Fostering Recovery from Life-Transforming Mental Health Disorders: A Synthesis and Model

Practitioner Review: It's time to bridge the gap - understanding the unmet needs of consumers with attention-deficit/hyperactivity disorder - a systematic review and recommendations

OBJECTIVE

Understanding the unmet needs of healthcare consumers with attention-deficit/hyperactivity disorder (ADHD) (individuals with ADHD and their caregivers) provides critical insight into gaps in services, education and research that require focus and funding to improve outcomes. This review examines the unmet needs of ADHD consumers from a consumer perspective.

METHODS

A standardised search protocol identified peer-reviewed studies published between December 2011 and December 2021 focusing on consumer-identified needs relating to ADHD clinical care or research priorities.

RESULTS

1,624 articles were screened with 23 studies that reviewed examining the needs of ADHD consumers from Europe, the U.K., Hong Kong, Iran, Australia, the U.S.A. and Canada. Consumer-identified needs related to: treatment that goes beyond medication (12 studies); improved ADHD-related education/training (17 studies); improved access to clinical services, carer support and financial assistance (14 studies); school accommodations/support (6 studies); and ongoing treatment efficacy research (1 study).

CONCLUSION

ADHD consumers have substantial unmet needs in clinical, psychosocial and research contexts. Recommendations to address these needs include: improving access to and quality of multimodal care provision; incorporating recovery principles into care provision; fostering ADHD health literacy; and increasing consumer participation in research, service development and ADHD-related training/education.

Cardiac disease in pregnancy and the first year postpartum: a story of mental health, identity and connection

Background

Women with cardiac disease in pregnancy and the first year postpartum often face uncertainty about their condition and the trajectory of their recovery. Cardiac disease is a leading cause of serious maternal morbidity and mortality, and the prevalence is increasing. Affected women are at risk of worsening cardiac disease, chronic illness, mental illness and trauma. This compounded risk may lead to significant and long-term negative outcomes. The aim of this study is to correct the lack of visibility and information on the experiences of women with cardiac disease in pregnancy and the first year postpartum.

Methods

A qualitative study using in-depth semi-structured interviews with twenty-five women who had acquired, congenital or genetic cardiac disease during pregnancy or the first year postpartum. Data were analysed and interpreted using a thematic analysis framework.

Results

Analysis of the interviews produced three major themes: 1) Ground zero: index events and their emotional and psychological impact, 2) Self-perception, identity and worthiness, and 3) On the road alone; isolation and connection. There was a narrative consistency across the interviews despite the women being diverse in age, cardiac diagnosis and cardiac health status, parity and timing of diagnosis. The thread prevailing over the temporal and clinical differences was one of distress, biographical disruption, identity, isolation, a necessitated re-imagining of their lives, and the process of multi-layered healing.

Conclusion

Acknowledging and understanding the breadth, complexity and depth of women’s experiences is fundamental to improving outcomes. Our findings provide unique insights into women’s experiences and challenges across a spectrum of diseases. Most women did not report an isolated trauma or distressing event, rather there was a layering and persistence of psychological distress necessitating enhanced assessment, management and continuity of care beyond the routine 6-week postpartum check. Further research is required to understand long-term outcomes and to refine the findings for specific disease cohorts to be able to respond effectively.

A Complexity Perspective on Narrative Identity Reconstruction in Mental Health Recovery

The issue of complex nonlinear change processes is one of the least understood aspects of recovery and one of the most difficult to apply in recovery-oriented health care. The purpose of this article is to explore the recovery stories of 17 mental health peer support workers to understand their narrative identity reconstruction in recovery using a complexity perspective. Using the Life Story Model of Identity (LSMI), a narrative thematic analysis of interviews suggests that self-mastery as part of personal agency is an important component of participants' narrative identity reconstruction. Self-mastery is particularly evident in redemptive story turning points (positive outcome follows negative experience). A complexity perspective suggests that participants realized their adaptive capacity in relation to self-mastery as part of recovery and that its use at story turning points critically influenced their recovery journey. Further exploring self-mastery as adaptive growth in narrative identity reconstruction appears to be a fruitful research direction.

Patient perspectives on how living with a mental illness affects making and maintaining healthy lifestyle changes

OBJECTIVE

To understand the ways that mental health symptoms interfere with achieving health goals.

METHODS

Individuals with mental illness diagnoses and varying levels of preventive service use were recruited from federally qualified health centers and an integrated health care delivery system and interviewed. Thematic analysis was used to characterize descriptions of how mental illness experiences influenced lifestyle change efforts.

RESULTS

Three themes described patients' (n = 163) perspectives on barriers to making healthy lifestyle changes: 1) Thinking about making lifestyle changes is overwhelming for individuals already managing the burdens of mental illnesses; 2) Depression makes it difficult to care about a healthy future; and 3) When mental illness symptoms are not adequately treated unhealthy behaviors that provide relief are unlikely to be discontinued. Participants also made suggestions for improving health care delivery to facilitate positive behavior change.

CONCLUSION

Patients with mental illnesses need their clinicians to be empathic, help them envision a healthier future, address unmet mental health needs, and provide resources.

PRACTICE IMPLICATIONS

Primary care clinicians should encourage their patients with mental illnesses to make healthy lifestyle changes within the context of a supportive relationship. Lifestyle change can be overwhelming; clinicians should acknowledge progress and provide ongoing tangible support.

Development and validation of a scale for self-efficacy for personal recovery in persisting mental illness

The personal recovery movement in mental health has emphasised consumers' individual responsibility and autonomy in defining and directing their own recovery journey. Self-efficacy, or an individual's belief that they can achieve their desired outcomes, is likely to be a key predictor of recovery success. However, there is no established measure of self-efficacy for personal recovery. The Self-Efficacy for Personal Recovery Scale was developed and its psychometric properties evaluated as part of a broader research program investigating a recovery-focused digital intervention in psychosis. Scale reliability and validity were investigated in a sample of 178 adults with persisting psychosis, and test-retest reliability was evaluated in a subset of 32 participants. The scale showed high internal consistency, test-retest reliability, and convergent validity, including correlating positively with hope, personal recovery, and generalised self-efficacy, whilst showing independence from social desirability, insight, and positive symptoms. This measure may be useful for research into the processes underlying recovery, and for understanding how self-efficacy for personal recovery may be enhanced in people with severe mental illness.

Getting by, getting back, and getting on: Matching mental health services to consumers' recovery goals

OBJECTIVE

The goal of this study was to better understand mental health recovery from the point of view of mental health consumers to identify opportunities for practice improvements that closely align services with consumer goals and consumer-preferred outcomes.

METHOD

As part of an exploratory study of recovery, semistructured interviews were conducted with 177 integrated health plan members diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, or affective psychosis. Transcripts of in-depth interviews were coded using Atlas.ti, and definitions of recovery were further subcoded. A qualitative analysis using a modified grounded theory approach and constant comparative method identified common themes and less common but potentially important recovery-related experiences and perspectives.

RESULTS

Three primary and 2 cross-cutting themes emerged. "Getting by" meant coping and meeting basic needs. "Getting back" meant learning to live with mental illness. "Getting on" meant living a life where mental illness was no longer prominent. Regaining control and recouping losses were cross-cutting themes.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Mental health recovery is complex and dynamic; individuals' recovery goals can be expected to change over time. Person-centered care must accommodate changing consumer priorities, services must be flexible and responsive, and outcomes need to match consumers' objectives. Clinicians can assist in (a) identifying recovery goals, (b) monitoring progress toward and recognizing movement away from goals, (c) tailoring support to different phases/stages, and (d) supporting transitions between phases/stages. (PsycINFO Database Record

Re: Mental health rehabilitation in therapeutic jurisprudence: Theoretical improvements

Legal scholarship relevant to criminal court mental health initiatives that divert people with mental illness from prosecution to treatment has created the concept of therapeutic jurisprudence (TJ), an approach that seeks to maximize the law's potential for therapeutic outcomes. Despite recognition that TJ includes a rehabilitative response as a key animating principle and that it advocates for interdisciplinary synthesis, TJ has developed mainly from within the practice and discipline of law and without reference to the discipline of rehabilitation science, in which approaches to mental health rehabilitation (MHR) have witnessed significant developments in recent decades. In particular, concepts of MHR have shifted from a biomedical focus to a psychosocial approach, such as the recovery model, that incorporates values of self-determination, independence, and empowerment. It is argued that greater consideration of MHR will improve the theoretical validity of TJ by 1) helping define what 'therapeutic' means; 2) constructing a normative framework; and 3) broadening the scope of TJ as an interdisciplinary approach. More research is needed to ensure concepts from MHR rehabilitation science are considered in TJ legal scholarship and criminal court mental health initiatives.

The impact of adverse child and adult experiences on recovery from serious mental illness

OBJECTIVE

The purpose of this study was to compare effects of adverse childhood experiences and adverse adult experiences on recovery from serious mental illnesses.

METHODS

As part of a mixed-methods study of recovery from serious mental illnesses, we interviewed and administered questionnaires to 177 members of a not-for-profit health plan over a 2-year period. Participants had a diagnosis of bipolar disorder, affective psychosis, schizophrenia, or schizoaffective disorder. Data for analyses came from standardized self-reported measures; outcomes included recovery, functioning, quality of life, and psychiatric symptoms. Adverse events in childhood and adulthood were evaluated as predictors.

RESULTS

Child and adult exposures to adverse experiences were high, at 91% and 82%, respectively. Cumulative lifetime exposure to adverse experiences (childhood plus adult experiences) was 94%. In linear regression analyses, adverse adult experiences were more important predictors of outcomes than adverse childhood experiences. Adult experiences were associated with lower recovery scores, quality of life, mental and physical functioning and social functioning and greater psychiatric symptoms. Emotional neglect in adulthood was associated with lower recovery scores.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Early and repeated exposure to adverse events was common in this sample of people with serious mental illnesses. Adverse adult experiences were stronger predictors of worse functioning and lower recovery levels than were childhood experiences. Focusing clinical attention on adult experiences of adverse or traumatic events may result in greater benefit than focusing on childhood experiences alone.

Dual recovery among people with serious mental illnesses and substance problems: a qualitative analysis

OBJECTIVE

Individuals with serious mental illnesses are more likely to have substance-related problems than those without mental health problems. They also face more difficult recovery trajectories as they cope with dual disorders. Nevertheless, little is known about individuals' perspectives regarding their dual recovery experiences.

METHODS

This qualitative analysis was conducted as part of an exploratory mixed-methods study of mental health recovery. Members of Kaiser Permanente Northwest (a group-model, not-for-profit, integrated health plan) who had serious mental illness diagnoses were interviewed four times over two years about factors affecting their mental health recovery. Interviews were recorded, transcribed, and coded with inductively derived codes. Themes were identified by reviewing text coded "alcohol or other drugs."

RESULTS

Participants (N = 177) had diagnosed schizophrenia/schizoaffective disorder (n = 75, 42%), bipolar I/II disorder (n = 84, 48%), or affective psychosis (n = 18, 10%). At baseline, 63% (n = 112) spontaneously described addressing substance use as part of their mental health recovery. When asked at follow-up, 97% (n = 171) provided codeable answers about substances and mental health. We identified differing pathways to recovery, including through formal treatment, self-help groups or peer support, "natural" recovery (without the help of others), and continued but controlled use of alcohol. We found three overarching themes in participants' experiences of recovering from serious mental illnesses and substance-related problems: Learning about the effects of alcohol and drugs provided motivation and a foundation for sobriety; achieving sobriety helped people to initiate their mental health recovery processes; and achieving and maintaining sobriety built self-efficacy, self-confidence, improved functioning and a sense of personal growth. Non-judgmental support from clinicians adopting chronic disease approaches also facilitated recovery.

CONCLUSIONS

Irrespective of how people achieved sobriety, quitting or severely limiting use of substances was important to initiating and continuing mental health recovery processes. Substance abuse treatment approaches that are flexible, reduce barriers to engagement, support learning about effects of substances on mental health and quality of life, and adopt a chronic disease model of addiction may increase engagement and success. Peer-based support like Alcoholics or Narcotics Anonymous can be helpful for people with serious mental illnesses, particularly when programs accept use of mental health medications.

Recovery from serious mental illness: trajectories, characteristics, and the role of mental health care

OBJECTIVE The objective was to identify trajectories of recovery from serious mental illnesses. METHODS A total of 177 members (92 women; 85 men) of a not-for-profit integrated health plan participated in a two-year mixed-methods study of recovery (STARS, the Study of Transitions and Recovery Strategies). Diagnoses included schizophrenia, schizoaffective disorder, bipolar disorder, and affective psychosis. Data sources included self-reported standardized measures, interviewer ratings, qualitative interviews, and health plan data. Recovery was conceptualized as a latent construct, and factor analyses and factor scores were used to calculate recovery trajectories. Individuals with similar trajectories were identified through cluster analyses. RESULTS Four trajectories were identified-two stable (high and low levels of recovery) and two fluctuating (higher and lower). Few demographic or diagnostic factors differentiated clusters at baseline. Discriminant analyses for trajectories found differences in psychiatric symptoms, physical health, satisfaction with mental health clinicians, resources and strains, satisfaction with medications, and mental health service use. Those with higher scores on recovery factors had fewer psychiatric symptoms, better physical health, greater satisfaction with mental health clinicians, fewer strains and greater resources, less service use, better quality of care, and greater satisfaction with medication. Consistent predictors of trajectories included psychiatric symptoms, physical health, resources and strains, and use of psychiatric medications. CONCLUSIONS Having access to good-quality mental health care-defined as including satisfying relationships with clinicians, responsiveness to needs, satisfaction with psychiatric medications, receipt of services at needed levels, support in managing deficits in resources and strains, and care for general medical conditions-may facilitate recovery. Providing such care may improve recovery trajectories.

Towards social inclusion through lifelong learning in mental health: analysis of change in the lives of the EMILIA project service users

BACKGROUND

The application of formal lifelong learning to enhance social inclusion in mental health is rarely investigated in terms of change in the lives of service users on a cross-country comparative scale.

AIMS

This study was aimed at examining changes in key areas of the lives of mental health service users across eight European mental health sites.

METHOD

A before and after case study design was applied. Users of mental health services who participated in the lifelong leaning interventions reviewed the changes in key areas of their lives at baseline and 10 months later, through the thematic analysis of qualitative data collected in semi-structured interviews (27 and 21, respectively) and self-reports (138 and 99, respectively). In-depth examples from one site are provided.

RESULTS

Most users reported positive changes in the areas of training and social networks, with a sizeable minority moving onto unpaid and paid employment. In addition most users reported active planning for job search and other goals. Obstacles that were highlighted included the negative effects of having a mental illness, difficulties in close relationships and economic disadvantages.

CONCLUSIONS

The lifelong learning intervention offered within an EU Framework 6 project to mental health service users in eight demonstration sites had a largely positive impact on key areas of their lives at 10 months, though obstacles remained which may be less amenable to change by social interventions.

Effective mental health consumer education: a preliminary exploration

People with serious mental illnesses are increasingly becoming more active participants in their treatment and recovery. At times, their participation may be limited by incomplete, unclear, or insufficient information. The authors used a grounded theory approach to look at the unmet informational needs described by consumers. Participants in this study called for materials appropriate to their level of understanding, assistance with interpreting and comprehending information when necessary, and information on policies that affect the treatment they receive. Ultimately, an informed consumer is one empowered to make decisions about the course of his or her recovery and participate meaningfully in the patient-provider relationship.

Another breed of "service" animals: STARS study findings about pet ownership and recovery from serious mental illness

This study elucidates the role of pets in recovery processes among adults with serious mental illness. Data derive from interviews with 177 HMO members with serious mental illness (52.2% women, average age 48.8 years) in the Study of Transitions and Recovery Strategies (STARS). Interviews and questionnaires addressed factors affecting recovery processes and included questions about pet ownership. Data were analyzed using a modified grounded theory method to identify the roles pets play in the recovery process. Primary themes indicate pets assist individuals in recovery from serious mental illness by (a) providing empathy and "therapy"; (b) providing connections that can assist in redeveloping social avenues; (c) serving as "family" in the absence of or in addition to human family members; and (d) supporting self-efficacy and strengthening a sense of empowerment. Pets appear to provide more benefits than merely companionship. Participants' reports of pet-related contributions to their well-being provide impetus to conduct more formal research on the mechanisms by which pets contribute to recovery and to develop pet-based interventions.

New endeavors, risk taking, and personal growth in the recovery process: findings from the STARS study

OBJECTIVE

This study examined consumers' perspectives on the role of personal growth-related risk taking in the recovery process and on clinicians' roles in patients' decisions to take on new activities and opportunities. Clinical approaches cited by patients as most helpful in making significant changes were also identified.

METHODS

A total of 177 members of a nonprofit health plan (93 women and 85 men), ranging in age from 16 to 84 years, participated in a mixed-methods exploratory study of recovery among individuals with serious mental illness (schizophrenia, schizoaffective disorder, bipolar disorder, and affective psychosis). Participants completed four in-depth semistructured interviews over 24 months; interviews were transcribed verbatim and coded for content by study staff. Data were analyzed using a modified grounded theory approach.

RESULTS

The most helpful discussions about new endeavors occurred in the context of healthy, collaborative, mutually trusting clinician-patient relationships. Advice was accepted when clinicians listened well, knew patients' capabilities and interests, and pushed gently at a pace that was comfortable for patients. Knowledge gained by clinicians in the context of good relationships with patients provided a firm grounding for approaching the delicate balance of providing helpful levels of support and encouragement without pushing consumers so hard that it caused difficulties.

CONCLUSIONS

Enduring, strong, collaborative relationships provide a healthy framework for discussions between patients and clinicians about taking on new activities, roles, or responsibilities and increase the likelihood that new activities and opportunities will be planned and carried out in ways that promote, rather than endanger, recovery.

New endeavors, risk taking, and personal growth in the recovery process: findings from the STARS study

OBJECTIVE

This study examined consumers' perspectives on the role of personal growth-related risk taking in the recovery process and on clinicians' roles in patients' decisions to take on new activities and opportunities. Clinical approaches cited by patients as most helpful in making significant changes were also identified.

METHODS

A total of 177 members of a nonprofit health plan (93 women and 85 men), ranging in age from 16 to 84 years, participated in a mixed-methods exploratory study of recovery among individuals with serious mental illness (schizophrenia, schizoaffective disorder, bipolar disorder, and affective psychosis). Participants completed four in-depth semistructured interviews over 24 months; interviews were transcribed verbatim and coded for content by study staff. Data were analyzed using a modified grounded theory approach.

RESULTS

The most helpful discussions about new endeavors occurred in the context of healthy, collaborative, mutually trusting clinician-patient relationships. Advice was accepted when clinicians listened well, knew patients' capabilities and interests, and pushed gently at a pace that was comfortable for patients. Knowledge gained by clinicians in the context of good relationships with patients provided a firm grounding for approaching the delicate balance of providing helpful levels of support and encouragement without pushing consumers so hard that it caused difficulties.

CONCLUSIONS

Enduring, strong, collaborative relationships provide a healthy framework for discussions between patients and clinicians about taking on new activities, roles, or responsibilities and increase the likelihood that new activities and opportunities will be planned and carried out in ways that promote, rather than endanger, recovery.

‘Stealing me from myself’: identity and recovery in personal accounts of mental illness

OBJECTIVES

To understand and promote recovery from serious mental illnesses, it is important to study the perspectives of individuals who are coping with mental health problems. The aim of the present study was to examine identity-related themes in published self-narratives of family members and individuals with serious mental illness. It adds to the body of research addressing how identity affects the process of recovery and identifies potential opportunities for using published narratives to support individuals as they move toward positive identities that facilitate recovery.

METHOD

Forty-five personal accounts from individuals with severe mental illness, which were published in two prominent research journals between 1998 and 2003, were qualitatively analysed.

RESULTS

Individuals with mental illness and their family members described a loss of self and identity that had to be overcome, or at least managed, for recovery to become possible. Writers described (i) a loss of self, (ii) the duality of (ill/well) selves, (iii) perceptions of normality, (iv) specific concerns about parenting and identity, and (v) hope and reconciliation.

CONCLUSIONS

Individuals' stories of their experiences of severe mental illness describe severe challenges managing identity. Efforts to publish personal accounts that focus on strengths-based patient-centred stories, rather than on deficits, could be helpful to provide hope for patients. These published narratives highlight the importance of moving recovery and hope to the forefront among patient, family, and clinician groups. Increasing such information and role models can provide important resources to individuals working to redefine themselves and create a sense of self-worth and stable identity that will support productive, happy lives.

Why I am not a "mental health consumer"

"Mental health consumer" is now a widely-accepted term used to identify individuals living with mental illness. Though this language may be an improvement over the word "patient," it can still be limiting and disempowering. The author explains her concern regarding the word "consumer" and explores the advantages of using the term "psychiatric disability" to describe the experience of those who live with mental illness.