38 Chapter 2 Our findings imply that patients, who still experience symptoms might nevertheless report good personal recovery. This results in the question which factors are specifically helpful to achieve personal recovery. Building on existing research on the domains of personal recovery, qualitative studies asking patients what exactly was helpful for their personal recovery, could provide useful information on the ingredients of interventions in clinical and other domains that promote personal recovery (14, 15, 95). Limitations A first limitation is the application of a specific definition of personal recovery, which limits the generalizability of our results to otherwise defined concepts of personal recovery. Besides the CHIME framework, mentioned in the introduction, several other concepts are used, such as resilience, self-determination, self-esteem, stigma, spirituality and life-satisfaction (13). Furthermore, we are not able to report on the relationship between clinical recovery and 2 aspects of CHIME, “identity” and “meaning,” as we chose to confine our search to the processes of personal recovery most frequently named by patients (13). The values of I2 indicate substantial heterogeneity of included studies, which probably reflects the use of multiple measures of personal recovery with different operationalisations of the concept (16), and/or heterogeneity in the study population. To avoid the problem that multiple dependent effect sizes from the same study could potentially bias the results, we calculated an average effect size within each study before analyses (35, 41). Although this method of calculating a simple mean effect-size to summarize a set of non-independent effect-sizes is commonly applied, this procedure may have led to over- or underestimation, especially in case of small correlations between averaged outcome measures (96). We tried to partially account for this problem by reporting separate meta-analysis for the different symptom domains. Another limitation relates to the possible negative association between insight and personal recovery. Interestingly, one study found a positive association between severity of psychopathology and personal recovery, whereas a negative correlation was reported between personal recovery and cognitive insight and self-reflectiveness. The authors conclude that perception of personal recovery is correlated with a lower awareness of symptomatology, which they call a “cognitive trap” (24). Apparently, patients can consider themselves recovered and lead a fulfilling life, while not being aware of symptoms. However, some patients consider acknowledging and accepting illness as an important step in their recovery process (95). Because study quality was variable, we investigated a possible effect in the metaregression analyses, but did not find a significant confounding effect.
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