiatric problems.Changes in comparison groups measured over 32 months.GROWers spent significantly fewer days in a psychiatric hospital than did comparison group. Members also increased their sense of security and self-esteem, decreased their existential anxiety, broadened their sense of spirituality, and increased their ability to accept problems without blaming self or others for them.
Campbell, J. & Schraiber, R. (1989)331 past and present mental health consumers who had been labeled chronically mentally ill; 53 family members of mental health clients; 150 mental health professionals & caregivers. Funded by the California Department of Mental Health.Qualitative and quantitative consumer-directed survey research on what factors promote or deter well-being of people in California with severe mental illness. Consumer-developed client questionnaire (151 items); family member questionnaire (76 items); mental health professional questionnaire (77 items).Descriptive self-reported statistics found significant correlation between poor well-being of clients and stigmatizing professional attitudes and behaviors; fear of involuntary treatment reported as deterring clients from seeking professional mental health. Peer support identified as promoting well-being.
Galanter, M. (1988a)201 Recovery group leaders & 155 recent Recovery members (joined 6-12 months previously).Recovery, Inc. supports self help groups for former mental patients using a standardized group process.Study designed to ascertain whether mental health self-help groups can serve as an adjunct or alternative to professional care. Group leaders selected at random in each of the 211 Recovery Inc. administrative areas in North America; member participants selected by group leaders. 211 item multiple choice questionnaire completed anonymously included: Demographics, General Well-Being Schedule, Neurotic distress Scale, Social Cohesiveness Scale, Ideological Commitment to Recovery & Psychiatric treatment.Decline in both symptoms and concomitant psychiatric treatment after participants joined Recovery Inc. Responses to items reflecting affiliative ties toward Recovery predicted an appreciable portion of the variance in respondents’ well-being and reported improvement after joining.
Galanter, M. (1988b)356 members of Recovery Inc. and 195 community residents of similar age and sex.Recovery, Inc. supports self help groups for former mental patients using a standardized group process.Comparison of members and community residents.Although about half of the Recovery Inc. members had been hospitalized before joining, only 8% of group leaders and 7% of recent members had been hospitalized since joining. Members used more outpatient non-psychiatric resources than did the community sample.
Kurtz, L. (1988)188 participants in the founding chapter of the National Depressive and Manic Depressive Association including people with mental illness and family members.National Depressive and Manic Depressive Association supports mutual-aid group activities throughout the United States for persons with psychiatric disorders.Survey of mutual-aid group for mental disorders to describe membership, examine member satisfaction with the association, and to elicit members’ perceptions of benefits to them as a result of participation. Anonymous 36-item questionnaire included demographic data, history of illness, rating of satisfaction with the association and perceptions of outcome (CSQ-8) mailed to 578 individuals on the MDDA mailing list. There was a 41% response rate.Length of membership & intensity of involvement was related to global satisfaction & information/support provided. 81.5% of consumer respondents coped better with the illness after participation and 83% better accepted their illness. Weak positive indication of medication compliance and participation.
Mowbray, C., Wellwood, R. & Chamberlain, P. (1988)Over 1,800 consumers, most with previous mental health experience, desiring mutual support were sampled. Funded by the Michigan Department of Mental Health.Daybreak Drop-In Centers offered an unstructured setting that included recreational, cooking, housing assistance, and employment activities.Surveyed program members, tracked attendance, and calculated costs per month.Centers averaged over 150 persons a month for 12 months; high member satisfaction; cost was $470/month.
Rappaport, J., Seidman, E., Paul, T. A., McFadden, L., Reischl, T., Roberts, L. J., Salem, D., Stein, C. & Zimmerman, M. (1985)Over 100 meetings representing 12 different GROW groups in Illinois. Funded by NIMH.GROW group meetings follow the method suggested by the founder, including personal testimonials, mutual support, education, presenting coping strategies, and personal development.Trained observers completed the Observer Rating Form, an observational coding system designed to record verbal interactions of group members during meetings. A coding strategy was developed to allow analysis of the observed group interactions.Mutual self-help organizations such as GROW are a viable alternative to fill the gap created by funding cuts and policy changes in professional Mental Health Services provisions.
Raiff, N. (1984)393 members of Recovery, Inc. (mostly female and married) were in the sample.Recovery, Inc. offers self-help groups for former mental patients following a standardized group process.Level of involvement in Recovery, Inc. tracked over a two-year period, and members surveyed.Highly involved members reported no more anxiety about their health than did the general population. Members who had participated for two years or more had the lowest levels of worry and the highest levels of satisfaction with their health. Members also rated their life satisfaction levels as high or higher than did the general public. Members who had participated less than two years were still on medication, lived below the poverty level, or lacked social network involvements also appeared to benefit from group participation, although to a lesser degree.
Edmunson, D., Bedell, J., et al. (1982)80 former psychiatric inpatients were studied.Participation in a consumer-led, professionally supervised network enhancement group was studied.Comparison of participants to non-participants after 10 months.One half as many former psychiatric inpatients (n=40) required rehospitalization as did non-participants (n=40). Participants also has much shorter hospital stays (7 days vs. 25 days), and a higher percentage of members than non-members could function with no contact with the mental health system (53% vs. 23%).

To answer the question of the influence of state mental health policy on recovery, Harding and colleagues compared the rates in Vermont with those in Maine (DeSisto, et al, 1995). These two states had distinctly different mental health policies in the 1950’s and 1960’s.  Vermont had a very innovative approach that emphasized rehabilitation, community integration, and self-help.  Maine focused on symptom reduction and maintenance. The recovery rates were strikingly different. In all dimensions, Vermont had a significantly higher recovery rate. The authors had carefully matched the sample of subjects in the two states. They concluded that the major reason for the higher recovery rate in Vermont was the result of a social policy that emphasized hope, rehabilitation, and a belief that each person, regardless of the severity of their condition, was capable of living a full and independent life in the community.

By today’s criteria (see NEC’s 7 characteristics of a person who has recovered), these numbers would be considerably higher because absence of symptoms and being off medication are no longer considered major criteria for recovery.  In addition, all these studies were done following people who had been hospitalized for lengthy periods. There is growing evidence that when people can be assisted in a non-hospital environment, closer to home, with lower doses of medication, that a person’s recovery is even higher (Mosher, 1999). Additional support for believing that everyone, under optimal conditions, can recover from schizophrenia, derives from cross cultural studies done by the World Health Organization showing that the recovery rate from schizophrenia is much higher in developing than in industrial countries (Jablensky, et al, 1992).


Long-term Epidemiological Studies of Schizophrenia

Bleuler, Manfred (1974). The long-term course of the schizophrenic psychoses. Psychological Medicine, 4, 244-254

Huber, G., Gross,G., Schuttler,R.. (1975). Long-term follow-up study of schizophrenia. Acta Psychiatrica Scandinavica, 53, 49-57.

Ciompi, L. (1988). Psyche and Schizophrenia. Harvard U. Press, Cambridge,MA.

Tsuang,M., Woolson, R., and Fleming, J. (1979). Long-term outcome of major psychosis. Archives of General Psychiatry, 36: 1295-1301.

Harding, C. et al. (1987). The Vermont longitudinal study of persons with severe mental illness, I. Methodology, study sample, and overall status 32 years later. American Journal of Psychiatry, 144:718-728.

DeSisto, et al. (1995). The Maine and Vermont three decade studies of serious mental illness. British Medical Journal of Psychiatry 167: 338-342.

Alternatives to Hospitalization

Mosher, L. R. (1999). “Soteria and Other Alternatives to Acute Psychiatric Hospitalization: A Personal and Professional Review.” Journal of Nervous and Mental Disease, 187, 142-149.

Cross Cultural Studies:

Jablensky, A., Sartorius, N., Ernberg, G., Anker, M., Korten, A., Cooper, J. E.,Day, R., and Bertelsen, A. (1992). “Schizophrenia: Manifestations, Incidence and Course in Different Cultures. A World Health Organization Ten-Country Study.” Psychological Medicine Monograph Supplement 20. Cambridge: Cambridge University Press.

These and additional references available in the Recovery Reader. Complete listing of contents