Person-centredness, recovery and user involvement in mental health services

Chapter 16
Person-centredness, recovery and user involvement in mental health services

Marit Borg & Bengt Karlsson

The University College of South-East Norway, Drammen, Norway


This chapter deals with the perspectives and approaches of person-centredness, recovery and user involvement, and their influences and potentials in mental health service transformation. First, we will briefly discuss major changes in mental health practices in the Western world. This is followed by an outline of the roots and perspectives of person-centredness, recovery and user involvement as we see it. Finally, we will debate some issues regarding standard approaches needed in mental health practice if we are going to claim person-centredness, recovery and user involvement.

The person in mental health contexts

Person-centredness, recovery and service user involvement in mental health practices all sound obvious and self-evident. All three approaches aim to place people at the forefront of their life projects and health and care programmes. This requires attention to who and what is to be in the actual centre. Carl Rogers (1978) claimed that person-centredness can be seen as radical in its attempts to give the person a central position and challenge bureaucracy and hierarchies in promoting egalitarian ideals of humans relating as equal persons, whatever their roles, status or positions. As we see it, the same challenges are present today, and are also inherent in the recent recovery-paradigm for mental health services. During the past decades, the concept of recovery has become familiar in mental health policy, practices and research as well as in voicing service users’ experiences of mental distress and processes towards well-being and citizenship – issues taken for granted in society, but ones that people living with mental health issues find challenging. Recovery, like person-centredness, is about the person retaining and keeping control over their life situation, helping the individual to make informed decisions and supporting real partnerships between persons, families and services.

As researchers and clinicians working in mental health settings, we have found ourselves caught between competing realities. On the one hand, our workplaces inevitably have humanistic and holistic-sounding vision statements that include valuing the whole person and focusing on the person in context rather than the health problems. On the other hand, we find ourselves in the midst of a health bureaucracy and procedures that by no means embody or develop these values. The World Health Organization (WHO 2007) as well as national policies have for some time stated that there remains a gap between rhetoric and reality in the field of mental health. First-person accounts tell us that the voices of service users are still not listened to, their knowledge is generally not recognised as valuable, and what they say to practitioners may well be interpreted within a diagnostic framework as a symptom of their illness rather than as a genuine exchange of crucial information. A young man described the following:

The terrible thing with the psychiatry I have met, is that whatever you say you are pathologised. If I asked what the medication is good for, they generally think that you are paranoid or something like that, instead of giving you an answer. It’s the total hardness and non-empathy.

Borg and Topor (2013, p. 14)

In the following section, we would like to take a step back and reflect on some of these critical issues. We start by setting the scene of mental health services.

Setting the scene

In The People-Centred Health Care – A Policy Framework (WHO 2007), the World Health Organization summarised the challenges in health systems. WHO urged that health systems need to move beyond the traditional models of providing health care and of measuring health system performance. Instead it suggested that greater attention to health system design, financing mechanisms, and the focus and process of care is required. Based on a literature review and a series of stakeholder consultations in selected countries, WHO identified a number of gaps and weaknesses in current health systems, which need attention:

1. Health systems and services have become overly biomedical oriented, disease focused, technology driven and doctor driven. 2. Health care financing mechanisms have not been optimal, pushing provider behavior towards inadequate care, short consultations and lack of referrals. 3. Medical education has increasingly concentrated on body systems or disease conditions. 4. There is little patient and family participation in health care. 5. Specialization and weak referral systems have led to fragmentation and discontinuity of care, both within and between health care institutions, systems and other sources of care such as support groups and the community. 6. It is time to pay more attention to the demand side – patients, families, communities and society at large.

WHO (2007, p. 6)

The named gaps became transformed into The Mental Health Action Plan 2013-2020 (WHO 2013). The Action Plan states that ‘…mental health, which is conceptualized as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. (p. 6). The overall goal for the Action Plan is: ‘…to promote mental health well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce mortality, morbidity and disability for persons with mental disorders’ (p. 9). The Action Plan also describes the transition from social marginalisation to full citizenship, and represents a daunting challenge in public mental health services. An approach that focuses primarily on individuals is not sufficient for creating access to valued roles that those individuals will be able to occupy in community settings. Instead, public intervention and debate are required to promote and monitor the bond of citizenship that connects people to their communities. People with mental health issues, intellectual disabilities and substance use conditions can be included in the community only if the community is informed and welcoming.

Mental health services in most Western countries have undergone major changes over recent decades. The number of persons staying in mental health institutions has been drastically reduced. Models of community care and outreach approaches have been established with the ideals of drawing on the perspectives and principles of person-centredness, recovery and user involvement. These ideals can be seen as important initiatives contributing to fundamental changes in some places. However, implementation of services that are aligned with these perspectives is often met with barriers rooted in the dominant psychiatric culture, including resistance to shift from the biomedical paradigm orientation to humanistic, person-oriented and social-oriented mental health services, and from professional control to service user orientation (Karlsson et al. 2008). In the next section, we will discuss the perspectives and principles of person-centredness, recovery and user involvement, and the relationships between them.

Recovery, person-centredness and user involvement


A central aspect of the notion of recovery is that this knowledge base is developed by and with people with lived experience of mental distress. The recovery perspectives are relatively recent, and as with many new terms, are inconsistently used and even somewhat contested. Yet some characteristics are typically mentioned (Davidson 2003; Borg 2007; Borg et al. 2013). Recovery has become increasingly important in mental health practices, service development and research over recent decades.

The nature of recovery in relation to mental health problems can be seen as a clinical outcome as well as a process. The outcome perspective traces recovery in mental distress back to the International Pilot Study of Schizophrenia of the World Health Organization beginning in the late 1960s, and to other parallel efforts examining the outcome of psychosis (Davidson e tal. 2005). With the finding of a broad heterogeneity in the outcomes, it became clear that individuals being diagnosed with schizophrenia or other psychoses can and do recover. Another outcome perspective is that of traditional treatment effect and symptom relief (Slade 2009). This sense of recovery refers to the fact that people can achieve mental health in which they no longer experience what is defined as clinical signs, symptoms or impairment associated with their given medical diagnosis (Davidson 2003). Furthermore, recovery can be understood as a personal as well as a social process (Tew 2005; Karlsson & Borg 2013).

The personal process is typically described in terms of regaining self-belief, self-control and moving beyond being a service user or patient. It is about reawakening hope for the future, developing a sense of meaning and purpose in life, and doing things you want to do. Taking back control over your situation and nurturing and pursuing ambitions are central. The social process emphasises the dynamic relationship between the person and the environment. Living conditions, feeling safe, work opportunities, community involvement, friends and families, helpful professionals, and available and accessible services are essential for peoples’ recovery processes. These are all ordinary parts of everyday life that people with mental health issues often are excluded from.

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May 30, 2017 | Posted by in NURSING | Comments Off on Person-centredness, recovery and user involvement in mental health services

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