Recovery contexts, not outcomes: An alternative way to evaluate non-clinical interventions for serious mental illness

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by Louisa Peters – Lecturer in Psychology at Leeds Trinity University and Yorkshire & Humber ARC PhD student

Relying on outcome measures to determine if an intervention can aid recovery from serious mental illness, is a fallacy. Outcome measures simplify a complex and personal experience, and are hard to predict, particularly within non-clinical community interventions. Yet intervention efficacy is often dependant on such measures, determining access to funding and even access to services. Given that establishing a context for recovery is within the control of facilitators, intervention contexts present an alternative approach to evaluating intervention success.

Recovery as a personal process

We can all agree that recovery from serious mental illness is a very personal and individual experience, yet recovery remains defined as clinical improvements using outcome measures (NHS England Service Standards, n.d.). This is despite recovery being defined within key government white papers as;

‘A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life, even with limitations caused by the illness… recovery involves the development of new meaning and purpose in one’s life’ (Anthony, 1993, pg. 527, cited in Department of Health, 2011)

Current research emphasises that recovery is not an end point, but a nonlinear process, that could potentially involve connecting to others; developing hope; identity change; finding meaning/purpose; feeling empowered; and overcoming challenges (Leamy et al., 2011; Stuart et al., 2017). For some the word ‘recovery’ does not accurately reflect the definition of personal recovery, instead preferring ‘remission’ or ‘living well with mental illness’. The term ‘recovery’ is used within this writing (and the research from which it stems) as defined in terms of non-linear, personal recovery processes as outlined above.

A person-centred view of recovery processes does not align with an outcome-based approach to determining recovery from serious mental illness. Outcomes have been found to be varied and numerous (Polley et al., 2020), and therefore hard to predict for any one individual. Therefore, utilising outcome measures is causing issues when attempting to evaluate the efficacy of non-clinical, community-based interventions. Often, research utilising outcome measures to determine whether community creative activities aid recovery produce “mixed evidence” which is then used as an argument to question intervention success (Van Lith et al., 2013). Even symptom reduction does not always occur when people are engaged with recovery, e.g. voice hearers (Hearing Voices Network, n.d.). Furthermore, completing self-reported questionnaires places a huge burden on the individuals who are trying to live well with serious mental illness, often unnecessarily reminding them of their illness. This experience is starkly exemplified in the below quote.

“I think so much is put upon me fudging a form just so they can get the funding and resources. It’s not about me getting well, I’m never going to get well. It’s about me being well… I wish, when I’m filling in forms and stuff, I could just tell the truth and they would still get the remit saying, well they are helping [me], she’s out of the house today, that’s a good day, she’s out of the bed, that’s a good day. Not “most of the time”, “some of the time” … I had to fill the form in and it’s all, what mental illness have you got? What mental health and mental health and mental health…” (Participant interview quote from Peters, 2024)

Let us look at context

An alternative approach to evaluating an intervention could be to look at the contextual features that promote successful engagement in recovery processes and allow individuals with serious mental illness to live well. To determine the contextual features of a successful non-clinical community intervention, a realist evaluation was conducted in partnership with NHS charity Creative Minds (Southwest Yorkshire Foundation Trust), and several community organisations across the North of England. The aim was to understand how and why community arts interventions enable recovery from serious mental illness. The evaluation revealed six contextual features that all needed to be in place for an intervention to be successful (see fig. 1). These interrelated contextual features create a safe and empowering space by being accessible, non–stigmatising, and remove the expectation of recovery (Peters et al., 2024).

Figure 1

Six contextual features of a successful creative community intervention

  1. Compassionate workers were found to be an important active agent within the community organisation who listen and respond to the needs of their local community. Workers (both staff and volunteers) understand the personal and wider social challenges of the people they support and make a concerted effort to establish positive relationships. The compassion shown by workers counteracts negative experiences such as stigma often faced by individuals with serious mental illness, establishing the intervention as a safe space.
  2. Creative activities are provided that are of interest and relevant to group members, an example of workers responding to their local community. Importantly, the activities focus on creativity such as arts activities, rather than recovery. In doing so, expectations of recovery are removed, and the community intervention offers a safe, alternative focus away from serious mental illness.
  3. Community setting is important, so that the activities are locally accessible to the community they serve. A non-clinical environment was found to be important as it further removes the expectation of recovery. Community settings were found to be more flexible to be able to meet the needs of the community, compared to clinical settings which are often restricted by institutional policy, resulting in inconsistent or time-limited support (Rankin et al., 2009).
  4. Choice over engagement is provided through the flexible approach taken by compassionate workers and the choice of activity offered, which is of interest to the group members. Successful interventions did not impose attendance requirements, time-limits or expectations on how to engage in the activity itself. Individuals respond to this choice by feeling empowered, often resulting in long-term engagement.
  5. Shared lived experiences within the group was important for a feeling of safety. Whilst the activity focuses on creativity, the group members often shared lived experiences of serious mental illness, as well as other characteristics such as gender, disability, ethnicity etc. This is an example of compassionate workers responding to the needs of their community. Shared lived experiences allow people to identify with others within a creative setting, developing a feeling of safety.
  6. Long-term access to the intervention was vital to success and underpins the other five contextual features. Time-limited groups and activities often do not have long-lasting effects. Long-term access ensures ongoing social support and access to a safe space, which can be lacking when living with serious mental illness due to wider social inequalities.

This is not to say that these contextual features do not appear in other settings. For example, Clibbens et al. (2023) explored the context of successful community mental health crisis care and found key contextual features for success, including compassionate workers, good access to services and peer support. Many of these features mirror the context of creative community interventions. However, each intervention will have a unique set of contextual features that enables success. For creative community interventions, all six features identified are needed to enable individuals with serious mental illness to engage with recovery processes.

Summary

Identifying contextual features presents alternative criteria to evaluate intervention efficacy. Community organisations can use such criteria to explain their value and success to funders/clinicians/social prescribers by demonstrating how their activities meet these criteria. Focusing on context also removes some of the burden of evidence from the individuals in recovery. However, this approach requires a move away from outdated outcome measures, such as well-being questionnaires, and creating a new norm, particularly within larger healthcare institutions. Funding bodies or care providers who are interested in exploring this approach, please contact Louisa Peters for more information: louisa.peters@leedstrinity.ac.uk

References

Department of Health. (2011). No health without mental health [PDF]. Her Majesty’s Government.

Clibbens, N., Booth, A., Sharda, L., Baker, J., Thompson, J., Ashman, M., Berzins, K., Weich, S., & Kendal, S. (2023). Explaining context, mechanism and outcome in adult community mental health crisis care: A realist evidence synthesis. International Journal of Mental Health Nursing, 32(6), 1636–1653. https://doi.org/10.1111/inm.13204

Hearing Voices Network. (2023). Hearing Voices Network: Welcome. https://www.hearing-voices.org/

Leamy, M., Bird, V., Boutillier, C. L., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. British Journal of Psychiatry, 199(6), 445–452. https://doi.org/10.1192/bjp.bp.110.083733

NHS England. (n.d.). Service standards. https://www.england.nhs.uk/mental-health/adults/nhs-talking-therapies/service-standards/

Peters, L. A. (2024). Community arts, identity, and recovery: A realist evaluation of serious mental illness recovery within community arts activities. (Unpublished Doctoral Thesis) University of Huddersfield.

Peters, L., Gomersall, T., & Lucock, M. (2024). Contexts for recovery: Creative communities filling a gap in mental health care. Findings from a realist evaluation. [Submitted]

Polley, M. J., Whiteside, J., Elnaschie, S., & Fixsen, A. (2020, February). What does successful social prescribing look like? Mapping meaningful outcomes [Project report]. University of Westminster. https://42b7de07-529d-4774-b3e1-225090d531bd.filesusr.com/ugd/14f499_5f193389d80c4503a4c800e026189713.pdf

Rankin, D., Backett-Milburn, K., & Platt, S. (2009). Practitioner perspectives on tackling health inequalities: Findings from an evaluation of healthy living centres in Scotland. Social Science & Medicine, 68(5), 925–932. https://doi.org/10.1016/j.socscimed.2008.12.013

Stuart, S. R., Tansey, L., & Quayle, E. (2017). What we talk about when we talk about recovery: A systematic review and best-fit framework synthesis of qualitative literature. Journal of Mental Health, 26(3), 291–304. https://doi.org/10.1080/09638237.2016.1222056

Van Lith, T., Schofield, M. J., & Fenner, P. (2013). Identifying the evidence-base for art-based practices and their potential benefit for mental health recovery: A critical review. Disability and Rehabilitation, 35(16), 1309–1323. https://doi.org/10.3109/09638288.2012.732188

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