An Integrated Recovery-oriented Model (IRM) for mental health services: evolution and challenges

Identifying the aspects of personal and clinical ‘recovery’ and related approaches that need to be considered in re-designing ‘recovery-oriented’ MH services.

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 co-morbidities (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].

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 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].

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 decision-making, 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 recovery-enabling [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 non-linear process, recovery-oriented experiences and opportunities during periods of hospitalisation also need to be adequately addressed [52].

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 time-limited 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.

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 over-arching ‘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 self-esteem 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 relations, problems with accommodation and accessing recreational activities. Consequently, an array of recovery-oriented 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 recovery-oriented 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 recovery-oriented support), which also highlight the need for a whole-systems approach in transforming services [74, 76].

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 de-emphasise 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.

Foremost among the key features of CR are the principles that guide the delivery of recovery-focused interventions: recovery-oriented; promoting independence; person-centred; 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 recovery-oriented 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 self-management 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 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.

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 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 self-management; 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.

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 hours; staff roles, competencies and training; service linkages; discharge pathways; and key performance indicators. Although these operational requirements should be guided by recovery-oriented and CR principles, other local and national factors may have an impact, including recording and reporting expectations. As with any reform, care also needs to be exercised in regard to agendas driven by vested interests and unrealistic expectations; most of all, there is a need to address the inertia within health services and to actively promote education and understanding of recovery and CR.

Devising implementation and evaluation strategies that enhance outcomes and facilitate review of recovery-oriented MH service models and components.

Evaluating the formulation, implementation and impact of specific intervention programs or MH service/practice changes can be a daunting task, especially when viewed from multiple stakeholder perspectives [91]. Expressed simply, the relevant issues are: what aspects of the service model are under evaluation (e.g., perceptions of practices and processes; EBI information, availability, uptake, fidelity and completion; compliance with guidelines and documentation; impact on clinical and/or personal outcomes; training and resource utilisation; and so on); from whose perspective (e.g., clients, carers, clinicians and/or service providers); with regard to what timeframes (e.g., initial impact, medium-term, ongoing); and using what evaluation methods or strategies (e.g., quantitative/qualitative, self-report, independent assessments, service data or other linkages).

The overriding question is: Can the chosen methods realistically address the identified evaluation goals within the required timeframes? In all likelihood, an assortment of evaluation strategies will be required, which vary in intensity and duration. Operationalising aspects of an evaluation could begin with a review of core resource materials and identified service pathways. For example, the 12 ‘clinical review’ items listed in the top right-hand corner of Table 1 could form the basis for a self-evaluation of CR processes within a particular service stream. Similarly, the flow diagram in Fig. 3, which depicts IRM processes and phases, could provide a useful starting point for auditing progress for a sample of clients and identifying service barriers (e.g., evidence in clinical records of collaborative assessments and care planning, provision of EBIs, multi-disciplinary and interagency reviews).

Ideally, program and service evaluations should incorporate a mixture of qualitative and quantitative methods, including: reviews of available evidence; client/carer/staff structured interviews or surveys; service audits; focus groups; first-person narratives and other feedback; and assessments of recovery trajectories, short- and longer-term outcomes, and associated processes and predictors. The latter could include: clinical recovery-focused evaluations (e.g., symptoms, medication compliance, relapse); personal recovery-focused evaluations (e.g., functioning, subjective wellbeing, independence and safety, social engagement, vocational activities, quality of life, community linkages); and service-related outcomes and evaluations (e.g., hospital presentations, contacts with community services, engagement/referral patterns, service transitions, staff perceptions and training, policy and guideline awareness, and associated costs).

There is a growing literature on the selection of strategies and measures for assessing recovery [4, 92‐94], recovery-oriented practice [65, 74, 95] and the recovery-orientation of services [71, 92, 96, 97]. In choosing a particular set of tools, it may be useful to cover a representative range of recovery domains or processes, such as the CHIME spectrum described earlier [38, 64] or the ‘broad superordinate recovery dimensions’ suggested by Whitley and Drake [98] (i.e., clinical, existential, functional, physical, and social dimensions of recovery). More generally, the capacity for client/carer self-evaluation of progress, for continuous review of recovery-oriented practices, and for reporting on key service outcomes and processes, need to become routine aspects of MH service provision, as recommended in several guidelines e.g., [31].

While the IRM was developed as a service-wide model, it also provides an overarching framework for progressive MH service changes and EBI refinement. Like other programs [66, 68, 70], a staggered IRM introduction is probably more practical and likely to be endorsed; consequently, flexible, staged evaluation programs are also required. In our case, as described below, preliminary IRM-related evaluations focused on clinician perspectives (across the whole service) and IRM implementation within a purpose-built 20-bed, sub-acute unit [35]. More extensive evaluations are planned, covering a broader array of stakeholders and timeframes.

One staff-based method for evaluating variations in recovery-orientation is to survey clinicians pre- and post-service changes. For example, we surveyed MH clinicians recently, with the intention of conducting repeat surveys after full implementation of model of care changes. Preliminary findings (N = 251 clinicians, see Additional file 1) suggest that acute and community MH clinicians differ in their perceptions of the relevance of a range of recovery domains (e.g., social networks and work are perceived as less relevant domains by acute care clinicians), reflective of their likely differential contributions to the remediation and restoration phases of client recovery. Other studies have identified less positive attitudes towards recovery among inpatient providers [52, 96], suggesting that treatment setting is an important factor to consider when refining recovery-oriented care practices and training.

Intrinsic to IRM evaluation and review is the ability to respond to new opportunities as they emerge and to ongoing feedback from various stakeholders. Our initial evaluation of the implementation of an IRM within a sub-acute ISMHU [35] provided preliminary confirmation that our 6-week recovery-oriented program was acceptable, valued, and capable of contributing to enhanced functioning and an improved recovery trajectory. With respect to the interface between program goals and the sensitivity of evaluation methods, within ISMHU the various EBIs (and associated program guides) were built around and expressed in comparable terms to the MHRS domains [90], the main collaborative assessment tool used within the unit, with marked admission to discharge MHRS improvements detected [35].