Origins of the recovery approach in mental health

It is fitting that this Special ‘themed’ Issue focused on the past, present, and future of the recovery approach is published in an Irish journal. The recovery journey of one of the first authors to document the lived experience of mental illness, and navigating the mental health system, began in Dublin. John Perceval, the son of the Prime Minister of the United Kingdom Spencer Perceval, became unwell with psychosis while staying with a family acquaintance in Ireland (Oyebode Reference Oyebode2025).

Perceval is one of the first known advocates for the recognition of mental health lived experience as a vital and unique form of knowledge. In his account, ‘A Narrative of the Treatment Experienced by a Gentleman, during a State of Mental Derangement’, published in 1840, he reflects on how his experiences in two private ‘madhouses’ in the United Kingdom were interwoven with both debasement, violence, and punitive regimes and encounters characterised by dignity and respect (Perceval Reference Perceval1840). The aim of Perceval’s writings was to ask society to reflect on the ‘needless tyranny’ of British psychiatric care in the 1830s and to centre the lived experience voice and human agency in understanding, managing, and making meaning in psychological distress. His writing and subsequent advocacy work enabled him to reclaim his identity, resisting the othering he experienced as a marginalised and subjugated ‘lunatic’, and author his own narrative. Perceval’s advocacy work led to the formation of the Alleged Lunatics’ Friend Society, which successfully campaigned for service user autonomy, humane treatment, and mental health system reform (Hervey Reference Hervey1986).

Perceval’s powerful appeal to humanise people experiencing mental illness and clarity of argument laid the intellectual and moral foundation for a lived experience civil rights social movement. The aim of his writing was to transform mental health systems and public attitudes, with people with lived experience asserting their societal value, demanding the same basic human rights as everyone else (including non-discrimination, legal capacity, and community inclusion), and advocating for the services, resources, and social opportunities to live the lives they wanted in the community (Davidson et al. Reference Davidson, Rowe, DiLeo, Bellamy and Delphin-Rittmon2021; Speyer et al. Reference Speyer, Roe and Slade2025). This grassroots social action, combined with 60 years of empirical data suggesting that mental health recovery, even in what is labelled ‘serious mental illness’, is not just possible but likely (O’Keeffe et al. Reference O’Keeffe, Sheridan, Kelly, Doyle, Madigan, Lawlor and Clarke2018; Huxley et al. Reference Huxley, Krayer, Poole, Prendergast, Aryal and Warner2021), is the genesis of what we now know as the recovery approach in mental health services, a cornerstone of modern mental health policy globally.

Almost 200 years after Perceval’s experience of dehumanisation in the British asylum system, the alignment of legislation that governs involuntary psychiatric care and the human rights enshrined in the United Nations Convention on the Rights of Persons with Disabilities remains contested (Wilson Reference Wilson2025).

The recovery approach defined

The aim of the recovery approach is to evolve value based mental health systems centred on shared humanity, justice, equality, respect, and compassion (Tuffour Reference Tuffour, Callaghan, Dickinson and Felton2024). Service user and family member, carer, and supporter perspectives are privileged and the outcomes they prioritise pursued. This approach asks clinicians to work, through coproduction, by having a humility about the professional knowledge they have and to hold it tentatively. It requires clinicians to respectfully invite in the knowledge, insight, and wisdom of lived experience; to step back from discipline surety and certainty; and to set their discipline-specific ‘expert’ knowledge alongside, not over and above, service users’ own (Rose and Kalathil Reference Rose and Kalathil2019; O’Keeffe et al. Reference O’Keeffe, Keogh and Higgins2025; Swords and Norton Reference Swords and Norton2024).

Recovery oriented clinicians view the person seeking help as an active agent who shapes, and is shaped by, their biology, psychology, and social worlds; with outcome being determined, in part, by how a person makes meaning in their life experiences and distress (Lysaker et al. Reference Lysaker, Buck, Carcione, Procacci, Salvatore, Nicolò and Dimaggio2011). They hold optimism for recovery for all (irrespective of diagnosis or the degree that a person’s mental illness has been deemed to be ‘enduring’ or ‘chronic’) (Solomon et al. Reference Solomon, Sutton and McKenna2021) and develop and maintain relationships with people seeing help centred on the principles of honesty, openness, and trust. These clinicians emphasise empowerment, collaborative decision-making, self-determination, choice, and the dignity of risk and right to fail as well as the needs, preferences, goals, and explanatory models of people with lived experience (Deegan Reference Deegan1993; Subandi et al. Reference Subandi, Nihayah, Marchira, Tyas, Marastuti, Pratiwi, Mediola, Herdiyanto, Sari, Good and Good2023). Within assessments, multidisciplinary team discussions, and interventions, clinicians focus on a person’s strengths and resilience rather than perceived ‘deficits’ (Roberts and Boardman Reference Roberts and Boardman2014). Recovery oriented mental health systems consider inclusivity in access, continuity of care, and the social, political, and economic forces that influence mental health outcomes (O’Keeffe et al. Reference O’Keeffe, Keogh and Higgins2018).

The critique of the recovery approach

While the recovery approach has undoubtedly led to improvements in the quality of mental health care worldwide, in recent years it has been critiqued extensively. Some key concerns include: the concept of recovery becoming professionalised and colonised to make services more acceptable and competitive, coopting and detaching it from lived experience perspectives; people with severe and enduring mental health difficulties experiencing abandonment to the recovery approach; its lack of transferability to non-westernised cultures that do not emphasise individualism and personal responsibility; and its absence of focus on the interpersonal contexts of recovery (Cohen Reference Cohen2025; Morrow Reference Morrow, LeFrancois, Menzies and Reaume2013; Poole et al. Reference Poole2011; Sinclair et al. Reference Sinclair, Gillieatt, Fernandes and Mahboub2023; O’Keeffe et al. Reference O’Keeffe, Sheridan, Kelly, Doyle, Madigan, Lawlor and Clarke2018). ‘Neorecovery’ (a concept introduced by the critical theorist and activist collective ‘Recovery in the Bin’) refers to how people can perceive the once grassroots, collective, and socially aware philosophy of the recovery approach being transformed into a neoliberal tool. A tool that emphasises self-management, market values, and personal responsibility, while ignoring structural injustices and erasing safety nets (Edwards et al. Reference Edwards, Burgess and Thomas2019). While the recovery approach was originally conceived as a ‘potential radical transformative vision’, the realisation of the revolutionary mental health system reform at the heart of this vision continues to be in debate (Cohen Reference Cohen2025, p. 248).

Progress and challenges

There has been much achieved in the fields of lived experience work, coproduction, and recovery approach implementation. In many jurisdictions, Recovery Colleges have been mainstreamed and integrated into public health services. These are spaces of community, belonging, and connection where people are supported through lived experience, clinical expertise, and adult learning principles to make sense of distress; avail of empowering and transformative learning opportunities; navigate and transcend suffering; and experience personal growth (Lefay et al. Reference Lefay, Briand, Sauvageau, Drolet, Vachon, Luconi, Aliki and Nadeau-Tremblay2025).

Significant progress has been made in embedding peer support work into, and valuing it on, clinical teams. Grounded in the principles of reciprocal respect, shared responsibility, and a mutual agreement of what is helpful, Peer Support Workers and Family Peer Support Workers utilise their own lived experience to offer empathy and validation; help people set and pursue goals; encourage informed decision-making; and normalise both the experience of mental illness and seeking help. They create a psychologically safe environment and foster relationships of trust; enabling people to reflect on what they need themselves to aid recovery. Mental Health Engagement is a power-sharing process between users and providers of services. This involves the authentic, equitable, dignified, and meaningful inclusion of lived experience voices in service innovation, change, and development. Mandated by many research funders internationally, Public and Patient Involvement (PPI) has emerged as a nascent marker of rigour and quality in mental health research; with the promise of enhancing the relevance, meaning, and impact of academic and clinical practice. Justifications for PPI are manifold. These include challenging embedded assumptions and siloed thinking; shaping research decision-making; bringing impartiality to assessments of research value; enhancing usefulness and impact of findings; and making knowledge produced accessible and translatable. Indeed, it has been argued that, for researchers, lived experience is a ‘source of empirical strength, innovation, and epistemic diversity’ not a liability or source of bias (Chatterjee et al. Reference Chatterjee, Schumer, Effinger, Jones, Vest, Cahill, Staglin and Nestler2025, p. 1).

Ireland has trailblazed recovery approach implementation with the establishment of the Health Service Executive Office of Mental Health Engagement and Recovery and two Irish colleagues, Michael Ryan and Catherine Brogan, have played leadership roles in the coproduction of the World Health Organization ‘Roadmap for integrating lived and living experience practitioners into policy, services and community’ (World Health Organization 2025).

However, these promising advances are not without their barriers and challenges. The lived experience workforce can struggle with role clarity, clinical team ‘readiness’, blurred professional boundaries and expectations, supervision structures, and career progression pathways (Mancini Reference Mancini2018). Qualitative data highlight the fight for parity of esteem between lived experience and clinical roles, especially regarding salaries, resources, job security, and what expertise is valued in the mental health system (Mirbahaeddin and Chreim Reference Mirbahaeddin and Chreim2022). Recently the concept of a ‘clinical ceiling’ has been introduced to the literature to illustrate how structural barriers can impede lived experience employees’ advancement, credibility, and epistemological authority (i.e. the power to determine what counts as legitimate knowledge) (Larsen et al. Reference Larsen, Roennfeldt, Carlon, Hodges and Byrne2025, p. e70159).

As lived experience employment becomes increasingly institutionalised and professionalised, it can be co-opted by mental health systems, to serve unintended functions that contradict its grassroots emancipatory, advocacy, and social justice intentions. For example, lived experience employees can encounter role dilution and professional assimilation (diminishing advocacy for structural change); occupy low-status roles with little decision-making power (reinforcing institutional norms, divisions, and exclusions); and inadvertently police behaviour rather than empower (e.g. by monitoring medication compliance) (Barrenger et al. Reference Barrenger, Stanhope and Atterbury2018; Beresford Reference Beresford2019; Sinclair et al. Reference Sinclair, Gillieatt, Fernandes and Mahboub2023).

Inadequate staffing, burnout, and compassion fatigue among clinicians can further hamper authentic human connection, causing psychological distancing and dehumanisation (Hoogendoorn and Rodríguez, Reference Hoogendoorn and Rodríguez2023). This can result in inauthentic, generic, or formulaic clinical encounters and impede informed decision-making and autonomy (Chatwiriyaphong et al. Reference Chatwiriyaphong, Moxham, Bosworth and Kinghorn2024; Diniz et al. Reference Diniz, Bernardes and Castro2019). Implementation is further hindered by an over-emphasis on risk management and clinician scepticism, resistance, and paternalism (Carroll and McSherry Reference Carroll and McSherry2021; Chatwiriyaphong et al. Reference Chatwiriyaphong, Moxham, Bosworth and Kinghorn2024). Poor political commitment, psychiatric stigma, and societal attitudes can also prevent lived experience-led innovations from being prioritised in health budgets (Mirbahaeddin and Chreim Reference Mirbahaeddin and Chreim2022). Clinicians have also reported confusion and uncertainty in how to operationalise the recovery approach (Rose Reference Rose2022).

In their recent meta-synthesis of mental health PPI implementation in universities, Evans et al. (Reference Evans, Lewin, Fabian, Alam, Calder, Hill, Khayri, Markham, Sweeney and Wykes2025) found evidence of extensive tokenism. The authors also identified low status of experiential knowledge, substantial power differentials, and resistance to change as barriers to genuine coproduction. There is also emerging evidence of representativeness and equity problems within mental health PPI Biddle et al. (Reference Biddle, Gibson and Evans2021) with often the most ‘recovered’, ‘acquiescent’, or ‘appropriate’ people being invited to contribute to research in the absence of true partnership or any change in decision-making power structures (Ocloo and Matthews Reference Ocloo and Matthews2016).

The mental health service reform agenda underpinning the recovery approach should be understood in the context of most clinicians and service managers being driven by humanitarian values, doing their best to deliver a biopsychosocial model of care and help people with limited resources. How mental health systems and societies move forward in this dialectic is what this IJPM Special Issue on the recovery approach is hoping to address.

The focus of this special issue on the recovery approach

We, the special issue’s Guest Editors, are humbled to have had the privilege of soliciting submissions for, and coordinating and contributing to the peer review process of, this timely and important body of work. The themed issue, which focuses on progress made, challenges faced, and future directions for the recovery approach in mental health contains scholarly work that helps answer the question: ‘How can mental health services best implement the recovery approach in the real world, with consideration given to addressing its deficits, and an emphasis on translating policy into practice?’

An overview of the special issue contributions

The issue opens with two important Invited Editorials. Lal offers a nuanced and extensive reflection on the suitability of recovery approach implementation in Child and Youth Mental Health Services. Hannigan and Coffey highlight how comprehending systems, having awareness of complexity, and accommodating competing understandings impact recovery oriented practice.

Numerous engaging and thought-provoking Perspective Piece articles appear next. Beresford, from a Mad Studies standpoint, highlights the continued need to evolve understandings of madness and distress and the ethical imperative of PPI in knowledge production. Jordan et al. consider ways post-traumatic growth following psychosis can be supported in the mental health system. Elwan offers a powerful lived experience account that challenges us to actualise holistic, empathetic, multifaceted mental health services rooted in cocreation. Watts reflects on his PhD research on, and his work with, the peer support organisation Grow Mental Health to make recommendations for mental health system change to enable re-enchantment with life. With an empowerment and social justice lens, Brisola et al. describe the successes and challenges of lived experience-led innovations and initiatives in the Brazilian psychiatric reform movement. Zierotin et al., utilising autoethnography, provide a unique perspective on the impact of antipsychotics on physical health, with implications for clinician education, care planning, and recovery approach implementation. Street-Mattox et al. outline their perspective on how mental health services can challenge public, institutional, and self-stigma to help people diagnosed with Borderline Personality Disorder engage in more compassionate acts (towards themselves and others). Rutledge offers a self-aware reflection, from the perspective of Consultant Psychiatrist, on the use of Open Dialogue (a novel therapeutic approach and way of organising care) in realising recovery focused services. Finally, Gibbons describes the 9-step Collaborative Care Pathway (CCP-9) and considers the factors that impact its sustainability. This is a recovery oriented approach to mental health assessment, case formulation, and care planning.

Following this, a number of Original Research papers are included. O’Keeffe et al. present data on how meaning making in psychotic experiences influences Meaning in Life and recommend how services can address the existential deficit that may be left by psychosis treatment. Eiroa-Orosa et al. offer a nuanced qualitative analysis, of clinician focus group interviews, that identifies barriers to people with lived experience exercising their rights in mental health services. Villani et al. provide an in-depth exploration of Irish Traveller needs from a culturally appropriate recovery oriented mental health service; recommending intersectoral action to address mental health social determinants. Koretsidou et al. examine the barriers to, and facilitators of, implementing the recovery approach in therapeutic farm settings to inform service design at Kyrie Therapeutic Farm. Norton et al., using autoethnography and an online focus group, explore the role and impact of the Recovery Experience Forum of Carers and Users of Services in the College of Psychiatrists of Ireland. Geary et al., in light of the recovery approach emphasis on removing barriers to service access, examine how clinicians, from different disciplines, across settings, experience interpreters in mental health assessment. Lastly, Keogh et al. evaluate service user, family member, supporter, and clinician satisfaction with the operation of the CCP-9 using surveys.

After this, several Reviews are included. Eiroa-Orosa and Ball report on a qualitative meta-synthesis of service user and clinician understandings of citizenship in mental health. Norton documents a scoping review on the concept of coproduction in mental health service provision. Completing this section, Norton et al. detail the findings of a rapid scoping review on the definition, implementation, and experience of peer support work in mental health.

The Special Issue ends with Letters to the Editor. Swords and Norton argue for the need to reframe psychological distress as the responsibility of social institutions and society and not just of the service user and frontline clinician. Finally, Norton contends that the Interest Checklist UK can be used in the Peer Support Worker-service user relationship to foster informality, explore interests, and create ideas for connection.