Research on recovery

There has been a significant amount of research and published work attempting to support each of the individual recovery concepts, but little has been done on the positive outcomes of converging the constructs. Recovery research ranges from personal accounts^{Reference Armstrong7} to attempts to define, standardise or measure the conceptual framework,^{Reference Piat, Sabetti, Couture, Sylvestre, Provencher and Botschner8,Reference Neil, Kilbride, Pitt, Nothard, Welford and Sellwood9} alongside histories^{Reference Bradstreet and McBrierty10} and empirical studies.^{Reference Lloyd, King and Moore11,Reference Clarke, Oades, Crowe, Caputi and Deane12} Recovery-orientated practice guidelines exist for service provision,^{Reference Le Boutillier, Leamy, Bird, Davidson, Williams and Slade13–Reference Newnham and Page18} including an emerging critique^{Reference Tilley and Cowan19} resting on personal recovery,^{Reference Neil, Kilbride, Pitt, Nothard, Welford and Sellwood9,Reference Andresen, Caputi and Oades20–Reference Mueser, Corrigan, Hilton, Tanzman, Schaub and Gingerich22} recovery-oriented services,^{Reference O'Connell, Tondora, Croog, Evans and Davidson6,Reference Armstrong and Steffen23–Reference Lloyd-Evans, Mayo-Wilson, Harrison, Istead, Brown and Pilling29} in addition to provider competencies.^{Reference Burgess, Pirkis, Coombs and Rosen25,Reference Russinova, Rogers, Ellison and Lyass30–Reference Bird, Leamy, Tew, Le Boutillier, Williams and Slade36} Despite the accumulation of research produced to support or isolate contested elements of recovery, disagreement and criticism remains over the definitions of recovery and on whether recovery has to be survivor-led or a policy directive.^{Reference Woods, Hart and Spandler37}

Narrative and systematic forms of syntheses and reviews have tested tools^{Reference Andresen, Caputi and Oades20,Reference Mueser, Corrigan, Hilton, Tanzman, Schaub and Gingerich22} to incorporate accepted components of recovery.^{Reference Williams, Leamy, Bird, Harding, Larsen and Le Boutillier34,Reference Leamy, Bird, Le Boutillier, Williams and Slade38} This, however, has only led to further compound the idea of mainstreaming of recovery.^{Reference Woods, Hart and Spandler37} Amid this accumulation of criticisms, Braslow has shown that ‘recovery is everywhere’ despite including an array of perspectives.^{Reference Braslow5} Since the 1990s, the concept of recovery in mental health domain has affected both the person experiencing mental health difficulties and the clinicians.^{Reference Woods, Hart and Spandler37} A conceptual framework that acknowledges recovery^{Reference Leamy, Bird, Le Boutillier, Williams and Slade33,Reference Bird, Leamy, Tew, Le Boutillier, Williams and Slade36} has been produced by Leamy et al, highlighting five main approaches in their CHIME framework: Connectedness, Hope – optimism, Identity, Meaning – purpose, and Empowerment.^{Reference Leamy, Bird, Le Boutillier, Williams and Slade38} However, CHIME has not been without its critics. Bird et al carried out a validation study applying thematic analysis of data from CHIME, using focus groups with those with diagnosed schizophrenia, bipolar disorder and depression.^{Reference Bird, Leamy, Tew, Le Boutillier, Williams and Slade36} They demonstrated that the CHIME framework was both valid and appropriate for use, but highlighted areas that were not included, such as ‘a desire for practical support, issues around diagnosis and medication, and scepticism about the concept of recovery’.^{Reference Stuart, Tansey and Quayle39} As noted, evaluating recovery is an inherently complex concept,^{Reference Davidson and Roe40} challenging the essence of creating ‘reliable measures of individual recovery’^{Reference Stuart, Tansey and Quayle39} and the construct validity of this. Andresen et al suggest that if the said concept of recovery is entirely individual,^{Reference Smith-Merry, Freeman and Sturdy41} contrary to ‘what can it be normed and as might be expected for a concept in which symptom reduction is not paramount’, then ‘correlations with customary clinical outcome measures may possibly be poor and convergent validity low’.^{Reference Andresen, Caputi and Oades42}

Embracing diversity

Given all of this diversity of recovery principles, it is perhaps not surprising to find professionals misunderstanding and confused^{Reference Davidson and Roe40,Reference Pilgrim43} in the operational aspects, emphasised in popular guidelines, discourse, policies and research. Pilgrim aptly suggested that recovery is a polyvalent concept.^{Reference Pilgrim43} However, this does not translate easily to those who may wish to activate the recovery construct for better patient outcomes and improved service delivery. Quiet so, Braslow has argued that recovery remains an ‘unquestioned overarching principle and popularly known to include a melange of beliefs, values that materialized because of the intellectual and social movements’.^{Reference Braslow5}

An anthropological model

To further link back to the discussion on the concept of converging the person-directed management of illness and professionally directed treatment, we recognise, similar to Davidson and Roe, that an anthropological model – one situated upon ‘principles of reciprocity’ that concerns itself more with the integration of healthcare^{Reference Davidson and Roe40} – could complement and augment professional knowledge.^{Reference Khan, Bower and Rogers44} However, this requires a substantial shift in the clinical lens, incorporating ‘lay types of knowledge’, such as a person's own understandings of dealing with illness, including social functioning.^{Reference Khan, Bower and Rogers44} Suitably, Davidson and Roe conceptualise that meaningful illness narratives are a gift exchange, providing meaning, emotive steadiness, narration and collective experience.^{Reference Davidson and Roe40}

Illness narratives and professionals’ treatment

Biological aspects have often been viewed by patients as both coercive and impersonal,^{Reference Pilgrim45} although we may be seeing some welcomed change with this, and COVID-19 may offer an interesting corollary, with the emphasis of ‘long-COVID’ care moving toward wellness and self-management of long-term chronic difficulties. Pilgrim has pointed out that the root basis of patients’ adverse perceptions can be based on pathology, making clinicians appear as ‘chemotherapists with a prescription pad’.^{Reference Pilgrim45}

The UK and co-production: the Care Programme Approach as an exemplar

In the UK, the National Institute for Health and Care Excellence explicitly calls for care plans to be jointly drawn up between individuals and their clinician, with shared decision-making and agreed dates to review its progress.⁴⁶ The Care Programme Approach (CPA) necessitates that health and social needs are comprehensively assessed and reviewed with individuals with serious mental illness, with a ‘philosophy of recovery and to foster personalised care’.^{47–Reference Coffey, Hannigan, Barlow, Cartwright, Cohen and Faulkner49}

Despite their imbedding in contemporary British mental healthcare,^{Reference Coffey, Hannigan and Simpson50} there remains a general lack of data exploring actual practice in the community, and even less that is focused on in-patient care.^{Reference Jones, Hannigan, Coffey and Simpson51} The Healthcare Commission in the UK assessed in-patient performance across 554 wards in 69 National Health Service (NHS) Trusts. About 40% were rated as ‘weak’ when it came to including patients and carers; astonishingly, half of care plans had no evidence of recording patients’ views, and about a third made no mention as to whether there was a carer involved. A further third had input from the patients’ community care coordinators only some or none of the time.⁵²

Work by Simpson et al examined the views and experiences of stakeholders involved in community mental healthcare, investigating factors related to the provision of personalised, collaborative, recovery-focused care.^{Reference Simpson, Hannigan, Coffey, Barlow, Cohen and Jones53} They found substantial variations among sites for results on therapeutic relationships and participant groups in their study, related to the experiences of care planning and understandings of recovery and personalisation.^{Reference Simpson, Hannigan, Coffey, Barlow, Cohen and Jones53} Consequently, carers expressed varying levels of input, and despite risk assessments being part of central clinical concerns, they were rarely discussed with patients.^{Reference Simpson, Hannigan, Coffey, Jones, Barlow and Cohen54}

Patients valued therapeutic relationships with care coordinators and others, and saw these as central to recovery. However, in another study by the same team, the staff, patient and carer interviews revealed gaps between shared aspirations and realities,^{Reference Simpson, Coffey, Hannigan, Barlow, Cohen and Jones55} and staff accounts of routine collaboration contrasted with patient accounts and care plan reviews. They also found that personalisation was not a common phrase, but care was often delivered in an individualised way.^{Reference Simpson, Coffey, Hannigan, Barlow, Cohen and Jones55} McWade has argued that this endorses that perspective of failure of co-opting or mainstreaming the ‘thing’ that is recovery.^{Reference Mcwade3}

Contact with clinicians and patient engagement

‘Illness management’ can be understood as an approach to support patients with a diagnosis to engage with clinicians, to reduce patient susceptibility to the disease.^{Reference MacDonald-Wilson, Deegan, Hutchison, Parrotta and Schuster56} Conversely, ‘illness problems’ are the principal difficulties that symptoms and disability create in lives, and ‘illness behaviour’ then consists of initiating treatment (for example, changing diet and activities, resting, engaging in exercise, taking over-the-counter or prescribed medications and deciding when to seek care from professionals).^{Reference Aurther57} There is an overdue lack of understanding placed on the notion that there is a pre-existing underlying relationship between the person and their illness. Albeit in separation of formal treatment environments, this occurs in the way individuals perceive their difficulties, the type of help they envisage, and the approach they are willing to engage with for formal treatments; it includes making contact with clinicians and entering into a contract with services for future treatment.

The socialisation of the practitioner

For the purpose of this editorial, a critical discussion cannot be complete without including a focus on clinicians understandings. Hitherto, psychiatric models have perhaps viewed the concepts of recovery from mental illness in a similar style to how clinicians have viewed physical illnesses.^{Reference Jacobs58} We propose that Kleinman's illness narratives model has proved influential in this regard, remarking how the practitioner has also been socialised into a distinct collective experience of sickness. It is true that clinicians are trained to capture the essence of illness by using concepts that delineate disease. For instance the use of expressions such as relapse, recurrence, remission and recovery.^{Reference Frank, Prien, Jarrett, Keller, Kupfer and Lavori59} In this way, the symptom profile is used to transform the patient's illness (in a form of recasting of illness in accordance with the theories of disorder) into a disease formation.^{Reference Aurther57} The absence of an ongoing intervention other than that relationship can be perceived by care managers as a need for premature discharge from services, for fear of creating dependency. However, some who use services desire an ongoing relationship, which commonly matters more than interventions, and this aspect can be missing in some recovery narratives. The construct of so-called ‘palliative psychiatric care’ is informative in this regard.^{Reference Trachsel, Irwin, Biller-Andorno, Hoff and Riese60} Further, moral experience is central to Kleinman's model of illness narratives, incorporating constructs of ideal virtues of the practitioner^{Reference Kleinman61} and so opening up ‘illness narratives’ to create patient ‘storylines’, which brings to life inanimate parts of practices, policies and discourses.^{Reference Pilgrim62,Reference Rose63} Hajer suggests that storylines are ‘narratives on social reality’, which combine elements from many different domains and ‘provide actors with a set of symbolic references that suggest a common understanding’.^{Reference Hajer64} Albeit critically, Kleinman also envisaged that partnership is vital and is susceptible to change over time, with caregiving perceived as a construct focused more on ‘doing good for others in their world’ and projecting that ‘as earnest and naïve as it sounds, it is what medicine is really about’.^{Reference Kleinman65}

Patient perspectives of ‘corporate’ recovery/criticism

Despite the common understandings, it should be noted that some patients remain suspicious of the recovery concept because it is potentially intolerant of those who do not change, and so it may remain, in their eyes, a source of oppression used against them.^{Reference Pilgrim and McCranie66} There is a recurring critique of recovery presented as the ‘next best thing’,^{Reference Davidson, O'Connell, Tondora, Styron and Kangas67} and a mere form of symbolism, undermining ‘authentic alliances’^{Reference El Enany, Currie and Lockett68} donning recovery in a sense to reduce effective support.^{Reference Vandekinderen, Roets, Roose and Van Hove69} Service cuts have been associated with the manner in which services and health systems manage future demand for mental healthcare, allied to the economic cutbacks planned for financial savings.^{Reference Fernando70,Reference Roberts and Hollins71} Consequently, recovery concepts used in this method risk being used, or at least perceived, as indicative of justification to reduce services or their ability to provide timely input.