Social Positioning Analysis as a Qualitative Methodology to Study Identity Construction in People Diagnosed With Severe Mental Illnesses

For Peer Review Social positioning analysis as a qualitative methodology to study identity construction in people diagnosed with severe mental illnesses Journal: Qualitative Health Research Manuscript ID QHR-2020-1236.R2 Manuscript Type: Research Article Keywords: Self, Recovery < Adaptation, Coping, Enduring, Mental Health and Illness, Stigma, Qualitative, Methodology Regions, Cultures, and Peoples: Western Europe < Europe, Europeans Methods: Conversation Analysis, Dialogue, Linguistics < Content Analysis < Research Strategies, Discourse Analysis < Content Analysis < Research Strategies http://mc.manuscriptcentral.com/qhr Qualitative Health Research Accepted for publication: Saavedra, J., Arias-Sánchez, S., de la Mata, M. L., & Matías-García, J. A. (2021). Social Positioning Analysis as a Qualitative Methodology to Study Identity Construction in People Diagnosed With Severe Mental Illnesses. Qualitative Health Research. https://doi.org/10.1177/10497323211050377 For Peer Review Abstract Severe mental illnesses (SMI) in general, and schizophrenia in particular, have been characterized as alterations of the experience of self and identity. When first diagnosed with SMI, the subjective experiences and specific narrative challenges faced by this population are particularly important. Therefore, qualitative approaches which allow to analyze these subjective experiences should be developed. This article presents in detail a specific method, called Social Positioning Analysis (SPA), which makes the complexity of narratives and life stories with multiple turning points understandable. To develop this methodological proposal, it has been taken into account the performative aspects of social interaction in which narratives are constructed. The methodology has previously been used in other health contexts and is innovative in the field of mental health. Linguistic criteria, definitions, and multiple examples are included to facilitate its application, as well as some reflections about its potential and possible benefits. Keywords: Self, Recovery, Mental Health and Illness, Stigma, Qualitative, Methodology. Page 1 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 2 The first conceptualizations of schizophrenia described it as a disorder of subjectivity which was specified as loss of a cohesive sense of the self and of connection with the world (Bleuer, 1911/1950). The experiences undergone by individuals diagnosed with this disorder cannot be explained exclusively by associated brain alterations, but span psychological, social, cultural and even political dimensions. From a phenomenological perspective, schizophrenia has been characterized as an alteration of self-experience, which impacts on organization of the self, and in short, in identity construction (Sass & Parnas, 2003). It has therefore been qualified as a disorder of ipseity, from the Latin ipse (itself). Pérez-Álvarez et al. (2010) established three characteristics of the alteration of subjectivity in schizophrenia: hyperreflexivity, diminished sense of self, and alteration of awareness of the world. The first involves an intensified form of self-consciousness. Thus, one may become aware of aspects implicit in psychological processes, transforming them in objects of one’s own experience. For example, the flow of thoughts may be objectivized, breaking their silence, and thus they are re-experienced as hallucinations. The second characteristic refers to a weakened or lack of sense of self as the subject of experience. One no longer considers herself the subject-agent of her own experiences and understands them exclusively as a passive observer. All of this leads to an alteration of bodily experience and of continuity in time. Logically, the third characteristic, alteration of awareness of the world, is a consequence of the previous one. A person diagnosed with schizophrenia becomes disconnected from the world when it loses its naturality, the individual feels strange, lost, and without affective connection to the world or the people who inhabit it. There is no doubt that these experiences alter the psychosocial construction of identity and one’s relationship with the social world (Sass & Parnas, 2003, 2007). The Page 2 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 3 essential instrument for organizing and expressing subjective experience and identity construction are personal narratives, the stories we create about ourselves. There is much empirical evidence demonstrating that although people with schizophrenia have not lost the ability to make narratives about themselves, it is very hard for them to do so (Lysaker & Lysaker, 2010; Saavedra et al., 2009). Their narratives are frequently incoherent and simplified, do not include significant events in their lives and tend to contain few themes related to agency or communion. Furthermore, such individuals do not describe themselves as agents in them, and they usually include an abundance of negative emotions about the past. In the last few decades, the model of recovery in mental health has emphasized the need to prioritize identity reconstruction in people with severe mental illnesses (SMI), such as schizophrenia, beyond just symptoms. According to Anthony’s (1993) classic definition, recovery is a personal journey which requires the reconstruction of identity with the goal of achieving, in spite of the illness, new significance and a meaningful life. Contrary to the traditional view of psychiatry and due to stories in first person of people affected, the recovery model considers that persons with SMI still are able to reconstruct their identity and connect again with others and with the world. This has led to considering that their voices are a source of knowledge and that the recovery model is fundamental for organizing services and defining professional practice (Slade, 2009). Considering the relevance of the voices of patients in defining their recovery, and beyond psychometric-type instruments, qualitative analysis techniques should be implemented that enable in situ analysis of identity reconstruction of people with SMI, such as schizophrenia, in their recovery process. From our perspective, the discussion above takes on special meaning to the extent that we assume that identity itself is a narrative construction. According to Bruner (1990), Page 3 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 4 when people are asked what they are truly like, they usually tell a wide variety of stories, using traditional elements of narrative. In a related vein, McAdams (2001; McAdams & Olson, 2010), defines identity as a life-story, with characters, setting, scenes, plot and theme. Identity is, then, constructed within the framework of the stories that we tell ourselves and others in social interaction. In this vein, people who have been diagnosed with a mental illness are faced with important narrative challenges. We deal with these narrative challenges in the following section. The severe mental illness diagnosis: Narrative challenges There is no doubt that suffering a first acute episode or having been diagnosed with a label as powerful as a psychiatric diagnosis profoundly changes the way the self is defined. For some authors, the diagnosis of SMI represents a turning point (McAdams, 2001). This diagnosis, as well as later recovery, requires reworking identity narratives of those affected. In such cases, where the diagnostic label comes into direct confrontation with a whole system of values, beliefs or previous ideas, narrative elaboration becomes necessary for one’s social integration and mental health. Narrative elaboration can be understood as the reconstruction of the individual's life-story (McAdams, 2001), incorporating new meanings and, more specifically, the SMI as part of the plot of the lifestory. In fact, as mentioned above, most of the definitions of personal recovery refer to a search for new meanings and the reconstruction of identity as core psychosocial processes (Anthony, 1993; Leamy et al. 2011). Reasons, stories, examples and other support are needed to help understand the unknown and make sense of the new experiences. Narration is a particularly useful and relevant way of organizing experience when something unexpected happens (Bruner, 1990). In the following we further develop these points in greater depth. Page 4 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 5 As mentioned above, some authors consider the narratives of people with an SMI impoverished (Lysaker & Lysaker, 2002; Saavedra et al., 2009; Saavedra, 2010). Since narratives are an essential instrument in the construction of identity, it is difficult to imagine how people who struggle to elaborate these narratives can actively participate in society. This is not only because of their clinical problems and symptoms, but also because of the pressure of public stigma and the tremendous challenge of dealing with all these issues. In this sense, public stigma presents one of the most significant difficulties in this process of narrative elaboration. Widespread stereotypes and prejudices about people with SMI characterize them as dangerous, unstable or unpredictable and having extravagant and disorganized behavior (Brohan et al., 2010; Corrigan et al., 2012; Rüsch et al., 2005; Van Beveren et al., 2020). It is therefore particularly important to understand how the narratives of affected people deal with public stigma. People with SMI very often internalize the stereotypes, negative prejudices, and discriminatory behavior toward them, a process that has been called self-stigma (Corrigan et al., 2006, LeBel, 2008). For some authors, this can only be understood through a narrative approach (Kondrat & Teater, 2009). Similarly, active and effective resistance to the internalization of these discourses requires those affected to bring narrative resources into play. From this perspective, we assume that a diagnosis of SMI presents many challenges that must be addressed. Identity and the medium and long-term past, present and expected life trajectory must be resignified in different domains, such as intimate relationships, employment, and friendships. In each of these contexts, conflictive situations and stress may arise. For example: When can or should a friend be informed of the diagnosis? And a potential romantic partner? Is it mandatory, beneficial or harmful to Page 5 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 6 inform an employer of the illness? These and many other questions may arise during the recovery process. In short, these narrative challenges often require 1) deciding how much to agree with the diagnosis, and the label to be used in explaining the SMI; 2) exploring explanatory models and inserting them into the own life narrative; 3) negotiating how much agency or responsibility is acknowledged by the individual at the onset of the problems and in their current state; 4) posing strategies to deal with public stigma and self-stigma; 5) deciding the form and degree of disclosure and to whom; and finally, 6) managing expectations regarding the recovery process, i.e., projection into the future. In the following sections, we present a proposal aimed at analyzing these narrative challenges. Analyzing narrative identity: Social positioning The concepts of positions and positioning (Davies and Harré, 1990; Bamberg, 1997; Harre & Van Languenhove, 1999) are central to the analysis of narrative identity. These concepts are based on the idea that identity emerges from the use of language in the framework of social interaction. In such situations, we are constantly managing our image (Goffman, 1967), negotiating and renegotiating our roles, as if we were performing on a stage. Goffman coined the term “footing” to point out to the different forms of “alignment” between a speaker and their listeners. Thus, different listeners may reject, accept, or question the role with which the same speaker presents him or herself. In a related vein, Harré and Van Languenhove (1999) described several properties of social interaction. The first is its moral character. This means that, in social interaction, participants negotiate the configuration of their personal attributes by allocating rights, obligations or responsibilities, thus legitimizing roles and practices. Secondly, all social interactions are historical in the sense that a past sequence of interactions is recreated in Page 6 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 7 the current interaction. The third property refers to the capacity of utterances to redefine the interaction at any time. This feature provides interlocutors with agency. In other words, participants in any interaction can change and resituate their position in the social space of the interaction at any time. Thus, the term “positioning” refers to the place in the social space, for example, between a psychologist and his or her client. The interlocutors claim this position for themselves as opposed to other subjects (who may or may not be present in the actual context of the conversation) (Bamberg 1997; Lucius-Hoene & Depperman, 2002). By claiming a certain social space in an interaction (self-positioning), we place our interlocutors within that social space (other-positioning). Positioning can be understood as a “self-presentation”, an “act of identification” or a “self-attribution”. These self-attributions indicate how people want to be understood and recognized by their interlocutors. In our opinion, the notion of positioning is more flexible than the “role” construct, as it can flow differently in the same conversation at different levels. Although positioning analysis is closely related to the study of social interactions in everyday life, what Bamberg (2006) calls “small stories”, we believe that it can be applied to any text, as long as it is understood within an interactive framework. From our perspective, the notions of position and positioning can be fruitfully applied to understanding the narrative identity of people with SMI. This analysis addresses the way the dilemma of continuity vs change (Bamberg, 2011) is dealt with in the narratives of people with SMI. Since life always involve changes, and often ruptures (turning points), narratives provide individuals with a sense of continuity by making sense of them and preventing the dissolution of identity (Bruner, 1990; McAdams, 1993; Nelson, 2003). In the case of those diagnosed with SMI, whose experience is characterized by an alteration of the sense of the self, how they face the challenge of continuity becomes critical. Page 7 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 8 According to previous studies (Prados et al., 2013; Santamaría et al. 2013; de la Mata et al., 2015), this qualitative methodological approach enables us to inquire how people face the challenges mentioned above. By analyzing the narratives produced in social interactive contexts, the processes of identity reconstruction can be explored dynamically. In this sense, social positioning analysis provides us with conceptual and methodological tools that can be productively applied in this population. The following section systematically presents the Social Positioning Analysis methodology. Social Positioning Analysis (SPA): a methodological proposal In line with the theoretical ideas introduced above, this approach analyzes identity reconstruction in people diagnosed with SMI. It has been successful with other populations in health contexts (Genuis, 2013; Williams et al., 2015; Glintborg & Thogersen, 2021) as a tool to assist in understanding the complexity of their narratives and life stories with multiple turning points. Therefore, we are convinced that this methodology, which is a combination of techniques based on Social Positioning Theory, can be beneficial as a qualitative approach to SMI. The Social Positioning Analysis (SPA) methodology is described below by explaining the key steps in its application to an interview or any other fragment of discourse of a person diagnosed with SMI. This description gives some examples extracted from narratives of SMI patients, and includes a table summarizing the examples, linguistic criteria, and definitions. Table 1 summarizes the steps in Social Positioning Analysis. These steps are briefly explained below: Table 1. Social Positioning Analysis application. 1. Identify the positions of the narrated self through other characters in the narrative. 2. Identify the positions of the narrator in the interactive context of the narration. 3. Analyze the sequence of positioning throughout the narrative to identify changes, core positions and possible conflicts. Page 8 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 15 U: I used to sleep very well all my life and one night I went to bed and I was a little sick. I said, what is this? Let's see if they have put something in my…, is this possible? I: How? U: I thought my mother didn't love me; she was my grandmother. The bricklayer put… I: The bricklayer? U: And she says, leave him, leave him, I liked a boy who was there, I said let’s see if they are putting poison in my beer, all night. In bed, shivering, very bad, me, she got up very early, at eight, Mom, what's wrong? And what do I know, something's wrong with me, look, but what do you have? My legs. Let’s see if a nurse can come, or we call a taxi, we take a taxi... Social positioning analysis is also useful in interpreting texts with lack of cohesion caused by communication problems that people with SMI may have. In the last extract, the participant shows problems in coherently narrating the episode of her first psychotic break. In the first line, the researcher asks if the user suffers from a problem with her "nerves", a very general, little stigmatizing, and widely used colloquial term. Thus, the researcher distances himself from positions that could identify him as a health professional. The participant responds with a concrete experience: the moment in which she identifies the beginning of her problems. She positions herself as a victim of poisoning, somebody put something in her drink: "Let's see if they have put something…". The narrative is quite incoherent. We know that the user "slept very well all her life" and that she was "a little sick". The disbelief in this first experience of illness is translated into a set of weakly described and connected symptoms: sleeping problems, shivering, cognitive problems, "I thought my mother didn't love me, she was my grandmother", and problems with her legs. The participant expresses her inability to understand what was happening to her. The proliferation of the direct style (voice of the mother and participant in direct style) indicates a lack of control of speech and a high emotional charge. The participant's discourse is a justification for her current state. Page 15 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 16 However, the episode is vaguely narrated, and problems can be found in contextualizing characters such as "the bricklayer", or with deictic expressions such as "there". The social positions shown in these four extracts are very different. The first participant positioned himself as a person with an illness who had problems being autonomous. Institutions and people related to mental health services were essential in his answer to the researcher’s question. The second one did not accept the social context of the interview and tried to avoid it by giving a stereotyped answer. The third one used a technical term to describe his problems, but then positioned himself as an honest person discussing his social position as mentally ill with health professionals. This participant’s configuration of social positioning is probably the most complex. The last participant’s narration of her first episode of psychosis lacked coherence, but positioned her as a victim of poisoning, which is what caused her psychiatric problems. In the excerpts above, the participants positioned themselves in complex sophisticated manners that could hardly be captured from the classical concept of illness insight, and require a qualitative microanalysis of identity construction in interactive contexts. SPA reveals how people with SMI interpret their experiences of illness and how they explain their diagnoses and their relationships with significant others, including healthcare professionals. In addition, with this methodology, it is possible to explore how they project themselves into the future and their ability to act in the world (agency). Although the excerpts analyzed are very brief, several in-depth interviews using this methodology would make it possible to analyze the recovery process of people with SMI. We think the recovery process cannot be studied exclusively with psychometric instruments, and that the level of analysis addressed with SPA provides highly relevant information that is very difficult to access by other means. It is therefore an appropriate Page 16 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 17 methodology that can help to better comprehend the recovery process for a particularly sensitive and diverse population. Conclusions This article is based on the concept of identity as a fluid dialogue among different social positions in narratives, which constitutes an ever-changing process (Saavedra, 2010). Social Positioning Analysis is a methodological approach for capturing this dialogue, which can account for the dynamics of social positions in the narratives of people with SMI in interactive frameworks. Social Positioning Analysis differentiates from other qualitative methodologies in several respects. It is aimed at the analysis of identity construction. Other approaches to narrative identity often focus on the content and the general structure of narratives (Kerr et al., 2020), leaving its micro-interactional nature behind. Social Positioning Analysis involves not only the person interviewed, but also the interviewer, who is frequently ignored in research. As a methodological tool, it is useful for studying the dynamic nature of identities during the course of a conversation, situating recovery narratives in specific social interactions. It can therefore account for how individuals (re)construct themselves in cultural settings. More specifically, it can account for the performative aspects, how identities are brought into play in the course of social interaction. It also helps understand the narrative construction of continuity-discontinuity in the individuals' life stories, or the way they appropriate cultural discourses, or master narratives, in their identity narratives. In this vein, SPA is close to conversational analysis and can be applied to "small stories" (Bamberg, 2006), that is, to informal interactions in daily life, not only the analysis of formal narrative interviews. Other qualitative mental health methodologies, such as Critical Realist Discourse Analysis (Sims-Schouten & Riley, 2019), have been published in this journal. This approach combines several methodological traditions to examine Page 17 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 18 external material realities. However, our analysis, which is based exclusively on discourse analysis and discursive psychology, is mainly focused on participant text and interaction. Since that identity reconstruction is the cornerstone of recovery, we must use analytical tools which allow capturing all the complexity and dynamism of this process. Although this methodology is too sophisticated to be employed in situ in the clinical practice, it can be used a posteriori by therapists and supervisor teams as a qualitative assessment procedure of recovery processes and implemented interventions. As it has been pointed out previously, Social Position Analysis is perfectly applicable in the context of the everyday interactions between therapists and patients, not being necessary structured interviews, as in our examples, nor a specific focus on research. Our methodology would have to be triangulated with other approaches to verify the accuracy of our analysis. For example, longitudinal studies in which the narratives of affected people are analyzed during their recovery, could be compared with other evaluations using other methodologies (diagnostic interviews, psychopathological evaluations, psychometric tests, etc.). This could determine the characteristics of the narratives and the linguistic markers most closely associated with recovery. This methodology is not free of limitations. First, this analysis requires complex linguistic explorations of the text to identify positions (semantic, syntactic and prosodic, nonverbal, etc.) far from the usual thematic analysis, which requires the same narratives to be reread several times. In this sense, we have tried to provide the reader with the linguistic criteria most frequent in such analyses. Second, reliable determination of positioning throughout the interviews is difficult, time-consuming and hard work. In addition, reports on the results must be lengthy to demonstrate the depth and the reliability of the analysis. Therefore, publication of this kind of analysis is frequently complicated. Also, due to its situated and qualitative nature, generalization can be achieved solely in Page 18 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 19 terms of analytical generalization, not statistical Giménez, 2012; Yin, 2009). Analytical generalization would allow for the application of theory in a variety of contexts. Despite those limitations, we are convinced of the great potential of SPA and the value of the information that it can provide, especially for the population with SMI. First, as discussed above, because schizophrenia is a disorder of the self, and second, because the core of the prevailing model of recovery in mental health is identity reconstruction. Moreover, this methodology has been demonstrated to be effective in other vulnerable populations and health-related contexts, such as migrants (Calderón-García et al., 2017), women victims of gender violence (de la Mata et al., 2015), and patients recovering from brain-injury (Glintborg, 2019). It has also been employed for analysis of identity construction of education and health professionals (Prados et al., 2013). We consider the narrative analysis of social positioning a significant contribution to the complex study of recovery and stigma, which requires the combination of qualitative and quantitative methodologies to significantly advance in knowledge. Funding This research was carried out within the framework of the research project funded by the Spanish Government, Ministry of Science and Innovation, State Research Agency and European Regional Development Fund-ERDF, entitled “Challenges of the self: Identity reconstruction in situations of inequality and social exclusion” (Reference: PSI2016–80112–P). ____________________ 1 All extracts included in this article belong to research projects in which informed consents were obtained and approved by the IRB Andalusian Biomedical Research Ethics Portal (Code: 0339-N-17). Page 19 of 24 http://mc.manuscriptcentral.com/qhr Qualitative Health Research 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 20 References Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. 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