A conceptual framework for personal recovery in mental health

Mary LeamyProgramme Co-ordinator, REFOCUS study,

Institute of Psychiatry, King’s College, London

on behalf of REFOCUS teamVictoria Bird, Clair le Boutillier, Julie Williams and Mike Slade

Overview

1. What is personal recovery and why is a conceptual framework needed?

2. Systematic review and narrative synthesis

4. Conceptual framework of personal recovery

5. What next for REFOCUS study?

What is personal recovery?• A deeply personal, unique process of changing one’s

attitudes, values, feelings, goals, skills and roles. It is a way of living a satisfying, hopeful and contributing life even with limitations caused by the illness.

• Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.

• Anthony WA (1993) Recovery from mental illness: • the guiding vision of the mental health service system in the 1990s,

• Psychosocial Rehabilitation Journal, 16, 11-23.

•A recovery orientation is mental health policy in most English speaking countries.

• The Mental health plan for England 2010-2019 “expectation that services to treat and care for people with mental health problems will be…based on the best available evidence and focused on recovery, as defined in

discussion with the service user”, (New Horizons)

Rationale

Key knowledge gaps have been identified: • Need for conceptual clarity about the underpinning philosophy of recovery • Better understanding of the stages and processes of recovery • Valid measurement tools • Current approaches based on qualitative research or consensus methods, no systematic review has been undertaken • Need a conceptual framework to provide an empirical basis for recovery-oriented research and practice.

Systematic review

Aim: to undertake a systematic review and narrative synthesis of the available literature on recovery, so as to develop a conceptual framework for recovery

Eligibility: •Identify papers explicitly described or developed a conceptualisation of personal recovery from mental illness.

•Visual or narrative model of recovery, or themes of recovery which emerged from synthesis of review papers or analysis of primary data.

Inclusion criteria(i) contains a conceptualisation of personal recovery

from which a succinct summary could be extracted;

(ii) presented an original model or framework of recovery;

(iii) was based on either secondary research synthesising the available literature or primary research involving quantitative or qualitative data based on at least three participants;

(iv) was available in printed or downloadable form; and

(v) was available in English.

Exclusion criteria(a) studies solely focussing upon clinical

recovery;

(b) studies involving modelling of predictors of clinical recovery;

(c) studies defining remission criteria or recovery from substance misuse, addiction or eating disorders; and

(d) dissertations and doctoral theses

Data searching, abstraction and quality assessment

12 bibliographic databases + web-based and hand searching

5208 papers identified

819 papers abstracts reviewed

376 full papers retrieved

97 papers included

Papers quality rated

Data extraction and Quality assessment

• Random sub-sample of 88 retrieved papers independently rated against eligibility criteria by 2nd rater (91% agreement concordance)

• RATS scale used to assess qualitative papers; sub-sample of 10 papers independently rated (acceptable concordence, mean scores 1st rater = 14.8; 2nd rater = 15.1)

Data analysis

A modified narrative synthesis approach was used (Popay et al. 2006)

• Develop a preliminary synthesis

• Explore relationships within and between studies

• Assess the robustness of the synthesis

Developing a preliminary synthesis

• Tabulation of all papers

• Thematic analysis of review papers and highest quality, primary qualitative data studies

• Vote counting of recovery themes

Exploring relationships within and between studies

• Sub-group comparison – studies which focussed upon a population of

people from predominantly Black and Minority Ethnic backgrounds thematically analysed and findings compared to themes within preliminary conceptual framework

Assessing the robustness of the synthesis

• Moderately rated qualitative papers thematically analysed until category saturation was achieved

• An expert panel asked to comment upon the extent to which the preliminary conceptual framework adequately captures the construct of personal recovery

Findings

• Characteristics of Recovery journey comprised 13 dimensions

• Recovery processes comprised 5 higher order categories

– Connectedness

– Hope and optimism about the future

– Identity

– Meaning in life

– Empowerment

• Stages of recovery were varyingly described, but can be mapped on to the Transtheoretical Model of Change

Characteristics of recovery journeyCharacteristics of recovery journey N (%) of 87 studies identifying dimension

Individual and unique process 25 (26%)Non-linear process 21 (22%)Recovery as a journey 17 (18%)Recovery as active process 44 (50%)Recovery as stages or phases 15 (17%)Recovery as a struggle 14 (16%)Recovery as gradual process 13 (15%)Multi-dimensional process 13 (13%)Recovery is life-changing experience 11 (13%)Recovery without cure 9 (9%)Recovery can occur without professional intervention 6 (7%)Trial and error process 6 (7%)Recovery aided by a supportive and healing environment 6 (7%)

Connectedness

Identity

Meaning and

purposeEmpowerment

Hope and Optimism

Personal Recovery

Dreams and Aspirations

Belief in Recovery

Individuality

Positive Self Identity

Control over Life

Personal Responsibility

Focussing on Strengths

Spirituality

Quality of Life

Meaning of Mental Illness Experiences

Rebuilding of Life

Rebuilding Identity

RelationshipsPeer

Support

Support from Others

Being Part of the Community

Motivation

Positive Thinking

Implications• Scientific implications

– Coding framework provides key-words for undertaking secondary research, provides taxonomy for reviews

– Characteristics of recovery journey - helpful yardstick to measure success in not co-opting personal recovery into mental health system view of world

– Recovery processes – when viewed as targets for interventions, highlights need for extended evidence base

Limitations

• Tends to over-emphasis individual rather than environmental factors in recovery

• Not a rigid or prescriptive model of what recovery is, but pragmatic, organising framework Personal Recovery

• Encompasses many multi-dimensional, inter-related, overlapping concepts which cannot easily be separated, so any attempt to reduce this complexity best considered as offering only one of many possible interpretations and synthesises

• Should not be regarded as the definitive version

Thank youAny questions?

mary.leamy@kcl.ac.uk

Further information: Leamy et al. A conceptual framework for personal recovery in mental health: systematic review and narrative synthesis, British Journal of Psychiatry.

(accepted on 18.8.10)