Mental Health Recovery Narratives Play Central Role in Trauma-Informed Care

A systematic review study, published recently in the open access journal PLoS ONE, analyzes 629 recovery narratives across 45 studies to develop a conceptual framework for such narratives to guide trauma-informed care. In all, nine common dimensions were identified across 629 narratives, with the theme of Turning Points appearing especially relevant for recovery narratives about trauma.

Emphasizing the non-linear natures of narrative, the authors of this study—led by Joy Llewellyn-Beardsley, a research assistant in the Department of Medicine & Health Sciences at the University of Nottingham as well as a service user—seek to incorporate various sociopolitical and cultural dimensions of recovery that are all to often marginalized in mental health treatment plans. The goal is for this to provide more options for those who struggle with a range of psychosocial issues relating to trauma. Llewellyn-Beardsley and colleagues describe their research as important because:

“Knowledge about recovery is based primarily on the individual stories and resulting insights of those with lived experience of psychological distress. The sharing of individual stories was central to the psychiatric survivor and user-led movements which originated in the 1960s and 1970s. Stories of psychological distress and recovery emphasized empowerment and self-determination. Heard collectively, they enabled survivors and users to build solidarity and inspire hope in the face of widespread stigma, discrimination, and denial of rights.”

“Recovery has thus been framed as a civil rights movement and mirrors other forms of identity politics in which (re)claiming a voice to author one’s own story is a central emancipating act. A core preoccupation of Mad Studies, the academic discipline which has emerged around the survivor/service user movement, is correspondingly the production of knowledge based on collective discourses of direct experience of madness.”

The authors further explain that “research interest in narratives grew rapidly in the late twentieth-century ‘narrative turn’ within the social sciences.” Such a ‘narrative turn’ promoted new approaches to the study of language and processes of change that occur within and across individuals. During this time, qualitative research methods were developed to transcend the traditionally narrow conception of evidence used in social science research, shifting the focus from behavior to elements of experience that are not easily quantified.

In terms of mental health concerns, specifically, it has been well-documented that constructing narratives and forming solidarity through shared meaning are powerful facilitators of processes of recovery. Thinking through narratives in this way allows treatment to be informed by dimensions of subjectivity that, as Llewellyn-Beardsley et al. suggest, are “not available through direct observation or traditional forms of medical inquiry, yet central to illness and recovery experiences.”

Taking the narratives of service users seriously also provides avenues for them to provide critical feedback about prior experiences they have had navigating mental health systems. The authors describe narrative analyses as particularly well-suited for the aims of the recovery movement, which has been hailed as an increasingly popular alternative to the pathologizing, biomedical approach traditional to psychiatry. And yet, others have cautioned that even the recovery movement is at risk of being co-opted by “pharma-centric approaches” if user concerns do not remain at the basis of the movement.

This study is characterized as the first systematic review of recovery narratives across mental health literature. For their purposes, the authors define recovery narratives as “first-person lived experience accounts of recovery from mental health problems, which refer to events or actions over a period of time, and which include elements of both adversity/struggle and of self-defined strengths/successes/survival.”

To identify appropriate narratives to analyze, the authors searched through peer-reviewed journals spanning the “health sciences, social sciences and the arts and humanities,” covering a total of 8951 article titles, 366 abstracts and 121 full-text articles published from January 2000-July 2018. Articles were excluded if they did not discuss the importance of narratives themselves, did not focus primarily on recovery from mental health issues, or were based on third-person rather than first-person accounts.

A thematic, narrative analysis of the 45 articles selected was carried out to identify nine dimensions that the authors found to be relevant to the recovery process. Of these nine dimensions four are related to what the authors refer to as the form of the narratives, including (1) genre, (2) positioning of recovery in relation to mental health systems (i.e., within, despite, or outside), (3) emotional tone, and (4) current relationship to recovery (e.g., recovered, making progress, etc). Three of the nine dimensions are related to the structure of the narrative, which includes (5) trajectory of change, (6) use of turning points, and (7) narrative sequence. While the final two dimensions are related to content, including (8) type of protagonist (i.e., personal, socio-cultural, or systemic) and the (9) use of metaphor (i.e., distress metaphors or recovery metaphors). Most of these terms were taken directly from the reviewed literature.

The authors are careful to note that this “conceptual framework is not presented as a definitive or exhaustive list of types; but as a ‘network or plane of linked concepts that together provide a comprehensive understanding or a phenomenon’ . . .  the aim is not to suggest what a recovery narrative is, but what its possibilities are—what it can be.”

Llewellyn-Beardsley et al. are optimistic about their framework’s potential as a transdiagnostic tool situating the concept of narrative as central to any evidence-based treatment processes. And as gaps are identified regarding which groups’ narratives are most excluded across the literature, researchers can begin working towards “a diversity metric for recovery story collections” that can address these shortcomings.

As for the limitations of their own study, the authors note that the publications searched were limited to those written in English. They also note that, despite two of the authors having experience navigating mental health systems as users, and a Lived Experience Advisory Panel being consulted at certain points of the study, there was not quite enough involvement on the part of self-advocacy groups and others with lived experience related to mental health recovery as warranted by the nature of the study itself.

Llewellyn-Beardsley and colleagues conclude by emphasizing how “recovery narratives have played a vital role in establishing the recovery paradigm for survivor movements and individuals, and within mental health services and policy. Care is needed to ensure that recovery narrative interventions are used to expand the available choices within the narrating of recovery instead of curtailing them.”

Their hope is that through such qualitative, narrative-based research practices, the processes underlying recovery can be more fully expressed through the range of diverse voices of those living it.

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Llewellyn-Beardsley J, Rennick-Egglestone S, Callard F, Crawford P, Farkas M, Hui A, et al. (2019) Characteristics of mental health recovery narratives: Systematic review and narrative synthesis. PLoS ONE 14(3): e0214678. https://doi.org/10.1371/journal.pone.0214678 (Link)