Research Article

Staff experiences of the REFOCUS intervention to support recovery in mental health: A qualitative study nested within a cluster randomized controlled trial

M Leamy*, R Macpherson, G Riley, K Sanger, E Clarke, V Bird, M Janosik, H Jordan, C Le Boutillier, J Williams and M Slade

Published: 27 April, 2020 | Volume 4 - Issue 1 | Pages: 024-032

Background: The REFOCUS intervention was a whole team, complex intervention, designed to increase the recovery support offered by community based, mental health staff. The intervention consisted of two components: Recovery promoting relationships, which focused on how staff work with service users, and Recovery working practices, which focused on what activities and tasks staff and service users could do together.

Aim: We aimed to investigate the experiences of community mental health workers using the REFOCUS intervention to support personal recovery.

Method: In the context of the REFOCUS Trial (ISRCTN02507940), 28 semi-structured individual interviews and 4 staff focus groups, with 24 participants were conducted and thematically analyzed.

Results: Staff valued coaching training and used coaching skills to have tough as well as empowering, motivational conversations with service users. They were positive about the resources within the ‘working practices’ intervention component. The whole team training and reflection sessions helped create team cultures, structures and processes which were conducive to supporting recovery practice.

Conclusion: We recommend the wider use of coaching skills, strengths-based assessments, and approaches to support clinicians to broaden their understanding of service users’ values, treatment preferences and to support striving towards personally-meaningful goals. Staff who used these working practices changed their beliefs about what their service users were capable of, and became more hopeful practitioners. A team-based approach to support recovery creates a learning environment in which staff can support and challenge one another, making sustained practice change more likely.

Read Full Article HTML DOI: 10.29328/journal.apmh.1001014 Cite this Article Read Full Article PDF


Recovery; Complex interventions; Process evaluation; Psychosis; Cluster randomized controlled trial; Staff experiences; REFOCUS


  1. Bonney S, Stickley T. Recovery and mental health: A Review of the British Literature. J Psychiatr Ment Health Nurs. 2005; 15: 140-153. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/18211561
  2. Everett B, Adams B, Johnson J, Kurzawara G, Quigley M, et al. Recovery rediscovered: Implications for the Ontario mentla health system. In: Association CMH, editor.: Ontario Division; 2003.
  3. Australian Health Ministers’ Advisory Council. A national framework for recovery-oriented mental health services: Policy and Theory. In: ageing DoHa, editor.: Commonwealth of Australia; 2013.
  4. Anthony W. Recovery from Mental Illness: The Guiding Vision of the Mental Health Service System in the 1990s. Psych Rehab J. 1993;16: 11-23.
  5. Farkas M, Gagne C, Anthony W, Chamberlin J. Implementing Recovery oriented evidence based programs: Identifying the Critical Dimensions. Community Ment Health J. 2005; 41: 141 - 158. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/15974495
  6. Davidson L, Rowe M, Tondora J. A Practical Guide to Recovery-Oriented Practice: Tools for Transforming Mental Health Care USA: Oxford University Press; 2008.
  7. Le Boutillier C, Slade M, Lawrence V, Bird V, Chandler R, et al. Competing Priorities: staff perspectives on supporting recovery. Administration and Policy in Mental Health and Mental Health Services Research. in press.
  8. Slade M, Amering M, Farkas M, Hamilton B, O'Hagan M, et al. Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems. World Psychiatry. 2014; 13: 12-20. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24497237
  9. Gilburt H, Slade M, Bird V, Oduola S, T. C. Promoting recovery-oriented practice in mental health services: a quasi-experimental mixed-methods study. BMC Psychiatry. 2013; 13: 167. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/23764121
  10. Repper J, Perkins R. Social Inclusion and Recovery: An Approach for Mental Health Practice: Balliere-Tindall; 2003.
  11. Rapp C, Goschka R. The Strengths model: Case Management for People with Psychiatric Disabilities. 2nd ed. Oxford: Oxford University Press; 2006.
  12. Slade M, Bird V, Le Boutillier C, Williams J, McCrone P, et al. The REFOCUS Trial: A cluster randomised controlled trial of a pro-recovery intervention within community based mental health teams. 2011; 11: 185. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22112008
  13. Bird V, Leamy M, Le Boutillier C, Williams J, Slade M. REFOCUS: promoting recovery in community mental health services. 2011.
  14. Le Boutillier C, Leamy M, Bird V, Davidson L, Williams J, et al. What does recovery mean in practice? A qualitative analysis of international recovery-oriented practice guidance. Psychiatr Serv. 2011; 62: 1470-1476. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22193795
  15. 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: 445-452. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22130746
  16. Bird V, Leamy M, Tew J, Le Boutillier C, Williams J, et al. Fit for purpose? Validation of the conceptual framework of personal recovery with current mental health service users. Aust N Z J Psychiatry. in press.
  17. Slade M, Leamy M, Bacon F, Janosik M, Le Boutillier C, et al. International differences in understanding recovery: systematic review. Epidemiol Psychiatr Sci. 2012; 21: 353-364. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22794507
  18. Bird V, Le Boutillier C, Leamy M, Larsen J, Oades L, et al. Assessing the strengths of mental health service users - systematic review. Psychol Assess. 2012; 24: 1024-1033. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22708573
  19. Shanks V, Williams J, Leamy M, Bird V, Le Boutillier C, et al. Measures of personal recovery: systematic review. Psychiatr Serv. 2013; 64: 974-980. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/23820592
  20. Williams J, Leamy M, Bird V, Harding C, Larsen J, et al. Measures of the recovery orientation of mental health services: systematic review. Soc Psychiatry Psychiatr Epidemiol. 2012; 47: 1827-1835. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22322983
  21. Grant A, Treweek S, Dreischulte T, Foy R, Guthrie B. Process evaluations for cluster-randomised trials of complex interventions: a proposed framework for design and reporting. Trials. 2013; 14: 15. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/23311722
  22. Leamy M, Clarke E, Le Boutillier C, Bird V, Janosik M, et al. Implementing a manualised intervention to support personal recovery: a qualitative study nested within a Cluster Randomised Controlled Trial. PLoS One. 2014; 9: e97091. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24875748
  23. Slade M, Bird V, Chandler R, Fox J, Larsen J, et al. The contribution of advisory committees and public involvement to large studies: case study. BMC Health Serv Res. 2010; 10: 323. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/21126353
  24. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psycho. 2006; 3: 34.
  25. Hungerford C, Kench P. The perceptions of health professionals of the implementation of Recovery-oriented health services: A case study analysis. J Mental Health Training, Education and Practice. 2013; 8: 208 - 218.
  26. Piat M, Lai S. Service Providers’ Experiences and Perspectives on Recovery- Oriented Mental Health System Reform. Psychiatr Rehabil J. 2012; 35: 289–296. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22491368
  27. Tickle A, Brown D, Hayward M. Can we risk recovery? Agrounded theory of clinical psychologists’ perceptions of risk and recoveryoriented mental health services. Psychol Psychother.. 2014; 87: 96–110. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24497399
  28. Courtney M, Moulding N. Beyond Balancing Competing Needs: Embedding Involuntary Treatment Within a Recovery Approach to Mental Health Social Work. Aus Soc Work. 2013.
  29. Felton BJ, Barr A, Clark G, Tsemberis SJ. ACT Team Members’ Responses to Training in Recovery-Oriented Practices. Psychiatr Rehabil J. 2006; 30: 112-119. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/17076054
  30. Cleary M, Horsfall J, O'Hara-Aarons M, Hunt GE. Mental health nurses’ views of recovery within an acute setting. Int J Ment Health Nurs. 2013; 22: 205–212. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22882297
  31. Bora R, Leaning S, Moores A, Roberts G. Life coaching for mental health recovery: the emerging practice of recovery coaching. Advances in Psychiatric Treatment. 2010; 16: 459-467.
  32. Sullivan P, Floyd D. Spirit Lifting: Hope and Recovery in Case Management Practice. Families in Society: J Contemporary Social Serv. 2013; 94: 38.
  33. Slade M, Bird V, Clarke E, Le Boutillier C, McCrone P, et al. Supporting recovery in patients with psychosis using adult mental health teams (REFOCUS): a multi-site cluster randomised controlled trial. Lancet Psychiatry. 2015; 2: 503-514. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/26360446
  34. Macpherson R, Pesola F, Leamy M, Bird V, Le Boutillier C, et al. The relationship between clinical and recovery dimensions of outcome in mental health. Schizophr Res. 2016 175, 1-3, 142-147. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/26527245
  35. Wallace G, Bird V, Leamy M, Bacon F, Janosik M, et al. Service user experience of the REFOCUS intervention. Soc Psychiatry Psychiatr Epidemiol. 2016; 51: 1275-1284. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27365099
  36. Meadows G, Brophy L, Shawyer F, Enticott J, Fossey E, et al. REFOCUS-PULSAR recovery-oriented practice training in specialist mental health care: a stepped-wedge cluster randomised controlled trial. Lancet Psychiatry. 2019; 6: 103-114.
  37. Shawyer F, Enticott J, Brophy L, Bruxner A, Fossey E, et al. The PULSAR Specialist Care protocol: a stepped-wedge cluster randomized control trial a training intervention for community mental health teams in recovery-oriented practice. BMC Psychiatry. 2017; 17: 172. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28482829

Similar Articles

Recently Viewed

Read More

Most Viewed

Read More

Help ?