Qualitative Social Work

Copyright ©2007 Sage Publications London, Thousand Oaks, CA and New Delhi, Vol. 6(1): 49–74
www.sagepublications.com DOI:10.1177/1473325007074166

ARTICLE
The Role of Self-efficacy in
Recovery from Serious
Psychiatric Disabilities
A Qualitative Study with Fifteen
Psychiatric Survivors

Michael A. Mancini
St Louis University, USA

ABSTRACT
This qualitative analysis applied the theory of self-efficacy to
results from a study that used grounded theory to identify
the factors that influenced the recoveries of 15 psychiatric
survivors. Participants identified the development of a more
competent and efficacious sense of self as a central aspect
contributing to their recoveries. Analysis also revealed four
factors related to this development: meaningful activities,
supportive professional relationships, peer-support and
choice among a variety of treatment alternatives. Partici-
KEY WORDS:
pants’ description of the recovery process and how they were
consumer able to develop a competent sense of self, possessed several
narratives parallels with Bandura’s social cognitive theory of self-
efficacy. This article argues that self-efficacy may provide
psychiatric
practitioners with a useful guide for creating the contexts
rehabilitation
that facilitate the recovery process. Implications for practice
recovery and research will be explored.
self-efficacy

severe and
persistent mental
illness 49

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50 ■ Qualitative Social Work 6(1)

INTRODUCTION
Studies have shown that people diagnosed with serious psychiatric disabilities
such as schizophrenia are able to recover and live satisfying and productive
lives in the community (Anthony, 1993; Anthony et al., 2002; Deegan, 1988;
deGirolamo, 1996; Harding et al., 1987a,b; US Department of Health and
Human Services [USDHHS], 1999).
The growing use of qualitative methodologies to understand how people
recover from serious psychiatric disabilities has taken many forms and has led
to numerous important discoveries (Davidson, 2003). For instance, several studies
have used personal accounts of psychiatric survivors to develop an in-depth,
first person understanding of the recovery process (Barham and Hayward, 1998;
Cohen, 2005; Corin and Lauzon, 1992, 1994; Davidson and Strauss, 1992;
Estroff, 1989; Jacobson, 2000; Mancini et al., 2005; Ochocka et al., 2005;
Ridgway, 2001; Sullivan, 1994). These studies as well as personal testimony from
leaders in the psychiatric survivor movement (Chamberlin, 1979; Deegan, 1988)
and psychiatric rehabilitation literature (Anthony, 1993; Anthony et al., 2002;
Corrigan and Ralph, 2005) have positioned recovery as a complex, subjective
and dynamic process dependent upon numerous factors (Davidson and Strauss,
1992; Estroff, 1989; Jacobson, 2000; Jacobson & Greenley, 2001; Ridgway, 2001).
Data from early studies suggests that the development of self-efficacy –
a view of the self as competent and agentic – may represent a significant and
important contributory factor in helping people with psychiatric disabilities
recover (Bandura, 1977, 1986, 2001; Watson and River, 2005). This discovery
may hold important practice implications because identifying frameworks that
effectively integrate the subjective aspects of the recovery process has been
difficult (Kelley and Gamble, 2005).
This study explored the subjective aspects of the recovery process with
15 psychiatric survivors. Participants were consumer providers of mental health
services meaning that they were diagnosed with serious psychiatric disabilities
(e.g. schizophrenia-spectrum disorders; bipolar disorder, major depression), have
utilized mental health services and provided mental health services to other
psychiatric survivors. Participants were asked to reflect and describe the key
factors that influenced their recoveries from serious psychiatric disabilities.
Responses were originally analysed using a grounded theory approach (Glaser
and Strauss, 1967) within the framework of symbolic interactionism (Blumer,
1969). Participants indicated that the heart of the recovery process was the trans-
formation from an illness-dominated identity to an identity of agency,
competence and well-being (see Mancini et al., 2005). Following this initial
finding the theory of self-efficacy was used to organize the data post hoc after
it was realized that: (1) the data possessed many parallels with the theory of self
efficacy; and, (2) this theory could provide useful information for practitioners
seeking to understand how they could create contexts that would facilitate

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 Mancini The Role of Self-efficacy in Recovery ■ 51

recovery in their clients. The theory of self-efficacy (Bandura, 1986) will then
be explored as a way to make sense of participants’ accounts of recovery and
to identify how practitioners may begin to think about how to construct their
practice in ways that acknowledge and value the subjective dimensions of the
recovery process.

SUBJECTIVE ASPECTS OF THE RECOVERY CONCEPT

Recovery has been conceptualized as a unique and subjective experience. The
subjective factors contributing to recovery that have been identified through
qualitative analyses include the existence of hope (Ridgway, 2001), choice among
recovery oriented treatment strategies (Cohen, 2005; Jacobson and Greenley,
2001; Sullivan, 1994), social support (Cohen, 2005; Jacobson and Greenley, 2001;
Mancini et al., 2005), spirituality and religious life apart from one’s psychiatric
condition (Barham and Hayward, 1998), meaningful activities such as work,
school or activism (Mancini et al., 2005; Ridgway, 2001; Sullivan, 1994),
establishment of human rights and elimination of stigma ( Jacobson and Greenley,
2001; Ridgway, 2001), self-help and peer support (Cohen, 2005; Mowbray and
Tan, 1993), and self-determination (Fisher, 1994; Ochocka et.al., 2005).
Among the most important factors found to be associated with recovery
has been the development of a positive, competent and agentic sense of self
(Davidson and Strauss, 1992; Estroff, 1989; Jacobson, 2000; Jacobson & Greenley,
2001; Ochocka et al., 2005; Pettie & Triolo, 1999; Ridgway, 2001). For instance,
in a longitudinal, qualitative study using grounded theory to analyze in-depth
interviews with 28 people experiencing mental health issues, Ochocka et al.
(2005) found that an important part of recovery involved a development of a
positive sense of self through a negotiation of internal and external circum-
stances. The authors note that taking control and becoming competent in one’s
life is a key aspect of recovery from serious psychiatric disabilities. In addition,
Cohen (2005) in analyzing oral histories of 36 psychiatric survivors identified
self-efficacy and the development of an empowered sense of self as key
components of the recovery process.
Quantitative methodologies have also been used to examine the sub-
jective aspects of the recovery process. Resnick et al. (2005) have recently
attempted to develop an empirical understanding of the subjective experience
of recovery. Applying principle components and confirmatory factor analyses
with a dataset from a large study of schizophrenia, they identified four main
factors associated with the development of a ‘recovery orientation’ or ‘recovery
attitude’: empowerment, hope and optimism, knowledge and life satisfaction.
They propose that clinical interventions should focus on helping individuals
develop recovery attitudes and suggest that recovery attitudes and positive
outcomes may influence each other bi-directionally (Resnick et al., 2005).

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52 ■ Qualitative Social Work 6(1)

It is clear that empowerment is also important in the recovery process

(Linhorst, 2006). Although the term empowerment can have different meanings
in different contexts the subjective experience of empowerment includes a
sense of perceived agency, control and self esteem (Linhorst, 2006). Therefore,
understanding the contexts and conditions necessary for the development of
self-efficacy, the belief in one’s own competence and agency, may hold
important insights into how practitioners can facilitate the recovery process in
their clients.

SOCIAL COGNITIVE THEORY AND SELF-EFFICACY

Bandura (1966) first defined self-efficacy as an individual’s personal assessment
of their competence to perform tasks. Self-efficacy refers to a person’s belief in
their ability to, ‘organize and execute the courses of action required to attain
designated types of performances’ (Bandura, 1986: 391). Self-efficacy is a concept
rooted in the idea that what one believes about their abilities in a given situ-
ation are just as, if not more important than, their actual ability. This concept
states that people’s behavior, performance, motivation, and emotions are based
heavily on what people believe about themselves. In addition, how efficacious
one believes they are in a given situation influences the choices they make, the
risks they take, the motivation they have to engage in that situation and their
overall performance. It has also proven to be a very good predictor of success
on given tasks. For example, it has been shown that people who possess high
self-efficacy on a given task do better on that task than people who have low
self-efficacy on the same task (Bandura, 2001). Individuals with a high sense of
competence in a given area are more likely to perceive difficult situations as
challenges rather than risks, set more challenging goals, possess a high degree
of perseverance in the face of obstacles, and are more resilient after failures
(Bandura, 1986).
Therefore, self-efficacy has also been theorized to be a central component
to human agency. That is, the extent to which people believe that they are in
control of their own lives will determine the types of choices they will make
and how they will behave (Bandura, 1986, 2001).
Self-efficacy develops from four main sources. One source of self-efficacy
is ‘social persuasion’ defined as support and encouragement from important
others. That is, self-efficacy is shown to improve if an individual is exposed to
sustained and genuine encouragement from other individuals whom the person
values or respects (Bandura, 1986).
Another source of self-efficacy is ‘vicarious experiences’. This refers to
observing others successfully performing tasks. The effects of role-modeling
become important here. If individuals who are uncertain about their own
abilities in performing a specific task see similar others performing the task

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 Mancini The Role of Self-efficacy in Recovery ■ 53

successfully, they are more likely to develop positive self-efficacy beliefs about
their own abilities regarding that task (Bandura, 1986, 2000).
Third, the development of ‘mastery experiences’ is important in the
development of a competent sense of self (Bandura, 1986). Perceived success
on tasks can influence the creation of positive self-efficacy beliefs and can have
a positive influence on an individual’s competence, motivation and persistence
on tasks in the future.
Lastly, the ‘somatic and emotional states’ experienced while contemplat-
ing and engaging in a certain task can influence how one perceives his or her
competency regarding that task (Bandura, 1986). Experiencing a high level of
anxiety, fear or negative thoughts can lead to the development of negative
self-efficacy beliefs about a particular task (Bandura, 1986, 2000). Conversely,
experiencing excitement, positive thoughts or joy when performing a particu-
lar task is likely to increase self-efficacy (Bandura, 1986).
Since its development four decades ago (Bandura, 1966), the concept of
self-efficacy has been used to analyze, understand and predict human behavior
and cognition in a number areas including tobacco use (Colleti, 1985) and
academic performance (D’Amico and Cardaci, 2003). This theory has also been
used to examine and explain psychosocial well-being in children (Bandura et
al., 2003) and in the areas of clinical depression (Stanley and Maddux, 1986)
and substance abuse (DiClemente et al., 1995).
Self-efficacy has been less often utilized in research examining recovery
from severe and persistent psychiatric disabilities and its effects are less clear.
There is some weak empirical support for the relationship of self-efficacy and
increased psychosocial functioning. Ventura et al. (2004) found that self-efficacy
was related to better psychosocial coping responses in individuals with recent
onset schizophrenia when faced with negative life events. Mueser et al. (1997)
also found a relationship between self-efficacy and increased coping among
individuals diagnosed with schizophrenia.
In addition, Pratt et al. (2005) recently found that self-efficacy was
positively associated with psychosocial functioning in a sample of 85 adults
diagnosed with schizophrenia or schizoaffective disorder. However, the nature
of this relationship was less clear. For instance, when compared to other pre-
dictors of psychosocial functioning such as premorbid functioning, negative
symptoms and cognitive functioning it was found that negative symptoms were
the most critical determinant of psychosocial functioning and not self-efficacy
(Pratt et al., 2005). Therefore, early evidence suggests that the influence of self-
efficacy on psychosocial functioning for people with schizophrenia spectrum
disorders may be indirect and contingent on and mediated by other important
factors (Pratt et al., 2005).
Although questions remain regarding the nature of self-efficacy’s role in
the recovery of people diagnosed with serious psychiatric disabilities evidence

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54 ■ Qualitative Social Work 6(1)

does suggest that self-efficacy is in some way associated with improved outcomes.
Understanding how practitioners can construct the contexts necessary for the
successful development of self-efficacy is thus important for helping practitioners
facilitate the recovery process in their clients.
This analysis will apply the theory of self-efficacy to results from a study
that used grounded theory to identify the factors that influenced the recoveries
of 15 psychiatric survivors who provide consumer-based services. Results indi-
cated that environmental resources such as meaningful activities, professional and
peer support, and choice among a variety of treatment alternatives played a key
role in facilitating participants’ recoveries (Mancini et al., 2005). It was also
discovered that these environmental resources were associated with an identity
transformation that involved the development of a positive sense of self marked
by agency, competence, and well-being (Mancini et al., 2005). The question that
emerged from these original findings was: What frameworks exist that can be
used to translate these findings into ways that could help mental health
practitioners create the contexts necessary to facilitate this transformation?. The
author utilized self-efficacy theory in order to answer this question because the
personal and environmental factors participants identified as influencing their
recoveries possessed several parallels with the concept of self-efficacy just
described. These parallels will be outlined and discussed in the following sections
along with suggestions and implications for social work practice with individuals
diagnosed with psychiatric disabilities.

METHODOLOGY
Data Collection
This study utilized in-depth, semi-structured interviews with 15 psychiatric
survivors active in the survivor movement and the consumer provision of mental
health services. An interview guide was constructed for this study. It emerged
from the psychiatric rehabilitation, community mental health and consumer
literature and through consultations and piloting with key informants within the
psychiatric survivor movement. These informants reviewed the structure, content
and language of the guide and provided insights into appropriate questions and
question-wording in relation to their personal understanding of recovery, thus
helping to contribute to the credibility and authenticity of the guide. For
instance, key informants reviewed the language of the interview guide in order
to ensure that it was clear, relevant and non-offensive. This information was
triangulated with information from the literature on recovery from psychiatric
disabilities. In order to further test the interview guide for relevance, clarity and
usefulness it was piloted with two additional consumer-providers.
In interviews lasting 1.5 to 2.5 hours, participants were asked to discuss
the experiences that helped and hindered their recoveries. For instance,

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 Mancini The Role of Self-efficacy in Recovery ■ 55

participants were asked to discuss the people and experiences that facilitated
their recovery as well as to identify and discuss setbacks or obstacles in their
recovery. They were then asked to reflect on how their view of themselves as
individuals has changed throughout the recovery process (if at all).

Sampling
Participants were recruited through convenience and purposive sampling
methods. Eligible participants (psychiatric survivors) in the study were defined
as persons diagnosed with a psychiatric disability; were users of mental health
services; currently provided services to other survivors in the form of advocacy,
self-help, counseling, training, and/or research; and, self identified as being in
recovery. As leaders in their field, the psychiatric survivors in this study had a
working knowledge and understanding of what helps people recover and were
able to apply that understanding in their current work. As a result, these indi-
viduals were viewed as a particularly rich and untapped source of information
regarding the recovery process.
Through a working relationship with consumer advocates within a
Statewide Department of Mental Health in the Northeastern part of the USA,
the author was able to identify and gain access to appropriate participants for
this study.
Participants were members of a statewide consumer advocacy advisory
panel. These individuals, by virtue of their position, had experienced serious
psychiatric disability and recovery. These experts were actively involved in
providing services to current mental health consumers and in promoting
statewide recovery-oriented services, practices, and policies.
Participant criteria for the purposes of this study were threefold. First,
participants had to be current or former consumers of psychiatric services and
experienced serious psychiatric disability. Second, participants had to have
experienced their own recovery from psychiatric disability via self-definition.
Third, participants in the study were consumer-providers of mental health
services. The author’s rationale for selecting participants diagnosed with serious
psychiatric disability and who had experienced recovery is self-evident and
contributes to the credibility of the sample. To discuss a personal account of
illness and recovery, one must have experienced both of these phenomena.
Persons who have experienced the phenomenon of recovery are best able to
explicate and communicate the nuances of the experience.
The rationale for selecting only consumer-providers was to gather expert
perspectives on the recovery experience. Consumer-providers are individuals
who possess vast knowledge and experience with the concept of recovery. A
key role of the peer advocate is to engage and assist other consumers in their
own recovery and act as a role model to the recovery process. In other words,
as a function of their position, they must have a working knowledge and

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56 ■ Qualitative Social Work 6(1)

understanding of what helps people recover and be able to apply that under-
standing in their work. In order to do this they may routinely draw upon their
own experiences and as a result, represent a rich source of information regard-
ing the recovery process.
With the help of a key informant, eligible participants were identified
and recruited by telephone and asked to participate in an interview study that
would examine how they initiated, developed and maintained their recovery.
All participants enthusiastically agreed to participate during the initial phone
call. Because of scheduling constraints, one individual could not be interviewed
resulting in an additional participant being scheduled.
Participants were interviewed in four urban centers located throughout
the state. Two participants were interviewed in a large urban center in the
western part of the state. Two other participants were interviewed in a semi-
urban area in the central part of the state. Seven participants were interviewed
in an urban center in the eastern part of the state and four participants were
interviewed in a large metropolitan city in the southern part of the state.

Sample Characteristics
Participants ranged in age from approximately 40–55 years old. Six participants
held administrative positions in community agencies, while six participants
engaged in direct service provision. Three were involved in program develop-
ment, policy, training and/or research. Nine participants were women and 13
were Caucasian. One participant was an African American woman and one was
a Latino woman.
Participants voluntarily reported diagnoses of schizophrenia, schizo-
affective disorder, major depression, and bipolar disorder. Many stated that they
received several diagnoses over the course of their treatment histories. In
addition, all participants reported at least one hospitalization, while the majority
reported more than one such incident. A decision was made not to formally
ask participants their diagnosis after key informants had warned that this might
be considered offensive and jeopardize the research relationship as many partici-
pants rejected the relevance and validity of these diagnoses.

Analysis
Commonalities in participant responses were identified and explored using a
grounded theory approach (Charmaz, 2000; Glaser and Strauss, 1967; Miles and
Huberman, 1994; Strauss, 1987; Strauss and Corbin, 1990). Grounded theory is
an inductive method of cross-comparative analysis ideal for providing a ‘thick’
description of subjective and complex phenomena (Glaser and Strauss, 1967;
Miles and Huberman, 1994; Strauss, 1987; Strauss and Corbin, 1990). Analysis
using a grounded theory approach is also a credible means for understanding
how individuals perceive themselves within a particular context (Charmaz, 2000).

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 Mancini The Role of Self-efficacy in Recovery ■ 57

In short, grounded theory allows for the inductive and systematic exploration of
the processes individuals engage in to develop meaning and action from their
experiences (Charmaz, 2000).
Therefore, themes and categories from interviews were not defined
beforehand and emerged from the data through a process of ‘open-coding’ and
were refined through a process of ‘memo-writing’ and ‘theoretical sampling’
(Charmaz, 2000). The analysis process consisted of the investigator reading each
interview three to four times prior to coding. During this immersion the in-
vestigator took memo notes based on observations of the data. Memo notes
were taken during the coding process as well. Interviews were audio-recorded,
transcribed and coded by hand. Codes and themes emerged inductively from
the data itself and did not originate from other outside sources (Charmaz, 2000;
Glaser and Strauss, 1967). As the codes developed, sensitizing concepts emerged
through the background literature and theoretical frameworks that informed
the study. These sensitizing concepts were used to develop interpretations and
organize an understanding of the data (Charmaz, 2000).
Common codes were then collapsed into broader categories and sub-
categories through a constant comparison method within and between cases
(Miles and Huberman, 1994). The memo notes taken during this process
assisted in the identification and interpretation of these categories. Based on
these observations, case summaries of each interview were constructed. These
summaries were then used to make comparison both within and between cases.
Categories and subcategories were then constructed and reconstructed through
this process.
Through these comparisons, individual codes eventually developed into
larger categories. These categories then developed into the analytic frameworks
that help to better understand or describe the larger phenomenon under study
(Charmaz, 2000; Glaser and Strauss, 1967). In this study, four main categories
emerged: recovery definitions; recovery turning points; recovery barriers; and,
recovery facilitators. There were approximately 102 initial codes across all inter-
views, which were further grouped and collapsed. Following this initial analysis
the categories and sub-categories were then re-synthesized using the theoreti-
cal framework of social cognitive theory of self-efficacy as a guide.
The analysis in this study followed the grounded theory approach with
some modifications. Grounded theory is distinctive in that data analysis and
collection occur simultaneously (Charmaz, 2000). As data are refined through
the coding and memo writing process, gaps or holes in the data often emerge.
When this occurs the researcher then returns to his or her data sources and asks
focused and specific questions that are limited to addressing these gaps. This
allows researchers to further their understanding of the phenomena they are
studying, refine ideas, and develop more valid understandings of their data
(Charmaz, 2000; Strauss and Corbin, 1990).

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In this study interviews were conducted close in time to one another

due to the feasibility constraints of time, travel costs and the schedules of the
participants. For instance, interviews often had to be scheduled in clusters
through all parts of the state in order to accommodate participants’ schedules
since they often traveled extensively. This left narrow windows of time to
schedule and complete interviews resulting in interviews being scheduled close
in time to one another. This often prevented analysis of interviews to be
conducted simultaneously with data collection. This limited the ability of the
investigator to identify themes within each interview and to ask questions related
to these emerging themes in subsequent interviews.As a result, data was formally
analyzed subsequent to completion of all interviews. This may have limited the
richness of the data. The notion and impact of self-efficacy could have been
identified sooner and better explored in subsequent interviews had they been
formally analyzed simultaneous with data collection.
However, extensive piloting of the interview instrument resulted in
extremely rich interviews that provided voluminous amounts of data directly
related to the research questions guiding this study. Therefore, the data gathered
provided an enormous amount of information related to these questions. In
addition, extensive field notes consisting of observations, thoughts and per-
ceptions of the investigator were taken during and following each interview.
These field notes were then analyzed and used to inform subsequent interviews.
The researcher performed theoretical sampling during analysis by repeatedly
asking questions of the data and then conducted analysis of the data based on
these questions. The researcher then returned to the data in order to address
the emerging questions. In addition, an outside reviewer was used in order to
triangulate codes and categories and to debrief with the investigator about
analysis issues. This outside reviewer analyzed codes developed from transcripts
and cross compared these codes with case summaries and field notes in order
to establish that codes adequately and exhaustively represented participants’
stories of recovery and that saturation of concepts relevant to recovery had been
achieved in relation to the number of participants interviewed. It was concluded
that saturation had been achieved as no new themes or ‘surprises’ had emerged
in the participants’ stories.

LIMITATIONS
Due to the exploratory nature of this study, important limitations exist. First,
the participants in this study represent a small and highly specialized group of
recovered individuals. Their responses, beliefs and experiences may not be repre-
sentative of the general population of individuals diagnosed with psychiatric
disabilities. In addition, convenience sampling will prohibit the results from being
generalized outside of this study’s data set, as responses may have been
influenced by gender, geography, culture, age and a host of other characteristics.

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Second, the elicitation of narratives from individuals carries with it

methodological caveats. Responses from participants may be influenced in a
variety of ways. For instance, participants may have selective recall or gaps in
their memory of events. Participants may also be motivated to frame their
responses in a way that represents them in a favorable light. They may be moti-
vated to frame their responses in ways that furthers their own socio-political
goals regarding the recovery concept. And, they may have been influenced by
cues from the researcher and have altered their responses to either comply with
or contradict perceived cues.
Third, time constraints and restrictions in participants’ schedules resulted
in some modifications to the grounded theory methodology. Although analysis
of field notes and the development of case studies occurred after each inter-
view and guided subsequent interviews via theoretical sampling procedures,
formal analysis and data collection were not completely integrated as stipulated
by the grounded theory methodology. This limitation could have limited the
researchers ability to identify and explore issues in interviews as they emerged.
In addition, although the investigator took steps to assure the trust-
worthiness of the results including using key informants in the construction
and piloting of the interview instrument, and consultation with an outside
debriefer to triangulate codes and categories, this study’s findings are limited
because the investigator acted as the sole interviewer and main coder in this
study. Because inter-rater reliability statistics were not generated and because
outside interviewers and coders were not used, this study’s findings may be
biased due to the subjectivity of the investigator.
Finally, this study did not originally seek to examine the role of self-
efficacy in the recovery process. Rather, this theory was used to organize the
data post hoc after it was realized that: (1) the data possessed many parallels
with the theory of self-efficacy; and, (2) this theory could provide useful infor-
mation for practitioners seeking to understand how they could create contexts
that would facilitate recovery in their clients. As a result of this post hoc appli-
cation, the data does not always display a ‘tight fit’ with the theory of self-
efficacy. However, it is believed that the parallels that do exist provide important
insights into how practitioners can create contexts that may facilitate recovery
and are sufficient to warrant further discussion and explication in future
research.

RESULTS
A significant theme in participants’ responses with regard to the factors that
hindered and facilitated their recovery was that their recovery hinged on the
development of competent and agentic identities. The factors that participants
stated facilitated those identities will be presented via the lens of self-efficacy
theory. Specifically, all participants reported four factors that helped facilitate

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their recoveries: supportive and egalitarian relationships; self-help peer role

models; meaningful activities; and, choice among a variety of traditional and
alternative treatments. These factors will be categorized according to their simi-
larity with the four sources of self-efficacy described earlier: social persuasion,
vicarious learning, mastery experiences and somatic and emotional well-being.
Participants’ voices will be used to illustrate each concept. These concepts will
then be synthesized into an overall framework for helping practitioners create
the contexts conducive to the development of self-efficacious identities in their
clients.

Social Persuasion via Supportive and Egalitarian Relationships

Supportive relationships helped foster hope by communicating the expectation
that participants could live productive and satisfying lives. Vincent described
supportive relationships as a ‘cornerstone’ to his recovery.

I was given a message early on by everybody around me that I could get better
. . . that recovery is possible . . . (Vincent)

Participants described relationships with supportive professionals as

collaborative partnerships characterized by trust and respect rather than
paternalism and coercion. Self-efficacy beliefs have been shown to develop
through genuine support and encouragement from respected individuals
(Bandura, 1986). Social persuasion has been identified as a main contributing
source for self-efficacy. All participants attributed all or at least part of their
recovery to the existence of at least one person who believed in them and
provided unwavering interpersonal support over an extended period of time.
Indeed, the recovery concept as described by participants was an extremely social
process nurtured by egalitarian, collaborative partnerships with professionals. In
contrast, participants were in agreement with other published personal accounts
and testimony from psychiatric consumer-survivors that have concluded that
coercion and force present significant barriers to recovery (Chamberlin, 1997;
Deegan, 1988, 1996; Fisher, 1994).
Participants repeatedly described effective professionals in terms of their
ability to develop positive relationships through active listening, understanding,
support and warmth. These qualities were unanimously viewed as the most
important factors in determining effective practitioners – even more so than
specific interventions or treatment approaches. In fact, every participant stated
they continued to utilize professionals either continuously or intermittently.
Kelly provided a poignant example of a psychiatrist who provided her with
warmth and compassion.

[She would say] ‘Kelly, I know in my heart of hearts you’re going to recover . . .
you’ve got so much love of life and so many talents . . . borrow my belief in
you until you can feel it again in yourself.’ . . . (Kelly)

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 Mancini The Role of Self-efficacy in Recovery ■ 61

Therefore, participants’ stories indicate that the process of developing

positive, supportive relationships, a cornerstone of effective social work practice
and an essential ingredient in the development of self-efficacy, may represent a
necessary ingredient in assisting individuals diagnosed with serious psychiatric
disabilities in moving forward in their recoveries (Mead and Copeland, 2000).

Vicarious Learning via Self-Help Peer Role Models

Another source for contributing to the development of positive self-efficacy
beliefs is having access to respected and successful role models. Hope for the
future has been found to be a vital part of recovery (Resnick et al., 2005;
Ridgway, 2001). Likewise, when individuals diagnosed with serious psychiatric
disabilities believe that recovery is impossible they are likely to fall into despair
(Deegan, 1988). However, according to the self-efficacy model, if people have
access to recovery role models – individuals with similar diagnoses who have
recovered – they are more likely to develop positive self-efficacy beliefs about
their own abilities regarding recovery (Bandura, 1986, 2001).
A substantial proportion of participants stated that the existence of peer
support was a key factor in their recovery. They stated that being exposed to
individuals who had similar experiences and had achieved recovery provided
them with hope that recovery was possible. This realization motivated them to
engage in activities that would help them move forward in their recovery. For
instance, after attending a consumer-run conference, Cheryl described how she
felt after meeting others who shared her experiences.
I felt transformed . . . I mean like a light bulb went off . . . I knew that it would
be a continued struggle, but I had hope that there’s something more to me,
there’s something more in my life that I can do. (Cheryl)

Through contact with other peers she learned that there were oppor-
tunities to develop as a person. She learned that she could be ‘something more’
than a patient and could do many activities she was told were not possible. Self-
help and peer support has also been cited in the literature as extremely useful
in helping clients move forward in their lives and in their recovery (Cohen,
2005; Mead and Copeland, 2000; Mowbray and Tan, 1993; USDHHS, 1999).
Participants stated they often encountered an overall lack of understand-
ing from their families and professionals and that this translated to further
confusion and despair. Self-help groups provided participants with a sense of
shared understanding and acceptance as evidenced by the following quote from
Paul describing his first experience of a self-help meeting:
People were talking about their experiences . . . what was going on with them
. . . what helped and what didn’t help . . . I consider that the turning point of
my life . . . moving from an extremely dark, lonely isolated place to finding an
environment where people weren’t going to judge me or tell me that I was lazy
and they understood some of the things that I was going through. (Paul)

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Self-help provided Paul with hope and with information about how to
achieve recovery. Peers provided undeniable proof that recovery was possible.
Acting as recovery consultants or role models, they offered acceptance and ideas
about how to best set and achieve recovery goals. As a result, participants were
offered a road map for how to navigate their recovery journeys. The develop-
ment of a collaborative and communal network of support provided partici-
pants with a sense of agency and purpose that they stated was important in
their recovery processes. The importance of self-help in the recovery process,
both in this study and in the literature, suggests that helping clients access peer
support networks may represent a useful practice in facilitating recovery.

Mastery Experiences via Challenging and Meaningful Activities

An important source of self-efficacy is having an opportunity to develop a sense
of mastery over a challenging or meaningful task (Bandura, 1986). Individuals
who are able to engage successfully in particular tasks develop positive self-
efficacy beliefs and can have a positive influence on an individual’s competence,
motivation and persistence when undertaking tasks in the future. Participants
indicated that engaging in meaningful and challenging activities such as work,
school, volunteering, hobbies, self-help, activism or other pursuits provided them
an opportunity to develop a sense of competence in their abilities and helped
them grow and develop. For example, Sarah, now a consumer advocate, was
discouraged by many mental health professionals from working due to their fear
she would fail and exacerbate her symptoms. With the support of her mother
and friends, Sarah began to work part time and then, later, full time. She also
enrolled in computer classes and volunteered at a local prison. Eventually, she
developed a career working for the Department of Mental Health as an
advocate. She attributes part of her success to her early decision to resist the
low expectations of her providers and find employment. When asked about
what facilitates recovery she said the following:

Everything comes out of choice . . . I think when you are making your own
choices and you’re determined that they’re yours and you’re doing what feels
right for you then even when you’re in a lousy job that’s stressing you out making
you symptomatic it’s the right way to go . . . (Sarah)

Participants stated that taking risks and engaging in growth-oriented

experiences was one of the most important aspects of the recovery process. In
the following quote Robert described his experience as a graduate psychology
intern. He had recently been discharged from a six-month hospitalization. Follow-
ing a recuperation period, he decided to resume his graduate studies and was
accepted for an internship at a local psychiatric hospital. Robert was terrified at
first because at the time, due to insulin coma treatments and psychiatric drugs,

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 Mancini The Role of Self-efficacy in Recovery ■ 63

he states, ‘my mind was shot’. Despite this, Robert accepted the internship and
over time became successful. Robert describes the confidence he was able to
build through his successful negotiation of his internship.

[I] started to pick up on the stuff that I needed to learn and started to make
some friends there and I was pretty well accepted among the other interns so
that that success allowed me to build . . . and [I] sort of learned that I could do
a lot and at the same time I was getting sharper mentally and feeling fairly normal
. . . it was succeeding in a sense I was doin’ it as well or better than most. (Robert)

Taking risks, struggling and being successful were important themes

generated by participants. Participants noted that the ability to take risks and
learn from successes (and failures) was a key aspect of their recovery process
because taking risks often led to building confidence in themselves and their
abilities.
Participants were also unanimous in stating that professional paternalism
was a barrier to recovery. They advocated for assisting and supporting clients in
taking risks and suggested that overprotection and paternalism reinforced the
message in them that they were incompetent, sick and fragile. They claimed
that over time, these messages could solidify and result in an intractable sense
of incompetence too often labeled as ‘lack of motivation’. Data from this study
suggests that taking risks through challenging activities actually led to a better
sense of mastery and self-efficacy in participants, and was one of the building
blocks of their development toward a successful and satisfying life.

Emotional and Somatic Well-being via a Variety of Wellness Enhancing Tools

Healthy and positive emotional and somatic states are vital in the development
of efficacy (Bandura, 1986). Experiencing severe emotional or cognitive distress
due to psychiatric symptoms, treatment effects, fear or negative thoughts can lead
to the development of negative self-efficacy beliefs (Bandura, 1986). Therefore,
reducing emotional and cognitive distress may help facilitate the development of
self-efficacy. Participants relied on a wide variety of approaches to maintain a
sense of stability in their thoughts, feelings and behaviors and that once they
were able to think and feel more clearly, they were then able to effectively reflect
on their lives, formulate plans and engage in activities designed to achieve
recovery related goals. Whether through the use of medications, therapy or
alternative approaches, all participants agreed that ‘self-determination and
informed choice’ was of primary importance. This finding is also supported else-
where (Cohen, 2005; Jacobson and Greenley, 2001; Mead and Copeland, 2000).
The strategies or tools that participants utilized were unique and often
developed over many years of trial and error. Professional interventions such as
counseling or medication were used in combination with self-help, meditation,

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64 ■ Qualitative Social Work 6(1)

exercise, hobbies, leisure, nutrition and lifestyle adjustments such as getting the
right amount of sleep or limiting alcohol consumption to establish and maintain
recovery.
Many participants described alternative ways in which they maintained
their well-being. Kelly, in the following quote, described the ways she main-
tains her well-being through alternative approaches:

A lot of us have explored and utilized the alternative therapies in our recovery.
I have studied Tai Chi and studied Chi Quong and that really just gave me the
awareness of subtle energy and just really learning to be able to kind of manipu-
late that energy, to utilize that energy, to draw in that energy, to release energy
really become conscious of the mind-body-spirit connection. (Kelly)

Some participants stated that getting the right type and dosage of medi-
cation(s), sometimes after years of trial and error, had a major impact on
initiating and maintaining their recovery. Nancy, a consumer-provider and
rights activist, described her experience with medication and the impact it had
on her recovery:

I went from crazy to pretty much remission due to medication . . . clearly if I

didn’t take it I went crazy [and] if I did take it I was fine. (Nancy)

Nancy’s point illustrated some participants’ recoveries were facilitated by

medications that allowed them to think more clearly, feel better, be more in
control of their lives, and achieve a level of stability not possible prior to taking
them.
However, other participants stated that medication was detrimental to
their recoveries because of severe and persistent side effects. Terry, for example,
described a situation in which she attempted to get off medications entirely.
After a long search she stated that she had finally found a doctor who agreed
to help her.

I brought a shoe box full of medication I think I was taking seventeen different
things I was taking stuff for pain I was takin’ stuff for my depression they were
given me stuff to go to sleep they were given me stuff to get me up in the
morning I mean just it was craziness/I was a freakin’ zombie. (Terry)

Terry, and other participants, reported that her psychiatric medications

hindered her recovery rather than facilitated it. These medications were often
described as keeping participants in a state of confusion and lethargy that inter-
rupted their ability to be productive and adequately perform normal adult roles.
The role of medication in participants’ recovery was a key tension point in the
study.

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 Mancini The Role of Self-efficacy in Recovery ■ 65

However, those that did rely on medications stated that what was
important was that their practitioners worked closely with them in helping
ensure that they were fully educated about the various aspects of their medi-
cations including side effects and their management, long-term effects, inter-
actions, contraindications, dosages and alternative medications. Participants were
therefore, well informed and supported in their decisions regarding their treat-
ment regimen, a key factor in recovery advocated elsewhere (Mead and
Copeland, 2000). Likewise, all participants in this study reported that taking
responsibility for their health was a key factor in helping facilitate and maintain
their recovery. They advocated that mental health clients should not be overtly
or covertly encouraged to maintain a passive stance in their treatment. Rather,
clients, presumably with the help of their practitioners should learn strategies
designed to help them understand their diagnosis, realize what helps and hinders
their well-being, learn how to recognize when symptoms may be returning or
escalating and develop a crisis plan for action.

DISCUSSION
The development of self-efficacy played a key role in participants’ recoveries.
Explicating how practitioners can enhance recovery in people diagnosed with
serious psychiatric disabilities has been difficult and the exact nature and magni-
tude of self-efficacy’s relationship with improved psychosocial functioning and
recovery for people with serious psychiatric disabilities remains unclear and
requires further study.
However, evidence from this study demonstrates that understanding the
contexts that facilitate self-efficacy development may provide social workers and
other mental health practitioners with valuable information regarding how
professionals can positively influence the recovery process in people diagnosed
with serious psychiatric disabilities. This study suggests that contexts that facili-
tate self-efficacy beliefs are those in which clients: (1) are encouraged to take
risks and engage in meaningful and challenging activities; (2) have warm and
egalitarian professional relationships; (3) have access to self-help and peer-
support networks; and, (4) can make informed choices among a variety of formal
and alternative treatments. The following discussion will frame what partici-
pants said helped their recovery within the context of self-efficacy and position
these findings as preliminary suggestions for how social workers might facili-
tate the recovery process in their clients.

Implications for Practice

Developing competence through mastery experiences represents a key source
of self-efficacy (Bandura, 1986). This may be important for people diagnosed
with schizophrenia as mastery has also been found to be negatively associated

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66 ■ Qualitative Social Work 6(1)

with psychopathology in schizophrenia patients (Bengtsson-Tops, 2004). Partici-

pants’ stories suggest that engaging in meaningful activities such as work as well
as other activities such as school, activism and volunteering helped them develop
a sense of competence and agency. The important role of work in building a
positive sense of self is established in the literature (Provencher et al., 2002).
Participants also stated that meaningful activities such as work and school gave
them the opportunity to develop skills and confidence. Providing opportunities
to engage in mastery experiences such as employment or school represent
important ways practitioners can help enhance clients’ self-efficacy and improve
recovery outcomes.
Practitioners and agencies can create contexts for recovery by infusing
the expectation that clients can engage in meaningful activities. This may sound
self-evident, however, participants indicated in their stories that they were often
discouraged from participating in work or other meaningful activities by
practitioners because they feared that the stress of these activities would cause
participants to relapse. Social workers concerns of liability and the pervasive
conception of relapse as a failure of the client, worker or system may fuel a
tendency to overprotect clients and discourage clients’ attempts to take mean-
ingful, growth-oriented risks. Paternalism was described as a key barrier in
participants’ recoveries (see Mancini et al., 2005). It may be a natural response
for practitioners to feel protective of clients. However, it is important for
practitioners and their clinical supervisors to recognize when these good in-
tentions begin to interfere with a client’s sense of competence and recovery.
Clients take risks by engaging in meaningful activities. Clients should be
encouraged and supported in taking these types of risks and have opportunities
to be successful, thus enhancing their self-efficacy. It should be noted that clients
might fail. However, with support, practitioners can help their clients learn from
their mistakes and move forward.
The evidence-based practice models of supported employment (Bond and
Jones, 2005), supported education (Sullivan-Soydan, 2005) and supported housing
(Carling, 1995) may assist practitioners in supporting their clients as they work
toward their goals and also develop a sense of personal self-efficacy. These models
have been proven to improve employment, education and housing outcomes for
individuals with serious psychiatric disabilities. Supported employment and
supported education models allows people with psychiatric disabilities to chose
from a wide range of competitive employment positions or education programs
and then provides them with professional support tailored to meet their needs
and ensure continued success (Bond and Jones, 2005; Sullivan-Soydan, 2005).
Likewise, supported housing helps people with psychiatric disabilities to attain
mainstream community housing and provides structured and ongoing supports
that help them to be successful as they live independently (Carling, 1995). These
models of practice possess the potential to enhance self-efficacy because they

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 Mancini The Role of Self-efficacy in Recovery ■ 67

give people the opportunity to develop mastery experiences in a number of life

domains. More research is needed in order to understand if and how these models
affect self-efficacy.
Participants in this study were unanimous in their identification of
supportive professionals as vital to the recovery process. Participants defined
supportive professionals as warm, respectful, caring and steadfast in their support.
Participants stated that the professionals that supported them believed in their
ability to recover and provided them with hope and strength. Social persuasion
has been identified as another important source of self-efficacy (Bandura, 1986).
Individuals develop self-efficacy through the encouragement and support of
respected others. Although empathic understanding and relationship building
are taught as hallmarks of social work practice it is often the case that the
importance of relationship building is overlooked in real-world practice settings.
Professional codes of ethics often promote ‘professional boundaries’ and the idea
of ‘professional distance’, and may inadvertently inhibit practitioners’ abilities to
form deep, warm and supportive relationships with clients by reinforcing
hierarchical relationship structures. In addition, huge caseloads, decreased
funding and high turnover rates prohibit practitioners from investing the time
and energy it takes to form these relationships. Finally, the increased focus on
the importance of compliance with psychiatric medication and the rise of forced
inpatient and outpatient commitment laws may again restrict practitioners’
abilities to form egalitarian and trusting relationships, and may enhance the
development of coercive treatment settings – identified as a key barrier to
recovery (Mancini et al., 2005). These factors inhibit social workers and other
practitioners from developing empowering relationships with their clients
(Linhorst, 2006).
It is important for clinical supervisors to recognize the inherent
importance of supportive professional relationships in helping individuals
diagnosed with serious psychiatric disabilities in their recoveries. These relation-
ships can provide the sense of agency and competence necessary for recovery.
Social work training programs must also recognize that supportive, trusting and
egalitarian relationships are the cornerstone to helping people develop self-
efficacy and emphasize to students that supportive relationships are necessary in
developing contexts conducive to recovery.
A third area that participants agreed was important to recovery was having
access to self-help and peer support. Self-help and peer support provided many
participants with mutual support and recovery role models. Once isolated,
participants stated that when they were able to access peer support services they
realized that they were not alone in their struggles and that recovery was possible.
Self-efficacy is known to emerge from vicarious learning experiences (Bandura,
1986). That is, when an individual sees similar others performing tasks success-
fully, their belief in their own abilities improves. Therefore, having access to

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68 ■ Qualitative Social Work 6(1)

individuals who have experienced recovery provides people with psychiatric

disabilities with hope that recovery is possible and a blueprint for achieving
recovery.
Self-help and peer-provided services have shown positive clinical
outcomes (Solomon and Draine, 1995a,b, 2001). Self-help programs have
outcomes similar to professional therapists (Christensen and Jacobson, 1994;
Gould and Clum, 1993) and have been shown to improve psychiatric symptoms
and quality of life (Davidson et. al., 1999). They also show decreases in
hospitalizations, improved daily functioning and an improved ability to manage
one’s condition(s) (Kurtz, 1988; Powell, et. al., 2001). Less is known about how
self-help and peer support effects self-efficacy and is an area of future research.
Practitioners can create contexts for clients that may help enhance their
own self-efficacy and facilitate recovery by helping client’s access self-help and
peer supports in the community. Social work practitioners can do this in a
number of ways. Linhorst (2006) provides a review of the ways in which
agencies and practitioners can help clients to access peer support networks. First,
practitioners can become knowledgeable of the self-help and peer support
resources in their particular community and help clients access these networks
through referral (Segal et al., 2002). Second, social work practitioners and
agencies can develop collaborative peer-partnerships with peer-support agencies
in which each agency can share knowledge, training, services and resources in
ways that are mutually beneficial (Solomon, 2004). Finally, social work agencies
can recruit and hire paid peer providers to their teams. Agencies can then have
a built in access point to self-help peer services for their clients (Solomon, 2004).
By utilizing peer support networks, practitioners and agencies can help clients
have access to vicarious learning experiences and role models that can help
build self-efficacy and hope in the possibility of recovery. These networks can
also help professional staff learn the importance of developing the supportive
and egalitarian relationships that have already been shown to be important.
Participants also stated that choice among a variety of traditional and
alternative mental health treatments was important in their overall recovery.
Participants stated that traditional approaches such as medication and psycho-
therapy and non-traditional approaches such as yoga and sports were vital to
establishing emotional, physical and cognitive well-being. Participants stated that
emotional and cognitive distress from both psychiatric symptoms and iatrogenic
treatment effects were barriers to their recovery. A fourth source of self-efficacy
is positive somatic and emotional states (Bandura, 1986). Individuals are better
able to build self-efficacy and are better motivated if they are able to associate
tasks with positive feelings such as exhilaration or joy. Feelings of anxiety,
depression and fear interfere with the development of self-efficacy. In addition,
Shahar et al. (2004) found that efficacy predicted a reduction in depressive
symptoms over time.

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 Mancini The Role of Self-efficacy in Recovery ■ 69

Participants stated that they were able to achieve states of well-being

using a variety of approaches. Prior to their recoveries participants stated that
they often did not have access to information about treatment options and
associated part of their recovery with making informed choices about the
approaches that worked best for them.
Being able to choose from a variety of options has also been identified
as a key condition for empowerment (Linhorst, 2006) and recovery
(Chamberlin, 1997; Jacobson and Greenley, 2001; Tenney, 2000). In this study,
having access to a variety of treatment options and having the ability to choose
from those treatments, enhanced participants’ self-efficacy and recovery.
Practitioners can help enhance their clients’ self-efficacy and recovery if they
are able to create treatment contexts defined by informed choice (Mead and
Copeland, 2000).
Evidence suggests that helping clients diagnosed with serious psychiatric
disabilities manage their own conditions through a structured psychoeducation
program can lead to better symptom management and lower rates of relapse
(Mueser et al., 2002). Practitioners must take the time to educate clients about
the range of treatment options available to them. In addition, clients must be
fully educated about the benefits, risks and drawbacks of all treatment options,
particularly psychiatric medication. In addition, clients after being fully informed
should have the right to choose which approaches they wish to pursue. This
may be difficult if clients make choices that the practitioner believes to be
unwise. However, the right to self-determination is a guiding principle in social
work’s code of ethics and denying clients’ right to choose carries its own
negative consequences such as apathy, despair and hopelessness.

Implications for Research

Several implications for research exist. This study sought to apply the theory of
self-efficacy to findings that emerged from a grounded theory analysis of
consumer-providers’ stories about the factors that facilitate and hinder the
recovery process (Mancini et al., 2005). This study did not originally seek to
examine the role of self-efficacy in the recovery process. As a result of this post
hoc application, the data does not always fit with the theory of self-efficacy.
This is a limitation, and future research should explicitly and systematically seek
to explore and define the connections between self-efficacy and recovery. Quali-
tative studies that examine personal narratives of recovery should specifically
explore how self-efficacy influences recovery and the contexts that facilitate its
development. In addition, this study used an extremely limited sample. Partici-
pants in this study were providers of peer services, middle class, educated and
many possessed a high level of functioning prior to experiencing psychiatric
disability. Participants were also similar in age and most were white. These factors
may influence the importance self-efficacy plays in the recovery process. More

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70 ■ Qualitative Social Work 6(1)

research is needed that explores the contexts that facilitate recovery and self-
efficacy in diverse populations.
Quantitative methodologies should continue to explore the causal
pathways of recovery and establish whether self-efficacy has a direct effect or
is mediated by other factors. Pratt et al. (2005) recently found that although
self-efficacy was associated with higher levels of psychosocial functioning, this
association was influenced by other factors, namely, the presence of negative
symptoms and premorbid functioning. Further research is needed in this area
as few studies have examined the role of self-efficacy in the recovery process.
Doing so will better explicate how self-efficacy influences recovery and may
lead to the discovery of other important factors associated with recovery.
In addition, there appears to be much overlap and confusion regarding
concepts such as empowerment, self-efficacy, self-esteem and agency when
discussing recovery. Further research that untangles these concepts and deciphers
their individual influences may be especially important in further developing and
explicating a recovery model. Likewise, developing more precise models of
recovery will assist in the development of interventions that are complimentary
to the contexts that facilitate recovery. For instance, Resnick et al. (2005) have
recently proposed that interventions should be designed that enhance ‘recovery
attitudes’ identified as consisting of: empowerment, hope and optimism, knowl-
edge and life satisfaction.
Research on recovery should embrace a bio-psychosocial approach as it
is becoming clear that psychological factors such as self perception and person-
ality may be as important as biological (e.g. genetics, vulnerability) or social
(income, housing, healthcare access) factors in determining outcomes for people
diagnosed with serious psychiatric disorders (Shahar et. al, 2004). Further
research that explores recovery contexts should be linked with intervention
research in order to develop interventions that facilitate, compliment or enhance
the bio-psychosocial factors found to facilitate recovery. Integrating objective,
outcome oriented intervention research with what is known about the sub-
jective aspects of recovery may help move beyond interventions that simply
improve concrete research-oriented outcomes such as a reduction in hospital-
ization days or number of symptoms, to interventions that help people with
psychiatric disabilities become active citizens living fuller, more satisfying and
productive lives.

References
Anthony,W.A. (1993) ‘Recovery from Mental Illness: The Guiding Vision of the Mental
Health Service System in the 1990s’, Psychosocial Rehabilitation Journal 16(4): 11–23.
Anthony, W., Cohen, M., Farkas, M. and Gagne, C. (2002) Psychiatric Rehabilitation, 2nd
edn. Boston, MA: Boston Psychiatric Center Press.

Downloaded from qsw.sagepub.com at Umea University Library on April 7, 2015

 Mancini The Role of Self-efficacy in Recovery ■ 71

Bandura, A. (1966) ‘Reflection on Human Agency’, in J. Georgas and M. M. Manthouli,

E. Besevegis and A. Kokkevi (eds) Contemporary Psychology in Europe, pp. 194–210.
Seattle, WA: Hogrefe & Huber.
Bandura, A. (1977) ‘Self-efficacy: Toward a Unifying Theory of Behavioral Change’,
Psychological Review 84: 191–215.
Bandura, A. (1986) Social Foundations of Thought and Action: A Social Cognitive Theory.
Englewood Cliffs, NJ: Prentice Hall.
Bandura, A. (2001) ‘Social Cognitive Theory: An Agentic Perspective’, Annual Review of
Psychology 52: 1–26.
Bandura, A., Caprara, G. V., Barbaronelli, C., Garbino, M. and Pastorelli, C. (2003) ‘Role
of Affective Self-regulatory Efficacy in Diverse Spheres of Functioning’, Child
Development 74(3): 769–82.
Barham, P. and Hayward, R. (1998) ‘In Sickness and in Health: Dilemmas of the Person
with Severe Mental Illness’, Psychiatry 61(2): 163–70.
Bengtsson-Tops, A. (2004) ‘Mastery in Patients with Schizophrenia Living in the
Community: Relationship to Sociodemographic and Clinical Characteristics, Needs
for Care and Support, and Social Network’, Journal of Psychiatric & Mental Health
Nursing 11(3): 298–304.
Blumer, H. (1969) Symbolic Interactionism: Perspective & Method. Englewood Cliffs, NJ:
Prentice Hall.
Bond, G. and Jones, A. (2005) ‘Supported Employment’, in R. Drake, M. Merrens and
D. Lynde (eds) Evidence-based Mental Health Practice: A Textbook, pp. 367–94. New
York: Norton.
Carling, P. J. (1995) Return to Community: Building Support Systems for People with Psychi-
atric Disabilities. New York: Guilford Press.
Chamberlin, J. (1979) On Our Own: Patient-Controlled Alternatives to the Mental Health
System. New York: McGraw-Hill.
Chamberlin, J. (1997) ‘Confessions of a Non-Compliant Patient’, National Empowerment
Center Newsletter, http://www.power2u.org/articles/recovery/confessions.html
(consulted Nov. 2006).
Charmaz, K. (2000) ‘Grounded Theory: Objectivist & Constructivist Methods’, in
N. Denzin and Y. Lincoln (eds) The Handbook of Qualitative Research, 2nd edn,
pp. 509–35. Thousand Oaks, CA: Sage.
Christensen, A. and Jacobson, N. (1994) ‘Who (or What) can do Psychotherapy:
The Status and Challenge of Nonprofessional Therapies’, Psychological Science 5(1):
8–14.
Cohen, O. (2005) ‘How do we Recovery?: An Analysis of Psychiatric Survivor Oral
Histories’, Journal of Humanistic Psychology 45(3): 333–54.
Colleti, G. (1985) ‘The Smoking Self-efficacy Questionnaire (SSEQ): Preliminary Scale
Development and Validation’, Behavioral Assessment 7(3): 249–60.
Corin, E. and Lauzon, G. (1992) ‘Positive Withdrawal and the Quest for Meaning: The
Reconstruction of Experience among Schizophrenics’, Psychiatry: Journal for the Study
of Interpersonal Processes 55(3): 266–78.
Corin, E. and Lauzon, G. (1994) ‘From Symptoms to Phenomena: The Articulation of
Experience in Schizophrenia’, Journal of Phenomenological Psychology 25(1): 3–50.

Downloaded from qsw.sagepub.com at Umea University Library on April 7, 2015

72 ■ Qualitative Social Work 6(1)

Corrigan, P. O. and Ralph, R. O. (2005) ‘Recovery as Consumer Vision and Research

Paradigm’, in R. O. Ralph and P. W. Corrigan (eds) Recovery in mental illness:
Broadening our Understanding of Wellness, pp. 3–17.Washington, DC: American Psycho-
logical Association.
D’Amico, A. and Cardaci, M. (2003) ‘Relations among Perceived Self-efficacy, Self-
esteem and School Achievement’, Psychological Reports 92(3 pt1): 745–54.
Davidson, L. (2003) Living Outside Mental Illness: Qualitative Studies of Recovery in
Schizophrenia. New York: New York University Press.
Davidson, L. and Strauss, J. (1992) ‘Sense of Self in Recovery from Severe Mental Illness’,
British Journal of Medical Psychology 65(2): 131–45.
Davidson, L., Chinman, M., Kloos, B., Weingarten, R., Stayner, D. and Tebes, J. (1999)
‘Peer Support among Individuals with Severe Mental Illness: A Review of the
Evidence’, Clinical Psychology 6(2): 165–87.
Deegan, P. (1988) ‘Recovery: The Lived Experience of Rehabilitation’, Psychosocial Reha-
bilitation Journal 11(4): 11–19.
Deegan, P. (1996) ‘Recovery as a Journey of the Heart’, Psychiatric Rehabilitation Journal
19(3): 91–7.
deGirolamo, G. (1996) ‘WHO Studies on Schizophrenia: An Overview of the Results
and their Implications for the Understanding for the Disorder’, The Psychotherapy
Patient 9(3–4): 213–23.
DiClemente, C. C., Faithhurst, S. K. and Piotrowski, N. A. (1995) ‘The Role of Self-
efficacy in the Addictive Behaviors’, in J. Maddux (ed.) Self-efficacy, Adaptation and
Adjustment: Theory, Research, & Application, pp. 109–41. New York: Plenum Press.
Estroff, S. E. (1989) ‘Self, Identity and Subjective Experiences of Schizophrenia: In,
Search of the Subject’, Schizophrenia Bulletin 15(2): 189–96.
Fisher, D. (1994) ‘A New Vision of Healing as Constructed by People with Psychiatric
Disabilities Working as Mental Health Providers’, Psychosocial Rehabilitation Journal
17(3): 67–81.
Glaser, B. G. and Strauss, A. L. (1967) Discovery of Grounded Theory: Strategies for Quali-
tative Research. Chicago, IL: Aldine DeGruyter.
Gould, R. A. and Clum, G. A. (1993) ‘A Meta-analysis of Self-help Treatment
Approaches’, Clinical Psychology Review 13(2): 169–86.
Harding, C. M., Brooks, G. W., Ashikaga, T., Strauss, J. S. and Breier, A. (1987a) ‘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(6):
718–26.
Harding, C. M., Brooks, G. W., Ashikaga, T., Strauss, J. S. and Breier, A. (1987b) ‘The
Vermont Longitudinal Study of Persons with Severe Mental Illness: II. Long Term
Outcome of Subjects who Retrospectively met DSM-III Criteria for Schizophrenia’,
American Journal of Psychiatry 144(6): 727–35.
Jacobson, N. (2000) ‘Experiencing Recovery: A Dimensional Analysis of Recovery
Narratives’, Psychiatric Rehabilitation Journal 24(6): 248–56.
Jacobson, N. and Greenley, D. (2001) ‘What is Recovery?: A Conceptual Model and
Explication’, Psychiatric-Services 52(6): 482–5.
Kelley, M. and Gamble, C. (2005) ‘Exploring the Concept of Recovery in Schizo-
phrenia’, Journal of Psychiatric and Mental Health Nursing 12(2): 245–51.

Downloaded from qsw.sagepub.com at Umea University Library on April 7, 2015

 Mancini The Role of Self-efficacy in Recovery ■ 73

Kurtz, L. (1988) ‘Mutual Aid for Affective Disorders: The Manic Depressive and
Depressive Association’, American Journal of Orthopsychiatry 58(1): 152–5.
Linhorst, D. (2006) Empowering People with Severe Mental Illness: A Practical Guide. New
York: Oxford University Press.
Mancini, M. A., Hardiman, E. R. and Lawson, H. A. (2005) ‘Making Sense of it All:
Consumer Providers’ Theories about Factors Facilitating and Impeding Recovery
from Psychiatric Disabilities’, Psychiatric Rehabilitation Journal 29(1): 48–55.
Mead, S. and Copeland, M. (2000) ‘What Recovery Means to Us: Consumer Per-
spectives’, Community Mental Health Journal 36(3): 315–28.
Miles, M. and Huberman, A. (1994) Qualitative Data Analysis: An Expanded Sourcebook,
2nd edn. Thousand Oaks, CA: Sage.
Mowbray, C. T. and Tan, C. (1993) ‘Consumer-operated Drop-in Centers: Evaluation
of Operations and Impact’, Journal of Mental Health Administration 20(1): 8–19.
Mueser, K. T., Corrigan, P. W., Hilton, D. W., Tanzman, B., Schaub, A., Gingerich, S.,
Essock, S. M., Tarrier, N., Morey, B., Vogel-Scibilia, S. and Herz, M. I. (2002) ‘Illness
Management and Recovery: A Review of the Research’, Psychiatric Services 53(10):
1272–84.
Mueser, K. T., Valentiner, D. P. and Agresta, J. (1997) ‘Coping with Negative Symptoms of
Schizophrenia: Patient and Family Perspectives’, Schizophrenia Bulletin 23(2): 329–39.
Ochocka, J. Nelson, G. and Janzen, R. (2005) ‘Moving Forward: Negotiating Self and
External Circumstances in Recovery’, Psychiatric Rehabilitation Journal 28(4): 315–22.
Pettie, D. and Triolo, A. M. (1999) ‘Illness as Evolution: The Search for Identity and
Meaning in the Recovery Process’, Psychiatric Rehabilitation Journal 22(3): 255–62.
Powell, T., Yeaton, W., Hill, E. and Silk, K. (2001) ‘Predictors of Psychosocial Outcomes
for Patients with Mood Disorders: The Effects of Self-help Group Participation’,
Psychiatric Rehabilitation Journal 25(1): 3011.
Pratt, S. I., Mueser, K. T., Smith, T. E. and Lu, W. (2005) ‘Self-efficacy and Psychosocial
Functioning in Schizophrenia: A Mediational Analysis’, Schizophrenia Research
78(2–3): 187–97.
Provencher, H. L., Gregg, R., Mead, S. and Mueser, K. T. (2002) ‘The Role of Work in
the Recovery of Persons with Psychiatric Disabilities’, Psychiatric Rehabilitation Journal
26(2): 132–44.
Resnick, S. G., Fontana, A. Lehman, A. F. and Rosenheck, R. A. (2005) ‘An Empirical
Conceptualization of the Recovery Orientation’, Schizophrenia Research 75(1):
119–28.
Ridgway, P. (2001) ‘Re-storying Psychiatric Disability: Learning from First Person Nar-
rative Accounts of Recovery’, Psychiatric Rehabilitation Journal 24(4): 335–43.
Segal, S. P., Hardiman, E. R. and Hodges, J. Q. (2002) ‘Characteristics of New Clients
at Self-help and Community Mental Health Agencies in Geographic Proximity’,
Psychiatric Services 53(9): 1145–52.
Shahar, G., Trower, P., Iqbal, Z., Birchwood, M., Davidson, L. and Chadwick, P. (2004)
‘The Person in Recovery from Acute and Severe Psychosis: The Role of De-
pendency, Self-criticism, and Efficacy’, American Journal of Orthopsychiatry 74(4):
480–8.
Solomon, P. (2004) ‘Peer Support/Peer Provided Services: Underlying Processes,
Benefits, and Critical Ingredients’, Psychiatric Rehabilitation Journal 27(4): 392–401.

Downloaded from qsw.sagepub.com at Umea University Library on April 7, 2015

74 ■ Qualitative Social Work 6(1)

Solomon, P. and Draine, J. (1995a) ‘The Efficacy of Consumer Case Management Team:
2-year Outcomes of a Randomized Trial’, Journal of Mental Health Administration
22(2): 135–46.
Solomon, P. and Draine, J. (1995b) ‘One Year Outcomes of a Randomized Trial of
Consumer Case Management’, Evaluation & Program Planning 18(2): 117–27.
Solomon, P. and Draine, J. (2001) ‘The State of Knowledge of the Effectiveness of
Consumer Provided Services’, Psychiatric Rehabilitation Journal 25(1): 20–7.
Stanley, M. A. and Maddux, J. E. (1986) ‘Self-efficacy Theory: Potential Contributions
to Understanding Cognition in Depression’, Journal of Social and Clinical Psychology
4(3): 268–78.
Strauss, A. L. (1987) Qualitative Analysis for Social Scientists. Cambridge: Cambridge
University Press.
Strauss,A. L. and Corbin, J. (1990) Basics of Qualitative Research: Grounded Theory Procedures
and Techniques. Newbury Park, CA: Sage.
Sullivan, W. P. (1994) ‘A Long and Winding Road: The Process of Recovery from Severe
Mental Illness’, Innovations and Research 3(3): 19–27.
Sullivan-Soydan, A. (2005) ‘Supported Education: A Portrait of a Psychiatric Re-
habilitation Intervention’, American Journal of Psychiatric Rehabilitation 7(3): 227–48.
Tenney, L. J. (2000) ‘It has to be about Choice’, Journal of Clinical Psychology 56(11):
1433–45.
US Department of Health and Human Services (1999) Mental Health: A Report of the
Surgeon General. Washington, DC: US Government Printing Office.
Ventura J., Nuechterlein K. H., Subotnik K. L., Green M. F. and Gitlin, M. J. (2004)
‘Self-efficacy and Neurocognition may be Related to Coping Responses in Recent-
onset Schizophrenia’, Schizophrenia Research 69(2–3): 343–52.
Watson, A. C. and River, P. L. (2005) ‘A Social Cognitive Model of Personal Responses
to Stigma’, in P. W. Corrigan (ed.) On Stigma and Mental Illness: Practical Strategies for
Research and Social Change, pp. 145–64. Washington, DC: American Psychological
Association.

Michael A. Mancini is assistant professor in the School of Social Work at

St Louis University. His teaching and research specializes in community mental
health practices, qualitative methods, severe and persistent psychiatric dis-
abilities, psychiatric rehabilitation and recovery. Address: Assistant Professor,
St Louis University, School of Social Work, 302 Tegeler Hall, 3550 Lindell Blvd,
St Louis, MO 63139, USA. [email: mancinim@slu.edu]

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