East Asian Arch Psychiatry 2012;22:39-48

ORIGINAL ARTICLE

Mental Health Recovery for Psychiatric Inpatient Services: Perceived Importance of the Elements of Recovery

针对精神科住院服务的精神康复：「康复进程」元素的感知 重要性

Dr Bonnie Wei-Man Siu, MRCPsych, FHKCPsych, MSc, Department of  Psychiatry, Castle Peak Hospital, Hong Kong SAR, China.
Mr Bacon Fung-Leung Ng, MSc, Head Office, Hospital Authority, Hong Kong SAR, China.
Mr Victor Chun-Kwong Lee, MSc, Department of Psychiatry, Castle Peak Hospital, Hong Kong SAR, China.
Ms Yee-Mei Yeung, MSc, Department of Psychiatry, Castle Peak Hospital, Hong Kong SAR, China.
Mr Michael Kwong-Leong Li, BSc, Department of Psychiatry, Castle Peak Hospital, Hong Kong SAR, China.
Ms Annabel Yuet-Hang Leung, BSc, Department of Psychiatry, Castle Peak Hospital, Hong Kong SAR, China.

Address for correspondence: Dr Bonnie Wei-Man Siu, Department of Psychiatry, Castle Peak Hospital, 15 Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong SAR, China.
Tal: (852) 2456 7111; Fax: (852) 2456 9118; email: bonniew114m@yahoo.com

Submitted: 19 September 2011; Accepted: 13 December 2011

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Introduction

Mental health recovery is a journey of healing and transformation enabling a person with a mental disability to live a meaningful life in the community of his or her choice, while striving to achieve his or her full potential.¹

As an essential direction of mental health care reform and a move towards continuous service quality improvement, the concept of recovery-oriented care has already been incorporated into the national policies, service standards, and guiding principles for the transformation of the mental health systems in many countries, including Australia, the US, Canada, the United Kingdom, and New Zealand.^2-7 In order to catch up with global trends in mental health care reform, there is an urgency to explore whether the local mental health services should become ‘recovery-oriented’. Moreover, as recovery is a relatively novel concept in the Chinese population, it is important to define it and assess the meanings of recovery in relation to people with mental illness in Hong Kong.

Mental health recovery has been described and defined by different health care organisations. In 2003, the US Commission on Mental Health stated that “the goal of a transformed mental health system is to implement recovery and recovery refers to the process in which people are able to live, work, learn, and participate fully in their community”.⁸

In the report, recovery was defined as “the ability to live a fulfilling and productive life despite disability”. The US Department of Health in 2004 issued a National Consensus Statement on Mental Health Recovery, in which recovery was cited as “the single most important goal” for the mental health service delivery system. It mentioned that the 10 fundamental elements of recovery are self-direction, individualised and person-centred, empowerment, holistic, non-linear, strength-based, peer support, respect, responsibility, and hope.¹ In 2010, the South London and Maudsley National Health Service (NHS) Foundation Trust and the South West London and St George’s Mental Health NHS Trust jointly issued a position statement.⁹ The latter suggested that recovery-focused services are a central component to make our mental health services fit for the 21st century, and that recovery is about “individualised approaches and having a satisfying and fulfilling life, as defined by each person”.⁹ The statement elaborated that “recovery does not necessarily mean clinical recovery — it does mean social recovery — building a life beyond illness without necessarily achieving the elimination of the symptoms of illness”. Mental health was often described as “a journey, with its inevitable ups and downs, and people often describing themselves as being in recovery rather than recovered”.⁹

Researchers have diverse views on the definition of recovery. Deegan¹⁰ stated that “instead of focusing primarily on symptom relief, as the medical model dictates, recovery casts a much wider spotlight on restoration of self-esteem and identity and on attaining meaningful roles in society”. This definition by Deegan does not, however, imply full recovery, in which full functioning is restored and no medications are needed. Instead, recovery is suggested as “a journey or process, not a destination or cure”. Anthony¹¹ has developed a widely used definition of recovery as “a way of living a satisfying, hopeful and contributing life even with the limitations caused by illness. Recovery involves the development of a new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness”. A US report¹² stated that “recovery is variously called a process, an outlook, a vision, a guiding principle”. Thus, there is neither a single agreed-upon definition of recovery nor a single way to measure it. However, the overarching message is that hope and restoration of a meaningful life are possible, despite serious mental illness.^13,14

Obviously, there is no single universally agreed- upon conceptualisation of recovery and empirically the exploration of recovery has in fact been a continuous challenge for researchers.¹⁵ In the initial phase of considering a service transformation to be more recovery-oriented, it is essential to explore the relevance and importance of the elements of recovery to patients. Up to when this study was designed, there was no available validated assessment tool in the Chinese language to measure the importance of the elements of recovery in this locality. On the other hand, there are no validated assessment tools available in other languages that are designed solely to measure the perceived importance of the elements of recovery by patients. An assessment tool that measures the perceived importance of the elements of mental health recovery has to be user- friendly and applicable to the mental health service in Hong Kong.

This study set out to develop a local assessment tool for the identification of the key elements of mental health recovery that are of high perceived importance by psychiatric inpatients in Hong Kong. The psychometric properties of this assessment tool were tested. The identification of the elements of recovery that are perceived to be most important by patients helps as a guide for health care providers to design programmes for the implementation of recovery- oriented service. Moreover, for Chinese populations, as recovery is a novel concept for both patients and the mental health care system, the views of staff on the importance of elements of patient recovery were also explored.

Methods

Development of the Recovery Elements Assessment Questionnaire–Patient Version

Thematic content analysis of identified literature on mental health recovery was performed by 4 researchers to identify the definitions related to recovery. Measures on mental health recovery, as well as government reports and position statements on recovery-oriented mental health service were reviewed for the definitions of recovery, with particular reference to the Developing Recovery Enhancing Environments Measure (DREEM),¹⁶ the Recovery Self-Assessment (Person in Recovery version),¹⁷

and the National Consensus Statement on Mental Health Recovery¹ which embraced almost all of the elements of recovery in the literature. A total of 85 definitions of recovery were identified and the 4 researchers adopted a modified Delphi approach (i.e. each researcher was allowed to explain his or her own reasoning verbally and respond to questions and requests for clarifications) to reach a consensus on the categorisation of the 85 definitions of recovery into 24 elements of recovery as well as the wordings of the 24 elements. The results of this content analysis were published and reported in a conference proceeding (Table 1).¹⁸

The English terms of these 24 elements were translated into Chinese and then back translated to English by 2 bilingual psychiatric nurses. The Chinese translations were then modified until the back-translated English terms were comparable to the original English terms. A 24-item self-reported questionnaire in the Chinese language, the Recovery Elements Assessment Questionnaire–Patient Version (REAQ-PV), was developed by the researchers of this study based on the 24 elements identified in content analysis.¹⁸ The response to each item was given on a 5-point Likert scale on the importance of the elements of mental health recovery by people with mental illness in Hong Kong. For example, a person with mental illness was asked to rate the statement “Hope is an important element of recovery” as strongly agree, agree, neutral, disagree, or strongly disagree. In this study, the perceived importance of the elements of recovery was defined as the extent to which the person with mental illness agreed on the importance of each of the 24 items (elements) of the questionnaire.

The content validity of the REAQ-PV (the first draft) was evaluated by an expert panel consisting of 1 psychiatrist, 2 psychiatric nurses and 1 occupational therapist, all with more than 10 years of working experience in the mental health field. All the panel members were bilingual and they applied the Delphi technique to evaluate the relevance and representativeness of the elements of recovery in assessing recovery of people with mental illness in Hong Kong. Each of the elements was retained in the questionnaire, only if all the panel members agreed that it was relevant and representative. Four focus groups were held with a convenient sample of 36 inpatients of Castle Peak Hospital for the face validity of the REAQ-PV. Each focus group comprised 9 inpatients and was led by one of the researchers of this study together with a research assistant. According to a set of guiding questions, focus group members discussed the acceptability and the practicality of the REAQ-PV item by item. The group paid special attention to the wording of the items and their applicability and relevance to the recovery of people with mental illness in Hong Kong. The research assistant transcribed and recorded all the relevant points discussed in the focus group for their applicability and relevance to the items in the REAQ-PV.

Patients

Another sample of 101 patients (i.e. different from the sample who joined the focus group discussion) was recruited from the medium-stay and rehabilitation wards of the Department of General Adult Psychiatry of Castle Peak Hospital, Hong Kong, from November 2010 to January 2011. The purpose was to assess the perceived importance of the elements of recovery in psychiatric inpatients. The sample size was affordable and representative with respect to the total number of inpatients and the inpatient turnover rate of this mental health facility. The inclusion criteria were: Chinese ethnicity, aged 18 to 60 years, and ability and willingness to provide written informed consent to participate in the study. Persons with moderate mental deficiency or of inability to comprehend Chinese were excluded. Approval to conduct the study was granted by the Ethics and Research Committee of the New Territories West Cluster. The researchers approached eligible patients in the wards, explained the purpose of the study with an information sheet, and obtained written informed consent from them to participate as subjects. The recruits were asked to complete the REAQ-PV for assessment of the perceived importance of the elements of recovery. To evaluate test- retest reliability, the first 32 recruited patients were asked to complete the REAQ-PV for the second or more times (1 to 2 weeks after completing their first test). The time frame of 2 weeks was set as it was believed that the perceived importance of the elements of recovery was rather stable and would not change much within that period.

Other Measures

The patients were also assessed by the Global Assessment of Functioning (GAF) scale and the World Health Organization (WHO) Quality of Life Brief (QOL BREF) scale.^19,20 The GAF scale is a 100-point single-item rating scale for overall psychosocial functioning and takes into account the patient’s psychological, social, and occupational functioning. In this study, the functional level of the patient over the preceding 2 weeks was assessed. The WHO QOL BREF scale is a 26-item questionnaire used to assess the QOL of the patient over the preceding 2 weeks and denoted as an individual’s perception of QOL in 4 domains: satisfaction with physical functioning; psychological dimension; social dimension; and satisfaction with the environment. The scores on the WHO QOL BREF and GAF scales were used to evaluate the divergent validity of REAQ-PV. As these 2 scales were measuring different constructs (i.e. QOL and functioning) from the recovery construct that the REAQ-PV measured, the associations between the scores on the REAQ-PV and that on those 2 scales were expected to be low.

Staff

Modifications were made on the REAQ-PV to develop a staff version (REAQ-SV), which was also a 24-item questionnaire and responded to on a 5-point Likert scale to assess the staff’s views on the importance of each of the 24 elements of mental health recovery in patients.

Staff from different disciplines including psychiatrists, psychiatric nurses, clinical psychologists, occupational therapists, and social workers of the Department of General Adult Psychiatry of Castle Peak Hospital were recruited. They were asked to complete the REAQ-SV to explore any major discrepancies between the patient’s and the staff’s views on the importance of the elements of recovery.

Statistical Analysis

Data were analysed with the Statistical Package for the Social Sciences, Windows version 17.0. Descriptive statistics were used for the analysis of the socio-demographic and clinical data of the patients. Correlational analysis was applied to explore the correlations between the WHO QOL BREF and the GAF scale scores and the REAQ-PV scores for divergent validity. Cronbach’s alpha and item-total correlations were adopted for internal consistency. Explorative factor analysis was adopted to evaluate the factor structure of the REAQ-PV. Intraclass correlation coefficients (ICCs) were computed for the test-retest reliability. Analysis of variance was used to compare the differences between the perceived importance of the elements of recovery by patients and staff. Throughout this study, the significance level was set at p < 0.05.

Results

Psychometric Properties of the Questionnaire and Patients’ Views

For the content validity of REAQ-PV evaluated by the expert panel, all the panel members agreed that the elements of recovery in REAQ-PV were highly relevant and representative for assessing recovery of persons with mental illness in Hong Kong. For the face validity as evaluated by focus group discussion, all focus group members agreed that the REAQ-PV was acceptable and applicable, and the wording of each item was understandable. Members of the expert panel and focus groups did not think that any elements of recovery were omitted from the questionnaire. The first draft of REAQ-PV was therefore unmodified and ready for the assessment of the perceived importance of the elements of recovery by patients.

In all, 101 inpatients were recruited to assess the perceived importance of the elements of recovery by the REAQ-PV. Slightly more than half (53%) were males and the mean (standard deviation [SD]) age of the subjects was 42 (11) years. About half (47%) of them had been in receipt of mental health services in Hong Kong for more than 10 years; their mean length of stay in Castle Peak Hospital was 23 (SD = 23; range, 8-122) months.

The majority of the patients had schizophrenia (75%), others suffered from schizoaffective disorder (9%), bipolar affective disorder (8%), unspecified non-organic psychosis (3%), delusional disorder (2%), personality disorder (2%), and depression (1%) as the primary diagnosis according to the 10th revision of the International Classification of Diseases.²¹

The mean WHO QOL BREF scores were as follows: physical domain score was 62 / 100 (SD = 13); psychological domain score was 55 / 100 (SD = 14); social domain score was 50 / 100 (SD = 17); and environment domain score was 57 / 100 (SD = 14). The mean GAF score was 58 (SD = 16) indicating moderate difficulty in functioning. The QOL scores and the GAF scores were correlated with the degree of perceived importance of some of the elements of recovery, but the Kendall’s tau-b correlation coefficients were all lower than 0.4. The divergent validity of REAQ-PV was supported.

Table 1 showed the percentage of agreement of the 24 elements, among which 11 elements had a percentage of agreement greater than 75% by the patients (i.e. > 75% of them either strongly agreed or agreed that the elements were important).

The elements that had the lowest percentage of agreement on their importance by patients were intimacy and sexuality and peer support, with 37% and 18% respectively. For the remaining 11 elements, more than half of the patients either strongly agreed or agreed that they were important.

Regarding internal consistency, Cronbach’s alpha was 0.91. The item-total correlations of the 24 items ranged from 0.18 to 0.71. The Cronbach’s alpha did not change much when any of single item was deleted. Explorative factor analysis suggested 7 factors with eigenvalues of > 1, as shown in Table 2.

Thirty-two patients completed the REAQ-PV twice for test-retest reliability. Intraclass correlation coefficients of 23 out of the 24 items ranged from 0.20 to 0.69, revealing that the items had fair to substantial test-retest reliability. The ICC of the item role model was 0.17.

Staff Views

A total of 53 staff completed the REAQ-SV. About 70% of them were male. The majority (66%) ranged from 26 to 45 years. Also, 77% of them were serving psychiatric inpatients only, whereas the remaining serving inpatients and outpatients. About 60% were psychiatric nurses and the others were occupational therapists (15%), psychiatrists (9%), clinical psychologists (9%), and medical social workers (8%). The majority (70%) had more than 10 years of working experience in the mental health service.

Table 3 shows a comparison of the patients’ and the staff’s ratings on the importance of the elements of recovery. The staff had higher ratings on all the 24 elements, in particular they had high ratings for the top 10 elements perceived as most important by the patients. Similarly, the staff members had a relatively low rating on the importance of intimacy and sexuality, yet they had a very high rating on the importance of peer support.

Discussion

The Concept of Recovery and Psychometric Properties of the Questionnaire

The adoption of the concept of recovery in mental health service transformation and delivery has been widely discussed in recent years.^16,22-24 Incorporation of recovery principles into government reports and policy statements on mental health services in overseas, as well as the rapid emergence of local research on mental health recovery, relevant definitions, and strategy considerations indicate a resurgence of interest in this area.^1-7,10-14 To catch up with global trends in mental health care reform and delivery of patient-centred mental health services, the exploration of patient perceptions on the importance and relevance of the elements of recovery is of utmost significance to Hong Kong.

There were no validated assessment tools in the Chinese language available in this locality for measuring the perceived importance of the elements of recovery by patients. This study was therefore devised to develop the REAQ-PV for this purpose. Information collected by the REAQ-PV is essential for service prioritisation in the implementation of mental health recovery.

Regarding the format of the questionnaire to identify the perceived importance of the elements of recovery, the rule of agreement-disagreement in the Likert scale on response categories were adopted. This scale can overcome the potential covariance error or halo effect (i.e. the tendency to rate all items similarly), if the item statements are drafted with reversed polarity.²⁵ Also, in the focus group discussions, the patients opined that Likert format with agreement-disagreement response categories for the importance of the given statements could reflect their perceptions of the elements of recovery. The authors therefore decided to develop the questionnaire using the Likert scale format and with some of the statements in reversed polarity. The finalised version of REAQ-PV with operationalised definitions for the 24 elements of recovery is shown in the Appendix.

The concurrent validity of REAQ-PV was not tested by comparison with a gold standard, as such a standard was not available for measuring the perceived importance of the elements of recovery in this locality. Nevertheless, the face validity and content validity of the developed REAQ-PV were supported. The divergent validity of REAQ-PV was revealed by the low correlations between the degree of perceived importance of the elements of recovery and the QOL and GAF scores. The Cronbach’s alpha was 0.91 and the item-total correlations ranged from 0.18 to 0.71. Moreover, the Cronbach’s alpha did not change much if any of the items were deleted, so all 24 items were retained in the questionnaire. The construct validity of REAQ-PV was proven by factor analysis with a yield of 7 factors, which supported recovery being a multi-faceted construct. The ICCs of 23 out of 24 items revealed fair to substantial test-retest reliability (range, 0.20-0.69) whereas the ICC of the item role model was low (0.17). This low ICC could be due to the small sample size (n = 32) used in assessing the test-retest reliability. Because of this small sample size, the different ratings on the item (e.g. role model) by a few participants could contribute substantially to lower the ICC of the item. The small sample size (n = 32) recruited for test-retest reliability and the small sample size (n = 101) recruited for internal consistency and factor analysis were possible reasons for the wide range of ICCs, item-total correlations, and eigenvalues.

Differences between Patients’ and Staffs’ Views on the Importance of the Elements of Recovery

In the present study, having meaning in life (91%), hope (86%), general health and wellness (85%), basic needs (84%), and assistance when in need (81%) were the top 5 elements of recovery that patients had the highest level of agreement regarding their importance. On the other hand, intimacy and sexuality (37%) and peer support (18%) had the lowest percentage of agreement by patients on their importance. In a Canadian study using the DREEM to assess the perceived importance of the elements of recovery in a community sample of 189 persons with mental health or addiction issues, ‘having basic needs met’, ‘having my rights respected’, ‘having a sense of control over my life’,

‘physical health’, and ‘having a sense of hope’ were ranked the top 5 elements, whereas ‘peer support’ and ‘intimacy and sexuality’ were the elements of recovery that received the lowest importance ratings.²⁴ The results of our study echo some of the findings of the above study²⁴ in that hope, general health and wellness, and basic needs are among the elements of recovery that perceived to be the most important, whereas peer support and intimacy and sexuality had the lowest ratings. However, in the Canadian study,²⁴ despite peer support and intimacy and sexuality having the lowest ranking by patients, all the participants either agreed or strongly agreed that these 2 elements were important. In fact, in the implementation of recovery-oriented service in other countries, peer support programmes have been given a high priority. The reasons for the low rating of peer support in this local study needs further exploration. One of the reasons could be negative symptoms (e.g. social withdrawal) in schizophrenia. Thus in the present study, the majority (75%) of patients being schizophrenic had decreased initiatives to seek peer support; a low percentage of patients who agreed or strongly agreed that intimacy and sexuality was important could be due to their inpatient status and no chance of having sex in a mental hospital setting. Patients living in the community in Hong Kong might have a different rating on this element of recovery.

For the ratings by staff, who were mental health professionals, general health and wellness (100%), positive relationship (100%), hope (98%), basic needs (98%), assistance when in need (98%), and being active (98%) were the top 6 elements of recovery having the highest percentage of agreement on their importance. Despite a difference in the rank order of the top 5 elements between the patients and the staff, the latter gave higher ratings of the top 10 elements of recovery perceived as most important by the former. On the other hand, both the patients and staff rated intimacy and sexuality as less important (37% vs. 56%, respectively) than the other elements. Few patients (18%) rated peer support as an important element of recovery in contrast to the staff’s expectation (96%). The different views between patients and mental health professionals on the importance of these elements of recovery provide insight for mental health professionals about recovery-oriented services designed to take account of patient perceptions and views. Mental health professionals might need to involve patients in service planning and programme design in order to ensure that their needs are addressed in the development and implementation of recovery-oriented services, i.e. services are implemented based on the elements or principles of recovery.¹⁶

Clinical Implications in the Implementation of Recovery-oriented Service

The patients in this study were recruited from the medium- stay and rehabilitation wards of Castle Peak Hospital, with a mean (SD) length of current hospitalisation of almost 2 years (23 months) and a range of 8 months to 122 months. As suggested by Ng and Leung²⁶ in the study of a group of relatively long-stay patients in a mental hospital in Hong Kong, intensive and novel approaches for rehabilitation are needed to facilitate their resettlement in the community. To be in line with the global trend of mental health service reform to be more recovery-oriented, it is worth determining whether mental health recovery is applicable to patients living in mental hospitals in Hong Kong. The results of this study and the information collected by the REAQ-PV support this possibility in this locality, in that the patients did agree that the majority of the elements of recovery were important to them. Recovery-oriented service should meet the individualised and diversified needs of different groups of patients. Exploration of the perceived importance of the elements of recovery by patients might be the first step in its implementation. In the initial stage of the planning and implementation of a recovery-oriented mental health service in an inpatient setting, REAQ-PV could be used perhaps with different groups of inpatients to assess the importance of the elements of recovery best suited to them. Programmes can then be designed and implemented based on the elements of recovery perceived to be most important for specific patient groups. The REAQ-SV can also be used to assess the views of different staff groups on the importance of the elements of recovery to patients. Apart from instilling insight for staff on the importance of involving patients in the design of recovery-oriented service programmes, it can serve as an educational tool. This is important in the initial phases of the promotion and implementation of recovery in an organisation, and also to staff on what the meaning of recovery is and what the elements of recovery consist of.²⁴

On the other hand, outcome measures for the mental health inpatient service delivery in this locality usually include symptom control, psychopathology, functionality, QOL, and subjective satisfaction with the service.²⁷ The inclusion of recovery in policy statements, guiding principles, as well as evaluation criteria for the standard of care of mental health service supports further exploration of the need to include a recovery standard (i.e. whether the mental health service provided by an organisation is recovery-oriented) in any given locality.² The development of the REAQ-PV may provide the basis for developing another measurement tool at a later stage, with a view assessing whether the service provided by a mental hospital is recovery-oriented.

Limitations and Suggestions for Future Research

One limitation of this study was that in the expert panel evaluations and focus group discussions on the REAQ- PV, no family caregivers of the patients were involved. The sample was purposive and its size was small, and only inpatients of medium-stay and in rehabilitation wards were recruited. The sample was also over-represented by patients with schizophrenia, which compromised the generalisability of the findings. The sample would be more representative if patients at different stages of their mental illness (e.g. acute, subacute, and chronic) and in different settings (e.g. outpatient clinic or in the community) were recruited. This was a cross-sectional study and the sensitivity to change of REAQ-PV was not tested. A longitudinal study with a larger sample with patients in different settings, at different stages of mental illnesses, with different psychiatric diagnoses is warranted. This would enable further exploration of psychometric properties, including the facility to change the REAQ-PV and have a better understanding of the relationship between the items of REAQ-PV and the socio-demographic and clinical characteristics of patients. Moreover, the psychometric properties of the REAQ-SV, which were not tested in this study, could also be explored.

Conclusions

As an assessment tool to measure the perceived importance of the elements of recovery, the REAQ-PV was found to have satisfactory psychometric properties. The information collected by the REAQ-PV serves as the basis for the future development of recovery-oriented services in psychiatric inpatient settings in this locality. It appeared to be especially useful during the early stages of recovery model implementation.

Acknowledgements

We would like to thank all the patients and staff of Castle Peak Hospital who kindly participated in this study. We would also like to thank Dr Timothy Yeung and Dr K. L. Chung for their unfailing support for the promotion of mental health recovery in Castle Peak Hospital. The authors declared that there is no financial support and no conflict of interest in this study.

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