recovery model literature review

SYSTEMATIC REVIEW article

Recovery from severe mental health problems: a systematic review of service user and informal caregiver perspectives.

• 1 Health Service & Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
• 2 Department of Psychology, University of Warwick, Coventry, United Kingdom
• 3 Care Policy and Evaluation Centre, London School of Economics and Political Science, London, United Kingdom

Introduction: The recovery approach aims to have users' perspectives at the heart of service development and research; it is a holistic perspective that considers social needs, personal growth and inclusion. In the last decade recovery-oriented research and practice has increased greatly, however, a comprehensive model of recovery considering exclusively the perspectives of people with lived experience has not been devised.

Aims: This review aimed to develop a framework and contextualize service users' and informal caregivers' understanding of recovery from severe mental health problems.

Methods: We systematically searched 6 databases including key terms related to knowledge, experience and narratives AND mental health AND personal recovery. The search was supplemented with reference sourcing through gray literature, reference tracking and expert consultation. Data analysis consisted of a qualitative meta-synthesis using constant comparative methods.

Results: Sixty-two studies were analyzed. A pattern emerged regarding the recovery paradigms that the studies used to frame their findings. The resulting recovery framework included the domains Social recovery; Prosperity (Legal, political, and economic recovery); Individual Recovery; and Clinical Recovery Experience (SPICE). Service users' definitions of recovery tended to prioritize social aspects, particularly being accepted and connecting with others, while caregivers focused instead on clinical definitions of recovery such as symptom remission. Both groups emphasized individual aspects such as becoming self-sufficient and achieving personal goals, which was strongly linked with having economic means for independence.

Conclusions: The recovery model provided by this review offers a template for further research in the field and a guide for policy and practice. Predominant definitions of recovery currently reflect understandings of mental health which focus on an individual perspective, while this review found an important emphasis on socio-political aspects. At the same time, only a small number of studies took place in low-income countries, focused on minoritized populations, or included caregivers' perspectives. These are important gaps in the literature that require further attention.

Systematic Review Registration : The review protocol was registered on PROSPERO (CRD42017076450); https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=76450 .

Key Messages

- This systematic review generated a comprehensive model of recovery from severe mental health problems from the perspective of service users and informal carers, that can guide further research, policy, and practice.

- Four dimensions of recovery emerged: Social Recovery; Prosperity; Individual Recovery; and Clinical Recovery Experience (SPICE).

- These dimensions align with existing paradigms of recovery identified in the references of the literature: Social and political recovery models; the REFOCUS CHIME model of recovery; the United States user/survivor movement; and the clinical recovery model.

- Users' knowledge, experience, and narratives of recovery tended to prioritize social aspects, whereas caregivers focused on clinical understandings of recovery.

- Recovery is a multifaceted concept and requires a comprehensive/ecological approach. Each dimension of recovery identified in this review would benefit from specific therapeutic techniques or referral to specific professionals, including integrating civil rights or social work services into mental well-being response efforts.

Introduction

The ways in which people conceptualize mental health problems vary across cultures, and therefore there are also variations in the meaning of recovery ( 1 , 2 ). Much of mental health practice, research, and policy relies on what is known as a bio-medical understanding which speaks of mental distress in terms of diagnosis, and frames recovery in terms of clinical outcomes ( 3 , 4 ). From that perspective, recovery is focused on reduction of symptoms and functional impairment. The concept of clinical recovery derives from research led by mental health professionals: it involves diagnosis, and measures of symptoms and psychosocial functioning designed and rated by professionals ( 5 , 6 ). This type of recovery underpins a large number of data collection instruments that have been used in epidemiological research.

However, critics of the clinical recovery model have highlighted limitations regarding the lack of sensitivity to variability across individuals and contexts, and not including outcomes that are meaningful to service users ( 7 ). Since the 1990's, the focus in the field of recovery has shifted to an approach derived from literature led by mental health service users/survivors. This has been referred to as personal recovery, it stems from and focuses on attitudes toward life, personal growth and abilities, contribution to the community, and life satisfaction ( 8 , 9 ). This approach aims to have users' perspective at the heart of service development and research, and it is considered distinct from “clinical recovery” that focuses on achieving clinically-defined goals ( 10 – 13 ).

The personal recovery approach is an ideology that encourages a broader understanding of mental ill health experiences and how people who are feeling mentally unwell can be helped. Placing service users at the center of decision-making in mental health has initiated a major shift in traditional philosophical views of mental health, resulting in reduced discrimination and reduced association of mental health problems with deficit and chronicity ( 14 ). This definition of recovery is becoming a key concept in mental health research, policy, and service development world-wide, thus progressing toward the recognition of human and civil rights of those affected by mental health problems and their carers ( 15 ).

There has, however, been criticism about personal recovery being defined in individualistic terms ( 16 ) that neglect collectivist values that are more present in some cultural groups ( 17 – 20 ). A perspective that has been lacking in conceptualizations of recovery is that of informal caregivers, whose views are not typically taken into account in recovery definitions, and thus their key role in the users' recovery journey is not recognized. Acknowledging informal carers' perspectives of recovery could facilitate a deeper understanding of less common paradigms which emphasize the systemic nature of recovery and take into consideration socio-economic needs and inclusion ( 21 , 22 ). Less widely cited recovery paradigms propose social and political factors to be taken into account, and add pursuing civil rights to the aims of recovery ( 23 , 24 ).

In the last decade recovery-oriented research and practice has increased greatly. Recovery is now a focus world-wide and the intention to develop recovery-oriented services is typically present in official mental health service strategies ( 25 ). However, a synthesis of experts by experience's definitions of recovery has not been devised and, therefore a comprehensive model that reflects their views is not in place. The purpose of this research is to develop a comprehensive model that encompasses the full range of dimensions of recovery which are relevant to experts by experience (i.e., individual and systemic recovery), while at the same time providing context for this construct. This will be achieved by: (1) reviewing the evidence for mental health service users' and their informal caregivers' understandings of recovery from mental health problems, and (2) compiling key recovery paradigms referenced in this literature and specifying their characteristics and origins.

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement ( 26 ). A protocol was developed a priori and registered on PROSPERO (CRD42017076450).

Search Strategy and Study Selection

Six electronic databases (Embase, PsycINFO, Medline, ScIELO, LILACS, and CINAHL) were searched in October 2020. The search strategy included key terms related to knowledge, experience and narratives AND mental health AND personal recovery. A complete search strategy is provided in Supplementary File 1 . Further articles were sourced by searching for publications by authors of relevant gray literature identified in the database searches. Due to most publications identified being based in Europe and North America, a convenience sample of 10 recovery experts working in seven countries across Africa, Asia, and Latin America were contacted for suggestions of further literature relevant for inclusion. Additionally, the search was supplemented by reference searching through included literature, and the five authors with most publications were contacted to enquire about potential missed studies or work in press.

Initial screening was conducted based on the titles and abstracts of the search results using the web application Rayyan ( 27 ). Full texts were sourced for articles deemed relevant for inclusion and these were then screened against the full review eligibility criteria.

To establish consistency in the study selection, 300 randomly selected records at the title and abstract screening stage, and 50 records at the full text screening stage were independently reviewed by the author and a second screener, and discrepancies were resolved via discussion.

Eligibility Criteria

Studies were included in this review if (1) their focus was recovery from severe mental health problems, (2) as understood by service users and informal caregivers, and (3) enquired through methodologies where participants' perspectives were explored in an open-ended manner; studies with fixed survey responses were excluded. There were no restrictions on publication date or language.

Recovery was understood as changes toward feeling well, reaching meaningful outcomes or experiencing a positive sense of self. The term informal caregiver refers to people who provide unpaid care or support for people with mental health problems.

Articles were excluded if mental health problems were not the participants' primary condition, or if the focus of the study was limited to a specific aspect of recovery. Studies where the primary condition was substance misuse or exposure to traumatic events were excluded due to these fields having their own extensive bodies of recovery literature which describes specific recovery paths ( 28 ).

A full list of the inclusion/exclusion criteria is provided in Supplementary File 2 .

Data Extraction and Risk of Bias Assessment

Data collected from the studies included the recovery paradigms used to frame their findings in the introduction/background section (either in terms of a paradigm explicitly stated by study authors, or a paradigm as interpreted by the review team), and the recovery themes that studies reported in the results section/discussion. When themes were not explicitly presented, results were categorized into themes. Special attention was paid to extract themes of recovery described as an outcome, rather than when presented as helping or hindering recovery. In addition, data were collected on core study details (year, setting, population and methodological characteristics, and authors' interpretations and further discussions on the data). Missing details were requested from study authors.

Given the plurality of methodologies used in the identified studies, seven criteria for quality appraisal were adopted from different published tools ( 29 – 31 ) 1 with the aim of appraising transparency, description of key terms, and coherence. The full risk of bias assessment checklist is provided in Supplementary File 3 .

Qualitative Meta-Synthesis

An interpretative synthesis using constant comparison was conducted to develop a definition of core dimensions of recovery and an understanding of how they may be related ( 32 , 33 ). This method involved using reciprocal translational analysis to group the themes identified in the literature into higher order themes that best reflected their content, while keeping the theory grounded in the data and context of each study to gain a broader picture of the construct of recovery. Additionally, negative cases were kept in a log to have them present during data synthesis.

At a final stage, study characteristics were condensed into ecological sentences (i.e., “in this year, within this paradigm of recovery, in this setting, recovery meant…”) to facilitate mapping the concept of recovery ( 34 ).

Study Selection

A flow diagram of the screening and selection process, according to PRISMA guidelines, is presented in Figure 1 . A full list of citations and reasons for exclusion is provided in Supplementary File 4 . The remaining 62 studies were included in this review.

Figure 1 . Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the screening and selection process conducted in this systematic review.

Study Characteristics

From the 62 papers included in this systematic review, one was published in 1967, while the rest were conducted between 1999 and 2020. Study settings were primarily English-speaking ( n = 51, 82%), high-income countries ( n = 58, 94%). However, six (10%) of these papers focused on a low-income sample. In all included studies, recruitment was done through convenience or purposeful sampling in all studies, generally participants were reached through clinical contacts or announcements posted in recovery or service user groups.

Data were collected using in-depth interviews in 47 (76%) of the studies. Other methods included focus groups, photo-voice, ethnography field notes, and narrative interviews. Thematic analysis ( n = 27, 44%) and grounded theory ( n = 11, 18%) were the most commonly used analysis methods. Two studies (3%) applied a quantitative methodology, one followed a Delphi process for data collection and analysis ( 35 ), and one study used a snowball technique for data collection and Chi squared analysis ( 36 ).

Sample sizes ranged from 1 to 177 participants in qualitative studies, and 180–381 in the quantitative studies. Sixty (97%) studies included a user sample, and nine (15%) included a caregiver sample. Studies typically included both male and female participants between 18 and 65 years of age. Twenty-five (40%) studies specified participants' ethnicities; out of these, 19 were predominantly of white-European background. The remaining six studies included two in the USA and Canada which had specific interest in users of black-African descent ( 37 , 38 ); one that contrasted perspectives of Euro-Canadian and Caribbean-Canadian participants ( 39 ); one focused on the perspectives of women in Swaziland ( 40 ); one about Indian service users and caregivers ( 36 ); and one focused on individuals from a Chinese community in Hong Kong ( 41 ).

Participant information concentrated around stage of recovery and diagnosis. Authors described the stage of recovery in various ways such as length of service use or feeling well enough to participate in the study. Studies included heterogeneous transdiagnostic samples, with the exception of 17 (27%) studies that focused on psychosis/schizophrenia, 3 (5%) on depression, 3 (5%) on personality disorder, 3 (5%) on bipolar disorder, and 1 (2%) focusing on voice hearing following the single complaint approach ( 42 ). Limitations were stated in relation to comorbidity with other diagnoses and relevance and usefulness of diagnostic criteria.

User employment and education were reported in 18 (29%) and 13 (21%) studies, respectively. Based on these data, users were most commonly unemployed and education levels varied from no schooling to “25 years of education.”

A pattern emerged regarding the recovery paradigms that the studies referenced in their introduction and used to frame their findings. Five distinct categories/models were identified: USA consumer/survivor recovery movement (including Substance Abuse and Mental Health Services Administration—SAMHSA- model) ( n = 19, 30%); REFOCUS-CHIME model of recovery ( n = 12, 19%); Social recovery ( n = 8, 13%); Political recovery ( n = 3, 5%), and Bio-medical recovery ( n = 3, 5%). Further exploration of the paradigms referenced highlighted that the perspectives of experts by experience were present particularly in the development of models of recovery in the USA, and to a lesser extent in the REFOCUS-CHIME model and the Political recovery paradigm. The remaining paradigms emerged mainly from reflections of mental health professionals and social/political theorists. All the identified recovery paradigms concurred in acknowledging the potential to feel better after experiencing mental health problems, however, they differed in their position regarding four aspects of recovery: (1) The extent to which they focused on internal conditions such as individual's attitudes, vs. external conditions such as policies and social circumstances; (2) the importance placed on diagnosis; (3) the literature by which they were influenced, and thus (4) the recovery goals they proposed to focus on.

A brief description of each recovery paradigm is provided in Table 1 , and the overall main characteristics of the included studies are listed in Supplementary File 5 .

Table 1 . Description of recovery paradigms identified in the literature.

Risk of Bias

All studies met 50% or more of the quality criteria assessed, and 31 studies (50%) fulfilled all 7 criteria. Additionally, a substantial number of studies included user participation or mindful interviewer selection ( n = 29, 47%) to enhance rigor.

Recovery Themes

This list of themes is the result of the synthesis of the empirical data extracted from the results section of the studies included in this review. Table 2 illustrates the four core parent themes present in these data: Social Recovery; Prosperity; Individual Recovery; and Clinical Recovery Experience (SPICE). All themes were present to a greater or lesser extent in users' definitions of recovery; the cases where themes were also part of caregivers' understanding of recovery are highlighted where applicable. These themes are elaborated upon below, with selected quotes from the included studies illustrating the key characteristics of the parent themes and subthemes within these. Figure 2 provides a visual representation of how the findings in this review are related. Theme one (Propsperity) was aligned with the social and political recovery paradigms; themes two and three (Social and Individual Recovery) overlapped with the definition of recovery of the REFOCUS-CHIME, SAMHSA, and USA consumer/survivor movement, and theme four with the bio-medical recovery paradigm. At the same time, social and political aspects of recovery were more common among user samples, while clinical recovery goals were more prevalent among carer samples.

Table 2 . Parent themes identified in the data, the subthemes that fall within these and the number of user/carer studies which included them.

Figure 2 . Meta-synthesis map. Visual representation of how the recovery paradigms and themes identified in this systematic review are related and their predominance in user/carer samples. The circles on left and right represent recovery as understood by users and carers, respectively. The outer circle presents recovery paradigms, while the inner circles refer to the themes and subthemes. The most prevalent themes are highlighted in bold letters.

Theme 1: Prosperity

Framing recovery as a social construct was highly present in the literature. Examples of this can be found in Basso et al. ( 43 ) “ recovery has to be understood also as a social process, where people face, along with the disease, other tests such as the need for tangible resources, jobs, availability of housing, financial independence, and efficient services ” or ( 38 ), who studied recovery from the perspective of racialized women in Canada and remarked on the lack of discussion around symptoms and treatment in participant's recovery narratives: “ their challenges were very much framed as social rather than psychiatric .”

This recovery theme was especially common in literature linked to the user/survivor movement or advocating for collective action against human rights violations in mental health treatment.

Subthemes that fell under this theme were: “Legal and political recovery” and “Economic recovery.”

Legal and Political Recovery

Empowerment was one of the central aspects underlying this theme; recovery goals were related to rebelling against socially imposed rules or practices which users considered to stand in the way of their well-being and advocating for fairer legislation. This idea was especially prominent in the literature analyzing women's understanding of recovery, where these thoughts were discussed under the terms “ breaking away from limited woman roles ” ( 38 ) and “ doing and being beyond gendered responsibilities ” ( 44 ). Fullagar and O'Brien ( 44 ) concluded “ Practitioners and advocates in women's health movements have historically recognised that personal recovery is political .” At the same time Armour et al. ( 37 ), pointed out that black and minority ethnic (BME) groups experienced oppression both because of their mental health problems and because of their race, which would involve two different approaches when fostering empowerment.

Economic Recovery

A key recovery goal from both a user and caregiver perspective was reaching economic stability. Recovery was understood as having sufficient resources available to have an acceptable quality of life and live independently from family. Participants in Borg and Davidson's ( 45 ) study in Norway, included shopping and paying bills as part of their notion of achieving “normality” (see normalcy subtheme). Similarly, service users and carers in Italy considered recovery involved actions to reduce external barriers that impeded independent living, such as lack of jobs in the open market and lack of accessible living solutions which prolonged cohabitation with the family ( 43 ). The need for financial support and/or access to employment to mitigate adverse material circumstances was highlighted particularly in studies with participants from ethnic minorities or hard to engage populations ( 37 , 40 , 46 ).

Theme 2: Social Recovery

Two interrelated types of social recovery were identified. One was an externally derived social recovery which required approval and acceptance from the group. In this sense, recovery meant being trusted, being assigned responsibilities and being treated as an equal. Cárcamo Guzmán et al. ( 47 ) wrote about the meaning of recovery to service users in Chile, “ it is understood as the legitimacy of the user as a person, this implies the respect for their experiences, points of view and needs .” The other type of social recovery was derived from personal initiative and consisted of: socializing and establishing meaningful relationships, being a productive member of the community, and fulfilling family roles. Participants in Hancock et al. ( 48 ) study spoke about learning to navigate complex relationships, avoiding unhelpful interactions and managing the impact of their mental health problems on others.

Nxumalo Ngubane et al. ( 40 ) presented being accepted and able to contribute to their family and community as an important part of recovery for Swazi women diagnosed with schizophrenia. The socially constructed nature of recovery was emphasized repeatedly, with social discrimination and experiences of stigma being perceived as the opposite of recovery in many of the studies ( 36 , 40 , 47 , 49 – 52 ). The definition and achievement of recovery was thought to be co-constructed in society and developed by engaging in honest and genuine mutuality ( 53 ). In this sense, others offering help or feedback, and users being willing to accept it, were equally important recovery goals, as pointed out by Moltu et al. ( 54 ) in Norway saying “ In our analyses, we were struck by how important others were in noticing improvement and positive change, in a way that the suffering person could embody .”

An important part of externally derived social recovery was being allowed to take risks, this is to be considered to have adequate judgement in everyday life and legal capacity to consent in formal contexts. As written by Pitt et al. ( 55 ) “ ultimately recovery requires active participation in life. This involves taking risks and suffering setbacks .” Fullagar and O'Brien ( 44 ) described how an environment that allowed for free decision-making provided users with the opportunity to experience “ dignity of risk ” and realize their capabilities.

Some studies described a spiritual form of connection with a “ higher power ” or “ God ” as important for recovery ( 37 , 40 , 56 ). Allusion to spiritual or religious recovery concepts was present across the literature in the different populations and settings.

People with mental health problems which affect social interaction, such as people with a diagnosis of personality or bipolar disorder, were thought to face a greater challenge to achieve social recovery. This was both related to personally derived social recovery, as described by ( 57 ) “ improving relationships for this group might also be more complex than solely addressing social isolation [discrimination], which is commonly discussed in recovery literature ,” and externally derived social recovery, Kverme et al. ( 53 ) “ The experience of becoming safer as a human among other humans constituted a core meaning of recovery .”

Within this theme, caregivers' definitions of recovery concentrated mainly around users being attentive to others' needs and able to establish positive connections. As mentioned by ( 58 ) “ Families described changes in amount and content of interaction, noted their relative being helpful in the home, showing consideration for a parent, remembering a family member's birthday ,” and by ( 41 ) “ She [carer's daughter] can integrate into society through such things as going to church, having a job, returning to a normal life, going out .”

Theme 3: Individual Recovery

The third parent theme focused on individual goals, needs, and responsibilities. As expressed by ( 59 ) “ Contrary to the common belief that mental illness involves a purely degenerative condition, it appears that many people discover new potentials and new self-growth at various points throughout their recovery .”

This theme of individual recovery encompassed six subthemes: “Normalcy”; “Temporal understandings of recovery and identity”; “Recovery and knowledge”; “Recovery as an individual responsibility,” “Appearance and hygiene,” and “Recovery as a positive frame of mind.”

Related to social recovery was the idea of not feeling different from most people and achieving the goals that are considered the norm by your social group. Borg and Davidson ( 45 ) found “ being normal ” to be one of the major themes in recovery: “ What seems most crucial to “being normal” is spending time in ordinary environments with ordinary people .” Katsakou et al. ( 57 ) identified a link between employment and feeling normal, as expressed in one of their participant's quotes: “ I still haven't managed to get back to work and I can't see friends, I've been cut off because I've stopped working .”

A line of the recovery literature focused on understanding recovery through ordinary everyday activities. In this sense, the main recovery goal consisted of completing routine tasks and participating in common leisure activities. Milbourn et al. ( 46 ) noted that in order to appreciate participants' understandings of recovery, the list of everyday routines needs to be broadened to include personally meaningful activities which may be considered negative by others, such as “ recreational drugs and paying for sex .”

McCabe et al. ( 60 ) pointed out in forensic mental health services “ everyday activities such as walking and discussing books were talked about in the language of therapies administered by services. The ‘reader group’ and the ‘walking group’ were all discussed in terms of therapeutic interventions rather than fulfilling hobbies that people adopt in everyday life .”

Temporal Understandings of Recovery and Identity

There were two contrasting views regarding the temporal focus of the recovery journey: one described recovery as the ability to focus on future goals, having hope and seeing “ the light at the end of the tunnel ” ( 61 ), while the other described it as the ability to live in the present and complete daily routines (related to the “Normalcy” subtheme). This contrasting view of recovery was also present in different identity goals, with some service users striving to develop a “new self” by learning from their experience ( 62 , 63 ), and others wanting to return to the roles and occupation or everyday activities from before experiencing mental health problems ( 58 , 64 ). Recovery was not a single state of being but a complex mix of the past, the here and now and, the future ( 60 ).

This distinction was discussed by ( 65 ), who found participants wishing to reflect on and integrate the disorder experience into a new identity, while others wished to leave the experience behind and focus on symptom management. Participants in both groups were described as currently not having symptoms, good quality of life and no psychological distress, for this reason the authors advocated for the latter approach to recovery to not be pathologized. Instead, they promoted a broader understanding of recovery that does not require active engagement or reflecting on the mental health problems experienced.

The idea of returning to a former identity was a prominent topic throughout the literature, however, it was particularly highlighted in the definition of recovery of older adults presented by ( 66 ) “ The single core category identified from the analysis was ‘Continuing to be me.’ This related to the permanent and established sense of identity which service user participants held […] .”

Recovery and Knowledge

An important recovery goal was gaining new knowledge. This included knowledge about yourself (personal growth), knowledge about mental health, and knowledge gained through formal education. The latter was highlighted as particularly important in ( 67 ) study about adolescent service users.

Service users in ( 49 ) study underlined the role of understanding early lived experience as informing sense of self “ Most participants framed their understanding of their experiences within a description of their early life within their family, particularly their sense of belonging and the interpretations of their behaviour made by key family members .” Self-discovery was also a significant part of recovery for young people in ( 68 ) study, pointing to the limited life experience before mental health problems creating an additional vulnerability.

Knowing more about mental health was approached both as part of embracing a given diagnosis [e.g., the goal “ coming to know your illness ” ( 69 )] and discarding it [e.g., “ developing a critique of mental health services ” ( 55 )]. These considerations about diagnosis are explored further later under the theme “Clinical recovery experience.” In both cases the final aim was to develop strategies to feel better, building higher self-esteem, and self-awareness. As described by ( 70 ) “ Recovery usually occurs when people with mental disabilities discover or rediscover their strengths and the opportunities to pursue personal goals and a sense of self that allows them to grow, despite any residual symptoms and difficulties .”

Recovery as an Individual Responsibility

Being self-sufficient and having control over one's mental health problems and their consequences were highly prevalent recovery goals. Recovery within this theme is described as an internal fight, coming to the realization that “ It needs to be me ” ( 48 ). In most of the literature, recovery was presented as a personal choice to actively cope with mental health problems. An important aspect of reaching autonomy was no longer being reliant on mental health services. As stated in ( 71 ), participants did not consider mental health services to promote self-management and this was seen as going against their recovery. Participants wished to assert their position as experts by experience and those who did not engage with services were seen as “ winners ”: “ taking responsibility is at the heart of the recovery process as people are empowered to make their own choices and focus on their own outcomes .”

This understanding of recovery is summarized by a participant in the study conducted by ( 72 ) “ It reminds me of an author who said she's never avoided challenges but put her “ sails full tilt into the wind .” There's a certain bravery in facing obstacles head-on. With my mental health challenges, I've learned to put my sails full tilt to the wind and move towards my goals .”

This conceptualization of recovery as an individual responsibility was strongly linked to empowerment, which in turn was linked to having economic means for independence ( 43 , 73 , 74 ). A person with mental health problems reaching independence was a particularly important recovery goal for caregivers, this included financial autonomy and independent living that reduced the reliance on caregiver/family support (as mentioned in the subtheme “Economic recovery”) and reaching emotional stability. An example of this are the findings from the study by ( 58 ): “ They longed for their relative to be able to take care of themselves, live independently, or have improved judgment and concentration, or to work and become functional and self-sufficient .”

A distinctive understanding of recovery was presented by ( 75 ) who studied the views of forensic psychiatric patients (offenders with mental health problems). For the most part participants chose to rely on medication and medical guidance, rather than their own judgment and active participation: “ Their lack of control was in most cases, simply stated as an incontrovertible fact .”

Appearance and Hygiene

Some studies described improving appearance and keeping up good hygiene as part of personal recovery; the focus of this goal was adding to a personal sense of worth, rather than complying with social rules. Davis ( 76 ) who conducted an ethnography in a women's psychiatric ward noted “ Wearing their own clothing again adds to their appearance of well-being. […] this makes it all the more difficult for them to see themselves as ” “ sick persons .” A participant in the study by Santos et al. ( 74 ) expressed “ [I want to] maintain…good hygiene…, fitness, exercise, nutrition… .”

Recovery as Having a Positive Frame of Mind

A representative description of this understanding of recovery can be found in Kartalova-O'Doherty and Tedstone Doherty ( 77 ) “ Personal definitions of recovery fell into two broad areas: getting rid of negative feelings, such as anxiety, depression, or panic attacks; and acquiring positive feelings and actions, such as peace of mind […] .”

Accounts of recovery found in the literature that fall within this category include “ being positive ” ( 78 ), “ being happy and successful ” ( 67 , 77 ), “ finding hope and purpose ” ( 48 ), or “ having a meaningful and satisfying life ” ( 69 ), without a deeper description about what this meant. Recovery was described as general feelings and attitudes that were considered positive or the opposite of being unwell, dissatisfied, or unsuccessful.

Another important aspect within this theme was the idea of recovery as having peace of mind ( 59 , 61 , 77 ). This was described as feeling at ease, enjoying leisure moments or not experiencing constant anxiety and fear.

Theme 4: Clinical Recovery Experience

This theme includes topics traditionally related to clinical understandings of recovery such as diagnosis, medication, and symptom-related concerns. Examples when this was present in the literature were references to recovery goals such as “ chemical balance ” ( 63 ), “ adherence to treatment ” ( 79 ), or “ reducing clinical symptoms ” ( 47 , 51 , 67 , 80 ). Brijnath ( 73 ) challenged traditional personal recovery literature writing: “ Participants' emphasis on being ‘cured’, achieving an endpoint in their depression and discontinuing medicines runs counter to the recovery discourse that emphasises that one can be ill and still live a meaningful, contributory life .” In the same line, Piat et al. ( 12 ) remarked that “ The prominence of the illness perspective of recovery among consumers was unexpected. Many looked for recovery outside of themselves: in a cure, or in dreams of disappearing symptoms .”

For service users in some studies, recovery meant being discharged. This in turn had implications for recovery milestones being prioritized by participants, as described by McCabe et al. ( 60 ) “ service users identified their relationships with staff as of greater importance than those with other service-users […] attaining discharge was a more immediate and pressing goal and staff were seen as holding the key to discharge […] In order to be deemed to be recovering service users were keen to demonstrate an acceptance of the bio-medical model regardless of whether this actually fitted with their view of the world .”

With regard to diagnosis, there were two opposing views: recovery as embracing the label and recovery as dropping the label. For the first, Ridge and Ziebland ( 63 ) used the term “coming out of the closet,” since accepting the given diagnosis was understood as way to achieve authentic living without trying to pass as “normal.” Assimilating the diagnosis as part of one's identity also meant giving central importance to complying with treatment and medication. Brijnath ( 73 ) found that Indian participants found meaning in life through religion, while “ For Anglo participants, meaning in life was derived from the illness experience itself. Participants talked about the importance of a diagnostic label in validating how they felt, discovering their inner strength and learning to live with depression .”

In contrast, recovery as a rejection of the given diagnosis usually implied disengaging with services. This view was especially prevalent in literature from the user/survivor or feminist movements, and it was linked to poor practices of mental health services. Examples can be found in Adame and Knudson ( 81 ) “ Another traditional construction from the survivors' narratives was “ recovery from the mental health system ” […] all four participants felt that recovering from psychiatric interventions (e.g., ECT, drugs, solitary confinement) was one of, if not the biggest, challenge in their entire healing process ” and in ( 40 ), where participants believed health professionals, traditional healers and religious leaders had used labeling as a form of coercion to support their own ideas of recovery.

At the same time, some studies found both views represented in their sample, such as ( 49 ) who studied recovery in people diagnosed with personality disorder and concluded that most found it useful and “ For a minority of participants however the diagnosis of personality disorder was seen as unhelpful - representing a direct comment on them as a person, or as a representation of their previous behaviour, not a ‘mental illness’ per se .”

Clinical understandings of recovery were particularly common among carers (it was the predominant theme in five out of the nine papers that presented caregivers views) and it was normally presented as part of the guidance they received from their psychiatrist. To this respect ( 82 ) wrote “ Even though carers are the closest people that many consumers have in their life, carers had major divergence in their views on mental health recovery. Contrasting to consumers and nurses, none of the carers described regaining one's sense of self as an important aspect to mental health recovery. The carers' views on mental health recovery closely related to the traditional views of remission of symptom .” Also, the same study reported that of importance was that this understanding of recovery led caregivers to think recovery was impossible as they understood these goals (e.g., symptom remission, retuning to pre-illness status) as unattainable: “‘ I don't understand what you mean by recovery from mental illness, there isn't one… we went to the psychiatrist the other day and she said [that] the illness will never go’ .”

This review aimed to define the various ways in which service users and carers conceptualized recovery and to provide context for how this construct is represented in the existing literature. Data from sixty-two studies originating mainly from high-income countries were synthesized and analyzed resulting in the SPICE model of recovery. The most prominent themes in users' definitions of recovery were Social Recovery and Individual Recovery. Within these themes, users' understanding of recovery revolved especially around connecting with others, and recovery as an individual responsibility to reach control over mental health problems. In the case of informal carers, the most common themes when defining user recovery were Recovery as an Individual Responsibility, particularly reaching autonomy/being self-sufficient, and Clinical Recovery Experience, mainly symptom remission (see Table 3 ). Marshall et al. ( 83 ) also found informal carers had pessimistic views about the potential for recovery and emphasized clinical aspects of recovery. As a possible solution they pointed to recovery training which has been found to be effective among staff ( 84 ) and could perhaps be mirrored in carer populations.

Table 3 . Themes present in caregivers' understandings of recovery.

Service users' perspectives overall resonated with the more established models and definitions of recovery mentioned in the introduction ( 8 , 9 ) and identified as paradigms 1 and 2 in Table 1 . These definitions of recovery are present in the themes “Individual recovery” and “Social recovery” (derived from personal initiative) proposed in this review, which focuses on personal growth, autonomy, and individual initiatives. This is consistent with a review of user autobiographical accounts provided by ( 85 ), who concluded that recovery was “ a growing sense of agency and autonomy, as well as greater participation in normative activities, such as employment, education, and community life ,” or the study conducted by ( 86 ) who wrote “ For our participants, successful living is fundamentally connected to ” “ not being dependent on mental health care .”

However, along with providing further evidence in support of previously defined models and definitions of recovery, this review identified additional dimensions, namely social (externally derived), political and economic aspects of recovery, and factors related to social reciprocity and acceptance. These understandings of recovery were consistent with less prominent recovery paradigms (3 and 4 in Table 2 ). This is consistent with the findings of the systematic review conducted by ( 87 ) to synthesize typologies of user recovery narratives. The authors found that recovery narratives incorporated social, political and human rights aspects to a greater extent than illness narratives. Petros et al. ( 88 ) suggested an adaptation of the REFOCUS-CHIME model of recovery (paradigm 2 in Table 2 ) to underline the bi-directional nature of recovery. To this respect they wrote “ perceived reciprocity within […] relationships is correlated with higher levels of satisfaction in support and higher levels of personal confidence, self-esteem, and perceived recovery .” The integral role in personal recovery of family and community has been especially mentioned in literature referring to cultures that focus more on group goals than on self-responsibility ( 20 , 89 ). An example of this is ( 90 ) including the domains “family involvement” and “social ties and integration” as part of their scale to measure personal recovery in Chinese culture.

Furthermore, an emphasis on availability of basic needs as exemplified in the theme “Economic recovery” was also found to be a key concern for users in the review conducted by ( 91 ) and the Australian National Survey of Psychotic Illness ( 92 ). The importance of factors related to social justice which fall under the theme “Prosperity” is widely supported by research on social determinants of health ( 93 – 95 ).

Price-Robertson et al. ( 16 ) and Bayetti et al. ( 96 ). There has been substantive criticism about the field of recovery being excessively focused on the individual has raised awareness on the risk of glossing over important social challenges and the stressful social conditions that can be generated by high expectations of self-control in adverse contexts ( 18 , 97 – 99 ). Yates et al. ( 100 ) addressed this gap in recovery literature by studying in detail the social and environmental conditions in which recovery takes place, concluding recovery should be understood as an interaction of ecological processes such as the co-occurrence of personal growth and self-determination in contexts of social structures that restrict personal agency.

Thus, addressing social, political, and economic disparities and opportunities for participation in the community should also be recognized as a key dimension of recovery. This discussion is especially relevant for the development of the recovery approach in low- and middle-income countries (LMICs) that are affected to a greater extent by social inequality, violence, or other social stressors ( 101 , 102 ). Despite identifying a limited amount of research from LMICs that focused on recovery, the key role of economic sufficiency, housing, and respect of basic human rights in mental health are highly present in literature relating to both LMICs and BME groups ( 103 – 105 ). It has been the focus of recent calls for a paradigm change in the field of global mental health ( 106 – 108 ), particularly in the context of the COVID-19 pandemic ( 109 ).

Another aspect of dominant definitions of recovery that is contested in our findings of the clear distinction between clinical and personal recovery. Despite an attempt in the recovery-oriented discourse to diverge from “clinical” language and make a clear-cut distinction between “clinical” and “personal” recovery, the theme “Clinical Recovery Experience” highlighted how topics traditionally considered to fall under clinical rather than personal recovery are actually important aspects of users and carers' everyday lives and notion of recovery. Clinical concepts present in users and carers' understandings of recovery, however, have a distinctive social meaning behind them. There is also a need to study the meaning of clinical language when used by lay stakeholders in order to further understand the role that it plays in their individual and social recovery. This disparity between a social and a clinical understanding of clinical language has great importance for the development of meaningful mental health evaluation tools and clinician-user communication. This would affect decisions such as that made by ( 110 ) of removing items related to symptom management and medication from a personal recovery measure.

Regarding diagnosis, the criticism about the lack of validity and practical use of diagnostic categories expressed in the background literature of the included studies contrasted greatly with the notable adherence to the diagnosis identity on the part of users and caregivers. Some authors have highlighted the social role of diagnostic labels, such as Cruwys and Gunaseelan ( 111 ) who found that people diagnosed with depression tended to identify more with their diagnosis when they faced stigma, using the identification with a group as a buffer against discrimination. Tekin ( 112 ) pointed to risks of diagnosis being a “double-edged sword” that on one hand may facilitate self-understanding and communication, while on the other hand may lead users to make sense of situations focusing only on unrealistic dichotomous outcomes. At the same time, some researchers have suggested there may be an excessive representativeness of user narratives which align with medical views due to user samples consisting for the most part of responsive persons who are in a disempowered position ( 78 , 113 , 114 ).

Implications

Service user and carer accounts reviewed in this study show experiences of severe mental health problems are multifaceted and require an ecological/holistic approach. In light of these results, efforts in mental health policy and service development should address users' social and legal disadvantages and economic distress. Articulating a civil rights or social work perspective on recovery from mental health problems would help to meet the recovery goals presented as most important to service users.

With respect to practice, worrying levels of stigma and discrimination in psychiatric practice were identified in users' testimonies and reflected in caregivers' notion of recovery. These are direct barriers to recovery and therefore there is a pressing need to consider the negative effects that narrow medicalized attitudes have on people's lives. At the same time, the legal or social barriers that prevent psychiatrists from promoting user freedom and participation should be addressed ( 16 , 115 , 116 ). Clinical and personal recovery are intrinsically related and can complement each other; optimal provision of services can be achieved by combining the strength of professional's knowledge and epidemiological research, with stakeholder's experience and feedback about their needs ( 117 ).

The particular understandings of recovery identified in this review would benefit from specific therapeutic techniques. Service users who underlined the importance of bi-directional communication for recovery may adhere better to treatments of a dialogical nature ( 54 ), while users less interested in active engagement and meaning-making, such as those searching to achieve normalcy through completing everyday routines, could find more use in mindfulness-oriented techniques ( 118 , 119 ). In the same way, service users expressing concerns relating to discrimination, legal, and economic circumstances should be referred to appropriate help which focuses on facilitating access to adequate housing, employment, education, and money management, to ultimately be empowered to address their needs ( 120 ). Examples of this are initiatives such as the Bapu Trust for Research on Mind and Discourse, in India ( 121 ), and advice services set by government in the United Kingdom such as the Money Advice Service. Altogether, identifying users' personal recovery goals and mapping them onto the framework proposed in this review would in turn facilitate the development of person-centered individualized care.

There is a need for research about recovery across different cultures. Predominant definitions of recovery currently reflect Western understandings of mental health which focus on an individual perspective, without adequately addressing important socio-political aspects. Recovery-oriented research and practice should take an additional step beyond focusing on what occurs in clinical settings and empower communities for the promotion of human rights, thus shifting from questions around why addressing socio-political recovery to how we can address user's holistic well-being.

At the same time, only a small number of studies included caregivers' perspectives. Findings from these studies suggest the recovery approach has not yet permeated this group's view, and further attention to informal carers in research would be a step toward recognizing their potential to contribute to mental health care and users' well-being. Users and caregivers should be included as partners in the development of knowledge and services to ensure their personal needs and external challenges are accounted for and met.

Lastly, research into recovery identified in this review demonstrated important characteristics that helped to mitigate bias. Studies benefitted from patient and public involvement; ethnographic methodologies, which allow for study of individuals who are not usually inclined to engage in research activities otherwise; the use of measures such as autovideography to allow participants to shape their own data freely; and mixed methods that allow for the inclusion of larger samples, such as Delphi studies used for questionnaire development.

Strengths and Limitations

The findings in this review should be considered within the context of its strengths and limitations. To the authors' knowledge, this is the first systematic review to examine users and caregivers' understanding of recovery. The use of PRISMA guidelines and quality assessment of the studies added transparency and rigor to the research. However, research about recovery from the perspective of people of diverse backgrounds seemed to only start being documented in recent years. Despite applying a comprehensive search strategy, the evidence found in this review originated mainly from high-income, white-European populations due to a paucity of research in the field of recovery outside of these groups. Therefore, applicability of these findings outside of this context should be done with caution. Additionally, the proposed model of recovery could be strengthened in the future by researching gray literature or literature about concepts adjacent to recovery, such as studies which focused specifically on the notion of hope, empowerment, or social inclusion.

The SPICE model of recovery proposed in this review provide context and depth to the construct of recovery, and add further evidence to emphasize the importance of social and clinical aspects of recovery. The comprehensive recovery model provided by this review offers a template for further research in the field and a guide for policy and practice development.

Evidence-based recovery research and practice relies on accurate representations of recovery goals and experiences in order to adequately address people's needs. With sufficient attention to holistic models of recovery that represent the broad range of domains that interest users and carers, along with the promotion of their active participation, the recovery movement can continue toward fulfilling its commitment to have people with lived experience at the center of decision-making in mental health.

Data Availability Statement

The original contributions generated for the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author/s.

Author Contributions

NV participated in the conception, analysis, interpretation of data, drafting, revising, and final approval. PG and MB participated in analysis, interpretation of data, revising, and final approval. MH, SE-L, and VL participated in the conception, interpretation of data, revising and final approval. AO participated in analysis and final approval. All authors contributed to the article and approved the submitted version.

This study was part of NV's PhD supported by National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London (NIHR CLAHRC South London) at King's College Hospital NHS Foundation Trust. PG was supported by the UK Medical Research Council (UKRI) in relation the Indigo Partnership (MR/R023697/1) award.

Author Disclaimer

The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2021.712026/full#supplementary-material

1. ^ Critical Appraisal Skills Programme (CASP) Checklist.

1. Kleinman. The Illness Narratives: Suffering, Healing, and the Human Condition . Basic Books (1988). Available online at: https://psycnet.apa.org/record/1988-97187-000 (accessed May 1, 2021).

Google Scholar

2. Adeponle A, Whitley R, Kirmayer LJ. Cultural contexts constructions of recovery. In: Rudnick A, editor. Recovery of People with Mental Illness: Philosophical Related Perspectives. Oxford: Oxford University Press (2012). p. 109–32. doi: 10.1093/med/9780199691319.003.0008

CrossRef Full Text | Google Scholar

3. Read J, Bentall RP, Roar F. Time to abandon the bio-bio-bio model of psychosis: exploring the epigenetic and psychological mechanisms by which adverse life events lead to psychotic symptoms. Epidemiologia e Psichiatria Sociale. (2009) 18:299–310. doi: 10.1017/s1121189x00000257

PubMed Abstract | CrossRef Full Text | Google Scholar

4. Pilgrim D. Recovery from mental health problems: scratching the surface without ethnography. J Soc Work Pract. (2009) 23:475–87. doi: 10.1080/02650530903375033

5. Slade M. Personal Recovery and Mental Illness: A Guide for Mental Health Professionals - Mike Slade - Google Books . Cambridge University Press (2009). Available online at: https://books.google.co.uk/books?hl=en&lr=&id=_kMnaUMiJXUC&oi=fnd&pg=PR1&dq=slade+2009+recovery&ots=zcH0inBgW_&sig=qX2t3iLCKtTk9dLV71zzO2m-gt0&redir_esc=y#v=onepage&q=slade2009recovery&f=false (accessed July 3, 2021).

6. Piat M, Lal S. Service providers' experiences and perspectives on recovery-oriented mental health system reform. Psychiatr Rehabil J. (2012) 35:289–96. doi: 10.2975/35.4.2012.289.296

7. Crawford MJ, Robotham D, Thana L, Patterson S, Weaver T, Barber R, et al. Selecting outcome measures in mental health: the views of service users. J Mental Health. (2011) 20:336–46. doi: 10.3109/09638237.2011.577114

8. Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. Br J Psychiatry. (2011) 199:445–52. doi: 10.1192/bjp.bp.110.083733

9. Anthony WA. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychos Rehabil J. (1993) 16:11–23. doi: 10.1037/h0095655

10. Farkas M. The vision of recovery today: what it is and what it means for services. World Psychiatry. (2007) 6:68–74.

PubMed Abstract | Google Scholar

11. Slade M. Personal Recovery and Mental Illness : A Guide for Mental Health Professionals . Cambridge: Cambridge University Press (2009).

12. Piat M, Sabetti J, Couture A, Sylvestre J, Provencher H, Botschner J, et al. What does recovery mean for me? Perspectives of Canadian mental health consumers. Psychiatr Rehabil J. (2009) 32:199–207. doi: 10.2975/32.3.2009.199.207

13. van Os J, Burns T, Cavallaro R, Leucht S, Peuskens J, Helldin L, et al. Standardized remission criteria in schizophrenia. Acta Psychiatrica Scandinavica. (2006) 113:91–5. doi: 10.1111/j.1600-0447.2005.00659.x

14. O'Hagan M, Reynolds P, Smith C. Recovery in New Zealand: an evolving concept? Int Rev Psychiatry. (2012) 24:56–63. doi: 10.3109/09540261.2011.651447

15. Bird V, Leamy M, Tew J, le Boutillier C, Williams J, Slade M. Fit for purpose? Validation of a conceptual framework for personal recovery with current mental health consumers. Austral N Z J Psychiatry. (2014) 48:644–53. doi: 10.1177/0004867413520046

16. Price-Robertson R, Obradovic A, Morgan B. Relational recovery: beyond individualism in the recovery approach. Adv Mental Health. (2017) 15:108–20. doi: 10.1080/18387357.2016.1243014

17. Slade M, Amering M, Farkas M, Hamilton B, O'Hagan M, Panther G, et al. Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems. World Psychiatry. (2014) 13:12–20. doi: 10.1002/wps.20084

18. Rose D. The mainstreaming of recovery. J Mental Health. (2014) 23:217–8. doi: 10.3109/09638237.2014.928406

19. Tanaka-Matsumi J, Marsella AJ. Cross-cultural variations in the phenomenological experience of depression. J Cross Cult Psychol. (1976) 7:379–96. doi: 10.1177/002202217674001

20. Chiba R, Miyamoto Y, Kawakami N. Reliability and validity of the Japanese version of the Recovery Assessment Scale (RAS) for people with chronic mental illness: scale development. Int J Nurs Stud. (2010) 47:314–22. doi: 10.1016/j.ijnurstu.2009.07.006

21. Onken SJ, Craig CM, Ridgway P, Ralph RO, Cook JA. An analysis of the definitions and elements of recovery: a review of the literature. Psychiatr Rehabil J. (2007) 31:9–22. doi: 10.2975/31.1.2007.9.22

22. Mezzina R, Davidson L, Borg M, Marin I, Topor A, Sells D. The social nature of recovery: discussion and implications for practice. Am J Psychiatr Rehabil. (2006) 9:63–80. doi: 10.1080/15487760500339436

23. Hopper K. Rethinking social recovery in schizophrenia: what a capabilities approach might offer. Soc Sci Med. (2007) 65:868–79. doi: 10.1016/J.SOCSCIMED.2007.04.012

24. Pelletier J-F, Corbière M, Lecomte T, Briand C, Corrigan P, Davidson L, et al. Citizenship and recovery: two intertwined concepts for civic-recovery. BMC Psychiatry. (2015) 15:37. doi: 10.1186/s12888-015-0420-2

25. Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet. (2018) 392:1553–98. doi: 10.1016/S0140-6736(18)31612-X

26. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Int Med. (2009) 151:264. doi: 10.7326/0003-4819-151-4-200908180-00135

27. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. (2016) 5:210. doi: 10.1186/s13643-016-0384-4

PubMed Abstract | CrossRef Full Text

28. Davidson L, O'Connell MJ, Tandora J, Lawless M, Evans AC. Recovery in serious mental illness: a new wine or just a new bottle? Professional Psychol Res Pract. (2005) 36:480. doi: 10.1037/0735-7028.36.5.480

29. Hong QN, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M, et al. Mixed Methods Appraisal Tool (MMAT) Version 2018 User guide . Montreal, QC: McGill (2018).

30. Bromley H, Dockery G, Fenton C, Nhlema B, Smith H, Tolhurst R, et al. LSTM. Criter Eval Qual Stud . (2002).

31. Dixon-Woods M, Shaw RL, Agarwal S, Smith JA. The problem of appraising qualitative research. Qual. Safety Health Care. (2004) 13:223–5. doi: 10.1136/qhc.13.3.223

32. Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: a critical review. BMC Med. Res. Methodol. (2009) 9:59. doi: 10.1186/1471-2288-9-59

33. Noblit GW, Dwight Hare R. Meta-Ethnography : Synthesizing Qualitative Studies . Sage Publications (1988).

34. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. A Product from the ESRC Methods Programme Version 1 . ESRC Methods Programme (2006). p. b92.

35. Law H, Morrison AP. Recovery in psychosis: a Delphi study with experts by experience. Schizophr Bull. (2014) 40:1347–55. doi: 10.1093/schbul/sbu047

36. Gopal S, Mohan G, John S, Raghavan V. What constitutes recovery in schizophrenia? Client and caregiver perspectives from South India. Int J Soc Psychiatry. (2020) 66:118–23. doi: 10.1177/0020764019886339

37. Armour MP, Bradshaw W, Roseborough D. African Americans and recovery from severe mental illness. Soc Work Mental Health. (2009) 7:602–22. doi: 10.1080/15332980802297507

38. Kidd SA, Virdee G, Quinn S, McKenzie KJ, Toole L, Krupa T. Racialized women with severe mental illness: an arts-based approach to locating recovery in intersections of power, self-worth, and identity. Am J Psychiatr Rehabil. (2014) 17:20–43. doi: 10.1080/15487768.2013.873371

39. Whitley R. Ethno-racial variation in recovery from severe mental illness: a qualitative comparison. Can J Psychiatry. (2016) 61:340–7. doi: 10.1177/0706743716643740

40. Nxumalo Ngubane S, McAndrew S, Collier E. The experiences and meanings of recovery for Swazi women living with “schizophrenia.” J Psychiatric Mental Health Nurs . (2019) 26:153–62. doi: 10.1111/jpm.12520

41. Yuen WW, Tse S, Murray G, Davidson L. ‘From my point of view, my wife has recovered': a qualitative investigation of caregivers' perceptions of recovery and peer support services for people with bipolar disorder in a Chinese community. Int J Soc Psychiatry. (2019) 65:305–12. doi: 10.1177/0020764019842287

42. Bentall R. Madness explained: why we must reject the Kraepelinian paradigm and replace it with a ‘complaint-orientated' approach to understanding mental illness. Med Hypotheses. (2006) 66:220–33. doi: 10.1016/J.MEHY.2005.09.026

43. Basso L, Boggian I, Carozza P, Lamonaca D, Svettini A. Recovery in Italy: an update. Int J Mental Health. (2016) 45:71–88. doi: 10.1080/00207411.2016.1159891

44. Fullagar S, O'Brien W. Social recovery and the move beyond deficit models of depression: a feminist analysis of mid-life women's self-care practices. Soc Sci Med. (2014) 117:116–24. doi: 10.1016/j.socscimed.2014.07.041

45. Borg M, Davidson L. The nature of recovery as lived in everyday experience. J Mental Health. (2008) 17:129–40. doi: 10.1080/09638230701498382

46. Milbourn BT, McNamara BA, Buchanan AJ. Do the everyday experiences of people with severe mental illness who are “hard to engage” reflect a journey of personal recovery? J Mental Health. (2014) 23:241–5. doi: 10.3109/09638237.2014.951485

47. Cárcamo Guzmán K, Cofré Lira I, Flores Oyarzo G, Lagos Arriagada D, Oñate Vidal N, Grandón Fernández P. Mental health care for persons with a severe psychiatric diagnosis and their recovery. Psicoperspectivas Individuo y Sociedad. (2019) 18. doi: 10.5027/psicoperspectivas-vol18-issue2-fulltext-1582

CrossRef Full Text

48. Hancock N, Smith-Merry J, Jessup G, Wayland S, Kokany A. Understanding the ups and downs of living well: the voices of people experiencing early mental health recovery. BMC Psychiatry. (2018) 18:121. doi: 10.1186/s12888-018-1703-1

49. Shepherd A, Sanders C, Shaw J. Seeking to understand lived experiences of personal recovery in personality disorder in community and forensic settings – a qualitative methods investigation. BMC Psychiatry. (2017) 17:282. doi: 10.1186/s12888-017-1442-8

50. Tofthagen R, Talseth AG, Fagerstrøm LM. Former patients' experiences of recovery from self-harm as an individual, prolonged learning process: a phenomenological hermeneutical study. J Adv Nurs. (2017) 73:2306–17. doi: 10.1111/JAN.13295

51. Nowak I, Waszkiewicz J, Switaj P, Sokół-Szawłowska M, Anczewska M. A qualitative study of the subjective appraisal of recovery among people with lived experience of Schizophrenia in Poland. Psychiatric Q. (2017) 88:435. doi: 10.1007/S11126-016-9459-6

52. Lee M, Eads R, Yates N, Liu C. Lived experiences of a sustained mental health recovery process without ongoing medication use. Commun Mental Health J . (2020) 57:540–51. doi: 10.1007/S10597-020-00680-X

53. Kverme B, Natvik E, Veseth M, Moltu C. Moving toward connectedness – a qualitative study of recovery processes for people with borderline personality disorder. Front Psychol. (2019) 10:430. doi: 10.3389/fpsyg.2019.00430

54. Moltu C, Stefansen J, Nøtnes JC, Skjølberg Å, Veseth M. What are “good outcomes” in public mental health settings? A qualitative exploration of clients' and therapists' experiences. Int J Mental Health Syst. (2017) 11:12. doi: 10.1186/s13033-017-0119-5

55. Pitt L, Kilbride M, Nothard S, Welford M, Morrison AP. Researching recovery from psychosis: a user-led project. Psychiatr Bull. (2007) 31:55–60. doi: 10.1192/pb.31.2.55

56. Ochocka J, Nelson G, Janzen R. Moving forward: negotiating self and external circumstances in recovery. Psychiatric Rehabil J. (2005) 28:315–22. doi: 10.2975/28.2005.315.322

57. Katsakou C, Marougka S, Barnicot K, Savill M, White H, Lockwood K, et al. Recovery in borderline personality disorder (BPD): a qualitative study of service users' perspectives. PLoS ONE. (2012) 7:e36517. doi: 10.1371/journal.pone.0036517

58. Tweedell D, Forchuk C, Jewell J, Steinnagel L. Families' experience during recovery or nonrecovery from psychosis. Arch Psychiatr Nurs. (2004) 18:17–25. doi: 10.1053/J.APNU.2003.11.004

59. Young SL, Ensing DS. Exploring recovery from the perspective of people with psychiatric disabilities. Psychiatr Rehabil J. (1999) 22:219–31. doi: 10.1037/h0095240

60. McCabe R, Whittington R, Cramond L, Perkins E. Contested understandings of recovery in mental health. J Mental Health. (2018) 27:475–81. doi: 10.1080/09638237.2018.1466037

61. Vander Kooij C. Recovery themes in songs written by adults living with serious mental illnesses/thèmes de rétablissement dans des chansons écrites par des adultes ayant une maladie mentale sévère. Can J Music Ther. (2009) 15:37–58.

62. Leavey JE. Youth experiences of living with mental health problems: emergence, loss, adaptation and recovery (ELAR). Can J Commun Mental Health. (2005) 24:109–26. doi: 10.7870/cjcmh-2005-0018

63. Ridge D, Ziebland S. “The old me could never have done that”: how people give meaning to recovery following depression. Qual. Health Res. (2006) 16:1038–53. doi: 10.1177/1049732306292132

64. Hipolito MMS, Carpenter-Song E, Whitley R. Meanings of recovery from the perspective of people with dual diagnosis. J Dual Diagn. (2011) 7:141–9. doi: 10.1080/15504263.2011.592392

65. de Jager A, Rhodes P, Beavan V, Holmes D, McCabe K, Thomas N, et al. Investigating the lived experience of recovery in people who hear voices. Qual Health Res. (2016) 26:1409–23. doi: 10.1177/1049732315581602

66. Daley S, Newton D, Slade M, Murray J, Banerjee S. Development of a framework for recovery in older people with mental disorder. Int J Geriatr Psychiatry. (2013) 28:522–9. doi: 10.1002/gps.3855

67. Simonds LM, Pons RA, Stone NJ, Warren F, John M. Adolescents with anxiety and depression: is social recovery relevant? Clin Psychol Psychother. (2014) 21:289–98. doi: 10.1002/cpp.1841

68. McCauley C-O, McKenna H, Keeney S, McLaughlin D. Service user engagement: a co-created interview schedule exploring mental health recovery in young adults. J Adv Nurs. (2017) 73:2361–72. doi: 10.1111/jan.13314

69. Yarborough BJH, Yarborough MT, Janoff SL, Green CA. Getting by, getting back, and getting on: matching mental health services to consumers' recovery goals. Psychiatr Rehabil J. (2016) 39:97–104. doi: 10.1037/prj0000160

70. Engqvist I, Nilsson K. The recovery process of postpartum psychosis from both the woman's and next of kin's perspective - an interview study in Sweden. Open Nurs J. (2014) 8:8–16. doi: 10.2174/1874434601408010008

71. Todd NJ, Jones SH, Lobban FA. “Recovery” in bipolar disorder: how can service users be supported through a self-management intervention? A qualitative focus group study. J Mental Health. (2012) 21:114–26. doi: 10.3109/09638237.2011.621471

72. Mizock L, Russinova Z, Shani R. New roads paved on losses. Qual Health Res. (2014) 24:1481–91. doi: 10.1177/1049732314548686

73. Brijnath B. Applying the CHIME recovery framework in two culturally diverse Australian communities: qualitative results. Int J Soc Psychiatry. (2015) 61:660–7. doi: 10.1177/0020764015573084

74. Santos MM, Kopelowicz A, López SR. Recovery from schizophrenia: the case of Mexican-origin consumers and family caregivers. J Nervous Mental Dis. (2018) 206:439–45. doi: 10.1097/NMD.0000000000000826

75. Mezey GC, Kavuma M, Turton P, Demetriou A, Wright C. Perceptions, experiences and meanings of recovery in forensic psychiatric patients. J Forensic Psychiatr Psychol. (2010) 21:683–96. doi: 10.1080/14789949.2010.489953

76. Davis M. Patient perceptions of self-recovery and staff expectations. Comprehens Psychiatry. (1967) 8:175–82. doi: 10.1016/S0010-440X(67)80021-X

77. Kartalova-O'Doherty Y, Tedstone Doherty D. Recovering from recurrent mental health problems: giving up and fighting to get better. Int J Mental Health Nurs. (2010) 19:3–15. doi: 10.1111/j.1447-0349.2009.00636.x

78. Gillard S, Turner K, Neffgen M. Understanding recovery in the context of lived experience of personality disorders: a collaborative, qualitative research study. BMC Psychiatry. (2015) 15:183. doi: 10.1186/s12888-015-0572-0

79. Mizuno E, Iwasaki M, Sakai I, Kamizawa N. Experiences of community-dwelling persons recovering from severe mental illness. Arch Psychiatr Nurs. (2015) 29:127–31. doi: 10.1016/j.apnu.2014.12.001

80. Wood L, Price J, Morrison A, Haddock G. Conceptualisation of recovery from psychosis: a service-user perspective. Psychiatrist. (2010) 34:465–70. doi: 10.1192/pb.bp.109.027409

81. Adame AL, Knudson RM. Beyond the counter-narrative. Narrat Inquiry. (2007) 17:157–78. doi: 10.1075/ni.17.2.02ada

82. Jacob S, Munro I, Taylor BJ. Mental health recovery: lived experience of consumers, carers and nurses. Contempor Nurse. (2015) 50:1–13. doi: 10.1080/10376178.2015.1012040

83. Marshall S, Deane F, Crowe T, White A, Kavanagh D. Carers' hope, wellbeing and attitudes regarding recovery. Commun Mental Health J. (2013) 49:344–53. doi: 10.1007/s10597-012-9568-0

84. Salgado JD, Deane FP, Crowe TP, Oades LG. Hope and improvements in mental health service providers' recovery attitudes following training. J Mental Health. (2010) 19:243–8. doi: 10.3109/09638230903531126

85. Drake RE, Whitley R. Recovery and severe mental illness: description and analysis. Can J Psychiatry. (2014) 59:236–42. doi: 10.1177/070674371405900502

86. Boumans J, Baart I, Widdershoven G, Kroon H. Coping with psychotic-like experiences without receiving help from mental health care. A qualitative study. Psychosis. (2017) 9:1–11. doi: 10.1080/17522439.2016.1178798

87. Llewellyn-Beardsley J, Rennick-Egglestone S, Callard F, Crawford P, Farkas M, Hui A, et al. Characteristics of mental health recovery narratives: systematic review and narrative synthesis. PLoS ONE. (2019) 14:e0214678. doi: 10.1371/journal.pone.0214678

88. Petros R, Solomon P, Linz S, DeCesaris M, Hanrahan NP. Autovideography: the lived experience of recovery for adults with serious mental illness. Psychiatric Q. (2016) 87:417–26. doi: 10.1007/s11126-015-9397-8

89. Adeponle A, Whitley R, Kirmayer LJ. Cultural contexts constructions of recovery. In: Rudnick A, editor. Recovery of People with Mental Illness: Philosophical Related Perspectives . Oxford: Oxford University Press (2012). doi: 10.1093/med/9780199691319.001.0001

90. Mak WWS, Chan RCH, Yau SSW. Development and validation of attitudes towards recovery questionnaire across Chinese people in recovery, their family carers, and service providers in Hong Kong. Psychiatry Res. (2018) 267:48–55. doi: 10.1016/j.psychres.2018.05.047

91. Macías FJS. Cómo encontrar un lugar en el mundo: explorando experiencias de recuperación de personas con trastornos mentales graves. História Ciências Saúde-Manguinhos. (2011) 18:121–39. doi: 10.1590/S0104-59702011000100008

92. Morgan VA, Waterreus A, Jablensky A, Mackinnon A, McGrath JJ, Carr V, et al. People living with psychotic illness in 2010: the second Australian national survey of psychosis. Austral N Z J Psychiatry. (2012) 46:735–52. doi: 10.1177/0004867412449877

93. Verhaegh J, Hasel R, Becker T. Social justice is pivotal to mental health care. Psychiatrische Praxis. (2011) 38:SD1. doi: 10.1055/s-0031-1277865

94. Wickham S, Shryane N, Lyons M, Dickins T, Bentall R. Why does relative deprivation affect mental health? The role of justice, trust and social rank in psychological wellbeing and paranoid ideation. J Public Mental Health. (2014) 13:114–26. doi: 10.1108/JPMH-06-2013-0049

95. Morrow M, Weisser J. Towards a social justice framework of mental health recovery. Stud Soc Just. (2012) 6:27–43. doi: 10.26522/ssj.v6i1.1067

96. Bayetti C, Jadhav S, Jain S. The re-covering self: a critique of the recovery-based approach in India's mental health care. Disabil Glob South. (2016) 3:889–909.

97. Myers NL. Culture of recovery? Schizophrenia, the United States' Mental Health System, and the American Ethos of the Self-Made Man . Chicago, IL: The University of Chicago (2009).

98. Myers NL. Culture, stress and recovery from schizophrenia: lessons from the field for global mental health. Cult Med Psychiatry. (2010) 34:500–28. doi: 10.1007/s11013-010-9186-7

99. Spandler H, Anderson J, Sapey B. Madness, Distress and the Politics of Disablement . Bristol: Policy Press (2015).

100. Yates I, Holmes G, Priest H. Recovery, place and community mental health services. J Mental Health. (2012) 21:104–13. doi: 10.3109/09638237.2011.613957

101. Rauchfuss K, Schmolze B. Justice heals: the impact of impunity and the fight against it on the recovery of severe human rights violations' survivors. Torture. (2008) 18:38–50.

PubMed Abstract

102. Annan J, Green EP, Brier M. Promoting recovery after war in northern Uganda: reducing daily stressors by alleviating poverty. J Aggr Maltreat Trauma. (2013) 22:849–68. doi: 10.1080/10926771.2013.823636

103. Câmara MC, Ornellas Pereira MA. Percepções de transtorno mental de usuários da Estratégia Saúde da Família. Rev Gaúcha Enferm. (2011) 31. doi: 10.1590/S1983-14472010000400017

104. Blignault I, Bunde-Birouste A, Ritchie J, Silove D, Zwi AB. Community perceptions of mental health needs: a qualitative study in the Solomon Islands. Int J Mental Health Syst. (2009) 3:6. doi: 10.1186/1752-4458-3-6

105. Sanders-Phillips K. The ecology of urban violence: its relationship to health promotion behaviors in low-income Black and Latino communities. Am J Health Promotion. (1996) 10:308–17. doi: 10.4278/0890-1171-10.4.308

106. Mezzina R, Rosen A, Amering M, Javed A. The practice of freedom: human rights and the Global Mental Health Agenda. In: Advances in Psychiatry . Cham: Springer International Publishing (2019). p. 483–515. doi: 10.1007/978-3-319-70554-5_30

107. Cosgrove L, Morrill Z, Karter JM, Valdes E, Cheng C-P. The cultural politics of mental illness: toward a rights-based approach to global mental health. Commun Mental Health J. (2020) 57:3–9. doi: 10.1007/s10597-020-00720-6

108. Cosgrove L, Mills C, Karter JM, Mehta A, Kalathil J. A critical review of the Lancet Commission on global mental health and sustainable development: time for a paradigm change. Critic Public Health. (2020) 30:624–31. doi: 10.1080/09581596.2019.1667488

109. Kola L, Kohrt BA, Hanlon C, Naslund JA, Sikander S, Balaji M, et al. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. Lancet Psychiatry . (2021) 8:535–50. doi: 10.1016/S2215-0366(21)00025-0

110. Mak WWS, Chan RCH, Yau SSW. Validation of the Recovery Assessment Scale for Chinese in recovery of mental illness in Hong Kong. Qual Life Res. (2016) 25:1303–11. doi: 10.1007/s11136-015-1157-6

111. Cruwys T, Gunaseelan S. “Depression is who I am”: mental illness identity, stigma and wellbeing. J Affect Disord. (2016) 189:36–42. doi: 10.1016/j.jad.2015.09.012

112. Tekin S. Self-concept through the diagnostic looking glass: narratives and mental disorder. Philosoph Psychol. (2011) 24:357–80. doi: 10.1080/09515089.2011.559622

113. Rector C. Whose Story Is It Anyway? Constructing the Stories and Pathology of Madness/Mental Illness in the Contemporary U.S . Digital repository at the University of Maryland (2009).

114. Castillo H, Ramon S, Morant N. A recovery journey for people with personality disorder. Int J Soc Psychiatry. (2013) 59:264–73. doi: 10.1177/0020764013481891

115. Gambino M, Pavlo A, Ross DA. Recovery in mind: perspectives from postgraduate psychiatric trainees. Acad Psychiatry. (2016) 40:481–8. doi: 10.1007/s40596-015-0414-x

116. Sartorius N. Stigma: what can psychiatrists do about it? Lancet. (1998) 352:1058–9. doi: 10.1016/S0140-6736(98)08008-8

117. Van Eck RM, Burger TJ, Vellinga A, Schirmbeck F, de Haan L. The relationship between clinical and personal recovery in patients with schizophrenia spectrum disorders: a systematic review and meta-analysis. Schizophr Bull. (2018) 44:631–42. doi: 10.1093/schbul/sbx088

118. Barnhofer T, Crane C. Mindfulness-based cognitive therapy for depression and suicidality. In: Didonna F, editor. Clinical Handbook of Mindfulness . New York, NY: Springer (2009). p. 221–43. doi: 10.1007/978-0-387-09593-6_13

119. Siegel RD. The Mindfulness Solution : Everyday Practices for Everyday Problems . New york, NY: Guilford Press. (2010).

120. Elbogen EB, Tiegreen J, Vaughan C, Bradford DW. Money management, mental health, and psychiatric disability: a recovery-oriented model for improving financial skills. Psychiatr Rehabil J. (2011) 34:223–31. doi: 10.2975/34.3.2011.223.231

121. Davar B, Dhanda A. Enabling Policy Bapu Trust for Research on Mind & Discourse . Available online at: https://baputrust.com/enabling-policy/ (accessed April 9, 2021).

Keywords: recovery, well-being (definitions of), severe mental disorder, service user, carer, systematic review, disability rights

Citation: Vera San Juan N, Gronholm PC, Heslin M, Lawrence V, Bain M, Okuma A and Evans-Lacko S (2021) Recovery From Severe Mental Health Problems: A Systematic Review of Service User and Informal Caregiver Perspectives. Front. Psychiatry 12:712026. doi: 10.3389/fpsyt.2021.712026

Received: 19 May 2021; Accepted: 14 July 2021; Published: 01 September 2021.

Reviewed by:

Copyright © 2021 Vera San Juan, Gronholm, Heslin, Lawrence, Bain, Okuma and Evans-Lacko. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Norha Vera San Juan, norha.vera@kcl.ac.uk ; orcid.org/0000-0002-8677-7341

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Open access
• Published: 17 January 2017

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

• Barry G. Frost 1 , 2 ,
• Srinivasan Tirupati 3 , 4 ,
• Suzanne Johnston 3 ,
• Megan Turrell 3 ,
• Terry J. Lewin 2 , 3 , 4 ,
• Ketrina A. Sly 2 , 3 , 4 &
• Agatha M. Conrad 2 , 3 , 4  

BMC Psychiatry volume  17 , Article number:  22 ( 2017 ) Cite this article

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Over past decades, improvements in longer-term clinical and personal outcomes for individuals experiencing serious mental illness (SMI) have been moderate, although recovery has clearly been shown to be possible. Recovery experiences are inherently personal, and recovery can be complex and non-linear; however, there are a broad range of potential recovery contexts and contributors, both non-professional and professional. Ongoing refinement of recovery-oriented models for mental health (MH) services needs to be fostered.

This descriptive paper outlines a service-wide Integrated Recovery-oriented Model (IRM) for MH services, designed to enhance personally valued health, wellbeing and social inclusion outcomes by increasing access to evidenced-based psychosocial interventions (EBIs) within a service context that supports recovery as both a process and an outcome. Evolution of the IRM is characterised as a series of five broad challenges, which draw together: relevant recovery perspectives; overall service delivery frameworks; psychiatric and psychosocial rehabilitation approaches and literature; our own clinical and service delivery experience; and implementation, evaluation and review strategies. The model revolves around the person's changing recovery needs, focusing on underlying processes and the service frameworks to support and reinforce hope as a primary catalyst for symptomatic and functional recovery. Within the IRM, clinical rehabilitation (CR) practices, processes and partnerships facilitate access to psychosocial EBIs to promote hope, recovery, self-agency and social inclusion. Core IRM components are detailed ( remediation of functioning; collaborative restoration of skills and competencies; and active community reconnection ), together with associated phases, processes, evaluation strategies, and an illustrative IRM scenario. The achievement of these goals requires ongoing collaboration with community organisations.

Conclusions

Improved outcomes are achievable for people with a SMI. It is anticipated that the IRM will afford MH services an opportunity to validate hope, as a critical element for people with SMI in assuming responsibility and developing skills in self-agency and advocacy. Strengthening recovery-oriented practices and policies within MH services needs to occur in tandem with wide-ranging service evaluation strategies.

Peer Review reports

Disorders such as schizophrenia were historically viewed as chronic, degenerative illnesses, with little prospect of improvement or recovery. These negative and debilitating notions of serious mental illness (SMI) were challenged by the consumer movement, with recovery perspectives bringing a new sense of meaning and purpose to individual’s lives, even though symptoms might remain [ 1 – 4 ]. However, in the absence of clear operational or scientific definitions of ‘recovery’, it was questioned whether the process would be understood and amenable to collaborative interventions [ 5 ], or the value of the term compromised [ 6 ] and potentially commandeered by those seeking to reduce service costs [ 7 , 8 ]. Concerns that recovery-focused initiatives could default to rhetoric rather than practice were also raised [ 9 , 10 ].

Consumer research identified recovery as both a process and an outcome, involving factors related to personal wellbeing and social inclusion, which were distinct from traditional clinical domains [ 4 , 11 ]. Nevertheless, some scepticism remains around the notion of recovery [ 12 ], coupled with concerns that the burden of risk will be borne by families and carers [ 13 ]. It is generally accepted that improved mental health (MH) outcomes can be achieved through access to a range of psychosocial evidence-based interventions (EBIs) [ 10 , 14 – 16 ]. However, sufficient service ‘infrastructure’ needs to be activated to ensure recovery-oriented approaches are successfully embedded into everyday practice and access to EBIs is enhanced.

Advances in psychopharmacology made it possible for many people with SMI to be discharged from long-stay care. However, they were often discharged from highly structured inpatient environments with little provisioning for their needs, which according to some reports, did not extend beyond a prescription [ 17 ]. It became increasingly apparent that many individuals experience a constellation of signs and symptoms superimposed and interacting with a background level of impairment and disability. Function is often impaired across multiple domains (e.g., cognition, living skills, social skills, occupation/education) and the level of impairment can often be exacerbated by relapse and deteriorate further with subsequent episodes [ 15 ].

Whilst psychopharmacological treatments have improved and are considered fundamental to illness management, their role in the restoration of skills considered essential for a satisfying and fulfilling life is at best limited. For example, Meltzer [ 18 ] was unable to identify a correlation between amelioration of positive symptoms and social outcomes. It is also evident that medications have not solved the problem of relapse [ 19 ] and carry significant side effects and risks, including over-reliance, poly-pharmacy and inappropriate use [ 20 ]. Following a 20 year longitudinal study, Harrow et al. [ 21 ] state that “ antipsychotics are not effective in eliminating or reducing psychosis for the great majority … and may impede recovery of some … ” (p. 3013). Further, Deacon [ 22 ] suggests that under biomedical treatment models there has been a sharp increase in psychiatric medication use, a broad lack of clinical innovation, and poor MH outcomes.

Despite calls for reform, the disparity between the recovery needs of individuals with SMI and service delivery paradigms is reflected at several levels. For example, among young people, schizophrenia remains one of the top ten causes of disability [ 23 ]. People with psychotic disorders represent 25% of total disease burden [ 24 ] and schizophrenia is the 3rd most important disease in terms of years lived with disability for those aged 15–44 years [ 25 ].

Poor physical health is also experienced by many people with psychotic disorders, with 45.1% classified as obese and 33.5% assessed as having low physical activity [ 26 ]. The majority of people with SMI are also unemployed (78.5%), have poor education levels, impaired social skills (63%), and limited contacts [ 26 ]. Consequently, the estimated annual economic cost in Australia for all psychotic disorders is $4.91 billion from a societal perspective and $3.52 billion from a government perspective [ 27 ]. Moreover, even though annual costs have been relatively stable (over the 2000–2010 decade), there has been a significant redistribution of costs to the non-health sector, in line with Australian government initiatives [ 28 ]. The high and continuing levels of burden associated with SMI have prompted some authors to call for ‘widespread systemic change’ to MH systems, promoting an increased emphasis on shared decision making, independence (e.g., financial, residential, personal) and social connectedness [ 10 ].

Regional opportunities and imperatives

Like many countries, Australian MH services are currently in a state of transition, including: formulation of national frameworks with an increased focus on recover-oriented care provision [ 29 – 31 ]; development of a new Australian MH Care Classification [ 32 ]; and introduction of Activity Based Funding [ 33 ]. In broad terms, recovery-oriented service delivery : “ … is centred on and adapts to people’s aspirations and needs, rather than people having to adapt to the requirements and priorities of services ” and it has a “… responsibility to provide evidence-informed treatment, therapy, rehabilitation and psychosocial support that assist in achieving the best outcomes for people’s mental health, physical health and wellbeing ” [ 30 ], p. 26.

Within New South Wales (NSW), planning commenced in 2005 to establish a number of sub-acute inpatient MH units, with the primary goal of improving access for people with SMI to recovery-focused rehabilitation services that were highly integrated and rigorously evaluated [ 34 ]. This provided an opportunity for Hunter New England Mental Health services to develop an innovative model of care at a level of service delivery that had not previously been explored. Details about the specific 20-bed, sub-acute Intermediate Stay Mental Health Unit (ISMHU) that was initially established are provided elsewhere, together with our preliminary service evaluation [ 35 ].

Importantly, development of a new level of regional MH care necessitated consideration of all of the potential MH service pathways and partnerships, together with their treatment models and intended goals. Within this context, and given the limited availability of established service-wide, recovery-focused models of care [ 36 – 39 ], a broader framework for an Integrated Recovery-oriented Model (IRM) for MH services was formulated, which sought to support and promote ‘ remediation , restoration and reconnection ’.

The primary purpose of this paper is to outline the IRM and to stimulate ongoing refinement of recovery-oriented service models. Evolution of the IRM is characterised with respect to five broad challenges. The first three challenges relate to identification of: 1) relevant recovery perspectives; 2) overall service delivery frameworks and models; and 3) key features and processes associated with current specialised clinical rehabilitation (CR) interventions for people with enduring SMI. The fourth, or central challenge, is to draw together the main elements from these first three challenges into a coherent, service-wide IRM for MH service delivery. The fifth challenge relates to devising relevant implementation, evaluation and review strategies for recovery-oriented MH service models and components.

Recovery perspectives

Challenge 1.

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

Recovery possibilities and needs

Research has shown that recovery is possible [ 40 , 41 ] and that people with SMI value the opportunity to participate and contribute to society [ 42 ]. However, for many there is limited access to EBIs that may prove effective in supporting hope and restoring confidence and competence [ 43 ]. Mojtabai et al. [ 44 ] found that more than 50% of people with schizophrenia received either no treatment or suboptimal treatment. Torres-González et al. [ 45 ] identified six areas of specific need: frequent complications and 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 ].

Recovery goals

The term recovery is clearly multi-layered. Nevertheless, it carries an unequivocal message of a better outcome, conveying a sense of hope; it may also carry expectations in regard to interventions, timeframes and supports. Attempts to reintroduce hope and optimism are based on the view that recovery is possible even though residual limitations may remain. Unlike physical medicine, where recovery goals are generally well understood, the role and significance of rehabilitation for people with SMI has been less well understood - even though psychiatric rehabilitation has always been about ‘recovery’ [ 19 ] and supporting self-determination and independence through improvements in wellbeing and role functioning.

Snyder et al. [ 46 ] described hope as “ the person’s perceived ability or internalised belief that he or she can produce goals, pathways and agency ” (p. 89), suggesting that, as a goal directed motivational process, hope requires constant feedback and agency. If hope is a catalyst for change and improved health outcomes [ 46 ], the question arises as to how hope is both generated and sustained. This also brings into focus the ethical requirements of beneficence (doing good) and maleficence (avoiding harm) that typically guide health service provision. Some recovery-oriented frameworks propose that hope may be generated through service and cultural reforms; for example, “… the physical, social and cultural service environment inspires hope, optimism and humanistic practices for all who participate in service provision ” ([ 47 ], p. 7). Although such statements are very positive, they run the risk of being overpowered and reverting to rhetoric, unless driven by outcomes that reconfirm the considerable investments in recovery.

Le Boutillier et al. [ 37 ] suggested that promoting citizenship and a clear sense of place are core goals for recovery-oriented MH services, the primary purpose of which is to encourage self-agency. Validating personal goals can also help to reduce a client’s sense of frailty and hopelessness. Liberman and Kopelowicz [ 5 ] proposed that as improvements are made in a range of personally valued domains, more subjective qualities such as hope, empowerment and autonomy become evident. Snyder et al. [ 46 ] suggested that the processes of hope and rehabilitation “ fuel each other in an iterative manner over the temporal course of treatments ” (p. 107). Recovery can be complex and non-linear, with hope seen as critical in shaping and sustaining improvements in a range of skill domains, consistent with social inclusion [ 48 , 49 ].

Recovery processes

Early access to rehabilitation interventions has been associated with better functional outcomes [ 50 ]. Making rehabilitation available across the continuum of care may reduce health costs by shortening hospital admissions, reducing activity limitations, and improving quality of life. More generally, the discipline of psychiatric rehabilitation has contributed much to improving service delivery and outcomes [ 17 ]. Psychiatric rehabilitation challenged the MH system to think more expansively and respectfully about people with SMI, promoting choice, shared 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 ].

Recovery contexts

Once again, it needs to be explicitly acknowledged that recovery experiences, opportunities, trajectories, and evaluations are inherently personal. Among people with SMI, recovery is generally viewed as “ a journey of small steps ”, within which participation in everyday activities is “ frequently considered as both facilitators and indicators of recovery ” ([ 10 ], p. 237). Moreover, while the current paper is primarily about recovery-oriented MH service provision, there are a broad range of potential recovery contexts and contributors and, for many people, professional interventions may play a relatively minor or 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.

Service delivery frameworks and models

Challenge 2.

Reconciling the broad array of general and specialised service delivery frameworks, models and intervention strategies of potential relevance to ‘recovery-oriented’ MH services.

There are numerous recommendations about service delivery approaches, ranging from general health or MH focused 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 ].

Clinical Rehabilitation (CR) within MH services

Challenge 3.

Building on the core elements of psychosocial and MH rehabilitation, to facilitate service provision along a recovery-oriented continuum, with specialised clinical rehabilitation processes and services nearer to one extremity, delivering targeted MH interventions and supporting people with enduring SMI.

In part, we use the expression ‘CR within MH services’ to draw a distinction with ‘disability support’ (associated primarily with care linked to enduring functional impairment or other activity limitations ) and to 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.

CR principles and priorities

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

Integrated Recovery-oriented Model (IRM)

Challenge 4.

Developing a recovery-oriented model for MH service delivery (promoting ‘remediation, restoration and reconnection’) that provides both an overarching, inherently collaborative and integrated approach, together with identification of opportunities for targeted specialist CR initiatives.

The IRM was designed to support the recovery needs of people with SMI by improving access to a range of EBIs provided within a service context that reinstates hope, rebuilds competencies and provides opportunities to reconnect. Three foundation elements or functions of this service model that partner with the individual client include: acute/emergency MH care; specialised CR; and community managed/non-government organisations (CMOs/NGOs) providing community integration services .

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.

Integrated Recovery-oriented Model (IRM) for mental health services

Integrated Recovery-oriented Model (IRM) - Phases of recovery

Remediation of functioning - reinstating a sense of possibility

This phase is the start of a complex journey in which the key elements that generate and sustain hope must be carefully reintroduced and nurtured. The goals are to intervene early to reduce the psychological and social sequelae associated with the onset of illness. Building trust and hope that is real and sustainable will be critical in developing a positive adjustment to the diagnosis. This phase also provides an opportunity to address physical health issues, ensure safety, manage any legal and financial issues, and to identify other likely impacts on the person, their partners, families and friends. When a person’s coping and protective strategies have been breached, resulting in acute psychosis, they are likely to feel overwhelmed, shocked, confused, fearful, anxious, in denial and exhausted. These reactions may be fuelled by stigma and run the risk of being exacerbated by treatment and management plans that are: circumspect in their vision; fail to respect and value the person, their family’s needs and aspirations; or lack credibility in terms of delivery and coordination.

Initial treatment provides an invaluable opportunity to reduce fear associated with the onset of symptoms and the diagnosis, and to commence development of a collaborative recovery-oriented plan that is consonant with the wishes and aspirations of the person and their family. To ensure that the client’s investment of hope is well placed, it is essential that there is a full understanding of their strengths, protective factors and possible risks. As with physical rehabilitation, care needs to be exercised as the events and triggers that precipitated the relapse are brought into sharp focus by an approaching discharge. The need for care is also reinforced by the knowledge that a successful resolution of positive symptoms does not necessarily indicate a return to pre-episode functioning. A thorough assessment is required to develop a supportive, individually tailored, multi-modal skill building program, which may be provided in combination with other treatments; a point highlighted in a recent review by Lyman et al. [ 86 ].

The need for a holistic plan, which supports hope through a range of strategies that build confidence and competencies and addresses vulnerabilities, underscores the importance of the early involvement of rehabilitation specialists. While this phase will generally be led by acute MH services (which have specific expertise in treating positive symptoms), they also require the support of CR, and CMO/NGO services, in building confidence and hope in a plan that extends beyond the acute setting. In order to demonstrate an unequivocal commitment to the goals of the collaborative recovery-oriented plan, a number of relevant clinical and nonclinical services may need to be involved, including: emergency assessment and triage; acute inpatient and community services; community MH teams; early intervention programs; specialist clinicians; and associated links with GPs, sub-acute inpatient and other specialist agencies.

Restoration – enabling, regaining competencies

The goal of this phase is to demonstrate that hope and the sense of possibility are valid constructs in the pathway to recovery. At the earliest opportunity, a range of EBIs should be available to assist in rebuilding or confirming personal, interpersonal and daily coping skills and competencies. This may also provide an opportunity to redress developmental gaps and lifetime goals, both of which could contribute to a renewed sense of self. As confidence is developed in personal coping skills and environmental adaptations, a more robust foundation for further pathway or goal-directed thinking should emerge. Exploring new and confirmatory experiences will obviously entail a degree of positive risk taking and comprehensive strategies may need to be in place to safeguard personal dignity. Throughout this phase, the focus will be unequivocally on the development of self-agency, particularly as it relates to mental and physical recovery, and social inclusion.

For some people with SMI, the recovery journey may initially hold few protective factors and pose considerable challenges and risks. For example, a move from a highly structured inpatient unit to a loosely structured home or residential setting, with a questionable and fragile confidence in coping skills and supports, may pose major risks. Insufficient supports during this challenging period may propel a person to find membership in segregated company or attempting to self-manage through the use of non-prescribed substances. Transitional arrangements may provide an opportunity to build confidence and minimise stress, as well as providing a positive foundation on which to build essential psychological and everyday functional skills. The development of additional competencies may include: strategies to manage residual symptoms; cognitive skills; social skills; activities of daily living; physical health; family education and support; and supported education or employment. These interventions should be based on a comprehensive assessment, including usage of collaborative tools such as the Mental Health Recovery Star MHRS; [ 90 ], and a collaboratively developed recovery-oriented plan.

CR services need to work in partnership with acute services, both inpatient and community, and CMOs/NGOs, but without duplicating either. CR services should be most closely aligned with community-based services, both clinical and non-clinical. Given the multitude of factors impacting on recovery, there is no single formula with which to predict or determine outcomes and timeframes [ 59 ]. For example, within non-acute MH services the timeframe for full client engagement would typically be for a period up to 12 months, but the overall extent of involvement, including partial or backup clinical support, would be dependent on a range of individual, social and environmental circumstances. This phase should be led by CR services but with significant involvement of CMOs/NGOs and back-up from acute and emergency services. The potential service elements include: CR teams and streams supporting both targeted and continuing care roles; specialist CR interventions; intermediate (sub-acute) stay recovery units – step-up and step-down; and links with early intervention services, GPs, housing providers, employment, education and other non-acute inpatient services.

Reconnection - with place and society

The aim of this phase is to reconnect and re-establish a place in the community, and to explore opportunities for independence and social inclusion with a new sense of confidence and hope, based on the competencies developed in the previous stages. Development of a supportive daily structure is highly desirable, together with progressive utilisation and refinement of skills in the pursuit of a range of personal goals. This may necessitate graduated exposure to less structured or supported situations (e.g., independent living, community, social situations). During this phase, initial steps may be guided by CR clinicians but with CMO/NGO workers assuming greater responsibility as confidence grows in the client’s ability to be more independent. Essentially, this phase is about validating the investment of hope and developing greater levels of self-esteem and self-agency through exploration of opportunity.

One of the advantages of CMOs/NGOs lies in their capacity to build rich and full connections with other community based groups and services. These connections may open up many satisfying and life enriching opportunities for people with enduring SMI. CMOs/NGOs may assist in the exploration of these opportunities and in the development of: stable accommodation; civic and social activities, reducing social isolation; employment opportunities; recreational and sporting activities; as well as guidance in regard to relationships and existential needs. Importantly, many CMOs/NGOs have partnerships with GPs, which, together with initial support from CR services, may ensure better access and improved mental and physical health. This phase should be led by CMO/NGO services, with the level of input from CR titrated against personal recovery needs, clinical support, risk and legal issues. As the client becomes more confident in their self-determination abilities in the community, CR services should progressively withdraw, allowing the CMOs/NGOs to assume leadership. Acute MH services would always remain available for the transfer of care and joint clinical reviews. The potential service elements include: supported accommodation (low to very high residential); low support accommodation; day centres; links with GPs; specialist employment and education services; recreational and fitness centres; and home care services.

Illustrative IRM scenario

Application of CR planning, intervention, review, transfer and evaluation processes (detailed in Table  1 ) within the IRM, to support and promote recovery for an individual client, are illustrated in Fig.  3 . Examples of how the IRM can promote recovery for individuals with a SMI are, in most instances, complex but an illustrative scenario is provided in Table  2 . Here the remediation phase is characterised in terms of relapse prevention and admission related decisions designed to reinstate hope, while the restoration/reconnection phases are illustrated via a series of recovery-focused actions in response to different concerns (e.g., about medication, treatment/intervention adherence, coping strategies to manage stress, substance misuse, family dynamics, and safety).

Clinical Rehabilitation (CR) processes within the IRM supporting and promoting recovery

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.

Evaluation and review

Challenge 5.

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

Evaluation goals – targets and perspectives

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).

Evaluation strategies – methods and measures

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 ].

Preliminary local evaluations

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 ].

MH services have been the subject of many reforms but have remained largely disease-focused and paternalistic. The consumer lead recovery movement advocated for the adoption of more optimistic, recovery-oriented approaches, based on their experience that recovery was possible, despite residual symptoms [ 1 – 4 ]. Others have suggested that better access to treatments and psychosocial EBIs [ 10 , 14 – 16 , 43 ] is essential to improve overall MH outcomes, especially given the complexity of service and organisational reform.

Notwithstanding the merits of previous approaches, the reality is that EBIs are currently under-utilised and typically not delivered within sustainable, integrated MH systems. To assist people with SMI achieve their goals, service-wide frameworks for recovery-oriented care provision are clearly needed [ 36 – 39 ], together with validated intervention strategies and programs [ 16 , 38 ], and workforce education programs promoting recovery-enabling competencies and positive attitudes [ 52 , 74 ].

In this paper, we have drawn on relevant recovery perspectives, the psychosocial rehabilitation literature, and our own clinical and service delivery experience, to document the evolution of a broad IRM for MH services, together with associated challenges. A range of national [ 29 , 30 ] and State-led initiatives [ 34 ] to improve outcomes for people with SMI, including the establishment of intermediate stay units [ 35 ], provided a unique opportunity to explore recovery-oriented models of care. Based on ICF concepts [ 57 , 89 ] and CR principles [ 19 , 77 ], the IRM has attempted to address the broader recovery needs of people with SMI from a health rather than a disease perspective, and to view outcomes as the interaction between the health issues, the person and their environment.

It is easy to pigeonhole new service initiatives as simply ‘good clinical practice’. The IRM was developed to facilitate access to a range of recovery-oriented EBIs, integrated across the spectrum of need. The model focuses on the fundamental factors that have been shown to promote hope, recovery, self-agency, and social inclusion. The IRM includes evidence-based CR practices and processes as a substantive component (see Table  1 and Fig.  3 ), which have considerable potential to help realise individual goals and aspirations. However, as recovery is often complex and non-linear (see Fig.  2 ), the achievement of such goals is difficult in isolation, and requires the specialised contributions of acute, non-acute and community managed/non-government organisations (CMOs/NGOs).

Service delivery models such as the IRM encourage MH services to embrace opportunities to validate hope, as a critical element for people with SMI in assuming responsibility and developing skills in self-agency and advocacy. To promote ongoing refinement of recovery-oriented service models and inform policy development, wide-ranging evaluation strategies are also critical, some aspects of which have been briefly touched on in this paper, including some preliminary IRM related evaluations.

Importantly, the three core components of the IRM revolve around and interact with the person's changing recovery needs (see Fig.  1 ): remediation of functioning (directed towards reinstating hope and a sense of possibility); collaborative restoration of skills and competencies; and active community reconnection . These core components have equally significant roles to play in promoting recovery as a process and an outcome. The ‘ remediation, restoration, and reconnection ’ refrain also provides a convenient mnemonic for the broad types of support that should be expected from recover-oriented MH services. However, the inherent strength of the IRM lies not in the capabilities of each of the contributing specialties but in the potential of the tripartite collaboration to promote and sustain hope of a life beyond mental illness that is both rich and satisfying.

Abbreviations

Community managed/non-government organisations

Clinical rehabilitation

Evidence-based interventions

General Practitioner

International classification of diseases

International classification of functioning, disability and health

Integrated recovery-oriented model

Intermediate stay mental health unit

Mental health

Mental health recovery star

New South Wales

• Serious mental illness

World health organisation

Andresen R, Oades L, Caputi P. The experience of recovery from schizophrenia: towards an empirically validated stage model. Aust N Z J Psychiatry. 2003;37:586–94.

Article   PubMed   Google Scholar  

Bellack AS. Scientific and consumer models of recovery in schizophrenia: Concordance, contrasts, and implications. Schizophr Bull. 2006;32:432–42.

Article   PubMed   PubMed Central   Google Scholar  

Davidson L. The recovery movement: Implications for mental health care and enabling people to participate fully in life. Health Aff. 2016;35:1091–7.

Article   Google Scholar  

Jose D, Ramachandra, Lalitha K, Gandhi S, Desai G, Nagarajaiah. Consumer perspectives on the concept of recovery in schizophrenia: A systematic review. Asian J Psychiatry. 2015;14:13–8.

Liberman RP, Kopelowicz A. Recovery from schizophrenia: A concept in search of research. Psychiatr Serv. 2005;56:735–42.

Jacobson N, Curtis L. Recovery as policy in mental health services: Strategies emerging from the states. Psychiatr Rehabil J. 2000;23:333–41.

Dickerson FB. Commentary: disquieting aspects of the recovery paradigm. Psychiatr Serv. 2006;57:647.

Johnson S. Misuse and abuse of ‘recovery’ by the psychiatric system. Ment Health Today. 2005;37.

Slade M, Adams N, O’Hagan M. Recovery: past progress and future challenges. Int Rev Psychiatry. 2012;24:1–4.

Drake RE, Whitley R. Recovery and severe mental illness: description and analysis. Can J Psychiatry. 2014;59:236–42.

PubMed   PubMed Central   Google Scholar  

Walsh J, Boyle J. Improving acute psychiatric hospital services according to inpatient experiences. A user-led piece of research as a means to empowerment. Issues Ment Health Nurs. 2009;30:31–8.

Bird V, Leamy M, Tew J, Le Boutillier C, Williams J, Slade M. Fit for purpose? Validation of a conceptual framework for personal recovery with current mental health consumers. Aust N Z J Psychiatry. 2014;48:644–53.

Repper J, Perkins R. Social Inclusion and Recovery: A Model for Mental Health Practice. London: Bailliere Tindall; 2006.

Google Scholar  

Matheson SL, Shepherd AM, Carr VJ. How much do we know about schizophrenia and how well do we know it? Evidence from the Schizophrenia Library. Psychol Med. 2014;44:3387–405.

Article   CAS   PubMed   Google Scholar  

Lieberman JA, Drake RE, Sederer LI, Belger A, Keefe R, Perkins D, Stroup S. Science and recovery in schizophrenia. Psychiatr Serv. 2008;59:487–96.

Mueser KT, Deavers F, Penn DL, Cassisi JE. Psychosocial treatments for schizophrenia. Annu Rev Clin Psychol. 2013;9:465–97.

Anthony WA, Farkas M. Primer on the psychiatric rehabilitation process. Boston: Boston University. Center for Psychiatric Rehabilitation; 2009.

Meltzer HY. Cognitive factors in schizophrenia: causes, impact, and treatment. CNS Spectr. 2004;9:15–24.

Wykes T, Drake RE. Rehabilitative therapies. In: Lieberman JA, Murray RM, editors. Comprehensive Care of Schizophrenia. New York: Oxford University Press; 2012. p. 182–98.

Kuipers E, Yesufu-Udechuku A, Taylor C, Kendall T. Management of psychosis and schizophrenia in adults: summary of updated NICE guidance. BMJ. 2014;348.

Harrow M, Jobe TH, Faull RN. Does treatment of schizophrenia with antipsychotic medications eliminate or reduce psychosis? A 20-year multi-follow-up study. Psychol Med. 2014;44:3007–16.

Deacon BJ. The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clin Psychol Rev. 2013;33:846–61.

Velligan D, Gonzalez J. Rehabilitation and recovery in schizophrenia. Psychiatr Clin North Am. 2007;30:535–48.

World-Bank. The World Bank annual report 1996. Washington: World-Bank; 1996.

Book   Google Scholar  

World-Health-Organisation. The Global Burden of Disease, 2004 update. Geneva: World-Health-Organisation; 2008.

Morgan VA, Waterreus A, Jablensky A, Mackinnon A, McGrath JJ, Carr V, Bush R, Castle D, Cohen M, Harvey C, Galletly C, Stain HJ, Neil AL, McGorry P, Hocking B, Shah S, Saw S. People living with psychotic illness in 2010. The second Australian national survey of psychosis. Aust N Z J Psychiatry. 2012;46:735–52.

Neil AL, Carr VJ, Mihalopoulos C, Mackinnon A, Morgan VA. Costs of psychosis in 2010: Findings from the second Australian National Survey of Psychosis. Aust N Z J Psychiatry. 2014;48:169–82.

Neil AL, Carr VJ, Mihalopoulos C, Mackinnon A, Lewin TJ, Morgan VA. What difference a decade? The costs of psychosis in Australia in 2000 and 2010: Comparative results from the first and second Australian national surveys of psychosis. Aust N Z J Psychiatry. 2014;48:237–48.

Commonwealth of Australia. A national framework for recovery-oriented mental health services: Guide for practitioners and providers. Canberra: Department of Health and Ageing, CoA; 2013.

Commonwealth of Australia. A national framework for recovery-oriented mental health services: Policy and theory. Canberra: Department of Health and Ageing, CoA; 2013.

Commonwealth of Australia. National Standards for Mental Health Services. Canberra: CoA; 2010.

Commonwealth of Australia. Development of the Australian Mental Health Care Classification - public consultation paper 1. Canberra: Independent Hospital Pricing Authority, CoA; 2015.

Commonwealth of Australia. Consultation paper on the Pricing Framework for Australian Public Hospital Services 2016–17. Canberra: Independent Hospital Pricing Authority, CoA; 2015.

NSW Department of Health. A New Direction for Mental Health. Sydney: NSW Health; 2006.

Frost BG, Turrell M, Sly KA, Lewin TJ, Conrad AM, Tirupati S, Petrovic K, Rajkumar S, Johnston S: Implementation of a recovery-oriented model in a sub-acute Intermediate Stay Mental Health Unit (ISMHU). BMC Health Services Research (In Press) 2016.

Kidd SA, McKenzie KJ, Virdee G. Mental health reform at a systems level: Widening the lens on recovery-oriented care. Can J Psychiatry. 2014;59:243–9.

Le Boutillier C, Leamy M, Bird VJ, Davidson L, Williams J, Slade M. What does recovery mean in practice? A qualitative analysis of international recovery-oriented practice guidance. Psychiatr Serv. 2011;62:1470–6.

Slade M, Amering M, Farkas M, Hamilton B, O’Hagan M, Panther G, Perkins R, Shepherd G, Tse S, Whitley R. Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems. World Psychiatry. 2014;13:12–20.

Waldemar AK, Arnfred SM, Petersen L, Korsbek L. Recovery-oriented practice in mental health inpatient settings: A literature review. Psychiatr Serv. 2016;67:596–602.

Harding CM, Brooks GW, Ashikaga T, Strauss JS, Breier A. The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. Am J Psychiatry. 1987;144:727–35.

McGlashan TH. A selective review of recent North American long-term followup studies of schizophrenia. Schizophr Bull. 1988;14:515–42.

Crosse C, Hocking B. Discussion Paper: Social Rehabilitation: What are the Issues? Canberra: Department of Veteran Affairs; 2004.

Harrow M, Grossman LS, Jobe TH, Herbener ES. Do patients with schizophrenia ever show periods of recovery? A 15-year multi-follow-up study. Schizophr Bull. 2005;31:723–34.

Mojtabai R, Fochtmann L, Chang SW, Kotov R, Craig TJ, Bromet E. Unmet need for mental health care in schizophrenia: an overview of literature and new data from a first-admission study. Schizophr Bull. 2009;35:679–95.

Torres-González F, Ibanez-Casas I, Saldivia S, Ballester D, Grandón P, Moreno-Küstner B, Xavier M, Gómez-Beneyto M. Unmet needs in the management of schizophrenia. Neuropsychiatr DisTreat. 2014;10:97–110.

Snyder CR, Ritschel LA, Rand KL, Berg CJ. Balancing psychological assessments: Including strengths and hope in client reports. J Clin Psychol. 2006;62:33–46.

Victorian Department of Health. Framework for recovery-oriented practice. Melbourne: State of Victoria, Department of Health; 2011.

Copic V, Deane FP, Crowe TP, Oades LG. Hope, meaning and responsibility across stages of recovery for individuals living with an enduring mental illness. Aust J Rehabil Couns. 2011;17:61–73.

Weinberg CM. Hope, meaning, and purpose: Making recovery possible. Aust J Rehabil Couns. 2013;36:124–5.

World-Health-Organisation. World Report on Disability. Geneva: World-Health-Organisation; 2011.

Kidd S, Kenny A, McKinstry C. The meaning of recovery in a regional mental health service: an action research study. J Adv Nurs. 2015;71:181–92.

Chen SP, Krupa T, Lysaght R, McCay E, Piat M. The development of recovery competencies for in-patient mental health providers working with people with serious mental illness. Adm Policy Ment Health. 2013;40:96–116.

McKenna B, Furness T, Dhital D, Ennis G, Houghton J, Lupson C, Toomey N. Recovery-oriented care in acute inpatient mental health settings: an exploratory study. Issues Ment Health Nurs. 2014;35:526–32.

Slade M, Williams J, Bird V, Leamy M, Le Boutillier C. Recovery grows up. J Ment Health. 2012;21:99–104.

De Vecchi N, Kenny A, Kidd S. Stakeholder views on a recovery-oriented psychiatric rehabilitation art therapy program in a rural Australian mental health service: a qualitative description. Int J Ment Health Syst. 2015;9.

Slade M, Longden E. Empirical evidence about recovery and mental health. BMC Psychiatry. 2015;15:285.

Reed GM, Leonardi M, Ayuso-Mateos JL, Materzanini A, Castronuovo D, Manara A, Martinez-Aran A, Starace F, Ajovalasit D. Implementing the ICF in a psychiatric rehabilitation setting for people with serious mental illness in the Lombardy region of Italy. Disabil Rehabil. 2009;31:S170–3.

Kilian R, Lauber C, Kalkan R, Dorn W, Rossler W, Wiersma D, Van Buschbach JT, Fioritti A, Tomov T, Catty J, Burns T, Becker T. The relationships between employment, clinical status, and psychiatric hospitalisation in patients with schizophrenia receiving either IPS or a conventional vocational rehabilitation programme. Soc Psychiatry Psychiatr Epidemiol. 2012;47:1381–9.

Perkins R, Slade M. Recovery in England: Transforming statutory services? Int Rev Psychiatry. 2012;24:29–39.

Hopper K. Rethinking social recovery in schizophrenia: What a capabilities approach might offer. Soc Sci Med. 2007;65:868–79.

Rodgers ML, Norell DM, Roll JM, Dyck DG. An overview of mental health recovery. Primary Psychiatry. 2007;14:76–85.

Thornicroft G, Tansella M. Components of a modern mental health service: a pragmatic balance of community and hospital care: Overview of systematic evidence. Br J Psychiatry. 2004;185:283–90.

Flannery F, Adams D, O’Connor N. A community mental health service delivery model: Integrating the evidence base within existing clinical models. Australas Psychiatry. 2011;19:49–55.

Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. Br J Psychiatry. 2011;199:445–52.

Smith-Merry J, Freeman R, Sturdy S. Implementing recovery: an analysis of the key technologies in Scotland. Int J Ment Health Syst. 2011;5.

Mueser KT, Corrigan PW, Hilton DW, Tanzman B, Schaub A, Gingerich S, Essock SM, Tarrier N, Morey B, Vogel-Scibilia S, Herz MI. Illness management and recovery: A review of the research. Psychiatr Serv. 2002;53:1272–84.

Slade M, Bird V, Le Boutillier C, Williams J, McCrone P, Leamy M. REFOCUS Trial: protocol for a cluster randomised controlled trial of a pro-recovery intervention within community based mental health teams. BMC Psychiatry. 2011;11.

Slade M, Bird V, Clarke E, Le Boutillier C, McCrone P, Macpherson R, Pesola F, Wallace G, Williams J, Leamy M. Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial. Lancet Psychiatry. 2015;2:503–14.

Tse S, Tsoi EWS, Hamilton B, O’Hagan M, Shepherd G, Slade M, Whitley R, Petrakis M. Uses of strength-based interventions for people with serious mental illness: A critical review. Int J Soc Psychiatry. 2016;62:281–91.

Bond GR, Drake RE, Becker DR, Noel VA. Sustaining Individual Placement and Support (IPS) services: the IPS learning community. World Psychiatry. 2016;15:81–3.

Petrakis M, Brophy L, Lewis J, Stylianou M, Scott M, Cocks N, Buckley L, Halloran K. Consumer measures and research co-production: a pilot study evaluating the recovery orientation of a mental health program collaboration. Asia Pac J Soc Work Dev. 2014;24:94–108.

Gilburt H, Slade M, Bird V, Oduola S, Craig TK. Promoting recovery-oriented practice in mental health services: a quasi-experimental mixed-methods study. BMC Psychiatry. 2013;13:167.

Horsfall J, Cleary M, Hunt GE. Acute inpatient units in a comprehensive (integrated) mental health system: a review of the literature. Issues Ment Health Nurs. 2010;31:273–8.

Le Boutillier C, Chevalier A, Lawrence V, Leamy M, Bird VJ, Macpherson R, Williams J, Slade M. Staff understanding of recovery-orientated mental health practice: a systematic review and narrative synthesis. Implement Sci. 2015;10.

Jacobson N, Greenley D. What is recovery? A conceptual model and explication. Psychiatr Serv. 2001;52:482–5.

Le Boutillier C, Slade M, Lawrence V, Bird VJ, Chandler R, Farkas M, Harding C, Larsen J, Oades LG, Roberts G, Shepherd G, Thornicroft G, Williams J, Leamy M. Competing priorities: Staff perspectives on supporting recovery. Adm Policy Ment Health Ment Health Serv Res. 2015;42:429–38.

Anthony WA, Farkas M. The essential guide to psychiatric rehabilitation practice. Boston: Boston University; 2012.

Wolwer W, Frommann N. Social-cognitive remediation in schizophrenia: generalization of effects of the Training of Affect Recognition (TAR). Schizophr Bull. 2011;37(2):S63–70.

Velligan D, Ritch J, Sui D, DiCocco M, Huntzinger C. Frontal Systems Behavior Scale in schizophrenia: relationships with psychiatric symptomatology, cognition and adaptive function. Psychiatry Res. 2002;113:227–36.

Roder V, Mueller DR, Schmidt SJ. Effectiveness of Integrated Psychological Therapy (IPT) for schizophrenia patients: A research update. Schizophr Bull. 2011;37:S71–9.

Verhaeghe N, De Maeseneer J, Maes L, Van Heeringen C, Annemans L. Effectiveness and cost-effectiveness of lifestyle interventions on physical activity and eating habits in persons with severe mental disorders: a systematic review. Int J Behav Nutr Phys Act. 2011;8:28.

Killackey E, Waghorn G. The challenge of integrating employment services with public mental health services in Australia: Progress at the first demonstration site. Psychiatr Rehabil J. 2008;32:63–6.

Lundahl B, Burke BL. The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. J Clin Psychol. 2009;65:1232–45.

Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol. 2009;64:527–37.

Kern RS, Green MF, Mintz J, Liberman RP. Does ‘errorless learning’ compensate for neurocognitive impairments in the work rehabilitation of persons with schizophrenia? Psychol Med. 2003;33:433–42.

Lyman DR, Kurtz MM, Farkas M, George P, Dougherty RH, Daniels AS, Ghose SS, Delphin-Rittmon ME. Skill building: Assessing the evidence. Psychiatr Serv. 2014;65:727–38.

Pilling S, Bebbington P, Kuipers E, Garety P, Geddes J, Orbach G, Morgan C. Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychol Med. 2002;32:763–82.

CAS   PubMed   Google Scholar  

Borg M, Kristiansen K. Recovery-oriented professionals: Helping relationships in mental health services. J Ment Health. 2004;13:493–505.

World-Health-Organisation. The International Classification of Functioning, Disability, and Health. Geneva: WHO; 2001.

MacKeith J, Burns S. Mental Health Recovery Star; User Guide. Secondth ed. London: Triangle Consulting and Mental Health Providers Forum; 2010.

Parker S, Dark F, Newman E, Korman N, Meurk C, Siskind D, Harris M. Longitudinal comparative evaluation of the equivalence of an integrated peer-support and clinical staffing model for residential mental health rehabilitation: a mixed methods protocol incorporating multiple stakeholder perspectives. BMC Psychiatry. 2016;16:1–21.

Burgess P, Pirkis J, Coombs T, Rosen A. Assessing the value of existing recovery measures for routine use in Australian mental health services. Aust N Z J Psychiatry. 2011;45:267–80.

Andresen R, Caputi P, Oades LG. Do clinical outcome measures assess consumer-defined recovery? Psychiatry Res. 2010;177:309–17.

Shanks V, Williams J, Leamy M, Bird VJ, Le Boutillier C, Slade M. Measures of personal recovery: A systematic review. Psychiatr Serv. 2013;64:974–80.

Chester P, Ehrlich C, Warburton L, Baker D, Kendall E, Crompton D. What is the work of recovery oriented practice? A systematic literature review. Int J Ment Health Nurs. 2016;25:270–85.

Tsai J, Salyers MP. Recovery orientation in hospital and community settings. J Behav Health Serv Res. 2010;37:385–99.

Williams J, Leamy M, Bird V, Harding C, Larsen J, Le Boutillier C, Oades L, Slade M. Measures of the recovery orientation of mental health services: systematic review. Soc Psychiatry Psychiatr Epidemiol. 2012;47:1827–35.

Whitley R, Drake RE. Recovery: a dimensional approach. Psychiatr Serv. 2010;61:1248–50.

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Acknowledgements

Thank you to the Executive of Hunter New England MH Services for their support and to Psychiatric Rehabilitation Services’ staff and clients for their contributions to model development and evaluation. We would also like to thank the acute and community MH clinicians who completed the initial staff surveys.

No external funding was received for this project.

Availability of data and materials

While data from this project will not be made publicly available, we will undertake reasonable requests for additional analyses.

Authors’ contributions

BGF: initiated the project and model development, contributed to project design, implementation, interpretation, and drafting of the manuscript. ST, SJ and MT: contributed to model development, project design, implementation, interpretation, and manuscript revision. KAS and TJL: contributed to project design, data collection, statistical analysis and interpretation, manuscript preparation and revision. AMC: contributed to project design, interpretation, and manuscript revision. All authors read and approved the final manuscript.

Competing interests

The authors report no conflicts of interest, and that they alone are responsible for the paper’s content.

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Not applicable, as the data analyses undertaken do not report any individual’s data.

Ethics approval and consent to participate

This project received confirmation from Hunter New England Human Research Ethics Committee that it was exempt from formal review (letter dated October 24th 2013), being viewed as part of an internal, low risk, service evaluation.

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Perceived impacts on and relevance of ‘recovery domains’: Responses from a recent survey of MH clinicians ( N  = 251). (DOCX 17 kb)

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Frost, B.G., Tirupati, S., Johnston, S. et al. An Integrated Recovery-oriented Model (IRM) for mental health services: evolution and challenges. BMC Psychiatry 17 , 22 (2017). https://doi.org/10.1186/s12888-016-1164-3

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DOI : https://doi.org/10.1186/s12888-016-1164-3

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The Recovery Model and Other Rehabilitative Approaches

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The recovery movement is very ambitious. It seeks to take us beyond treating illness, to focusing on helping people have better lives, and regain important roles and acceptance within their communities…even for people whose symptoms can’t always be eliminated or controlled and even for people with very serious persistent conditions like schizophrenia. While the mainstream of psychiatry seeks ever more successful illness treatments, the “outsider” recovery movement seeks ever more successful ways of promoting better lives.

This chapter will focus on several intertwined levels:

The roots of the recovery movement – people with mental health lived experience and other advocacy groups, groups working with people who don’t fit into the system, rehabilitation staff seeking to reintegrate people in the community, and other parallel recovery services like substance abuse and trauma recovery.

The core paradigm shifts of the recovery movement: from illness-centered to person-centered, from professional-driven to client-driven, and from deficit-based to strength-based.

The shifts in treatment relationships and services provided as we move from a medical model to a rehabilitation model to a recovery model (highlighting psychiatrists).

Examples of specific recovery-based services that can be used at different stages of illness and recovery that are embracing those three core paradigm shifts (highlighting peer provided services).

Examples of the development of larger, more complete recovery-based programs and systems of care as they organically grow and evolve in very different places and with very different leadership.

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Anonymous. (2002). Alcoholics anonymous: The big book, 4th edition. Alcoholics Anonymous World Services, Inc.

Google Scholar  

Bleuler, M. (1978). The schizophrenic disorders: Long-term patient and family studies (1972) . Yale University Press.

Brooks, C. (2018). Pro bono research conducted for the World Dignity Project . Presented at the Universal Health Mental Health for all Congress, 12–14 December 2018, Malta.

California Institute for Behavioral Health Solutions. (2011). Full service partnership toolkit . www.cibhs.org/publication/fsp-toolkits#:~:text=Full%20Service%20Partnership%20%28FSP%29%20programs%20were%20designed%20under,and%20their%20family%20members%2C%20mental%20health%20service%20providers . Accessed 2022.

Calton, T., Ferriter, M., Huband, N., et al. (2008). A systematic review of the Soteria paradigm for the treatment of people diagnosed with schizophrenia. Schizophrenia Bulletin, 34 (1), 181–192.

Article   Google Scholar  

Caregivers Alliance. (n.d.). https://www.cal.org.sg/milestones-and-awards . Accessed 2022.

Cirkus Paciento. (n.d.). www.cirkuspaciento.cz . Accessed 2022.

CIT CENTER. (n.d.). A resource for CIT programs across the nation. http://cit.memphis.edu/aboutCIT.php#:~:text=The%20Memphis%20Crisis%20Intervention%20Team%20%28CIT%29%20is%20an,training%20for%20helping%20those%20individuals%20with%20mental%20illness . Accessed 2022.

Copeland, M. E. (2011). Wellness recovery action plan . Peach Press.

Corrigan, P. W., & Watson, A. C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1 (1), 16–20.

Davidson, L., O’Connell, M., Tondora, J., Styron, T., & Kangas, K. (2006). The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services, 57 (5). ps.psychiatryonline.org

Davidson, L., Rowe, M., Tondora, J., O’Connell, M. J., & Lawless, M. S. (2008). A practical guide to recovery-oriented practice: Tools for transforming mental health care . Oxford University Press.

Book   Google Scholar  

de Wet, A., & Pretorius, C. (2020). From darkness to light: Barriers and facilitators to mental health recovery in the South African context. The International Journal of Social Psychiatry, 68 (1), 82–89. https://doi.org/10.1177/0020764020981126

Deegan, P. (1998). Coping with voices: Self-help strategies for people who hear voices that are distressing . National Empowerment Center.

Deegan, P. (n.d.). Common ground guides. Pat Deegan PhD & Associates, LLC Guides. commongroundprogram.com , https://patdeegan.myshopify.com/collections/commonground-guides . Accessed 2022.

Des Courtis, N., et al. (2008). Beliefs about the mentally ill: A comparative study between healthcare professionals in Brazil and in Switzerland. International Review of Psychiatry (Abingdon, England), 20 (6), 503–509. https://doi.org/10.1080/09540260802565125

Dixon, L. (2000). Assertive community treatment: Twenty-five years of gold. Psychiatric Services, 51 , 759–765.

Article   CAS   Google Scholar  

Dixon, L. B., Goldman, H. H., Srihari, V. H., et al. (2018). Transforming the treatment of schizophrenia in the United States: The RAISE initiative. Annual Review of Clinical Psychology, 14 , 237–258.

Does Recovery Have It’s Own Language? (n.d.). https://youtu.be/mesHHTfCDjU . Accessed 2022.

Dunn, E. C., et al. (2008). The meaning and importance of employment to people in recovery from serious mental illness: Results of a qualitative study. Psychiatric Rehabilitation Journal, 32 (1), 59–62. https://doi.org/10.2975/32.1.2008.59.62

Emotional CPR. (n.d.). www.emotional-cpr.org . Accessed 2022.

Evans, G. W. (2013). The built environment and mental health. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 80 (4), 536–555. https://doi.org/10.1093/jurban/jtg063

Marianne Farkas, Cheryl Gagne, William Anthony, Judi Chamberlin Implementing recovery oriented evidence based programs: Identifying the critical dimensions Community Mental Health Journal, Vol. 41, No. 2, April 2005.

Farrell, S. P., & Deeds, E. S. (1997). The clubhouse model as exemplar. Merging psychiatric nursing and psychosocial rehabilitation. Journal of Psychosocial Nursing and Mental Health Services, 35 (1), 27–34. https://doi.org/10.3928/0279-3695-19970101-15

Fisher, D., & Ahern, L. (2000). PACE, a recovery curriculum . National Empowerment Center. Accessed 2022.

Gilbert, B. J., Patel, V., Farmer, P. E., & Lu, C. (2015). Assessing development assistance for mental health in developing countries: 2007–2013. PLoS Medicine, 12 (6), e1001834. https://doi.org/10.1371/journal.pmed.1001834

Gun, S. Y., & Leong, J. J.-Y. (2016). Social inclusion: The Singapore story in community mental health development, psychiatric rehabilitation and recovery. Asia Pacific Journal of Social Work and Development, 26 (2–3), 167–177. https://doi.org/10.1080/02185385.2016.1218793

Happell, B., et al. (2014). Consumer involvement in the tertiary-level education of mental health professionals: A systematic review. International Journal of Mental Health Nursing, 23 (1), 3–16. https://doi.org/10.1111/inm.12021

Harding, C. M., Brooks, G. W., Ashikaga, T., Strauss, J. S., & Breier, A. (1987). The Vermont longitudinal study of persons with severe mental illness, I: Methodology, study sample, and overall status 32 years later. The American Journal of Psychiatry, 144 , 718–726.

Hauck, G.. (2021). USA Today. Denver successfully sent mental health professionals, not police, to hundreds of calls . https://www.usatoday.com/story/news/nation/2021/02/06/denver-sent-mental-health-help-not-police-hundreds-calls/4421364001/ . Accessed 28 Feb 2021.

Headspace National Youth Mental Health Foundation Ltd. (n.d.). www.headspace.org.au . Accessed 2022.

Hearing Voices Network. (n.d.). https://www.hearing-voices.org/ . Accessed 2022.

Hogan, M. F. (2003). President’s New Freedom Commission on mental health, p. 1. Microsoft Word – InsideCover-Full-Final 7-14.doc (unt.edu). Accessed 2022.

Jacob, K. S. (2015). Recovery model of mental illness: A complementary approach to psychiatric care. Indian Journal of Psychological Medicine, 37 (2), 117–119. https://doi.org/10.4103/0253-7176.155605

Ledovec s.r.o. (n.d.). https://www.zotaveni.cz/zotaveni-nazivo/download/17_ef2fd5b46509502a116935eb043c3524 . Accessed 2022.

Liberman, R. P. (2008). Recovery from disability: Manual of psychiatric rehabilitation . American Psychiatric Publishing.

Liberman, R. P., Wallace, C. J., Blackwell, G., Kopelowicz, A., Vaccaro, J. V., & Mintz, J. (1998). Skills training versus psychosocial occupational therapy for persons with persistent Schizophrenia. The American Journal of Psychiatry, 155 , 1087–1091. https://doi.org/10.1176/ajp.155.8.1087

McKay, C., Nugent, K. L., Johnsen, M., et al. (2018). A systematic review of evidence for the clubhouse model of psychosocial rehabilitation. Administration and Policy in Mental Health and Mental Health Services Research, 45 (1), 28–47.

Meisel, J., McGowen, M., Patotzka, D., Madison, K., & Chandler, D. (1993). Evaluation of AB 3777 Client and Cost Outcomes, July 1990 Through March 1992. Lewin-VHI. Available from California Department of Mental Health, Sacramento.

Mental Health Gap Action Programme. (2016). mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0 . World Health Organization.

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change . Guilford Press.

Mirnezami, H. F., Jacobsson, L., & Edin-Liljegren, A. (2016). Changes in attitudes towards mental disorders and psychiatric treatment 1976–2014 in a Swedish population. Nordic Journal of Psychiatry, 70 (1), 38–44.

National Council for Behavioral Health. (n.d.). www.mentalhealthfirstaid.org . Accessed 2022.

No Author. (1999). Gold award: The wellspring of the clubhouse model for social and vocational adjustment of persons with serious mental illness. Psychiatric Services (Washington, DC), 50 (11), 1473–1476. https://doi.org/10.1176/ps.50.11.1473

NSW Ministry of Health. (2018). Preventing seclusion and restraint: Mental health safety and quality in NSW built and therapeutic environments . https://www.health.nsw.gov.au/mentalhealth/reviews/seclusionprevention/Factsheets/built-therapeutic-environment.pdf . Accessed 28 Feb 2021.

O’Reilly, C. L., et al. (2010). Consumer-led mental health education for pharmacy students. American Journal of Pharmaceutical Education, 74 (9), 167. https://doi.org/10.5688/aj7409167

Oxfam International. (n.d.). A deadly virus: 5 shocking facts about global extreme inequality. https://www.oxfam.org/en/5-shocking-facts-about-extreme-global-inequality-and-how-even-it . Accessed 28 May 2020.

Patel, V., et al. (2018). The Lancet Commission on global mental health and sustainable development. The Lancet (London, England), 392 (10157), 1553–1598. https://doi.org/10.1016/S0140-6736(18)31612-X

Pilon, D., & Ragins, M.. (2006) Milestones of recovery scale . http://www.acbhcs.org/providers/QI/docs/WRR/Milestones_of_Recovery_(Dave_Pilon).pdf . Accessed 2022.

Pitt, V., Lowe, D., Hill, S., et al. (2013). Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database of Systematic Reviews, 3 , CD004807. https://doi.org/10.1002/14651858.CD004807.pub2

Puschner, B. (2018). Peer support and global mental health. Epidemiology and Psychiatric Sciences, 27 , 413–414.

Ragins, M. (2002). A road to recovery . Mental Health America.

Ragins, M. (2006). Person centered vs illness centered . PersonCenteredvsIllnessCentered.pdf – Google Drive. Accessed 2022.

Ragins, M. (2008). An overview of the village (1990–2008) . An Overview of the Village (1990-2008).doc – Google Drive. Accessed 2022.

Ragins, M.. (2009). A recovery culture progress report . https://drive.google.com/file/d/1CNOttT2w4F2nOVEg5P9DiJD2DtCprO_O/view . Accessed 2022.

Ragins, M. (2011). Taking strengths seriously . TakingStrengthsSeriously.pdf – Google Drive. Accessed 2022.

Ragins, M. (2021). Journeys beyond the frontier: A rebellious guide to psychosis and other extraordinary experiences . Kindle Direct Publishing.

Refocus on Recovery. (2019). https://vimeo.com/366263170 . Accessed 2022.

Rogers, E. S., Anthony, W. A., and Farkas, M. The choose–get–keep model of psychiatric rehabilitation: A synopsis of recent studies Rehabilitation Psychology 2006, Vol. 51, No. 3, 247–256.

Rusk, H. A. (1968, February 4). Mental rehabilitation; Fountain House on 47th St. is Mecca to many former patients in the state. The New York Times .

Substance Abuse and Mental Health Services Administration. (2009). Illness management and recovery: Practitioners guides and handouts , SMA-09-4462. Accessed 2022.

Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery . Publication ID: PEP12-RECDEF (brochure) SAMHSA’s Working Definition of Recovery. Accessed 2022.

Sunkel, C.. (2020). Global burden of mental illness. In Handbook of global health (pp. 1–27).

Tan, B.-L., Li, Z., and Tan, C. H.-M. Evaluation of a national supported employment programme for people with psychiatric conditions British Journal of Occupational Therapy 79(5) https://doi.org/10.1177/0308022615615891 January 2016.

The Institute for Dialogic Practice. (n.d.). www.dialogicpractice.net/open-dialogue/about-open-dialogue/ . Accessed 2022.

The New Zealand Mental Health Advocacy Coalition. (2008). Destination recovery . The Mental Health Foundation of New Zealand. http://www.arsvi.com/2000/t080000mha.htm . Accessed 2022.

Thornicroft, G., Brohan, E., Kassam, A., & Lewis-Holmes, E. (2008). Reducing stigma and discrimination: Candidate interventions. International Journal of Mental Health Systems, 2 (3). https://doi.org/10.1186/1752-4458-2-3

Thornicroft, G., et al. (2017). Undertreatment of people with major depressive disorder in 21 countries. The British Journal of Psychiatry: the Journal of Mental Science, 210 (2), 119–124. https://doi.org/10.1192/bjp.bp.116.188078

United Nations. (2006) Convention of the Rights of Persons with disabilities: United Nations Human Rights, Office of the High Commissioner for Human Rights, United Nations.

United Nations. (2017). Human Rights Council, Resolution on Mental Health and Human Rights, A/HRC/36/L.25 (2017). https://digitallibrary.un.org/record/1306486?ln=en . Accessed 28 Feb 2021.

van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma . Penguin Books.

Vigo, D. V., Kestel, D., Pendakur, K., Thornicroft, G., & Atun, R. (2019). Disease burden and government spending on mental, neurological, and substance use disorders, and self-harm: Cross-sectional, ecological study of health system response in the Americas. The Lancet Public Health, 4 (2), e89–e96. https://doi.org/10.1016/S2468-2667(18)30203-2

World Economic Forum. (2011). The global economic burden of non-communicable diseases.

World Health Organization. (1999). An overview of a strategy to improve the mental health of underserved populations. https://www.who.int/mental_health/media/en/46.pdf . Accessed 28 Feb 2021.

World Health Organization. (2010). User empowerment in mental health: A statement by the WHO regional office for Europe . WHO.

World Health Organization. (2018). Mental health atlas 2017 . World Health Organization.

World Health Organization. (2019). Mental disorders fact sheet [online]. https://www.who.int/en/news-room/fact-sheets/detail/mental-disorders . Accessed 28 Feb 2021.

World Health Organization. (2020). The impact of COVID-19 on mental, neurological and substance use services: results of a rapid assessment. https://www.who.int/publications/i/item/978924012455 . Accessed 28 February 2021.

Yung, A., & Nelson, B. (2013). The ultra-high risk concept – A review. The Canadian Journal of Psychiatry, 58 (1), 5–12.

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Allan Tasman

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Michelle B. Riba

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Renato D. Alarcón

Columbia University Medical Center, New York, USA

César A. Alfonso

Kyushu University, Fukuoka, Japan

Shigenobu Kanba

Department of Psychiatry, University of Nairobi, Nairobi, Kenya

David M. Ndetei

Malaysian Research Inst on Ageing, Universiti Putra Malaysia, Selangor, Malaysia

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Serbian Academy of Sciences and Arts, Belgrade, Serbia

Dusica Lecic-Tosevski

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David Ndetei

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Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, USA

Jacqueline Maus Feldman

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Ragins, M., Sunkel, C. (2023). The Recovery Model and Other Rehabilitative Approaches. In: Tasman, A., et al. Tasman’s Psychiatry. Springer, Cham. https://doi.org/10.1007/978-3-030-42825-9_157-1

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• Volume 10, Issue 8
• Recovery-oriented social work practice in mental health and addictions: a scoping review protocol
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• http://orcid.org/0000-0002-2491-2595 Toula Kourgiantakis 1 ,
• http://orcid.org/0000-0002-8697-0360 Amina Hussain 1 ,
• http://orcid.org/0000-0002-5666-1946 Rachelle Ashcroft 1 ,
• Judith Logan 2 ,
• Sandra McNeil 1 ,
• Charmaine C Williams 1
• 1 Factor-Inwentash Faculty of Social Work , University of Toronto , Toronto , Ontario , Canada
• 2 John P. Robarts Library , University of Toronto , Toronto , Ontario , Canada
• Correspondence to Dr Toula Kourgiantakis; toula.kourgiantakis{at}utoronto.ca

Introduction Social work is a key profession in the field of mental health worldwide and the profession has values that are aligned with a recovery paradigm. However, there are gaps in understanding how social workers are applying the recovery paradigm in practice. This study will scope and synthesise the literature related to recovery and social work practice in mental health and addictions. There will also be an exploration of best practices and gaps in recovery-oriented social work practice.

Methods and analysis Using a scoping review framework developed by Arksey and O’Malley, we will conduct our search in five academic databases: PsycINFO, Medline, CINAHL Plus, Sociological Abstracts and Social Services Abstracts. Articles meeting inclusion criteria will be charted to extract relevant themes and analysed using a qualitative thematic analysis approach.

Ethics and dissemination This review will provide relevant information about best practices and gaps in recovery-oriented social work practice in mental health and addictions. The study will inform the development of mental health curricula in social work programmes and clinical settings. Results will be disseminated through a peer-reviewed journal and at conferences focusing on mental health, addictions, and social work education. Ethics approval is not required for this scoping review.

• education & training (see medical education & training)
• protocols & guidelines
• substance misuse

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2020-037777

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Strengths and limitations of this study

This is the first comprehensive review of the recovery paradigm and social work practice in mental health and addictions.

The search strategy has been developed by a research team with expertise in the methodology and subject area.

Due to the nature of the scoping review framework, the studies included in the review will not be appraised for quality.

This scoping review will include all article types and methodologies but will not include books or grey literature.

Introduction

Recovery is a paradigm with increasing influence on mental health systems and policies in many high-income countries over the last two decades, 1–3 and it is included in the WHO’s Mental Health Action Plan. 4 The recovery paradigm was introduced in the 1980s by mental health consumers 5 as an alternative to the biomedical model focusing on illness, chronicity, and cure. 6 We will use the term paradigm defined by Kuhn as a ‘constellation of beliefs, values, techniques, and so on shared by the members of a given community’ 7 (p175). Members of a community share assumptions and beliefs, practice using a specific paradigm and pursue common goals. Practice interventions and theories are developed and shaped by paradigms. 8 9 Recovery has been defined as ‘a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness’ 9 (p15). Researchers in the UK developed a CHIME framework which refers to recovery-oriented processes that include connectedness, hope, identity, meaning, and empowerment. 10 Other countries have adopted common guiding principles for recovery that include CHIME concepts and other important processes related to recovery: (1) hope, (2) lived experiences, (3) individual, family and community strengths, (4) self-determination, (5) peer support, (6) collaborative relationships, (7) a non-linear process, (8) a holistic approach, (9) cultural diversity, and (10) social inclusion, stigma and discrimination. 11–13

A similar movement towards a recovery framework has been adopted for addiction-related concerns which include substance use and behavioural addictions. 11 13 14 While the services and approaches to treatment may be different for mental health concerns than they are for those coping with addictions, there are similar and overlapping principles of recovery. 11 15 For some individuals coping with an addiction-related concern, the pathway to recovery may involve abstinence, while for others, it is about reducing the harm. 14 A term that is specific to addictions is recovery capital, which refers to ‘the many resources one can use towards their recovery from alcohol and other drug dependency’ 16 (p.349). Mental health and addiction services have a longstanding history of being divided in terms of policies and service provisions but a review of recovery-oriented practice guidelines indicate that there are overlapping values and guiding principles related to recovery-oriented care and a ‘need for a unified vision of well-being’ 17 (p.12).

Although many countries such as Canada have adopted a recovery framework for their national mental health strategy, researchers report challenges for mental healthcare professionals to implement recovery principles in practice and the culture of many systems of mental healthcare does not reflect a recovery paradigm. 2 3 The social work profession has a longstanding history of important and unique contributions in the field of mental health 18 19 and addictions. 20 The WHO identifies social work as a key profession in mental health across 149 countries. 4 An American survey found that social workers’ most common speciality practice area is mental health and most social workers engage with individuals and families with mental health concerns even when working outside of this specific field. Irrespective of their practice domain, most social workers support clients with mental illness (96%), and addictions concern (87%). 21 The recovery paradigm is strongly aligned with social work values and conceptual frameworks promoting empowerment, partnership, and choice informed by ecosystems theory and a strength-based model. 6 22 23 Despite social work’s unique alignment with the recovery paradigm, researchers argue that social work has not had a strong voice in challenging and critiquing the dominant biomedical model. 23 24 There are gaps in understanding the extent to which social workers are applying recovery guiding principles in practice. 24 25 Researchers have identified several impediments to implementation, including the lack of a universal definition of recovery-oriented care and a paucity of evidence-based research to inform practice. 24–26 The organisational context may also influence implementation by pressuring social workers to adhere to institutional policies and procedures that may be incongruent with recovery principles. 24

Williams and colleagues 26 argue that recovery does not adequately address sociopolitical issues related to power and control over mental healthcare. Social work’s core value of social justice can make valuable contributions to advancing how recovery is implemented in mental healthcare systems; however, social work has also been critiqued for its conformity with dominant structural systems that are not recovery oriented and perpetuate stigma and discrimination. 26 Considering the important role of social workers internationally, we need a greater understanding of how social workers are conceptualising and implementing recovery in mental health and addictions. 13 Moreover, research has shown that recovery-oriented practice is ambiguous and it is important for clinicians to learn to operationalise this concept and guidelines needed that are context specific. 27 There is a lack of guidelines for clinical application of recovery-oriented care and attempts to operationalise this have been through the lens of organisational priorities. 28

This paper delineates a protocol for a scoping review on the recovery paradigm in social work in mental health and addictions. The objectives of this review are to (1) scope the literature related to the recovery paradigm in social work in mental health and addictions, (2) synthesise definitions, principles and values related to recovery-oriented social work practice in mental and addictions, (3) describe how recovery is implemented in social work practice, and (4) identify evidence-based practices and gaps in recovery-oriented social work practice in mental health and addictions.

Methods and analysis

A scoping review will be conducted to map existing literature on recovery-oriented practice within social work education, research and practice in mental health and addictions. Scoping reviews involve systematically mapping recurring themes, concepts and identifying recommendations from the current literature as they relate to the research question at hand. 29 This study will employ the scoping review framework espoused by Arksey and O'Malley 30 that consists of five stages: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarising and reporting the results. Given the nature of this exploratory study, this form of knowledge synthesis will be valuable in providing a breadth of literature pertaining to the recovery paradigm within social work education, research and practice. We will adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Extension for Scoping Reviews (PRISMA-ScR) reporting guidelines. 31 See online supplementary appendix A for the PRISMA-ScR checklist.

Supplemental material

Stage 1: identifying the research questions.

As highlighted throughout our literature review, recovery is central to social work practice and there have been no studies charting the evidence on the recovery paradigm in social work education, research, and practice in mental health and addictions. Based on recommendations by Colquhoun et al , 32 the research questions for this scoping review were developed collaboratively by our research team consisting of three social work faculty members (TK, RA, and CCW), one social science librarian (JL) and two social work doctoral students (AH and SM).

The research team developed the following research questions: (1) How is the recovery-paradigm conceptualised and defined in social work practice in mental health and addictions? (2) What are the principles and values of recovery in social work? (3) How is the recovery paradigm used in social work practice, education and research? (4) What are the gaps, challenges or barriers of recovery in social work? (5) What are the recommendations, evidence-based or best practices for using a recovery paradigm in social work research, education and practice?

Stage 2: identifying relevant studies

The initial search strategy was developed in PsycINFO (Ovid, 1806-) by the social sciences librarian (JL) in consultation with other team members. See table 1 for the draft search strategy in PsycINFO. It will be sent to a second librarian for peer review, using the Peer Review of Electronic Search Strategies framework. 33 Any subsequent feedback will be incorporated to enhance the breadth and scope of articles generated from the search. Our search strategy will be conducted in five academic databases: PsycINFO (1806-), Medline (1946 -), CINAHL Plus (1937-), Sociological Abstracts (1952-) and Social Services Abstracts (1979-). These databases were intentionally selected for their inclusion of mental health literature as well as research on social work practice and education, and thus are likely to capture relevant scholarly material. Furthermore, we will conduct a citation search of the reference lists of selected articles to ensure that a wider scope of articles are included.

• View inline

Search strategy for Ovid PsycINFO (1806-)

Stage 3: study selection

After generating a list of articles from our search strategy, we will engage in an iterative, peer-review two-stage screening process with two independent reviewers at each stage. In the first stage, two independent reviewers will screen articles for suitability based on their title and abstracts. In the second stage, the reviewers will independently conduct a full-text review of the selected articles to ensure their content meets our inclusion criteria outlined below. If there is ambiguity on whether certain articles fit the scope of this protocol, a third reviewer will be consulted. We will use Covidence—a web-based software for systematic and scoping reviews that facilitates screening, study selection and data extraction. 34 This protocol will focus on articles written in English only and selected material will include empirical studies, literature reviews, dissertations, teaching articles and conceptual/theoretical papers. There are no outlined geographical or date restrictions. Articles must meet the following inclusion criteria to be selected: (1) include the term recovery in the title or abstract, (2) use the term social work or social worker in the title or abstract, (3) have an explicit focus on recovery that may include different concepts such as recovery, recovery model, recovery-oriented practice, recovery-oriented care and so on, (4) explicitly focus on social work research, education, training or practice in relationship to recovery, and (5) focus on recovery with respect to mental health and/or addictions. We will exclude books, book reviews, editorials and grey literature.

Stage 4: Charting the data

Key themes extracted from the selected articles will be categorised, summarised and presented clearly within a data charting form. The research team developed initial charting variables based on the research questions and these variables will be used to extract data and identify key themes from selected articles. The preliminary variables that will be used to categorise information include (1) authors, (2) year, (3) country where study was conducted or country of first author’s affiliation, (4) journal, (5) format of paper (empirical, literature review, dissertation, conceptual/theoretical, editorial, teaching article, etc), (6) definition of recovery, (7) principles of recovery, (8) area of focus (eg, mental health, addictions, etc), (9) implementation of recovery, (10) targeted audience (eg, students, service users, social workers, etc), (11) focus on equity or access, (12) focus on stigma, (13) focus on race, culture and/or diversity, (14) gaps, challenges or barriers, and (15) recommendations, evidence-based or best practices. To assess whether these headings accurately capture the scope and breadth of the content, the reviewers will have two research assistants independently chart the first five articles that meet our inclusion criteria, and if necessary, refine the definitions for the variables/charting categories. We will also engage in a constant comparative method and peer review to minimise any discrepancies during the charting process. The researchers will also engage in a qualitative thematic analysis to identify and highlight themes present among this chart. The charted data will be organised and presented in a Microsoft Excel spreadsheet.

Stage 5: identification, synthesis and report of study findings

Findings outlined in the charted data will be reviewed, synthesised and analysed through a numerical summary analysis as well as a qualitative thematic analysis. The final scoping review will be presented in publications and at upcoming conferences. Study findings will be disseminated to relevant stakeholders such as researchers, clinicians and social work educators. Anticipated findings are expected to map out the current nature and scope of recovery in social work practice in mental health and addictions, and the scoping review will provide recommendations for recovery-oriented social work practice in mental health and addictions.

Patients and public involvement

Neither patients nor members of the public were involved in this project.

Ethics and dissemination

The scoping review outlined in this paper contributes to our current understanding and will advance knowledge of recovery-oriented social work practice in mental health and addictions. The information gathered for this paper and the outlined scoping review were retrieved from publicly available sources, therefore ethics approval is not required for this project. The results will be disseminated through a peer-reviewed journal and reported at national and international conferences on mental health and addictions as well as social work education, practice, and research.

• Daniels A ,
• Mckenzie KJ ,
• Carpenter J
• Ashcroft R ,
• Van Katwyk T ,
• Le Boutillier C , et al
• Mental Health Commission of Canada
• Commonwealth of Australia
• Substance Abuse and Mental Health Services Administration (SAMHSA)
• Canadian Centre on Substance Use and Addiction
• Davidson G ,
• Hennessy EA
• Van Katwyk T
• Kourgiantakis T ,
• Fearing G , et al
• Straussner SLA
• Whitaker T ,
• Weismiller T ,
• Davidson L ,
• Rodriguez del Barrio L
• Williams CC ,
• Almeida M ,
• Knyahnytska Y
• Le Boutillier C ,
• Bird VJ , et al
• Chevalier A ,
• Lawrence V , et al
• Colquhoun H ,
• Tricco AC ,
• Zarin W , et al
• Colquhoun HL ,
• O'Brien KK , et al
• McGowan J ,
• Sampson M ,
• Salzwedel DM , et al
• Macdonald M ,
• Martin Misener R ,
• Weeks L , et al

Twitter @DrKourgiantakis

Contributors All authors made substantive intellectual contributions to the development of this protocol. TK and AH developed, wrote and edited the initial protocol. JL developed the search strategy and contributed to the writing of the protocol. All authors (TK, AH, JL, SM, RA and CCW) critically reviewed and revised the final version prior to submission.

Funding This scoping review protocol is supported by a 2019–2020 Royal Bank of Canada Graduate Fellowship in Applied Social Work Research, Factor-Inwentash Faculty of Social Work, University of Toronto.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Read the full text or download the PDF:

Mental health recovery: A review of the peer-reviewed published literature

• PMID: 29218963
• DOI: 10.1016/j.colegn.2015.08.001

The concept of mental health recovery promotes collaborative partnership among consumers, carers and service providers. However views on mental health recovery are less explored among carers and service providers. The aim of this review was to analyse contemporary literature exploring views of mental health consumers, carers and service providers in relation to their understanding of the meaning of mental health recovery and factors influencing mental health recovery. The literature review questions were: How is mental health recovery and factors influencing mental health recovery viewed by consumers, carers and service providers? What are the differences and similarities in those perceptions? How can the outcomes and recommendations inform the Australian mental health practices? A review of the literature used selected electronic databases and specific search terms and supplemented with manual searching. Twenty-six studies were selected for review which included qualitative, mixed method, and quantitative approaches and a Delphi study. The findings indicated that the concept of mental health recovery is more explored among consumers and is seldom explored among carers and service providers. The studies suggested that recovery from mental illness is a multidimensional process and the concept cannot be defined in rigid terms. In order to achieve the best possible care, the stakeholders require flexible attitudes and openness to embrace the philosophy.

Publication types

• Aged, 80 and over
• Caregivers / psychology*
• Focus Groups
• Mental Disorders / therapy*
• Mental Health Recovery*
• Mental Health Services / organization & administration*
• Middle Aged
• Patients / psychology*

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The principles of recovery-oriented mental health services: A review of the guidelines from five different countries for developing a protocol to be implemented in Yogyakarta, Indonesia

M. a. subandi.

1 Faculty of Psychology, Gadjah Mada University, Yogyakarta, Indonesia

Maryama Nihayah

Carla r. marchira.

2 Department of Psychiatry, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, Indonesia

Trihayuning Tyas

Ariana marastuti, ratri pratiwi.

3 Faculty of Psychology, Mercu Buana University, Yogyakarta, Indonesia

Fiddina Mediola

4 Puri Nirmala Special Hospital, Yogyakarta, Indonesia

Yohanes K. Herdiyanto

5 Department of Psychology, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia

Osi Kusuma Sari

6 Directorate of Mental Health, Ministry of Health, Jakarta, Indonesia

Mary-Jo D. Good

7 Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America

Byron J. Good

Associated data.

All relevant data are within the paper.

Recovery-oriented mental health service has become the focus of global change in mental health services. Most of North industrialized countries have adopted and implemented this paradigm in the last two decades. Only recently that some developing countries are trying to follow this step. In Indonesia’s case, there has been little attention to developing a recovery orientation by mental health authorities. The aim of this article is to synthesize and analyze the recovery-oriented guidelines from five industrialized countries that we can use as a primary model for developing a protocol to be implemented in community health centre in Kulonprogo District, Yogyakarta, Indonesia.

We used a narrative literature review by searching for guidelines from many different sources. We found 57 guidelines, but only 13 from five countries met the criteria, including five guidelines from Australia, one from Ireland, three from Canada, two from the UK, and two from the US. To analyze the data, we used an inductive thematic analysis to explore the themes of each principle as described by the guideline.

The results of the thematic analysis revealed seven recovery principles, including (1) cultivating positive hope, (2) establishing partnerships and collaboration, (3) ensuring organizational commitment and evaluation, (4) recognizing the consumer’s rights, (5) focusing on person-centeredness and empowerment, (6) recognizing an individual’s uniqueness and social context, and (7) facilitating social support,. These seven principles are not independent, rather they are interrelated and overlap each other.

The principle of person-centeredness and empowerment is central to the recovery-oriented mental health system, while the principle of hope is also essential to embracing all the other principles. We will adjust and implement the result of the review in our project focusing on developing recovery-oriented mental health service in the community health center in Yogyakarta, Indonesia. We hope that this framework will be adopted by the central government in Indonesia and other developing countries.

Introduction

Recovery-oriented mental health services can be traced to the 1970s consumer movement in the US [ 1 ]. Initially, the movement tried to change psychiatric approaches to mental illness, notably by challenging the pessimistic idea that schizophrenia is incurable. Supported by psychiatrists who were also skeptical of this idea, a number of consumers wrote about their personal experiences. A large number of personal accounts have since appeared in well-respected scientific journals, such as Schizophrenia Bulletin , Psychiatric Services , Psychiatric Rehabilitation Journal , and Psychiatric Rehabilitation Skill . Spaniol and Koehler [ 2 ] then compiled these accounts into an anthology titled The Experience of Recovery . These accounts have become the founding stories of the recovery movement. They have provided a starting point of advocacy for health services to go beyond symptom reduction by promoting a meaningful life in the community.

The consumer movement had at least three different agendas. First, it fought against stigma and sought to change the public perception of mental illness. Second, since the movement highlighted the potential harm that the mental health profession could cause, it actively sought to change professional practice. Third, it played an influential role in shaping government policies on mental health care systems [ 3 – 5 ].

Anthony [ 3 ] introduced the notion of a recovery-orientation for mental health services, and in 2002, the state government of Connecticut adopted a policy for promoting a recovery-oriented system of care. Since then, the recovery movement and recovery-oriented mental health services have garnered global interest. Although it is not derived from an evidence-based research of new psychiatric medications or an accumulating body of research on clinical improvements, a recovery orientation has become part of the transformation of mental health systems [ 6 ]. In the last two decades, a commitment to recovery has become a major orientation in mental health policy, guidelines, action plans, and practice at the international level [ 7 ].

Pincus et al [ 8 ] reviewed the implementation of recovery-oriented mental health services from selected industrialized countries. In Australia, recovery became an important priority for its national and state mental health policies. In 2013, the Australian Health Ministers’ Advisory Council released the National Framework for recovery-oriented mental services. Some of the guidelines has also been released by many different institutions, such as St. Vincent’s Hospital and the West Australian Association for Mental Health. In Canada, the recovery idea has been incorporated into mental health services at the state/territorial level since 2010. In this regard, the Healthy Minds, Healthy People Initiative is a 10-year plan which promotes a recovery approach to transform the mental health system in Canada. The recovery movement has also been adopted in the UK as the guiding vision of its government policy since 2001. In Ireland, the Department of Health and Children recommended that Irish mental health services adopt a recovery perspective in 2006.

Following in their footsteps, other developed European countries, such as Scotland, Norway, Germany, the Netherlands, and Italy, have also incorporated this orientation into their healthcare services. Later, several non-European countries, such as Israel [ 9 ], Hong Kong [ 10 ], and South Africa [ 11 , 12 ], also adopted this approach to care. Recently, Chang et al. [ 13 ] provided a report of recovery-oriented mental health services in Taiwan.

In Indonesia’s case, there has been little attention to developing a recovery orientation by mental health authorities. However, we note two projects that have been trying to develop a recovery framework. Stratford et al. [ 14 ] reported a community recovery rehabilitation project in the Sukabumi district of the West Java province. This project was under the Ministry of Social Affairs and was claimed to be successful. However, its sustainability was later questioned. The West Java mental hospital initiated a hospital-based recovery-oriented program called “Kampung Walagri” [ 15 ] recently. It is, however, unclear whether these two projects are connected.

Since 2012, our research team has been trying to strengthen mental health programs in community health centers ( Puskesmas ) in one district through a research collaboration between Harvard University and Gadjah Mada University [ 16 – 18 ]. Titled “Bangkit Jiwa” (mental revival), our project—particularly over the last two years—has concentrated on adopting a recovery-oriented mental health approach by collaborating with the local government, particularly the district health office, of the Kulonprogo district, in the special province of Yogyakarta, Indonesia. After much deliberation, the local government agreed to incorporate a recovery-oriented program into its five year mental health plan.

As the initial step of the project, this literature review aims to synthesize the guidelines of various recovery-oriented mental health services in the world. The aim of this review is to guide the direction of this entire project.

This literature review uses a narrative analysis method. We searched for the relevant literature from various sources, such as Google Scholar, the online archive of the National Institute for Health and Care Excellence (NICE) UK, the US Substance Abuse and Mental Health Service Administration (SAMSHA) and Science Direct. We used several keywords. such as ‘recovery’ AND ‘guideline’ AND ‘mental health’. Alternatively, we also used the keywords ‘practical guide to recovery’ AND ‘mental health’. We did not use formal search engines, such as Scopus, EBSCO, or ProQuest, since they mostly search for journal articles that do not have practical guidelines.

The selection criteria for these guidelines/articles are those that are available online, can be downloaded, and are written in English. Other criteria include the availability of a definition for recovery-oriented services and a description of the service principles used. From the search, we found 57 guidelines. Of these guidelines, 13 met the criteria for further analysis. These 13 guidelines were from five different countries: five guidelines from Australia, one from Ireland, three from Canada, two from the UK, and two from the US. The link of guidelines can be seen in the References number 20–32.

To analyze the data, we used an inductive thematic analysis to explore the themes of each principle as described by the guideline. An inductive thematic analysis is the process of coding data without trying to fit it into a pre-existing coding framework or the researcher’s analytic preconceptions. Thematic analysis is used because it allows a flexible and pragmatic approach that can provide rich and detailed data [ 19 ].

The analysis was first carried out simultaneously by members of this research team to find important notes and appropriate themes. From the themes found, discussions were held regarding the category of themes and descriptions. Furthermore, to get a theme that describes the findings more accurately and comprehensively, a joint theme review was conducted. To reduce the possible errors, a senior professional checked and evaluated the result of analysis as a quality control. Technically, the steps taken in this stage are 1) familiarizing ourselves with the data by reading it over and over again, 2) creation of the initial code, drawing on initial notes, 3) searching for a theme, 4) doing a theme review, 5) defining and naming the theme, and 6) conducting a follow-up analysis by calculating the frequency of keywords of themes in each document.

Ethical approval for the project was obtained from the Ethical Committee, Faculty of Psychology, Gadjah Mada University, Yogyakarta, Indonesia number 4628/UN1/FPSi.1.3/SD/PT.01.04/202. The Ethic committee waived the need for consent because this is a review study. In addition, all the documents that we used for data analysis are available online.

A total of 135 recovery principles with 153 units of explanation were obtained from 13 documents. Each unit of explanation varied in length, from one sentence to a paragraph.

Table 1 shows the list of guidelines as the primary source of data in this study.

From the results of the thematic analysis, we synthesized seven principle themes listed according to the frequency of emergent keywords of the themes in the guidelines: (1) Cultivating positive hope, (2) Establishing partnership and collaboration, (3) Ensuring organizational commitment and evaluation, (4) Recognizing the consumer’s human and civil rights, (5) Focusing on person-centeredness and empowerment, (6) Recognizing an individual’s uniqueness and cultural context, (7) Facilitating social support. Table 2 shows the summary of the principles and the frequency of keywords of themes used in each guideline. The description of each theme follows the table.

1) Cultivating positive hope

Hope is the theme that appears most frequently in the guidelines, despite no word of ’hope’ in guideline D [ 23 ]. Meanwhile, guideline I [ 28 ] includes the word ’hope’ in the title and clearly states that recovery is about hope. Guideline C3 [ 22 ] mentions the first domain of recovery is hope.

Hope is central to recovery…promoting a culture and language of hope and optimism [ 22 : p.5]

The emotional essence of recovery is hope, a promise that things can and do change, that today is not the way it will always be [ 23 : p.12].

Guideline I [ 28 ] suggests that the first step in the recovery journey is cultivating hope. Not only hope among consumers but also among service providers. A sense of hope could be achieved by broadening the concept of recovery. Almost all guidelines suggest that recovery does not mean eradicating symptoms and a full return to premorbid functioning. Instead, recovery focuses more on social functioning, where people with mental illness can achieve a meaningful life, with or without symptoms.

The main task of service providers is to help consumers accept their illness and have positive expectations, be optimistic, and believe in the opportunity to grow and develop [ 28 ]. With this hope, consumers can construct a positive self-identity, while having an open view of themselves and their environment. In this regard, even a positive language from the service providers can make consumers feel valued [ 27 , 28 ].

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, such as stigma and discrimination [ 20 – 22 , 24 ]. To ensure this, a consumer’s hopes must be internalized and fostered by their families, peers, providers, allies, and others.

2) Establishing partnerships and collaborations

The theme of establishing partnerships and collaborations consists of two keywords, ‘partnership’ and ‘collaborations’. Some guidelines use these two words separately [ 23 , 25 , 28 ], but other guidelines combine them as ‘ collaborative partnership’ [ 20 , 28 , 32 ]. The journey of recovery cannot be accomplished alone. It needs a true working partnership. Most guideline suggest that recovery-oriented mental health service needs partnership and collaboration between consumers, their families, and service providers.

Mental health care is responsive to the range of different needs people may have, which involves effective collaboration with non-mental health service providers [ 20 : p.15].

…to initiate collaborative partnerships and coordinated planning efforts that include government policy planners, nongovernmental organizations, community agencies, people with lived experience and family caregivers [ 28 : p.96]

Most of the guidelines suggest that recovery-oriented mental health services should recognize the contribution of many different parties. Hence, partnerships are vital between consumers, caregivers, families, communities, health care staff, as well as multi-disciplinary service providers [ 23 – 25 , 28 ], governments, organizations, and communities [ 21 ], key agencies and voluntary groups in the community, as well as mainstream health services (e.g., primary care teams and other referring agents); social welfare; education services, and housing authorities [ 25 ]. Moreover, these stakeholders should work together in a respectful collaboration to support the recovery process. Out of these, the consumer’s involvement must be acknowledged primarily. They are considered experts of their own lives and experiences [ 21 , 29 ] while mental health services are considered experts when it comes to providing the treatment. The helping relationship between clinicians and consumers should be changed from being “expert-consumer” to being “coaches” or “partners” on a journey of discovery [ 28 ]. Service providers need to share power and acknowledge the contribution of “experts-by-experience” [ 22 , 29 ]. They should “do with” the consumers, not “do to” or “do for” them [ 21 , 30 , 32 ]. Moreover, a consumer’s peers can also support their recovery through formal self-help, informal encounters, mutual assistance, and exposure to their stories of recovery [ 24 , 30 , 31 ].

Here, the partnership should also include coordination and collaboration with a range of relevant agencies beyond the mental health system, including health services, disability services, employment, education, training services, and housing services [ 21 , 22 , 25 ]. They serve as referring agencies and explore new service partnerships. Moreover, partnerships that provide community support to aid social inclusion is also essential [ 22 , 23 , 27 , 30 , 32 ]. The involvement of various parties and agencies can enable consumers to maximize their potential, achieve wellbeing, and a positive future. Various agencies, NGOs, and other relevant stakeholders should be able to provide integrated, innovative, and flexible services so that they can effectively respond to the needs of the consumers, families, or communities [ 21 , 22 ].

3) Ensuring organizational commitment and evaluation

Table 1 shows that the frequency of keywords ‘commitment’ and ‘evaluation’ used in the guidelines is relatively high, meaning that it is an essential aspect of recovery-oriented services. All of the guidelines mention these keywords. A recovery-oriented services are not only about how services are provided, but also about how they are committed to facilitating a recovery approach using organizational resources. The recovery values should be implemented in all management processes, such as recruitment, professional development, supervision, appraisal, audit, service planning, and operational policies [G1, G3, G9, G12, G13]. The appropriate recovery language should also be incorporated into all key organizational documents and publications [ 21 , 22 , 29 , 31 , 32 ].

Almost all of the documents suggest that the attitude of the staff throughout the organization is very important in shaping environments which facilitate recovery, especially those that support people in developing and implementing their own recovery plans.

Service and work environments and an organizational culture that are conducive to recovery and to building a workforce that is appropriately skilled, equipped, supported and resourced for recovery-oriented practice [ 22 : p.4].

It is also important that an organization be committed to involving consumers in its functioning at all levels. By doing this, the organization could have a big impact in the service provided. A professional consumer (a former consumer with an academic background such as psychiatrist, clinical psychologist or social worker) with “lived experience” could work alongside other professionals in their organization [ 21 , 22 ]. They not only serve as a model figure for people in the journey toward recovery, but can also contribute to service planning and evaluation activities. It is also important that the organization commits to fostering a culture of continuous service improvement by implementing evaluations to ensure best practices and a high-quality service system [ 20 – 23 , 28 , 29 ].

Promote research and evaluation activity that involves peers and people in recovery; incorporate findings in service improvements and standards of practice [ 28 : p.87]

4) Recognizing the consumer’s human and civil rights

The keywords ‘human rights’ and ‘civil rights’ are in the same position as the organisational commitment and evaluation theme. Almost all of the documents mention this theme. Historically, the recovery movement began as a civil rights movement aimed at restoring consumers’ human rights and their opportunity to community inclusion and social integration [ 22 , 23 , 28 , 29 , 32 ]. These values have been incorporated in the guiding principle of recovery. Service providers should respect the rights and dignity of the consumers by focusing on their strengths and abilities [ 26 – 28 ]. Moreover, recovery-oriented mental health services must uphold, support, and protect a consumer’s legal, citizenship and human rights [ 2 – 4 ]. This is an important goal to be accomplished in the practice of recovery-oriented services.

Services providers should also give equal opportunities for every consumer to participate in education, work, as well as the community to encourage social inclusion [ 22 , 23 , 26 , 31 , 32 ]. According to this principle, they should remove the barriers to stigma and discrimination because they can negatively impact the consumer’s recovery and well-being. Consumers are supported to have the same rights as others in the fields of education, employment, community involvement, and opportunity to make choices, and achieve wellbeing.

building healthy public policy (such as reducing stigma, facilitating social inclusion, upholding human rights, facilitating employment [ 23 : p.17]

5) Focusing on person-centeredness and empowerment

The keywords ‘person-centered’ and ‘empowerment’ are integrated into one theme because they focus on the consumers. Most of the documents suggest the importance of holistically seeing the person in recovery and acknowledging their power or autonomy and empowerment [ 20 – 26 , 28 , 30 , 32 ]. In the first aspect, a person with mental illness needs to be seen holistically, i.e., their life and circumstances. This is as not limited to the person’s mental health, but also includes their physical health, emotions, developmental stage, and gender. It also includes external aspects such as cultural, social, and economic aspects. The providers should understand the individual’s complex needs and aspirations and view their personal recovery as the primary process of working towards wellness.

The principle of empowerment indicates that the service providers acknowledge the autonomy of the consumers. Recovery is not necessarily about cure but is about having opportunities for choices, living a meaningful, satisfying and purposeful life, and being a valued member of the community [ 22 , 23 , 25 – 28 , 30 , 31 ]. Service providers should believe that their consumers have the ability and right to make their own life decisions. In brief, the consumers are at the heart of the recovery-oriented culture. They should describe their own experiences and journeys and affirm their personal identity beyond the constraints of their diagnoses. They have the opportunity to lead, control, and select the service processes and practices that support their recovery. Consumers are active agents of change in their lives and not passive recipients of services [ 22 , 29 – 32 ]. They deserve to be included in the development of a recovery plan. In this regard, all services must be structured to support individuals in building their strengths and taking responsibility for their lives, while understanding that they may need support from time to time.

The principle of taking a person-centered orientation refers to the view that recovery is built on honoring each person’s capacities, knowledge, talents, coping abilities, resources, and potential for growth [ 25 , 30 , 32 ]. Hence, the primary focus should be put on a person’s strengths and abilities, not on their weakness and disability.

promoting self-determination and dignity, adopting a holistic and strengths-based approach, fostering hope and purpose and sustaining meaningful relationships, also form the foundation of a recovery orientation [ 28 : p.17]

6) Recognizing an individual’s uniqueness and cultural context

Most the documents recognise that the process of recovery is a personal, unique and complex journey [ 21 , 22 , 28 , 29 , 32 ]. There is no two people will have identical paths or use the same benchmarks to measure their journeys. Therefore, recovery-oriented services and care should be tailored according to an individual’s strengths. Service providers should evaluate each individual’s needs, including the physical, social, emotional, cultural and spiritual aspects of their life. The focus should be placed on the development of individualized self-management plans rather than compliance with a standard treatment regime [ 28 , 31 , 32 ]. Here, personal experience is central and vital to mobilizing the individual’s own resources. It involves being sensitive to and respectful of each individual, with regards to their values, beliefs and culture. This also includes their human rights.

The context in which the consumers live, including their social, economic, and cultural background, will influence on the recovery process [ 20 – 22 , 26 , 28 ]. Therefore, it is important to consider and utilize these values as a source of support for the recovery process. Recovery considers how the cultural and spiritual aspects of consumers lives impact on their view of mental health and the process of treatment. Given this context, traditional care or other culturally relevant practices should also be considered, as these practices have a sense of the individualism and collectivism of their culture.

While each person’s journey of recovery is unique, people do not journey alone; their journeys take place within a social, familial, political, economic, cultural and spiritual context that impacts their mental health and well-being [ 28 : p.11].

7) Facilitating social support

Some guideline suggest that supporting a consumer’s inner circle or community, such as their family, relatives, peers, and other supportive people, play a vital role in the recovery process [ 23 – 25 , 28 , 30 ]. A supportive community is a natural resource that encourages the creation of a positive self-identity and hope for recovery through social inclusion and community participation. Service providers should support and encourage individuals to remain connected with the significant people in their life. A consumer should have someone whom they can trust to “be there” in times of need.

In this regard, service providers can leverage support groups with the consumers and their immediate environment. It is important to note that service providers are required to have prior adequate knowledge of the local community, including identifying potential barriers that may exist. Factors like stigma, discrimination, gendered norms, and negative societal perceptions of mental illness could hinder the recovery process [ 20 , 22 , 23 , 26 , 28 , 30 – 32 ].

Strong connections among people are the foundation of mental health and wellbeing and resilience for individuals, families and the broader community. These connections help reduce stigma, nurture social inclusion and respect diversity [ 23 : p.13].

Family and other supporters are often crucial to recovery and they should be included as partners wherever possible. However, peer support is central for many people in their recovery [ 29 : p.0].

The seven principles described above are interrelated. Fig 1 shows that the principles overlap each other. In the center of the circle is the principle of partnerships and collaborations. All the other principles, except hope, surround the center while overlapping with each other, indicating their integration. Meanwhile, the principle of hope is located outside the circle, indicating that it is essential to embracing all the other principles.

This study aimed to identify the principle of recovery-oriented mental health services that have been included in the guidelines from five countries. The thematic analysis identified seven essential principles of recovery-oriented mental health services that have been included in the guidelines from five countries. Following the aim of this study, we will use these principles to develop a protocol and implement it in the context of our projects in Yogyakarta, Indonesia.

Most of the principles align with the principles described in several studies. Several studies suggested that hope is a central principle of recovery [ 33 – 35 ]. In the context of mental health recovery, hope is defined as a future-oriented expectation to achieve goals and personally valuable relationships [ 35 ]. Hope means remembering that recovery can be a long-term process with many setbacks and advances along the way [ 33 ] and non-linear and complex [ 7 ], but still believing that recovery is a reality. In the process of seeking recovery, hope is a word combined with other factors that promote recovery.

Hope is a very subtle concept, but serves as a “guiding principle” in recovery [ 36 ]. Thus, this simple belief belongs not only to the consumers themselves, but also professional workers. By embracing the possibility of recovery, mental health service providers could cultivate their own hope. Later, they could share their hope to the consumer and their family. Hope has enormous practical consequences and was found to have a positive impact on the recovery process [ 37 – 39 ]. It has the power to inspire change in everyone. Hope is the core of recovery-oriented services.

There are several ways to build and maintain hope. The experience of regaining authority through self-empowerment with adequate environmental support is essential for rebuilding and maintaining the hope of recovery [ 40 ]. Hope can also be cultivated through a welcoming and accepting environment. The humanistic principle of non-judgmental listening, genuineness, and warmth can facilitate personal growth. This also means focusing on the strengths and positive outcomes rather than deficits. Consumers could learn to reframe their illness-related setbacks as part of the long-term process towards achieving recovery goals. Peer support from fellow users or survivors has also been found to promote hope, self-determination, participation in services, along with the knowledge of lived experiences to help each other more than professionals can [ 39 , 41 , 42 ]. In this regard, several psychosocial interventions have been recommended to support consumers and foster hope, including advance directives [ 43 ] Wellness Recovery Action Planning (WRAP) models [ 42 , 44 ] and Illness Management programs and Recovery (IMR) [ 45 ].

Another strategy to cultivate hope is using a positive language as suggested by two guidelines [ 27 , 28 ]. Service providers should communicate hopeful messages about recovery, believing that recovery—in its broader definition of being able to live a meaningful life—is a reality. This hopeful message and optimism are essential for maintaining a focus on strengths, building resources, and helping people sustain relationships. In the history of the recovery movement, activists changed the word “patient” into “consumer” (one who uses mental health facilities). In the UK, the word “users” is preferred. To adopt this principle in our Kulonprogo, Indonesia project, we use the term “penjiwa” (penyintas jiwa) meaning “a survivor of mental problem problems". This term conveys the meaning of hope and resiliency. Meanwhile, the formal term is ODGJ (Orang Dengan Gangguan Jiwa) meaning “people with a mental disorder”. We consider this term to be stigmatizing since it includes the word “disorder”. This is why we have chosen to emphasize n the word “survivor”.

This research found the complexity of recovery-oriented mental health services, including personal, clinical, organizational, and community issues. This is in line with the narrative of mental health recovery found by Llewellyn-Beardsley et al. [ 7 ]. These authors described the characteristics of mental health recovery as being diverse and multidimensional, which incorporated social, political, and right aspects. Therefore, establishing partnerships and collaborations become essential principles.

The principle of ‘ensuring organisation commitment and evaluation’ is essential because developing a focus on recovery-oriented involves transformation within mental health systems. Slade et al. [ 42 ] suggested that human systems do not easily transform. Integrating many different perspectives and implementing them into practice requires a long process. Furthermore, Slade et al. [ 42 ] identified three scientific challenges of recovery-oriented mental health, including broadening cultural understandings of recovery, implementing organizational transformation, and promoting citizenship.

Several guidelines mention the essential aspect of principle ‘recognising the human and civil right’ in recovery-oriented mental health service [ 22 , 23 , 28 , 29 , 32 ]. Davidson et al. [ 6 ] reviewed the history of recovery movement and they suggested that this movement was rooted in the civil rights movement of the 1950s and 1960s and the independent living and disability rights movement of the 1970s in the US. They also suggested that to achieve recovery, a consumer should have “… the sense of being a full citizen and have certain rights (e . g ., the right to community inclusion) and resources (e . g ., a home , an income) and be able to take on certain roles and responsibilities (e . g ., neighbor , voter) while having meaningful relationships with others that offer the person a sense of belonging ” [ 6 ].

Focusing on person-centered and empowerment is another feature of recovery-based mental health services [ 7 , 33 , 46 ]. It relates considers recovery as a consumer’s subjective experience at its core. Mental health providers should recognize that each consumer has their own knowledge, strengths, abilities, and backgrounds. This is because the knowledge related to narratives or experiences of the consumer’s recovery process can increase empathy and understanding among health staff [ 47 ], act as a peer support mechanism [ 48 ], and offer important clues on how consumers can be facilitated in the recovery process [ 49 ] and guide clinical intervention and evaluation strategies [ 34 ]. However, accepting consumer diversity can be challenging. In their study of mental health providers, Lodge et al. [ 50 ] found that the ability of health workers to adapt interventions to the needs of different consumers is still insufficient due to their lack of knowledge, clarity, and experience in applying this principle. Another challenge is noting and guiding the mental health provider’s changing perception of the consumer as the object of care into the subject of treatment [ 51 ]. In this regard, training can be an important mechanism for enhancing skills and promoting recovery-oriented practices [ 52 ].

Empowerment is another issue that needs to be considered. The main difference between traditional mental health services and the more recovery-oriented ones is reflected in the principle of empowerment. In the former, consumers are seen as passive recipients of the treatment practice, while in the latter, the consumer must be involved in the preparation and planning of care [ 53 ]. They are given the opportunity to express their goals and self-direct their care. Empowerment can be seen further in the idea of regarding consumers as “experts-by-experience”, while professionals are seen as “experts in treatment availability” [ 26 , 27 ]. According to this principle, the consumer has the right to be involved in the system. It is in line with the principle of partnership. The providers not only collaborate with other government institutions and communities, but also with the family and the consumer’s organization.

Considering the consumer’s uniqueness and cultural characteristics is another important principle of recovery. The narratives of the recovery process are diverse and multidimensional, even involving aspects of social, cultural, political, and citizenship rights [ 7 , 54 ]. The consumer’s internal world interacts with systemic socio-political forces that affect their health and well-being, making these factors important when focusing on consumer independence [ 55 ]. In our early Indonesian project, we used a culturally specific term for the title of our project ( Bangkit Jiwa ). This term was taken from our previous project [ 56 ] because it has several positive meanings which are in line with the concept of recovery. The word “bangkit” represents the idea of gaining insight and awareness, acquiring the motivation to change, and changing from being passive to being active. “By conceptualizing the recovery process in terms of ‘bangkit’ , participants appropriated a powerful set of cultural meanings that exerted a transformative effect on their lives and their approach to their illnesses” [ 56 ].

The complexity of recovery-oriented mental health services found in this study align with a number of challenges found in the literature, especially regarding the practical application of the recovery principles and concepts as services. Shera and Ramon [ 57 ] compared the implementation of this orientation at multiple levels of practice in England and Canada. They identified similar challenges between the two countries. In the practical level, the challenge includes definitional clarity, stigma as the primary hindrance, and resources of recovery. It is not an easy task to change the definition of recovery from a medical (focusing on symptom reduction) perspective to one that is more consumer-driven perspective where recovery is seen as a personal journey that is unique to each individual [ 58 ]. At the policy level, the challenges include policy and program implementation and political will. Shera and Ramon [ 57 ] found that from an organizational, a cost-effective consideration is very important in reforming the current system of practice. This is the reason why changes in the mental health systems usually do not have a strong public support and high political priority. Community-based care may be supported but not given adequate resources.

Piat et al. [ 59 ] also suggested that implementing recovery guidelines is difficult for a number of reasons, including the perception among stakeholders that the guidelines themselves are complex, ambiguous or unclear. While working in Canada, these authors translated the recovery-oriented guide into an implementation strategy by forming implementation teams, comprising different stakeholders (service users, service providers, managers, knowledge users), and facilitating a 12-meeting implementation planning process. This strategy is a valuable model for a successful implementation program. However, we admit that our strategy to search the guideline as the primary source of the data analysis might have some limitations. For example, we might have missed out on some guidelines. Another limitation of this study is that we only reviewed the published guidelines written in English. We suggest that future studies should address these limitations.

The “recovery-oriented” concept has been adopted as a new framework for mental health services globally. Most of the developing countries have released guidelines for this framework. Through a narrative synthesis, this research identified seven common recovery-oriented principles for mental health services by synthesizing the guidelines from five countries. These include cultivating hope, person-centeredness and empowerment, acknowledging an individual’s uniqueness and social context, providing social support, establishing partnerships and collaborations, recognizing consumer’s rights, and ensuring organizational commitment and evaluation of service delivery. They will be used as the guiding principles for our project which is based in the community health center of the Kulonprogo District, Special Province of Yogyakarta, Indonesia. Currently, the project is still in the early stage of implementation, and we are aware that implementing these guidelines is not an easy task. However, we have received a strong support from the local government in this regard; recovery-oriented services have been incorporated in the five-year action plan of the local government. We hope that this framework will be adopted by the central government in Indonesia and other developing countries.

Acknowledgments

We would like to thank the District Health Office of the Kulonprogo District, Special Province of Yogyakarta for their continuous collaboration.

Funding Statement

This study was funded by Innovative and Productive Research Program, the Minister of Finance, the Government of Indonesia The authors who received the award: MAS CM TT AM are Grant numbers: 110/LPDP/2019 URL funder: https://lpdp.kemenkeu.go.id/riset/kebijakan-rispros-umum/ The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability

• PLoS One. 2023; 18(3): e0276802.

Decision Letter 0

18 Jul 2022

PONE-D-22-11468The principles of recovery-oriented mental health services: A review of the guidelines from five different countriesPLOS ONE

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Reviewer #2: Yes

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Reviewer #1: The paper is well organized and has a clear viewpoint, outlining 7 principles of recovery-oriented mental health services. However, we see that in Method, the inductive thematic analysis was conducted by multiple people, which may have errors in the generalization of different concepts. Although a joint theme review was subsequently conducted, it is not stated whether there was a uniform quality control by senior professionals to reduce the possible errors.

Reviewer #2: Thanks for asking me to review this manuscript titled: “The principles of recovery-oriented mental health services: A review of the guidelines from five different countries”

The authors have written a manuscript that summarizes the theoretical background to their attempt towards developing a guideline for establishing a recovery-oriented mental health service in Indonesia. Their decision to leverage what has been implemented in other countries establishes a firm theoretical foundation for their intended program. I have no reservations in recommending that their manuscript be published as this will form a guide for other developed countries who might desire to pursue the same course.

However, I have some concerns.

The title does not seem to capture the essence of this manuscript. The manuscript isn’t just about a review. It is a review of guidelines for the development of a protocol. This is also seen in the conclusion of the abstract where the authors write “We will adjust and implement the result of the review in our project focusing on developing recovery-oriented mental health service in the community health centre in Yogyakarta, Indonesia. We hope that this framework will be adopted by the central government in Indonesia and other developing countries”. I suggest that the title should be modified to reflect what this manuscript is about.

The authors stated that the aim of the review is to guide the direction of the entire project. This doesn’t suffice as a specific aim of the manuscript. If the aim is to guide the direction of the entire project, then the title should actually be about the entire project. The authors need to determine the aim of the research, and let it be in tandem with the title.

The authors stated that “We did not use formal search engines, such as Scopus, EBSCO, or ProQuest, since they mostly search for journal articles that do not have practical guidelines.” Are they sure that they would not have missed out on some studies? This might need to be stated as a limitation. Restricting the publications to those written in English should also be stated as a limitation.

A chart showing how the publications reviewed were excluded before the final selection can also be helpful.

Expatiating on the results from line 182 downwards looked more like discussions which needed to be cited. There is a need to rewrite this section.

The aim needs to be properly phrased to make it be in tandem with the discussion as it is. Otherwise, the discussion will appear to be superfluous.

Many thanks for this opportunity.

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Reviewer #1: No

Reviewer #2:  Yes:  Olanrewaju Ibikunle Ibigbami

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Author response to Decision Letter 0

Review Comments to the Author

Reviewer #1: The paper is well organized and has a clear viewpoint, outlining 7 principles of recovery-oriented mental health services. However, we see that in Method, the inductive thematic analysis was conducted by multiple people, which may have errors in the generalization of different concepts. Although a joint theme review was subsequently conducted, it is not stated whether there was a uniform quality control by senior professionals to reduce the possible errors.

We have added one sentence to follow this suggestion (lines 161-162)

Reviewer #2: Thanks for asking me to review this manuscript titled: “The principles of recovery-oriented mental health services: A review of the guidelines from five different countries”

We have changed the title to follow this suggestion (lines 3-4)

We added some words so that the aim aligns with the title (lines 32-33).

We added limitations of the study in the end of the Discussion section (lines 1016-1037)

We have made a significant change in the Result and Discussion sections. First, following the reviewers' suggestions, we checked the themes identified in the previous analysis by using the keywords of each theme and calculated the frequency of each theme in the guidelines. Based on this frequency, we could make an order of the list for the theme. Another significant change in the Result is that we explicitly mention and refer to the guidelines as the source of analysis. By doing this, the readers can differentiate the Result section (using References from the guidelines) from the Discussion session (using References from the literature).

Decision Letter 1

14 Oct 2022

The principles of recovery-oriented mental health services: A review of the guidelines from five different countries for developing a protocol to be implemented in Yogyakarta, Indonesia.

PONE-D-22-11468R1

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• Open access
• Published: 21 May 2024

A modern way to teach and practice manual therapy

• Roger Kerry 1 ,
• Kenneth J. Young   ORCID: orcid.org/0000-0001-8837-7977 2 ,
• David W. Evans 3 ,
• Edward Lee 1 , 4 ,
• Vasileios Georgopoulos 1 , 5 ,
• Adam Meakins 6 ,
• Chris McCarthy 7 ,
• Chad Cook 8 ,
• Colette Ridehalgh 9 , 10 ,
• Steven Vogel 11 ,
• Amanda Banton 11 ,
• Cecilia Bergström 12 ,
• Anna Maria Mazzieri 13 ,
• Firas Mourad 14 , 15 &
• Nathan Hutting 16  

Chiropractic & Manual Therapies volume  32 , Article number:  17 ( 2024 ) Cite this article

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Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment , patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care.

The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety , comfort , and efficiency . These practical elements are contextualised by positive communication , a collaborative context , and person-centred care . The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies.

A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements.

Conclusions

Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Musculoskeletal (MSK) conditions are leading contributors to the burden of global disability and healthcare [ 1 ]. Amongst other interventions, manual therapy (MT) has been recommended for the management of people with MSK conditions in multiple clinical guidelines, for example [ 2 , 3 ].

MT has been described as the deliberate application of externally generated force upon body tissue, typically via the hands, with therapeutic intent [ 4 ]. It includes touch-based interventions such as thrust manipulation, joint mobilisation, soft-tissue mobilisation, and neurodynamic movements [ 5 ]. For people with MSK conditions, this therapeutic intent is usually to reduce pain and improve movement, thus facilitating a return to function and improved quality of life [ 6 ]. Patient perceptions of MT are, however, vague and sit among wider expectations of treatment including education, self-efficacy and the role of exercise, and prognosis [ 7 ].

Although the teaching and practice of MT has invariably changed over time, its foundations arguably remain unaltered and set in biomedical and outdated principles. This paper sets out to review contemporary literature and propose a revised model to inform the teaching and practice of MT.

The aim of this paper is to stimulate debate about the future teaching and practice of manual therapy through the proposal of an evidence-informed re-conceptualised model of manual therapy. The new model dismisses traditional elements of manual therapy which are not supported by research evidence. In place, the model offers a structure based on common humanistic principles of healthcare.

Consenus methodology

We present the literature synthesis and proposed framework as a consensus document to motivate further professional discussion developed through a simple three-stage iterative process over a 5-year period. The consensus methodology was classed as educational development which did not require ethical approval. Stage 1: a change of teaching practice was adopted by some co-authors (VG, RK, EL) on undergraduate and postgraduate Physiotherapy programmes at a UK University in 2018. This was a result of standard institutional teaching practice development which includes consideration of evidence-informed teaching. Stage 2: Input from a broader spectrum of stakeholders was sought, so a group of experienced, internationally-based educators, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through discussions in an iterative process. Stage 3: Presentations were made by some of the co-authors (VG, RK, SV, KY) to multidisciplinary groups (UK, Europe, North America) and feedback via questions and discussions was incorporated into further co-author discussions on the development of the framework. Consensus was achieved through repeated discussion of relevant elements. Figure  1 summarises the consensus methodology.

Summary and timeline of iterative consensus process for development of framework (MT: Manual Therapy; UG: Undergraduate; PG: Postgraduate)

Clinical & cost effectiveness of manual therapy

Manual therapy has been suggested to be a valuable part of a multimodal approach to managing MSK pain and disability, for example [ 8 ]. The majority of recent systematic reviews of clinical trials report a beneficial effect of MT for a range of MSK conditions, with at least similar effect sizes to other recommended approaches, for example [ 9 ]. Some systematic reviews report inconclusive findings, for example [ 10 ], and a minority report effects that were no better than comparison or sham treatments, for example [ 11 ].

Potential benefits must always be weighed against potential harms, of course. Mild to moderate adverse events from MT (e.g. mild muscle soreness) are common and generally considered acceptable [ 12 ], whilst serious adverse events are very rare and their risk may be mitigated by good practice [ 13 ]. MT has been reported by people with MSK disorders as a preferential and effective treatment with accepted levels of post-treatment soreness [ 14 ].

MT is considered cost-effective [ 15 ] and the addition of MT to exercise packages has been shown to increase clinical and cost-effectiveness compared to exercise alone in several MSK conditions [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Further, manual therapy has been shown to be less costly and more beneficial than evidence-based advice to stay active [ 24 ].

In summary, MT is considered a useful evidence-based addition to care packages for people experiencing pain and disability associated with MSK conditions. As such, MT continues to be included in national and international clinical guidelines for a range of MSK conditions as part of multimodal care.

Principles of traditional manual therapy (TMT)

Manual therapy has been used within healthcare for centuries [ 4 ] with many branches of MT having appeared (and disappeared) over time [ 25 ]. In developed nations today, MT is most commonly utilised by the formalised professional groups of physiotherapy, osteopathy, chiropractic, as well as groups such as soft tissue therapists. All of these groups have a history that borrows heavily from traditional healers and bone-setters [ 26 ].

Although there are many elements of MT, three principles appear to have become ubiquitous within what we shall now refer to as ‘traditional manual therapy’ (TMT): clinician-centred assessment , patho-anatomical reasoning , and technique specificity [ 27 , 28 , 29 , 30 ]. These principles continue to influence the teaching and practice of manual therapy over recent years, for example [ 31 ].

However, they have become increasingly difficult to defend given a growing volume of empirical evidence to the contrary.

Traditional manual therapy (TMT) principles: origins and problems

Clinician-centred assessment.

TMT has long had an emphasis on what we shall refer to as clinician-centred assessments . Within this, we claim, is an assumption that clinical information is both highly accurate and diagnostically important, for example [ 32 ]. Clinician-centred assessments include, for example, routine imaging, the search for patho-anatomical 'lesions’ and asymmetries, and specialised palpation. Although the focus of this paper is on the ‘hands-on’ examples of client-centred assessment, the notion of imaging is presented below to expose some of the flaws in the underlying belief system for TMT.

The emphasis on clinician-centred assessments has probably been driven, in part, by a desire for objective diagnostic tests which align well with gold-standard imaging. Indeed, since the discovery of x-rays, radiological imaging been used as an assessment for spinal pain – and a justification for using spinal manipulation – particularly in the chiropractic profession [ 33 ]. Contrary to many TMT claims, X-ray imaging is not without risk [ 34 ]. Additionally, until relatively recently (with the advent of magnetic resonance imaging) it was not widely appreciated that patho-anatomical ‘lesions’ believed to explain MSK pain conditions were nearly as common in pain-free individuals as those with pain [ 35 ]. Accordingly, the rates of unnecessary treatments, including surgery, are known to increase when imaging is used routinely [ 36 ]. For patients with non-specific low back pain, for example, imaging does not improve outcomes and risks overdiagnosis and overtreatment [ 37 ]. Hence, despite being objective in nature, the value of imaging for many MSK pain conditions (particularly spinal pain) has reduced drastically with clinical guidelines across the globe recommending against routine imaging for MSK pain of non-traumatic origin [ 38 ]. Even so, the practice of routine imaging continues [ 39 ].

Hands-on interventions are inextricably related to hands-on assessment [ 40 ], and often associated with claims of ‘specialisation’ [ 41 ]. By this we mean where a great level of training and precision are claimed to be necessary for influencing the interpretation of assessment findings, treatment decisions, and/or treatment outcomes. Implicit within this claim is that therapists who are unable to achieve such precision are not able to perform MT to an acceptable level (and thereby are not able to provide benefit to patients).

There are numerous studies that cast doubt over claims of highly specialised palpation skills. Palpation of anatomical landmarks does not reach a clinically acceptable level of validity [ 42 ]. Specialised motion palpation does not appear to be a good method for differentiating people with or without low back pain [ 43 ]. Poor content validity of specialised motion tests have been reported, in line with a lack of acceptable reference standards [ 44 ]. Palpable sensations reported by therapists are unlikely to be due to tissue deformation [ 45 ]. Furthermore, the delivery of interventions based on specialised palpatory findings is no better than non-specialised palpation [ 46 ]. Generally poor reliability of motion palpation skills has been reported, for example [ 47 ] and appear to be independent of clinician experience or training, for example [ 48 ]. Notably, person-centred palpation—for pain and tenderness for example—has slightly higher reliability, but is still fair at best [ 49 ].

This does not mean that palpation is of no use at all though; just that effective manual therapy does not depend upon it. For example, expert therapists can display high levels of interrater reliability during specialised motion palpation [ 50 ]. Focused training can improve the interrater reliability of specialised skills [ 51 ]. However, the validity of the phenomenon remains poor. Given the weight of the evidence and consistency of data over recent decades, we suggest that the role of clinician-centred hands-on assessment is no longer central to contemporary manual therapy.

Patho-anatomical reasoning

The justification for selecting particular MT interventions has historically been based upon the patho-anatomical status of local peripheral tissue [ 52 , 53 , 54 , 55 ]. Patho-anatomical reasoning, we propose, is the framework that links clinician-centred assessments to the desire for highly specific delivery of MT interventionsKey to this is the relationship between a patho-anatomic diagnosis and the assumed mechanisms of action of the intervention employed.

Theories for the mechanisms of action of MT interventions are many. Some of the most prominent include reductions of disc herniations [ 56 ], re-positioning of a bone or joint [ 32 ], removal of intra-articular adhesions [ 57 ], changes in the biomechanical properties of soft tissues [ 58 ], central pain modulation [ 59 ], and biochemical changes [ 60 ]. These theories have been used to justify the choice of certain interventions: a matching of diagnosis (i.e., existence of a lesion) to the effect of treatment takes place. However, most of these mechanistic theories either lack evidence or have been directly contested [ 61 ].

The causal relationship between proposed tissue-based factors such as posture, ergonomic settings, etc. and painful experience has also been disputed [ 62 ]. Although local tissue stiffness has been observed in people with pain, this is typically associated with neuromuscular responses, rather than patho-anatomical changes at local tissue level [ 63 , 64 , 65 , 66 ]. Overall, although some local tissue adaptions have been identified in people with recurrent MSK pain, this is inconsistent and the evidence is currently of low quality [ 67 ] are generally limited to short-term follow-up measures [ 68 ].

Technique specificity

TMT techniques have been taught with an emphasis that a particular direction, ‘grade’ of joint movement, or deformation of tissue at a very specific location in a certain way, is required to achieve a successful treatment outcome.

One problem with a demand for technique specificity in manual therapy is that an intervention does not always result in the intended effect. For example, posteroanterior forces applied during spinal mobilization consistently induce sagittal rotation, as opposed to the assumed posteroanterior translation, for example [ 69 ]. Furthermore, irrespective of the MT intervention chosen, restricting movements to a particular spinal segment is difficult and a regional, non-specific motion is typically induced, for example [ 70 ].

To support technique specificity, comparative data must repeatedly and reproducibly show superiority of outcome from specific MT interventions over non-specific MT, which is consistently not observed [ 71 , 72 , 73 ]. Some studies have demonstrated localised effects of targeted interventions [ 74 ] but there appears to be no difference in outcome related to: the way in which techniques are delivered [ 75 ]; whether technique selection is random or clinician-selected [ 41 ]; or variations in the direction of force or targeted spinal level [ 76 ]. Conversely, there is evidence that non-specific technique application may improve outcomes [ 77 , 78 , 79 ]. Further, sham techniques produce comparable results to specialised approaches [ 11 ].

Passive movement and localised touch have been associated with significant analgesic responses [ 80 ]. These data indicate the presence of an analgesic mechanism. Unfortunately, mechanistic explanation for the therapeutic effects of MT upon pain and disability still remain largely in a ‘black box’ state [ 81 ]. Nevertheless, there are several plausible mechanisms of action to explain the analgesic action of MT interventions, including the activation of modulatory spinal and supraspinal responses [ 82 , 83 , 84 , 85 ]. In support of this, MT interventions have been associated with a variety of neurophysiological responses [ 61 ]. However, it must be acknowledged that these studies provide mechanistic evidence based on association, which is insufficient to make causal claims [ 86 ]. Importantly, none of these neurophysiological responses have been directly related to either the analgesic mechanisms or clinical outcome and may therefore be incidental.

There is evidence that MT does not provide analgesia in injured tissues [ 87 , 88 ]. Conversely, MT has been shown to decrease inflammatory biomarkers [ 89 , 90 , 91 , 92 , 93 ], although these changes have not been evaluated in the longer-term, nor associated with clinical outcomes.

A modern framework for manual therapy

We propose a new direction for the future of MT in which the teaching and practice of this core dimension of MSK care are no longer based on the traditional principles of clinician-centred assessment , patho-anatomical reasoning , and technique specificity .

In doing so, this framework places MT more explicitly as part of person-centred care and appeals to common principles of healthcare, best available evidence, and contemporary theory which avoids unnecessary and over-complicated explanations of observed effects. The framework is simple in terms of implementation and delivery and contextualised by common elements of best practice for healthcare, in line with regulated standard of practice, e.g., [ 94 , 95 , 96 , 97 ]. Our proposal simply illustrates the operationalisation of these common elements through manual therapy.

Too much emphasis has been given to clinician-centred assessments and this should be rebalanced with an increased use of patient-centred assessments, such as a thorough case history, the use of validated patient-reported outcome measures (PROMS), and real-time patient feedback during assessments.

The new framework considers fundamental and humanistic dimensions of touch-based therapies, such as non-specific neuromodulation, communication and sense-making, physical education, and contextual clinical effectiveness. This aligns to contemporary ideas regarding therapeutic alliance and a move towards genuinely holistic healthcare [ 98 , 99 ]. The framework needs to be “open” in order to represent and allow expression of the complexity of the therapeutic encounter. However, to prevent the exploitation of this openness the framework is underpinned by evidence, and any manual therapy approaches without plausible and measurable mechanisms are not supported.

To provide the best care, common healthcare elements such as the safety and comfort of the person seeking help and therapist must be considered, and care should be provided as efficiently as possible. Our framework embraces these dimensions and employs an integration of current evidence. It is transdisciplinary in nature and may be adopted by all MT professions. Figure  1 provides a graphical representation of the framework. It is acknowledged that all components overlap, relate, and influence each. There are two main components: the practical elements on the inside, comprised of safety, comfort, and efficiency, and the conceptual themes on the outer regions, consisting of communication, context, and person-centred care Fig. 2 .

Representation of a modern teaching and practice framework for manual therapy. The image is purposefully designed to be simple, and has been developed primarily to be used as a teaching aid. When displayed in a learning environment, learners and clinicians can quickly refer to the image to check their practice against each element. To keep the image clear, each element of the image is described in detail in the text below”

Practical elements

Safety for people seeking help is a primary concern for all healthcare providers, with the aims to “ prevent and reduce risks, errors and harm that occur to patients [sic] during provision of health care… and to deliver quality essential health services ” [ 100 ]. This, and the notion of safety more generally (including that of the therapist), should be central to way MT is taught and practised.

A fundamentally safe context should be created where there is an absence of any obvious danger or risk of harm to physical or mental health. Consideration should be given to ensuring that communication and consent processes are orientated towards the safety of both the person seeking help and the therapist. The therapist should pay attention to any sense of threat that could be present in the physical, emotional, cognitive and environmental domains of the clinical encounter, and use skilful communication to mitigate anxiety about the assessment or therapeutic process.

Safety should also be considered in the clinical context of the assessment and treatment approach, ensuring that relevant and meaningful safety screenings have been undertaken [ 67 , 101 ]. There remains a need for good, skilful practice and development of manually applied techniques, but this can be achieved without reference to the principles of TMT and without the dogma of a proprietary therapeutic approach.

Comfort suggests that both the person seeking help and the therapist are physically and emotionally content during the assessment and therapeutic process. For example, the person seeking help is agreeable with any necessary state of dress (sociocultural difference should be considered); the person is relaxed and untroubled in whatever position they are in, and is adequately supported whether sitting, standing or recumbent during assessment and treatment; the therapist is comfortable with their positioning and posture; any discomfort produced by the therapeutic process is negotiated and agreed. Any physical mobilisation or touch should be applied with respect to the feedback from the person in relation to their comfort, rather than a pre-determined force based on the notion of resistance. This process requires clinical phronesis, sensitivity, responsivity, dexterity, and embodied communication [ 102 ].

The therapeutic process should be undertaken in a well-organised, competent manner aiming to achieve maximum therapeutic benefit with minimum waste of effort, time, or expense. To enhance the efficiency dimension, the assessment and therapeutic process should be an integral part of a holistic educational and/or activity-based approach to the management of the people which might also address psychological, nutritional, or ergonomic aspects of care, while being aware of social determinants to health. Recommendations exist which serve as a useful guide for enhancing care and promoting self-management in an efficient way [ 103 ].

A principle of this new model of MT is that therapists should not lose sight of the goals they develop with the people they help and ensure that there is coherence between their management aims and their techniques. Therapists should aim to support a person’s self-efficacy and use active approaches to empower them in their recovery. The overall number of therapeutic applications should be made in the context of fostering therapeutic alliance and supporting people to make sense of their situation and symptoms. This should be informed by contemporary views of the effects of manual therapy, emphasising a “physical education process” to promote sense-making and self-efficacy in alliance with the people they aim to help.

Clinical interactions need to be reproducible under a person’s own volition, serving to enhance self-empowerment. For example, someone could be taught how to “self-mobilise” if a positive effect is found with a particular therapeutic application. This should be appropriately scaffolded with behavioural change principles and functional contextualism that promote autonomy and self-management, rather than inappropriate reliance on the therapist [ 103 , 104 ].

An important and emergent notion from the proposed model is to question what constitutes indications for MT given that the model excludes traditional factors which would have informed whether manual therapy is indicated or not for a particular person. The response to this sits within the efficiency and safety dimensions: MT can be beneficial as part of a multi-dimensional approach to management across a broad population of people with musculoskeletal dysfunction, with no evidence to suggest any clinician-centered or patho-anatomical finding influences outcomes. The choice of whether or not to include MT as part of a management strategy should therefore be a product of a lack of contraindications and shared-decision making.

This framework aligns with evidence-based propositions that effectiveness and efficiency in assessment, diagnosis, and outcomes are not reliant on the therapist’s skill set of specialised elements of TMT, but rather other factors—for example variations in pain phenotypes [ 5 ].

Conceptual themes

Communication.

Communication is the overriding critical dimension to the whole therapeutic process and should be aimed at addressing peoples’ fundamental needs to make sense of their symptoms and path to recovery. The delivery and uptake of the therapy should therefore be operationalised in a communication process that meaningfully represents shared-decision making and the best possible attempt to contextualise the therapy in positive and evidence-informed explanations of the process and desired effects [ 105 ].

Within a therapeutic encounter, practitioners must give the time to listen to peoples’ accounts and explanations of their symptoms, including their ideas about their cause [ 106 ]. The assessment and diagnostic process should be a shared endeavour, for example, the negotiation of symptom reproduction. This should be done in a manner that facilitates sense-making, and which simultaneously encourages people to move on from unhelpful beliefs about their symptoms [ 107 , 108 ], encouraging understanding of the uncertain nature of pain and injury. Person-centered communication requires attention to what we communicate and how we communicate across the entire clinical interaction including interview, examination, and management planning [ 109 ]. Therapists need to be open, reflective, aware and responsive to verbal and non-verbal cues, and demonstrate a balance between engaging with people (e.g. eye-gaze) and writing/typing notes during the interview [ 110 , 111 , 112 ].

People should be given the opportunity to discuss their understanding of the diagnosis and options for treatment and rehabilitation. The decision-making process is dialogical, in which alternative options to the offered therapy should also be discussed with the comparative risks and benefits of all available management options, including doing nothing [ 113 , 114 ].

The therapist must fully appreciate the potential consequences of touch without consent. Continual dialogue should ensure that all parties are moving towards mutually agreed goals. The context of the therapy should be explicitly communicated to give appropriate context for any particular intervention as part of a holistic, evidence-based approach [ 115 , 116 , 117 ]. Therapists should be aware that their own beliefs can affect the way they communicate with their people; in the same way, a person’s context affects how they communicate what they expect from their treatment [ 107 , 118 , 119 , 120 ]. The construction of contextual healing scenarios which support positive outcomes, whilst minimising nocebic effects, is critical to effective healthcare [ 121 , 122 , 123 ].

There is a growing academic interest in the nature, role, and purpose of social and affective touch, and any re-framing of MT should consider touch as a means of communication to develop and enhance cooperative communications and strengthen the therapeutic relationship [ 124 , 125 , 126 , 127 , 128 , 129 ]. It can be soothing for a person in pain to experience the caring touch of a professional therapist [ 130 ]; on the other hand, probing, diagnostic, and touch can be experienced as alienating [ 131 , 132 , 133 ]. Touch can alter a person’s sense of body ownership and their ability to recognise and process their emotions by modulating interoceptive precision [ 129 , 134 , 135 ], and intentional touch may be perceived differently from casual, unfocussed touch [ 136 , 137 ]. There is also a thesis that touch generates shared understanding and meaning [ 138 , 139 , 140 ]. This wider appreciation of touch should be embedded in modern MT communication.

The contextual quality of a person’s experience of the therapeutic encounter can affect satisfaction and clinical outcomes [ 141 , 142 , 143 , 144 , 145 ]. The context in which therapeutic care takes place should therefore be developed to enhance this experience. There could be very local, practical aspects of the context, such as the type of passive information available in the clinical space, e.g. replacing biomedical and pathological imagery and objects with positive, active artefacts; judicious and thoughtful organisation and use of treatment tables to discourage a sense of passivity and disempowerment; allocating a comfortable space where communication can take place; colour schemes and light sources which facilitate positivity; ensuring consistency through all clinical and administrative staff promoting encouraging and non-nocebic messages. Importantly, the way the therapist dresses influences peoples’ perception of their healthcare experience [ 146 , 147 ], and that in turn should be contextually and culturally sensitive [ 148 , 149 , 150 ].

Beyond the local clinical space is the broader social environment. The undertaking of MT should serve a role in a person’s engagement with their social environment. For example, someone returning home after engaging with their therapist and disseminating positive health messages within their home and social networks; people acting as advocates for self-empowered healthcare. Furthermore, early data have demonstrated that aligning treatment with the beliefs and values of culturally and linguistically diverse communities enhances peoples’ engagement with their healthcare [ 151 ].

Person-centred care

Here we borrow directly from one of the most established and clinically useful definitions of Person-Centered Medicine [ 152 ]:

“(Person-Centered Medicine is) an affordable biomedical and technological advance to be delivered to patients [sic] within a humanistic framework of care that recognises the importance of applying science in a manner that respects the patients [sic] as a whole person and takes full account of [their] values, preferences, aspirations, stories, cultural context, fears, worries and hopes and thus that recognises and responds to [their] emotional, social and spiritual necessities in addition to [their] physical needs” [ 152 ] , p219.

Person-centred care incorporates a person’s perspective as part of the therapeutic process. In practice, therapists need to communicate in a manner that creates adequate conversational space to elicit a person’s agenda (i.e. understanding, impact of pain, concerns, needs, and goals), which guides clinical interactions. This approach encourages greater partnership in management [ 109 , 153 , 154 ].

A roadmap outlining key actions to implement person-centeredness in clinical practice has been outlined in detail elsewhere [ 155 ]. This includes screening for serious pathology, health co-morbidities and psychosocial factors; adopting effective communication; providing positive health education; coaching and supporting people towards active self-management; and facilitating and managing co-care (when needed) [ 154 ].

It is critical and necessary now to make these features explicit and central to the revised model of MT proposed in this paper. We wish to identify common ground across all MT professions in order to achieve a trans-disciplinary understanding of the evidence supporting the use of MT.

We acknowledge that our arguments here are rooted in empiricism and deliberately based on available research data from within the health science disciplines. We also acknowledge that there is a wider debate about future directions in person-centred care arising from the current evolution of the evidence-based health care movement, which has pointed to the need to learn more about peoples’ lived experiences, to redefine the model of the therapeutic relationship. Although beyond the scope of this paper, a full exploration of modern health care provision involves reconsideration of the ethics and legal requirements of communication and shared decision-making [ 156 , 157 , 158 , 159 ]. The authors envision this paper as a stimulus for self-reflection, stakeholder discussions, and ultimately change that can positively impact outcomes for people who seek manual therapy interventions.

Manual therapy has long been part of MSK healthcare and, given that is likely to continue. Current evidence suggests that effectiveness does not rely on the traditional principles historically developed in any of the major manual therapies. Therefore, the continued teaching and practice based on the principles of clinician-centred palpation , patho-anatomical reasoning , and technique specificity are no longer justified and may well even limit the value of MT.

A revised and reconceptualised framework of MT, based on the humanistic domains of safety, comfort and efficiency and underpinned by the dimensions of communication, context and person-centred care will ensure an empowering, biopsychosocial, evidence-informed approach to MSK care. We propose that the future teaching and practice of MT in physiotherapy, osteopathy, chiropractic, and all associated hands-on professions working within the healthcare field should be based on this new framework.

Availability of data and materials

Young C, Argáez C. CADTH Rapid Response Reports. Manual Therapy for Chronic Non-Cancer Back and Neck Pain: A Review of Clinical Effectiveness. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. Copyright © 2020 Canadian Agency for Drugs and Technologies in Health.; 2020.

Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, et al. Neck Pain: Revision 2017. J Orthop Sports Phys Ther. 2017;47(7):A1-a83.

Article   PubMed   Google Scholar  

NICE. Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]. 2016.

Pettman E. A history of manipulative therapy. J Man Manip Ther. 2007;15(3):165–74.

Article   PubMed   PubMed Central   Google Scholar  

Damian K, Chad C, Kenneth L, David G. Time to evolve: the applicability of pain phenotyping in manual therapy. J Man Manip Ther. 2022;30(2):61–7.

McCarthy CJ. Combined Movement Theory: Rational Mobilization and Manipulation of the Vertebral Column. London, UK: Churchill Livingstone; 2010.

Google Scholar  

Subialka JA, Smith K, Signorino JA, Young JL, Rhon DI, Rentmeester C. What do patients referred to physical therapy for a musculoskeletal condition expect? A qualitative assessment. Musculoskel Sci Pract. 2022;59:102543.

Article   Google Scholar  

Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017;25(3):160–8.

Wilhelm M, Cleland J, Carroll A, Marinch M, Imhoff M, Severini N, et al. The combined effects of manual therapy and exercise on pain and related disability for individuals with nonspecific neck pain: A systematic review with meta-analysis. J Man Manip Ther. 2023;31(6):393–407.

Schenk R, Donaldson M, Parent-Nichols J, Wilhelm M, Wright A, Cleland JA. Effectiveness of cervicothoracic and thoracic manual physical therapy in managing upper quarter disorders - a systematic review. J Man Manipulative Therap. 2021:1–10.

Lavazza C, Galli M, Abenavoli A, Maggiani A. Sham treatment effects in manual therapy trials on back pain patients: a systematic review and pairwise meta-analysis. BMJ Open. 2021;11(5):e045106.

Funabashi M, Pohlman KA, Goldsworthy R, Lee A, Tibbles A, Mior S, et al. Beliefs, perceptions and practices of chiropractors and patients about mitigation strategies for benign adverse events after spinal manipulation therapy. Chiropr Man Therap. 2020;28(1):46.

Rushton A, Carlesso LC, Flynn T, Hing WA, Rubinstein SM, Vogel S, et al. International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework. J Orthop Sports Phys Ther. 2022;53(1):7–22.

Thomas M, Thomson OP, Kolubinski DC, Stewart-Lord A. The attitudes and beliefs about manual therapy held by patients experiencing low back pain: a scoping review. Musculoskelet Sci Pract. 2023;65:102752.

Lilje S, van Tulder M, Wykman A, Aboagye E, Persson U. Cost-effectiveness of specialised manual therapy versus orthopaedic care for musculoskeletal disorders: long-term follow-up and health economic model. Ther Adv Musculoskelet Dis. 2023;15:1759720x221147751.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Abbott JH, Robertson MC, Chapple C, Pinto D, Wright AA, Leon de la Barra S, et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness. Osteoarthritis Cartilage. 2013;21(4):525–34.

Article   CAS   PubMed   Google Scholar  

Bove AM, Smith KJ, Bise CG, Fritz JM, Childs JD, Brennan GP, et al. Exercise, Manual Therapy, and Booster Sessions in Knee Osteoarthritis: Cost-Effectiveness Analysis From a Multicenter Randomized Controlled Trial. Phys Ther. 2018;98(1):16–27.

Leininger B, McDonough C, Evans R, Tosteson T, Tosteson AN, Bronfort G. Cost-effectiveness of spinal manipulative therapy, supervised exercise, and home exercise for older adults with chronic neck pain. Spine J. 2016;16(11):1292–304.

Tsertsvadze A, Clar C, Court R, Clarke A, Mistry H, Sutcliffe P. Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: a systematic review and narrative synthesis of evidence from randomized controlled trials. J Manipulative Physiol Ther. 2014;37(6):343–62.

UK Beam Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ. 2004;329(7479):1377.

Article   PubMed Central   Google Scholar  

UK Beam Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ (Clinical research ed). 2004;329(7479):1381.

van Dongen JM, Groeneweg R, Rubinstein SM, Bosmans JE, Oostendorp RA, Ostelo RW, et al. Cost-effectiveness of manual therapy versus physiotherapy in patients with sub-acute and chronic neck pain: a randomised controlled trial. Eur Spine J. 2016;25(7):2087–96.

Woods B, Manca A, Weatherly H, Saramago P, Sideris E, Giannopoulou C, et al. Cost-effectiveness of adjunct non-pharmacological interventions for osteoarthritis of the knee. PLoS ONE. 2017;12(3):e0172749.

Aboagye E, Lilje S, Bengtsson C, Peterson A, Persson U, Skillgate E. Manual therapy versus advice to stay active for nonspecific back and/or neck pain: a cost-effectiveness analysis. Chiropr Man Therap. 2022;30(1):27.

Paris SV. A History of Manipulative Therapy Through the Ages and Up to the Current Controversy in the United States. J Man Manipulative Ther. 2000;8(2):66–77.

MacDonald CW, Osmotherly PG, Parkes R, Rivett DA. The current manipulation debate: historical context to address a broken narrative. J Man Manipulative Therap. 2019;27(1):1–4.

Fryer G. Intervertebral dysfunction: a discussion of the manipulable spinal lesion. J Am Osteopath Assoc. 2003;6(2):64–73.

McCarthy CJ. Spinal manipulative thrust technique using combined movement theory. Man Ther. 2001;6(4):197–204.

Vickers A, Zollman C. ABC of complementary medicine Massage therapies. BMJ (Clinical research ed). 1999;319(7219):1254–7.

Evans DW. Osteopathic principles: More harm than good? Int J Osteopath Med. 2013;16(1):46–53.

Mourad F, Yousif MS, Maselli F, Pellicciari L, Meroni R, Dunning J, et al. Knowledge, beliefs, and attitudes of spinal manipulation: a cross-sectional survey of Italian physiotherapists. Chiropr Man Therap. 2022;30(1):38.

Cyriax JH, Cyriax PJ. Cyriax's Illustrated Manual of Orthopaedic Medicine. 3rd ed: Butterworth-Heinemann; 1996.

Young KJ. Words matter: the prevalence of chiropractic-specific terminology on Australian chiropractors’ websites. Chiropr Man Therap. 2020;28(1):18.

Jenkins HJ, Downie AS, Moore CS, French SD. Current evidence for spinal X-ray use in the chiropractic profession: a narrative review. Chiropr Man Therap. 2018;26:48.

Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–6.

Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013;173(17):1573–81.

Hall AM, Aubrey-Bassler K, Thorne B, Maher CG. Do not routinely offer imaging for uncomplicated low back pain. BMJ (Clinical research ed). 2021;372:n291.

PubMed   Google Scholar  

Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79.

Hall AM, Scurrey SR, Pike AE, Albury C, Richmond HL, Matthews J, et al. Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework. Implement Sci. 2019;14(1):49.

Eriksson L, Ekenberg L, Melander-Wikman A. The concept of palpation of the shoulder – A basic element of physiotherapy practice: A focus group study with physiotherapists. Adv Physiother. 2012;14(4):183–93.

Nim CG, Downie A, O’Neill S, Kawchuk GN, Perle SM, Leboeuf-Yde C. The importance of selecting the correct site to apply spinal manipulation when treating spinal pain: Myth or reality? A systematic review. Sci Rep. 2021;11(1):23415.

Alexander N, Rastelli A, Webb T, Rajendran D. The validity of lumbo-pelvic landmark palpation by manual practitioners: A systematic review. Int J Osteopath Med. 2021;39:10–20.

Leboeuf-Yde C, van Dijk J, Franz C, Hustad SA, Olsen D, Pihl T, et al. Motion palpation findings and self-reported low back pain in a population-based study sample. J Manipulative Physiol Ther. 2002;25(2):80–7.

Najm WI, Seffinger MA, Mishra SI, Dickerson VM, Adams A, Reinsch S, et al. Content validity of manual spinal palpatory exams - A systematic review. BMC Complement Altern Med. 2003;3:1.

Chaudhry H, Schleip R, Ji Z, Bukiet B, Maney M, Findley T. Three-dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc. 2008;108(8):379–90.

Gabriel A, Konrad A, Roidl A, Queisser J, Schleip R, Horstmann T, et al. Myofascial Treatment Techniques on the Plantar Surface Influence Functional Performance in the Dorsal Kinetic Chain. J Sports Sci Med. 2022;21(1):13–22.

PubMed   PubMed Central   Google Scholar  

Nolet PS, Yu H, Côté P, Meyer A-L, Kristman VL, Sutton D, et al. Reliability and validity of manual palpation for the assessment of patients with low back pain: a systematic and critical review. Chiropr Man Therap. 2021;29(1):33.

Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson VM, Murphy LS, et al. Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine. 2004;29(19):E413–25.

Beynon AM, Hebert JJ, Walker BF. The interrater reliability of static palpation of the thoracic spine for eliciting tenderness and stiffness to test for a manipulable lesion. Chiropr Man Therap. 2018;26:49.

Petersen EJ, Thurmond SM, Shaw CA, Miller KN, Lee TW, Koborsi JA. Reliability and accuracy of an expert physical therapist as a reference standard for a manual therapy joint mobilization trial. J Man Manip Ther. 2021;29(3):189–95.

Petersen EJ, Thurmond SM, Buchanan SI, Chun DH, Richey AM, Nealon LP. The effect of real-time feedback on learning lumbar spine joint mobilization by entry-level doctor of physical therapy students: a randomized, controlled, crossover trial. J Man Manip Ther. 2020;28(4):201–11.

Abbott JH, Flynn TW, Fritz JM, Hing WA, Reid D, Whitman JM. Manual physical assessment of spinal segmental motion: intent and validity. Man Ther. 2009;14(1):36–44.

Bialosky JE, Simon CB, Bishop MD, George SZ. Basis for spinal manipulative therapy: a physical therapist perspective. J Electromyogr Kinesiol. 2012;22(5):643–7.

Henderson CN. The basis for spinal manipulation: chiropractic perspective of indications and theory. J Electromyogr Kinesiol. 2012;22(5):632–42.

Sizer PS Jr, Felstehausen V, Sawyer S, Dornier L, Matthews P, Cook C. Eight critical skill sets required for manual therapy competency: a Delphi study and factor analysis of physical therapy educators of manual therapy. J Allied Health. 2007;36(1):30–40.

Ombregt L. A System of Orthopaedic Medicine: Elsevier; 2013.

Cramer GD, Henderson CN, Little JW, Daley C, Grieve TJ. Zygapophyseal joint adhesions after induced hypomobility. J Manipulative Physiol Ther. 2010;33(7):508–18.

George JW, Tunstall AC, Tepe RE, Skaggs CD. The Effects of Active Release Technique on Hamstring Flexibility: A Pilot Study. J Manipulative Physiol Ther. 2006;29(3):224–7.

Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531–8.

Plaza-Manzano G, Molina-Ortega F, Lomas-Vega R, Martínez-Amat A, Achalandabaso A, Hita-Contreras F. Changes in biochemical markers of pain perception and stress response after spinal manipulation. J Orthop Sports Phys Ther. 2014;44(4):231–9.

Zusman M. Mechanism of mobilization. Physical Therapy Reviews. 2011;16(4):233–6.

De Carvalho DE, de Luca K, Funabashi M, Breen A, Wong AYL, Johansson MS, et al. Association of Exposures to Seated Postures With Immediate Increases in Back Pain: A Systematic Review of Studies With Objectively Measured Sitting Time. J Manipulative Physiol Ther. 2020;43(1):1–12.

Colloca CJ, Keller TS. Stiffness and neuromuscular reflex response of the human spine to posteroanterior manipulative thrusts in patients with low back pain. J Manipulative Physiol Ther. 2001;24(8):489–500.

Colloca CJ, Keller TS, Gunzburg R. Biomechanical and neurophysiological responses to spinal manipulation in patients with lumbar radiculopathy. J Manipulative Physiol Ther. 2004;27(1):1–15.

Reed WR, Long CR, Kawchuk GN, Sozio RS, Pickar JG. Neural Responses to Physical Characteristics of a High-velocity, Low-amplitude Spinal Manipulation: Effect of Thrust Direction. Spine. 2018;43(1):1–9.

Reed WR, Pickar JG, Sozio RS, Liebschner MAK, Little JW, Gudavalli MR. Characteristics of Paraspinal Muscle Spindle Response to Mechanically Assisted Spinal Manipulation: A Preliminary Report. J Manipulative Physiol Ther. 2017;40(6):371–80.

Devecchi V, Rushton AB, Gallina A, Heneghan NR, Falla D. Are neuromuscular adaptations present in people with recurrent spinal pain during a period of remission? a systematic review. PLoS ONE. 2021;16(4):e0249220.

Pagé I, Nougarou F, Lardon A, Descarreaux M. Changes in spinal stiffness with chronic thoracic pain: Correlation with pain and muscle activity. PLoS ONE. 2018;13(12):e0208790.

Lee RY, McGregor AH, Bull AM, Wragg P. Dynamic response of the cervical spine to posteroanterior mobilisation. Clin Biomech (Bristol, Avon). 2005;20(2):228–31.

Ross JK, Bereznick DE, McGill SM. Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine. 2004;29(13):1452–7.

Donaldson M, Petersen S, Cook C, Learman K. A Prescriptively Selected Nonthrust Manipulation Versus a Therapist-Selected Nonthrust Manipulation for Treatment of Individuals With Low Back Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2016;46(4):243–50.

McCarthy CJ, Potter L, Oldham JA. Comparing targeted thrust manipulation with general thrust manipulation in patients with low back pain. A general approach is as effective as a specific one. A randomised controlled trial. BMJ Open Sport  Exerc Med. 2019;5(1):e000514.

Sutlive TG, Mabry LM, Easterling EJ, Durbin JD, Hanson SL, Wainner RS, et al. Comparison of short-term response to two spinal manipulation techniques for patients with low back pain in a military beneficiary population. Mil Med. 2009;174(7):750–6.

Tuttle N, Evans K, Sperotto dos Santos Rocha C. Localised manual therapy treatment has a preferential effect on the kinematics of the targeted motion segment. Musculoskelet Sci Pract. 2021;56:102457.

Ali MN, Sethi K, Noohu MM. Comparison of two mobilization techniques in management of chronic non-specific low back pain. J Bodyw Mov Ther. 2019;23(4):918–23.

de Oliveira RF, Costa LOP, Nascimento LP, Rissato LL. Directed vertebral manipulation is not better than generic vertebral manipulation in patients with chronic low back pain: a randomised trial. J Physiother. 2020;66(3):174–9.

Gevers-Montoro C, Provencher B, Northon S, Stedile-Lovatel JP, Ortega de Mues A, Piché M. Chiropractic Spinal Manipulation Prevents Secondary Hyperalgesia Induced by Topical Capsaicin in Healthy Individuals. Front Pain Res (Lausanne, Switzerland). 2021;2:702429.

Provencher B, Northon S, Piché M. Segmental Chiropractic Spinal Manipulation Does not Reduce Pain Amplification and the Associated Pain-Related Brain Activity in a Capsaicin-Heat Pain Model. Front Pain Res (Lausanne, Switzerland). 2021;2:733727.

Watanabe N, Piché M. Editorial: Mechanisms and Effectiveness of Complementary and Alternative Medicine for Pain Management. Front Pain Res (Lausanne, Switzerland). 2022;3:863751.

Muhsen A, Moss P, Gibson W, Walker B, Jacques A, Schug S, et al. The Association Between Conditioned Pain Modulation and Manipulation-induced Analgesia in People With Lateral Epicondylalgia. Clin J Pain. 2019;35(5):435–42.

Howick J, Glasziou P, Aronson JK. Evidence-based mechanistic reasoning. J Roy Soc Med. 2010;103(11):433–41.

Haavik Taylor H, Murphy B. The effects of spinal manipulation on central integration of dual somatosensory input observed after motor training: a crossover study. J Manipulative Physiol Ther. 2010;33(4):261–72.

Haavik-Taylor H, Murphy B. Cervical spine manipulation alters sensorimotor integration: a somatosensory evoked potential study. ClinNeurophysiol. 2007;118(2):391–402.

Ogura T, Tashiro M, Masud M, Watanuki S, Shibuya K, Yamaguchi K, et al. Cerebral metabolic changes in men after chiropractic spinal manipulation for neck pain. Altern Ther Health Med. 2011;17(6):12–7.

Sparks C, Cleland JA, Elliott JM, Zagardo M, Liu WC. Using functional magnetic resonance imaging to determine if cerebral hemodynamic responses to pain change following thoracic spine thrust manipulation in healthy individuals. J Orthop Sports Phys Ther. 2013;43(5):340–8.

Evans DW. How to gain evidence for causation in disease and therapeutic intervention: from Koch’s postulates to counter-counterfactuals. Med Health Care Philos. 2022;25(3):509–21.

Lascurain-Aguirrebeña I, Newham D, Critchley DJ. Mechanism of Action of Spinal Mobilizations: A Systematic Review. Spine. 2016;41(2):159–72.

Parravicini G, Bergna A. Biological effects of direct and indirect manipulation of the fascial system Narrative review. J Bodyw Mov Ther. 2017;21(2):435–45.

Crane JD, Ogborn DI, Cupido C, Melov S, Hubbard A, Bourgeois JM, et al. Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Sci Transl Med. 2012;4(119):119ra13.

Degenhardt BF, Darmani NA, Johnson JC, Towns LC, Rhodes DC, Trinh C, et al. Role of osteopathic manipulative treatment in altering pain biomarkers: a pilot study. J Am Osteopath Assoc. 2007;107(9):387–400.

Kovanur-Sampath K, Mani R, Cotter J, Gisselman AS, Tumilty S. Changes in biochemical markers following spinal manipulation-a systematic review and meta-analysis. Musculoskelet Sci Pract. 2017;29:120–31.

Lohman EB, Pacheco GR, Gharibvand L, Daher N, Devore K, Bains G, et al. The immediate effects of cervical spine manipulation on pain and biochemical markers in females with acute non-specific mechanical neck pain: a randomized clinical trial. J Man Manip Ther. 2019;27(4):186–96.

Teodorczyk-Injeyan JA, McGregor M, Triano JJ, Injeyan SH. Elevated Production of Nociceptive CC Chemokines and sE-Selectin in Patients With Low Back Pain and the Effects of Spinal Manipulation: A Nonrandomized Clinical Trial. Clin J Pain. 2018;34(1):68–75.

Council GC. The Code: Standards of conduct, performance and ethics for chiropractors. GCC; 2019.

Council HaCP. Standards of Proficiency - Physiotherapists. HCPC; 2013.

Council GO. Osteopathic Practice Standards. GOC; 2023.

Therapies TCfST. GCMT Code of Practice, Ethics and Proficiency for Professional Associations. GCMT; 2023.

Daluiso-King G, Hebron C. Is the biopsychosocial model in musculoskeletal physiotherapy adequate? An evolutionary concept analysis. Physiotherapy theory and practice. 2020:1–17.

Søndenå P, Dalusio-King G, Hebron C. Conceptualisation of the therapeutic alliance in physiotherapy: is it adequate? Musculoskelet Sci Pract. 2020;46:102131.

World Health Organisation. Patient Safety 2019 [Available from: https://www.who.int/news-room/fact-sheets/detail/patient-safety#:~:text=Patient%20Safety%20is%20a%20health,during%20provision%20of%20health%20care .

Vogel S, Mars T, Keeping S, Barton T, Marlin N, Froud R, et al. Clinical Risk Osteopathy and Management Scientific Report. 2012.

Ekerholt K, Bergland A. Learning and knowing bodies: Norwegian psychomotor physiotherapists’ reflections on embodied knowledge. Physiother Theory Pract. 2019;35(1):57–69.

Hutting N, Johnston V, Staal JB, Heerkens YF. Promoting the Use of Self-management Strategies for People With Persistent Musculoskeletal Disorders: The Role of Physical Therapists. J Orthop Sports Phys Ther. 2019;49(4):212–5.

Kongsted A, Ris I, Kjaer P, Hartvigsen J. Self-management at the core of back pain care: 10 key points for clinicians. Braz J Phys Therap. 2021.

Elwyn G, Durand MA, Song J, Aarts J, Barr PJ, Berger Z, et al. A three-talk model for shared decision making: multistage consultation process. BMJ (Clinical research ed). 2017;359:j4891.

Broom B. The Practice of Whole Person-Centred Healthcare. In: Anjum RL, Copeland S, Rocca E, editors. Rethinking Causality, Complexity and Evidence for the Unique Patient: A CauseHealth Resource for Healthcare Professionals and the Clinical Encounter. Cham: Springer International Publishing; 2020. p. 215–26.

Chapter   Google Scholar  

Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013;11(6):527–34.

Stewart M, Loftus S. Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation. J Orthop Sports Phys Ther. 2018;48(7):519–22.

Lin I, Wiles L, Waller R, Caneiro JP, Nagree Y, Straker L, et al. Patient-centred care: the cornerstone for high-value musculoskeletal pain management. Br J Sports Med. 2020;54(21):1240–2.

Cowell I, O’Sullivan P, O’Sullivan K, Poyton R, McGregor A, Murtagh G. Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study. Musculoskelet Sci Pract. 2018;38:113–9.

Edmond SN, Keefe FJ. Validating pain communication: current state of the science. Pain. 2015;156(2):215–9.

O’Keeffe M, Cullinane P, Hurley J, Leahy I, Bunzli S, O’Sullivan PB, et al. What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis. Phys Ther. 2016;96(5):609–22.

Copnell G. Informed consent in physiotherapy practice: it is not what is said but how it is said. Physiotherapy. 2018;104(1):67–71.

Lee A. Bolam’ to “Montgomery” is result of evolutionary change of medical practice towards ’patient-centred care. Postgrad Med J. 2017;93(1095):46–50.

Lewis J, O’Sullivan P. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? Br J Sports Med. 2018;52(24):1543–4.

Lewis J, Ridehalgh C, Moore A, Hall K. This is the day your life must surely change: Prioritising behavioural change in musculoskeletal practice. Physiotherapy. 2021.

Lewis JS, Stokes EK, Gojanovic B, Gellatly P, Mbada C, Sharma S, et al. Reframing how we care for people with persistent non-traumatic musculoskeletal pain. Suggestions for the rehabilitation community. Physiotherapy. 2021.

Bishop A, Foster NE, Thomas E, Hay EM. How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists. Pain. 2008;135(1–2):187–95.

Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. Eur J Pain (London, England). 2012;16(1):3–17.

Article   CAS   Google Scholar  

Lakke SE, Soer R, Krijnen WP, van der Schans CP, Reneman MF, Geertzen JH. Influence of Physical Therapists’ Kinesiophobic Beliefs on Lifting Capacity in Healthy Adults. Phys Ther. 2015;95(9):1224–33.

Howe LC, Leibowitz KA, Crum AJ. When Your Doctor “Gets It” and “Gets You”: The Critical Role of Competence and Warmth in the Patient-Provider Interaction. Front Psych. 2019;10:475.

Newell D, Lothe LR, Raven TJL. Contextually Aided Recovery (CARe): a scientific theory for innate healing. Chiropr Man Therap. 2017;25:6.

Rossettini G, Camerone EM, Carlino E, Benedetti F, Testa M. Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy. Arch Physiother. 2020;10:11.

Gallace A. Social Touch. In: Olausson H, Wessberg J, Morrison I, McGlone F, editors. Affective Touch and the Neurophysiology of CT Afferents: Springer; 2016.

Gallace A, Spence C. The science of interpersonal touch: an overview. Neurosci Biobehav Rev. 2010;34(2):246–59.

Kelly MA, Nixon L, McClurg C, Scherpbier A, King N, Dornan T. Experience of Touch in Health Care: A Meta-Ethnography Across the Health Care Professions. Qual Health Res. 2018;28(2):200–12.

McGlone F, Cerritelli F, Walker S, Esteves J. The role of gentle touch in perinatal osteopathic manual therapy. Neurosci Biobehav Rev. 2017;72:1–9.

Olausson H, Wessberg J, Morrison I, McGlone F. Affective Touch and the Neurophysiology of CT Afferents: Springer; 2016.

McParlin Z, Cerritelli F, Rossettini G, Friston KJ, Esteves JE. Therapeutic Alliance as Active Inference: The Role of Therapeutic Touch and Biobehavioural Synchrony in Musculoskeletal Care. Front Behav Neurosci. 2022;16:897247.

Meijer LL, Ruis C, van der Smagt MJ, Scherder EJA, Dijkerman HC. Neural basis of affective touch and pain: A novel model suggests possible targets for pain amelioration. J Neuropsychol. 2021.

Allen-Collinson J, Pavey A. Touching moments: phenomenological sociology and the haptic dimension in the lived experience of motor neurone disease. Sociol Health Illn. 2014;36(6):793–806.

Bjorbækmo WS, Mengshoel AM. “A touch of physiotherapy” - the significance and meaning of touch in the practice of physiotherapy. Physiother Theory Pract. 2016;32(1):10–9.

Nummenmaa L, Tuominen L, Dunbar R, Hirvonen J, Manninen S, Arponen E, et al. Social touch modulates endogenous μ-opioid system activity in humans. Neuroimage. 2016;138:242–7.

Calsius J, De Bie J, Hertogen R, Meesen R. Touching the Lived Body in Patients with Medically Unexplained Symptoms. How an Integration of Hands-on Bodywork and Body Awareness in Psychotherapy may Help People with Alexithymia. Front Psychol. 2016;7:253.

Gentsch A, Crucianelli L, Jenkinson P, Fotopoulou A. The touched self: Affective touch and body awareness in health and disease. Affective touch and the neurophysiology of CT afferents Springer; 2016.

Cerritelli F, Chiacchiaretta P, Gambi F, Ferretti A. Effect of Continuous Touch on Brain Functional Connectivity Is Modified by the Operator’s Tactile Attention. Front Hum Neurosci. 2017;11:368.

Tramontano M, Cerritelli F, Piras F, Spanò B, Tamburella F, Piras F, et al. Brain Connectivity Changes after Osteopathic Manipulative Treatment: A Randomized Manual Placebo-Controlled Trial. Brain Sci. 2020;10(12):969.

Øberg GK, Blanchard Y, Obstfelder A. Therapeutic encounters with preterm infants: interaction, posture and movement. Physiother Theory Pract. 2014;30(1):1–5.

Øberg GK, Normann B, Gallagher S. Embodied-enactive clinical reasoning in physical therapy. Physiother Theory Pract. 2015;31(4):244–52.

Consedine S, Standen C, Niven E. Knowing hands converse with an expressive body – An experience of osteopathic touch. Int J Osteopath Med. 2016;19:3–12.

Barbosa CD, Balp MM, Kulich K, Germain N, Rofail D. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adherence. 2012;6:39–48.

Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41–8.

Manary MP, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. N Engl J Med. 2013;368(3):201–3.

Sherriff B, Clark C, Killingback C, Newell D. Musculoskeletal practitioners’ perceptions of contextual factors that may influence chronic low back pain outcomes: a modified Delphi study. Chiropr Man Therap. 2023;31(1):12.

Sherriff B, Clark C, Killingback C, Newell D. Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review. Chiropr Manual Therap. 2022;30(1):20.

Mercer E, Mackay-Lyons M, Conway N, Flynn J, Mercer C. Perceptions of outpatients regarding the attire of physiotherapists. Physiother Can. 2008;60(4):349–57.

Petrilli CM, Mack M, Petrilli JJ, Hickner A, Saint S, Chopra V. Understanding the role of physician attire on patient perceptions: a systematic review of the literature— targeting attire to improve likelihood of rapport (TAILOR) investigators. BMJ Open. 2015;5(1):e006578.

Beach MC, Fitzgerald A, Saha S. White Coat Hype: Branding Physicians With Professional Attire. JAMA Intern Med. 2013;173(6):467–8.

Bearman G, Bryant K, Leekha S, Mayer J, Munoz-Price LS, Murthy R, et al. Healthcare Personnel Attire in Non-Operating-Room Settings. Infect Control Hosp Epidemiol. 2014;35(2):107–21.

Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005;118(11):1279–86.

Brady B, Veljanova I, Schabrun S, Chipchase L. Integrating culturally informed approaches into physiotherapy assessment and treatment of chronic pain: a pilot randomised controlled trial. BMJ Open. 2018;8(7):e021999.

Miles A, Mezzich JE. The care of the patient and the soul of the clinic: person-centered medicine as an emergent model of clinical practice. Int J Person Centred Med. 2012;1(2):207–22.

Cowell I, McGregor A, O’Sullivan P, O’Sullivan K, Poyton R, Schoeb V, et al. How do physiotherapists solicit and explore patients’ concerns in back pain consultations: a conversation analytic approach. Physiother Theory Pract. 2021;37(6):693–709.

Hutting N, Caneiro JP, Ong'wen MO, Miciak M, Roberts LE. Patient-centered care in musculoskeletal practice: key elements to support clinicians to focus on the person. 2021.

Caneiro JP, Roos EM, Barton CJ, O’Sullivan K, Kent P, Lin I, et al. It is time to move beyond “body region silos” to manage musculoskeletal pain: five actions to change clinical practice. Br J Sports Med. 2020;54(8):438–9.

Greenhalgh T, Howick J, Maskrey N, EBM Renaissance Group. Evidence based medicine: a movement in crisis? Brit Med J. 2014;348:g3725.

Greenhalgh T, Snow R, Ryan S, Rees S, Salisbury H. Six ‘biases’ against patients and carers in evidence-based medicine. Bmc Med. 2015;13(1):200.

Loughlin M, Fuller J, Bluhm R, Buetow S, Borgerson K. Theory, experience and practice. J Eval Clin Pract. 2016;22(4):459–65.

Simpson JK, Innes S. Informed consent, duty of disclosure and chiropractic: where are we? Chiropr Man Therap. 2020;28(1):60.

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A double machine learning model for measuring the impact of the Made in China 2025 strategy on green economic growth

• Jie Yuan 1 &
• Shucheng Liu 2  

Scientific Reports volume  14 , Article number:  12026 ( 2024 ) Cite this article

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The transformation and upgrading of China’s manufacturing industry is supported by smart and green manufacturing, which have great potential to empower the nation’s green development. This study examines the impact of the Made in China 2025 industrial policy on urban green economic growth. This study applies the super-slacks-based measure model to measure cities’ green economic growth, using the double machine learning model, which overcomes the limitations of the linear setting of traditional causal inference models and maintains estimation accuracy under high-dimensional control variables, to conduct an empirical analysis based on panel data of 281 Chinese cities from 2006 to 2021. The results reveal that the Made in China 2025 strategy significantly drives urban green economic growth, and this finding holds after a series of robustness tests. A mechanism analysis indicates that the Made in China 2025 strategy promotes green economic growth through green technology progress, optimizing energy consumption structure, upgrading industrial structure, and strengthening environmental supervision. In addition, the policy has a stronger driving effect for cities with high manufacturing concentration, industrial intelligence, and digital finance development. This study provides valuable theoretical insights and policy implications for government planning to promote high-quality development through industrial policy.

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Introduction.

Since China’s reform and opening up, the nation’s economy has experienced rapid growth for more than 40 years. According to the National Bureau of Statistics, China’s per capita GDP has grown from 385 yuan in 1978 to 85,698 yuan in 2022, with an average annual growth rate of 13.2%. However, obtaining this growth miracle has come at considerable social and environmental costs 1 . Current pollution prevention and control systems have not yet fundamentally alleviated the structural and root causes, impairing China’s economic progress toward high-quality development 2 . The report of the 20th National Congress of the Communist Party of China proposed that the future will be focused on promoting the formation of green modes of production and lifestyles and advancing the harmonious coexistence of human beings and nature. This indicates that transforming the mode of economic development is now the focus of the government’s attention, calling for advancing the practices of green growth aimed at energy conservation, emissions reduction, and sustainability while continuously increasing economic output 3 . As a result, identifying approaches to balance economic growth and green environmental protection in the development process and realize green economic growth has become an arduous challenge and a crucially significant concern for China’s high-quality economic development.

An intrinsic driver of urban economic growth, manufacturing is also the most energy-intensive and pollution-emitting industry, and greatly constrains urban green development 4 . China’s manufacturing industry urgently needs to advance the formation of a resource-saving and environmentally friendly industrial structure and manufacturing system through transformation and upgrading to support for green economic growth 5 . As an incentive-based industrial policy that emphasizes an innovation-driven and eco-civilized development path through the development and implementation of an intelligent and green manufacturing system, Made in China 2025 is a significant initiative for promoting the manufacturing industry’s transformation and upgrading, providing solid economic support for green economic growth 6 . To promote the effective implementation of this industrial policy, fully mobilize localities to explore new modes and paths of manufacturing development, and strengthen the urban manufacturing industry’s influential demonstration role in advancing the green transition, the Ministry of Industry and Information Technology of China successively launched 30 Made in China 2025 pilot cities (city clusters) in 2016 and 2017. The Pilot Demonstration Work Program for “Made in China 2025” Cities specified that significant results should be achieved within three to 5 years. After several years of implementation, has the Made in China 2025 pilot policy promoted green economic growth? What are the policy’s mechanisms of action? Are there differences in green economic growth effects in pilot cities based on various urban development characteristics? This study’s theoretical interpretation and empirical examination of the above questions can add to the growing body of related research and provide valuable insights for cities to comprehensively promote the transformation and upgrading of manufacturing industry to advance China’s high-quality development.

This study constructs an analytical framework at the theoretical level to analyze the impact of the Made in China 2025 strategy on urban green economic growth, and uses the double machine learning (ML) model to test its green economic growth effect. The contributions of this study are as follows. First, focusing on the field of urban green development, the study incorporates variables representing the potential economic and environmental effects of the Made in China 2025 policy into a unified framework to systematically examine the impact of the Made in China 2025 pilot policy on the urban green economic growth, providing a novel perspective for assessing the effects of industrial policies. Second, we investigate potential transmission mechanisms of the Made in China 2025 strategy affecting green economic growth from the perspectives of green technology advancement, energy consumption structure optimization, industrial structure upgrading, and environmental supervision strengthening, establishing a useful supplement for related research. Third, leveraging the advantage of ML algorithms in high-dimensional and nonparametric prediction, we apply a double ML model assess the policy effects of the Made in China 2025 strategy to avoid the “curse of dimensionality” and the inherent biases of traditional econometric models, and improve the credibility of our research conclusions.

The remainder of this paper is structured as follows. Section “ Literature review ” presents a literature review. Section “ Policy background and theoretical analysis ” details our theoretical analysis and research hypotheses. Section “ Empirical strategy ” introduces the model setting and variables selection for the study. Section “ Empirical result ” describes the findings of empirical testing and analyzes the results. Section “ Conclusion and policy recommendation ” summarizes our conclusions and associated policy implications.

Literature review

Measurement and influencing factors of green economic growth.

The Green Economy Report, which was published by the United Nations Environment Program in 2011, defined green economy development as facilitating more efficient use of natural resources and sustainable growth than traditional economic models, with a more active role in promoting combined economic development and environmental protection. The Organization for Economic Co-operation and Development defined green economic growth as promoting economic growth while ensuring that natural assets continue to provide environmental resources and services; a concept that is shared by a large number of institutions and scholars 7 , 8 , 9 . A considerable amount of research has assessed green economic growth, primarily using three approaches. First, single-factor indicators, such as sulfur dioxide emissions, carbon dioxide emissions intensity, and other quantified forms; however, this approach neglects the substitution of input factors such as capital and labor for the energy factor, which has certain limitations 5 , 10 . Second, studies have been based on neoclassical economic growth theory, incorporating factors of capital, technology, energy, and the environment, and constructing a green Solow model to measure green total factor productivity (GTFP) 11 , 12 . Third, based on neoclassical economic growth theory, some studies have simultaneously considered desirable and undesirable output, applying Shepard’s distance function, the directional distance function, and data envelopment analysis to measure GTFP 13 , 14 , 15 .

Economic growth is an extremely complex process, and green economic growth is also subject to a combination of multiple complex factors. Scholars have explored the influence mechanisms of green economic growth from perspectives of resource endowment 16 , technological innovation 17 , industrial structure 18 , human capital 19 , financial support 20 , government regulation 21 , and globalization 22 . In the field of policy effect assessment, previous studies have confirmed the green development effects of pilot policies such as innovative cities 23 , Broadband China 24 , smart cities 25 , and low-carbon cities 26 . However, few studies have focused on the impact of Made in China 2025 strategy on urban green economic growth and identified its underlying mechanisms.

The impact of Made in China 2025 strategy

Since the industrial policy of Made in China 2025 was proposed, scholars have predominantly focused on exploring its economic effects on technological innovation 27 , digital transformation 28 , and total factor productivity (TFP) 29 , while the potential environmental effects have been neglected. Chen et al. (2024) 30 found that Made in China 2025 promotes firm innovation through tax incentives, public subsidies, convenient financing, academic collaboration and talent incentives. Xu (2022) 31 point out that Made in China 2025 policy has the potential to substantially improve the green innovation of manufacturing enterprises, which can boost the green transformation and upgrading of China’s manufacturing industry. Li et al. (2024) 32 empirically investigates the positive effect of Made in China 2025 strategy on digital transformation and exploratory innovation in advanced manufacturing firms. Moreover, Liu and Liu (2023) 33 take “Made in China 2025” as an exogenous shock and find that the pilot policy has a positive impact on the high-quality development of enterprises and capital markets. Unfortunately, scholars have only discussed the impact of Made in China 2025 strategy on green development and environmental protection from a theoretical perspective and lack empirical analysis. Li (2018) 27 has compared Germany’s “Industry 4.0” and China’s “Made in China 2025”, and point out that “Made in China 2025” has clear goals, measures and sector focus. Its guiding principles are to enhance industrial capability through innovation-driven manufacturing, optimize the structure of Chinese industry, emphasize quality over quantity, train and attract talent, and achieve green manufacturing and environment. Therefore, it is necessary to systematically explore the impact and mechanism of Made in China 2025 strategy on urban green economic growth from both theoretical and empirical perspectives.

Causal inference based on double ML

The majority of previous studies have used traditional causal inference models to assess policy effects; however, some limitations are inherent to the application of these models. For example, the parallel trend test of the difference-in-differences model has stringent requirements on appropriate sample data; the synthetic control method can construct a virtual control group that conforms to the parallel trend, but it requires that the treatment group does not have the extreme value characteristics, and it is only applicable to “one-to-many” circumstances; and the propensity score matching (PSM) method involves a considerable amount of subjectivity in selecting matching variables. To compensate for the shortcomings of traditional models, scholars have started to explore the application of ML in the field of causal inference 34 , 35 , 36 , and double ML is a typical representative.

Double ML was formalized in 2018 34 , and the relevant research falls into two main categories. The first strand of literature applies double ML to assess causality concerning economic phenomena. Yang et al. (2020) 37 applied double ML using a gradient boosting algorithm to explore the average treatment effect of top-ranked audit firms, verifying its robustness compared with the PSM method. Zhang et al. (2022) 38 used double ML to quantify the impact of nighttime subway services on the nighttime economy, house prices, traffic accidents, and crime following the introduction of nighttime subway services in London in 2016. Farbmacher et al. (2022) 39 combined double ML with mediating effects analysis to assess the causal relationship between health insurance coverage and youth wellness and examine the indirect mechanisms of regular medical checkups, based on a national longitudinal health survey of youth conducted by the US Bureau of Labor Statistics. The second strand of literature has innovated methodological theory based on double ML. Chiang et al. (2022) 40 proposed an improved multidirectional cross-fitting double ML method, obtaining regression results for high-dimensional parameters while estimating robust standard errors for dual clustering, which can effectively adapt to multidirectional clustered sampled data and improve the validity of estimation results. Bodory et al. (2022) 41 combined dynamic analysis with double ML to measure the causal effects of multiple treatment variables over time, using weighted estimation to assess the dynamic treatment effects of specific subsamples, which enriched the dynamic quantitative extension of double ML.

In summary, previous research has conducted some useful investigations regarding the impact of socioeconomic policies on green development, but limited studies have explored the relationship between the Made in China 2025 strategy and green economic growth. This study takes 281 Chinese cities as the research object, and applies the super-slacks-based measure (SBM) model to quantify Chinese cities’ green economic growth from 2006 to 2021. Based on a quasi-natural experiment of Made in China 2025 pilot policy implementation, we use the double ML model to test the impact and transmission mechanisms of the policy on urban green economic growth. We also conduct a heterogeneity analysis of cities based on different levels of manufacturing agglomeration, industrial intelligence, and digital finance. This study applies a novel approach and provides practical insights for research in the field of industrial policy assessment.

Policy background and theoretical analysis

Policy background.

The Made in China 2025 strategy aims to encourage and support local exploration of new paths and models for the transformation and upgrading of the manufacturing industry, and to drive the improvement of manufacturing quality and efficiency in other regions through demonstration effects. According to the Notice of Creating “Made in China 2025” National Demonstration Zones issued by the State Council, municipalities directly under the central government, sub-provincial cities, and prefecture-level cities can apply for the creation of demonstration zones. Cities with proximity and high industrial correlation can jointly apply for urban agglomeration demonstration zones. The Notice clarifies the goals and requirements for creating demonstration zones in areas such as green manufacturing, clean production, and environmental protection. In 2016, Ningbo became the first Made in China 2025 pilot city, and a total of 12 cities and 4 city clusters were included in the list of Made in China 2025 national demonstration zones. In 2018, the State Council issued the Evaluation Guidelines for “Made in China 2025” National Demonstration Zone, which further clarified the evaluation process and indicator system of the demonstration zone. Seven primary indicators and 29 secondary indicators were formulated, including innovation driven, quality first, green development, structural optimization, talent oriented, organizational implementation, and coordinated development of urban agglomerations. This indicator system can evaluate the creation process and overall effectiveness of pilot cities (city clusters), which is beneficial for the promotion of successful experiences and models in demonstration areas.

Advancing green urban development is a complex systematic project that requires structural adjustment and technological and institutional changes in the socioeconomic system 42 . The Made in China 2025 strategy emphasizes the development and application of smart and green manufacturing systems, which can unblock technological bottlenecks in the manufacturing sector in terms of industrial production, energy consumption, and waste emissions, and empower cities to operate in a green manner. In addition, the Made in China 2025 policy established requirements for promoting technological innovation to advance energy saving and environmental protection, improving the rate of green energy use, transforming traditional industries, and strengthening environmental supervision. For pilot cities, green economy development requires the support of a full range of positive factors. Therefore, this study analyzes the mechanisms by which the Made in China 2025 strategy affects urban green economic growth from the four paths of green technology advancement, energy consumption structure optimization, industrial structure upgrading, and environmental supervision strengthening.

Theoretical analysis and research hypotheses

As noted, the Made in China 2025 strategy emphasizes strengthening the development and application of energy-saving and environmental protection technologies to advance cleaner production. Pilot cities are expected to prioritize the driving role of green innovation, promote clustering carriers and innovation platforms for high-tech enterprises, and guide the progress of enterprises’ implementation of green technology. Specifically, pilot cities are encouraged to optimize the innovation environment by increasing scientific and technological investment and financial subsidies in key areas such as smart manufacturing and high-end equipment and strengthening intellectual property protection to incentivize enterprises to conduct green research and development (R&D) activities. These activities subsequently promote the development of green innovation technologies and industrial transformation 43 . Furthermore, since quality human resources are a core aspect of science and technology innovation 44 , pilot cities prioritize the cultivation and attraction of talent to establish a stable human capital guarantee for enterprises’ ongoing green technology innovation, transform and upgrade the manufacturing industry, and advance green urban development. Green technology advances also contribute to urban green economic growth. First, green technology facilitates enterprises’ adoption of improved production equipment and innovation in green production technology, accelerating the change of production mode and driving the transformation from traditional crude production to a green and intensive approach 45 , promoting green urban development. Second, green technology advancement accelerates green innovations such as clean processes, pollution control technologies, and green equipment, and facilitates the effective supply of green products, taking full advantage of the benefits of green innovations 46 and forming a green economic development model to achieve urban green economic growth.

The Made in China 2025 pilot policy endeavors to continuously increase the rate of green and low-carbon energy use and reduce energy consumption. Under target constraints of energy saving and carbon control, pilot cities will accelerate the cultivation of high-tech industries in green environmental protection and high-end equipment manufacturing with advantages of sustainability and low resource inputs 47 to improve the energy consumption structure. Pilot cities also advance new energy sector development by promoting clean energy projects, subsidizing new energy consumption, and supporting green infrastructure construction and other policy measures 48 to optimize the energy consumption structure. Energy consumption structure optimization can have a profound impact on green economy development. Optimization means that available energy tends to be cleaner, which can reduce the manufacturing industry’s dependence on traditional fossil energy and raise the proportion of clean energy 49 , ultimately promoting green urban development. Pilot cities also provide financial subsidies for new energy technology R&D, which promotes the innovation and application of new technologies, energy-saving equipment, efficient resource use, and energy-saving diagnostics, which allow enterprises to save energy and reduce consumption and improve energy use efficiency and TFP 50 , advancing the growth of urban green economy.

At its core, the Made in China 2025 strategy promotes the transformation and upgrading of the manufacturing sector. Pilot cities guide and develop technology-intensive high-tech industries, adjust the proportion of traditional heavy industry, and improve the urban industrial structure. Pilot cities also implement the closure, merger, and transformation of pollution-intensive industries; guide the fission of professional advantages of manufacturing enterprises 51 ; and expand the establishment and development of service-oriented manufacturing and productive service industries to promote the evolution of the industrial structure toward rationalization and high-quality development 52 . Upgrading the industrial structure can also contribute to urban green economic growth. First, industrial structure upgrading promotes the transition from labor- and capital-intensive industries to knowledge- and technology-intensive industries, which optimizes the industrial distribution patterns of energy consumption and pollutant emissions and promotes the transformation of economic growth dynamics and pollutant emissions control, providing a new impetus for cities’ sustainable development 53 . Second, changes in industrial structure and scale can have a profound impact on the type and quantity of pollutant emissions. By introducing high-tech industries, service-oriented manufacturing, and production-oriented service industries, pilot cities can promote the transformation of pollution-intensive industries, promoting the adjustment and optimization of industrial structure and scale 54 to achieve the purpose of driving green urban development.

The Made in China 2025 strategy proposes strengthening green supervision and conducting green evaluations, establishing green development goals for the manufacturing sector in terms of emissions and consumption reduction and water conservation. This requires pilot cities to implement stringent environmental regulatory policies, such as higher energy efficiency and emissions reduction targets and sewage taxes and charges, strict penalties for excess emissions, and project review criteria 55 , which consolidates the effectiveness of green development. Under the framework of environmental authoritarianism, strengthening environmental supervision is a key measure for achieving pollution control and improving environmental quality 56 . Therefore, environmental regulatory enhancement can help cities achieve green development goals. First, according to the Porter hypothesis 57 , strong environmental regulatory policies encourage firms to internalize the external costs of environmental supervision, stimulate technological innovation, and accelerate R&D and application of green technologies. This response helps enterprises improve input–output efficiency, achieve synergy between increasing production and emissions reduction, partially or completely offset the “environmental compliance cost” from environmental supervision, and realize the innovation compensation effect 58 . Second, strict environmental regulations can effectively mitigate the complicity of local governments and enterprises in focusing on economic growth while neglecting environmental protection 59 , urging local governments to constrain enterprises’ emissions, which compels enterprises to conduct technological innovation and pursue low-carbon transformation, promoting urban green economic growth.

Based on the above analysis, we propose the mechanisms that promote green economic growth through Made in China 2025 strategy, as shown in Fig.  1 . The proposed research hypotheses are as follows:

Mechanism analysis of Made in China 2025 strategy and green economic growth.

Hypothesis 1

The Made in China 2025 strategy promotes urban green economic growth.

Hypothesis 2

The Made in China 2025 strategy drives urban green economic growth through four channels: promoting green technology advancement, optimizing energy consumption structure, upgrading industrial structure, and strengthening environmental supervision.

Empirical strategy

Double ml model.

Compared with traditional causal inference models, double ML has unique advantages in variable selection and model estimation, and is also more applicable to the research problem of this study. Green economic growth is a comprehensive indicator of transformative urban growth that is influenced by many socioeconomic factors. To ensure the accuracy of our policy effects estimation, the interference of other factors on urban green economic growth must be controlled as much as possible; however, when introducing high-dimensional control variables, traditional regression models may face the “curse of dimensionality” and multicollinearity, rendering the accuracy of the estimates questionable. Double ML uses ML and regularization algorithms to automatically filter the preselected set of high-dimensional control variables to obtain an effective set of control variables with higher prediction accuracy. This approach avoids the “curse of dimensionality” caused by redundant control variables and mitigates the estimation bias caused by the limited number of primary control variables 39 . Furthermore, nonlinear relationships between variables are the norm in the evolution of economic transition, and ordinary linear regression may suffer from model-setting bias producing estimates that lack robustness. Double ML effectively overcomes the problem of model misspecification by virtue of the advantages of ML algorithms in handling nonlinear data 37 . In addition, based on the idea of instrumental variable functions, two-stage predictive residual regression, and sample split fitting, double ML mitigates the “regularity bias” in ML estimation and ensures unbiased estimates of the treatment coefficients in small samples 60 .

Based on the analysis above, this study uses the double ML model to assess the policy effects of the Made in China 2025 strategy. The partial linear double ML model is constructed as follows:

where i denotes the city, t denotes the year, and Y it represents green economic growth. Policy it represents the policy variable of Made in China 2025, which is set as 1 if the pilot is implemented and 0 otherwise. θ 0 is the treatment coefficient that is the focus of this study. X it denotes the set of high-dimensional control variables, and the ML algorithm is used to estimate the specific functional form \(\hat{g}(X_{it} )\) . U it denotes the error term with a conditional mean of zero.

Direct estimation of Eqs. ( 1 ) and ( 2 ) yields the following estimate of the treatment coefficient:

where n denotes the sample size.

Notably, the double ML model uses a regularization algorithm to estimate the specific functional form \(\hat{g}(X_{it} )\) , which prevents the variance of the estimate from being too large, but inevitably introduces a “regularity bias,” resulting in a biased estimate. To speed up the convergence of the \(\hat{g}(X_{it} )\) directions so that the estimates of the treatment coefficients satisfy unbiasedness with small samples, the following auxiliary regression is constructed:

where \(m(X_{it} )\) is the regression function of the treatment variable on the high-dimensional control variable, using ML algorithms to estimate the specific functional form \(\hat{m}(X_{it} )\) . V it is the error term with a conditional mean of zero.

The specific operation process follows three stages. First, we use the ML algorithm to estimate the auxiliary regression \(\hat{m}(X_{it} )\) and take its residuals \(\hat{V}_{it} = Policy_{it} - \hat{m}(X_{it} )\) . Second, we use the ML algorithm to estimate \(\hat{g}(X_{it} )\) and change the form of the main regression \(Y_{it} - \hat{g}(X_{it} ) = \theta_{0} Policy_{it} + U_{it}\) . Finally, we regress \(\hat{V}_{it}\) as an instrumental variable for Policy it , obtaining unbiased estimates of the treatment coefficients as follows:

Variable selection

• Green economic growth

We apply the super-SBM model to measure urban green economic growth. The super-SBM model is compatible with radial and nonradial characteristics, which avoids inflated results due to ignoring slack variables and deflated results due to ignoring the linear relationships between elements, and can truly reflect relative efficiency 61 . The SBM model reflects the nature of green economic growth more accurately compared with other models, and has been widely adopted by scholars 62 . The expression of the super-SBM model considering undesirable output is as follows:

where x is the input variable; y and z are the desirable and undesirable output variables, respectively; m denotes the number of input indicators; s 1 and s 2 represent the respective number of indicators for desirable and undesirable outputs; k denotes the period of production; i , r , and t are the decision units for the inputs, desirable outputs, and undesirable outputs, respectively; \(s^{ - }\) , \(s^{ + }\) , and \(s^{z - }\) are the respective slack variables for the inputs, desirable outputs, and undesirable outputs; and γ is a vector of weights. A larger \(\rho_{SE}\) value indicates greater efficiency. If \(\rho_{SE}\)  = 1, the decision unit is effective; if \(\rho_{SE}\)  < 1, the decision unit is relatively ineffective, indicating a loss of efficiency.

Referencing Sarkodie et al. (2023) 63 , the evaluation index system of green economic growth is constructed as shown in Table 1 .

Made in China 2025 pilot policy

The list of Made in China 2025 pilot cities (city clusters) published by the Ministry of Industry and Information Technology of China in 2016 and 2017 is matched with the city-level data to obtain 30 treatment group cities and 251 control group cities. The policy dummy variable of Made in China 2025 is constructed by combining the implementation time of the pilot policies.

Mediating variables

This study also examines the transmission mechanism of the Made in China 2025 strategy affecting urban green economic growth from four perspectives, including green technology advancement, energy consumption structure optimization, industrial structure upgrading, and strengthening of environmental supervision. (1) The number of green patent applications is adopted to reflect green technology advancement. (2) Energy consumption structure is quantified using the share of urban domestic electricity consumption in total energy consumption. (3) The industrial structure upgrading index is calculated using the formula \(\sum\nolimits_{i = 1}^{3} {i \times (GDP_{i} /GDP)}\) , where GDP i denotes the added value of primary, secondary, or tertiary industries. (4) The frequency of words related to the environment in government work reports is the proxy for measuring the intensity of environmental supervision 64 .

Control variables

Double ML can effectively accommodate the case of high-dimensional control variables using regularization algorithms. To control for the effect of other urban characteristics on green economic growth, this study introduces the following 10 control variables. We measure education investment by the ratio of education expenditure to GDP. Technology investment is the ratio of technology expenditure to GDP. The study measures urbanization using the share of urban built-up land in the urban area. Internet penetration is the number of internet users as a share of the total population at the end of the year. We measure resident consumption by the total retail sales of consumer goods per capita. The unemployment rate is the ratio of the number of registered unemployed in urban areas at the end of the year to the total population at the end of the year. Financial scale is the ratio of the balance of deposits and loans of financial institutions at the end of the year to the GDP. Human capital is the natural logarithm of the number of students enrolled in elementary school, general secondary schools, and general tertiary institutions per 10,000 persons. Transportation infrastructure is the natural logarithm of road and rail freight traffic. Finally, openness to the outside world is reflected by the ratio of actual foreign investment to GDP. Quadratic terms for the control variables are also included in the regression analysis to improve the accuracy of the model’s fit. We introduce city and time fixed effects as individual and year dummy variables to avoid missing information on city and time dimensions.

Data sources

This study uses 281 Chinese cities spanning from 2006 to 2021 as the research sample. Data sources include the China City Statistical Yearbook, the China Economic and Social Development Statistics Database, and the EPS Global Statistics Database. We used the average annual growth rate method to fill the gaps for the minimal missing data. To remove the effects of price changes, all data measured in monetary units are deflated using the consumer price index for each province for the 2005 base period. The descriptive statistics of the data are presented in Table 2 .

Empirical result

Baseline results.

The sample split ratio of the double ML model is set to 1:4, and we use the Lasso algorithm to predict and solve the main and auxiliary regressions, presenting the results in Table 3 . Column (1) does not control for fixed effects or control variables, column (2) introduces city and time fixed effects, and columns (3) and (4) add control variables to columns (1) and (2), respectively. The regressions in columns (1) and (2) are highly significant, regardless of whether city and time fixed effects are controlled. Column (4) controls for city fixed effects, time fixed effects, and the primary term of the control variable over the full sample interval, revealing that the regression coefficient of the Made in China 2025 pilot policy on green economic growth is positive and significant at the 1% level, confirming that the Made in China 2025 strategy significantly promotes urban green economic growth. Column (5) further incorporates the quadratic terms of the control variables and the regression coefficients remain significantly positive with little change in values. Therefore, Hypothesis 1 is verified.

Parallel trend test

The prerequisite for the establishment of policy evaluation is that the development status of cities before the pilot policy is introduced is similar. Referring to Liu et al. (2022) 29 , we adopt a parallel trend test to verify the effectiveness of Made in China 2025 pilot policy. Figure  2 shows the result of parallel trend test. None of the coefficient estimates before the Made in China 2025 pilot policy are significant, indicating no significant difference between the level of green economic growth in pilot and nonpilot cities before implementing the policy, which passes the parallel trend test. The coefficient estimates for all periods after the policy implementation are significantly positive, indicating that the Made in China 2025 pilot policy can promote urban green economic growth.

Parallel trend test.

Robustness tests

Replace explained variable.

Referencing Oh and Heshmati (2010) 65 and Tone and Tsutsui (2010) 66 , we use the Malmquist–Luenberger index under global production technology conditions (GML) and an epsilon-based measure (EBM) model to recalculate urban green economic growth. The estimation results in columns (1) and (2) of Table 4 show that the estimated coefficients of the Made in China 2025 pilot policy remain significantly positive after replacing the explanatory variables, validating the robustness of the baseline findings.

Adjusting the research sample

Considering the large gaps in the manufacturing development base between different regions in China, using all cities in the regression analysis may lead to biased estimation 67 . Therefore, we exclude cities in seven provinces with a poor manufacturing development base (Gansu, Qinghai, Ningxia, Xinjiang, Tibet, Yunnan, and Guizhou) and four municipalities with a better development base (Beijing, Tianjin, Shanghai, and Chongqing). The other city samples are retained to rerun the regression analysis, and the results are presented in column (3) of Table 4 . The first batch of pilot cities of the Made in China 2025 strategy was released in 2016, and the second batch of pilot cities was released in 2017. To exclude the effect of point-in-time samples that are far from the time of policy promulgation, the regression is also rerun by restricting the study interval to the three years before and after the promulgation of the policy (2013–2020), and the results are presented in column (4) of Table 4 . The coefficients of the Made in China 2025 pilot policy effect on urban green economic growth decrease after adjusting for the city sample and the time interval, but remain significantly positive at the 1% level. This, once again, verifies the robustness of the benchmark regression results.

Eliminating the impact of potential policies

During the same period of the Made in China 2025 strategy implementation, urban green economy growth may be affected by other relevant policies. To ensure the accuracy of the policy effect estimates, four representative policy categories overlapping with the sample period, including smart cities, low-carbon cities, Broadband China, and innovative cities, were collected and organized. Referencing Zhang and Fan (2023) 25 , dummy variables for these policies are included in the benchmark regression model and the results are presented in Table 5 . The estimated coefficient of the Made in China 2025 pilot policy decreases after controlling for the effects of related policies, but remains significantly positive at the 1% level. This suggests that the positive impact of the Made in China 2025 strategy on urban green economic growth, although overestimated, does not affect the validity of the study’s findings.

Reset double ML model

To avoid the impact of the double ML model imparting bias on the conclusions, we conduct robustness tests by varying the sample splitting ratio, the ML algorithm, and the model estimation form. First, we change the sample split ratio of the double ML model from 1:4 to 3:7 and 1:3. Second, we replace the Lasso ML algorithm with random forest (RF), gradient boosting (GBT), and BP neural network (BNN). Third, we replace the partial linear model based on the dual ML with a more generalized interactive model, using the following main and auxiliary regressions for the analysis:

among them, the meanings of each variable are the same as Eqs. ( 1 ) and ( 2 ).

The estimated coefficients for the treatment effects are obtained from the interactive model as follows:

Table 6 presents the regression results after resetting the double ML model, revealing that the sample split ratio, ML algorithm, and the model estimation form in double ML model did not affect the conclusion that the Made in China 2025 strategy promotes urban green economic growth, and only alters the magnitude of the policy effect, once again validating the robustness of our conclusions.

Difference-in-differences model

To further verify the robustness of the estimation results, we use traditional econometric models for regression. Based on the difference-in-differences (DID) model, a synthetic difference-in-differences (SDID) model is constructed by combining the synthetic control method 68 . It constructs a composite control group with a similar pre-trend to the treatment group by linearly combining several individuals in the control group, and compares it with the treatment group 69 . Table 7 presents the regression results of traditional DID model and SDID model. The estimated coefficient of the Made in China 2025 policy remains significantly positive at the 1% level, which once again verifies the robustness of the study’s findings.

Mechanism verification

This section conducts mechanism verification from four perspectives of green technology advancement, energy consumption structure, industrial structure, and environmental supervision. The positive impacts of the Made in China 2025 strategy on green technology advancement, energy consumption structure optimization, industrial structure upgrading, and strengthening environmental supervision are empirically examined using a dual ML model (see Table A.1 in the Online Appendix for details). Referencing Farbmacher et al. (2022) 39 for causal mediating effect analysis of double ML (see the Appendix for details), we test the transmission mechanism of the Made in China 2025 strategy on green economic growth based on the Lasso algorithm, presenting the results in Table 8 . The findings show that the total effects under different mediating paths are all significantly positive at the 1% level, verifying that the Made in China 2025 strategy positively promotes urban green economic growth.

Mechanism of green technology advancement

The indirect effect of green technological innovation is significantly positive for both the treatment and control groups. After stripping out the path of green technology advancement, the direct effects of the treatment and control groups remain significantly positive, indicating that the increase in the level of green technological innovation brought about by the Made in China 2025 strategy significantly promotes urban green economic growth. The Made in China 2025 strategy proposes to strengthen financial and tax policy support, intellectual property protection, and talent training systems. Through the implementation of policy incentives, pilot cities have fostered the concentration of high-technology enterprises and scientific and technological talent cultivation, exerting a knowledge spillover effect that further promotes green technology advancement. At the same time, policy preferences have stimulated the demand for innovation in energy conservation and emissions reduction, which raises enterprises’ motivation to engage in green innovation activities. Green technology advancement helps cities achieve an intensive development model, bringing multiple dividends such as lower resource consumption, reduced pollution emissions, and improved production efficiency, which subsequently promotes green economic growth.

Mechanism of energy consumption structure

The indirect effect of energy consumption structure is significantly positive for the treatment and control groups, while the direct effect of the Made in China 2025 pilot policy on green economic growth remains significantly positive, indicating that the policy promotes urban green economic growth through energy consumption structure optimization. The policy encourages the introduction of clean energy into production processes, reducing pressure on enterprise performance and the cost of clean energy use, which helps enterprises to reduce traditional energy consumption that is dominated by coal and optimize the energy structure to promote green urban development.

Mechanism of industrial structure

The indirect effects of industrial structure on the treatment and control groups are significantly positive. After stripping out the path of industrial structure upgrading, the direct effects remain significantly positive for both groups, indicating that the Made in China 2025 strategy promotes urban green economic growth through industrial structure optimization. Deepening the restructuring of the manufacturing industry is a strategic task specified in Made in China 2025. Pilot cities focus on transforming and guiding the traditional manufacturing industry toward high-end, intelligent equipment upgrades and digital transformation, driving the regional industrial structure toward rationalization and advancement to achieve rational allocation of resources. Upgrading industrial structure is a prerequisite for cities to advance intensive growth and sustainable development. By assuming the roles of “resource converter” and “pollutant controller,” industrial upgrading can continue to release the dividends of industrial structure, optimize resource allocation, and improve production efficiency, establishing strong support for green economic growth.

Mechanism of environmental supervision

The treatment and control groups of environmental supervision has a positive indirect effect in the process of the Made in China 2025 pilot policy affecting green economic growth that is significant at the 1% level, affirming the transmission path of environmental supervision. The Made in China 2025 strategy states that energy consumption, material consumption, and pollutant emissions per unit of industrial added value in key industries should reach the world’s advanced level by 2025. This requires pilot cities to consolidate and propagate the effectiveness of green development by strengthening environmental supervision while promoting the manufacturing sector’s green development. Strengthening environmental supervision promotes enterprises’ energy saving and emissions reduction through innovative compensation effects, while restraining enterprises’ emissions behaviors by tightening environmental protection policies, promoting environmental legislation, and increasing penalties to advance green urban development. Based on the above analysis, Hypothesis 2 is validated.

Heterogeneity analysis

Heterogeneity of manufacturing agglomeration.

To reduce production and transaction costs and realize economies of scale and scope, the manufacturing industry tends to accelerate its growth through agglomeration, exerting an “oasis effect” 70 . Cities with a high degree of manufacturing agglomeration are prone to scale and knowledge spillover effects, which amplify the agglomeration functions of talent, capital, and technology, strengthening the effectiveness of pilot policies. Based on this, we use the locational entropy of manufacturing employees to measure the degree of urban manufacturing agglomeration in the year (2015) before policy implementation, using the median to divide the full sample of cities into high and low agglomeration groups. Columns (1) and (2) in Table 9 reveal that the Made in China 2025 pilot policy has a stronger effect in promoting green economic growth in cities with high manufacturing concentration compared to those with low concentration. The rationale for this outcome may be that cities with a high concentration of manufacturing industries has large population and developed economy, which is conducive to leveraging agglomeration economies and knowledge spillover effects. Meanwhile, they are able to offer greater policy concessions by virtue of economic scale, public services, infrastructure, and other advantages. These benefits can attract the clustering of productive services and the influx of innovative elements such as R&D talent, accelerating the transformation and upgrading of the manufacturing industry and the integration and advancement of green technologies, empowering the green urban development.

Heterogeneity of industrial intelligence

As a landmark technology for the integration of the new scientific and technological revolution with manufacturing, industrial intelligence is a new approach for advancing the green transformation of manufacturing production methods. Based on this, we use the density of industrial robot installations to measure the level of industrial intelligence in cities in the year (2015) prior to policy implementation 71 , using the median to classify the full sample of cities into high and low level groups. Columns (3) and (4) in Table 9 reveals that the Made in China 2025 pilot policy has a stronger driving effect on the green economic growth of highly industrial intelligent cities. The rationale for this outcome may be that with the accumulation of smart factories, technologies, and equipment, a high degree of industrial intelligence is more likely to leverage the green development effects of pilot policies. For cities where the development of industrial intelligence is in its infancy or has not yet begun, the cost of information and knowledge required for enterprises to undertake technological R&D is higher, reducing the motivation and incentive to conduct innovative activities, diminishing the pilot policy’s contribution to green economic growth.

Heterogeneity of digital finance

As a fusion of traditional finance and information technology, digital finance has a positive impact on the development of the manufacturing industry by virtue of its advantages of low financing thresholds, fast mobile payments, and wide range of services 72 . Cities with a high degree of digital finance development have abundant financial resources and well-developed financial infrastructure that provide enterprises with more complete financial services, with subsequent influence on the effects of pilot policies. We use the Peking University Digital Inclusive Finance Index to measure the level of digital financial development in cities in the year (2015) prior to policy implementation, using the median to divide the full sample of cities into high and low level groups. Columns (5) and (6) in Table 9 reveal that the Made in China 2025 pilot policy has a stronger driving effect on the green economic growth of cities with highly developed digital finance. The rationale for this outcome may be that cities with a high degree of digital finance development can fully leverage the universality of financial resources, provide financial supply for environmentally friendly and technology-intensive enterprises, effectively alleviate the mismatch of financial capital supply, and provide financial security for enterprises to conduct green technology R&D. Digital finance also makes enterprises’ information more transparent through a rich array of data access channels, which strengthens government pollution regulation and public environmental supervision and compels enterprises to engage in green technological innovation to promote green economic growth.

Conclusion and policy recommendation

Conclusions.

This study examines the impact of the Made in China 2025 strategy on urban green economic growth using the double ML model based on panel data for 281 Chinese cities from 2006 to 2021. The relevant research results are threefold. First, the Made in China 2025 strategy significantly promotes urban green economic growth; a conclusion that is supported by a series of robustness tests. Second, regarding mechanisms, the Made in China 2025 strategy promotes urban green economic growth through green technology advancement, energy consumption structure optimization, industrial structure upgrading, and strengthening of environmental supervision. Third, the heterogeneity analysis reveals that the Made in China 2025 strategy has a stronger driving effect on green economic growth for cities with a high concentration of manufacturing and high degrees of industrial intelligence and digital finance.

policy recommendations

We next propose specific policy recommendations based on our findings. First, policymakers should summarize the experience of building pilot cities and create a strategic model to advance the transformation and upgrading of the manufacturing industry to drive green urban development. The Made in China 2025 pilot policy effectively promotes green economic growth and highlights the significance of the transformation and upgrading of the manufacturing industry to empower sustainable urban development. The government should strengthen the model and publicize summaries of successful cases of manufacturing development in pilot cities to promote the experience of manufacturing transformation and upgrading by producing typical samples to guide the transformation of the manufacturing industry to intelligence and greening. Policies should endeavor to optimize the industrial structure and production system of the manufacturing industry to create a solid real economy support for high-quality urban development.

Second, policymakers should explore the multidimensional driving paths of urban green economic growth and actively stimulate the green development dividend of pilot policies by increasing support for enterprise-specific technologies, subsidizing R&D in areas of energy conservation and emissions reduction, consumption reduction and efficiency, recycling and pollution prevention, and promoting the progress of green technologies. The elimination of outdated production capacity must be accelerated and the low-carbon transformation of traditional industries must be targeted, while guiding the clustering of high-tech industries, optimizing cities’ industrial structure, and driving industrial structure upgrading. Policymakers can regulate enterprises’ production practices and enhance the effectiveness of environmental supervision by improving the system of environmental information disclosure and mechanisms of rewards and penalties for pollution discharge. In addition, strategies should consider cities’ own resource endowment, promote large-scale production of new energy, encourage enterprises to increase the proportion of clean energy use, and optimize the structure of energy consumption.

Third, policymakers should engage a combination of urban development characteristics and strategic policy implementation to empower green urban development, actively promoting optimization of manufacturing industry structure, and accelerating the development of high-technology industries under the guidance of policies and the market to promote high-quality development and agglomeration of the manufacturing industry. At the same time, the government should strive to popularize the industrial internet, promote the construction of smart factories and the application of smart equipment, increase investment in R&D to advance industrial intelligence, and actively cultivate new modes and forms of industrial intelligence. In addition, new infrastructure construction must be accelerated, the application of information technology must be strengthened, and digital financial services must be deepened to ease the financing constraints for enterprises conducting R&D on green technologies and to help cities develop in a high-quality manner.

Data availability

The datasets used or analysed during the current study are available from the corresponding author on reasonable request.

Cheng, K. & Liu, S. Does urbanization promote the urban–rural equalization of basic public services? Evidence from prefectural cities in China. Appl. Econ. 56 (29), 3445–3459. https://doi.org/10.1080/00036846.2023.2206625 (2023).

Article   Google Scholar  

Yin, X. & Xu, Z. An empirical analysis of the coupling and coordinative development of China’s green finance and economic growth. Resour. Policy 75 , 102476. https://doi.org/10.1016/j.resourpol.2021.102476 (2022).

Fernandes, C. I., Veiga, P. M., Ferreira, J. J. M. & Hughes, M. Green growth versus economic growth: Do sustainable technology transfer and innovations lead to an imperfect choice?. Bus. Strateg. Environ. 30 (4), 2021–2037. https://doi.org/10.1002/bse.2730 (2021).

Orsatti, G., Quatraro, F. & Pezzoni, M. The antecedents of green technologies: The role of team-level recombinant capabilities. Res. Policy 49 (3), 103919. https://doi.org/10.1016/j.respol.2019.103919 (2020).

Lin, B. & Zhou, Y. Measuring the green economic growth in China: Influencing factors and policy perspectives. Energy 241 (15), 122518. https://doi.org/10.1016/j.energy.2021.122518 (2022).

Fang, M. & Chang, C. L. Nexus between fiscal imbalances, green fiscal spending, and green economic growth: Empirical findings from E-7 economies. Econ. Change Restruct. 55 , 2423–2443. https://doi.org/10.1007/s10644-022-09392-6 (2022).

Qian, Y., Liu, J. & Forrest, J. Y. L. Impact of financial agglomeration on regional green economic growth: Evidence from China. J. Environ. Plan. Manag. 65 (9), 1611–1636. https://doi.org/10.1080/09640568.2021.1941811 (2022).

Awais, M., Afzal, A., Firdousi, S. & Hasnaoui, A. Is fintech the new path to sustainable resource utilisation and economic development?. Resour. Policy 81 , 103309. https://doi.org/10.1016/j.resourpol.2023.103309 (2023).

Ahmed, E. M. & Elfaki, K. E. Green technological progress implications on long-run sustainable economic growth. J. Knowl. Econ. https://doi.org/10.1007/s13132-023-01268-y (2023).

Shen, F. et al. The effect of economic growth target constraints on green technology innovation. J. Environ. Manag. 292 (15), 112765. https://doi.org/10.1016/j.jenvman.2021.112765 (2021).

Zhao, L. et al. Enhancing green economic recovery through green bonds financing and energy efficiency investments. Econ. Anal. Policy 76 , 488–501. https://doi.org/10.1016/j.eap.2022.08.019 (2022).

Ferreira, J. J. et al. Diverging or converging to a green world? Impact of green growth measures on countries’ economic performance. Environ. Dev. Sustain. https://doi.org/10.1007/s10668-023-02991-x (2023).

Article   PubMed   PubMed Central   Google Scholar  

Song, X., Zhou, Y. & Jia, W. How do economic openness and R&D investment affect green economic growth?—Evidence from China. Resour. Conserv. Recycl. 149 , 405–415. https://doi.org/10.1016/j.resconrec.2019.03.050 (2019).

Xu, J., She, S., Gao, P. & Sun, Y. Role of green finance in resource efficiency and green economic growth. Resour. Policy 81 , 103349 (2023).

Zhou, Y., Tian, L. & Yang, X. Schumpeterian endogenous growth model under green innovation and its enculturation effect. Energy Econ. 127 , 107109. https://doi.org/10.1016/j.eneco.2023.107109 (2023).

Luukkanen, J. et al. Resource efficiency and green economic sustainability transition evaluation of green growth productivity gap and governance challenges in Cambodia. Sustain. Dev. 27 (3), 312–320. https://doi.org/10.1002/sd.1902 (2019).

Wang, K., Umar, M., Akram, R. & Caglar, E. Is technological innovation making world “Greener”? An evidence from changing growth story of China. Technol. Forecast. Soc. Change 165 , 120516. https://doi.org/10.1016/j.techfore.2020.120516 (2021).

Talebzadehhosseini, S. & Garibay, I. The interaction effects of technological innovation and path-dependent economic growth on countries overall green growth performance. J. Clean. Prod. 333 (20), 130134. https://doi.org/10.1016/j.jclepro.2021.130134 (2022).

Ge, T., Li, C., Li, J. & Hao, X. Does neighboring green development benefit or suffer from local economic growth targets? Evidence from China. Econ. Modell. 120 , 106149. https://doi.org/10.1016/j.econmod.2022.106149 (2023).

Lin, B. & Zhu, J. Fiscal spending and green economic growth: Evidence from China. Energy Econ. 83 , 264–271. https://doi.org/10.1016/j.eneco.2019.07.010 (2019).

Sohail, M. T., Ullah, S. & Majeed, M. T. Effect of policy uncertainty on green growth in high-polluting economies. J. Clean. Prod. 380 (20), 135043. https://doi.org/10.1016/j.jclepro.2022.135043 (2022).

Sarwar, S. Impact of energy intensity, green economy and blue economy to achieve sustainable economic growth in GCC countries: Does Saudi Vision 2030 matters to GCC countries. Renew. Energy 191 , 30–46. https://doi.org/10.1016/j.renene.2022.03.122 (2022).

Park, J. & Page, G. W. Innovative green economy, urban economic performance and urban environments: An empirical analysis of US cities. Eur. Plann. Stud. 25 (5), 772–789. https://doi.org/10.1080/09654313.2017.1282078 (2017).

Feng, Y., Chen, Z. & Nie, C. The effect of broadband infrastructure construction on urban green innovation: Evidence from a quasi-natural experiment in China. Econ. Anal. Policy 77 , 581–598. https://doi.org/10.1016/j.eap.2022.12.020 (2023).

Zhang, X. & Fan, D. Collaborative emission reduction research on dual-pilot policies of the low-carbon city and smart city from the perspective of multiple innovations. Urban Climate 47 , 101364. https://doi.org/10.1016/j.uclim.2022.101364 (2023).

Cheng, J., Yi, J., Dai, S. & Xiong, Y. Can low-carbon city construction facilitate green growth? Evidence from China’s pilot low-carbon city initiative. J. Clean. Prod. 231 (10), 1158–1170. https://doi.org/10.1016/j.jclepro.2019.05.327 (2019).

Li, L. China’s manufacturing locus in 2025: With a comparison of “Made-in-China 2025” and “Industry 4.0”. Technol. Forecast. Soc. Change 135 , 66–74. https://doi.org/10.1016/j.techfore.2017.05.028 (2018).

Wang, J., Wu, H. & Chen, Y. Made in China 2025 and manufacturing strategy decisions with reverse QFD. Int. J. Prod. Econ. 224 , 107539. https://doi.org/10.1016/j.ijpe.2019.107539 (2020).

Liu, X., Megginson, W. L. & Xia, J. Industrial policy and asset prices: Evidence from the Made in China 2025 policy. J. Bank. Finance 142 , 106554. https://doi.org/10.1016/j.jbankfin.2022.106554 (2022).

Chen, K. et al. How does industrial policy experimentation influence innovation performance? A case of Made in China 2025. Humanit. Soc. Sci. Commun. 11 , 40. https://doi.org/10.1057/s41599-023-02497-x (2024).

Article   CAS   Google Scholar  

Xu, L. Towards green innovation by China’s industrial policy: Evidence from Made in China 2025. Front. Environ. Sci. 10 , 924250. https://doi.org/10.3389/fenvs.2022.924250 (2022).

Li, X., Han, H. & He, H. Advanced manufacturing firms’ digital transformation and exploratory innovation. Appl. Econ. Lett. https://doi.org/10.1080/13504851.2024.2305665 (2024).

Liu, G. & Liu, B. How digital technology improves the high-quality development of enterprises and capital markets: A liquidity perspective. Finance Res. Lett. 53 , 103683 (2023).

Chernozhukov, V. et al. Double/debiased machine learning for treatment and structural parameters. Econom. J. 21 (1), C1–C68. https://doi.org/10.1111/ectj.12097 (2018).

Article   MathSciNet   Google Scholar  

Athey, S., Tibshirani, J. & Wager, S. Generalized random forests. Ann. Stat. 47 (2), 1148–1178. https://doi.org/10.1214/18-AOS1709 (2019).

Knittel, C. R. & Stolper, S. Machine learning about treatment effect heterogeneity: The case of household energy use. AEA Pap. Proc. 111 , 440–444 (2021).

Yang, J., Chuang, H. & Kuan, C. Double machine learning with gradient boosting and its application to the Big N audit quality effect. J. Econom. 216 (1), 268–283. https://doi.org/10.1016/j.jeconom.2020.01.018 (2020).

Zhang, Y., Li, H. & Ren, G. Quantifying the social impacts of the London Night Tube with a double/debiased machine learning based difference-in-differences approach. Transp. Res. Part A Policy Pract. 163 , 288–303. https://doi.org/10.1016/j.tra.2022.07.015 (2022).

Farbmacher, H., Huber, M., Lafférs, L., Langen, H. & Spindler, M. Causal mediation analysis with double machine learning. Econom. J. 25 (2), 277–300. https://doi.org/10.1093/ectj/utac003 (2022).

Chiang, H., Kato, K., Ma, Y. & Sasaki, Y. Multiway cluster robust double/debiased machine learning. J. Bus. Econ. Stat. 40 (3), 1046–1056. https://doi.org/10.1080/07350015.2021.1895815 (2022).

Bodory, H., Huber, M. & Lafférs, L. Evaluating (weighted) dynamic treatment effects by double machine learning. Econom. J. 25 (3), 628–648. https://doi.org/10.1093/ectj/utac018 (2022).

Waheed, R., Sarwar, S. & Alsaggaf, M. I. Relevance of energy, green and blue factors to achieve sustainable economic growth: Empirical study of Saudi Arabia. Technol. Forecast. Soc. Change 187 , 122184. https://doi.org/10.1016/j.techfore.2022.122184 (2023).

Taskin, D., Vardar, G. & Okan, B. Does renewable energy promote green economic growth in OECD countries?. Sustain. Account. Manag. Policy J. 11 (4), 771–798. https://doi.org/10.1108/SAMPJ-04-2019-0192 (2020).

Ding, X. & Liu, X. Renewable energy development and transportation infrastructure matters for green economic growth? Empirical evidence from China. Econ. Anal. Policy 79 , 634–646. https://doi.org/10.1016/j.eap.2023.06.042 (2023).

Ferguson, P. The green economy agenda: Business as usual or transformational discourse?. Environ. Polit. 24 (1), 17–37. https://doi.org/10.1080/09644016.2014.919748 (2015).

Pan, D., Yu, Y., Hong, W. & Chen, S. Does campaign-style environmental regulation induce green economic growth? Evidence from China’s central environmental protection inspection policy. Energy Environ. https://doi.org/10.1177/0958305X231152483 (2023).

Zhang, Q., Qu, Y. & Zhan, L. Great transition and new pattern: Agriculture and rural area green development and its coordinated relationship with economic growth in China. J. Environ. Manag. 344 , 118563. https://doi.org/10.1016/j.jenvman.2023.118563 (2023).

Li, J., Dong, K. & Dong, X. Green energy as a new determinant of green growth in China: The role of green technological innovation. Energy Econ. 114 , 106260. https://doi.org/10.1016/j.eneco.2022.106260 (2022).

Herman, K. S. et al. A critical review of green growth indicators in G7 economies from 1990 to 2019. Sustain. Sci. 18 , 2589–2604. https://doi.org/10.1007/s11625-023-01397-y (2023).

Mura, M., Longo, M., Zanni, S. & Toschi, L. Exploring socio-economic externalities of development scenarios. An analysis of EU regions from 2008 to 2016. J. Environ. Manag. 332 , 117327. https://doi.org/10.1016/j.jenvman.2023.117327 (2023).

Huang, S. Do green financing and industrial structure matter for green economic recovery? Fresh empirical insights from Vietnam. Econ. Anal. Policy 75 , 61–73. https://doi.org/10.1016/j.eap.2022.04.010 (2022).

Li, J., Dong, X. & Dong, K. Is China’s green growth possible? The roles of green trade and green energy. Econ. Res.-Ekonomska Istraživanja 35 (1), 7084–7108. https://doi.org/10.1080/1331677X.2022.2058978 (2022).

Zhang, H. et al. Promoting eco-tourism for the green economic recovery in ASEAN. Econ. Change Restruct. 56 , 2021–2036. https://doi.org/10.1007/s10644-023-09492-x (2023).

Article   ADS   Google Scholar  

Ahmed, F., Kousar, S., Pervaiz, A. & Shabbir, A. Do institutional quality and financial development affect sustainable economic growth? Evidence from South Asian countries. Borsa Istanbul Rev. 22 (1), 189–196. https://doi.org/10.1016/j.bir.2021.03.005 (2022).

Yuan, S., Li, C., Wang, M., Wu, H. & Chang, L. A way toward green economic growth: Role of energy efficiency and fiscal incentive in China. Econ. Anal. Policy 79 , 599–609. https://doi.org/10.1016/j.eap.2023.06.004 (2023).

Capasso, M., Hansen, T., Heiberg, J., Klitkou, A. & Steen, M. Green growth – A synthesis of scientific findings. Technol. Forecast. Soc. Change 146 , 390–402. https://doi.org/10.1016/j.techfore.2019.06.013 (2019).

Wei, X., Ren, H., Ullah, S. & Bozkurt, C. Does environmental entrepreneurship play a role in sustainable green development? Evidence from emerging Asian economies. Econ. Res. Ekonomska Istraživanja 36 (1), 73–85. https://doi.org/10.1080/1331677X.2022.2067887 (2023).

Iqbal, K., Sarfraz, M. & Khurshid,. Exploring the role of information communication technology, trade, and foreign direct investment to promote sustainable economic growth: Evidence from Belt and Road Initiative economies. Sustain. Dev. 31 (3), 1526–1535. https://doi.org/10.1002/sd.2464 (2023).

Li, Y., Zhang, J. & Lyu, Y. Toward inclusive green growth for sustainable development: A new perspective of labor market distortion. Bus. Strategy Environ. 32 (6), 3927–3950. https://doi.org/10.1002/bse.3346 (2023).

Chernozhukov, V. et al. Double/Debiased/Neyman machine learning of treatment effects. Am. Econ. Rev. 107 (5), 261–265. https://doi.org/10.1257/aer.p20171038 (2017).

Chen, C. Super efficiencies or super inefficiencies? Insights from a joint computation model for slacks-based measures in DEA. Eur. J. Op. Res. 226 (2), 258–267. https://doi.org/10.1016/j.ejor.2012.10.031 (2013).

Article   ADS   MathSciNet   Google Scholar  

Tone, K., Chang, T. & Wu, C. Handling negative data in slacks-based measure data envelopment analysis models. Eur. J. Op. Res. 282 (3), 926–935 (2020).

Sarkodie, S. A., Owusu, P. A. & Taden, J. Comprehensive green growth indicators across countries and territories. Sci. Data 10 , 413. https://doi.org/10.1038/s41597-023-02319-4 (2023).

Jiang, Z., Wang, Z. & Lan, X. How environmental regulations affect corporate innovation? The coupling mechanism of mandatory rules and voluntary management. Technol. Soc. 65 , 101575 (2021).

Oh, D. H. & Heshmati, A. A sequential Malmquist-Luenberger productivity index: Environmentally sensitive productivity growth considering the progressive nature of technology. Energy Econ. 32 (6), 1345–1355. https://doi.org/10.1016/j.eneco.2010.09.003 (2010).

Tone, K. & Tsutsui, M. An epsilon-based measure of efficiency in DEA - A third pole of technical efficiency. Eur. J. Op. Res. 207 (3), 1554–1563. https://doi.org/10.1016/j.ejor.2010.07.014 (2010).

Lv, C., Song, J. & Lee, C. Can digital finance narrow the regional disparities in the quality of economic growth? Evidence from China. Econ. Anal. Policy 76 , 502–521. https://doi.org/10.1016/j.eap.2022.08.022 (2022).

Arkhangelsky, D., Athey, S., Hirshberg, D. A., Imbens, G. W. & Wager, S. Synthetic difference-in-differences. Am. Econ. Rev. 111 (12), 4088–4118 (2021).

Abadie, A., Diamond, A. & Hainmueller, J. Synthetic control methods for comparative case studies: Estimating the effect of California’s tobacco control program. J. Am. Stat. Assoc. 105 (490), 493–505 (2010).

Article   MathSciNet   CAS   Google Scholar  

Fang, J., Tang, X., Xie, R. & Han, F. The effect of manufacturing agglomerations on smog pollution. Struct. Change Econ. Dyn. 54 , 92–101. https://doi.org/10.1016/j.strueco.2020.04.003 (2020).

Yang, S. & Liu, F. Impact of industrial intelligence on green total factor productivity: The indispensability of the environmental system. Ecol. Econ. 216 , 108021. https://doi.org/10.1016/j.ecolecon.2023.108021 (2024).

Zhang, P., Wang, Y., Wang, R. & Wang, T. Digital finance and corporate innovation: Evidence from China. Appl. Econ. 56 (5), 615–638. https://doi.org/10.1080/00036846.2023.2169242 (2024).

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Acknowledgements

This work was supported by the Major Program of National Fund of Philosophy and Social Science of China (20&ZD133).

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School of Public Finance and Taxation, Zhejiang University of Finance and Economics, Hangzhou, 310018, China

School of Economics, Xiamen University, Xiamen, 361005, China

Shucheng Liu

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J.Y.: Methodology, Validation. S.L.: Writing - Reviewing and Editing, Validation, Methodology. All authors have read and agreed to the published version of the manuscript.

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Yuan, J., Liu, S. A double machine learning model for measuring the impact of the Made in China 2025 strategy on green economic growth. Sci Rep 14 , 12026 (2024). https://doi.org/10.1038/s41598-024-62916-0

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Received : 05 March 2024

Accepted : 22 May 2024

Published : 26 May 2024

DOI : https://doi.org/10.1038/s41598-024-62916-0

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