CORC Research Lead Jenna Jacob: can we define mental health 'recovery'?
It was great to be asked to contribute to the launch of the Kooth Theory of Change report and to share some of my thoughts about ‘recovery’ and outcomes in young people’s mental health. The reason I am interested in this area is first and foremost because it is important to consider change when people are receiving support for mental health and wellbeing difficulties. Whilst clinical judgement is important, research has demonstrated that clinicians are less accurate than self-reported questionnaires at predicting how things are going in therapy, especially when someone is going off track. How else are you able to determine improvement or deterioration without asking? When used appropriately, outcome tools can be useful clinically throughout the therapy process to help direct treatment, as well as for tracking outcomes.
Research suggests that recovery means different things to different people and more research in this area is needed, particularly for children and young people (Bergman et al., 2018). A wide range of domains are routinely measured, using a number of outcome measures (Krause, Bear, Edbrooke-Childs & Wolpert, 2018). I also like to differentiate between ‘personal change’ and ‘clinical change’ (see, Macpherson et al., 2016), the former being change that is important to the individual, which may or may not include symptom reduction, and the latter being change that is considered important in clinical terms – which is often related to symptoms. Research suggests that personal change may be more likely to emphasise how a person is functioning, their quality of life or self-exploration. I think more exploration of what important outcomes look like is needed.
As I say in the video, the best way to understand what ‘recovery’ means to someone is by asking them. In some cases there is an existing, standardised questionnaire (i.e. with fixed items) that can help to measure what is wrong and track progress. However, it is often helpful and important to use an idiographic measure as well (idiographic measures being those that are client-defined and capture outcomes in the young person’s own words). The client-defined measure our members in CORC use is the Goals and Goal-based Outcome tool (GBO; Law, 2011), which enables young people to track progress in moving towards their therapeutic goals. Although other client-defined measures are available! National frameworks and guidance suggest that client-defined and standardised outcome measures can be helpfully used alongside each other in a meaningful and complementary way. This is of course with clinical judgement and I highlight here the importance of multiple perspectives and wherever appropriate, tracking change in a number of domains.
I do think it’s possible to track recovery of importance to young people, but we might not always have the best idea from existing means alone. All measures are imperfect, which is to say that I don’t think we are waiting for the perfect measure to be created; we must make the best use of what is available. Knowledge is evolving and we are working with the best options we have at this moment in time. By ‘recovery’, I mean change that is important to the young person and where they would consider themselves to be in a place in which they can live a meaningful and fulfilled life…whatever that means to them. That might mean the reduction of symptoms, or it might mean living with symptoms. Statistically speaking, in CORC, we refer to recovery as something a bit different, meaning the movement from within a clinical threshold (or where their scores on an outcome measure fall within a category that is considered to be of someone with mental health difficulties) to below it on a symptom-based outcome measure. Perhaps there is something in the semantics here, and what I mean is personal change of importance to the young person. Whilst there is clinical use in thinking about outcomes in this way, there is a lot of work currently being done on the use of the word recovery, whereby young people and their advocates would like to reclaim the word to be about the individual and whether they consider themselves to be recovered or not, as opposed to movement on a symptom-based measure.
References
Bergman, H., Kornør, H., Nikolakopoulou, A., Hanssen‐Bauer, K., Soares‐Weiser, K., Tollefsen, T. K., & Bjørndal, A. (2018). Client feedback in psychological therapy for children and adolescents with mental health problems. Cochrane Database of Systematic Reviews, (8). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513116/.
Krause, K. R., Bear, H. A., Edbrooke-Childs, J., & Wolpert, M. (2019). What outcomes count? Outcomes measured for adolescent depression between 2007 and 2017. Journal of the American Academy of Child & Adolescent Psychiatry, 58(1), 61-71.
Law, D. (2011). Goals and goal based outcomes (GBOs): some useful information. Version 2.0. London: CAMHS Press.
Macpherson, R., Pesola, F., Leamy, M., Bird, V., Le Boutillier, C., Williams, J., & Slade, M. (2016). The relationship between clinical and recovery dimensions of outcome in mental health. Schizophrenia Research, 175(1-3), 142-147.