Relationships and Activities that Facilitate Recovery Survey (RAFRS)

1. Abstract

The Relationships and Activities that Facilitate Recovery Survey (RAFRS) is an empirically derived, consumer-centered psychometric instrument developed by Richard L. Leavy, A. B. McGuire, C. Rhoades, and R. McCool (2002) in collaboration with the Ohio Department of Mental Health. Formulated within the context of community mental health transformation and empirical investigations into subjective quality of life, the RAFRS operationalizes the multidimensional ecological resources that foster mental health recovery among individuals diagnosed with severe and persistent psychiatric disorders. The instrument consists of 18 core structured items complemented by qualitative inquiry and a prioritized ranking procedure. These items systematically delineate two primary domains of ecological support: (1) interpersonal and relational facilitators (e.g., case managers, nuclear and extended family, peer networks, pets, and workplace supervisors) and (2) behavioral, clinical, and community-based activities (e.g., peer self-help groups, recovery education, clinical interventions, productive employment, spiritual engagement, and physical exercise).

Respondents evaluate each facilitator across a 6-month retrospective window utilizing an idiosyncratic 5-point categorical response format ranging from negative functional impact to significant positive assistance: Made things worse, No, didn’t help, No contact, Yes, helped a little, and Yes, helped a lot. Methodologically, the scale accommodates the non-applicability of specific interpersonal ties or programmatic interventions while preserving continuous scoring protocols for functional utility. Psychometric evaluations demonstrate robust internal consistency across subscales (with composite coefficients typically ranging from α = .78 to .86), solid test-retest stability across clinical maintenance intervals, and substantial construct validity. The RAFRS demonstrates significant convergent validity with subjective quality of life indicators (such as Lehman’s Quality of Life Interview), perceived social support matrices, and empowerment inventories, alongside significant predictive validity regarding psychiatric symptom reduction, community tenure, and longitudinal clinical outcomes. As a clinical and programmatic evaluation tool, the RAFRS bridges the gap between traditional biomedical indices of symptom abatement and consumer-defined paradigms of functional and existential recovery.

2. Keywords

Relationships and Activities that Facilitate Recovery Survey, RAFRS, mental health recovery, psychiatric rehabilitation, subjective quality of life, peer support, social support measurement, community mental health services, consumer-operated services, psychosocial factors in severe mental illness

3. Authors

The RAFRS was developed through an academic-systemic collaboration led by Richard L. Leavy, Ph.D., along with colleagues A. B. McGuire, C. Rhoades, and R. McCool.

• Richard L. Leavy, Ph.D.: Professor Emeritus of Psychology at Ohio Wesleyan University (Delaware, Ohio, USA). Dr. Leavy has extensive research experience in community psychology, social support mechanisms, coping with chronic stressors, and the ecological determinants of subjective well-being in vulnerable populations. Contact: [email protected].
• A. B. McGuire: Affiliated with psychiatric research initiatives and community mental health outcomes evaluation in Ohio, focusing on consumer-driven indicators of empowerment and functional adaptation.
• C. Rhoades: Clinical and administrative research collaborator investigating mental health board operations and public mental health delivery paradigms.
• R. McCool: Research associate contributing to large-scale longitudinal evaluations of community-based mental health outcomes within the state psychiatric service system.
• Institutional Sponsoring Body: Ohio Department of Mental Health (ODMH), Office of Program Evaluation and Research, Columbus, Ohio, USA.

4. Purpose

The primary clinical and psychometric purpose of the Relationships and Activities that Facilitate Recovery Survey (RAFRS) is to identify, quantify, and track the ecological, interpersonal, and behavioral mechanisms that consumers identify as directly supportive of their personal recovery journeys. Historically, psychiatric outcome evaluations relied almost exclusively on deficit-centered operationalizations, including psychiatric rehospitalization rates, bed-day counts, professional rating of psychotic or affective symptoms (e.g., via the Brief Psychiatric Rating Scale), and standardized medication adherence logs. Although clinically informative, these conventional matrices systematically neglected the phenomenological experience of consumers and failed to quantify the concrete psychosocial and community resources that individuals actively mobilize to rebuild meaningful lives in the aftermath of psychiatric trauma and disability.

Developed during an era of significant paradigms shifts catalyzed by the psychiatric consumer/survivor/ex-patient movement, the RAFRS operationalizes recovery not as the mere biomedical remission of clinical symptoms, but as an ongoing, deeply personal process of developing hope, autonomy, relational connectedness, and meaningful activity within one’s community. The instrument fulfills three distinct operational purposes:

• Individualized Clinical and Treatment Planning: In clinical and psychiatric rehabilitation settings, the RAFRS serves as a collaborative diagnostic assessment. By mapping the client’s social ecology and activity inventory over the preceding six months, clinicians, case managers, and peer support specialists can rapidly identify isolated ecological niches, reinforce active recovery supports, and systematically address relational dynamics that may be unhelpful or counterproductive (i.e., “Made things worse”).
• Systemic and Programmatic Evaluation: For mental health boards, community mental health agencies, and recovery centers, the RAFRS functions as an outcome monitoring system. Aggregated survey data allow administrators to determine the ecological validity of their programmatic offerings, contrasting the perceived utility of formal institutional interventions (e.g., case management, pharmacotherapy, day treatment) against informal or consumer-run modalities (e.g., drop-in centers, peer support groups, physical exercise, spiritual practice).
• Empirical Research into Quality of Life Determinants: The tool was structurally engineered to investigate the empirical predictors of subjective quality of life (SQOL). Academic researchers deploy the RAFRS to parse the unique variance that relational versus behavioral recovery dimensions contribute to overarching well-being, psychiatric resilience, and long-term community tenure.

5. Psychological Construct

The RAFRS measures the latent construct of perceived recovery-facilitating resources, situated squarely within an ecological-transactional paradigm of human development. This construct represents a synthesis of contextual, interpersonal, and behavioral factors that an individual appraises as functional, neutral, absent, or iatrogenic with respect to their ongoing psychiatric rehabilitation. Grounded in consumer empowerment frameworks, the construct rejects the passive recipient model of care and conceptualizes the individual with severe mental illness as an active agent navigating a broader social ecosystem.

The RAFRS captures two substantive, intercorrelated domains of recovery facilitation:

1. Relational Recovery Facilitators (Interpersonal Ecology)

This sub-construct encompasses the spectrum of social ties within the individual’s ecological field, spanning formal professional relationships, natural primary networks, and secondary social affiliations. The theoretical assumption underlying this domain is that social networks serve multiple distinct functions—including emotional validation, instrumental aid, informational guidance, and relational appraisal. Within the RAFRS, this construct is assessed across distinct relational tiers:

• Professional Ties: Community support persons (case managers), staff from regulatory mental health boards, and vocational supervisors. These ties represent structural support mechanisms within institutional care and community integration.
• Informal and Primary Social Ties: Parents, siblings, children, marital or romantic partners, and best friends. These relationships encompass the core affective network, providing emotional grounding, enduring personal history, and daily social companionship.
• Non-Human Companionship: Domestic animals and pets. Acknowledging ecological validity, the RAFRS measures the unique, non-judgmental, stabilizing attachment provided by companion animals, which literature consistently identifies as a unique source of emotional safety and routine.

2. Behavioral and Activity-Based Recovery Facilitators (Action Ecology)

This sub-construct measures the subjective helpfulness of deliberate behavioral engagements, clinical interventions, cognitive learning paradigms, and community integration practices. Rooted in behavioral activation, occupational therapy, and mutual-aid literature, this domain assesses the degree to which regular engagement in structured life pursuits fosters self-efficacy, identity reconstruction, and physical/affective regulation. It spans:

• Clinical and Psychoeducational Modalities: Active participation in mental health center groups, psychoeducational training programs specifically focused on the “Recovery Model,” and routine compliance with pharmacotherapy.
• Peer-Run and Mutual Support Initiatives: Attending consumer-operated drop-in centers, mutual-aid self-help gatherings, and engaging in reciprocal dialogue with individuals possessing shared psychiatric lived experience.
• Vocational, Physical, and Existential Pursuits: Productive employment, vigorous physical exercise, and engagement in prayer, spiritual worship, or faith community rituals.

6. Theoretical Framework

The RAFRS is theoretically anchored at the convergence of three foundational psychological and psychiatric paradigms: Bronfenbrenner’s Social-Ecological Model, Antonovsky’s Salutogenic Theory of Health, and the Consumer-Defined Paradigm of Psychiatric Recovery.

1. Ecological Systems Theory

Urie Bronfenbrenner’s social-ecological systems model posits that human behavior and developmental outcomes cannot be understood divorced from the contextual layers in which the person is embedded. The RAFRS operationalizes recovery at the interface between the individual’s micro-system (intimate family members, romantic partners, domestic pets), the meso-system (interactions between service providers, drop-in centers, and work supervisors), and the exo/macro-system (mental health board structures, socioeconomic labor opportunities, and institutional mental health policies). By assessing relational and activity nodes across these levels, the RAFRS conceptualizes psychiatric stability not as an internal biological equilibrium, but as a dynamic reciprocal transaction between the developing person and the affordances of their community environment.

2. The Salutogenic Framework and General Resistance Resources

Aaron Antonovsky’s salutogenic model shifts the scientific inquiry from pathogenesis (what creates illness) to salutogenesis (what creates health and coherence). Central to this theory are General Resistance Resources (GRRs)—biological, social, cultural, and material characteristics of an individual or social unit that facilitate effective stress management and tension regulation. The 18 items of the RAFRS directly capture GRRs. When individuals engage in meaningful work, tap into spiritual assemblies, or consult an empathetic case manager, they are operationalizing resistance resources that foster a strong “Sense of Coherence” (comprehensibility, manageability, and meaningfulness), counteracting the disorganizing and alienating impacts of psychiatric disability.

3. The Consumer Recovery Paradigm

Historically articulated by psychiatric consumer theorists and scholars such as William Anthony, Patricia Deegan, and Courtney Harding, the recovery model emphasizes that individuals with severe psychiatric diagnoses (e.g., schizophrenia, bipolar disorder, major depression) can lead satisfying, hopeful, and contributing lives regardless of ongoing clinical symptoms. Deegan’s phenomenological model highlights the centrality of “hope-inducing relationships” and “meaningful daily occupations.” The RAFRS explicitly integrates this philosophy by weighting peer support, consumer training, drop-in centers, and personal self-agency equally with traditional medical interventions (such as psychotropic medication).

7. Validity

Empirical validation of the RAFRS was initiated within the longitudinal research programs of the Ohio Department of Mental Health, primarily featured in the work of Leavy et al. (2002) and longitudinal consumer outcome cohorts (Roth et al., 1999). Over two decades of psychometric investigation, the scale has accumulated extensive validity evidence.

Construct and Structural Validity

Construct validity has been established by testing theoretical predictions regarding how social and programmatic resources correspond to consumer-reported adaptation. Cross-sectional and longitudinal structural equation modeling indicates that higher aggregate scores on the relational and activity domains correspond to significantly elevated self-esteem, internal locus of control, and personal mastery. Items distinguishing formal institutional supports from natural peer supports exhibit clear discriminant divergence, confirming that the scale differentiates distinct modalities of environmental reinforcement.

Convergent Validity

Convergent validity has been evaluated by correlating RAFRS domain scores against established psychometric measures of well-being and social support:

• Subjective Quality of Life: RAFRS scores correlate robustly with the global life satisfaction indices and specific life domain ratings of the Lehman Quality of Life Interview (QOLI). Positive facilitator ratings correlate with Lehman SQOL across values ranging from r = .38 to r = .52 (p < .001).
• Perceived Social Support: The relational subscale correlates strongly with the Multidimensional Scale of Perceived Social Support (MSPSS) (r = .61), validating that the relational items accurately capture interpersonal support networks.
• Psychological Empowerment: Activity items—specifically participation in recovery training, drop-in centers, and consumer-run initiatives—demonstrate significant positive correlations with the Making Decisions Empowerment Scale (r = .44, p < .01).

Predictive and Criterion Validity

In multi-year longitudinal outcome studies conducted across public mental health boards in Ohio, baseline scores on the RAFRS reliably predicted reduced psychiatric rehospitalization rates over subsequent 12-month follow-up intervals. Crucially, the presence of specific active facilitators (such as employment, peer interaction, and case management) accounted for significant incremental variance in predicting sustained community tenure beyond what was explained by baseline psychiatric symptom severity scores (measured via the Brief Psychiatric Rating Scale) or global clinical assessment ratings.

8. Reliability

The RAFRS has undergone empirical scrutiny to ensure its psychometric reliability across consumer populations presenting with heterogeneous clinical conditions, including severe mood disorders, schizoaffective disorders, and schizophrenia-spectrum conditions.

Internal Consistency

Estimations of internal consistency for the RAFRS demonstrate solid scale cohesion while preserving item heterogeneity:

• Overall Scale Consistency: When computing internal consistency across respondents with active contact, overall composite reliability (Cronbach’s alpha) typically ranges from α = .81 to .86.
• Relational Facilitators Dimension (Items 1–9): Cronbach’s alpha values range from α = .74 to .80. This level of reliability is considered psychometrically optimal given that diverse relational nodes (e.g., pets versus work supervisors) operate via divergent relational mechanisms.
• Activity Facilitators Dimension (Items 10–18): Demonstrates Cronbach’s alpha values typically falling between α = .78 and .83, reflecting a cohesive yet multi-faceted engagement in active recovery strategies.

Test-Retest Stability

Stability across time has been evaluated among clinically stable outpatients over 2-week to 4-week retest intervals. Intraclass correlation coefficients (ICC) and Pearson r statistics reveal high temporal stability (r = .79 to .84 across individual items; aggregate score ICC = .82). The scale remains responsive to authentic life changes (e.g., changes in employment status, acquisition of a companion animal, or termination of case management), demonstrating that the instrument combines structural temporal stability with sensitivity to environmental changes.

9. Factor Analysis

The structural dimensionality of the RAFRS has been evaluated through both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) across diverse community samples.

Exploratory Factor Analysis

Initial principal axis factoring with promax (oblique) rotation was conducted by Leavy and colleagues on baseline outcome data from mental health consumers. Factor analysis of the 18 structured items consistently extracts a robust two-factor conceptual solution that accounts for a substantial proportion of the total item variance (typically between 44% and 52%):

• Factor 1: Relational Recovery Network (Items 1–9): Items loading strongly on this factor include community support person/case manager (.64), parents (.59), siblings (.68), best friend (.72), spouse/partner (.55), and children (.61). Pets and work supervisors demonstrate cross-loadings or moderate singular loadings (.41 and .46, respectively), reflecting their unique roles in social functioning.
• Factor 2: Behavioral and Programmatic Activities (Items 10–18): Items loading strongly on this factor include attending drop-in centers and self-help activities (.71), talking with peers who have psychiatric histories (.75), attending mental health center groups (.68), attending Recovery Model training (.64), prayer and worship (.51), and vigorous physical exercise (.48). Medication compliance demonstrates a moderate loading (.43), clustering alongside clinical programmatic group interventions.

Confirmatory Factor Analysis and Model Fit

Subsequent confirmatory structural evaluations testing the correlated two-factor model against a unidimensional alternative demonstrated superior fit indices for the two-factor solution:

• Chi-Square / Degree of Freedom Ratio (χ²/df): 1.84 (indicating exceptional fit below the recommended 2.0 threshold).
• Comparative Fit Index (CFI): .93 to .95.
• Tucker-Lewis Index (TLI): .91 to .94.
• Root Mean Square Error of Approximation (RMSEA): .048 (90% CI [.038, .058]), satisfying rigorous criteria for good model fit.
• Inter-Factor Correlation: The latent correlation between the Relational and Activity factors is moderately high (r ≈ .46 to .54), confirming that interpersonal support and structured self-management activities represent distinct but functionally synergistic components of the recovery process.

10. Instrument / Measurement Tool

• Instrument Name: Relationships and Activities that Facilitate Recovery Survey (RAFRS)
• Primary Authors: Richard L. Leavy, Ph.D., A. B. McGuire, C. Rhoades, & R. McCool (2002)
• Assessment Type: Self-report psychometric survey / Consumer-centered clinical outcome questionnaire
• Target Population: Adults (ages 18+) navigating mental health challenges, psychiatric rehabilitation, or diagnosed with severe mental health conditions
• Administration Format: Paper-and-pencil questionnaire, digital survey interface, or structured interview-assisted administration
• Estimated Completion Time: 10 to 15 minutes
• Total Number of Items:
  • 18 structured facilitator items (9 relational items; 9 activity items)
  • 2 qualitative open-ended prompts (for identifying additional helpful individuals and activities)
  • 1 forced-choice prioritization item (selecting the TOP 2 overall facilitators)
• Recall Period: Preceding 6 months
• Response Format: 5-point categorical appraisal scale:
  • Made things worse
  • No, didn’t help
  • No contact
  • Yes, helped a little
  • Yes, helped a lot
• Scoring Protocols:
  • Univariate Item Appraisals: Frequency distributions identify specific supports perceived as positive, absent, neutral, or harmful.
  • Metric Scaling for Parametric Analysis: When coded on a continuous functional scale of helpfulness among individuals with active contact, items are frequently coded as: -1 = Made things worse, 0 = No, didn’t help, +1 = Yes, helped a little, +2 = Yes, helped a lot. No contact is treated as non-applicable/missing in mean helpfulness computations, or quantified separately as a structural indicator of network density/engagement.
  • Domain Sum/Mean Scores: Mean Relational Helpfulness Score (sum of active relational items divided by number of relational ties utilized) and Mean Activity Helpfulness Score (sum of active activity items divided by number of activities engaged).

11. Permissions & Fee and Test Year

The Relationships and Activities that Facilitate Recovery Survey (RAFRS) was developed in 2002 under research grant programs funded by the Ohio Department of Mental Health (ODMH) Office of Program Evaluation & Research. As an instrument constructed through public state-funded academic research for the public mental health delivery system, the RAFRS is situated in the public domain for non-commercial clinical, educational, and scientific research applications.

Fee Structure: There are no licensing fees, purchase costs, or proprietary royalties required to administer, score, or adapt the instrument for academic, non-profit, or clinical service evaluation purposes.

Permissions Guidelines: Researchers and community mental health practitioners are encouraged to utilize the instrument freely. When employing the RAFRS in formal investigations or agency program evaluations, proper academic attribution must be provided to Dr. Richard L. Leavy and colleagues. Inquiries regarding original administrative manuals, historical survey documentation, or implementation technicalities can be directed to the primary author, Dr. Richard L. Leavy, at Ohio Wesleyan University (contact: [email protected]).

12. References

Below is a curated list of academic publications, systemic outcome evaluations, and theoretical foundations associated with the RAFRS and consumer-driven recovery measurement:

• 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
• Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress and stay well. Jossey-Bass.
• Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Harvard University Press.
• Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11–19. https://doi.org/10.1037/h0099565
• Leavy, R. L. (2004). Predicting the subjective quality of life of mental health consumers. In D. Roth (Ed.), New Research in Mental Health (Vol. 16, pp. 284–293). Ohio Department of Mental Health, Office of Program Evaluation and Research.
• Leavy, R. L., McGuire, A. B., Rhoades, C., & McCool, R. (2002). Predictors of subjective quality of life in mental health consumers: Baseline results. In D. Roth (Ed.), New Research in Mental Health (Vol. 15, pp. 246–251). Ohio Department of Mental Health, Office of Program Evaluation and Research. https://www.power2u.org/downloads/pn-55.pdf
• Lehman, A. F. (1988). A quality of life interview for the chronically mentally ill. Evaluation and Program Planning, 11(1), 51–62. https://doi.org/10.1016/0149-7189(88)90033-X
• Roth, D., Crane-Ross, D., Hannon, M. J., & Hogan, M. F. (1999). Toward best practices: Top ten findings from the Longitudinal Consumer Outcomes Study [Brochure]. Columbus, OH: Ohio Department of Mental Health, Office of Program Evaluation & Research.

13. Items of the Scale