Recovery: conceptual and ethical aspects

A grounded theory on acceptance of diagnosis as a pathway to recovery in bipolar disorder

The recovery process in bipolar disorder is a subjective and multidimensional experience that seeks to develop new meanings and purposes for living a satisfying life despite the limitations imposed by the disorder. Thus, this qualitative study aimed to explore the perceptions of recovery and the meanings attributed by individuals undergoing treatment for bipolar disorder to the elements considered relevant in this process. Semi-structured interviews with open-ended questions were conducted to explore the experiences and perspectives of recovery in individuals undergoing treatment for bipolar disorder. Grounded Theory was used as the method for qualitative analysis. The study included 26 participants aged between 18 and 65 years. Based on the analysis of participant reports, we identified two main themes: living with the illness and what it means to be in recovery. The perception of recovery is an individual process and can differ from the medical model. Participants suggest that accepting the diagnosis of bipolar disorder and finding meaning in life are essential to their recovery. They also describe how mental health professionals can facilitate or hinder this process. Understanding patients' perceptions can facilitate access to healthcare services and treatment adherence.

From existing to living: Exploring the meaning of recovery and a sober life after a long duration of a substance use disorder

Aim: The study explores how former patients with substance use disorder (SUD) experience the benefits and challenges of a reoriented identity and way of living. Methods: Semi-structured interviews were conducted with 10 participants who had completed treatment for SUD and considered themselves either recovered or in an ongoing rehabilitation process. Interview transcripts were analysed using the content analysis approach. Results: The analysis furthers our understanding of several purposeful aspects of a reorientation towards a sober life in terms of: (1) avoiding illegal drugs, (2) avoiding contact with the substance use relations and milieu, (3) renewing relations and social network, (4) daily occupation, (5) discovering the value of the great, little things in everyday life, (6) new coping strategies, and (7) developing a new identity. Conclusion: The study indicates that rehabilitation from SUDs should take a broader focus than just sobriety. With attention to the present findings, a focus on psychosocial aspects of recovery could contribute to a more overarching framework for SUD treatment.

Exploring factors associated with personal recovery in bipolar disorder

BACKGROUND

Personal recovery is increasingly recognized as important outcome for people with bipolar disorder (BD), but research addressing associated factors of personal recovery in this group remains scarce. This study aimed to explore the association of sociodemographic variables, social participation, psychopathology, and positive emotion regulation with personal recovery in BD.

METHODS

Baseline data from a randomized controlled trial and survey data were combined (N = 209) and split into a training (n = 149) and test sample (n = 60). Block-wise regression analyses and model training were used to determine the most relevant predictors. The final parsimonious model was cross-validated in the test sample.

RESULTS

In the final parsimonious model, satisfaction with social roles (β = .442, p < .001), anxiety symptoms (β = -.328, p < .001), manic symptoms (β = .276, p < .001), and emotion-focused positive rumination (β = .258, p < .001) were independently associated with personal recovery. The model explained 57.3% variance in personal recovery (adjusted R²  = .561) and performed well in predicting personal recovery in the independent test sample (adjusted R²  = .491).

CONCLUSIONS

Our findings suggest that especially social participation, anxiety and positive rumination might be relevant treatment targets when aiming to improve personal recovery.

PRACTITIONER POINTS

Personal recovery is considered an increasingly important outcome for people with chronic mental health conditions, including bipolar disorder. We found that anxiety and manic symptoms as well as positive rumination and social participation were independently associated with personal recovery in bipolar disorder. Therefore, these outcomes might be relevant treatment targets when aiming to improve personal recovery in bipolar disorder. Possible interventions to improve these outcomes are discussed, including supported employment and vocational rehabilitation for social participation and exercising with savoring strategies to increase positive rumination.

Service user involvement in a secure setting before and after the implementation of recovery-oriented practice: A quasi-experimental study

AIM

To measure change in service user involvement in secure mental health units, before and after the implementation of recovery-oriented practice.

DESIGN

Quasi-experimental study pretest-posttest design with non-equivalent comparison groups.

METHODS

Data were collected from May 2018 to December 2019 in four medium-/high-security units in Norway. Two intervention units that implemented recovery-oriented practice were compared with two comparison units that did not. Data were obtained using anonymous questionnaires at baseline and at 6-month follow-up. For intervention units, data were also obtained at a 12-month follow-up to measure sustainability of improvements over time. Twenty inpatients ('patients'; intervention group: 10, comparison group: 10) and 141 members of frontline staff ('service providers'; intervention group: 92, comparison group: 49) participated at baseline. Mann-Whitney U-tests and independent sample t-tests were applied at the group-level to analyse changes in mean scores in groups.

RESULTS

Among patients in the intervention units, findings indicated no improvements after 6 months, but significant improvements after 12 months in terms of patients' opportunities to participate in formulating their individual care plans, to influence decision-making about therapy and to receive information about complaint procedures. Opportunities to participate in discussions about medication and treatment regimens did not improve. After 6 months, service providers in the intervention units reported an increase in democratic patient involvement, patient collaboration and management support, but not in carer involvement and assisted patient involvement. The improvements in democratic patient involvement and management support were sustained over time. No changes were found in the comparison groups.

CONCLUSION

The patients and the service providers reported a higher degree of service user involvement after implementing recovery-oriented practice. Specific work is needed to ensure patients' involvement in all domains.

IMPACT

The findings are encouraging with respect to the potential to increase empowerment in a restricted setting through the implementation of recovery-oriented practice.

Subjective Recovery in Patients with Schizophrenia and Related Factors

Subjective recovery is a personally perceived recovery involving other factors beyond clinical recovery. This study aims at investigating the factors related to subjective recovery in patients with schizophrenia living in Turkey. This study assessed 120 clinically stable outpatients with schizophrenia or schizoaffective disorder using the clinical and psychosocial scales. Gender, type of the diagnosis of disease, and age of the illness onset were found to be correlated with the subjective recovery. Subjective recovery was significantly correlated with CGI-S (r = - 0.25), total PANSS score (r = - 0.29), global assessment of functioning (r = 0.27), social functioning (r = 0.43), internalized stigma (r = - 0.38), self-esteem (r = 0.56), depression (r = - 0.59), and hopelessness (r = - 0.55). Hopelessness and self-esteem were found to be predictive of the subjective recovery explaining 52% of the variance. It can be argued that efforts to promote hope and self-esteem contribute to the subjective recovery.

Psychometric properties and utility of the Responses to Positive Affect questionnaire (RPA) in a sample of people with bipolar disorder

Objectives

To evaluate the psychometric properties of the Responses to Positive Affect (RPA) questionnaire in a sample of persons with bipolar disorder (BD).

Method

Cross‐sectional survey study with 107 persons with BD. The original 3‐factor model of the RPA was compared with a 2‐factor model. Construct validity was determined with measures of well‐being, personal recovery, social role participation, and psychopathology and incremental validity was evaluated.

Results

The fit of the 3‐factor model was acceptable for most fit indices. Subscores of the RPA revealed a significant relationship with aspects of well‐being, personal recovery, and psychopathology. Dampening and self‐focused positive rumination explained additional variance in personal recovery above and beyond well‐being.

Conclusions

The RPA is an internally consistent and valid tool to assess positive emotion regulation processes in persons with BD. Specifically, the processes of dampening and emotion‐focused positive rumination seem to play an important role in BD.

Measuring personal recovery in people with bipolar disorder and exploring its relationship with well‐being and social role participation

The relevance of personal recovery receives increasing attention in mental health care and is also important for people with bipolar disorder (BD). There is a need for reliable and valid instruments measuring personal recovery. Therefore, the current study evaluated the psychometric properties of a Dutch translation of the Questionnaire about the Process of Recovery (QPR) in a sample of people with BD and explored the relationship with constructs of well‐being, social role participation, and psychopathology. A cross‐sectional survey study was conducted in which 102 people diagnosed with BD completed the QPR. Factor structure of the QPR was evaluated by conducting confirmatory factor analyses (CFA), and internal consistency was assessed by calculating reliability coefficients. Convergent validation measures assessed well‐being, social role participation, and symptomatology. Incremental validity was determined by evaluating the ability of the QPR to explain variance in symptomatology above and beyond well‐being. Findings of the CFA supported a unidimensional factor structure, and internal consistency estimates were excellent. Scores of the QPR showed strong correlations with convergent measures, but were only weakly associated with manic symptomatology. Moreover, personal recovery explained additional variance in symptoms of depression and anxiety above and beyond well‐being, indicating incremental validity. The QPR appears to be a reliable and valid tool to assess personal recovery in people with BD. Our findings underline the importance of personal recovery in the context of treatment of BD. Personal recovery demonstrates a substantial overlap with well‐being.

Crucial factors preceding compulsory psychiatric admission: a qualitative patient-record study

BACKGROUND

Compulsory admissions have a strong effect on psychiatric patients and represent a deprivation of personal liberty. Although the rate of such admissions is tending to rise in several Western countries, there is little qualitative research on the mental health-care process preceding compulsory admission. The objective of the study was to identify crucial factors in the mental health-care process preceding compulsory admission of adult psychiatric patients.

METHODS

This retrospective, qualitative multiple-case study was based on the patient records of patients with severe mental illness, mainly schizophrenia and other psychotic disorders. Twenty two patient records were analyzed. Patients' demographic and clinical characteristics were heterogeneous. All were treated by Flexible Assertive Community Treatment teams (FACT teams) at two mental health institutions in the greater Rotterdam area in the Netherlands and had a compulsory admission in a predefined inclusion period. The data were analyzed according to the Prevention and Recovery System for Monitoring and Analysis (PRISMA) method, assessing acts, events, conditions, and circumstances, failing protective barriers and protective recovery factors.

RESULTS

The most important patient factors in the process preceding compulsory admission were psychosis, aggression, lack of insight, care avoidance, and unauthorized reduction or cessation of medication. Neither were health-care professionals as assertive as they could be in managing early signs of relapse and care avoidance of these particular patients.

CONCLUSION

The health-care process preceding compulsory admission is complex, being influenced by acts, events, conditions and circumstances, failing barriers, and protective factors. The most crucial factors are patients' lack of insight and cessation of medication, and health-care professionals' lack of assertiveness.

The Concept of Recovery as Experienced by Persons with Dual Diagnosis: A Systematic Review of Qualitative Research From a First-Person Perspective

OBJECTIVES

In recent years, the concept of recovery has gained ground in the treatment of persons with dual diagnosis. Recovery refers to living a meaningful life despite limitations caused by mental illness and substance use disorders. It also implies that support for persons with dual diagnosis should be organized according to the personal needs and wishes of its users. Therefore, it is important to gain insight into the aspects that persons with dual diagnosis deem important for their recovery process. This systematic review aims to summarize existing qualitative research on the meaning of recovery from the perspective of persons with dual diagnosis.

METHODS

A literature search was conducted following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic reviews in the following databases: Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Medline, Embase, and Web of Science.

RESULTS

Sixteen studies using a qualitative research design were retained in which four overarching themes could be identified. The first theme focused on feeling supported by family and peers and being able to participate in the community. The second theme focuses on the need for a holistic and individualized treatment approach, seeing the persons "behind the symptoms." The third theme that emerged was having personal beliefs, such as fostering feelings of hope, building a new sense of identity, gaining ownership over one's life, and finding support in spirituality. The last theme identified was the importance of meaningful activities that structure one's life and give one motivation to carry on.

CONCLUSIONS

In this review, the participants pleaded for "flexibility" in mental health care, i.e., an approach that allows for both successes and failures. However, in order to come to a more comprehensive theoretical model of recovery in persons with dual diagnosis, future research is necessary to gain insight into the underlying mechanisms of recovery processes.

Healing journey: a qualitative analysis of the healing experiences of Americans suffering from trauma and illness

OBJECTIVES

To elucidate pathways to healing for people having suffered injury to the integrity of their function as a human being.

METHODS

A team of physician-analysts conducted thematic analyses of in-depth interviews of 23 patients who experienced healing, as identified by six primary care physicians purposefully selected as exemplary healers.

RESULTS

People in the sample experienced healing journeys that spanned a spectrum from overcoming unspeakable trauma and then becoming healers themselves to everyday heroes functioning well despite ongoing serious health challenges.The degree and quality of suffering experienced by each individual is framed by contextual factors that include personal characteristics, timing of their initial or ongoing wounding in the developmental life cycle and prior and current relationships.In the healing journey, bridges from suffering are developed to healing resources/skills and connections to helpers outside themselves. These bridges often evolve in fits and starts and involve persistence and developing a sense of safety and trust.From the iteration between suffering and developing resources and connections, a new state emerges that involves hope, self-acceptance and helping others. Over time, this leads to healing that includes a sense of integrity and flourishing in the pursuit of meaningful goals and purpose.

CONCLUSION

Moving from being wounded, through suffering to healing, is possible. It is facilitated by developing safe, trusting relationships and by positive reframing that moves through the weight of responsibility to the ability to respond.

Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks

BACKGROUND

As a significant proportion of patients receiving palliative care suffer from states of anxiety, depression, delirium, or other mental symptoms, psychiatry and palliative care already collaborate closely in the palliative care of medical conditions. Despite this well-established involvement of psychiatrists in palliative care, psychiatry does not currently explicitly provide palliative care for patients with mental illness outside the context of terminal medical illness.

DISCUSSION

Based on the WHO definition of palliative care, a, a working definition of palliative psychiatry is proposed. Palliative psychiatry focuses on mental health rather than medical/physical issues. We propose that the beneficiaries of palliative psychiatry are patients with severe persistent mental illness, who are at risk of therapeutic neglect and/or overly aggressive care within current paradigms. These include long-term residential care patients with severe chronic schizophrenia and insufficient quality of life, those with therapy-refractory depressions and repeated suicide attempts, and those with severe long-standing therapy-refractory anorexia nervosa. An explicitly palliative approach within psychiatry has the potential to improve quality of care, person-centredness, outcomes, and autonomy for patients with severe persistent mental illness.

CONCLUSIONS

The first step towards a palliative psychiatry is to acknowledge those palliative approaches that already exist implicitly in psychiatry. Basic skills for a palliative psychiatry include communication of diagnosis and prognosis, symptom assessment and management, support for advance (mental health) care planning, assessment of caregiver needs, and referral to specialized services. Some of these may already be considered core skills of psychiatrists, but for a truly palliative approach they should be exercised guided by an awareness of the limited functional prognosis and lifespan of patients with severe persistent mental illness.

Recovery in Mind: Perspectives from Postgraduate Psychiatric Trainees

OBJECTIVE

The authors assessed psychiatric trainees' understanding of recovery-oriented care, a therapeutic philosophy with varied meanings but wide purchase in contemporary mental health policy.

METHODS

Four cohorts of residents were presented with a clinical vignette as part of a written curricular evaluation and asked what it would mean to engage the patient from a recovery-oriented perspective. Responses were subjected to qualitative analysis, with the analysts examining each cohort independently, then meeting to discuss their findings and build consensus on the most pertinent themes.

RESULTS

Nine themes emerged in trainees' understanding of recovery-oriented care: (1) a person is more than his or her illness; (2) hope; (3) an emphasis on patient goals; (4) taking a collaborative approach; (5) an emphasis on level of social function; (6) valuing subjective experience; (7) psychosocial interventions; (8) empowerment of the patient; and (9) persistence of traditional attitudes.

CONCLUSIONS

Residents revealed an understanding of recovery that reflected many, but not all, of the guiding principles in the Substance Abuse and Mental Health Services Administration's 2010 working definition. For many of these trainees, recovery-oriented care signified a shift in the traditional power dynamic between physician and patient that allowed patients to take an active role in their own care. Residents also recognized the importance of hope and the complexity of their patients' social identities, though some trainees had difficulty reconciling a collaborative approach with their perceived responsibilities as physicians. If educators wish to incorporate elements of the American Psychiatric Association's Recovery to Practice initiative into their curricula, they would do well to recognize residents' variable receptivity to elements of the model.

Patients' subjective perspective on recovery orientation on an acute psychiatric unit

BACKGROUND

Evaluations of the recovery orientation of mental health services have focused on outpatient and rehabilitative rather than acute inpatient facilities.

AIM

This naturalistic observational study seeks to evaluate the subjective perspective and functional outcome of inpatients before and after structural alterations. The changes made were the introduction of treatment conferences and conjoint treatment planning, reduction of the total time spent on reports about patients (in their absence), and recovery-oriented staff training on an acute psychiatric unit of the University Hospital of Psychiatry, Zurich, Switzerland.

METHODS

During 1 year (2011/2012) eligible patients on the study unit were interviewed on a voluntary basis using established instruments to assess several recovery-relevant aspects. Two different samples (before and after the project; n = 34 and n = 29) were compared with regard to subjective parameters (e.g. patients' attitudes toward recovery, quality of life, perceived coercion, treatment satisfaction, and hope), clinical and socio-demographic basic data, as well as the functional outcome according to the Health of the Nation Outcome Scales (HoNOS).

RESULTS

Some patient attitudes towards recovery and their self-assessment of the recovery process improved during the study. Other subjective parameters remained stable between samples. Functional outcome was better in subjects who were treated after the implementation of the new concept. The length of stay remained unchanged.

CONCLUSIONS

The implementation of recovery-oriented structures and providing the necessary theoretical underpinning on an acute psychiatric unit is feasible and can have an impact on attitudes and knowledge of personal recovery.

A recovery-oriented approach for an acute psychiatric ward: is it feasible and how does it affect staff satisfaction?

To evaluate professionals' attitudes to recovery and coercion, as well their satisfaction with working conditions before and after the implementation of a recovery-oriented ward concept on an admission ward. Longitudinal study design with two measurement times of the study sample, with a control group assessed at study end. Evaluating the implementation of the recovery concept, attitudes towards recovery, coercion, perceptions of the ward and working satisfaction were assessed with questionnaires and computed using Chi square and ANOVA variance analyses. The members of the intervention ward (n = 17) did not differ from the control group (n = 21), except that control group members were younger. The recovery-orientation of the study ward (ROSE questionnaire) increased significantly (alpha level = 0.05) from study begin to study end (p = 0.003), and compared to the control group (p = 0.002). The attitudes towards coercion did not change significantly in the intervention group, but did so compared to the control group. The contentedness (GMI) and the satisfaction with working conditions (ABB) of the intervention group members compared to control group was significantly higher (GMI: p = 0.004, ABB subscale working conditions: p = 0.043, satisfaction: p = 0.023). The study indicates that recovery-oriented principles can be implemented even in an acute admission ward, increasing team satisfaction with work, while attitudes towards coercion did not change significantly within this single-unit project.