Stages of Recovery Instrument (STORI)

1. Abstract

The Stages of Recovery Instrument (STORI) is a self-report psychometric measure designed to operationalize and assess the multidimensional process of psychological recovery in individuals diagnosed with severe and enduring psychiatric conditions, most notably schizophrenia and related affective psychoses. Developed by Retta Andresen, Peter Caputi, and Lindsay G. Oades in 2006 at the University of Wollongong, the instrument translates consumer-derived, qualitative narratives of recovery into an empirically verifiable stage model. The instrument comprises 50 items organized into 10 thematic groups representing five distinct, sequential stages: Moratorium, Awareness, Preparation, Rebuilding, and Growth. Each stage is indexed by a dedicated 10-item subscale. Respondents rate each item on a 6-point Likert scale ranging from 0 (Not at all true now) to 5 (Completely true now), reflecting their current subjective psychological orientation toward their illness, self-concept, agency, and future outlook.

Extensive psychometric investigations substantiate the STORI’s robust structural and measurement properties. Internal consistency estimates across diverse clinical cohorts demonstrate strong subscale reliability, with Cronbach’s alpha coefficients typically ranging from .74 to .88 for Moratorium, .76 to .86 for Awareness, .77 to .89 for Preparation, .83 to .91 for Rebuilding, and .86 to .92 for Growth. Construct validity has been rigorously demonstrated through convergent associations with standardized measures of hope, empowerment, resilience, and personal autonomy, alongside predictable inverse relationships with psychological distress, self-stigma, and hopelessness. Multidimensional scaling (MDS) and cluster analytic procedures confirm a simplex-like quasi-circumplex or ordered continuum that mirrors the theoretically postulated developmental progression. As a prominent tool within psychiatric rehabilitation, routine mental health outcome measurement, and consumer-centered intervention design, the STORI bridges clinical evaluation with the subjective paradigm of human transformation beyond illness.

2. Keywords

Stages of Recovery Instrument, STORI, psychological recovery, psychiatric rehabilitation, serious mental illness, schizophrenia, hope, empowerment, stage model of recovery, psychometrics.

3. Authors

The Stages of Recovery Instrument was conceptualized, operationalized, and psychometrically validated by a specialized research team at the University of Wollongong in New South Wales, Australia:

• Retta Andresen, PhD: Senior Research Fellow, School of Psychology and Illawarra Institute for Mental Health (IIMH), University of Wollongong, Australia. Contact: [email protected]
• Peter Caputi, PhD: Associate Professor of Psychology, School of Psychology, Faculty of Social Sciences, University of Wollongong, Australia. Contact: [email protected]
• Lindsay G. Oades, PhD: Professor of Positive Psychology and Mental Health, Melbourne Graduate School of Education, The University of Melbourne (formerly of the University of Wollongong), Australia. Contact: [email protected]

4. Purpose

The primary purpose of the Stages of Recovery Instrument (STORI) is to systematically track and evaluate an individual’s subjective journey through the transformative process of psychological recovery from serious mental illness (SMI). Historically, clinical psychiatry operationalized recovery strictly within a biomedical framework characterized by symptom remission, stabilization, neuroleptic compliance, relapse prevention, and functional restoration. However, the international mental health consumer movement demonstrated that recovery involves cultivating a deeply personal, hopeful, and self-directed existence despite the ongoing presence of mental health vulnerabilities or limitations. The STORI was constructed to translate this qualitative, experiential paradigm into an empirically robust, quantitative assessment architecture.

In clinical practice, the STORI serves several interrelated purposes:

• Collaborative Treatment Planning: Rather than imposing universal clinical interventions, the STORI identifies a consumer’s specific developmental recovery stage, allowing multidisciplinary teams to match therapeutic interventions to readiness for change. For example, individuals navigating early stages require compassionate engagement, validation, and gradual instillation of hope, whereas those in later stages benefit from vocational integration, community engagement, and autonomous goal pursuit.
• Routine Outcome Monitoring (ROM): In public and private psychiatric rehabilitation facilities, the STORI provides longitudinal data on whether service delivery facilitates holistic self-determination, autonomy, and identity evolution over time.
• Psychoeducational Dialogue: Because the STORI is administered with items arranged in comparative themes, consumers and clinicians can co-examine responses, demystifying the nonlinear progression of recovery and validating setbacks as expected phases rather than permanent therapeutic failures.

In academic and clinical research, the STORI provides a validated metric for testing stage-based theoretical models, evaluating the comparative efficacy of recovery-oriented programs (e.g., peer-led interventions, Illness Management and Recovery [IMR], and Supported Employment), and clarifying the predictive associations between subjective recovery, neurocognitive functioning, and psychiatric symptom trajectories.

5. Psychological Construct

The STORI operationalizes psychological recovery as a self-directed, continuous process comprising five experiential stages spanning four overarching psychological processes: finding and maintaining hope, re-establishment of a positive identity, building a meaningful life, and taking responsibility and control. Each of the five stages encapsulates an integrated cognitive, emotional, and behavioral state:

Stage 1: Moratorium

The Moratorium stage represents a period of pervasive withdrawal, hopelessness, identity dissolution, and profound crisis following the onset or catastrophic exacerbation of severe mental illness. Individuals in this phase often experience existential numbness, profound alienation, and a perceived loss of personhood, viewing themselves exclusively through the lens of pathology. Key manifestations include:

• A pervasive conviction that improvement or healing is impossible (e.g., Item 1: “I don’t think people with a mental illness can get better”).
• Profound identity collapse, where the psychiatric label subsumes personal individuality (e.g., Item 11: “I feel like I’m nothing but a sick person now”).
• A complete loss of internal locus of control and profound helplessness (e.g., Item 36: “I can’t do anything about my situation”).

Stage 2: Awareness

The Awareness stage marks the fragile emergence of hope and the initial recognition that an individual’s life is not entirely defined by their diagnosis. In this phase, consumers begin to perceive the possibility of recovery, often inspired by role models, supportive peers, or clinical staff. Key characteristics include:

• Nascent optimism and awareness of others who have recovered (e.g., Item 2: “I’ve only recently found out that people with a mental illness can get better”).
• External validation fostering tentative internal beliefs (e.g., Item 12: “Because others believe in me, I’ve just started to think maybe I can get better”).
• Initial curiosity regarding self-advocacy and coping, accompanied by a tentative belief that distress need not be perpetual.

Stage 3: Preparation

The Preparation stage represents an active internal appraisal and mobilization phase. Consumers engage in self-reflection, assess personal capabilities, identify personal values, and initiate foundational learning to cope with their illness. Key components include:

• Proactive information-seeking regarding mental health conditions and coping strategies (e.g., Item 43: “I am beginning to learn about mental illness and how I can help myself”).
• Clarifying personal strengths, boundaries, and vulnerabilities (e.g., Item 23: “I am starting to figure out what I am good at and what my weaknesses are”).
• Separating core personal identity from psychiatric symptoms, recognizing internal self-worth independently of clinical status.

Stage 4: Rebuilding

The Rebuilding stage is characterized by behavioral execution, autonomous goal strivings, positive risk-taking, and active identity reconstruction. Consumers transition from internal contemplation to external self-actualization, pursuing vocational, educational, social, and creative goals. Characteristics include:

• Sustained personal dedication to holistic wellness (e.g., Item 4: “I am working hard at staying well, and it will be worth it in the long run”).
• Development of resilience in the face of setbacks (e.g., Item 39: “Sometimes there are setbacks, but I come back and keep trying”).
• Re-establishing agency, self-management, and meaningful community roles (e.g., Item 49: “I am beginning to feel responsible for my own life”).

Stage 5: Growth

The Growth stage represents an integrated culmination of the recovery journey characterized by wisdom, empowerment, emotional equilibrium, and continuous self-transcendence. Psychiatric challenges are integrated into the holistic fabric of life, functioning as catalysts for personal development. Hallmarks include:

• Experiencing profound inner peace and existential acceptance (e.g., Item 5: “I have a sense of ‘inner peace’ about life with the illness now”).
• Demonstrating comprehensive self-efficacy and authentic mastery (e.g., Item 45: “I can manage the illness well now” and Item 50: “I am in control of my own life”).
• Attaining transformed personal values and generative meaning through altruism, advocacy, and community contribution.

6. Theoretical Framework

The theoretical architecture of the STORI is grounded in the qualitative synthesis of mental health consumer narratives conducted by Andresen, Caputi, and Oades (2003). The authors conducted a comprehensive meta-synthesis of autobiographical accounts, published consumer testimonies, and grounded-theory qualitative investigations of recovery from schizophrenia and affective psychosis (e.g., Deegan, 1988; Anthony, 1993; Davidson & Strauss, 1992). This synthesis revealed recurring structural commonalities across diverse lived experiences, culminating in the development of a conceptual five-stage model of psychological recovery.

The model draws heavily upon established psychological paradigms:

• The Transtheoretical Model of Behavior Change (TTM): Formulated by James O. Prochaska and Carlo DiClemente, the TTM posits that human behavioral transformation progresses through distinct, non-linear stages (Precontemplation, Contemplation, Preparation, Action, Maintenance). Andresen and colleagues mapped these motivational shifts onto the psychological dynamics of coping with psychiatric diagnoses, conceptualizing recovery not as a discrete event, but as an evolving motivational trajectory.
• Self-Determination Theory (SDT): Developed by Edward L. Deci and Richard M. Ryan, SDT posits that psychological well-being depends on satisfying three innate psychological needs: autonomy (experiencing oneself as the origin of one’s actions), competence (feeling effective within one’s environment), and relatedness (feeling securely connected to others). The transition from Moratorium to Growth reflects an progressive restoration of internal perceived locus of causality and basic psychological need satisfaction.
• Hope Theory: Derived from C. R. Snyder’s cognitive formulation of hope, the model identifies hope as composed of pathways thinking (perceived capacity to generate routes to desired goals) and agency thinking (motivation to utilize those pathways). The STORI explicitly operationalizes hope as an engine propelling individuals from passive despair toward active self-determination.
• Narrative and Existential Psychology: The framework draws upon Bruner’s constructivist paradigm of narrative identity and Frankl’s existential logotherapy, viewing recovery as the reclamation of authorship over one’s life story and the discovery of meaning within psychological distress.

7. Validity

The psychometric validity of the STORI has been rigorously demonstrated across diverse clinical populations and international health jurisdictions.

Construct and Structural Validity

Construct validity was initially confirmed by Andresen, Caputi, and Oades (2006) using non-metric multidimensional scaling (MDS). The analysis demonstrated that the 50 items plotted in a distinct, circular or simplex pattern, supporting the developmental continuity of the five stages. Adjacent stages displayed higher statistical proximity than non-adjacent stages, validating the theoretical ordering (Moratorium → Awareness → Preparation → Rebuilding → Growth).

Convergent and Discriminant Validity

Extensive correlation analyses with established psychometric scales provide strong convergent and discriminant validity evidence:

• Hope and Optimism: Subscales for Rebuilding and Growth display robust, statistically significant positive correlations with the Adult Trait Hope Scale ($r = .65$ to $.78, p < .001$) and the Life Orientation Test-Revised (LOT-R) ($r = .58$ to $.71, p < .001$). Conversely, Moratorium correlates negatively with hope metrics ($r = -.52$ to $-.68, p < .001$).
• Empowerment and Self-Efficacy: Rebuilding and Growth demonstrate substantial positive associations with the Making Decisions Empowerment Scale ($r = .60$ to $.74$) and the General Self-Efficacy Scale ($r = .62$ to $.70$).
• Psychological Distress and Depression: The Moratorium subscale correlates positively with psychological distress indices, including the Beck Depression Inventory-II (BDI-II) ($r = .64$ to $.75$) and the Kessler Psychological Distress Scale (K10) ($r = .58$ to $.69$). In contrast, Rebuilding and Growth show significant inverse correlations with depressive symptomatology ($r = -.45$ to $-.62$).
• Quality of Life: The higher recovery subscales associate strongly with subjective quality of life measures, such as the Manchester Short Assessment of Quality of Life (MANSA) and the WHOQOL-BREF ($r = .51$ to $.68$).

Validation studies across global cohorts—including the United Kingdom (Weeks et al., 2011), Australia (Burgess et al., 2011), and non-English adaptations across European and Asian contexts—support the cross-cultural generalizability of these validity indices.

8. Reliability

The STORI displays excellent internal consistency across both research and clinical samples. In the foundational validation study by Andresen, Caputi, and Oades (2006) involving 97 individuals diagnosed with psychotic disorders, the Cronbach’s alpha coefficients for the five 10-item subscales were:

• Moratorium: $\alpha = .88$
• Awareness: $\alpha = .81$
• Preparation: $\alpha = .78$
• Rebuilding: $\alpha = .88$
• Growth: $\alpha = .89$

Replication studies by Weeks, Slade, and Hayward (2011) in a UK mental health trust ($N = 104$) corroborated these reliability parameters, reporting subscale alpha coefficients of .84 (Moratorium), .77 (Awareness), .82 (Preparation), .89 (Rebuilding), and .90 (Growth). Composite scale internal consistency regularly exceeds $\alpha = .92$.

Test-retest reliability evaluations over intervals ranging from two to four weeks demonstrate adequate temporal stability among clinically stable outpatients, with intra-class correlation coefficients (ICC) ranging between .72 and .86 across all subscales. These metrics confirm that the instrument captures enduring subjective orientations while retaining sensitivity to genuine longitudinal clinical and developmental change.

9. Factor Analysis

Investigating the internal structural properties of the STORI has generated nuanced psychometric dialogue regarding stage models versus continuous recovery dimensions.

Exploratory Factor Analysis (EFA)

Initial Exploratory Factor Analyses using principal axis factoring with oblique rotations (Promax) consistently reveal three to five substantive latent factors. However, high inter-factor correlations between adjacent stages (e.g., between Preparation and Rebuilding, and between Rebuilding and Growth, often exhibiting $r > .70$) frequently result in factor collapses in unconstrained EFAs. Specifically, items from Stages 4 (Rebuilding) and 5 (Growth) routinely load onto a single higher-order factor representing “Active Flourishing and Resilience,” while Stage 1 (Moratorium) cleanly segregates into an independent “Hopelessness and Identity Loss” factor. Stage 2 (Awareness) and Stage 3 (Preparation) typically load onto a transitional “Awakening and Preparedness” latent construct.

Confirmatory Factor Analysis (CFA)

Structural evaluations through Confirmatory Factor Analysis reveal challenges when fitting standard, highly restrictive five-factor orthogonal models, driven by the theoretical continuum underlying the scale. When modeled as a five-factor correlated structure, fit indices achieve acceptable thresholds across empirical evaluations (e.g., Root Mean Square Error of Approximation [RMSEA] $\approx .058$ to $.068$; Comparative Fit Index [CFI] $\approx .90$ to $.93$; Standardized Root Mean Square Residual [SRMR] $\approx .062$).

Multidimensional Scaling and Circumplex Modeling

Because the STORI conceptualizes recovery as a continuous developmental process, classical linear independent factor models do not fully capture its structural architecture. Researchers frequently employ multidimensional scaling (MDS) and Rasch analysis. MDS confirms a quasi-circumplex or simplex pattern where correlation coefficients decay monotonically as developmental distance between stages increases—a diagnostic hallmark of true developmental continuum models. Rasch polytomous rating scale analyses further substantiate that individual item thresholds advance smoothly from low-recovery item endorsements in Moratorium to high-recovery endorsements in Growth.

10. Instrument / Measurement Tool

• Instrument Name: Stages of Recovery Instrument (STORI)
• Target Population: Adults diagnosed with severe mental illness (e.g., schizophrenia, schizoaffective disorder, bipolar disorder, severe major depressive disorder).
• Administration Type: Self-administered paper-and-pencil or interactive computer-based questionnaire; can be administered as a clinician-assisted interview if cognitive or literacy impairments are present.
• Time Required: Approximately 15 to 25 minutes.
• Item Architecture: 50 items arranged systematically into 10 groups of 5 questions each. Each group contains one statement representing each of the five recovery stages: Moratorium, Awareness, Preparation, Rebuilding, and Growth.
• Response Format: 6-point Likert rating scale:
  • 0 = Not at all true now
  • 1 = Slightly true now
  • 2 = Somewhat true now
  • 3 = Moderately true now
  • 4 = Mostly true now
  • 5 = Completely true now
• Scoring and Stage Allocation Methods:
  • Continuous Subscale Scores: Sum the item ratings within each of the five 10-item stage domains (Score range: 0 to 50 for each stage subscale). This yields a continuous profile reflecting the respondent’s endorsement across all stages simultaneously.
  • Categorical Stage Allocation (Profile Scoring): Identify the highest raw subscale score. The stage with the highest score indicates the consumer’s primary recovery stage. In cases of identical highest scores across adjacent stages, the respondent is categorized into the more advanced stage; ties across non-adjacent stages reflect an unclassifiable or transitional profile requiring qualitative clinical review.
  • Cluster Scoring Algorithm: Advanced psychometric research utilizes a standardized $k$-means cluster template to assign individuals to empirically validated recovery profiles based on their 5-subscale score configuration.

11. Permissions, Fee, and Test Year

• Publication Year: 2006 (Foundational qualitative stage model published in 2003).
• Authorship & Copyright: Retta Andresen, Peter Caputi, and Lindsay G. Oades; University of Wollongong, New South Wales, Australia.
• Licensing & Usage Rights: The STORI is an open-access psychometric instrument available free of charge for non-commercial clinical, health-service evaluation, and academic research purposes. Commercial distribution, software bundling, or integration into proprietary electronic health records requires explicit written permission from the original developers.
• Official Repository: Australian Mental Health Outcomes and Classification Network (AMHOCN) and the University of Wollongong’s School of Psychology / Illawarra Institute for Mental Health (IIMH).

12. References

• Andresen, R., Caputi, P., & Oades, L. G. (2003). The experience of recovery from schizophrenia: Towards an empirically validated stage model. Australian and New Zealand Journal of Psychiatry, 37(5), 586–594. https://doi.org/10.1046/j.1440-1614.2003.01234.x
• Andresen, R., Caputi, P., & Oades, L. G. (2006). Stages of recovery instrument: Development of a measure of recovery from serious mental illness. Australian and New Zealand Journal of Psychiatry, 40(11-12), 972–980. https://doi.org/10.1080/j.1440-1614.2006.01921.x
• Andresen, R., Oades, L. G., & Caputi, P. (2011). Psychological Recovery: Beyond Mental Illness. Wiley-Blackwell. https://doi.org/10.1002/9781119973164
• 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. https://doi.org/10.1037/h0095655
• Burgess, P., Pirkis, J., Coombs, T., & Rosen, A. (2011). Assessing the value of existing recovery measures for routine use in Australian mental health services. Australian and New Zealand Journal of Psychiatry, 45(4), 267–280. https://doi.org/10.3109/00048674.2010.540861
• Davidson, L., & Strauss, J. S. (1992). Sense of self in recovery from severe mental illness. British Journal of Medical Psychology, 65(2), 131–145. https://doi.org/10.1111/j.2044-8341.1992.tb01693.x
• Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11–19. https://doi.org/10.1037/h0099565
• Weeks, G., Slade, M., & Hayward, M. (2011). A UK validation of the Stages of Recovery Instrument. International Journal of Social Psychiatry, 57(5), 446–454. https://doi.org/10.1177/0020764010365416

13. Items of the Scale (Questionnaire)