In recent years, the concept of recovery from severe mental illness has increasingly gained relevance in the mental health field. Countries all over the world have been introducing recovery policy into mental health services (e.g. Australia, Ireland, New Zealand, USA), including England and Wales (Department of Health, 2001). However, there is still debate about the concept, such as whether symptom reduction is central (Reference Liberman and KopelowiczLiberman & Kopelowicz, 2005) or not (Reference Roberts and WolfsonRoberts & Wolfson, 2004). This editorial proposes a conceptual framework for recovery and identifies emergent practical issues.

One term, two meanings

Two classes of definitions which emerged from two different influences, can be identified for the term recovery in mental health. In psychiatry the idea of recovery is based on longitudinal studies demonstrating a widely heterogeneous course for severe mental illnesses (Reference Davidson, O'Connell and TondoraDavidson et al, 2005b ). In this context, remission is defined as an improvement in symptoms and other deficits to a degree that they would be considered within a normal range. Recovery can be seen as a long-term goal of remission (Reference Andreasen, Carpenter and KaneAndreasen et al, 2005). We call this the service-based definition of recovery.

A second definition of the term recovery came from the self-help and consumer/user/survivor movement. Here, recovery may include, but does not require, symptom remission or a return to normal functioning. However, recovery is seen as a process of personal growth and development, and involves overcoming the effects of being a mental health patient, with all its implications, to regain control and establish a personally fulfilling, meaningful life (Reference Davidson, O'Connell and TondoraDavidson et al, 2005b ). We call this the user-based definition of recovery. This is exemplified by the National Institute for Mental Health in England definition of recovery as the ‘achievement of a personally acceptable quality of life’ (National Institute for Mental Health in England, 2004).

Components of recovery

In contrast to the mostly clearly defined service-based criteria for recovery, the user-based approach is much more complex. From a narrative literature review of user-based recovery we identified conceptual works by Davidson et al (Reference Davidson, Borg and Marin2005a , Reference Davidson, O'Connell and Tondora b ), Andresen et al (Reference Andresen, Oades and Caputi2003) and Jacobson & Greenley (Reference Jacobson2001). These were synthesised into an emergent framework identifying the key components of recovery, as shown below.

Stages of recovery

According to the user-based definition, individuals tend to go through phases in their recovery process in which they approach the tasks outlined above. Although named differently, the various outlines of recovery phases in the literature are largely consistent (e.g. Reference Andresen, Oades and CaputiAndresen et al, 2003; National Institute for Mental Health in England, 2004). The National Institute for Mental Health in England outlines four consecutive stages:

1. • dependent and unaware

2. • dependent and aware

3. • independent and aware

4. • interdependent and aware.

The starting point is described as a state of dependency owing to the experience of illness/distress, the impact of the mental health system, traumatic events and the disruption of daily life and relationships. This period of crisis is characterised by denial, confusion, hopelessness, identity confusion and self-protective withdrawal. The goal and final stage of the recovery process is a state of psychological well-being, defined as personal growth, self-acceptance, autonomy, positive relationships, environmental mastery and purpose in life. Characteristics of this stage are not necessarily the absence of symptoms but the ability to manage the illness and live a fulfilling and meaningful life, show resilience in the face of setbacks and have a positive attitude towards the future.

To proceed from the initial state of disruption towards well-being, the individual first has to become aware of their condition as well as the fact that recovery is possible, and start to work on recovery. This early phase in the recovery process (dependent and aware) involves recognising one's values, strengths and weaknesses, beginning to set goals, learning about mental illness and services available, acquiring recovery skills and connecting with peers. The next stage (independent and aware) involves setting and working towards personally valued goals, taking responsibility for managing the illness and taking control of one's life, developing increasing knowledge and skills, and building and maintaining relationships. An important characteristic of this phase is the constant growth in resilience, which requires the opportunity to take risks (i.e. to try something new); this requirement is challenging for risk-averse mental health services.

The step from being overwhelmed or resigned to gaining awareness, hope and determination is frequently described as a turning point in an individual's life, and may be triggered by an event, a clinician, a role model or a significant other. It can also be a conscious decision arrived at after being ill for a long period (Reference Andresen, Oades and CaputiAndresen et al, 2003; Reference Davidson, Borg and MarinDavidson et al, 2005a ).

Recovery orientation in service provision

Overall, two shortcomings in current practice are identified by proponents of recovery orientation in mental health services:

1. • best available evidence is not followed

2. • there are limitations to the evidence base (Reference Frese, Stanley and KressFrese et al, 2001).

Those who focus on the needs of individuals with the most serious disabilities tend to demand evidencebased interventions, since many service users do not have a full choice of treatments. An example is the over-reliance on pharmacotherapy (Office of the Deputy Prime Minister, 2004) even for conditions where guidelines indicate psychological interventions should be the first-line treatment (National Institute for Clinical Excellence, 2004).

On the other hand, people who have recovered from mental health problems often report that very individual things helped them, things that may have never been scientifically investigated (Reference Frese, Stanley and KressFrese et al, 2001). They call for the implementation of user-based recovery orientation in mental health services. An understanding that the planning, arrangement and delivery of support should be determined by the needs of the service user has now received policy endorsement (Department of Health, 2004).

One step in this direction internationally is the programme of the current president of the World Psychiatric Association - ‘Psychiatry for the Person’ - which considers

From this perspective, the primary aim of psychiatric care is to enable people to function within their individual social context, irrespective of their symptoms, and to help them live a personally fulfilling and meaningful life, irrespective of their need to use professional help in times of crisis.

This perspective on recovery may be reminiscent of the concept of quality of life, which also takes into account a whole range of aspects of daily life and aims to place the consumer at its centre. However, similar to the concept of recovery, there is still no single universally accepted definition of quality of life, and the distinction, interplay and importance of subjective and objective factors remains debated. It has also been shown that subjective (or user-based) and objective (or service-based) appraisals of quality of life often bear little relation (Reference Ruggeri, Bisoffi and FontecedroRuggeri et al, 2001).

To some extent, similar tensions exist between the two classes of recovery definitions. However, the user-based concept of recovery goes far beyond the concept of quality of life or a simple needs-based service approach. The individual consumer is not only placed at the centre of attention but actively encouraged to take the responsibility for their own life, with the aim of true power-sharing, consumer participation and a reduced dependence on services. Recovery-oriented systems of mental health are supposed to flexibly adapt to the consumer's needs, focus on strength rather than on deficits or dysfunction and include a wide range of alternative facilities, such as peer-run services or faith communities (National Institute for Mental Health in England, 2004). These ambitious aims, although national policy, are far from being realised in England and empirical research on the application of recovery-oriented principles in service provision is largely lacking.

What needs to change?

Adopting a recovery-oriented approach may have profound implications for mental health services. The goals of mental healthcare have to be redefined to focus on the individual's life goals and to respect service users’ rights to make individual decisions about all aspects of their recovery. It is now recognised in legislation that a person ‘is not to be treated as unable to make a decision merely because he makes an unwise decision’ (Mental Capacity Act 2005). Indeed, the evidence of equivalent rates of mental incapacity between psychiatric and non-psychiatric in-patients (Reference Raymont, Bingley and BuchananRaymont et al, 2004) suggests that the traditional reservations of psychiatric services towards ceding decision-making power to service users because they lack ‘ insight’ may not be empirically justified. A successful example of such shared decision-making is joint crisis plans, which realise advanced agreements and directives for mental healthcare that have long been advocated by user group organisations (Reference Henderson, Flood and LeeseHenderson et al, 2004).

Equally the values and attitudes of staff may have to shift. Recovery orientation for staff may mean redefining their roles from that of ‘ outside experts’ for people's illnesses to that of companions and helpers on people's paths of life, accepting equal partnerships with their clients. This shift in roles changes the balance of power and may be challenging for staff. However, limited, mainly qualitative, research indicates that adapting such an individual and holistic approach may have a positive impact on the recovery process (Reference Farkas, Gagne and WilliamFarkas et al, 2005).

The National Institute for Mental Health in England outlines a whole range of working practices for clinicians to support recovery. These include demonstrating hope and offering encouragement, for example in supporting people to achieve their individual goals, providing comprehensive information on the illness and available treatments, making shared decisions with clients, engaging families, facilitating peer interaction, supporting social, cultural and spiritual activities, etc.

In service structures, recovery values may be reflected in the organisation, administration and staffing: in a mission statement identifying recovery outcomes; policy statements and guidelines providing recovery-based principles for service delivery, quality assurance developed, implemented and monitored collaboratively with service users; staff selection, training and supervision according to recovery values and with user involvement. Recovery-oriented services ideally work in flexible networks, adjusting to the individual's support needs and their personal resources in their environment (Reference Farkas, Gagne and WilliamFarkas et al, 2005). The importance of user involvement, which is particularly emphasised in the user-based recovery approach, has been known and applied in other fields, such as management or information technology, since the 1980s. In the mental health field, however, both sound practical experience with and systematic empirical research on the value, practicability and the effects of user involvement remain limited to date.

Without doubt, implementing recovery orientation in service provision will be a challenging and time-consuming process, with respect to both practice and research. In mental healthcare practice, a first step may be the promotion of understanding of the concept and its implications among the stakeholders (National Institute for Mental Health in England, 2004). Recovery orientation is intended to complement rather than replace existing roles, functions, therapeutic interventions and structures. The central implementation challenge may be moving beyond an oppositional user-professional discourse that emphasises the shortcomings of mental healthcare (and hence alienates mental health staff) towards a value-adding discourse that harnesses the professional and personal qualities of staff. Such a partnership model of change will be difficult. Service user activists, who have previously defined their role by opposing a ‘ biomedical model’, will be asked to shift towards a collaborative approach in which their constructive input is needed by mental health services to develop practice change. In addition, giving power to ‘experts by experience’ may not be a welcome development for some service users. For staff, the central challenges may be in meeting demands to change practice, to be less in a formal professional role when working with distressed (and distressing) individuals, to manage the anxiety involved in supporting the person to take chances, and in not imposing their values and models on service users.

However, it may be detrimental to the evolving recovery movement if service developments are ahead of research. In order to guarantee that the recovery concept will outlive its current fashion and acquire lasting importance for service delivery, a firm evidence base needs to be created on the distinct components of recovery orientation within mental health services, their acceptability, applicability and effects. Some important ground-work has already been laid: there is a wealth of qualitative research; several attempts to systematise the concept; and some newly developed measurement tools, such as the Stages of Recovery Instrument (STORI; Reference Andresen, Caputi and OadesAndresen et al, 2006), the Recovery Process Inventory (RPI; Reference Jerrell, Cousins and RobertsJerrell et al, 2006) and the Recovery Assessment Scale (RAS; Reference Corrigan, Salzer and RalphCorrigan et al, 2004). However, much research, especially that using such quantitative tools, still needs to be conducted to explore the challenges, possibilities and benefits this concept of recovery orientation can provide for both service users and staff.

Declaration of interest

None.