A conceptual framework for personal recovery in mental health

1. A conceptual framework for personal recovery in mental health Mary Leamy Programme Co-ordinator, REFOCUS study, Institute of Psychiatry, King’s College, London on behalf of REFOCUS team Victoria Bird, Clair le Boutillier, Julie Williams and Mike Slade

2. 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?

3. 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.

4. 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)

5. 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.

6. 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. Systematic review

7. Inclusion criteria • contains a conceptualisation of personal recovery from which a succinct summary could be extracted; • presented an original model or framework of recovery; • was based on either secondary research synthesising the available literature or primary research involving quantitative or qualitative data based on at least three participants; • was available in printed or downloadable form; and • was available in English.

8. 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

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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

16. Characteristics of recovery journey

17. Being Part of the Community Support from Others Peer Support Relationships Motivation Rebuilding Identity Positive Thinking Rebuilding of Life Personal Responsibility Quality of Life Control over Life Meaning of Mental Illness Experiences Spirituality Focussing on Strengths

18. 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

19. 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

20. Thank you Any 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)