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Social workers understand that evidence that informs practice derives from multi-disciplinary sources and multiple ways of knowing. They also understand the processes for translating research findings into effective practice. You have read about guiding principles of recovery produced by the Substance Abuse and Mental Health Administration. Based on this information, prepare a tip sheet of the five most important recovery principles for individuals with severe mental illness that new social workers in the field should consider including why social workers are knowledgeable about evidence-informed interventions to achieve the goals of clients and constituencies, including individuals, families, groups, organizations, and communities.

Be sure to expound on why you chose these five recovery principles for application.

Support your assignment with at least two scholarly resources. In addition to these specified resources, other appropriate scholarly resources, including seminal articles, may be included.

Length: 2-3 pages, not including title or reference pages

Your assignment should demonstrate thoughtful consideration of the ideas and concepts presented in the course by providing new thoughts and insights relating directly to this topic. Your response should reflect scholarly writing and current APA standards. Be sure to adhere to Northcentral University’s Academic Integrity Policy.

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https://www.tandfonline.com/action/journalInformation?journalCode=rswd20 Asia Pacific Journal of
Social Work and Development ISSN: 0218-5385 (Print) 2165-0993 (Online) Journal homepage:
https://www.tandfonline.com/loi/rswd20 Challenges of recovery-oriented practice in inpatient mental
health settings – the potential for social work leadership Bronwyn Hyde, Wendy Bowles & Manohar
Pawar To cite this article: Bronwyn Hyde, Wendy Bowles & Manohar Pawar (2014) Challenges of
recovery-oriented practice in inpatient mental health settings – the potential for social work leadership,
Asia Pacific Journal of Social Work and Development, 24:1-2, 5-16, DOI: 10.1080/02185385.2014.885205
To link to this article: https://doi.org/10.1080/02185385.2014.885205 Published online: 09 Apr 2014.
Submit your article to this journal Article views: 5045 View related articles View Crossmark data Citing
articles: 8 View citing articles Challenges of recovery-oriented practice in inpatient mental health
settings – the potential for social work leadership Bronwyn Hyde*, Wendy Bowles and Manohar Pawar
School of Humanities and Social Sciences, Charles Sturt University, Wagga Wagga, Australia (Received 31
October 2013; final version received 23 December 2013) Recovery-oriented practice has become the
main mantra in mental health services, irrespective of the way it is understood, accepted and practised.
This article aims to analyse the principles of recovery as stipulated in Australian national policies and to
examine the challenges associated with implementing these in an inpatient mental health facility. Using
a qualitative method incorporating a literature review, documentary analysis of policy and standards
and reflections on social work practice in an inpatient facility, this analysis reveals a powerful alignment
between recovery and social work principles. However, the analysis also highlights the noticeable
absence of social work in contributions to the literature and research around the move to
recoveryoriented practice. The paper concludes with a call to the social work profession to recognise its
potential for taking a leadership role in mental health reform with participatory and person-centred
approaches. Keywords: recovery; mental health; social work; inpatient Introduction In recent years the
global context of mental health care has undergone a revolution. The ‘recovery-oriented approach’ or
the ‘recovery movement’ was initially driven by people who had experienced mental health services,
and their supporters, and has now emerged as the mandated approach in Australian mental health
policy and internationally. This change has profound implications for the mental health workplace,
particularly in an inpatient setting where the dominance of the biomedical and legal models of care
continues to be pervasive. The recovery movement has not only questioned the assumptions of these
dominant models, but it has also achieved action. Tenets of the recovery movement are now enshrined
in Australian policy documents. However, the implementation of these recovery principles, particularly
in the inpatient setting, is proving to be challenging. This paper discusses the notion of recovery in the
western mental health field and examines how entrenched biomedical approaches in inpatient settings
present challenges to the implementation of a recovery-oriented approach. It argues that social work is
a profession inherently aligned with recovery principles and thus it is ideally situated to provide
participatory and person-centred leadership in bringing a recovery-oriented approach to these
seemingly hostile environments. Reflection on five practice examples illustrates the potential of social
work to lead by example in implementing recoveryoriented practice in inpatient settings. q 2014
Department of Social Work, National University of Singapore, Singapore *Corresponding author. Email:
bronwyn.hyde@health.nsw.gov.au Asia Pacific Journal of Social Work and Development, 2014 Vol. 24,
Nos. 1–2, 5–16, http://dx.doi.org/10.1080/02185385.2014.885205 Methodology This qualitative study
employs a variety of approaches to critically examine the implementation of recovery principles in
inpatient settings and the contribution social work can offer. A literature review is conducted, analysing
the international debates around the notion of recovery in mental health service delivery and the
challenges of implementing recovery-oriented practice within the context of an inpatient setting. A
documentary analysis is used to examine the policy context in Australia, revealing the level to which
recovery has become embedded in official documents that direct mental health service delivery and
practice. These documents are compared to the guiding documents of the social work profession,
notably the Codes of Ethics of the Australian Association of Social Workers (AASW) and the International
Federation of Social Workers (IFSW) and the AASW (2008) Practice Standards for Mental Health Social
Workers. Within the framework of this literature review and documentary analysis, a brief reflection on
five examples of social work practice within a mental health inpatient unit is undertaken as an
illustration of the role social workers have in modeling recovery-oriented practice and to highlight the
potential for social workers to be at the forefront of mental health reform. The contested notion of
‘recovery’ in mental health The recovery concept in mental health has emerged as a response to the
narrow and constrictive notions inherent in the biomedical model that has traditionally viewed
consumers as passive recipients of treatment, and practitioners as the experts and holders of
knowledge. According to two authors who are attributed with pioneering the movement in the late
1980s and early 1990s, the recovery approach is based on the simple tenets that people with a mental
illness need more than symptom relief (Anthony, 1993) and that people who have been diagnosed with
a mental illness are human beings (Deegan, 1995). Ramon, Healy, and Renouf (2007) describe the
historical development of the recovery movement, asserting that recovery as a concept has been
around since the nineteenth century and has recently been ‘rediscovered’. They note the inclusion of
elements that reflect a more contemporary meaning of recovery, including the recognition of trauma,
the concepts of hope and the right to fail, the move to a strengths model and the inclusion of users’ selfagency. The importance of the notion of self-agency has been empirically demonstrated in a recent
study by Chiu, Davidson, Lo, Yiu, and Ho (2013) in which self agency is shown to permeate many
dimensions of recovery. Recovery is a deeply individual experience (Anthony, 1993) and, as a result, the
clarification of the meaning of recovery in mental health practice is one that is fraught with debate and
discussion. The debates centre on the lack of consensus for a definition (Cleary & Dowling, 2009;
Davidson, O’Connell, Tondora, Styron, & Kangas, 2006; Kogstad, Ekeland, & Hummelvoll, 2011; Thornton
& Lucas, 2011). Some authors prefer to conceptualise recovery as a process about which agreed themes
can be identified. They liken the concept to a social movement or a framework supporting recovery
principles (Glover, 2009; Walker, 2006). As Deegan notes, recovery remains elusive, perhaps because it
is so fundamental and cannot be described in scientific, psychiatric or psychological language (Deegan,
1988). Slade, Amering, and Oades (2008) state that rational debate about recovery cannot take place in
the absence of further clarity of its meaning, believing that the ‘rhetorical consensus conceals a more
complex reality’ (p. 128). This rhetorical consensus, according to Slade et al. (2008), relates to the use of
the term ‘recovery’ in mental health policy on an international level that often fails to recognise the
sometimes incompatible meanings. Thus, 6 B. Hyde et al. a ‘two-part’ definition of recovery has
emerged to distinguish between clinical recovery and personal recovery. Clinical recovery is described as
an absence of symptoms and functional impairment and can be reasonably measured. This aligns closely
with the biomedical model. Personal recovery, on the other hand, is uniquely individual, narrative based
and involves gaining new meaning and purpose in life even in the presence of ongoing symptoms. The
personal meaning of recovery provides challenges for evidence-based practice, as it is not something
that can be easily measured or scientifically scrutinised. Walsh and Boyle (2009) note that individual
definitions of recovery pose problems for academics and professionals in developing recovery-focused
services. In response to this, a number of authors call for the exploration of personal meanings of
recovery to enrich the knowledge base of mental health practice and service delivery. Kogstad et al.
(2011) call for the challenging of reductionist and symptom-oriented views of recovery through the
epistemological acknowledgement of lived experience. They put forward the case for knowledge within
the mental health field to be based more on users’ experiences, placing emphasis on the role of
language in the social construction of mental illness. This is echoed strongly by Walker (2006), who
argues that failing to acknowledge the role of language, or the ‘linguistic paradigm’, has enormous
implications for the implementation of the recovery model in mental health. Failing to understand that
language creates reality, according to Walker, may result in the creation of the ‘best’ recovery program
that continues unwittingly to linguistically cast people in a pathological and deficit-based vocabulary,
limiting the chance of improving quality of life and even creating iatrogenic problems. Policy in the
Australian context In the Australian context the National Mental Health Plans are key documents that
aim to provide a vision for mental health service delivery across Australia. The current National Mental
Health Plan 2009 –2014 identifies ‘Social Inclusion and Recovery’ as the first priority area (Australian
Health Ministers, 2009). It acknowledges that a recovery focus in Australia has been adopted more
readily by the non-government sector and calls for the attitudes and expectations underpinning the
recovery focus to be taken up by clinical staff within the public and private sectors (p. 26). The National
Standards for Mental Health Services were first introduced in 1996, with the most recent document
published in 2010 (Department of Health and Ageing, 2010). While only one of the key principles of this
document directly refers to recovery – ‘Services are delivered with the aim of facilitating sustained
recovery’ (p. 5) – many of the other principles contain recovery concepts. Two of the Standards in this
document explicitly address recovery: Standard 6, addressing the right to comprehensive needsbased
care that achieves recovery; and Standard 10, ‘Delivery of Care’, with a subsection 10.1 entitled
‘Supporting Recovery’: ‘The MHS incorporates recovery principles into service delivery, culture and
practice providing consumers with access and referral to a range of programs that will support
sustainable recovery (p. 21).’ This document also contains a section on ‘Principles of Recovery Oriented
Mental Health Practice’ (p. 42) that clearly sets out six principles of practice. These include uniqueness
of the individual; real choices; attitudes and rights; dignity and respect; partnership and communication;
evaluating recovery. Other Australian government/policy documents that articulate recovery in mental
health services include The Roadmap for National Mental Health Reform 2012– 2022 (Council of
Australian Government, 2012); Framework for Recovery-Oriented Practice (Victorian Department of
Health, 2011) and NSW: A New Direction for Mental Health Asia Pacific Journal of Social Work and
Development 7 (NSW Department of Health, 2006): Sharing Responsibility for Recovery: Creating and
Sustaining Recovery Oriented Systems of Care for Mental Health (Queensland Health, 2005). Two
documents on recovery-oriented mental health services have recently been released in Australia. A
National Framework to Recovery-Oriented Mental Health Services: Guide for Practitioners and Providers
(Australian Health Ministers’ Advisory Council, 2013a) and its accompanying document A National
Framework for RecoveryOriented Mental Health Services: Policy and Theory (Australian Health
Ministers’ Advisory Council, 2013b) are described as ‘a vital new policy direction to enhance and
improve mental health service delivery in Australia’ (Australian Health Ministers’ Advisory Council,
2013a, p. 7). It is stated that these documents are underpinned by the National Standards for Mental
Health Services (Australian Government Department of Health, 2013) and have in turn informed the
revised National Practice Standards for the Mental Health (Australian Government Department of
Health, 2013). Lived experience is described within this document as ‘the heart of the framework’. In
this context, lived experience, enshrining the ‘personal recovery’ notion of recovery discussed above, is
recognised in equal measure alongside the knowledge and skills of mental health practitioners. The
framework is designed to assist mental health professionals in all aspects of service delivery to align
practice with recovery principles. However, for many professions within mental health practice,
especially those trained within a biomedical orientation this alignment requires a major shift in attitude
and practice. The inpatient context – a challenging environment for recovery-focused practice The
inpatient mental health facility is undoubtedly the most challenging environment in which to introduce
recovery-oriented practice. This context is strongly impacted by the dominant biomedical discourse that
is in turn underpinned by a legal discourse. The key concepts of the law include objectivity, rationality
and authority (Healy, 2005), paralleling the positivist language of the biomedical approach. The
combination of a biomedical and legal discourse forms a powerful partnership in creating a culture of
control and coercion in mental health care. There is much literature from the USA and UK that describes
the inpatient environment in exceptionally negative terms. Bartholomew and Kensler (2010) comment
on state psychiatric hospitals in the USA as continuing to use methodologies that predate evidencebased
practice and recovery principles including a continuing emphasis on custodial measures and the use of
medication – characteristics of a biomedical model. They note that a significant barrier to the
introduction of a recovery-oriented approach within inpatient settings is the existence of a ‘pervasive
culture of custodial care and control’ (p. 123). This is supported by Tsai and Salyers (2008), also writing
in the USA, who describe hospitals as using methods that predate the recovery movement, including
coercive measures to manage disruptive behaviours and symptom-focused treatments. Nolting (2010)
argues that there is still a role for state hospitals in the USA to provide care for those for whom the
community is unable to care. However, he refers to the contradictions inherent in the wording of state
policies that put patients at the centre of mental health care, while for the bureaucracies that run the
hospital system this is clearly not the primary concern. In a report by the Sainsbury Centre for Mental
Health (2006) in the UK acute inpatient units are noted as being places of last resort when all else fails.
The report vividly describes the inpatient environment: We admit people at their most distressed into
an environment that would be hard for anyone to cope with: a poor environment with many other
distressed people, sharing a dormitory with 8 B. Hyde et al. strangers, mixed wards, being watched,
liberty removed, loss of autonomy, no information and boredom. (p. 84) Somewhat countering the
overwhelmingly negative descriptions of hospitalisation, a qualitative study by Walsh and Boyle (2009)
from Northern Ireland explores patient experiences of mental health inpatient services and reveals the
existence of positive perceptions of hospital as a safe place. However, other themes revealed by this
study are consistent with the negative perceptions of the preceding studies, including boredom on the
units, poor communication with staff, lack of information and a perceived valuing of hospital routines
over patient needs. Positive perceptions of hospital experiences are often referred to as an aside or as a
‘false-positive’. As an example, the UK report from Rethink (2009) recounts consumer experiences of
hospitalisation as ‘a necessary evil’ or ‘an immensely sobering experience’ (p. 21). To a large extent the
literature questions the ability of inpatient services to provide care that is aligned with recovery
principles. For instance, in the USA, Tsai and Salyers (2008) surveyed hospital and community mental
health staff to gauge their levels of personal optimism, consumer optimism and the recovery orientation
of the agency. The results indicate that staff at state hospitals score significantly lower on all three levels
and the authors note the difficulties that hospital staff experience in accepting ideas of recovery,
compared to community staff who are more exposed to consumers living independently and
experiencing success. They state that little is known about the extent of recovery orientation in a
hospital setting, while drawing attention to the importance of fostering a recovery perspective in an
acute phase of a mental illness. The authors highlight the importance of a recovery orientation in any
mental health organisation but emphasize that the hospital environment has a wider gap to address in
order to adopt a recovery mindset. The realisation of recovery-oriented practice within an organisation
such as a public hospital setting, which is itself embedded in a wider bureaucracy, presents its own
challenges. Cleary, Horsfall, O’Hara-Aarons, and Hunt (2013), in a study of mental health nurses’ views
of recovery within an Australian inpatient setting, noted that many of the participants did not see the
organisation’s structures or functioning adhering to the principles of recovery practice and processes.
Structural and organisational issues such as understaffing and insufficient beds were viewed as barriers
to implementing recovery-oriented practice and it was noted that while a recovery focus is endorsed at
the organisational level in policy mission statements, these documents were not developed in a
collaborative partnership with service users. This begs the question of how a recovery focus can be
implemented at the practice level when the organisation mandating such practice demonstrates a
blatant disregard for, orignorance of,the very principles demanded of the workers. Nolting (2010) set
out to test the hypothesis that psychiatric rehabilitation can operate in ‘a traditional “centralized”
institutional organizational and administrative framework’ (p. 3). The methodology utilised a case study
approach involving one psychiatric rehabilitation service in the USA, located in a state psychiatric
hospital. Sadly, the hypothesis was not supported and inherent conflicts between a recovery focus or ‘a
psychiatric rehabilitation model’ and the institutional status quo were identified, eventually leading to
the closure of the service. Recovery and biomedical model – complementary models? It is clear from the
literature regarding the context of hospital care that there are many challenges to be faced in ensuring
the successful implementation of recovery principles into existing inpatient mental health care delivery.
Recovery-oriented practice can be seen Asia Pacific Journal of Social Work and Development 9 as
oppositional to the traditional ways of working within a biomedical model. The downplaying of lived
experience is seen as an epistemic injustice (Bell, 2014) where a dominant discourse has the effect of a
‘testimonial quieting’ or ‘testimonial smothering’ (Dotson, 2011, p. 242) of the voices of those affected –
in this case, by the phenomenon of mental illness. However, it is possible to reframe the language of
difference into the language of complementarity. From this perspective the recovery movement is
providing the ‘other half’ of the story, traditionally overlooked by the biomedical model. If placed
together in a complementary relationship wherein the epistemic justice is addressed and lived
experience is acknowledged and respected, these two approaches provide a formidable opportunity to
create a responsive and effective mental health service. Recovery principles of practice and social work
practice The recovery movement has given rise to the acceptance within mental health service delivery
of many concepts and values that are embedded within social work principles and practice. Narrative,
strengths-based, empowerment and anti-oppressive practice theories can actualise the move to
recovery-oriented practice. Of the many definitions of recovery, the following from Slade (2009) outlines
the meaning of recovery from a consumer perspective: ‘Recovery happens in the space in-between
person and context: personal relationships, physical space and other economic, social and cultural
factors’ (p. 4). The notion of recovery happening ‘in the space in-between’ aligns with social work’s
description of its position within the domain of mental health. The Statement of Domain in the AASW
Practice Standards for Mental Health Social Workers (AASW, 2008) notes that ‘Social work practice
occurs at the interface between the individual and the environment’ (p. 8). This ‘interface’ or ‘space inbetween’ is familiar and critical in mental health reform and intrinsic to social work practice. The
closeness of fit between social work principles and values and those of the recovery movement stands
out in the reading of many of the policy and guideline documents now published to inform mental
health practice. The descriptions of recoveryoriented practice in the newly published Recovery
frameworks mentioned previously closely resemble the principles of practice and values of the social
work profession as set out in the AASW and the IFSW Codes of Ethics. This alignment is startling when
examples of descriptions of recovery-oriented practice from the literature are placed alongside the
social work Codes of Ethics and the AASW Practice Standards for Mental Health Social Workers (Table 1).
The invisibility of social work Much of the literature review was sourced through PsychINFO and Embase
via CIAP (Clinical Information Access Portal). One of the observations made while conducting this
literature review was that few documents sourced using the terms ‘recovery’ and ‘mental health’
yielded articles authored by social workers. This was surprising, given that the principles of recoveryoriented practice in mental health align so closely with the values and principles of social work as shown
in Table 1. The invisibility of the social work profession within the debates about recoveryoriented
practice in mental health was brought to the fore by a comment in Slade et al. (2008) in which 10
principles of recovery-focused practice identified through a consensus based approach in the USA were
outlined. The 10 principles are basic to the social work 10 B. Hyde et al. approach and include self
direction; individualised and person-centred; empowerment; holistic; non-linear; strengths-based; peer
support; respect; responsibility; hope. The following statement then made by the authors – ‘It will be
challenging for mental health services to develop these characteristics, many of which are not central to
the professional training of any mental health group’ (p. 131). – is remarkable for a mental health social
worker to read, whose clinical training was embedded with precisely ‘these characteristics’. Ramon
(2009), writing in the British Journal of Social Work, acknowledges that while social workers have been
responsible for some of the changes in mental health practice, such as the introduction of a strengths
approach and the inclusion of service users in policymaking, social workers have, on the whole, been
invisible in the move to recoveryfocused practice in mental health. She states: ‘While recovery should
have been a natural domain for social workers, given its psycho-social and self-determination emphasis,
relatively few UK social workers are in the forefront of recovery work’ (p. 1620). Ramon (2009) adds that
social work’s reluctance to engage in research is not only a weakness of the profession as a whole, but
one that has resulted in its lack of influence specifically in the mental health field. Ramon, Lachman,
Healy, Shera, and Renouf (2009) reiterate this concern and add that social work perceives itself as being
less powerful than other professions in the field of mental health. They call for further research to
explore the obstacles and opportunities for social workers to engagein the formulation of recovery
policy. Interestingly, these authors, in describing the UK experience, comment that mental health social
workers ‘assume’ they practice within a recovery focus of knowledge and skills due to the stated
similarities between recovery principles and social work principles, when in reality they need to move
away from pathologising and patronising approaches inherent in their work. This concession of social
work to the dominant medical model is taken up by Morley (2003), who strongly admonishes social
work for its lack of critical focus and ready capitulation to the dominant biomedical discourse in mental
health. Indeed, just noting an alignment between principles of social work such as ‘acceptance Table 1.
Comparison of social work and recovery principles. Social work Recovery approach Self-determination
Self-determination Empowerment Empowerment Acceptance and uniqueness of individuals Personal
meaning, expert by experience Collaboration and participation Collaborative relationships Identifying
and developing strengths Strengths Respect for inherent dignity, worth and autonomy of every person
Self-identity, sense of agency, inherent capacity to live a full and meaningful life of their choosing
Respects the human rights of individuals and groups Upholding of human rights Fosters personal/social
responsibility Focusing on strengths and personal responsibility Hope-giving Hope and optimism
Reflective awareness as part of professional integrity Staff to engage in reflective practice Compiled
from IFSW Statement of Ethical Principles (2012); AASW (2010) Code of Ethics; AASW Practice Standards
for Mental Health Social Workers (AASW, 2008) Compiled from Onken et al. (2007); Rethink (2009);
Glover (2009); Deegan (1995), Australian Health Ministers’ Advisory Council (2013a, 2013b) Asia Pacific
Journal of Social Work and Development 11 and uniqueness of individuals’ and the recovery concept of
‘expert by experience’ (Table 1) does not of itself guarantee that the concepts are one and the same or
that true recovery-oriented practice will automatically be intrinsic to the practice of all mental health
social workers. The move from principal to practice requires deeper critical reflection that needs to
commence at the level of mental health social work training, acknowledging and respecting lived
experience as an alternative participatory and patientcentred epistemology. This will equip the mental
health social worker to resist and critique the ‘pull’ of the dominant discourse. Ramon et al. (2009) refer
to the potential that exists for social work to act as a catalyst for much-needed change in mental health
service delivery across four countries – the UK, Australia, Canada and Israel. This leadership role for
social work is also recognised in Canada by Shera (1996), in America by Starnino (2009) and in Australia
by Bland, Renouf, and Tullgren (2009). In their book Social Work Practice in Mental Health, Bland et al.
note the similarity between the recovery approach and social work principles but this noted alignment
does not play a significant role in their argument for social work leadership in mental health. The
introduction of recovery principles now embedded in State and national mental health policy
documents presents the opportunity for social work to be at the forefront of mental health reform.
Instead of strengths-based, narrative and anti-oppressive language being marginalised and in opposition
to the language of mainstream and traditional models of care, it is now mandated as the prominent
discourse. Social work’s strong alignment with recovery principles affords the opportunity for the
profession to play an important role in modeling how recovery practice can be realised. In line with a
social work perspective, and as noted previously, the organisational context must also be taken into
account. In this case, the organisational barriers encountered in a public hospital inpatient facility need
to be carefully considered in the move to practice change. Social workers will need to consider a
leadership role at both a practice and an organisational level to ensure that the principles of recovery
are truly embedded in service delivery. Towards this end, organisations need to cherish a more
democratic dialogue from within on democratic leadership, and a more people- (patient-)oriented
structure. Social work contribution to recovery-focused practice in acute inpatient facility – practice
examples The following five examples are drawn from the personal experience and observations of one
of the authors, a social worker in a large rural inpatient mental health facility. These examples
demonstrate how everyday social work practice which draws on narrative theories, strengths-based,
anti-oppressive and mutual aid methods of practice models recovery-oriented approaches in action.
Strengths-based practice was utilised in the running of a group in the acute units, called ‘What’s Right
With Me’. Even the language chosen for the title is a direct challenge to the milieu of deficit-based
language of the medical model with its emphasis on symptoms and ‘what’s wrong’. The group differed
from other groups run on the unit in that it used a mutual aid model of group work and not the didactic
approach of other groups that focus on a psycho-educational approach seeking to teach or inform. The
psycho-educational model can be seen to unintentionally typify the passive recipient/expert
relationship, notwithstanding its proven value in this setting (Cohen & Graybeal, 2007; Glick & Dixon,
2002). Over a period of 15 months, 144 evaluations were analysed from 184 participants of the ‘What’s
Right With Me’ group. Results indicated that participants valued the 12 B. Hyde et al. opportunity to
share experiences and provide support to each other. They developed a greater understanding of their
own strengths and appreciated being listened to and having the opportunity to listen to others. A
strengths-based approach within a model of mutual aid group work provides an empowering episode of
care that acknowledges the lived experience and collective resourcefulness of the participants. A second
example is the use of a telephone-mediated mutual aid model of group work for carers whose relatives
were admitted to a long-term mental health rehabilitation unit. This example has been reported
elsewhere (Hyde, 2013). Data collated over a seven-year period of evaluations with these groups
indicated that the carers valued the supportive and collaborative nature of the groups, consistently
reporting a reduction in isolation as well as benefits in the short term to their health and well-being. A
third example is a social work-initiated group in a unit for women experiencing chronic and complex
mentalillness. This was a most challenging experience but onethat demonstrates that recovery-oriented
practice is possible in the most oppressive of environments. The majority of women in these units have
suffered traumatic histories of personal abuse as well as drug and/or alcohol use. Many of them are
disenfranchised from their families and from community services. All the women have a diagnosis of a
long-standing mental illness and many have suffered the loss of their children, some through forcible
removal. The experience of providing group work in this environment drew on theories of mutual aid, of
strengths-based practice, of existential group approach and Gestalt therapy. It stretched the
understanding of the application of anti-oppressive practice within an oppressive environment and was
highly confronting in respect of ensuring client selfdetermination and choice. The group provided a
forum for the exploration of suppressed painful emotions (psychotherapeutic focus) and facilitated
intense support between participants (mutual support). Evaluations at the conclusion of the group
indicated that the participants most appreciated the strengths approach, with one participant
articulating her ability to speak about ‘buried feelings’ for the first time. The value of a narrative
approach has been observed in the inpatient setting in the work done by a social worker with young
men suffering from long-term mental illness, the fourth example. The purpose of this work was
deliberately narrative focused and centred on challenging the acquired identity of these young men as
‘mentally ill’ – an identity that had been imposed on them through years of diagnostic labelling. Using a
narrative approach within a group-work model, they were provided with a safe environment in which to
question these labels, choose what they wanted to keep and what they wanted to discard, and
reconstruct an alternative narrative. For some in these groups this just meant having their stories
validated and acknowledged. This was no mean feat, given the hostile environment of an inpatient
setting which is not conducive to open discussion about behaviours and experiences such as voicehearing that are readily pathologised and ‘treated’. Like strengths-based work, this practice with
narrative strategies provides a counterbalance to the disempowering effects of the dominant
biomedical discourse. The Recovery framework documents referred to previously (Australian Health
Ministers’ Advisory Council, 2013a, 2013b) emphasise the important role of family and carers in the
recovery of a person with a mental illness. The final example of social work practice illustrates how the
support and acknowledgement of family and carers has been introduced to a long-stay residential unit
of the hospital. These family members have dealt with the effects of a chronic and complex mental
illness within their families for many years. The average age of the residents of this unit is 51, with some
having been a resident of this facility for over 30 years. There are no families who reside in the local area
and visits are limited due to the distances the family members have to travel. The social worker initiated
a Asia Pacific Journal of Social Work and Development 13 Family and Carer Open Day once a year, when
families travel to spend one or two days with their relative and participate in activities and a lunch.
Accommodation is funded and the day provides an opportunity for family members to meet with staff
and to interact with each other. The carer-support component of this program is now enhanced with a
telephone linkup every two months for those family members who are able and who want to
participate. This has proved to be extremely popular, with all 10 telephone lines being utilised on most
occasions. The family members have used their collective voice to lobby for things such as a pedestrian
crossing on the road outside the hospital grounds and to provide input into the programs provided by
the unit and into the direct care of their loved ones. Conclusion Recovery-oriented practice has become
the mandated model of care in mental health service delivery on a global level. In Australia, principles of
recovery are now articulated in national policy guidelines and frameworks for practice. These principles
of practice are founded on the acknowledgement of consumer lived experience and are challenging the
traditional biomedical model, which is at its most influential in the mental health inpatient setting. An
admission to a mental health inpatient unit is almost universally viewed as a negative experience and
the translation of recovery principles into practice in this setting is a significant challenge. Despite the
strong alignment between recovery principles and those of the social work profession, social work
voices have been noticeably absent from the international recovery literature. On the other hand, social
work interventions in mental health inpatient settings such as those discussed in this paper have been
quietly proceeding ‘under the radar’ of the biomedical model for many years while perhaps not being
seen as contributing directly to ‘treatment’ of the ‘patient’. These interventions can now come into the
spotlight in their own right as examples of good practice using recovery principles. Interventions that
focus on the lived experience of the person with mental health issues, working in partnership with them,
or that encourage family members to play an active part in inpatient services, draw directly on recovery
principles as well as traditional social work approaches. This directly addresses the ‘epistemic injustice’
(Bell, 2014) perpetrated by a disregard of the lived experiences of these people and their carers.
Although the article is based on Australian data and experiences, its analysis and arguments have
implications for recovery-oriented practice in Asia-Pacific countries and beyond. The time has come for
social work in all countries and cultures to take up the challenge raised in much of the mental health
literature, to step into leading roles together with people who have experienced mental health issues,
and their supporters. First, however, social workers need to become aware of and acknowledge their
professional alignment with principles of recovery and their ability to practice within a recovery
orientation in mental health services. They need to explicitly make links between their everyday practice
and recovery principles and take a democratic and person-centred leadership role in the
implementation of recovery-oriented mental health practice in accordance with national policy. Notes
on contributors Bronwyn Hyde is a doctorate student in the Doctor of Social Work, School of Humanities
and Social Sciences, Charles Sturt University, Australia. Wendy Bowles is Associate Professor of Social
Work, School of Humanities and Social Sciences, Charles Sturt University, Australia. 14 B. Hyde et al.
Manohar Pawar is Professor of Social Work, School of Humanities and Social Sciences, Charles Sturt
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D EBA T E Open Access An Integrated Recovery-oriented Model (IRM) for mental health services:
evolution and challenges Barry G. Frost1,2, Srinivasan Tirupati3,4, Suzanne Johnston3 , Megan Turrell3 ,
Terry J. Lewin2,3,4*, Ketrina A. Sly2,3,4 and Agatha M. Conrad2,3,4 Abstract Background: Over past
decades, improvements in longer-term clinical and personal outcomes for individuals experiencing
serious mental illness (SMI) have been moderate, although recovery has clearly been shown to be
possible. Recovery experiences are inherently personal, and recovery can be complex and non-linear;
however, there are a broad range of potential recovery contexts and contributors, both nonprofessional and professional. Ongoing refinement of recovery-oriented models for mental health (MH)
services needs to be fostered. Discussion: This descriptive paper outlines a service-wide Integrated
Recovery-oriented Model (IRM) for MH services, designed to enhance personally valued health,
wellbeing and social inclusion outcomes by increasing access to evidenced-based psychosocial
interventions (EBIs) within a service context that supports recovery as both a process and an outcome.
Evolution of the IRM is characterised as a series of five broad challenges, which draw together: relevant
recovery perspectives; overall service delivery frameworks; psychiatric and psychosocial rehabilitation
approaches and literature; our own clinical and service delivery experience; and implementation,
evaluation and review strategies. The model revolves around the person’s changing recovery needs,
focusing on underlying processes and the service frameworks to support and reinforce hope as a
primary catalyst for symptomatic and functional recovery. Within the IRM, clinical rehabilitation (CR)
practices, processes and partnerships facilitate access to psychosocial EBIs to promote hope, recovery,
self-agency and social inclusion. Core IRM components are detailed (remediation of functioning;
collaborative restoration of skills and competencies; and active community reconnection), together with
associated phases, processes, evaluation strategies, and an illustrative IRM scenario. The achievement of
these goals requires ongoing collaboration with community organisations. Conclusions: Improved
outcomes are achievable for people with a SMI. It is anticipated that the IRM will afford MH services an
opportunity to validate hope, as a critical element for people with SMI in assuming responsibility and
developing skills in self-agency and advocacy. Strengthening recovery-oriented practices and policies
within MH services needs to occur in tandem with wide-ranging service evaluation strategies. Keywords:
Evidence-based psychosocial interventions, Hope, Mental health services, Models, Recovery, Recoveryoriented, Rehabilitation, Serious mental illness * Correspondence: Terry.Lewin@hnehealth.nsw.gov.au 2
Centre for Brain and Mental Health Research, Hunter New England Mental Health and the University of
Newcastle, Callaghan, NSW 2308, Australia 3 Hunter New England Mental Health, Newcastle, NSW 2300,
Australia Full list of author information is available at the end of the article © The Author(s). 2017 Open
Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,
and reproduction in any medium, provided you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative
Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/)
applies to the data made available in this article, unless otherwise stated. Frost et al. BMC Psychiatry
(2017) 17:22 DOI 10.1186/s12888-016-1164-3 Background Disorders such as schizophrenia were
historically viewed as chronic, degenerative illnesses, with little prospect of improvement or recovery.
These negative and debilitating notions of serious mental illness (SMI) were challenged by the consumer
movement, with recovery perspectives bringing a new sense of meaning and purpose to individual’s
lives, even though symptoms might remain [1–4]. However, in the absence of clear operational or
scientific definitions of ‘recovery’, it was questioned whether the process would be understood and
amenable to collaborative interventions [5], or the value of the term compromised [6] and potentially
commandeered by those seeking to reduce service costs [7, 8]. Concerns that recovery-focused
initiatives could default to rhetoric rather than practice were also raised [9, 10]. Consumer research
identified recovery as both a process and an outcome, involving factors related to personal wellbeing
and social inclusion, which were distinct from traditional clinical domains [4, 11]. Nevertheless, some
scepticism remains around the notion of recovery [12], coupled with concerns that the burden of risk
will be borne by families and carers [13]. It is generally accepted that improved mental health (MH)
outcomes can be achieved through access to a range of psychosocial evidence-based interventions
(EBIs) [10, 14–16]. However, sufficient service ‘infrastructure’ needs to be activated to ensure recoveryoriented approaches are successfully embedded into everyday practice and access to EBIs is enhanced.
Advances in psychopharmacology made it possible for many people with SMI to be discharged from
long-stay care. However, they were often discharged from highly structured inpatient environments
with little provisioning for their needs, which according to some reports, did not extend beyond a
prescription [17]. It became increasingly apparent that many individuals experience a constellation of
signs and symptoms superimposed and interacting with a background level of impairment and disability.
Function is often impaired across multiple domains (e.g., cognition, living skills, social skills,
occupation/education) and the level of impairment can often be exacerbated by relapse and deteriorate
further with subsequent episodes [15]. Whilst psychopharmacological treatments have improved and
are considered fundamental to illness management, their role in the restoration of skills considered
essential for a satisfying and fulfilling life is at best limited. For example, Meltzer [18] was unable to
identify a correlation between amelioration of positive symptoms and social outcomes. It is also evident
that medications have not solved the problem of relapse [19] and carry significant side effects and risks,
including over-reliance, poly-pharmacy and inappropriate use [20]. Following a 20 year longitudinal
study, Harrow et al. [21] state that “antipsychotics are not effective in eliminating or reducing psychosis
for the great majority … and may impede recovery of some …” (p. 3013). Further, Deacon [22] suggests
that under biomedical treatment models there has been a sharp increase in psychiatric medication use,
a broad lack of clinical innovation, and poor MH outcomes. Despite calls for reform, the disparity
between the recovery needs of individuals with SMI and service delivery paradigms is reflected at
several levels. For example, among young people, schizophrenia remains one of the top ten causes of
disability [23]. People with psychotic disorders represent 25% of total disease burden [24] and
schizophrenia is the 3rd most important disease in terms of years lived with disability for those aged 15–
44 years [25]. Poor physical health is also experienced by many people with psychotic disorders, with
45.1% classified as obese and 33.5% assessed as having low physical activity [26]. The majority of people
with SMI are also unemployed (78.5%), have poor education levels, impaired social skills (63%), and
limited contacts [26]. Consequently, the estimated annual economic cost in Australia for all psychotic
disorders is $4.91 billion from a societal perspective and $3.52 billion from a government perspective
[27]. Moreover, even though annual costs have been relatively stable (over the 2000–2010 decade),
there has been a significant redistribution of costs to the nonhealth sector, in line with Australian
government initiatives [28]. The high and continuing levels of burden associated with SMI have
prompted some authors to call for ‘widespread systemic change’ to MH systems, promoting an
increased emphasis on shared decision making, independence (e.g., financial, residential, personal) and
social connectedness [10]. Regional opportunities and imperatives Like many countries, Australian MH
services are currently in a state of transition, including: formulation of national frameworks with an
increased focus on recoveroriented care provision [29–31]; development of a new Australian MH Care
Classification [32]; and introduction of Activity Based Funding [33]. In broad terms, recoveryoriented
service delivery: “… is centred on and adapts to people’s aspirations and needs, rather than people
having to adapt to the requirements and priorities of services” and it has a “…responsibility to provide
evidence-informed treatment, therapy, rehabilitation and psychosocial support that assist in achieving
the best outcomes for people’s mental health, physical health and wellbeing” [30], p. 26. Within New
South Wales (NSW), planning commenced in 2005 to establish a number of sub-acute inpatient MH
units, with the primary goal of improving access for people Frost et al. BMC Psychiatry (2017) 17:22 Page
2 of 17 with SMI to recovery-focused rehabilitation services that were highly integrated and rigorously
evaluated [34]. This provided an opportunity for Hunter New England Mental Health services to develop
an innovative model of care at a level of service delivery that had not previously been explored. Details
about the specific 20-bed, sub-acute Intermediate Stay Mental Health Unit (ISMHU) that was initially
established are provided elsewhere, together with our preliminary service evaluation [35]. Importantly,
development of a new level of regional MH care necessitated consideration of all of the potential MH
service pathways and partnerships, together with their treatment models and intended goals. Within
this context, and given the limited availability of established service-wide, recovery-focused models of
care [36–39], a broader framework for an Integrated Recoveryoriented Model (IRM) for MH services
was formulated, which sought to support and promote ‘remediation, restoration and reconnection’. The
primary purpose of this paper is to outline the IRM and to stimulate ongoing refinement of
recoveryoriented service models. Evolution of the IRM is characterised with respect to five broad
challenges. The first three challenges relate to identification of: 1) relevant recovery perspectives; 2)
overall service delivery frameworks and models; and 3) key features and processes associated with
current specialised clinical rehabilitation (CR) interventions for people with enduring SMI. The fourth, or
central challenge, is to draw together the main elements from these first three challenges into a
coherent, service-wide IRM for MH service delivery. The fifth challenge relates to devising relevant
implementation, evaluation and review strategies for recovery-oriented MH service models and
components. Recovery perspectives Challenge 1 Identifying the aspects of personal and clinical
‘recovery’ and related approaches that need to be considered in re-designing ‘recovery-oriented’ MH
services. Recovery possibilities and needs Research has shown that recovery is possible [40, 41] and that
people with SMI value the opportunity to participate and contribute to society [42]. However, for many
there is limited access to EBIs that may prove effective in supporting hope and restoring confidence and
competence [43]. Mojtabai et al. [44] found that more than 50% of people with schizophrenia received
either no treatment or suboptimal treatment. Torres-González et al. [45] identified six areas of specific
need: frequent complications and comorbidities (e.g., substance misuse); psychological, social and
economic needs; early interventions to reduce illness progression; treatment augmentation with
rehabilitation EBIs; maintenance of service contacts; and greater research efforts into existential needs.
Better access to psychosocial interventions and well-managed medication are warranted [14, 45],
together with a shift away from case/risk management practices to service models that facilitate access
to EBIs [10, 20]. Recovery goals The term recovery is clearly multi-layered. Nevertheless, it carries an
unequivocal message of a better outcome, conveying a sense of hope; it may also carry expectations in
regard to interventions, timeframes and supports. Attempts to reintroduce hope and optimism are
based on the view that recovery is possible even though residual limitations may remain. Unlike physical
medicine, where recovery goals are generally well understood, the role and significance of rehabilitation
for people with SMI has been less well understood – even though psychiatric rehabilitation has always
been about ‘recovery’ [19] and supporting self-determination and independence through improvements
in wellbeing and role functioning. Snyder et al. [46] described hope as “the person’s perceived ability or
internalised belief that he or she can produce goals, pathways and agency” (p. 89), suggesting that, as a
goal directed motivational process, hope requires constant feedback and agency. If hope is a catalyst for
change and improved health outcomes [46], the question arises as to how hope is both generated and
sustained. This also brings into focus the ethical requirements of beneficence (doing good) and
maleficence (avoiding harm) that typically guide health service provision. Some recovery-oriented
frameworks propose that hope may be generated through service and cultural reforms; for example, “…
the physical, social and cultural service environment inspires hope, optimism and humanistic practices
for all who participate in service provision” ([47], p. 7). Although such statements are very positive, they
run the risk of being overpowered and reverting to rhetoric, unless driven by outcomes that reconfirm
the considerable investments in recovery. Le Boutillier et al. [37] suggested that promoting citizenship
and a clear sense of place are core goals for recovery-oriented MH services, the primary purpose of
which is to encourage self-agency. Validating personal goals can also help to reduce a client’s sense of
frailty and hopelessness. Liberman and Kopelowicz [5] proposed that as improvements are made in a
range of personally valued domains, more subjective qualities such as hope, empowerment and
autonomy become evident. Snyder et al. [46] suggested that the processes of hope and rehabilitation
“fuel each other in an iterative manner over the temporal course of Frost et al. BMC Psychiatry (2017)
17:22 Page 3 of 17 treatments” (p. 107). Recovery can be complex and non-linear, with hope seen as
critical in shaping and sustaining improvements in a range of skill domains, consistent with social
inclusion [48, 49]. Recovery processes Early access to rehabilitation interventions has been associated
with better functional outcomes [50]. Making rehabilitation available across the continuum of care may
reduce health costs by shortening hospital admissions, reducing activity limitations, and improving
quality of life. More generally, the discipline of psychiatric rehabilitation has contributed much to
improving service delivery and outcomes [17]. Psychiatric rehabilitation challenged the MH system to
think more expansively and respectfully about people with SMI, promoting choice, shared decisionmaking, consumer involvement, and a focus on inherent strengths and recovery possibilities. The
discipline of psychiatric rehabilitation promoted the adoption of a broad, holistic approach and
advocated for access to quality residential, education and employment opportunities. Quality
frameworks were also introduced, including comprehensive multidisciplinary and inter-service team
reviews. Due to the obvious synergies with the recovery approach, rehabilitation services have been
proactive in adopting consumer oriented recovery strategies. Much has also been done to reduce the
negative approach associated with the official nosology of schizophrenia, in which therapeutic nihilism
and stigma have operated as self-fulfilling prophecies [5]. Perhaps, reluctance to accept the discipline
stems from the fact that psychiatric rehabilitation is relatively easy to define but, as highlighted by
Anthony and Farkas [17], any explanation belies the complexities of the processes involved. An
understanding of personal recovery as a subjective experience has emerged and this meaning now
underpins MH policy internationally e.g., [38, 51]. While the provision of recovery-oriented care is a
guiding principle, implementing recovery-oriented or recoveryenabling [52] practices requires
transformations within MH systems [10, 38, 39]. In some sectors, such as MH inpatient settings, there is
limited research directly addressing recovery-oriented practice [39, 53]. However, a recovery enabling
framework has been proposed to address workforce gaps in core recovery competencies among
inpatient providers [52]. Until recently, the focus was almost exclusively on clinical recovery [54]. Central
to the delivery of recovery-oriented services is a shared understanding of recovery between consumers,
carers and health professionals [51]. Recovery-oriented psychiatric rehabilitation can be seen as
supporting people with SMI in the pursuit of a meaningful life [55]. As recovery is an ongoing and nonlinear process, recovery-oriented experiences and opportunities during periods of hospitalisation also
need to be adequately addressed [52]. Recovery contexts Once again, it needs to be explicitly
acknowledged that recovery experiences, opportunities, trajectories, and evaluations are inherently
personal. Among people with SMI, recovery is generally viewed as “a journey of small steps”, within
which participation in everyday activities is “frequently considered as both facilitators and indicators of
recovery” ([10], p. 237). Moreover, while the current paper is primarily about recovery-oriented MH
service provision, there are a broad range of potential recovery contexts and contributors and, for many
people, professional interventions may play a relatively minor or timelimited role [56]. On the other
hand, individuals with enduring SMI are likely to be influenced proportionately more by the attitudes
and practices of specialised MH, general health, and community managed services. Importantly, key
processes associated with recovery (e.g., sustaining hope, promoting self-agency and reconnection)
need to occur both within and outside of MH services [56] and, where possible, be enhanced by
integrated, recovery-oriented practices. Service delivery frameworks and models Challenge 2
Reconciling the broad array of general and specialised service delivery frameworks, models and
intervention strategies of potential relevance to ‘recovery-oriented’ MH services. There are numerous
recommendations about service delivery approaches, ranging from general health or MH focused overarching ‘frameworks’, through broad ‘intervention strategies’ or ‘models’, to specific ‘targeted
interventions’. The WHO International Classification of Functioning, Disability and Health [ICF, 57]
provides a general framework for considering the spectrum of needs of people with SMI. Integrating
medical and social models for people with health conditions, the ICF focuses on human functioning,
activity and participation, rather than disease and disability. It also provides a comprehensive guide to
the identification of a range of protective and risk factors. For example, at the level of body function, the
ICF framework includes consideration of psychotic symptoms, poor concentration and memory, low selfesteem and confidence. Activity limitations may include poor self-care, poor physical health, social
withdrawal, and an inability to follow instructions. Participation restrictions may be reflected as the
inability to continue education, difficulties maintaining social Frost et al. BMC Psychiatry (2017) 17:22
Page 4 of 17 relations, problems with accommodation and accessing recreational activities.
Consequently, an array of recoveryoriented approaches may be required to promote and sustain hope
and resilience, facilitating improvements in personal functioning, activity and social participation. The
ICF has previously been implemented in an Italian psychiatric rehabilitation setting and reported to be a
helpful framework among people with SMI, promoting a common language and integrated treatment
model, supporting the development of client focused individual rehabilitation plans and improving
services [57]. Similarly, individualised approaches to recovery in vocational rehabilitation have found
positive effects on both clinical and employment outcomes [58]. Although the research literature
provides some assistance in regard to recoveryoriented frameworks, it provides limited guidance on
optimal delivery systems or recovery-oriented models for MH services. Perkins and Slade ([59], p. 33)
noted that “there can be no ‘blueprint’ for recovery – each person must find their own way”, although
key factors important in supporting recovery-oriented practice and transforming MH services have been
identified in the recovery literature. Le Boutillier et al. [37] proposed a conceptual framework to guide
practice, focusing on four domains: promoting citizenship; organisational commitment; supporting
personally defined recovery; and working relationships. Hopper [60] viewed recovery as a therapeutic
endeavour and proposed four stages in the recovery process: renewing a sense of possibility; regaining
competencies; reconnecting and finding a place in society; and reconciliation. Rodgers et al. [61]
employed a staged approach, mapping EBIs for each stage of the recovery process. From a service
model perspective, Thornicroft and Tansella [62] suggested service configurations should be balanced
between hospital and community services, outlining three levels of care: primary care with specialist
back-up; mainstream MH care; and specialised MH services. Specialised services included: early
intervention; assertive treatment teams; alternatives to acute inpatient care; residential care and
vocational rehabilitation. Adopting a slightly different approach, Flannery et al. [63] developed a service
model based on the core functions required for a recovery-focused MH system: acute care (community
teams and alternatives to inpatient care); emergency services; continuing care partnerships (assertive
treatment teams, supported accommodation, therapy services, vocational rehabilitation and drop-in
centres); and early intervention services. Although this pragmatic approach could be introduced with
minimal cost, it is unclear how access to EBIs and other major requirements of recovery-focused models
would be achieved. The fundamental tenant of any reform should be that recovery is supported as both
a process and an outcome. If this does not occur, there is an inherent risk that traditional imperatives
will prevail and re-establish a disconnected dichotomous system (e.g., acute/emergency vs. disability
support services). Slade et al. [38] identified ten validated interventions that support recovery by
targeting key processes (connectedness, hope, identity, meaning and empowerment [CHIME]) [64],
illustrative of the types of interventions expected in recovery-oriented MH systems. These included:
peer support workers; advance directives (if future capacity is lost); wellness recovery action planning
(WRAP) tools and processes [65]; illness management and recovery (IMR) [66]; the REFOCUS model
(recovery-promoting relationships and work practices) [67, 68]; strengths-based models [69]; recovery
colleges or recovery education programs; individual placement and support (IPS) [70]; supported
housing; and MH trialogues (community forums). Many of these EBIs can be implemented regardless of
the specific recovery-oriented model; although some have been evaluated predominantly in community
MH settings [38]. Others involve more complex manualised pro-recovery interventions or modules, such
as the REFOCUS model, IMR program, and WRAP, which also emphasises peer support in the
development of individual recovery plans [65]. Strengths-based case management models supporting
consumer directed care have also been implemented in both acute and community MH settings [69, 71],
focusing on personal strengths and goals rather than deficits, and integrating a variety of EBIs. While all
approaches support recovery, few provide an overarching framework and service-wide model for MH
care provision. Internationally, implementing recovery-oriented practices has posed challenges for MH
services [65, 72]. In Australia, a need for MH systems transformation has also been identified, in order to
provide a continuous recovery-oriented care framework that links acute inpatient and community
services [73]. Recent conceptualisations of recovery-oriented practice have focused primarily on clinical
and personal recovery; however, a new concept of service-defined recovery is seen as translating
recovery into practice according to the goals and needs of an organisation [74]. This accords with earlier
suggestions that an ideal model should “link the abstract concepts that define recovery with specific
strategies, that systems, agencies and individuals can use to facilitate it” ([75], p. 482). While service
approaches operationalising recovery-oriented practice are yet to be extensively evaluated, research on
staff perspectives has identified perceived barriers (e.g., competing priorities in providing recoveryoriented support), which also highlight the need for a whole-systems approach in transforming services
[74, 76]. Frost et al. BMC Psychiatry (2017) 17:22 Page 5 of 17 Clinical Rehabilitation (CR) within MH
services Challenge 3 Building on the core elements of psychosocial and MH rehabilitation, to facilitate
service provision along a recovery-oriented continuum, with specialised clinical rehabilitation processes
and services nearer to one extremity, delivering targeted MH interventions and supporting people with
enduring SMI. In part, we use the expression ‘CR within MH services’ to draw a distinction with
‘disability support’ (associated primarily with care linked to enduring functional impairment or other
activity limitations) and to deemphasise the discipline-specific aspects of ‘psychiatric rehabilitation’, in
favour of a recovery-oriented care continuum of relevance to all MH workers. All of these approaches
have roles to play but require different skills sets, competencies and professional and clinical processes.
Encouraging clients to progressively assume independence and responsibility for their own care is
axiomatic to CR and consistent with personal recovery approaches [6, 16, 17, 19, 77]. Given that CR
provides a unique opportunity to empower people with SMI to assume greater levels of self-agency, the
question arises as to how these opportunities can be further realised within service delivery models that
not only respect this role but also complement and enhance opportunities for recovery and social
inclusion? CR employs a set of interventions and processes that aim to achieve and maintain optimal
functioning in the client’s environment of choice. CR is about helping individuals to realise their personal
goals, in a supportive context that builds trust and confidence in self-agency. It is about affirming and
reaffirming that the investment of hope in personal coping and everyday functional skills has been
justified and, in so doing, support the independent exploration of new and more satisfying personal
goals. Developing interventions and supports that promote recovery and challenge commonly held
stereotypes, which by definition disable and segregate, is a complex undertaking. Hope is a key factor in
this process and, in taking the first tentative steps to regaining a sense of control and self-agency, it is
vitally important to understand the risks involved and to ensure trust and personal dignity are
protected. Ensuring that an individual’s investment in rehabilitation and recovery processes is
supported, and not adversely affected as new goals are explored, is also critical. Depending on individual
recovery goals, CR may involve single or multiple EBIs delivered by a skilled practitioner, in conjunction
with a CR team. The interventions should be developed in a collaborative, empowering and optimistic
manner, based on a thorough understanding of the person’s goals and abilities (including both strengths
and vulnerabilities). The plan may also be cross-sectoral, involving health professionals working in
conjunction with general practitioners (GPs), community support agencies, as well as educational,
employment and housing organisations. From a service-led recovery perspective [74], it should also be
recognised that there may need to be different service streams even within specialised CR services,
reflective of variations in the complexity of client needs and available resources; for example, some
service streams may offer targeted, time limited EBIs, while others provide more of a ‘continued care’
approach, supporting clients with enduring SMI to maintain their MH and community tenure. CR
principles and priorities Foremost among the key features of CR are the principles that guide the
delivery of recovery-focused interventions: recovery-oriented; promoting independence; personcentred; flexible, responsive and inclusive; accommodating different learning styles; focusing on
strengths; utilising EBIs; providing integrated multidisciplinary care (including service continuity); and
facilitating community and environmental supports. Some of the CR processes that flow from these
principles are detailed in Table 1, including establishing recoveryoriented goals, undertaking
assessments and recovery planning, delivering interventions, and clinical review or recovery-focused
tracking. People change and grow, and various factors promote positive adaptation, such as setting your
own goals, learning new skills, hope, and self-efficacy [17]. With respect to specific or targeted CR
intervention priorities, Mueser et al. [16] recently classified psychosocial interventions according to
whether the evidence was sufficient or promising. Included among the established EBIs were: cognitive
behavioural therapy for psychosis; cognitive remediation; family psycho-education; illness selfmanagement training; social skills training; and supported employment. Other interventions considered
to be very promising [16] were: social cognitive remediation [78]; cognitive adaptive training [79];
integrated psychological therapy [80]; healthy lifestyle interventions [81]; and supported education [82].
Additional interventions with an evidence base included: motivational interviewing reviewed by [83, 84];
errorless learning [85]; skill building reviewed by [86]; and family interventions reviewed by [87].
Specialised CR services may also require a staffing compliment and roster arrangements that depart
from traditional approaches. Ideally, staff should be recruited against a set of values and competencies
consistent with rehabilitation and recovery-oriented approaches, including: openness; empathy and
encouragement; supporting responsible risk taking; a positive outlook; a collaborative Frost et al. BMC
Psychiatry (2017) 17:22 Page 6 of 17 focus on client’s inner resources and strengths, and a preparedness
to go the extra distance [88]. Experience suggests that CR staff also need to be patient, resourceful, and
innovative, and enjoy problem solving. Professional background and training is also important, as some
professions have extensive theoretical and practical training in provision of complex interventions. For
example, increasing the number of occupational therapists, social workers and psychologists, relative to
those with generalist training, may significantly increase service capacity and recovery focus. However,
such guidelines may be misleading, as some generalist-trained staff with a passion for CR may make
outstanding contributions. Importantly, CR teams should also include consumer advocates, as these
staff may provide direct assistance to clients and clinical staff, and help ensure that the team retains a
strong client-centred recovery-oriented approach. Integrated Recovery-oriented Model (IRM) Challenge
4 Developing a recovery-oriented model for MH service delivery (promoting ‘remediation, restoration
and reconnection’) that provides both an overarching, inherently collaborative and integrated approach,
together with identification of opportunities for targeted specialist CR initiatives. The IRM was designed
to support the recovery needs of people with SMI by improving access to a range of EBIs provided within
a service context that reinstates hope, rebuilds competencies and provides opportunities to reconnect.
Three foundation elements or functions of this service model that partner with the individual client
include: acute/emergency MH care; specialised CR; and community managed/non-government
organisations (CMOs/NGOs) providing community integration services. Table 1 Clinical rehabilitation
(CR) processes Planning and Diagnosis Intervention and Review Transfer of Care/Discharge Recovery
Goals CR Assessment Recovery Planning CR Interventions Clinical Review or Recovery-focused Tracking
Aspirations – Hope of a better life may include: wellness enjoyment, participation, contribution and
opportunity. Personal – working with an individual’s goals no matter how well grounded, is pivotal in
fostering commitment to recovery processes. Self-identified – imposing goals that are incongruent with
the individual’s is simply counter-productive and diametrically opposed to the tenants of CR. Well
formulated – using assessment toolsa that have credibility with a person may assist in discussing and
formulating recovery goals. Comprehensive – thorough and holistic, not adopting a pathological view of
SMI, but unashamedly a comprehensive appraisal of relevant factors to assist in the formulation of a
collaborative recovery plan. Multiple domains – may include: medication, treatment, co-morbidity,
substance-use, physical & cognitive issues, coping, daily living skills, living arrangements, education &
employment, family interactions, social, sexual and existential needs & stage of change. Function
oriented – may include an array of issues in domains of functioning, activity & participation, role &
impact on environmental and personal factors. Promoting hope – the knowledge gleaned assists
clinicians to work effectively with clients & their family in generating and validating hope. Collaborative
– may be developed using tools such as the MHRSa . Recovery-oriented plan outlines individual recovery
needs and develops strategies dependent on motivation for change in specific domains. Evidence-based
– guiding access to a range of interventions (e.g., cognitive remediation, skills training, family
interventions, employment & education strategies), as well as support & environmental adaptation.
Delivery methods – interventions may be detailed as concurrent, sequential, in individual or group
settings, as well as identifying who participates (family, carers, friends, support workers). Coordinated –
across clinical and non-clinical interfaces, as well as addressing the interaction of CR & pharmacological
intervention. Goal focused – related to a range of personal, social & environmental factors, not diagnosis
dependent. Interventions assist in achieving goals & improving mental & physical health. Individually
tailored – interventions are individually tailored but, to assist clinicians in recovery-oriented service
provision, core interventions may be linked with domains of recovery (e.g., using the MHRSa ).
Integrated programs – provide a foundation for developing strategies and interventions. Core & elective
programs operate in individual, group, milieu/residential and community settings. Structured –
collaborative, goal focused, evidence-based and motivational to promote generalisation, and
accommodate different learning styles and abilities. To support achievement, higher level therapy
programs are run in parallel to compliment activity-based programs. Aim to ensure the highest level of
care & that: 1. Strategies are comprehensive, responsive & positive; 2. Support is available to the CR
clinician at every step; 3. Continuity maintained through information sharing; 4. Concurrent
interventions are implemented and monitored; 5. Early intervention strategies are available; 6.
Multidisciplinary team skills are available; 7. Risks are quickly identified & resolved; 8. Interventions are
evidence &/or practice-based; 9. Positive recovery-oriented outcomes are shared; 10. Care coordination
facilitates high quality service; 11. Opportunities exist to build service networks and linkages; 12. Key
performance indicators are discussed and reviewed. The review provides a forum to oversee, support &
co-ordinate service delivery & maximise recovery possibilities. Time demands – time intensive due to
complexity of issues & need to ensure a positive and productive milieu. Recovery trajectories are
complex & dynamic. Work contexts can be demanding, particularly when the time course is extensive &
progress minimal. Processes – innovative, recovery-focused, inclusive & holistic. Review should be led by
a senior CR clinician due to complex processes & timeframes, & include client, family, peer-support &
relevant agencies. Feedback informs goal development & collaborative interventions. Recovery
pathways – may be simple & linear or interspersed with minor setbacks, even relapse. Incremental
recovery in some domains & profound in others. Gains may be interdependent. Numerous reiterations
of CR processes may be required to trigger a decision to adopt a more inclusive & adaptive approach
(e.g., for SMI & substance misuse). Achievements – Clinical review can objectively affirm achievements;
facilitate development of options &/or determine when another strategy is warranted; & aid making
complex decisions regarding level of service need. Achievement of self-determination in several
domains may require minimal short-term interventions accompanied by follow-up & review. a For
example, collaborative measures such as the MHRS provide a framework and shared language for
discussing pathways to recovery and wellbeing that may be employed across a range of service settings
including clinical and non-clinical. The strength of this particular tool lies in its ability to connect with
people with SMI in identifying need, developing individually tailored recovery and relapse prevention
plans, and reflecting progress along the recovery journey Frost et al. BMC Psychiatry (2017) 17:22 Page 7
of 17 The IRM operates as a tripartite agreement, with each of the partners providing recovery-focused
services in an integrated and seamless manner. Each of the core services may also operate in
conjunction with a range of other specialist services (e.g., sub-acute inpatient, substance misuse,
neuropsychiatry) and community-based organisations, including GPs, accommodation services,
employment services, education providers, drop-in centres, community participation and recreation
services. To ensure continuity, the IRM requires flexibility, transparency and responsiveness, but with
the degree of service involvement titrated according to client recovery needs. Clearly, this requires a
solid understanding by all partners of service and management core functions and processes.
Consequently, a major strength of the IRM is the ability to safeguard hope and self-esteem by
intervening early to preserve coping and functional skills across a number of domains, including
everyday living skills, accommodation, social networks, employment and education endeavours. Key
principles guiding service delivery within the IRM include: 1) services are recovery-oriented; 2) care
delivered is person-centred, holistic and inclusive; 3) care enables and supports choice and selfmanagement; 4) services are integrated across the care continuum; 5) service delivery is seamless and
complementary across all providers (i.e., no ‘wrong door’); 6) services and care are based on the most
appropriate available evidence; 7) partnerships with other services, government departments and
CMOs/NGOs are integral to service delivery; 8) consideration of equity issues informs decisions about
services and care; 9) information technologies are used to improve access to care, facilitate enhanced
collaboration and communication within the service, consumers, their families and carers; and 10)
services and care delivery is aligned with national, state and local directions. The three main
components of the IRM have been based on the ICF concepts of function, activity and participation [89],
but also incorporate elements identified by Hopper [60]. Under the IRM, it is proposed that acute
services should focus on ameliorating positive symptoms and reinstating a sense of possibility. At the
earliest available opportunity, CR services, supported by CMOs/NGOs, would begin to restore hope
through the development of a range of skills pertinent to personal goals. As the client regains
confidence, CMO/NGO services would focus on exploring opportunities that would reinforce personal
recovery and reconnection with the community. However, it also needs to be acknowledged that there
is variation across Australian States in the service delivery roles performed by CMO/ NGO services, and
even more so from an international perspective. The manner in which these remediation, restoration
and reconnection components revolve around the person’s changing recovery needs is highlighted in
Fig. 1. The overlapping and, somewhat idealised, sequential phases of recovery are further illustrated in
Fig. 2; acknowledging again that recovery can be multi-layered and non-linear [48, 49]. More detail
about the complementary roles of the respective IRM components is provided below. 1. Remediation of
functioning – reinstating a sense of possibility This phase is the start of a complex journey in which the
key elements that generate and sustain hope must be carefully reintroduced and nurtured. The goals
are to intervene early to reduce the psychological and social sequelae associated with the onset of
illness. Building trust and hope that is real and sustainable will be critical in developing a positive
adjustment to the diagnosis. This phase also provides an opportunity to address physical health issues,
ensure safety, manage any legal and financial issues, and to identify other likely impacts on the person,
their partners, families and friends. When a person’s coping and protective strategies have been
breached, resulting in acute psychosis, they are likely to feel overwhelmed, shocked, confused, fearful,
anxious, in denial and exhausted. These reactions may be fuelled by stigma and run the risk of being
exacerbated by treatment and management plans that are: circumspect in their vision; fail to respect
and value the person, their family’s needs and aspirations; or lack credibility in terms of delivery and
coordination. Initial treatment provides an invaluable opportunity to reduce fear associated with the
onset of symptoms and the diagnosis, and to commence development of a collaborative recoveryoriented plan that is consonant with the wishes and aspirations of the person and their family. To
ensure that the client’s investment of hope is well placed, it is essential that there is a full understanding
of their strengths, protective factors and possible risks. As with physical rehabilitation, care needs to be
exercised as the events and triggers that precipitated the relapse are brought into sharp focus by an
approaching discharge. The need for care is also reinforced by the knowledge that a successful
resolution of positive symptoms does not necessarily indicate a return to pre-episode functioning. A
thorough assessment is required to develop a supportive, individually tailored, multi-modal skill building
program, which may be provided in combination with other treatments; a point highlighted in a recent
review by Lyman et al. [86]. Frost et al. BMC Psychiatry (2017) 17:22 Page 8 of 17 Fig. 1 Integrated
Recovery-oriented Model (IRM) for mental health services Fig. 2 Integrated Recovery-oriented Model
(IRM) – Phases of recovery Frost et al. BMC Psychiatry (2017) 17:22 Page 9 of 17 The need for a holistic
plan, which supports hope through a range of strategies that build confidence and competencies and
addresses vulnerabilities, underscores the importance of the early involvement of rehabilitation
specialists. While this phase will generally be led by acute MH services (which have specific expertise in
treating positive symptoms), they also require the support of CR, and CMO/ NGO services, in building
confidence and hope in a plan that extends beyond the acute setting. In order to demonstrate an
unequivocal commitment to the goals of the collaborative recovery-oriented plan, a number of relevant
clinical and nonclinical services may need to be involved, including: emergency assessment and triage;
acute inpatient and community services; community MH teams; early intervention programs; specialist
clinicians; and associated links with GPs, sub-acute inpatient and other specialist agencies. 2.
Restoration – enabling, regaining competencies The goal of this phase is to demonstrate that hope and
the sense of possibility are valid constructs in the pathway to recovery. At the earliest opportunity, a
range of EBIs should be available to assist in rebuilding or confirming personal, interpersonal and daily
coping skills and competencies. This may also provide an opportunity to redress developmental gaps
and lifetime goals, both of which could contribute to a renewed sense of self. As confidence is
developed in personal coping skills and environmental adaptations, a more robust foundation for
further pathway or goal-directed thinking should emerge. Exploring new and confirmatory experiences
will obviously entail a degree of positive risk taking and comprehensive strategies may need to be in
place to safeguard personal dignity. Throughout this phase, the focus will be unequivocally on the
development of self-agency, particularly as it relates to mental and physical recovery, and social
inclusion. For some people with SMI, the recovery journey may initially hold few protective factors and
pose considerable challenges and risks. For example, a move from a highly structured inpatient unit to a
loosely structured home or residential setting, with a questionable and fragile confidence in coping skills
and supports, may pose major risks. Insufficient supports during this challenging period may propel a
person to find membership in segregated company or attempting to self-manage through the use of
non-prescribed substances. Transitional arrangements may provide an opportunity to build confidence
and minimise stress, as well as providing a positive foundation on which to build essential psychological
and everyday functional skills. The development of additional competencies may include: strategies to
manage residual symptoms; cognitive skills; social skills; activities of daily living; physical health; family
education and support; and supported education or employment. These interventions should be based
on a comprehensive assessment, including usage of collaborative tools such as the Mental Health
Recovery Star MHRS; [90], and a collaboratively developed recovery-oriented plan. CR services need to
work in partnership with acute services, both inpatient and community, and CMOs/ NGOs, but without
duplicating either. CR services should be most closely aligned with communitybased services, both
clinical and non-clinical. Given the multitude of factors impacting on recovery, there is no single formula
with which to predict or determine outcomes and timeframes [59]. For example, within non-acute MH
services the timeframe for full client engagement would typically be for a period up to 12 months, but
the overall extent of involvement, including partial or backup clinical support, would be dependent on a
range of individual, social and environmental circumstances. This phase should be led by CR services but
with significant involvement of CMOs/NGOs and back-up from acute and emergency services. The
potential service elements include: CR teams and streams supporting both targeted and continuing care
roles; specialist CR interventions; intermediate (sub-acute) stay recovery units – step-up and step-down;
and links with early intervention services, GPs, housing providers, employment, education and other
non-acute inpatient services. 3. Reconnection – with place and society The aim of this phase is to
reconnect and re-establish a place in the community, and to explore opportunities for independence
and social inclusion with a new sense of confidence and hope, based on the competencies developed in
the previous stages. Development of a supportive daily structure is highly desirable, together with
progressive utilisation and refinement of skills in the pursuit of a range of personal goals. This may
necessitate graduated exposure to less structured or supported situations (e.g., independent living,
community, social situations). During this phase, initial steps may be guided by CR clinicians but with
CMO/NGO workers assuming greater responsibility as confidence grows in the client’s ability to be more
independent. Essentially, this phase is about validating the investment of hope and developing greater
levels of self-esteem and self-agency through exploration of opportunity. Frost et al. BMC Psychiatry
(2017) 17:22 Page 10 of 17 One of the advantages of CMOs/NGOs lies in their capacity to build rich and
full connections with other community based groups and services. These connections may open up
many satisfying and life enriching opportunities for people with enduring SMI. CMOs/NGOs may assist in
the exploration of these opportunities and in the development of: stable accommodation; civic and
social activities, reducing social isolation; employment opportunities; recreational and sporting
activities; as well as guidance in regard to relationships and existential needs. Importantly, many
CMOs/NGOs have partnerships with GPs, which, together with initial support from CR services, may
ensure better access and improved mental and physical health. This phase should be led by CMO/NGO
services, with the level of input from CR titrated against personal recovery needs, clinical support, risk
and legal issues. As the client becomes more confident in their self-determination abilities in the
community, CR services should progressively withdraw, allowing the CMOs/NGOs to assume leadership.
Acute MH services would always remain available for the transfer of care and joint clinical reviews. The
potential service elements include: supported accommodation (low to very high residential); low
support accommodation; day centres; links with GPs; specialist employment and education services;
recreational and fitness centres; and home care services. Illustrative IRM scenario Application of CR
planning, intervention, review, transfer and evaluation processes (detailed in Table 1) within the IRM, to
support and promote recovery for an individual client, are illustrated in Fig. 3. Examples of how the IRM
can promote recovery for individuals with a SMI are, in most instances, complex but an illustrative
scenario is provided in Table 2. Here the remediation phase is characterised in terms of relapse
prevention and admission related decisions designed to reinstate hope, while the
restoration/reconnection phases are illustrated via a series of recovery-focused actions in response to
different concerns (e.g., about medication, treatment/ intervention adherence, coping strategies to
manage stress, substance misuse, family dynamics, and safety). As an outline, this description of the IRM
does not detail operational issues, such as: admission, referral and transfer processes; service ho…
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