Brief Report

Promoting recovery: service user and staffperceptions of resilience provided by a new Early

Intervention in Psychosis serviceeip_151 89..92

Adrian Morton, Alicia Fairhurst and Rebecca Ryan

Early Intervention in Psychosis service,Runwell Hospital, Wickford, Essex, UK

Corresponding author: Dr Adrian Morton,Early Intervention in Psychosis service,Runwell Hospital, Wickford, Essex, SS117XX, UK. Email:adrian.morton@southessex-trust.nhs.uk

Received 29 April 2008; accepted 7September 2009

Abstract

Aim: The principles and practice ofrecovery are guiding many changes inmental health service provision. As anew Early Intervention in Psychosis(EIP) service, we were interested infinding out if both staff and usersperceive the service as promotingresilience and in turn, recovery.

Methods: A naturalistic sample ofservice users and staff completed theOrganizational Climate questionnaireto assess the degree to which theservice promotes resilience in over-coming a first episode psychosis.

Results: The results indicated thatboth staff and service users similarlyperceive the service as positively sup-porting resilience. The one exceptionwas the staff rated the ‘availableresources to meet people’s needs’ asless than service users.

Conclusions: The positive rating ofresilience indicated that the service isworking in a manner consistent with arecovery orientation. The results willact as a benchmark to compare withboth other EIP services and futureperformance.

Key words: early intervention, psychosis, recovery, service user.

INTRODUCTION

The philosophy of recovery embodies both hopeand the expectation that people grow beyond theimpact of psychosis and similar threats to mentalhealth and well-being. In the UK, much of this phi-losophy of recovery has been incorporated into theNational Service Framework for Mental Health andthe National Health Service (NHS) Plan.1,2 Thesepolicies have initiated the development of EarlyIntervention in Psychosis (EIP) services to cover thewhole UK population. The international Early Psy-chosis Declaration3 places recovery as central to thisservice model and highlights the importance of EIPteams in promoting resilience and hope. The atti-tude of staff should be that following a first episodepsychosis, the person will recover to lead a mean-

ingful and productive life similar to one’s peers, andthese expectations are in turn communicated toservice users.4

From policy to practice

There are few studies examining differences in per-ception between staff and service users and evenless, also considering aspects of recovery. One studyreported that care coordinators identified signifi-cantly more personal deficits acting as barriers andfewer environmental factors when compared withservice users. For example, a care coordinator mayperceive the service user to be poorly motivated towork in contrast to the service user who thinks thatthere are no suitable employment opportunitiesand/or no one who would employ them.5 Additionalstudies examining these differences in perceptionhave identified differences in ratings of fidelity torecovery principles, collaboration in relation totreatment plans, treatment goals and preferences

All authors were part of the service when this survey was carriedout.

Early Intervention in Psychiatry 2010; 4: 89–92 doi:10.1111/j.1751-7893.2009.00151.x

© 2010 Blackwell Publishing Asia Pty Ltd 89

for support. For example, service users and carecoordinators can measure symptom improvementin different ways.6,7

Typically, these studies find significant differencesin perception between staff and service users whenrating aspects of recovery, with staff rating theirfidelity to recovery principles higher than ratingsfrom service users.

Measuring recovery

There are few validated measures of recovery andno consensus as to the ‘gold standard’ or mosteffective instrument,8 which is not surprising giventhe multiplicity of meanings implicit in the termrecovery. For example, recovery may refer to psy-chiatric symptoms, social or psychological recov-ery, and the term is used in a variety of settings,such as drug and alcohol, mental health and theuser movement, each with their own specificemphasis and meanings. Nonetheless, it ispossible to identify the principles of recovery andmeasure orientation of a service towards theseprinciples.

The Developing Recovery Enhancing Environ-ments Measure (DREEM) has been developedthrough the use of first person accounts and associ-ated descriptions of the components of the servicethat supported them, supplemented with a reviewof the literature and practices that appear topromote recovery.9 It is designed to be used bymental health services to measure their commit-ment to, and effectiveness in, providing recovery-based care.

The DREEM questionnaire is composed of sevencomponents: (i) demographic data; (ii) stage ofrecovery for the individual; (iii) elements of recoveryservices; (iv) specific needs of the individual; (v)organizational climate; (vi) recovery markers; and(vii) a qualitative component. This entire measurehas been edited and adapted for use in the UK byPiers Allot, recovery fellow for the National Institutefor Mental Health in England (NIMHE) to becomeone of the more familiar and recommended mea-sures in the UK.10

DREEM has many components, and asa new and developing EIP service, we wereinterested in evaluating the degree to whichthe service promoted resilience and in turn,recovery. The organizational climate componentof DREEM has been developed to measure thisand can be completed by staff and service usersto find out if there are any differences inperception.

METHODS

Study site

The EIP service has been operational since January2005 and covers an area with a population of715 000 people across South Essex, a region identi-fied by the government as a priority for regenerationand growth. The service has been established inaccordance with government policy, and providesan intensive, specialized 3-year service to 14- to35-year-olds with first episode psychosis.11

Sample

A total of seven staff, six female and one male, metthe inclusion criteria of at least 6 months workingwithin the EIP service. A total of 28 service users metthe service criteria for first episode psychosis, hadmore than 6 months experience of receiving theservice, averaged a minimum of weekly contact andwere in recovery, defined as at least 3 months froman acute episode. A sample of 20 service users com-pleted the questionnaire from a total of 28 who wereeligible at the time the study was undertaken. All ofthe participants lived in community settings.

Measure

DREEM was recommended by the NIMHE, and theOrganizational Climate questionnaire componentis brief and easy to complete and allows for com-parisons between staff’s and the service users’ per-ceptions. The questionnaire contains 14 items thatexamine significant aspects of the health-care socialenvironment, which promote resilience and in turnrecovery. Resilience is defined as the ability to dealwith adversity and in this context, relates to the typeof health care provided after an acute first episode ofpsychosis.

DREEM has good face validity, being based onfirst-person accounts, and in field tests examiningreliability, the Organizational Climate questionnaireachieved a good estimate for internal consistency(Cronbach’s alpha 0.97).9

RESULTS

The responses of both staff and service users to theOrganizational Climate questionnaire are presentedin Figure 1. The participants rated each of the 14items on a five-point Likert-type scale ranging from‘strongly agree’ (coded as 5) to ‘strongly disagree’(coded as 1). Values over 3 represent a positive rating

Promoting recovery

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of the service. The total mean score for the staff is3.96 and is very similar to the mean score of 4.02 ofthe service users. The correlation, using Spearman’srank order correlation coefficient, between thestaff and the service users as a whole was found tobe r = 0.83, n = 12, P � 0.01, indicating a strongpositive agreement that the service promotedresilience.

Only in response to the item, ‘the service hasenough resources to meet people’s needs’ was therea significant difference between the staff and theservice users (Mann–Whitney U = 25.500, N1 = 20,N2 = 17, P � 0.05). The staff reported significantlyless agreement with this item when compared withthe service users.

Of the eight non-participants, five declined totake part in the study, one had moved out of thearea, one was no longer in contact and one was intelephone contact only during the 4-month dura-tion of the survey. No significant differencesappeared between the service user participants andthe non-participants in relation to gender (ninefemales and 11 males participated, and two femalesand six males did not) or age (mean age of the par-ticipants: 21.3 years, standard deviation (SD) = 2.3;range = 19–27, non-participants 20.8 years, SD =2.7; range 17–25). Both the participants and thenon-participants had a mean engagement with theservice of 11.6 months.

DISCUSSION

This study found good positive results reported byboth the staff and the service users alike to each

item, with the exception of the staff ratingof EIP service resources. Similarly, a strong positiveagreement exists between the staff and theservice users in rating the degree to which theEIP service promotes resilience. The responses ofthe service users to each item are largely consistentand do not demonstrate a wide variation, suggest-ing they are generally positive about how the EIPservice promotes resilience. However, the lowestresponse was in connection with the item, ‘theservice provides real choices, desirable outcomesand opportunities’, which gives the service anindication of how it might improve on recoveryorientation.

The only significant difference between the twogroups was the response to the item, ‘the service hasenough resources to meet people’s needs’, whichthe staff rated lower than the service users. It is dif-ficult from such a general question to know pre-cisely what resources the staff are appraising.Subsequent discussions with the staff suggestedthat this low, negative rating relates to: the ability toprovide high intensity support (over two visits aday), access to social workers and occupationaltherapists, and access to medical colleagues at atime of crisis. On the basis of this anecdotal evi-dence, it appears that the lack of resources relatesprimarily to staffing levels and skill mix.

Previous published work has highlighted differ-ences in perception of recovery orientation betweenservice users and care coordinators as service userstend to be less positive in their ratings.5–7 No suchdifference was found in this study because theresponses were broadly similar, and in fact, theopposite was found in relation to the ‘resource’

FIGURE 1. Organizational Climate ques-tionnaire: mean and �1 standard error(SE) of the mean for each question item.

A. Morton et al.

© 2010 Blackwell Publishing Asia Pty Ltd 91

question as the staff rated this as significantly lower.However, it is difficult to know if this is a real varia-tion or merely an artefact because of the differencesin methodology and the questionnaire employed.For example, different questionnaires are likely tovary in their sensitivity to detecting differences inperceptions between staff and service users. Fewstudies compare service user perceptions with thoseof service providers, and published work using theOrganizational Climate questionnaire is limited aseven a recent study using DREEM excluded thequestionnaire.12

Although the results suggest that service usersperceive the service as engendering resilience andin turn, promoting recovery, it is important not to becomplacent as there are limitations and biases thatmay unduly influence these findings. Not least, thereliability and validity of the Organizational Climatequestionnaire is yet to be adequately demonstrated.In addition, the small sample sizes of this study, acommon feature of the literature comparing staffand service user’s perceptions and recovery orien-tation, are problematic. The service user sample inthis study (n = 20) provides a good representationfrom the total population who were eligible at thetime (n = 28). However, the small population sizeand in turn, smaller sample limit the generalizationof the findings to other EIP services.

Although a high proportion of both eligible staffand service users participated in the study, there areproblems with bias affecting the selection of theparticipants. Care coordinators identified serviceusers for inclusion in this survey and may well havechosen those who were more positively engagedwith them and arguably more likely to provide posi-tive ratings of recovery orientation. In addition,there were service users who were difficult to engagewith, with whom there was little contact and whodid not fulfil the inclusion criteria for this survey. Itis possible that these people may have less positiveviews about the recovery orientation of the service.

This survey has examined how a new and devel-oping EIP team and their users rate the capacity ofthe service to promote resilience after a first episodepsychosis. The results indicate the provision of anEIP service that positively promotes resilience afteran acute first psychotic episode. It suggests that staffmembers understand the philosophy of recovery

and are perceived by service users as working withinthis orientation. However, the small number ofservice users who met the inclusion criteria at thetime the study was conducted and consequentialsmaller sample, together with the limited psycho-metric properties of the measure used, ensures thatsuch conclusions are at best, tentative.

ACKNOWLEDGEMENTS

We would like to thank the staff for their participa-tion, distribution and collection of questionnaires,and the service users for their participation. We aregrateful to Ms Sophie Holmes for her helpful com-ments on the earlier drafts of this manuscript.

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