In the UK, mental health services are increasingly becoming focussed on the promotion of ‘recovery’. This position was reinforced by the 2011 Department of Health position statement: No Health without Mental Health which defines ‘recovery’ as being the business of all mental health services and providers.

However, the concept of recovery is complex and not easily defined; with the most commonly used description being made by Anthony in the 1990s:

a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. (Anthony 1993)

This is a controversial description; making a number of assumptions regarding the experience of ‘mental illness’, and is in potential opposition to many of the key factors of ‘personal experience’ and ‘empowerment’ often espoused in describing the recovery process.

Exploration of understanding of the concept of recovery is therefore essential from both professional and service user perspectives; making a recent review from Le Boutillier and colleagues particularly timely.

In their review the authors look to:

…conduct a systematic review and narrative synthesis of primary research investigating how clinicians and managers understand recovery orientated practice in mental health services.

With the specific review question:

How do clinicians and managers understand the concept of recovery as applied to their practice?

Methods

• A systematic search strategy was used to identify studies in which the understanding of staff (paid and unpaid) in relation to recovery in mental health was explored.
• Studies were excluded if they focussed on specialist care settings (e.g. substance misuse and eating disorder)
• The search strategy was developed iteratively in order to balance ‘sensitivity’ and ‘specificity’ with six pre-identified ‘marker studies’ being used to ensure sensitivity.
• Identified studies were subjected to a narrative analysis approach.

Results

The initial search strategy generated 18,244 hits. An additional 28 papers were identified through non-systematic methods (reference list searching, expert consultation etc).

After application of inclusion/exclusion criteria a total of 22 studies were identified for analysis.

Thematic analysis within the narrative synthesis process produced three overarching descriptive headings that indicated a degree of confusion from staff regarding their role perception:

Clinical recovery

• This theme equated recovery with clinical understanding in terms of symptom remission, insight, absence of relapse and mastery of daily living skills. Definitions within this heading were very focussed on clinician based understandings of recovery.

Personal recovery

• This theme constructed recovery as an holistic approach; sensitive to considerations of individuality and ideas of partnership working between professionals and service users.

Service defined recovery

• This final theme presented recovery as a concept defined by organisations with administrative, primarily financial goals shaping the delivery of care and being measured through targets such as admission and discharge rates.

These three themes were not mutually exclusive with a degree of overlap of understanding between them.

Conclusion

The authors concluded:

Organisational 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.

Discussion

Division in staff understanding between clinical versus personal recovery constructs is perhaps unsurprising, representing a well rehearsed argument within the academic literature.

The novel finding from this review however is the emergence of an institutionally defined concept of recovery: Defined not by professionals or users but by bureaucratic, and primarily economic, forces. Such a finding should not be considered too surprising given recent political rhetoric regarding care costs and the global economic climate. The experience of mental distress will always be intimately connected with social forces and institutions and it should be expected that ultimately recovery will also reflect this social influence (see Davidson, 2008).

Arguments regarding the development of mental health services on an economic basis are not novel (Layard, 2006). However, a critical and cautionary note is surely necessary? We must take care regarding the implications of such decision making. Research or exploration of the phenomena is clearly indicated to allow further description and discussion.

Links

Primary paper

Le Boutillier C, Chevalier A, Lawrence V, Leamy M, Bird VJ, Macpherson R. et al (2015) Staff understanding of recovery-orientated mental health practice: a systematic review and narrative synthesis. Implementation Science, 10(1), 445–458. [Open Access]

Other references

No Health without Mental Health (PDF). Department of Health, 2011.

Anthony WA. (1993) Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16, 521–538. [Abstract]

Davidson L. (2008) ‘Recovery’ as a response to oppressive social structures. Chronic Illness, 4(4), 305–306. [PubMed abstract]

Layard R, Clark D, Bell S, Knapp M, Meacher B, Priebe S, Turnberg L, Thornicroft G, Wright B. (2006) The depression report; A new deal for depression and anxiety disorders (PDF). The Centre for Economic Performance’s Mental Health Policy Group, LSE.