Mary Leamy

Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis

BACKGROUND No systematic review and narrative synthesis on personal recovery in mental illness has been undertaken. AIMS To synthesise published descriptions and models of personal recovery into an empirically based conceptual framework. METHOD Systematic review and modified narrative synthesis. RESULTS Out of 5208 papers that were identified and 366 that were reviewed, a total of 97 papers were included in this review. The emergent conceptual framework consists of: (a) 13 characteristics of the recovery journey; (b) five recovery processes comprising: connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (giving the acronym CHIME); and (c) recovery stage descriptions which mapped onto the transtheoretical model of change. Studies that focused on recovery for individuals of Black and minority ethnic (BME) origin showed a greater emphasis on spirituality and stigma and also identified two additional themes: culturally specific facilitating factors and collectivist notions of recovery. CONCLUSIONS The conceptual framework is a theoretically defensible and robust synthesis of peoples experiences of recovery in mental illness. This provides an empirical basis for future recovery-oriented research and practice.

What does recovery mean in practice? A qualitative analysis of international recovery-oriented practice guidance.

OBJECTIVES Recovery is a multifaceted concept, and the need for operationalization in practice has been identified. Although guidance on recovery-oriented practice exists, it is from disparate sources and is difficult to apply. The aims of the study were to identify the key characteristics of recovery-oriented practice guidance on the basis of current international perspectives and to develop an overarching conceptual framework to aid the translation of recovery guidance into practice. METHODS A qualitative analysis of 30 international documents offering recovery-oriented practice guidance was conducted. Inductive, semantic-level, thematic analysis was used to identify dominant themes. Interpretive analysis was then undertaken to group the themes into practice domains. RESULTS The guidance documents were diverse; from six countries-the United States, England, Scotland, Republic of Ireland, Denmark, and New Zealand-and varied in document type, categories of guidance, and level of service user involvement in guidance development. The emerging conceptual framework consists of 16 dominant themes, grouped into four practice domains: promoting citizenship, organizational commitment, supporting personally defined recovery, and working relationship. CONCLUSIONS A key challenge for mental health services is the lack of clarity about what constitutes recovery-oriented practice. The conceptual framework contributes to this knowledge gap and provides a synthesis of recovery-oriented practice guidance.

International differences in understanding recovery: systematic review.

AIMS Mental health policy internationally varies in its support for recovery. The aims of this study were to validate an existing conceptual framework and then characterise by country the distribution, scientific foundations and emphasis in published recovery conceptualisations. METHODS Update and modification of a previously published systematic review and narrative synthesis of recovery conceptualisations published in English. RESULTS A total of 7431 studies were identified and 429 full papers reviewed, from which 105 conceptualisations in 115 papers were included and quality assessed using established rating scales. Recovery conceptualisations were identified from 11 individual countries, with 95 (91%) published in English-speaking countries, primarily the USA (47%) and the UK (25%). The scientific foundation was primarily qualitative research (53%), non-systematic literature reviews (24%) and position papers (12%). The conceptual framework was validated with the 18 new papers. Across the different countries, there was a relatively similar distribution of codings for each of five key recovery processes. CONCLUSIONS Recovery as currently conceptualised in English-language publications is primarily based on qualitative studies and position papers from English-speaking countries. The conceptual framework was valid, but the development of recovery conceptualisations using a broader range of research designs within other cultures and non-majority populations is a research priority.

Measures of Personal Recovery: A Systematic Review

OBJECTIVE Mental health systems internationally have adopted a goal of supporting recovery. Measurement of the experience of recovery is, therefore, a priority. The aim of this review was to identify and analyze recovery measures in relation to their fit with recovery and their psychometric adequacy. METHODS A systematic search of six data sources for articles, Web-based material, and conference presentations related to measurement of recovery was conducted by using a defined search strategy. Results were filtered by title and by abstract (by two raters in the case of abstracts), and the remaining papers were reviewed to identify any suitable measures of recovery. Measures were then evaluated for their fit with the recovery processes identified in the CHIME framework (connectedness, hope, identity, meaning, and empowerment) and for demonstration of nine predefined psychometric properties. RESULTS Thirteen measures of personal recovery were identified from 336 abstracts and 35 articles. The Recovery Assessment Scale (RAS) was published most, and the Questionnaire About the Process of Recovery (QPR) was the only measure to have all items map to the CHIME framework. No measure demonstrated all nine psychometric properties. The Stages of Recovery Instrument demonstrated the most psychometric properties (N=6), followed by the Maryland Assessment of Recovery (N=5), and the QPR and the RAS (N=4). Criterion validity, responsiveness, and feasibility were particularly underinvestigated properties. CONCLUSIONS No recovery measure can currently be unequivocally recommended, although the QPR most closely maps to the CHIME framework of recovery and the RAS is most widely published.

Measures of the recovery orientation of mental health services: systematic review

PurposeThe review aimed to (1) identify measures that assess the recovery orientation of services; (2) discuss how these measures have conceptualised recovery, and (3) characterise their psychometric properties.MethodsA systematic review was undertaken using seven sources. The conceptualisation of recovery within each measure was investigated by rating items against a conceptual framework of recovery comprising five recovery processes: connectedness; hope and optimism; identity; meaning and purpose; and empowerment. Psychometric properties of measures were evaluated using quality criteria.ResultsThirteen recovery orientation measures were identified, of which six met eligibility criteria. No measure was a good fit with the conceptual framework. No measure had undergone extensive psychometric testing and none had data on test–retest reliability or sensitivity to change.ConclusionsMany measures have been developed to assess the recovery orientation of services. Comparisons between the measures were hampered by the different conceptualisations of recovery used and by the lack of uniformity on the level of organisation at which services were assessed. This situation makes it a challenge for services and researchers to make an informed choice on which measure to use. Further work is needed to produce measures with a transparent conceptual underpinning and demonstrated psychometric properties.

Recovery grows up

Health Service and Population Research Department, Institute of Psychiatry, London, UKIntroductionRecovery has come of age. The recoveryapproach has gained traction in mental health policythroughout the English-speaking world, and – at least rhetorically – within mental healthsystems internationally (Slade et al., 2008). But with age comes responsibility. An idea caninitiate change, but that change must work in practice if it is to be sustained.This special issue on recovery marks a shift from ideology to empirical investigation. Thestudies report dataaddressingimportant questions.Webeginbyidentifying someideologicalstatements made by recovery proponents, and reviewing recent evidence relating to thesebeliefs. We then consider some of the scientific challenges in investigating recovery.“Recovery is a process, not just an outcome”A valid understanding of recovery must be grounded in lived experience. Todd and col-leagues (2012) explore the meaning of recovery for people with bipolar disorder, adding togrowingevidence basedonself-managementinthisgroup(Jones etal.,2011).Theirfindingsmake clear that the key dimensions of personal recovery differ from traditional clinicalpreoccupations.To clarify what personal recovery means, a systematic review was undertaken to collateand synthesise published frameworks and models of recovery (Leamy et al., 2011). A totalof 97 papers from 13 different countries which offered new conceptualisations of recoverywere identified. The types of papers included qualitative studies, narrative literaturereviews, book chapters, consultation documents reporting the use of consensus methods,opinion pieces, editorials, quantitative studies, as well as papers which combined differentmethods.Empirical studies recruited participants from a range of settings including commu-nity mental health teams and facilities, self-help groups, consumer-operated mental healthservices and supported housing facilities. The majority of studies used inclusion criteriathat covered any diagnosis of severe mental illness.A modified narrative synthesis of these papers showed that recovery can be thought of (a)as a journey which varies from one person to another, (b) as inter-linking sets of processes,

Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial

BACKGROUND Mental health policy in many countries is oriented around recovery, but the evidence base for service-level recovery-promotion interventions is lacking. METHODS We did a cluster, randomised, controlled trial in two National Health Service Trusts in England. REFOCUS is a 1-year team-level intervention targeting staff behaviour to increase focus on values, preferences, strengths, and goals of patients with psychosis, and staff-patient relationships, through coaching and partnership. Between April, 2011, and May, 2012, community-based adult mental health teams were randomly allocated to provide usual treatment plus REFOCUS or usual treatment alone (control). Baseline and 1-year follow-up outcomes were assessed in randomly selected patients. The primary outcome was recovery and was assessed with the Questionnaire about Processes of Recovery (QPR). We also calculated overall service costs. We used multiple imputation to estimate missing data, and the imputation model captured clustering at the team level. Analysis was by intention to treat. This trial is registered, number ISRCTN02507940. FINDINGS 14 teams were included in the REFOCUS group and 13 in the control group. Outcomes were assessed in 403 patients (88% of the target sample) at baseline and in 297 at 1 year. Mean QPR total scores did not differ between the two groups (REFOCUS group 40·6 [SD 10·1] vs control 40·0 [10·2], adjusted difference 0·68, 95% CI -1·7 to 3·1, p=0·58). High team participation was associated with higher staff-rated scores for recovery-promotion behaviour change (adjusted difference -0·4, 95% CI -0·7 to -0·2, p=0·001) and patient-rated QPR interpersonal scores (-1·6, -2·7 to -0·5, p=0·005) at follow-up than low participation. Patients treated in the REFOCUS group incurred £1062 (95% CI -1103 to 3017) lower adjusted costs than those in the control group. INTERPRETATION Although the primary endpoint was negative, supporting recovery might, from the staff perspective, improve functioning and reduce needs. Implementation of REFOCUS could increase staff recovery-promotion behaviours and improve patient-rated recovery. FUNDING National Institute for Health Research.

Fit for purpose? Validation of a conceptual framework for personal recovery with current mental health consumers

Objective: Mental health services in the UK, Australia and other Anglophone countries have moved towards supporting personal recovery as a primary orientation. To provide an empirically grounded foundation to identify and evaluate recovery-oriented interventions, we previously published a conceptual framework of personal recovery based on a systematic review and narrative synthesis of existing models. Our objective was to test the validity and relevance of this framework for people currently using mental health services. Method: Seven focus groups were conducted with 48 current mental health consumers in three NHS trusts across England, as part of the REFOCUS Trial. Consumers were asked about the meaning and their experience of personal recovery. Deductive and inductive thematic analysis applying a constant comparison approach was used to analyse the data. The analysis aimed to explore the validity of the categories within the conceptual framework, and to highlight any areas of difference between the conceptual framework and the themes generated from new data collected from the focus groups. Results: Both the inductive and deductive analysis broadly validated the conceptual framework, with the super-ordinate categories Connectedness, Hope and optimism, Identity, Meaning and purpose, and Empowerment (CHIME) evident in the analysis. Three areas of difference were, however, apparent in the inductive analysis. These included practical support; a greater emphasis on issues around diagnosis and medication; and scepticism surrounding recovery. Conclusions: This study suggests that the conceptual framework of personal recovery provides a defensible theoretical base for clinical and research purposes which is valid for use with current consumers. However, the three areas of difference further stress the individual nature of recovery and the need for an understanding of the population and context under investigation.

Staff understanding of recovery-orientated mental health practice: a systematic review and narrative synthesis

BackgroundMental health policy is for staff to transform their practice towards a recovery orientation. Staff understanding of recovery-orientated practice will influence the implementation of this policy. The aim of this study was to conduct a systematic review and narrative synthesis of empirical studies identifying clinician and manager conceptualisations of recovery-orientated practice.MethodsA systematic review of empirical primary research was conducted. Data sources were online databases (n = 8), journal table of contents (n = 5), internet, expert consultation (n = 13), reference lists of included studies and references to included studies. Narrative synthesis was used to integrate the findings.ResultsA total of 10,125 studies were screened, 245 full papers were retrieved, and 22 were included (participants, n = 1163). The following three conceptualisations of recovery-orientated practice were identified: clinical recovery, personal recovery and service-defined recovery. Service-defined recovery is a new conceptualisation which translates recovery into practice according to the goals and financial needs of the organisation.ConclusionsOrganisational priorities influence staff understanding of recovery support. This influence is leading to the emergence of an additional meaning of recovery. The impact of service-led approaches to operationalising recovery-orientated practice has not been evaluated.Trial RegistrationThe protocol for the review was pre-registered (PROSPERO 2013: CRD42013005942).

Assessing the strengths of mental health consumers: a systematic review.

Strengths assessments focus on the individuals talents, abilities, resources, and strengths. No systematic review of strengths assessments for use within mental health populations has been published. The aims of this study were to describe and evaluate strengths assessments for use within mental health services. A systematic review identified 12 strengths assessments (5 quantitative, 7 qualitative). The Strengths Assessment Worksheet (SAW) was the most widely utilized and evaluated qualitative assessment. Psychometric properties of the assessments were assessed against set quality criteria. Data on psychometric properties were available for 4 measures. The Client Assessment of Strengths, Interests and Goals (CASIG) had the strongest psychometric evidence. The SAW and CASIG assessments can be tentatively recommended within clinical practice, although the evidence for all strengths assessments is currently limited. To describe the content of the strengths assessment, the items used to operationalize the concept of strengths in each assessment were extracted and themed. Twenty-four themes were identified and organized into 3 overarching categories: individual factors, environmental factors, and interpersonal factors. These categories form the basis of an empirically based definition of strengths that could be used as a conceptual foundation for new clinical assessments.