Over at the Mental Elf, the bloggers have done a fair amount of thinking about recovery, ranging from service user to staff concepts. A recent blog by fellow elf John Baker on a study trialling mental health recovery training for staff came up with some disappointing findings although it indicated that some interventions could help change staff recovery-oriented behaviours.
This systematic review study also looks more broadly at what influences recovery for people who have a diagnosis of schizophrenia, particularly psychosocial and environmental factors. The authors note that their objective was to
Conduct a systematic review and thematic analysis and identify factors which influence recovery
All major electronic databases were searched from inception date until February 2014 using key search terms associated with recovery and schizophrenia. Grey literature was searched and hand searching was also employed.
Studies were screened and selected using SPIDER (sample, phenomenon of interest, design, evaluation, result type) and PICOs (patients, interventions, comparator, outcomes, study design) criteria. Articles were excluded if they did not include psychosocial factors relating to recovery. A total of 139 records were screened and 20 articles were finally included for review.
The included studies were critically appraised using Consolidated Criteria for Reporting Qualitative Studies (COREQ). They were then thematically analysed using a three-stage thematic synthesis approach.
Factors that promote and factors that challenge recovery were derived from the thematic analysis.
Factors that promote recovery included
- Adjustment coping and reappraisal: accepting the illness is real and has happened; time to understand what has happened and who they now are; accounting for medication effects; references to past self and strengths; managing appearance; being hopeful and desiring change.
- Responding to the illness: role of medication; responsibility for health habits; role of occupation and distraction in managing symptoms.
- Social support, close relationships and belonging: value of friends and peers; family support; role of faith and community.
In addition, there were three key aspects of good support
- Accessing people who can listen, accept, value and understand
- Restoration of trust in relationships and improved honesty
- Reciprocity and caring for others
Factors that challenge recovery included
- Negative interactions and isolation: substance use; stigmatizing experiences; social isolation and disconnection from supportive relationships
- Internal barriers: lack of social confidence
- Uncertainty and hopelessness: fear and management of relapse; no hope that anything positive can come from illness; impact of symptoms on everyday life and relationships.
The authors conclude that mental health practitioners will
Benefit from a greater understanding of the psychosocial factors which influence recovery for individuals for schizophrenia
Strengths and limitations
This study uses a systematic review methodology. This is meticulously reported in a way that makes the process transparent. It is clear that the search for literature extended beyond that available through traditional electronic databases. The inclusion of a ‘PRISMA’ diagram to illustrate the selection and inclusion process is particularly helpful. Researchers used established tools to assess and appraise the studies, an approach which inspires further confidence in the study reliability.
I was left with a question concerning the relationship of traditional mental health service use to stigma and how stigma relates to help-seeking behaviour. I wrote a blog about another systematic review concerning this topic a while ago and wondered how the findings on stigma might relate to the psychosocial factors identified for recovery in this study.
Finally, user research on recovery (again, blogged about by yours truly here) shows that people from black and minority ethnic backgrounds may have particular psychosocial concepts of and contributions to their own recovery that can be overlooked by practitioners. It would have been very useful to identify any particular issues for black and minority ethnic communities (and indeed other people with protected characteristics under the Equality Act 2010) in this systematic review.
The authors emphasise the central importance of identity and recognizing the psychosocial factors that facilitate recovery in people with a diagnosis of schizophrenia.
This study provides a comprehensive, robust evidence base for both policy and practice, again identifying the fundamental psychosocial factors that are can be sidelined in mental health practice dominated by clinical and biomedical approaches to treatment. While medication and traditional treatment is recognized having a contribution to recovery, its side effects also need to be considered. Psychosocial factors such as identity, activity, relationships and belonging are found to be equally important. This type of evidence demonstrates the continued need for social work and broader social approaches in mental health.
As the NHS England Mental Health Task Force work on the Five Year Strategy for Mental Health (NHS England, 2015), they should to use this type of reliable research evidence to inform their plans and decisions on recovery for those with complex and long term conditions such as schizophrenia. This means focusing on and investing in highly personalised, psychosocial support as well as traditional clinical or service-centred approaches.
NHS England (2015) Terms of Reference: Mental Health Taskforce – A Five Year Strategy for Mental Health London: NHS England [Full Text]