Explication_and_Definition_of_Mental_Health_Recove.pdf
Document Details
Uploaded by SincerePoplar
Tags
Related
- Mental Health Disorders, Disabilities, and Delinquency
- SCL6002 - Session 5 Comorbidities of Mental Health and Chronic Disease.pdf
- 202360 EHR525 Week 01b Understanding Mental Health Conditions (1 Slide).pdf
- PTWE 5 Storyboard - Mental Health and Resilience Tools Final Copy (1).pdf
- Mental health.pdf
- jacobson-greenley-2001-what-is-recovery-a-conceptual-model-and-explication.pdf
Full Transcript
Adm Policy Ment Health (2018) 45:91–102 https://doi.org/10.1007/s10488-016-0767-9 ORIGINAL ARTICLE Explication and Definition of Mental Health Recovery: A Systematic Review Marsha Langer Ellison1,4 · Lindsay K. Belanger2 · Barbara L. Niles3 · Leigh C. Evans2,5 · Mark S. Bauer2,6 Published online: 5...
Adm Policy Ment Health (2018) 45:91–102 https://doi.org/10.1007/s10488-016-0767-9 ORIGINAL ARTICLE Explication and Definition of Mental Health Recovery: A Systematic Review Marsha Langer Ellison1,4 · Lindsay K. Belanger2 · Barbara L. Niles3 · Leigh C. Evans2,5 · Mark S. Bauer2,6 Published online: 5 October 2016 © Springer Science+Business Media New York (outside the USA) 2016 Abstract This review assessed the concordance of the literature on recovery with the definition and components of recovery developed by the Substance Abuse and Mental Health Services Administration (SAMHSA). Each SAMHSA identified recovery component was first explicated with synonyms and keywords and made mutually exclusive by authors. Inter-rater reliability was established on the coding of the presence of 17 recovery components and dimensions in 67 literature reviews on the recovery concept in mental health. The review indicated that concordance varied across SAMHSA components. The components of recovery with greatest concordance were: individualized/ person centered, empowerment, purpose, and hope. This research was presented at the 2015 Psychiatric Rehabilitation Association Workforce Summit. Marsha Langer Ellison [email protected] 1 Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Rd, Bedford, MA 01730-0012, USA 2 Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA 3 National Center for PTSD Behavioral Science Division, VA Boston Healthcare System, Boston, MA, USA 4 Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA 5 School of Public Health, Boston University, Boston, MA, USA 6 Department of Psychiatry, Harvard Medical School, Boston, MA, USA Keywords Recovery · Systematic review · Mental health · Mental illness Introduction A new paradigm for describing the process of overcoming the detrimental effects of a severe mental illness has emerged in recent decades. Promoting “recovery” is now the guiding vision for many mental health services, rather than the medical model of treatment or cure (Anthony 1993). National calls for using the recovery paradigm emerged in the landmark President New F reedom Commission on Mental Health (2003) and recovery can now be found in the missions of both international and state mental health authorities as well as for the U.S. Veterans Health Administration (Beale and Lambric 1995; Fallot et al. 2011; Iowa Department of Human Services 2016; Jacobson 2003; Meehan et al. 2008; Massachusetts Department of Health and Human Services 2016; Mental Health Commission 2012; New Freedom Commission on Mental Health 2003; Ramon et al. 2007; Veterans Health Administration 2008; Virginia Department of Behavioral Health & Developmental Services 2014). One of the earlier definitions of recovery was presented in the “National Consensus Statement on Mental Health Recovery” (Substance Abuse and Mental Health Services Administration 2006). This stated that ‘Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of the person’s choice while striving to achieve his or her full potential’ (Substance Abuse and Mental Health Services Administration 2006). Despite its proliferation, however, the term “recovery” is a slippery concept that is inconsistently used (Meehan et al. 2008). “It is an amalgam of cultural beliefs, treatment 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. 92 Adm Policy Ment Health (2018) 45:91–102 practices, and ideas about mental illness. Like mental illness itself, the notion of recovery represents a multidimensional set of phenomena” (Davidson and Roe 2007, p. 460). There is now a large literature that attempts to delineate the central components of recovery, with many providing overlapping conceptualizations of recovery and none providing a clear consensus. The selection of any one recovery description runs the risk of dismissing key components or conversely over-emphasizing minor ones. To guide future research on recovery, the authors of this paper aimed to assess the concordance of scientific and policy-based definitions and operationalizations of the recovery concept through a systematic literature review. Systematic literature reviews gather, assess, and summarize current information found in the literature about a specific topic. They use a systematic, structured process to do this, which is determined in advance and explicitly stated. Utilization of such a process ensures transparency and lends itself better to replication (Moher et al. 2009). We aim also to assist the mental healthcare systems that are grappling with how to implement recovery-oriented services. One such system is the Veterans Health Administration (VHA), which delivers health care to 9.1 million Veterans (Department of Veterans Affairs National Center for Veterans Analysis and Statistics 2015). The VHA is arguably one of the largest systems attempting recovery-oriented services; note the recent mandate to hire large numbers of mental health peer supporters (The White House Office of the Press Secretary 2012) and to transform day treatment centers to recovery centers (Veterans Health Administration 2008). Thus, this review uses as a reference the 2004 definition of recovery explicated by the United States national office for Substance Abuse and Mental Health Services Administration (SAMHSA) in their National Consensus Statement, which is also used by the VHA in their recovery programming and research (Veterans Health Administration 2008) and the later SAMHSA consensus on recovery in 2012 (Substance Abuse and Mental Health Services Administration 2012). The two SAMHSA statements together identify 17 components of recovery. These include 13 “guiding principles” identified collectively in the two SAMHSA statements and “four major dimensions that support a life in recovery” (Substance Abuse and Mental Health Services Administration 2012). This systematic review measured the frequency by which each of these principles and dimensions were noted in the mental health recovery literature, including both peer-reviewed articles and “gray literature” (e.g. policy statements and other relevant documents published by non-commercial entities (California State University Library 2015)). To do so we had the following objectives: (1) Develop a clear and mutually exclusive understanding of each of the 17 SAMHSA fundamental recovery components to use for coding selected articles; (2) achieve a high inter-rater reliability score for coding literature on recovery using the 17 components, (3) identify all relevant juried and “gray” literature using systematic transparent procedures; and (4) establish concordance by coding all selected articles for the presence of any one of the fundamental components. Method Literature Search Strategy and Eligibility Criteria This systematic review of recovery sought to identify only review papers (narrative and systematic) from peerreviewed journals and additional sources, in order to maximize the yield of articles that addressed multiple dimensions of recovery together. We utilized the following inclusion criteria: (1) contains an original model, framework, or conceptualization of recovery and the components of recovery from serious mental illness that could be summarized and extracted; (2) identified as a published review or an official policy statement of a state, province, or country; (3) available in English. The exclusion criteria were: (a) studies solely focusing on only one component of recovery but not the recovery concept as a whole; (b) articles defining recovery from substance abuse only. In order to promote a common understanding among three major constituent groups interested in recovery models for mental illness (i.e. individuals, providers, and systems), the current review included articles that identified components relevant to any one or more of these three groups. Three methods of article identification were used: electronic database searching, web-based searching, and hand searching as a cross-check. Electronic literature searches were conducted using six online databases: PubMed; EBSCO (databases of Psychology and Behavioral Sciences Collection, PsycINFO, PsycARTICLES, and SocINDEX); PROQUEST (databases of PsychiatryOnline and Nursing & Allied Health Source); EMBase; Cochrane Library; and CINAHL. All databases were searched from 1985 to 2014. The following terms were identified from the title, abstract, keywords, or mesh headings: (serious mental illness OR mental health OR mental illness OR mental disorder OR mental disease OR mental problem OR depression OR bipolar OR anxiety OR schizophrenia OR ptsd OR schizoaffective disorder). These mental health phrases were combined with the term “recovery” restricted to title or abstract. Search phrases were then systematically narrowed to review papers only using specific filters developed for each database, such as “systematic review” OR “evidence review” OR “critical appraisal” OR “framework” or “conceptual model” OR TI (evidence) OR TI (effective*). Electronic alerts of these search phrases were used to capture any newly published articles, resulting in the inclusion of one additional article. 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. 93 Adm Policy Ment Health (2018) 45:91–102 Several web-based resources were reviewed for inclusion including, Boston University’s repository on recovery (http://cpr.bu.edu/resources/recovery-repository), state health department policy papers, and international health policy papers. This search resulted in the identification of 64 additional sources that were screened. Finally, these electronic searches were cross-checked against several selected seminal articles (Anthony 1993; Jacobson and Greenley 2001; Le Boutillier et al. 2011; Leamy et al. 2011; Onken et al. 2007; Whitley and Drake 2010) originally identified by the authors and experts advisors in the field. The two SAMHSA statements (Substance Abuse and Mental Health Services Administration 2006, 2012) were used to identify and define the components under examination in this review and were not included in the identified articles. Data Extraction and Risk of Bias Assessment One rater extracted data and assessed the eligibility criteria for all retrieved papers. Group consensus from all three raters was used to determine eligibility when there were questions about eligibility. Identification and Coding of Components In SAMHSA’s 2006 National Consensus Statement on Mental Health Recovery (Substance Abuse and Mental Health Services Administration 2006) 10 “guiding principles” were identified and this definition of recovery was also adopted by the Veterans Health Administration in the mental health handbook (Veterans Health Administration Fig. 1 Changes to SAMHSA Core Recovery Components from 2004 to 2012 2008). In 2012, an updated working definition of recovery was distributed by SAMSHA. Unlike the ealier version, the updated version is meant to provide a standard working definition of recovery that applies to both mental disorders and to substance use disorders. This definition is comprised of 10 guiding principles that clarify the recovery concept for service systems and consumers of services (Substance Abuse and Mental Health Services Administration 2012). The 10 guiding principles used in SAMHSA’s 2012 working definition are somewhat different than those identified in 2004, however, and F ig. 1 depicts the similarities and differences between the two SAMSHA definitions. Four guiding principles (hope, respect, peer support, and holistic) remained the same in the two definitions. Four guiding principles from the 2004 definition were combined into two guiding principles in the 2012 definition: (1) self-direction and individualized and person-centered were combined into person-driven, and (2) strengths-based and responsibility were combined into strengths/responsibility. The non-linear guiding principle in 2004 was slightly revised to become many pathways in the 2012 definition. Empowerment was dropped from the definition in 2012 and three new guiding principles (culture, addresses trauma, and relational) were added. In addition, in the 2012 publication, four “dimensions” of recovery were added to the ten guiding principles: home, health, community, and purpose. The newly added dimensions are explained by SAMHSA as those “that support a life in recovery”. For the current review, both the 2004 and 2012 SAMSHA consensus working definitions of recovery were utilized and 17 components were identified: 10 guiding principles SAMHSA Recovery Components in 2012 SAMHSA Recovery Components in 2004 Respect Peer Support Hope Self-Direction Individualized & PersonCentered Holistic Non-Linear Empowerment Hope Respect StrenghtsBased Responsibility Unaltered components Re-named component Person Driven Peer Support Strengths/ Responsibility Holistic Many Pathways Culture Relational Addresses Trauma New components (2012) Combined components Dropped component (2004) 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. 94 Adm Policy Ment Health (2018) 45:91–102 Table 1 Recovery components and dimensions with defining keywords Components Additional keywords SAMHSA keywords (Substance Abuse and Mental Health Services Administration 2006; Substance Abuse and Mental Health Services Administration 2012) 1. Individualized and person-centered Person-centered Identity/dimensions of identity (Leamy et al. 2011; Oades et al. 2005; Oades et al. 2009) Clinical treatment and medications (Jacobson and Greenly 2001; Gagne et al. 2007; Higgins and McBennett 2007, Happell 2008a, b) Therapeutic relationships/partnerships (Jacobson and Greenly 2001; Gagne et al. 2007) Collaborative decision making (Oades et al. 2009; Jacobson and Greenly 2001; Happell 2008b; Torrey and Wyzik 2000) 2. Empowerment Empowerment Individualized recovery plans (Higgins and McBennett 2007, Happell 2008b; Onken et al. 2007) Motivation to change (Leamy et al. 2011; Oades et al. 2009) Influences organizational and societal structures in his/her life Self-efficacy (Oades et al. 2005, 2009) Righteous angera Community activism Consumer rights (Oades et al. 2009; Jacobson and Greenly 2001; Higgins and McBennett 2007, Happell 2008a, b; Davidson and Roe 2007) Confidence (Oades et al. 2005; Jacobson and Greenly 2001, Higgins and McBennett 2007, Happell 2008a; Torrey and Wyzik 2000) Power over one’s self care/actual power (Oades et al. 2009; Gagne et al. 2007) Self-advocacy (Onken et al. 2007) Control over destiny/life Authority over decision making Collectivity; collective action; collective advocacy Allocation of resources Action (Oades et al. 2009; Jacobson and Greenly 2001; Higgins and McBennett 2007) Belief in possibilities (Leamy et al. 2011; Torrey and Wyzik 2000) Optimism (Jacobson and Greenly 2001; Higgins and McBennett 2007) Inspiration (Higgins and McBennett 2007) Dreams and aspirations (Leamy et al. 2011; Davidson and Roe 2007) Counterpoint to depressiona 3. Hope Hope Motivating message of a better future Belief that recovery is real 4. Self-direction Self-direction Choice Independence Autonomy Self-determination Define goals Can occur without professional intervention (Leamy et al. 2011; Higgins and McBennett 2007, Mancini et al. 2005) Recovery as an active process” (Leamy et al. 2011) Personal growth (Leamy et al. 2011; Oades et al. 2009; Gagne et al. 2007; Higgins and McBennett 2007, Mancini et al. 2005) 5. Non-linear/many pathways Non-linear Full and partial recovery possible (Gagne et al. 2007; Davidson and Roe 2007) Recovery as stages/phases (Leamy et al. 2011) Episodic (Higgins and McBennett 2007, Mancini et al. 2005) Can occur even though symptoms reoccur (Onken et al. 2007; Mancini et al. 2005) Long term perspective (Gagne et al. 2007) Opposite of deficient focusinga 6. Strengths-based Many pathways to recovery Growth with setbacks Journey Not step by step Learning from experience Strengths-based Builds on multiple capacities resiliencies, talents, coping abilities Recovery without cure (Leamy et al. 2011; Higgins and McBennett 2007) Coping strategies/abilities (Oades et al. 2009; Higgins and McBennett 2007, Happell, 2008a; Onken et al. 2007) Skills building (Mancini et al. 2005) Re-authoring/re-building self (Leamy et al. 2011; Onken et al. 2007) Unique strengthsa 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. 95 Adm Policy Ment Health (2018) 45:91–102 Table 1 (continued) Components Additional keywords SAMHSA keywords (Substance Abuse and Mental Health Services Administration 2006; Substance Abuse and Mental Health Services Administration 2012) 7. Respect Respect/self-respect/self-acceptance Dignitya Anti-stigma Respectful languagea Eliminating discrimination Self-esteem (Leamy et al. 2011; Jacobson and Greenly 2001; Mancini et al. 2005) Personhood/humanism (Happell 2008a; Mancini et al. 2005) Inherent wortha 8. Responsibility 9. Peer-support 10. Holistic Personal responsibility Living with consequences of choices (Jacobson and Greenly 2001) Self-care/self-managed care Opposite of learned helplessnessa Active participant in recovery Personal authority for risks/risks taking (Jacobson and Greenly 2001) Courage Peer support Peer mentoring (Jacobson and Greenly 2001) Mutual support (sharing knowledge and experiences) Role modeling (Jacobson and Greenly 2001) Self-help Connectedness with peersa Peer operated services Holistic Mind, body, spirit, and community Alternative medical approaches (Happell 2008b; Whitley and Drake 2010) Comforta Complimentary and naturalistic Spirituality Three new components SAMHSA 2012 11. Addresses trauma Trauma-informed care Promoting trust Traumatic events as precursors to illness Safety (e.g. in relationships) 12. Relational Crisis intervention (Jacobson and Greenly 2001, Gagne et al. 2007; Happell 2008a; Mancini et al. 2005) Family (non-peer relationships) Connectedness to others (family, friends etc.)a Faith-based groups Other community members (Gagne et al. 2007; Higgins and McBennett 2007) Interdependence (Leamy et al. 2011) Social aspect of recovery (Higgins and McBennett 2007, Happell 2008a, b; Onken et al. 2007; Anthony 1993) Co-workersa Allies 13. Culture Survivorshipa Personalized to one’s culture No additional keywordsb Cultural sensitivity Cultural competency Values Traditions Belief Four SAMHSA dimensions of recovery 14. Health Overcoming disease symptoms 15. Home Healthy lifestyle habitsa Physical and emotional wellbeing Adverse side-effects (from medications/treatment)a Illicit drug and alcohol abstinence Wellness A stable and safe place to live Living in the community (not living in an institution)a Safe housing (safety in the home) 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. 96 Adm Policy Ment Health (2018) 45:91–102 Table 1 (continued) Components Additional keywords SAMHSA keywords (Substance Abuse and Mental Health Services Administration 2006; Substance Abuse and Mental Health Services Administration 2012) 16. Purpose Fulfilling/meaningful life roles Financial independencea Job School Volunteerism Family caretaking Meaningful life 17. Community Independent income/resources No keywordsc Human interactive environmenta Counterpart to institutionalizationa Reintegration in the communitya Collective pridea Connectedness with the communitya a The authors developed these keywords to better differentiate recovery components and dimensions; they were not explicitly stated in the source documents referenced for the table although these concepts were inferred from the literature b c No additional keywords were extracted because those taken from SAMHSA’s definitions adequately described this component No keywords were taken from SAMHSA’s description of community overlapped substantially with other recovery components delineated in the consensus statement in 2004, three additional guiding principles added in 2012, and four dimensions added in 2012. For this review, the authors developed a list of key words for each of the 17 components; see Table 1. In both the 2004 and 2012 SAMSHA publications, a short definition of each guiding principle and dimension was provided. Key words were extracted from these short SAMHSA definitions and served as the basis for the definitions utilized in the current project. In addition, other highly cited publications that sought to define or explicate recovery were used to provide additional detail to each component. Finally, each component was reviewed to determine if there was overlap with other components. If more than one component addressed a concept, key words were added or removed in order to make the components clearly defined and mutually exclusive. Using the component hope as an example, the 2012 SAMSHA publication provides the following definition: “The belief that recovery is real provides the essential and motivating message of a better future—that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them. Hope is internalized and can be fostered by peers, families, providers, allies, and others. Hope is the catalyst of the recovery process.” The key words generated from this definition were: “motivating message of a better future” and “belief that recovery is real.” The additional key words generated via other publications were: “belief in possibilities,” “optimism,” “inspiration,” “dreams and aspirations,” and “counterpoint to depression.” An iterative process was used to establish interrater reliability for these enhanced definitions of the components/ dimensions and to provide additional clarity to the definitions. The three raters each reviewed the same three articles to generate ratings or “counts” for the presence or absence of each of the 17 components/dimensions in each article. When there was disagreement among the raters, the ratings were discussed until consensus was reached regarding how a concept should be coded. Additional details were added to definitions in order to broaden a definition or to differentiate one component/dimension from others. The three raters then provided counts for another three articles and again discussed discrepancies and added detail to the definitions. F inally, two of the raters provided counts for two articles and an agreement level of 91.2 % was reached; no further modifications were made to the rating scheme. Results From the 1657 publications identified in the literature search, a total of 67 review articles and policy papers met inclusion criteria for this systematic review. (see Table 2 for listing and F ig. 2 for PRISMA diagram of search results (Moher et al. 2009). Included articles are noted with an asterisk in the reference list). Almost half (33/67 or 49 %) of the articles were written by U.S. authors and reported on recovery and delivery of mental health services from an American perspective. A growing body of international literature on recovery was apparent, as the other 34 articles (51 %) were 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. 97 Adm Policy Ment Health (2018) 45:91–102 from other countries (United Kingdom, Australia, Canada, New Zealand, Ireland, Sweden, Taiwan, and China). The majority of the articles (38 or 57 %) were non-systematic literature reviews, 14 (21 %) were qualitative syntheses of the literature, nine (13 %) were policy papers, and six (9 %) were systematic literature reviews. The counts for absence or presence of discussion of each of the 17 components over the 67 articles are summarized in F ig. 3. Individualized/person centered, empowerment, purpose, and hope were the components most frequently identified and were addressed in 80 % or more of the articles reviewed. It is notable that empowerment was mentioned in a high proportion of the articles (57/67 or 85 %) although it was removed from the 2012 SAMHSA definition. One of the new components, relational, was mentioned in the majority of the articles (50/67 or 75 %), whereas the other two new components, culture and addresses trauma, were mentioned in fewer than 25 % of the articles. The four dimensions of recovery that support a life in recovery that were added to the 2012 SAMHSA definition were varied in the frequency of citations. Purpose was highly cited (third most frequently cited, in 56/67 or 81 %). Table 2 Alphabetical list of authors of 67 articles included in synthesis Andresen, Oades, and Caputi (2003) Anthony (1993) Markowitz (2001) Mental Health Commission (2012) Anthony, Rogers, and Farkas (2003) Armstrong and Steffen (2009) Aston and Coffey (2012) Australian Health Ministers’ Advisory Council (2013) Beale and Lambric (1995) Bellack (2006) Brennaman and Lobo (2011) Chen, Krupa, Lysaght, McCay, and Piat (2013) Corrigan (2006) Daley, Newton, Slade, Murray, and Banerjee (2013) Davidson et al. (2008) Davidson, O’Connell, Tondora, Lawless, and Evans (2005) Davidson and Roe (2007) Farkas (2007) Farkas, Gagne, Anthony, and Chamberlin (2005) Gagne, White, and Anthony (2007) Gordon et al. (2014) Happell (2008a) Happell (2008b) Higgins (2008) Hopper (2007) Mental health Commission of Canada (2009) Newberry and Strong (2009) Oades et al. (2005) Onken et al. (2007) Peebles et al. (2007) Provencher, Gregg, Mead, and Mueser (2002) Provencher and Keyes (2011) Ramon et al. (2007) Resnick, Fontana, Lehman, and Rosenheck (2005) Rudnick (2008) Salzmann-Erikson (2013) Schrank and Slade (2007) Self Help Alliance (2011) Sells, Stayner, and Davidson (2004) Shepherd, Boardman, and Slade (2008) Slade (2009) Song and Shih (2009) Sowers (2005) Starnino (2009) Stickley and Wright (2011a) Stickley and Wright (2011b) Hugen (2007) Jacobson (2001) Jacobson (2003) Jacobson and Curtis (2000) Jacobson and Greenley (2001) Kelly and Gamble (2005) Lal (2010) Le Boutillier et al. (2011) Leamy et al. (2011) Svanberg, Gumley, and Wilson (2010) Swarbrick (2009) Tew et al. (2012) Torrey and Wyzik (2000) Tse, Ran, Huang, and Zhu (2013) Warner (2009) Whitley and Drake (2010) Wood, Price, Morrision, and Haddock (2013) Substance Abuse and Mental Health Services Administration (2006)a Liberman (2002) Lloyd, Waghorn, and Williams (2008) Substance Abuse and Mental Health Services Administration (2012)a Lysaker and Buck (2008) Mancini, Hardiman, and Lawson (2005) a SAMHSA document not included in extracted articles but used to develop definitions of recovery components and dimensions 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. 98 Adm Policy Ment Health (2018) 45:91–102 Fig. 2 PRISMA Flow Diagram (Moher et al. 2009) Identification Records identified through databases restricted to “reviews” PubMed (n=591) EBSCO (n=300) PROQUEST (n=451) EMBASE (n=150) COCHRANE (n=5) CINAHL (n=160) n = 1,657 Additional reports identified through SAMHSA white papers, BU Repository, and health policy papers n = 64 Articles retrieved from electronic databases Included Eligibility Screening n = 1,721 Duplicates removed n = 344 Articles screened by title and abstract Articles excluded based on title n = 1,377 n = 1,041 Number of full text articles assessed for eligibility Excluded using criteria n = 336 n = 269 Articles included in synthesis Community and health were both identified in a majority of the articles (41/67 or 61 % and 40/67 or 60 % respectively). By contrast home was less frequently cited and identified in only 36 % (24/67) of the articles. Discussion Although the literature on recovery contains varying, ambiguous and overlapping definitions of recovery and its critical dimensions, the results suggest that there is a consensus among leaders on at least four critical aspects of recovery that ranged in mentions from 81 to 85 % of the 67 articles examined. These four are that recovery should be individualized/person centered, and that recovery is centrally connected to the constructs of empowerment, purpose, and hope. As systems and programs such as the VHA struggle to define recovery and to design services that are recovery-oriented, the application of these four aspects would align the program with consensus on how recovery is understood in the international field. n = 67 We also note that there is a broad consensus on the components and dimensions of recovery. This constellation of components could provide a basis for future attempts to measure recovery and recovery oriented practices and outcomes. There are however two outliers to this consensus. Those are culture and addresses trauma which were newly added to the 2012 SAMHSA consensus statement. The omission in the recovery literature of addresses trauma may have to do with the relatively recent appreciation of the importance of trauma informed mental health care. It is also possible that authors in the field may have intentionally omitted addresses trauma from their definitions because it applies to only a subset of the population; many individuals with mental health challenges who strive for recovery have not experienced a traumatic event. The omission of culture is more puzzling and may reflect an essentially Euro-American ethnocentrism to the recovery literature. We also note that the second most highly ranked component was “empowerment”. Empowerment was identified in the SAMHSA consensus 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. 99 Adm Policy Ment Health (2018) 45:91–102 Fig. 3 Percentage of 67 extracted articles that address each recovery component Individualized/Person-Centered 87% Empowerment 85% Purpose 84% Hope 81% Recovery Components Self-Direction 76% Relational 75% Non-Linear/Many Pathways 69% Strenghts-Based 64% Respect 63% Community 60% (40) 60% (40) 49% Home Culture Addresses Trauma 36% 22% 19% (50) (46) (41) Health Holistic (54) (51) (43) Responsibility 55% (57) (56) (42) 61% Peer Support (58) (37) (33) (24) New components/ dimensionsa Original componentsb Dropped componentc (15) (13) Percentage of Articles that Address Component (n) a b c Recovery components/dimensions SAMHSA added to their working definition in 2012 Original components defined by SAMHSA and adopted by the VA Empowerment was an original SAMHSA component that was dropped from the 2012 working definition statement but was dropped in the 2012 statement. The frequent reference to empowerment as a recovery construct may be mainly a reflection on how long empowerment has been in the recovery lexicon. Alternatively, the incorporation of substance use disorders in the recovery construct may have influenced the inclusion and exclusion of some principles identified earlier. This review of the literature also noted mentions of recovery components that were missing from the SAMHSA definitions. One example is quality of life (Anthony 2003; Gordon et al. 2014; Leamy et al. 2011). While the definition of purpose in this review encompasses the notion of finding meaning in life, quality of life was determined to be a different construct in the literature and was not included as keyword. Also missing was an environmental or ecological perspective (Onken et al. 2007), which incorporates both individual components (such as hope) and the environment (such as opportunities) and focuses on the relationships between the two. Finally we noted that several articles have made a strong argument for incorporating the role of work or employment and skills building into a recovery framework for service delivery. While the definition of purpose contained fulfilling/meaningful life roles such job, school or volunteerism, the building of skills to achieve these life roles is absent. Further explication of recovery should attend to the components of skill building, quality of life, and ecology. The authors can only speculate on what the drivers are for changes in recovery definitions over time. Does the evolution of the conceptualization of recovery reflect a growing crystallization of the concept born out of practice and experience, or changing values of the cultural milieu, or shifts in political winds? This can be a topic for future research. This study is limited by its exploration of recovery that is based on the SAMHSA defined components of recovery. Although SAMHSA engaged in an intensive effort to define recovery including public comment and iterative expert feedback, their definition is only one of several other frameworks for recovery that could have been used. Additionally, the latter SAMHSA framework is designed to embrace recovery both from the mental health and from addiction. However, as we were specifically interested in understanding mental health recovery the literature on addiction recovery was not included. The definitions of the components of recovery provided in the current review are built upon the authors’ interpretations of the definitions. Although these definitions were informed by the literature and represent a best effort to provide clear and mutually exclusive characterizations that capture the essence of each concept, the lines that distinguish one concept from another can be blurry. However, we were able to establish good inter-rater reliability, which is a key building block for establishing the validity of a construct. We anticipate that as the recovery literature and instruments to measure these concepts continue to evolve and develop, these definitions will also continue to evolve. Nevertheless, this study contributes to the ongoing effort to make recovery 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. Adm Policy Ment Health (2018) 45:91–102 100 conceptually clear as it provides definitions, synonyms and keywords that help distinguish one recovery component from another. The definitions too can provide a basis for both operationalizing and measuring these concepts. Combining the definitions and the rankings, the recovery field can move forward with confidence about the relative importance of these recovery components and what they mean. In conclusion, this systematic review provides recovery researchers with clear and distinct definitions of the SAMHSA recovery principles and dimensions that can be used as a rubric for later examination of the recovery concept. The definitions can also form the basis of measurement and fidelity assessment across systems. The analysis also arms recovery system designers with knowledge of what are the key recovery competencies. This knowledge can provide assurance that service designs accord with the broader recovery literature. Acknowledgments Elaine Alligood provided much appreciated library support services. This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development (Grant# CIN 14–234). The authors are solely responsible for the contents of the manuscript and the contents do not represent official views of the US Department of Veterans Affairs or the United States Government. Compliance with Ethical Standards Conflict of Interest Authors Ellison, Belanger, Niles, Evans and Bauer declare that he/she have no conflicts of interest with this paper. Ethical Approval This article does not contain any study with human participants performed by any of the authors. References References marked with an asterisk indicate the studies were selected for analysis *Andresen, R., Oades, L., & Caputi, P. (2003). The experience of recovery from schizophrenia: Towards an empirically validated stage model. Australian and New Zealand Journal of Psychiatry, 37(5), 586–594. doi:10.1046/j.1440-1614.2003.01234.x. *Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychiatric Rehabilitation Journal, 16(4), 11–23. Anthony, W. (2003). Expanding the evidence base in an era of recovery. Psychiatric R ehabilitation Journal, 27(1), 1–2. doi:10.2975/27.2003.1.2. *Anthony, W., Rogers, E. S., & Farkas, M. (2003). Research on evidence-based practices: F uture directions in an era of recovery. Community Mental Health Journal, 39(2), 101–114. doi:10.102 3/A:1022601619482. *Armstrong, N. P., & Steffen, J. J. (2009). The Recovery Promotion F idelity Scale: Assessing the organizational promotion of recovery. Community Mental Health Journal, 45(3), 163–170. doi:10.1007/s10597-008-9176-1. *Aston, V., & Coffey, M. (2012). Recovery: What mental health nurses and service users say about the concept of recovery. Journal of Psychiatric and Mental Health Nursing, 19(3), 257– 263. doi:10.1111/j.1365-2850.2011.01776.x. *Australian Health Ministers’ Advisory Council. (2013). A national framework for recovery-oriented mental health services: Guide for practitioners and providers. Commonwealth of Australia. Retrieved from https://www.health.gov.au/internet/main/publishing.nsf/content/67D17065514CF8E8CA257C1D00017A90/$F ile/recovgde.pdf. *Beale, V., & Lambric, T. (1995). The recovery concept: Implementation in the mental health system. Columbus, OH: Ohio Department of Mental Health. Retrieved from http://www2. dsgonline.com/web_documents/rtp/contributions/Contribution143.pdf. *Bellack, A. S. (2006). Scientific and consumer models of recovery in schizophrenia: Concordance, contrasts, and implications. Schizophrenia Bulletin, 32(3), 432–442. doi:10.1093/schbul/sbj044. *Brennaman, L., & Lobo, M. L. (2011). Recovery from serious mental illness: A concept analysis. Issues in Mental Health Nursing, 32(10), 654–663. doi:10.3109/01612840.2011.588372. California State University Library. (2015). Gray literature. Retrieved Mar 9, 2016, from http://csulb.libguides.com/graylit. *Chen, S.-P., Krupa, T., Lysaght, R., McCay, E., & Piat, M. (2013). The development of recovery competencies for in-patient mental health providers working with people with serious mental illness. Administration and Policy in Mental Health and Mental Health Services R esearch, 40(2), 96–116. doi:10.1007/ s10488-011-0380-x. *Corrigan, P. W. (2006). Recovery from schizophrenia and the role of evidence-based psychosocial interventions. Expert Review of Neurotherapeutics, 6(7), 993–1004. doi:10.1586/14737175.6.7.993. *Daley, S., Newton, D., Slade, M., Murray, J., & Banerjee, S. (2013). Development of a framework for recovery in older people with mental disorder. International Journal of Geriatric Psychiatry, 28(5), 522–529. doi:10.1002/gps.3855. *Davidson, L., Andres-Hyman, R., Bedregal, L., Tondora, J., F ry, J., & Kirk, T. A. Jr. (2008). F rom “double trouble” to “dual recovery”: Integrating models of recovery in addiction and mental health. Journal of Dual Diagnosis, 4(3), 273–290. doi:10.1080/15504260802072396. *Davidson, L., O’Connell, M. J., Tondora, J., Lawless, M., & Evans, A. C. (2005). Recovery in serious mental illness: A new wine or just a new bottle? Professional Psychology: Research and Practice, 36(5), 480–487. doi:10.1037/0735-7028.36.5.480. *Davidson, L., & Roe, D. (2007). Recovery from versus recovery in serious mental illness: One strategy for lessening confusion plaguing recovery. Journal of Mental Health, 16(4), 459–470. doi:10.1080/09638230701482394. Department of Veterans Affairs Center. (2015). Department of veterans affairs statistics at a glance. Department of Veterans Affairs. Retrieved from http://www.va.gov/vetdata/docs/Quickfacts/ Stats_at_a_glance_08_27_15.pdf. Fallot, R. D., McHugo, G. J., Harris, M., & Xie, H. (2011). The trauma recovery and empowerment model: A quasi-experimental effectiveness study. Journal of Dual Diagnosis, 7(1/2), 74–89. doi:10. 1080/15504263.2011.566056. *Farkas, M. (2007). The vision of recovery today: What it is and what it means for services. World Psychiatry, 6(2), 68–74. *Farkas, M., Gagne, C., Anthony, W., & Chamberlin, J. (2005). Implementing recovery oriented evidence based programs: Identifying the critical dimensions. Community Mental Health Journal, 41(2), 141–158. doi:10.1007/s10597-005-2649-6. *Gagne, C., White, W., & Anthony, W. A. (2007). Recovery: A common vision for the fields of mental health and addictions. Psychiatric Rehabilitation Journal, 31(1), 32. *Gordon, S. E., Ellis, P. M., Siegert, R. J., & Walkey, F. H. (2014). Core dimensions of recovery: A psychometric analysis. Administration 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. 101 Adm Policy Ment Health (2018) 45:91–102 and Policy in Mental Health and Mental Health Services Research, 41(4), 535–542. doi:10.1007/s10488-013-0489-1. *Happell, B. (2008a). Determining the effectiveness of mental health services from a consumer perspective: Part 1: Enhancing recovery. International Journal of Mental Health Nursing, 17(2), 116– 122. doi:10.1111/j.1447-0349.2008.00519.x. *Happell, B. (2008b). Determining the effectiveness of mental health services from a consumer perspective: Part 2: Barriers to recovery and principles for evaluation. International Journal of Mental Health Nursing, 17(2), 123–130. doi:10.1111/j.1447-0349.2008.00520.x. Higgins, A. (2008). A recovery approach within the Irish mental health services: A framework for development. Dublin, Ireland: Mental Health Commission. Retrieved from http://www.lenus.ie/hse/ bitstream/10147/75113/1/Framework%20for%20mental%20 health%20services.pdf. Higgins, A., & McBennett, P. (2007). The petals of recovery in a mental health context. British Journal of Nursing, 16(14), 852–856. *Hopper, K. (2007). Rethinking social recovery in schizophrenia: What a capabilities approach might offer. Social Science & Medicine, 65(5), 868–879. doi:10.1016/j.socscimed.2007.04.012. *Hugen, B. (2007). The role of religious orientation in the recovery process of persons with a severe mental illness. Social Work & Christianity, 34(4), 400–420. Iowa Department of Human Services. (2016). Division of mental health and disability services-overview. Retrieved F eb 5, 2016, from http://dhs.iowa.gov/mhds. *Jacobson, N. (2001). Experiencing recovery: A dimensional analysis of recovery narratives. Psychiatric Rehabilitation Journal, 24(3), 248–256. doi:10.1037/h0095087. *Jacobson, N. (2003). Defining recovery: An interactionist analysis of mental health policy development, Wisconsin 1996–1999. Qualitative Health R esearch, 13(3), 378–393. doi:10.1177/1049732302250334. *Jacobson, N., & Curtis, L. (2000). Recovery as policy in mental health services: Strategies emerging from the states. Psychiatric Rehabilitation Journal, 23(4), 333–341. doi:10.1037/h0095146. *Jacobson, N., & Greenley, D. (2001). What is recovery? A conceptual model and explication. Psychiatric Services, 52(4), 482–485. doi:10.1176/appi.ps.52.4.482. *Kelly, M., & Gamble, C. (2005). Exploring the concept of recovery in schizophrenia. Journal of Psychiatric and Mental Health Nursing, 12(2), 245–251. doi:10.1111/j.1365-2850.2005.00828.x. *Lal, S. (2010). Prescribing recovery as the new mantra for mental health: Does one prescription serve all? Canadian Journal of Occupational Therapy, 77(2), 82–89. doi:10.2182/ cjot.2010.77.2.4. *Le Boutillier, C., Leamy, M., Bird, V. J., Davidson, L., Williams, J., & Slade, M. (2011). What does recovery mean in practice? A qualitative analysis of international recovery-oriented practice guidance. Psychiatric Services, 62(12), 1470–1476. doi:10.1176/ appi.ps.001312011. *Leamy, M., Bird, V., Le Boutillier, C., 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. doi:10.1192/bjp.bp.110.083733. *Liberman, R. P. A. (2002). Recovery from schizophrenia: A challenge for the 21st century. International R eview of Psychiatry, 14(4), 245–255. doi:10.1080/0954026021000016897. *Lloyd, C., Waghorn, G., & Williams, P. L. (2008). Conceptualising recovery in mental health rehabilitation. British Journal of Occupational Therapy, 71(8), 321–328. doi:10.1177/030802260807100804. *Lysaker, P. H., & Buck, K. D. (2008). Is recovery from schizophrenia possible? An overview of concepts, evidence, and clinical implications. Primary Psychiatry, 15(6), 60–65. *Mancini, M. A., Hardiman, E. R., & Lawson, H. A. (2005). Making sense of it all: Consumer providers’ theories about factors facilitating and impeding recovery from psychiatric disabilities. Psychiatric R ehabilitation Journal, 29(1), 48–55. doi:10.2975/29.2005.48.55. *Markowitz, F. E. (2001). Modeling processes in recovery from mental illness: Relationships between symptoms, life satisfaction, and self-concept. Journal of Health and Social Behavior, 42(1), 64–79. doi:10.2307/3090227. Massachusetts Department of Health and Human Services. (2016). Vision and mission statement. Retrieved Feb 5, 2016, from http:// www.mass.gov/eohhs/gov/departments/dmh/vision-and-missionstatement.html. Meehan, T., King, R., Beavis, P., & Robinson, J. (2008). Recoverybased practice: Do we know what we mean or mean what we know? Australian and New Zealand Journal of Psychiatry, 42(3), 177–182. *Mental Health Commission. (2012). Blueprint II: How things need to be. Improving mental health and well being for all New Zealanders. Wellington, New Zealand: Mental Health Commission. Retrieved from http://www.hdc.org.nz/media/207642/blueprint%20ii%20how%20things%20need%20to%20be.pdf. *Mental Health Commission of Canada. (2009). Toward recovery and well-being: A framework for a mental health strategy for Canada. Calgary Alberta, Canada: Mental Health Commission of Canada. Retrieved from http://www.mentalhealthcommission.ca/English/ system/files/private/document/FNIM_Toward_Recovery_and_ Well_Being_Text_ENG.pdf. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Journal of Clinical Epidemiology, 62(10), 1006–1012. doi:10.1016/j. jclinepi.2009.06.005. New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report. Rockville, MD: US Department of Health and Human Services. Retrieved from http://govinfo.library.unt.edu/mentalhealthcommission/reports/FinalReport/downloads/InsideCover. pdf. *Newberry, D. J., & Strong, A. D. (2009). Beyond mental health maintenance: An evaluation framework driven by recovery-focused outcomes. Canadian Journal of Community Mental Health, 28(2), 73–94. doi:10.7870/cjcmh-2009-0024. *Oades, L., Deane, F., Crowe, T., Lambert, W. G., Kavanagh, D., & Lloyd, C. (2005). Collaborative recovery: An integrative model for working with individuals who experience chronic and recurring mental illness. Australasian Psychiatry, 13(3), 279–284. doi:10.1111/j.1440-1665.2005.02202.x. *Onken, S. J., Craig, C. M., Ridgway, P., Ralph, R. O., & Cook, J. A. (2007). An analysis of the definitions and elements of recovery: A review of the literature. Psychiatric R ehabilitation Journal, 31(1), 9–22. doi:10.2975/31.1.2007.9.22. *Peebles, S. A., Mabe, P. A., Davidson, L., Fricks, L., Buckley, P. F., & F enley, G. (2007). Recovery and systems transformation for schizophrenia. Psychiatric Clinics of North America, 30(3), 567– 583. doi:10.1016/j.psc.2007.04.009. *Provencher, H. L., Gregg, R., Mead, S., & Mueser, K. T. (2002). The role of work in the recovery of persons with psychiatric disabilities. Psychiatric R ehabilitation Journal, 26(2), 132–144. doi:10.2975/26.2002.132.144. *Provencher, H. L., & Keyes, C. L. M. (2011). Complete mental health recovery: Bridging mental illness with positive mental health. Journal of Public Mental Health, 10(1), 57–69. doi:10.1108/17465721111134556. *Ramon, S., Healy, B., & Renouf, N. (2007). Recovery from mental illness as an emergent concept and practice in Australia and the 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. Adm Policy Ment Health (2018) 45:91–102 102 UK. International Journal of Social Psychiatry, 53(2), 108–122. doi:10.1177/0020764006075018. *Resnick, S. G., F ontana, A., Lehman, A. F., & Rosenheck, R. A. (2005). An empirical conceptualization of the recovery orientation. Schizophrenia R esearch, 75(1), 119–128. doi:10.1016/j. schres.2004.05.009. *Rudnick, A. (2008). Recovery from Schizophrenia: A philosophical framework. American Journal of Psychiatric Rehabilitation, 11(3), 267–278. doi:10.1080/15487760802186360. *Salzmann-Erikson, M. (2013). An integrative review of what contributes to personal recovery in psychiatric disabilities. Issues in Mental Health Nursing, 34(3), 185–191. doi:10.3109/01612840. 2012.737892. *Schrank, B., & Slade, M. (2007). Recovery in psychiatry. Psychiatria Danubina, 19(3), 246–251. *Sells, D. J., Stayner, D. A., & Davidson, L. (2004). Recovering the self in schizophrenia: An integrative review of qualitative studies. Psychiatric Quarterly, 75(1), 87–97. doi:10.1023/B:P SAQ.0000007563.17236.97. *Self Help Alliance. (2011). R ecovery values and principles in the addiction and mental health system of care. Cambridge, England: Self Help Alliance. Retrieved from http://self-help-alliance.ca/ wp-content/uploads/2012/02/Recovery-Values-and-Principles. pdf. *Shepherd, G., Boardman, J., & Slade, M. (2008). Making recovery a reality, London: Sainsbury Centre for Mental Health. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1. 688.6109&rep=rep1&type=pdf. *Slade, M. (2009). The contribution of mental health services to recovery. Journal of Mental Health, 18(5), 367–371. doi:10.3109/09638230903191256. *Song, L., & Shih, C. (2009). F actors, process and outcomes of recovery from psychiatric disability: The unity model. International Journal of Social Psychiatry, 55(4), 348–360. doi:10.1177/0020764008093805. *Sowers, W. (2005). Transforming systems of care: The American Association of Community Psychiatrists guidelines for recovery oriented services. Community Mental Health Journal, 41(6), 757–774. doi:10.1007/s10597-005-6433-4. *Starnino, V. R. (2009). An integral approach to mental health recovery: Implications for social work. Journal of Human Behavior in the Social Environment, 19(7), 820–842. doi:10.1080/10911350902988019. *Stickley, T., & Wright, N. (2011a). The British research evidence for recovery, papers published between 2006 and 2009 (inclusive). Part one: A review of the peer-reviewed literature using a systematic approach. Journal of Psychiatric and Mental Health Nursing, 18(3), 247–256. doi:10.1111/j.1365-2850.2010.01662.x. *Stickley, T., & Wright, N. (2011b). The British research evidence for recovery, papers published between 2006 and 2009 (inclusive). Part two: A review of the grey literature including book chapters and policy documents. Journal of Psychiatric and Mental Health Nursing, 18(4), 297–307. doi:10.1111/j.1365-2850.2010.01663.x. Substance Abuse and Mental Health Services Administration. (2006). National consensus statement on mental health recovery. Rockville, MD: US Department of Health Human Services. Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s Working Definition of Recovery. Rockville, MD: US Department of Health and Human Services. Retrieved from https://store.samhsa.gov/shin/content/PEP12-RECDEF/PEP12RECDEF.pdf. *Svanberg, J., Gumley, A., & Wilson, A. (2010). How do social firms contribute to recovery from mental illness? A qualitative study. Clinical Psychology and Psychotherapy, 17(6), 482. doi:10.1002/ cpp.681. *Swarbrick, M. (2009). A wellness and recovery model for state psychiatric hospitals. Occupational Therapy in Mental Health, 25(3– 4), 343–351. *Tew, J., Ramon, S., Slade, M., Bird, V., Melton, J., & Le Boutillier, C. (2012). Social factors and recovery from mental health difficulties: A review of the evidence. British Journal of Social Work, 42(3), 443–460. doi:10.1093/bjsw/bcr076. The White House Office of the Press Secretary. (2012). Fact sheet: President Obama signs executive order to improve access to mental health services for Veterans, service members, and military families. Retrieved Mar 9, 2016, from https://www.whitehouse. gov/the-press-office/2012/08/31/fact-sheet-president-obamasigns-executive-order-improve-access-mental-h. *Torrey, W. C., & Wyzik, P. (2000). The recovery vision as a service improvement guide for community mental health center providers. Community Mental Health Journal, 36(2), 209–216. doi:10.1 023/A:1001802612944. *Tse, S., Ran, M.-S., Huang, Y., & Zhu, S. (2013). Mental health care reforms in Asia: The urgency of now: Building a recoveryoriented, community mental health service in China. Psychiatric Services, 64(7), 613–616. doi:10.1176/appi.ps.000022013. Veterans Health Administration. (2008). Uniform mental health services in VA Medical centers and clinics. Washington, DC: Department of Veterans Affairs. Retrieved from http://www.mirecc. va.gov/VISN16/docs/UMHS_Handbook_1160.pdf. Virginia Department of Behavioral Health & Developmental Services. (2014). Department of Behavioral Health & Developmental Services Mission and Vision. Retrieved F eb 5, 2016, from http:// www.dbhds.virginia.gov/about-dbhds/mission-vision. *Warner, R. (2009). Recovery from schizophrenia and the recovery model. Current Opinion in Psychiatry, 22(4), 374. doi:10.1097/ YCO.0b013e32832c920b. *Whitley, R., & Drake, R. E. (2010). Recovery: A dimensional approach. Psychiatric Services, 61(12), 1248–1250. doi:10.1176/ appi.ps.61.12.1248. *Wood, L., Price, J., Morrision, A., & Haddock, G. (2013). Exploring service users perceptions of recovery from psychosis: A Q-methodological approach. Psychology and Psychotherapy, 86(3), 245– 261. doi:10.1111/j.2044-8341.2011.02059.x. 13 Content courtesy of Springer Nature, terms of use apply. Rights reserved. Terms and Conditions Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”). Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for smallscale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial. These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription (to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will apply. We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as detailed in the Privacy Policy. While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may not: 1. use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access control; 2. use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is otherwise unlawful; 3. falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in writing; 4. use bots or other automated methods to access the content or redirect messages 5. override any security feature or exclusionary protocol; or 6. share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal content. In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue, royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any other, institutional repository. These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved. To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law, including merchantability or fitness for any particular purpose. Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed from third parties. If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not expressly permitted by these Terms, please contact Springer Nature at [email protected]
