Recovery orientation of services - Narrative review

Rationale of the study

Psychiatric disorders are among the leading causes of disability worldwide, often resulting in long-term impairment and social disadvantage. Traditional approaches have primarily focused on symptom reduction and relapse prevention, but these do not fully address the broader needs of individuals living with severe and persistent mental illness. In response, the recovery movement has shifted attention towards holistic, person-centered approaches that emphasize empowerment, identity reconstruction, meaningful roles, and community integration. Recovery-oriented practice has now become a central theme in mental health policy and service delivery globally, yet its implementation remains uneven, especially in low- and middle-income countries (LMICs) where resources are constrained. A comprehensive synthesis of the literature is therefore required to highlight the principles, strategies, challenges, and outcomes of recovery-oriented mental health care.

Aims and objectives

This review aims to examine the evolution of concepts of recovery in mental health, describe key principles and frameworks (such as CHIME and REFOCUS), summarize strategies for implementing recovery-oriented services (ROS), highlight challenges and barriers, and evaluate evidence on outcomes to guide policy, practice, and research.

What is recovery?

The traditional approach to recovery in mental health systems was on symptom improvement or stabilization, risk management, and functional outcomes, primarily grounded in the biomedical model. The treatment outcomes were measured in terms of symptom reduction that has been sustained, with a cure-oriented approach. Le Boutillier et al. (2011) have defined this construct - clinical recovery as a “deficit perspective where the mental state is improved or stabilized using medication and risk-management interventions” and is “measured by symptom remission, insight gain, absence of relapse and mastery in daily living skills.” The focus here is on the “professional as an expert working within an established health infrastructure, with clinical tasks shaping recovery-oriented practice.”¹

When organizational goals, administrative priorities, and financial needs (e.g., cost reduction, service throughput, discharge targets) shape how recovery is translated into practice, the term “service-defined recovery” is used.

Over the last three decades, the concept of “recovery” in mental health has undergone a significant transformation, moving from a traditional focus on symptom absence (clinical recovery) to a more holistic understanding of personal growth and meaningful life, even while symptoms are ongoing (personal recovery). The most cited definition of personal recovery has been provided by William Anthony: “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.”² Le Boutillier et al. define personal recovery as a “holistic approach (spanning physical health care, psychological therapies and stress management) where individuality (including client-centered goals, service-user autonomy and decision-making) takes precedence, and staff and service users work in partnership (through, for example, coaching, supporting hope).”¹

Personal recovery can be understood as a subjective and ongoing process, best evaluated by the individual. It may not necessarily involve a reduction of symptoms, nor does it always result directly from professional interventions. Clinical recovery, on the other hand, is typically regarded as an objective outcome, assessed by external observers. It prioritizes symptom control, functional improvement, and the effectiveness of treatments provided by mental health services.^1-3

The traditional mental health services emphasize illness recognition, expert-driven diagnosis, treatment, and compulsory interventions, with staff seen as fundamentally different from consumers or service users. In contrast, recovery-focused services view recovery as a personal journey centered on reclaiming identity and meaning, with professionals acting as mentors rather than experts. They minimize compulsion through value shared human experience, and encourage openness about strengths and vulnerabilities as part of recovery.¹

This process of recovery helps those in the recovery journey to find hope, develop their self-esteem, build resilience, have a positive sense of self, have a sense of purpose in life, build healthy relationships, become independent, and understand their abilities and limitations. It is multidimensional with recovery stages and encompasses processes that have been identified.⁴

Understanding recovery-oriented mental health practice

Internationally, policy developments have veered towards transforming the services to become recovery-oriented.⁵ A recent guidance on mental health policy and strategic action plans from the World Health Organization (WHO) in 2025 has advocated that the policies should be rights-based, person-centered, and recovery-oriented.⁶

The ‘recovery orientation’ of mental health services refers to the extent to which staff and services attempt to facilitate or promote personal recovery, and encompasses the various aspects of service delivery and practices that contribute to this.¹ Attempts have been made to define what service orientation towards recovery means and provide guidance on promoting recovery.⁷ While the evidence is evolving for recovery-oriented practice in mental health services, there has been limited implementation in inpatient settings.³

The shift towards a recovery-oriented approach is to facilitate support to lead a personally meaningful life and positive self-identity, irrespective of the presence of symptoms of mental illness. The ‘recovery-oriented practice’ incorporates self-determination and person-centered care, and emphasizes hope, social inclusion, community participation, goal setting, and self-management.⁸

A wide range of interventions based on the different recovery needs of each person (for example, psychological, social, educational, vocational, housing, recreational), instead of the traditional focus on pharmacological interventions alone, should be offered in the recovery-based models of services. It is important that the person in recovery can actively participate in making treatment decisions, including the available options for treatment, and be involved by jointly assessing with the professional the risks of each treatment option, including side effects, symptom worsening, or suicidality. The approach is non-coercive with emphasis on supported decision making instead of substitute decision making. Regulated mutual support is another aspect to be favored among practices based on this model. Recovery-oriented practice recognizes the inherent strengths and capacities of persons with mental illness. This strengths-based approach attempts to maximize self-efficacy and self-management in persons with mental illness. The service must be responsive to people’s values and respect diversity. Individual preferences, needs, values, strengths, unique circumstances, and goals in life must be actively considered.⁵

Peer support has been emphasized as a core feature of recovery-oriented mental health services. Peer support is broad-based and can include several types of shared experiences. It can refer to informal support between peers (e.g., through groups and/or online fora) or formal peer support provided in mental health services as a part of the service delivery team. However, both have in common the use of a person’s own lived experience to help and support others. The WHO’s (2021) Comprehensive Mental Health Action Plan⁶ states that Peer Support Workers are a ‘core service requirement’ while, more recently, Winsper et al.,⁹ have identified peer support as one of the main types of recovery-oriented interventions. A naturalistic study showed that consistent engagement in peer support services enhanced outcomes such as self-esteem, reduced internalized stigma, and autonomy.^10,11

ROS, therefore, recognize the complexity of mental ill health, the importance of social determinants in mental health and the role of structural factors, and the person-centered perspective that considers the “whole” of a person’s life. Interventions in a recovery-oriented service should focus on getting the person in recovery to find a new life project and supporting the patient in this direction with the resources they need.

Towards orienting services to personal recovery

Service providers in mental health settings should be educated about a practical working definition of personal recovery and the distinction from the clinical aspects of care through a process of recovery education that transfers knowledge. The CHIME (Connectedness, Hope, Identity, Meaning, and Empowerment) framework has been used to educate mental health professionals to understand the five components that are common to recovery journeys.¹¹

Recovery-oriented training involves the transfer of skills through programs, language, and documentation within the context of the service. Some examples include acquiring skills in recovery-oriented de-escalation, personal recovery goal setting, competencies in psychosocial rehabilitation, and wellness programs.¹

Recovery-oriented training and service development will involve partnerships with experts by experience. Co-production recognizes collaboration and active participation of people with lived experience of mental ill health, family carers, and the community in the transformation of services. Co-production can improve outcomes, including wellbeing, empowerment, social connectedness, inclusion, and personal competencies.⁵

Peer support workers play a particularly vital role by collaborating closely with clinical teams and helping service users navigate complex systems. Unlike traditional professionals, Peer support workers rely on recovery-oriented language that emphasizes hope, resilience, and strengths rather than deficits.⁵ Their work is grounded in principles of mutuality, reciprocity, inclusiveness, and safety. Providers who work closely with service users are best placed to lead change, and those deeply involved in the mental health system should be at the forefront of service development.⁵

The American Psychiatric Association (APA) has provided online training videos for psychiatrists that include understanding of recovery from mental illness and addictive disorders, and recovery-oriented care to make recovery-oriented practice mainstream. The APA has published a curriculum, “Recovery to Practice Initiative Curriculum,” to build capacity in this area for psychologists.¹²

Recovery-oriented care in psychiatry once lacked a clear definition, but the discussed curriculum brings together diverse elements, such as shared decision-making, peer support, engagement, and an environment that is welcoming, into a unified framework. This approach helps psychiatrists see their role in recovery as extending beyond medication, offering benefits not only for patients but also for the psychiatrists themselves.¹³

Organizations should have a commitment to ensure that the work culture and environment are conducive to promoting recovery-oriented practice. The service structure should aim at promoting citizenship for persons in the recovery journey so that they achieve community integration. At the level of the practitioner, the transformation will encompass a therapeutic relationship that looks at personal recovery at the heart of practice and not as an additional task.¹⁴

Recovery orientation of services in specific settings and populations

A spectrum of settings is available, each tailored to meet the diverse needs of individuals across different stages of recovery.

Emergency and acute care facilities, such as EmPATH units, provide immediate, short-term stabilization in a supportive environment, emphasizing rapid assessment and intervention to prevent escalation.¹⁵ In acute inpatient settings, recovery-oriented practice is evident but uneven. Service users value care and therapeutic relationships when the recovery focus is strong, though staff tend to rate these more positively. Safety and risk management dominate staff concerns, yet service users feel less involved in related decisions or care planning. While compassionate care is evident, applying recovery principles in acute wards remains ambivalent. Greater contact in treatment, shared decision-making, and tools that measure recovery could enhance person-centered recovery-oriented care.¹⁶

Inpatient settings

When services are perceived to be not catering to the recovery needs, alternative approaches such as Soteria houses and peer respites have been utilized by service users. Staff orientation and organizational efforts to recovery-oriented care did not get reflected in the patient’s lived experiences during the inpatient stay. In inpatient settings, implementing recovery-oriented practice faces challenges despite organizational efforts. Interviews with inpatients revealed they felt accepted and safe, and valued peer presence, but missed meaningful engagement with staff. Experiences were marked by limited choice, low involvement in treatment decisions, and scarce information, with treatment perceived as medication-focused. Overall, recovery-oriented reforms were not strongly reflected in patient experiences, highlighting the dominance of medical treatment and the need for greater collaboration, information-sharing, and person-centered care. Readmission was also not associated with recovery orientation of services in a veteran’s setting. Nevertheless, there is evidence of commitment to compassionate and respectful care.¹⁷

In hospital-based mental health services, despite policy mandates, the biomedical model is prevalent, characterized by a focus on acute symptom stabilization and risk minimization. Staff may understand recovery but feel unsure about how to translate it into daily practice, with a notable lack of service user involvement in implementation or in evaluating recovery-oriented interventions. Barriers include resistance to change from the embedded biomedical model, attitudes of the staff, and a lack of support to prioritize relational recovery. Successful implementation in these settings often requires multimodal strategies, including staff training, service user programs, and changes to care planning processes, applied over several years with strong organizational support.^7,8

Community-based services

Community-based recovery-oriented practices for individuals with mental illnesses can have moderate to high effects on mental rehabilitation. Collectively, these settings illustrate a continuum of care, each contributing uniquely to the recovery journey by offering appropriate levels of support and promoting individual empowerment. In community-based mental health services, recovery-oriented practices have shown moderate to high effectiveness in rehabilitation, reducing hospitalization rates, decreasing stigma, and helping individuals find new social identities.^7,8 Key components include:

• Psychoeducation: These programs enhance awareness of symptoms in patients, help skill development, and improve medication adherence. They can also foster communication skills and are considered cost-effective.

• Home visits: These interventions cut costs and reduce re-hospitalization rates; supporting housing programs can create a sense of “home” for patients.

• Recreational activities: Arts and sports can positively impact social relationships, self-confidence, and social inclusion, helping bridge the gap from isolation to community involvement.

• Employment support: Helping patients find suitable jobs can lead to higher self-esteem and satisfaction.

• Pivotal role of nurses: Nurses are central to providing community-based and ROS, acting as a bridge between caregivers and patients, supporting families, and improving empowerment and self-efficacy for self-management.

McGuire highlights that while ROS have made notable progress in outpatient settings.¹⁸ It has been done by promoting individualized mental health recovery plans, such as wellness recovery action plans (WRAP), which help individuals to identify life goals, manage triggers, and track mental health progress, reinforcing empowerment and personal agency.¹⁸ By prioritizing rights-based, community-integrated, and person-centered approaches, together with co-production and peer support that supports meaningful recovery for all individuals.¹⁸ Le Boutillier et al. also outlined seven interconnected principles of recovery: fostering hope, collaboration, organizational commitment, respect for rights, person-centered empowerment, recognition of individual context, and social support.¹

Recovery orientation of services in special populations

Implementation challenges and facilitators

Implementing recovery-oriented practice is a complex process, often facing challenges such as conceptual uncertainty and diverse understandings among professionals. Staff may struggle to reconcile conflicting demands, particularly between traditional clinical priorities and new recovery models.⁸

Services are limited in crisis-focused environments, such as acute inpatient wards and the criminal justice system. These settings are critical, as inappropriate responses can worsen outcomes and impede recovery. Promising alternatives, such as crisis response teams (CRTs), peer respites, and peer-run services, aim to reduce hospitalization and arrests while promoting recovery, autonomy, and meaningful activity. However, research on implementing recovery orientation of services in crisis settings is still limited, highlighting the need for further study to refine models, evaluate effectiveness, and support broader adoption.¹⁷

Evaluating recovery-orientation services

The implementation of ROS has not been without challenges. There have been several efforts to define and create guidance for principles and procedures to incorporate recovery orientation in routine clinical practice. This approach to care has been to be practical, besides having a sound theoretical and philosophical grounding, in the treatment of persons with mental disorders. Many theoretical models helped define the chief characteristics of recovery. The practical implementation in mental health services is challenging because what is the actual meaning of recovery-oriented practice still lacks a consensual answer, and there are challenges in transposing theory into practice.²³

For evaluating recovery-orientation of services, no single gold-standard measure has yet emerged. One review identified ten key instruments, such as the Recovery Self-Assessment (RSA), Recovery Enhancing Environment (REE), INSPIRE, and RECOLLECT, each varying in scope and psychometric robustness. The INSPIRE scale, which covers key recovery processes like the CHIME framework, is closely aligned with recovery principles and showed good reliability, validity, and sensitivity to change, making it particularly useful in practice. The RSA is the most widely used tool internationally and has been adapted across cultures, but it emphasizes empowerment more than other recovery areas. INSPIRE and RSA are comprehensive, have robust psychometric properties, can be administered quickly (4 and 10 min, respectively), and are easy to understand, aligning with the domains of the CHIME recovery model.¹¹

Tools like the Recovery Knowledge Inventory (RKI) and the Provider Expectations for Recovery Scale (PERS) have weaker conceptual clarity and limited validity, which reduces their usefulness. Overall, while various scales exist to assess recovery orientation at the service and staff levels, their partial coverage points to the need for a more comprehensive, reliable, and practical measure that can be applied across diverse settings. Measures developed to assess the recovery orientation of services include the RSA and the Recovery Oriented Systems Indicators (ROSI), and many other tools, which have been summarized in Table 1. Table 2 summarizes all the instruments that can be used for measuring personal recovery. Comparisons between measures are challenging due to different conceptualizations of recovery and varied levels of organizational assessment.²⁴

In many LMICs, the idea of personal recovery as framed in Western measures (like the Recovery Oriented Systems scale-ROSS) is not always the proper fit. Recovery tools often emphasize individual autonomy, independence, and self-determination. However, in collectivistic cultures (like India), recovery is often understood in terms of family involvement, social connectedness, and interdependence, rather than an individual standing apart and making independent choices.^25,26

Ultimately, while the policy direction strongly advocates for personal recovery, there is a recognized gap between this knowledge and its routine implementation in mental health services. Studies consistently show that professional practices based on the recovery model are positively associated with patients achieving greater personal recovery outcomes, emphasizing the importance of focusing on life goals, respecting rights and autonomy, and providing individualized treatment options. This highlights that successful transformation requires not only changes in interventions but also a focus on how the mental health system is managed and how professionals work within it.

Interrelated principles of recovery orientation in mental health services

ROS are structured around a set of interrelated principles that collectively promote hope, which serves as the central guiding theme. At the core is partnership and collaboration, highlighting the importance of collaborative decision-making between service users, families, and professionals. Around this core are six key domains. Uniqueness and cultural context recognize each person’s identity, experiences, and cultural background. Human and civil rights ensure dignity, fairness, and protection under the law. Social support emphasizes relationships, community involvement, and a sense of belonging. Person-centeredness and empowerment value individual choice, self-determination, and active participation in care. Commitment and evaluation reflect organizational responsibility and continuous improvement to better serve people. Hope runs through all these domains, tying them together and guiding recovery. Together, these principles offer a holistic, inclusive, and culturally sensitive approach to mental health care, focusing not only on symptom management but also on supporting each person’s journey toward a meaningful and fulfilling life.²⁷

Recovery-focused services and outcomes

Patients achieve better recovery outcomes when mental health services move beyond symptom reduction to include support for life goals, individualized care, and diverse treatment options.

The empirical support has been only preliminary or mixed. Recovery-oriented care has been associated with greater willingness to seek help, stronger goal orientation, improved social support, reduced hospitalization rates, lower stigma, and the development of a new social identity.³¹ An umbrella review has mapped recovery concepts, facilitators and barriers, recovery-oriented practices, and outcome assessments, confirming that personal recovery is a process of living meaningfully with the diagnosis of mental illness, complementing traditional clinical recovery.

The Mental Health Recovery Star (MHRS) is a collaborative outcome measure completed by both staff and service users. The tool can be administered quickly, is acceptable, and has demonstrated good test-retest reliability. However, interrater reliability was poor, particularly for staff-only ratings. Convergent validity showed stronger associations with social functioning than with personal recovery. Overall, the MHRS may be useful for promoting collaborative care planning, but as a routine clinical outcome measure, its utility is limited.³² The widely endorsed CHIME framework provides a conceptual structure for recovery, though it should be adapted for cultural and population-specific contexts. Additional elements, including difficulties and trauma, personal choice, risk-taking, and coping strategies, are also important.¹¹ Meta-analyses and systematic reviews indicate that interventions involving peer support or structured recovery programs like WRAP can enhance recovery, hope, and empowerment, though effect sizes are often modest and influenced by implementation fidelity. Barriers to recovery include stigma and the negative effects due to the services, including medications, whereas facilitators include spirituality, individual agency, and social support. Overall, these findings underscore that personal recovery is a process rather than an outcome, and that further research is needed to understand its mechanisms and to integrate recovery-oriented practices effectively into routine mental health care.^11,33

Recovery-oriented practices in India

Recovery-oriented practices are gradually being implemented in India. The Mental Healthcare Act, 2017,³⁴ and the Rights of Persons with Disability Act, 2016, respect the rights of individuals with mental illness and promote autonomy and access to care. Community-based initiatives, such as the District Mental Health Programme (DMHP) and Tele MANAS³⁵, expand the reach of mental health services to underserved populations while reducing stigma. Peer Support Workers who draw from the lived experience will have to be increasingly integrated into mental health teams, providing empathetic support, advocacy, and guidance, fostering hope and resilience among service users. Additionally, patient and caregiver representation in bodies such as the Central and State Mental Health Authorities (CMHA, SMHA) and Mental Health Review Boards (MHRB) has the potential to further enhance recovery orientation by ensuring that service users’ perspectives directly inform policy and service delivery.