The illness management and recovery program: a contribution to recovery-oriented secondary mental health services | BMC Health Services Research

To promote the recovery process of individuals’ with a mental illness and strengthen their ability to live well with mental illness in their communities, several psychosocial evidence-based practices (EBPs) for mental health services have been developed [1, 2], including assertive community teams (ACT), flexible assertive community treatment (FACT), supported employment (SE), and illness management and recovery (IMR). In this article, we explore practitioners’ perspectives on IMR as a recovery-oriented program in the context of secondary mental health services in Norway.

Recovery from mental illness has traditionally been understood as the elimination of symptoms and a return to normal functioning [3]. In the 1980s, however, Deegan [4] proposed a different conceptualization of recovery as the process of living a worthwhile and meaningful life with a mental illness, despite the presence of symptoms. She underscored that most people with a psychiatric illness have the same aspirations as those without one, such as to live, work and love in a community in which one makes a significant contribution [4]. Later, Anthony [5] introduced the term personal recovery to describe recovery as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles, which has become the most cited definition of recovery to date. However, with the rise of neoliberal influences, the emphasis in the mental health field has increased focus on individuals’ personal responsibility for their own health and well-being. This focus has often neglected recognition of the social determinants of mental health and the importance of contextual understandings in promoting recovery [6]. Several researchers have argued that recovery should be viewed not only as a personal process but also as a social one [6,7,8,9,10]. Topor et al. [6] argue for a need to incorporate the social, material, and contextual aspects of recovery more clearly and have suggested a new definition:

“Recovery is a deeply social, unique, and shared process in which an individual’s living conditions, material surroundings, social relations, and sense of self evolve. In that light, recovery is about striving to live satisfying, hopeful, and reciprocal lives, even despite threats, stressful social situations, and distress” [6].

In this study, we acknowledge the critique of viewing recovery solely as a personal process and thus consider it both personal and social.

Recovery-oriented practices and evidence-based practices

Recovery-oriented practices (ROPs) refer to approaches where professionals collaborate with people with mental illness to support their recovery journeys [11], where the focus is on the individual’s needs and active involvement in their own treatment [12]. Davidson and colleagues [13] have defined ROPs as person-centered, strengths-based, collaborative, and empowering [13]. Similarly, Farkas et al. [14] believe that recovery can be promoted when the practices are characterized by program structures (i.e., mission, policies, procedures, record keeping and quality assurance) and staffing concerns (i.e., selection, training, and supervision) that align with the four key values of recovery: person-orientation, person involvement, self-determination, and personal growth. Le Boutillier, et al. [15] have further developed a conceptual framework outlining the key characteristics of ROPs: promoting citizenship, organizational commitment, supporting personally defined recovery and working relationships. Often, ROPs are described as best practices, based on expert opinion, rather than evidence [16].

On the other hand, evidence-based practices (EBPs) integrate best researched practices and clinical expertise with patient values. EBPs are standardized interventions that have been shown to be effective in rigorous research to improve outcomes that patients value [17]. The best available scientific evidence is preferably from randomized controlled trials evaluating their effectiveness comparing the intervention to alternative practices or to no intervention [18]. As EBPs require clinical expertise and judgement to implement and are attuned to the patients’ specific goals and preferences, they are not rigid, one-size-fits-all approaches to treatment. While standardized interventions can provide much of the structure and content of an intervention, and prescribe specific methods for teaching and providing supports, their delivery must be tailored to each patient’s unique circumstances, goals, and preferences by the mental health practitioner [19].

The relationship between ROPs and EBPs has been a topic of considerable debate [13]. Davidson et al. [13] proposed several possible relationships between the two. Some ROPs can be seen as evidence-based if they are sufficiently standardized for rigorous testing and found to be effective at improving important outcomes. However, others view ROPs and EBPs as incompatible due to their divergent focuses and methodologies [20,21,22]. Some Norwegian recovery researchers question the compatibility of standardized protocols and quantifiable measures, such as symptom reduction and clinical outcomes from randomized controlled trials, with ROPs. They also doubt the person-centeredness and individual tailoring in EPBs based on these practices [21]. These researchers argue that EBPs primarily rely on quantitative, experimental research adhering to a scientific ideal, which cannot adequately study ROPs, as measures related to subjective experiences and personal narratives, central to ROPs, are harder to quantify [21, 23]. Bøe [23] advocates for a wider interpretation of evidence to include more user and insider perspectives, aligning more with ROPs. Despite these concerns, it is possible for some EBPs to incorporate elements of ROPs particularly when they are adapted to include person-centered approaches and subjective measures, such as hope, control, self-agency, self-efficacy and a sense of defining and setting personal goals [13].

The IMR program

IMR is an EBP aimed at empowering individuals with mental illness to develop and practice strategies to manage their conditions and both identify and work toward achieving personal recovery goals [24,25,26,27]. A starting point for psychosocial treatment programs is the belief that people with serious mental illness can play a decisive role in own recovery processes [26, 28]. For that reason, IMR practitioners work collaboratively with individuals to help them learn and put their illness management skills in action.

IMR involves using three different teaching approaches (educational, motivational and cognitive-behavioral) and incorporates five empirically supported illness management strategies (psychoeducation, relapse prevention, behavioral training, coping skills, and social skills) [25]. The theoretical underpinnings of IMR are: (1) the stress–vulnerably model, which posits that the course and outcome of severe mental illness is determined by the dynamic interaction between biological vulnerability, stress, and coping; and (2) the transtheoretical model, which maintains that the motivation to change develops across five stages—precontemplation, contemplation, preparation, action, and maintenance—and that facilitating change requires stage-specific interventions [25, 26]. IMR consists of 11 modules, listed in Table 1, and a workbook with educational handouts has been created to teach individuals with mental illness, either individually or in groups, weekly for 10 months or more intensively for 4–5 months. For IMR practitioners, including trained mental health practitioners and peer specialists, a toolkit has also been developed alongside fidelity checklists to guide the implementation of IMR [27, 29].

Most previous research on IMR has employed quantitative methods to assess its effectiveness [30,31,32,33] and implementation of IMR [34,35,36,37]. Qualitative studies have demonstrated that IMR aids patients and practitioners in setting individual goals [38, 39] and has highlighted that IMR’s core components – such as symptom management and peer sharing – enhance recovery processes [40]. Additionally, qualitative research indicates that the person-centered approach used by IMR practitioners’ fosters a good therapeutic alliance [41]. Despite these insights, information about practitioners’ experiences delivering IMR in hospital and district psychiatric centers remains scarce.

Aim and research question

The aim of this study was to shed light on whether illness management and recovery (IMR), as an EBP, can function as an ROP within secondary mental health services in Norway from the practitioners’ perspective. Thus, we sought to develop an understanding of whether IMR can contribute to recovery-oriented outcomes and were guided by this. The research question: In what ways does the delivery of Illness Management and Recovery impact the professional practices, attitudes, and beliefs of mental health practitioners in secondary mental health services?

Context of the study

Norway has a health care system with primary and secondary levels [42]. The primary level encompasses municipal services in mental health care, such as care homes, day centers, municipal mental health- and addiction teams and low-threshold mental health services. Their focus is on early intervention and community-based support [43]. The secondary level becomes relevant when patients require additional support beyond what primary healthcare can provide. At this level, health institutions offer a range of services, including outpatient clinics, day care units, flexible assertive community treatment and general psychiatric units. These services cater to patients with limited daily functioning, symptoms of psychosis, or who are a risk of harm to self or others [44]. Noteworthy features of secondary care services include timely treatment of mental illness, a focus on patient safety, and disease-oriented approach with an emphasis on risk management [11]. Additionally, when voluntary measures prove ineffective, coercive treatment is also available within secondary services [45]. The provision of specialized mental health services and interdisciplinary specialized substance use treatment (TSB) in hospitals and district psychiatric centers is overseen by four regional health authorities [43]. Although practitioners at both levels were offered IMR training, our study included only secondary-level practitioners.

Norway has the highest number of psychiatrists per capita globally (WHO) and ranks among the highest in numbers of psychologists and other mental health practitioners [46]. However, user-organizations, clinicians and politicians have questioned whether service delivery can be person-centered, human-rights-based, and recovery-oriented [47, 48]. Norwegian authorities are calling for radical cultural, attitudinal, and organizational leadership in mental health care [49, 50]. While the integration of research-based, clinical, and experiential knowledge is emphasized for effective treatment in secondary services, significant disagreement exists regarding their relative importance [47]. Criticism and doubt about treatments offered in Norway have proliferated to the point that even those claimed by mental health practitioners to be most effective, are not necessarily to be trusted (Reitan and Lien, 2024) or desired by patients [47]. This has led to a polarized debate [47, 51, 52], where critics have often been labeled as holding anti-psychiatric attitudes [46, 53], while the focus on developing efficient EBPs is criticized for conflicting with recovery-oriented principles [21].