Research in the area of contemporary psychotherapy has moved from a focus on symptom reduction to other effectiveness outcomes (Vissers, Keijsers, van der Veld, de Jong, & Hutschemaekers, 2010; Dohrenwend, Shrout, Egri, & Mendelsohn, 1980). Some authors have criticized the strong emphasis on symptom reduction in psychotherapy outcome research derived from the medical disease model (Hill & Lambert, 2004; Perkins, 2001). Other researchers have also pointed out that patients expect not only the reduction of symptoms but also the improvement of self-confidence and quality of life (e.g., Levitt, Beutler, & Hill, 2006; Lindfors, Knekt, Virtala, & Laaksonen, 2012).

An important development in the description of the positive effects of psychotherapy besides symptom reduction has been the concept of “demoralization”, and its opposite “remoralization”. Demoralization was introduced by Frank (1974) as a state of mind characterized by the belief of being incapable of solving problems and having a feeling of impotence, isolation and despair. This concept has significance across several psychotherapeutic traditions and approaches in the context of common therapeutic factors (Frank & Frank, 2004; Gelso, 2011). Many years after Frank's first description of demoralization, cognitive therapists introduced the term “remoralization” very much attuned with the goal of cognitive therapy in general (Vissers et al., 2010; Howard, Lueger, Maling, & Martinovich, 1993; Slavney, 1999). Remoralization implies a process of restoration of a person's morale, related to an improvement of self-esteem, self-value and self-concept, resulting in higher expectations and self-perceived power, positive anticipation, and active hope (Howard et al., 1993). In addition, remoralization is related to a sense of inner control and restored hope (Kuyken, 2004). Howard et al. (1993) state that remoralization could be the first step in the process of therapeutic change.

A related concept, “learned helplessness”, was proposed by Seligman (1998). “Learned helplessness was defined as a conditioned attributional state of perceived absence of control over a situation that could be overcome” (Robinson, Kissane, Brooker, & Burne, 2014, p. 3). Seligman (1998) states that a global and stable attribution for failure will lead to long-term generalized helplessness, and that internal attributions will intensify these effects. In this context, remoralization is a necessary process in order to reach a sense of active hope.

A large series of studies have distinguished changes in remoralization independently from symptom reduction (Callahan, Swift, & Hynan, 2006; Grissom, Lyons, & Lutz, 2002; Hilsenroth, Ackerman, & Blagys, 2001; Howard et al., 1993; Lutz, Lowry, Kopta, Einstein, & Howard, 2001, Lutz, Martinovich, & Howard, 1999). However, these studies did not focus on the relationship between both outcomes (Vissers et al., 2010). Therefore, further research needs to incorporate remoralization as a valuable component of the assessment of treatment outcome, as a generic therapeutic factor (Vissers et al., 2010). Moreover, the measurement of remoralization could be useful in the mental health area in general, allowing an early warning system for health promotion and mental health promotion in educational, workplace, and social settings. Although remoralization has been discussed in the psychotherapeutic literature, the development of reliable and valid outcome measures, not only for clinical area but also for health field, still requires further efforts.

A first measure of remoralization as a brief self-report instrument was developed for mental health-care patients in The Netherlands (Vissers et al., 2010). In that context, the goal was to develop an easy-to-use self-report measure of the patient's morale at different times of the treatment process. The morale involved the self-perception regarding his/her self-concept, self-value, hope, empowerment and positive anticipation (Vissers et al., 2010). It was first administered to a clinical population, in order to explore its correlation with other depression measures.

This original version of the Remoralization Scale (RS) was based on fundamental theoretical concepts that the literature has shown to be related to a state of demoralization when this state is measured with the various corresponding instruments: (1) self-esteem using items of the Rosenberg Self-Esteem Scale (Rosenberg, 1965); (2) personal empowerment and sense of mastery considering the Empowerment Scale (Rogers, Chamberlin, Ellison, & Crean, 1997); (3) feelings of competence applying the adapted Dutch version of the General Self-efficacy Scale (Bosscher, Smit, & Kempen, 1997; Sherer et al., 1982); (4) optimism using the Optimism Subscale from the Positive Outcome Scale (Appelo, 2005) and sense of inner control, via the Autonomy Subscale also from the Positive Outcome Scale; and (5) hope by the State Hope Scale (Snyder, Sympson, Ybasco, Borders, Babyak, & Higgins, 1996). A unidimensional structure was found through exploratory and confirmatory factorial analyses by the authors, suggesting that this original version of the RS measures a single concept. This single structure was confirmed for both patients and non-patients and it has been shown to have very good psychometric properties (for a more detailed description of the procedures and results see Vissers et al., 2010). The results suggest that patients do not interpret all these concepts described in the literature as highly different. In addition, this previous finding supports the hypothesis about a common state, namely remoralization that could be used across a variety of treatments to measure beneficial effects other than symptom reduction (Vissers et al., 2010; Howard et al., 1993).

The aim of the present study is to validate a Spanish version of the English version of the Remoralization Scale developed by Vissers et al. (2010), in a non-clinical sample from Argentina. Since this concept is so relevant to mental health in general, as in Frank's conceptualization of common therapeutic factors, it would be interesting to assess its psychometric properties including its reliability, as well as its discriminative and construct validity in a non-clinical sample with the objective of emphasizing prevention and/or promotion of mental health. Given the applicability of the construct in the general population, and not only in mental health patients, this would allow us to utilize the instrument in different settings in the future (e.g. educational and epidemiology areas).

The present study is based on an outcome measure that has been developed from several highly correlated psychological concepts: self-esteem, empowerment, self-efficacy, optimism, sense of inner control, and hope (Vissers et al., 2010). The objective of this previous study was to obtain a single measure of a common state underpinning a successful psychotherapy: remoralization (Vissers et al., 2010). Data confirmed that all these concepts have a common factor both in patients and non-patients (Vissers et al., 2010). However, the present validation offers an abridged and adapted version (in Spanish) of the RS, comprising 12 items and identifying two factors of this construct that were named self-satisfaction and self-concept, respectively. Although the correlation among both factors was high, a two-factor model achieved a better fit to the data than a one-factor model in this population.

The one-dimensional structure found in the validation of the English version of the RS, could not be replicated in this population. The original version of the RS also found factorial invariance between both clinical and non-clinical samples concluding that both groups understand the items similarly (Vissers et al., 2010). Instead, a two-factor model seems to be a more appropriate structure of this construct in a non-clinical population from Argentina. Socio-cultural differences and specific characteristics of this non-clinical sample (e.g. university students) could have influenced this result. Further research is necessary to understand this difference. In addition, multigroup confirmatory analyses should be carried out to provide further support for this finding using different samples from Argentina.

According to this study, Remoralization has two facets which could be identified in the self-perception of non-patients: (a) an emotional and situational component, and (b) a more general cognitive self-concept. Previous conceptualizations of “Demoralization” have involved two dimensions: distress and subjective incompetence (de Figueiredo & Frank, 1982). The first factor found in this study (self-satisfaction) could be related to the opposite of “distress” described as the incapacity to adapt to stressful events; the distress is characterized by feelings of anger, discouragement and sadness (de Figueiredo & Frank, 1982). On the other hand, the second factor in this version of the RS focuses on the opposite of subjective incompetence. This is supported by a previous psychometric study that has shown a strong negative correlation between the RS and the Demoralization Scale (DS) of Kissane et al., 2004 (Vissers et al., 2010). Moreover, the process of remoralization in the context of psychotherapy requires addressing the issue of subjective incompetence, but it also involves the decrease of the distress element, as it has been pointed out previously (de Figueiredo, 2007).

Although we cannot infer from this research that in clinical and non-clinical populations Remoralization is associated to self-satisfaction and self-concept, this is an interesting and relevant possibility that should be studied in further research. Remoralization is the enhancement of subjective well-being and it could be reached early in treatment (Howard et al., 1993). However, as shown in this study, these aspects could be better differentiated in a non-clinical sample than in a clinical sample. In order to be able to discriminate self-concept from self-satisfaction, subjects need to differentiate properly negative from positive expectations. For instance, a negative self-concept does not necessarily imply non-self-satisfaction and vice versa. Therefore, we can hypothesize that non-clinical populations can tolerate frustration (negative self-satisfaction) without altering self-concept. The reverse can also be true, for those incapable of certain things (negative self-concept) it does not necessarily follow that they are not able to obtain satisfaction in other things (negative self-satisfaction). In addition, healthy subjects could be unable to adapt to specific stressful events, feeling less control of him/herself (or another negative emotions), but at the same time they could also have a positive general self-concept. This result may be due to the use of more adaptive than maladaptive strategies to regulate negative emotions for both self-regulation and interpersonal regulation (Oberst, Company, Sánchez, Oriol-Granado, & Páez, 2013). These adaptive strategies allow a perception of an improvement in the achievement of adaptive goals and self-concept (functionality) (Oberst et al., 2013).

The second dimension of Remoralization found in this study (self-concept) is an important cognitive resource that could be used as a discriminating factor in the process of therapeutic change. Further studies, in different clinical samples, should explore whether the two-factor model underlying the RS could help psychotherapists to achieve a more discriminating evaluation of the changes in one or both dimensions, from a general subjective well-being at the beginning of psychotherapy, to a more discriminating self-assessment in a more advanced phase of treatment. This is coherent with the cognitive based conceptualization of the relevance of belief systems in clinical and non-clinical populations (Beck, 2010). In the clinical tradition, within the cognitive therapy perspective, the belief system bias (either overly positive or overly negative) is considered to support psychopathology symptoms. Depression, for instance, has been largely demonstrated to be associated with negative thinking and negative anticipation of the future (Beck, 1979). Since its first formulations, the concept of moralization (Frank & Frank, 2004) was associated with hope, and hope implies a positive expectation for the future. Within the cognitive psychology tradition, expectations are an essential part of human cognition (Gardner, 1985). It is possible that further studies discriminating clinical and non-clinical populations, may allow us to use this measure in the early detection of psychopathology, and thus be a useful tool in mental health prevention and promotion.

A possible limitation of the present validation study concerns the “convenience sampling” of the “healthy” student population, which could restrict the generalization of the results. In addition, the procedure of data collection in both clinical and non-clinical samples was carried out without assistance by the researcher to preserve the anonymity of the participants. Future research on RS should consider including a broader and random sample of the general population. Another limitation has to do with the absence of other self-concept and demoralization scales to evaluate the concurrent validity of the RS instrument. In addition, given that this is a cross-sectional study design, the predictive validity of the instrument should be further studied. Although test–retest reliability could not be evaluated with this design, the RS showed high internal consistency.

Regarding the factor structure differences found in comparison with the original version, further studies applying multi-group analyses should be carried out comparing non-clinical and clinical samples. In addition, further research on this Spanish version of the RS should examine its discriminating potential between patients and non-patients, and the relationships between symptom reduction and Remoralization in a similar population.

In conclusion, a brief scale to measure Remoralization was validated for its use in a non-clinical Argentinean population, obtaining a two-factor model which has a good fit to this non-clinical sample, contributing to its construct validity. The reliability coefficients found for the Spanish version of the RS were found to be satisfactory. This type of brief outcome measure could provide an important tool both for treatment effects research and for health promotion, beyond a simple symptom-reduction model (Vissers et al., 2016).