Transitions from biomedical to recovery-oriented practices in mental health: a scoping review to explore the role of Internet-based interventions

Personal recovery, hereafter referred to as recovery, has been defined as; “a way of living a satisfying, hopeful, and contributing life even with any limitations caused by illness” [22]. While not dismissing the important role that biomedical interventions can play for some individuals, recovery challenges biomedical approaches to recovery that prioritize symptom reduction in ways that can inadvertently undermine progress towards a life worth living [23, 24]. Proponents call for a fundamental shift away from the often paternalistic and pacifying nature of biomedical approaches, towards partnerships that acknowledge and support the decisive role that service-users and families play in defining and enacting their own recovery and wellbeing [23, 25]. This personal approach to recovery emerged from within consumer and civil rights movements, and increasingly guides reforms in mental health in English-speaking countries [26]. The approach is person-centered, values-based and is also increasingly reflected in the broader domain of chronic care research and practice [27]. Recovery-oriented interventions recommended in the 2014 NICE guidelines for psychosis as described by van der Krieke et al. [28] include Individual Wellness Recovery Action Planning (WRAP) [29], Illness management and recovery (IMR) [30] and Individual Placement Support (IPS) [31]. However, the complex, multiple and interacting components of such interventions are challenging to implement [32‐35], especially compared with pharmacological interventions, despite the latter’s higher risk of adverse events [28].

The holistic and multifaceted nature of recovery-oriented interventions has prompted efforts to operationalize components, also by examining links to related research such as positive psychology, wellbeing, strengths-based approaches and self-management [32, 36, 37]. In their systematic review and narrative synthesis of 97 papers from 13 countries, Leamy and co-workers [38] propose that personal recovery can be conceptualized as a process comprised of five dimensions: connectedness to others and the community; hope and optimism about the future; identity building beyond being a patient and towards a positive sense of identity without stigma; meaning in life; and empowerment, summarized in the acronym CHIME. The CHIME framework has been validated by service users and provides a theoretical base for clinical and research purposes [38].

While CHIME offers a conceptualization of personal recovery Le Boutillier et al. [26] offer a framework for characterizing recovery practices. They identified 16 dominant themes grouped in four practice domains that characterize recovery-oriented practice: (1) promoting citizenship, e.g., supporting the experience of wider entitlements of citizenship such as service user rights, social inclusion and meaningful occupation; (2) organizational commitment, e.g., giving primacy to the needs of people rather than those of services; (3) supporting personally defined recovery, e.g., informed choice, peer support, focus on strengths, and a holistic approach; and (4) working relationships, e.g., a therapeutic relationship that encourages partnership and promotes hope. In this paper, Internet-based interventions that support the four practice domains are referred to as e-recovery. Along with evolving conceptual frameworks for recovery-oriented practices, efforts are underway to identify meaningful outcome measures across cultures and contexts and to identify active ingredients of recovery, for whom, by whom, under what conditions [39‐42].

In stage 1, our initial research questions were defined. Although these remained more or less the same in foci and objectives, they were adjusted somewhat during the research process to result in those listed above under Objectives.

In stage 2, relevant studies were identified based on the research questions and purpose of the study. Due to our interest in mapping research-based literature, we chose to exclude gray literature. Systematic searches for articles published from January 2004 to May 2015 were carried out in the following electronic databases: MEDLINE, PsycINFO, EMBASE and Cinahl. In light of the rapidity of technological developments, we judged this period to be sufficient. Each database was searched using the database thesaurus and the key word/free text method. Searches included the following terms and varying synonyms and related concepts, alone and in various combinations: ‘mental illness’, ‘Internet interventions’, ‘recovery’, and ‘mental health service user–provider interaction’. The term recovery was supplemented with related concepts such as ‘positive psychology’, ‘empowerment’, ‘strengths’, ‘well-being’ and ‘self-management’. All types of study design were included in the search strategy, which was restricted to articles in English or Scandinavian languages and published in peer-reviewed journals. We also searched the reference lists of included studies and relevant conferences for pertinent publications.

Stage 3 entailed the process of study selection, illustrated in Fig. 1. In accordance with scoping study principles, selection was an iterative process of reviewing abstracts, refining the research strategy, and developing and revising inclusion and exclusion criteria [43, 45]. We identified a total of 1511 articles (Fig. 1) based on inclusion and exclusion criteria as described in Table 1.

After removal of duplicates and irrelevant studies based on the titles and abstracts (e.g., not about Internet interventions, not recovery-oriented or wrong target group), 132 potentially relevant studies remained.

All of the potentially relevant studies were read in full text by the first author. The second author independently read a random sample of 20% and additionally all of the articles where the first author had questions about inclusion and exclusion. Disagreements about study selection were resolved by discussion.

Stage 4 entailed charting the data of the included studies by extracting and coding in Excel each included article according to each of the following variables: intervention’s country of origin, aims, theoretical concepts, target group, settings, modules, study aims, design and methods, outcome, measures and results, implementation issues and the four practice domains and underlying 16 themes of recovery-oriented practice as described by Le Boutillier et al. [26]. The process of extracting the data was done by the first and second authors separately and then together to resolve any discrepancies in coding through consensus. When minor adjustments were made in the data charting form, the included articles and extracted data were reviewed again to ensure correspondence [43, 45].

The fifth and final stage of the scoping review entailed collating, summarizing and reporting the results [45]. Inspired by a semantic-level, thematic analysis approach [47], the four practice domains and 16 underlying themes served as a point of departure for collating and summarizing the interventions’ characteristics according to their support for recovery-oriented practice. During this processes we made memos that served as a basis for answering the research questions, as well as topics deserving attention in the discussion of our findings. Any discrepancies in interpretations of article content or the predefined domains and underlying themes were resolved through discussion [48]. Again, this is in line with the iterative nature of all the stages in scoping reviews [43, 45].

The modules are described in Table 2, together with a description of aim, target group and setting for each intervention.

The findings are presented relative to Le Boutillier et al.’s four domains and described with reference to the 16 underlying themes [26].

The studies’ place of origin, aims, design, methods, measures and outcomes, and main findings related to each intervention are presented in Table 3 Study characteristics. The number of studies available per interventions varied from one to six.

Only Koivunen et al. [52] explicitly addressed barriers and facilitators for implementation as the main study objective, identifying four main categories: organizational resources, nurses’ individual characteristics, patient-related factors, and portal-related factors. Barriers to implementation were lack of computers, lack of time for patients, nurses’ negative attitudes towards computer use and lack of training in how to use the intervention. Technological resources, easy Internet access, time and level of motivation among staff were found to be facilitators of implementation.

Two studies [51, 53] noted problems related to intervention and protocol fidelity which undermined their ability to draw conclusions. They pointed out a need for better training and ensuring the intervention’s optimal fit with the routine practices of participating clinics.

Other reflections included the facilitating role of peers in the use of the intervention [49, 54, 55]. These studies argued that peers not only have more time to give careful guidance, but can sometimes relate more readily to the needs and concerns of service users.

Barriers suggested from the practitioners’ point of view include lack of monetary compensation and a feeling of being overwhelmed [54]. One study noted the concerns of clinicians who feared that if they had access to service-user-controlled content, they could be held responsible for faulty or alarming content [55].

Throughout the analysis of interventions and research, we noted a wide range of impressions and topics that appeared important or relevant in efforts to exploit the potentials of Internet in transitioning towards recovery-oriented practices. Four of these are highlighted in the following.

This study shares the strengths and limitations of scoping studies in that it illuminates the volume, nature and characteristics of the field of interest, but does not appraise the quality or weight of evidence [43]. A strength is use of the conceptual framework for recovery-oriented practice as a basis for analysis and description of findings. This can turn aid in refining concepts during this formative stage of development, along with enabling a proactive and systematic discourse about Internet-based recovery-oriented interventions. However, limiting the inclusion criteria to interventions used in conjunction with ordinary care led to exclusion of interventions with potentially important contributions to the emerging field of e-recovery (e.g., [79, 80]). This can also be said of our exclusion of gray literature. Thus, we cannot claim to represent all the current work that is relevant to advancing e-recovery.