Mike Slade

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.

A self‐report Insight Scale for psychosis: reliability, validity and sensitivity to change

Lack of insight is a frequent concomitant of psychosis and has traditionally been viewed as a binary, all or none phenomenon. Recent conceptualization has formulated insight as a continuum representing the juxtaposition of 3 factors – awareness of illness, need for treatment and attribution of symptoms. Measurement of insight has been exclusively based on interview; this method does not easily lend itself to frequent repeated measurement and requires interrater reliability to be established. A self‐report Insight Scale is presented, and evidence in support of its reliability, validity and sensitivity is provided that includes a sample of 30 patients monitored during recovery from an acute psychosis. The scale is a quick and acceptable measure that may find application in investigations of acute care, cognitive therapy of psychotic symptoms and as a method of augmenting clinical judgements of insight.

Mental illness and well-being: the central importance of positive psychology and recovery approaches

BackgroundA new evidence base is emerging, which focuses on well-being. This makes it possible for health services to orientate around promoting well-being as well as treating illness, and so to make a reality of the long-standing rhetoric that health is more than the absence of illness. The aim of this paper is to support the re-orientation of health services around promoting well-being. Mental health services are used as an example to illustrate the new knowledge skills which will be needed by health professionals.DiscussionNew forms of evidence give a triangulated understanding about the promotion of well-being in mental health services. The academic discipline of positive psychology is developing evidence-based interventions to improve well-being. This complements the results emerging from synthesising narratives about recovery from mental illness, which provide ecologically valid insights into the processes by which people experiencing mental illness can develop a purposeful and meaningful life. The implications for health professionals are explored. In relation to working with individuals, more emphasis on the persons own goals and strengths will be needed, with integration of interventions which promote well-being into routine clinical practice. In addition, a more societally-focussed role for professionals is envisaged, in which a central part of the job is to influence local and national policies and practices that impact on well-being.SummaryIf health services are to give primacy to increasing well-being, rather than to treating illness, then health workers need new approaches to working with individuals. For mental health services, this will involve the incorporation of emerging knowledge from recovery and from positive psychology into education and training for all mental health professionals, and changes to some long-established working practices.

Uses and abuses of recovery: implementing recovery‐oriented practices in mental health systems

An understanding of recovery as a personal and subjective experience has emerged within mental health systems. This meaning of recovery now underpins mental health policy in many countries. Developing a focus on this type of recovery will involve transformation within mental health systems. Human systems do not easily transform. In this paper, we identify seven mis‐uses (“abuses”) of the concept of recovery: recovery is the latest model; recovery does not apply to “my” patients; services can make people recover through effective treatment; compulsory detention and treatment aid recovery; a recovery orientation means closing services; recovery is about making people independent and normal; and contributing to society happens only after the person is recovered. We then identify ten empirically‐validated interventions which support recovery, by targeting key recovery processes of connectedness, hope, identity, meaning and empowerment (the CHIME framework). The ten interventions are peer support workers, advance directives, wellness recovery action planning, illness management and recovery, REFOCUS, strengths model, recovery colleges or recovery education programs, individual placement and support, supported housing, and mental health trialogues. Finally, three scientific challenges are identified: broadening cultural understandings of recovery, implementing organizational transformation, and promoting citizenship.

Experiences of mental illness stigma, prejudice and discrimination: a review of measures

BackgroundThere has been a substantial increase in research on mental illness related stigma over the past 10 years, with many measures in use. This study aims to review current practice in the survey measurement of mental illness stigma, prejudice and discrimination experienced by people who have personal experience of mental illness. We will identify measures used, their characteristics and psychometric properties.MethodA narrative literature review of survey measures of mental illness stigma was conducted. The databases Medline, PsychInfo and the British Nursing Index were searched for the period 1990-2009.Results57 studies were included in the review. 14 survey measures of mental illness stigma were identified. Seven of the located measures addressed aspects of perceived stigma, 10 aspects of experienced stigma and 5 aspects of self-stigma. Of the identified studies, 79% used one of the measures of perceived stigma, 46% one of the measures of experienced stigma and 33% one of the measures of self-stigma. All measures presented some information on psychometric properties.ConclusionsThe review was structured by considering perceived, experienced and self stigma as separate but related constructs. It provides a resource to aid researchers in selecting the measure of mental illness stigma which is most appropriate to their purpose.

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.

The Camberwell Assessment of Need (CAN) : comparison of assessments by staff and patients of the needs of the severely mentally ill

The association between the assessment of need by staff and by severely mentally ill patients was examined using a new needs assessment instrument, the Camberwell Assessment of Need (CAN). In all, 49 staff-patient pairs were interviewed separately using the CAN as part of a larger reliability study. For each of 22 areas of need, we assessed agreement on (1) the presence of need, (2) the informal and formal help currently being given, (3) the formal help needed and (4) satisfaction with the type of help being received. Staff and patients rated a similar number of needs, but not in the same areas. There was better agreement between staff and patients regarding needs that have a specific service intervention. Agreement between staff and patient ratings of help received, help given and service satisfaction was low. We concluded that needs are very often assessed differently by staff and patients, which has implications for how needs are assessed in clinical practice.

A comparison of needs assessed by staff and by an epidemiologically representative sample of patients with psychosis

BACKGROUND Staff and severely mentally ill patients differ in their assessments of need. This study compares staff and patient assessments of need for people suffering from psychotic disorders. METHOD The needs of an epidemiologically representative sample of 137 patients from a catchment area psychiatric service in South London who had an ICD-10 diagnosis of a functional psychotic disorder were assessed cross-sectionally by patients and staff, using the Camberwell Assessment of Need. RESULTS Staff rated patients to have on average 6.1 needs, and patients rated 6.7 needs (t = 2.58, df = 136, P = 0.011). This difference was accounted for by the staff rating of 1.2 unmet needs and the patient rating of 1.8 unmet needs (t = 3.58, df = 136, P < 0.001). There was no difference in rating of total number of met needs. There was no difference in ratings in relation to any patient sociodemographic characteristics. There was moderate or better agreement on the presence of a need for 13 of the 22 domains in the Camberwell Assessment of Need. CONCLUSIONS Staff and patients moderately agree about met needs, but agree less often on unmet needs.

The feasibility of routine outcome measures in mental health.

Background: Standardised outcome measures are not being used in routine mental health care. Method: The importance of routine use of standardised outcome measures is argued, and reasons for their lack of use suggested. Results: One reason for standardised outcome measures not being used routinely is the lack of appropriate instruments. This property of being suitable for routine use is often called feasibility, but there is no consensus about the meaning of feasibility, or how it should be measured. We propose a definition of feasibility as a psychometric property of a standardised outcome measure, provide criteria for assessing feasibility, and then present a framework for changing practice to increase the routine use of standardised outcome measures. Conclusions: If mental health care is to maximise outcome, then more attention needs to be paid both to the process of developing and to facilitating the routine clinical use of feasible outcome measures.

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.