Service Users’ Descriptions of Recovery-Oriented Elements of a Rural Mental Health Service

ABSTRACT

Recovery-oriented practice is the dominant framework for mental health services in Australia. However, evidence demonstrating recovery processes outside public services is scant. This study explores how key processes from the Connectedness, Hope, Identity, Meaning, and Empowerment (CHIME) personal recovery conceptual framework related to service-user experiences of a rural mental health service during the COVID-19 pandemic. Qualitative telephone or video-conference interviews were conducted with 19 service users. Deductive and inductive data analysis was employed, applying the CHIME framework as a predetermined organisational structure. Themes were constructed according to the CHIME framework categories. The data reflected all five categories; connectedness and empowerment were salient. Participants’ service-delivery experiences could either enhance or hinder connectedness, the cultivation of hope, a positive identity, meaning in life, and empowerment. Nonclinical aspects of their experience were viewed as an extension of treatment. Opportunities exist for mental health practitioners to intentionally prioritise and strengthen recovery-oriented practice. Trauma-informed approaches are consistent with and complement personal recovery principles. Accountability structures are needed to monitor recovery-oriented practice in mental health settings. Family-focused interventions also need strengthening to build connectedness, meaning, and hope.

IMPLICATIONS

• Recovery can be promoted and enhanced within primary care mental health services through intentional focus on the key processes.

• Trauma-informed principles and care are congruent with a recovery-oriented approach and support connectedness and empowerment.

• Social workers are well placed to lead and drive recovery-oriented practices in private settings that move beyond an individualistic focus to include holistic care and family-focused practice.

KEYWORDS:

• Recovery-Oriented Practice
• Mental Health
• Private Practice
• Family-Focused Interventions
• Mental Health Social Workers
• Regional Health Services
• Primary Health Care
• Australia

Recovery-oriented practice is the dominant policy framework within mental health services (MHS) in Australia (McKenna et al., 2014; Price-Robertson et al., 2017). Emerging from consumer and carer movements (Anthony, 1993), definitions of personal recovery emphasise the subjective experience of the individual (Slade et al., 2014), and processes of growth and development across relational (Price-Robertson et al., 2017), social (Tew et al., 2012), emotional (Morrissey et al., 2018), vocational (Dunn et al., 2010) and spiritual (Jones et al., 2019) life domains. Personal recovery is unique, differentiated from clinical recovery, which is defined by remission of symptoms and measures of psychosocial functioning by medical hierarchy (Leonhardt et al., 2017).

The ways mental health services either hinder or enhance recovery have been the subject of sustained research and debate (Slade et al., 2014). Recovery approaches have been poorly operationalised in mental health settings (Slade et al., 2014; State Government of Victoria, 2021), including inpatient units (Waldemar et al., 2016) and with aged populations (McKenna et al., 2014). The Royal Commission into Victoria’s Mental Health System (State Government of Victoria, 2021) revealed an unbalanced system relying on medication to the detriment of recovery approaches. Nevertheless, recovery-oriented practice has the potential to transform hierarchical medical systems when operationalised to consider and redress power imbalances, enhancing the agency of consumers and carers (Davidson et al., 2011).

The CHIME Framework

Following a systematic review of personal recovery literature, Leamy et al. (2011) coined the term CHIME to frame the recovery processes of Connectedness, Hope, Identity, Meaning, and Empowerment. In adopting recovery as government policy, the concept has been reframed from radical roots as a social movement (O’Donnell & Shaw, 2016). This paradigm shift, some viewed as the colonisation of recovery, and the employment of its rhetoric as a mechanism to drive conformity to social norms enabling and reproducing neoliberal ideals (Hunt & Resnick, 2015; Recovery in the Bin, 2016). Some claim the right to remain “unrecovered” as valid and legitimate (Recovery in the Bin, 2016).

Many barriers to attaining personal recovery remain, including socioeconomic disadvantage, racism, poverty (Castro-Ramirez et al., 2021), and being a mother living in a rural area (Hine et al., 2018a). Socioeconomic barriers include homelessness, poverty, family violence, unemployment, and discrimination, all risk factors for mental health challenges. Further, CHIME critics highlight its individualistic orientation and failure to account for socioeconomic disparities, experience of interpersonal violence and trauma (Hine et al., 2018a; Nicholson, 2014) or the relational domains of life, particularly parenting roles and identities (Hine et al., 2019; Price-Robertson et al., 2017).

Recovery in Primary Care and Private MHS

The Australian private mental health sector is funded through a universal healthcare system, with providers operating as private businesses, managing their own supervision needs and professional development, as required by their disciplinary regulating bodies (e.g., Australian Association of Social Workers). Practice frameworks highlight that all private and primary mental healthcare should be underpinned by a recovery-oriented approach. However, accountability mechanisms are lacking and a recent study found some psychologists working in private practice had limited understanding of recovery principles and their application (Tchernegovski et al., 2021).

There are opportunities for primary care or private practitioners to enhance or obstruct each element of CHIME. For example, connectedness to self, others, and meaning in life can be supported through the physical environment, therapeutic relationships, and family-focused interventions. Services may promulgate hope and optimism through purposeful shared goal setting (Maybery et al., 2015a) and by sharing recovery stories, a particular strength of peer support models (Rennick-Egglestone et al., 2019). A positive and multifaceted identity can be fostered through recognition of the diverse needs of individuals, accommodating their valued social roles (Hine et al., 2018b, 2019) and acknowledging losses may accompany an identity change (Buck et al., 2013).

The Power of Language

Language is a crucial vehicle for conveying values and attitudes either supporting or hindering recovery. This article uses the term “service user” to describe the study informants. Other terms include patient, consumer, and participant. Some people reject the term service user as it suggests a one-way relational transaction, rather than representing the reciprocity of interactions. In the absence of a widely endorsed alternative, we respectfully use “service user” to distinguish our research cohort. We also acknowledge “mental illness” as a problematic and potentially derogatory description of psychological distress and confusion having social, political, and biological derivatives. Instead, we refer to mental health challenges.

Context of the Study

The Gippsland region covers 41,600 square kilometres of rural and regional Victoria, Australia. The area comprises six local government areas with a population of approximately 300,000 residents (Australian Bureau of Statistics, 2021). Within this catchment, some municipalities have higher than state average rates of death by suicide, anxiety and/or depression diagnosis, alcohol consumption, and family violence (Gippsland Primary Health Network (PHN), 2022). Following the outbreak of COVID-19, the Australian Government responded to increased mental health demand in Victoria due to “ … concerns over rising incidents of self-harm, and a spike in the use of services” (Gippsland PHN Media Release, 2020). This led to the development of a new mental health service, operating within a primary care model. Gippsland’s model was managed by Gippsland PHN. There was no cost to service users. Service delivery was a mixed workforce model with staff employed directly or subcontracted through consultancy arrangements. A regionally-focused hub and satellite model of care resulted. Two main “hubs” were supplemented by satellite offices to meet the demands of a sparse rural population. Service features included telehealth capacity, peer workforce, and an initial assessment and referral (IAR) tool. Recovery was included in the model’s care principles. The service accepted clinician and self-referrals. A total of 2,604 people accessed the service between September 2020 and March 2022. The stepped-care model meant initial intake determined support levels for clients. The service staff were a multidisciplinary team, including social workers, psychologists, peer support workers, and nurses. Service users were matched to practitioners who would meet their needs and service-user choice was considered. The service was delivered via a combination of telehealth and face-to-face (when pandemic restrictions allowed) modes. This study formed part of an evaluation of the approach. This study aimed to identify how people who accessed a new model of rural mental health care provided during the COVID-19 pandemic experienced the service’s recovery-oriented elements. The research question was how do service users experience key recovery-oriented elements of a rural mental health service during the COVID-19 pandemic?

Methods

Sample

In total, 19 service users participated in individual interviews. Seventeen spoke about their own experiences, one as a carer of their daughter, and another about both their own experiences and those of their child who also had accessed the service (see Table 1). The carer perspectives are considered legitimate lived-experience perspectives, providing a different lens on the service-user journey (Vera San Juan et al., 2021), although two people’s carer perspectives cannot represent carer experiences beyond their own. The mean age of participants was 47 years with a range of 22–77 and 74% (n = 14) were female. The majority (n = 17, 89%) identified as being heterosexual. Two participants identified as being Aboriginal, one identified as being Spanish, and the remainder identified as being Australian.

Table 1 Participant Characteristics

Participant characteristics	N N = 19	%
Gender
Woman	14	73.7
Man	5	26.3
Age (years)
Mean 47 years
Range 22–77 years
Cultural background
Aboriginal	2	10.5
Australian	16	84.2
Spanish	1	5.3
Sexuality
Heterosexual	17	89.5
LGBTQIA+	1	5.3
Did not disclose	1	5.3
Employment status
Self-employed	2	10.5
Unemployed or disability pension	6	31.6
Retired	3	15.8
Employed and/or studying full-time	7	36.9
Full-time carer	1	5.3
Highest educational attainment
Year 8–12	6	31.5
Certificate IV or diploma	8	42.1
Bachelor and higher degree	5	26.4
Housing
Buying own home	14	73.7
Public rental	3	15.8
Private rental	1	5.3
Emergency housing	1	5.3
Living arrangement
Alone	5	26.3
With partner only	6	31.6
With partner and children	3	15.8
With children only	4	21.1
Did not disclose	1	5.3
Carer status
Has a carer	1	5.3
Has no carer	18	94.7
Cares for another person^1	6	31.6
Past mental health concerns
Stress	2	10.5
Anxiety	7	36.9
Depression	11	57.9
Personality disorders	5	26.4
Grief	1	5.3
Trauma or posttraumatic stress disorder	8	42.1
Bipolar	2	10.5
Psychosis	1	5.3

¹ Cares for a child, partner, elderly or frail parent or sibling with a disability, but not for a person with a diagnosed mental health disorder.

Two participants had completed year eight at secondary school, seven had completed diplomas, three held bachelor-level degrees, and one had a masters qualification. One participant reported having carers to support them, while six people were in a caring role for someone else. Two participants reported they had no mental health challenges prior to this episode that led to engaging with the service. Seventeen people described prior mental health challenges: depression, anxiety, past trauma, stress emanating from natural disasters and family violence, grief, posttraumatic stress disorder, and borderline personality disorder.

Data Collection

Following ethics approval from the Monash University Human Research Ethics Committee (Approval number 29594), service users and carers were recruited between August 2021 and March 2022 via email, social media, word of mouth, and print advertising at service sites. Prospective participants were provided with a written explanatory statement, and this was reviewed verbally, before individual interviews commenced. Informed consent was confirmed either in writing or orally, recorded at the beginning of the interview. All interviews were conducted by qualitative researchers (RH, EM, MN) who had extensive experience with participants experiencing mental health challenges. Participants were provided with mental health support options if interviews elicited any distressing emotions and interviewers were sensitive to the need to use trauma-informed language and approaches such as validation and short breaks if required. Interviews were conducted in single sessions via telephone or video conferencing, recorded using Zoom. Audio files were transcribed using online software (https://otter.ai). De-identified transcripts were provided to participants for member checking. The interview schedule included questions focused on accessing and entering the service, the care received, how the service integrated with family members and/or other healthcare providers, and service users and carers/family members’ satisfaction with the service. The average interview length was 33 min.

Data Analysis

Data was analysed by two members of the research team (RH, EM) using inductive and deductive approaches (Azungah, 2018; Braun & Clarke, 2006). Initial inductive analyses identified the following five themes from service-user experiences: background and presenting issues, inclusion and access, reflections on the experience of treatment, outcomes of service provision, and responding to specific needs.

To understand how the key processes of personal recovery might influence the service-user experience the secondary analysis employed deductive content analysis to determine how well responses could be explained by the CHIME concept of recovery. Deductive analysis “ … is often used in cases where the researcher wishes to retest existing data in a new context” (Elo & Kyngas, 2008, p. 111). Elo and Kyngas (2008) highlighted that qualitative content could be applied to a predetermined framework (i.e., CHIME) to test responses against the predetermined knowledge on a topic (i.e., concepts of personal recovery). The CHIME framework was applied as a predetermined theoretical structure to enable deep data analysis according to the researcher-driven question around how the service operationalised key recovery processes. The raw data was reviewed again and re-sorted into the five CHIME categories. Within each category, the data was interrogated in relation to evidence of recovery-promoting features of the service. Data not fitting within that framework were analysed inductively to form additional thematic categories. As described by Braun and Clarke (2006, 2019), the researchers firstly familiarised themselves with the data, rereading the transcripts multiple times. Initial codes were generated, through a process of constant comparison, reflection, and review. The research team met several times during the process of developing and reviewing themes, discussing possible data interpretations including whether (and how) it related to the CHIME framework. Finally, themes were consolidated and named.

Findings

The majority of participants stated the mental health challenges they sought support for predated the COVID-19 pandemic and largely were associated with past trauma including sexual assault, family violence, and unresolved grief. Viewed through the CHIME framework lens, the data contained many examples of how participant experiences of, and interactions with, the service influenced their connectedness, hope and optimism, identity, meaning in life, and empowerment. These themes were not discreet, rather they were often overlapping. For example, building connectedness could also create hope, and learning new strategies could feel empowering and generate optimism. Participants spoke of their wellbeing being either enhanced or challenged by different elements during their episode of care. [Appendix 1]

Fostering Connectedness

Connectedness pertained either to relational aspects of family life, or the engagement participants perceived between themselves and the mental health service. Another subtheme was factors contributing to a sense of disconnection.

Participants generally perceived the service received to be individualistic. The majority of participants did not have family members or carers attend any of their sessions, and when asked whether this was offered, most provided vague responses such as “I can't really remember but they might have” (P7). Most participants did not view this as problematic, perceiving this as something to be addressed independently. Some did recall being asked if they wanted to bring a family member and declining due to personal preference. A deeper discussion by mental health practitioners (MHP) on the potential benefits of engaging with families reportedly was absent. This lack of family inclusion was a source of concern for one parent supporting her young teenage daughter: “I would have liked to have had a chat to the counsellor on my own first, without [daughter] there. Yeah, I was surprised we didn't have that opportunity to do that” (P4, carer). Participants spoke of the benefits their mental health support had on their relationships with family members and others. Communication and assertiveness skills aided and improved relationships. Gaining insight into the impact of trauma on the brain supported connection to self, with increased self-awareness and understanding.

The importance of psychological safety and belonging was recognised within the therapeutic relationship and the organisation. The physical environment and reception from administrative staff were emphasised as influential in shaping how comfortable participants felt and the likelihood of remaining engaged. Small gestures of kindness, such as a smile and welcoming word, being offered a hot drink, being remembered, and finding common interests in conversations were appreciated by participants attending the service in a vulnerable state. As one participant commented, the service “is in a house which is, like a house … so it's a safer place to go” (P16). Service connectedness was enhanced by feeling heard and validated, demonstrations of empathy, and the experience of continuity of care, having the same practitioner over time. Some participants explained this was different to previous experiences of mental health supports, and appreciated feeling “supported; I don't feel very alone and out on a limb, very confused” (P13). A number of participants spoke of “check-ins”, brief monitoring conversations with a mental health nurse acting in the case manager role. This practice was introduced when clients waited weeks for mental health practitioner appointments for psychological therapy. Participants remarked this was something not experienced in previous MHS: “It was a surprise. It was nice to know that I was still on somebody's mind you know?” (P14). They felt valued, seen, and cared for. Practical measures could be implemented, if required, and the relationship with the organisation was strengthened.

Participants felt disconnected through a lack of communication, unreturned phone calls, an episode of care being abruptly closed due to a practitioner leaving or when they received an unfriendly reception at the administrative desk. One participant shared some of the obstacles to engagement:

a lot of the time the appointments didn't happen, because you didn't have the Zoom link and no one was there at reception to answer the calls or they were so busy you didn't hear from them for a few days. So that was disappointing. (P17)

Noisy or clinical (rather than homely) environments also could hamper connection. Participants spoke about the lack of onward referral or collaboration between various health service providers involved in their care, leading to feelings of being unsupported and needing to coordinate one’s own care with inadequate resourcing. Feeling disconnected could lead to a sense of helplessness and hopelessness, particularly if participants had unsuccessfully attempted to seek mental health support in the past.

Hope and Optimism

This theme had three components—hope renewed, looking forward, and losing hope. Participants spoke of ways their service interactions had promoted an optimistic view of the future and cultivated the possibility of recovery.

Hope was found in the mental health practitioners’ words and actions. For one participant, healing was possible through building trust and “opening up” (P6), revealing long suppressed thoughts and emotions. After spending long periods, sometimes years, unsuccessfully seeking mental health support, participants were relieved there was a free service they could access. They particularly appreciated making positive progress in managing their mental health challenges during a pandemic, when many services were inaccessible. Being provided with tools and resources to use over time helped participants feel hopeful about their future coping capacity. Gaining a deeper understanding of their own thoughts, emotions, and behaviour in the context of trauma alleviated self-blame and guilt. Reframing and validation were important components of this understanding. For some, looking forward to the next appointment provided hope of an emotional outlet and enabled better coping in the present. For others, hope was more long-term, seeding a belief that recovery was “all pretty possible” (P15).

Influences on Identity

Identity was shaped by various social, relational, and vocational roles participants performed, including parent, carer, migrant, musician, and mental health professional. Identities transitioned when participants made life changes, such as ceasing alcohol use or seeking help. One participant became a carer to her husband who had developed an illness. Participants with children spoke of the significance of their parenting role to their mental health and how parenting stress, such as worrying about the impact of pandemic lockdowns, exacerbated mental health challenges. The pandemic impacted on another participant’s identity and livelihood, with music gigs being cancelled abruptly. During these challenges and changes, engaging with the service was a way to claim, reclaim, explore or strengthen a positive identity. One participant stated “I needed that one hour per week to … find [out] more about myself” (P2); another “wanted someone to get to know the real me” (P3). Practitioners’ recognition of the unique characteristics and roles individuals undertook was experienced as validating. Having discussion and strategies tailored to these diverse roles assisted participants to feel understood holistically.

Meaning in Life

Participants perceived mental health practitioners (MHP) could enhance their meaning in life through supporting them to make sense of past events and experiences. Exploring the nature of significant relationships also created meaning. For parents, their children provided strong purpose and motivation for life, and indeed for seeking psychological support:

“a big part of why I'm doing it is for the kids” (P6). Meaning could also be derived from vocational pursuits or life goals. Reflecting on positive change that had occurred through the therapeutic engagement promoted a sense of meaning and purpose, such as “getting stronger through your life.” (P2)

This was connected with the concept of hope. Having tools to refer to activated a sense of accountability that progressed wellness goals.

Empowerment

Along with connectedness, empowerment was the strongest theme, with most participants speaking to the multitude of ways their experiences had boosted their personal agency or, alternatively, had diminished it. Feeling safe, gaining confidence, being provided with options, and contributing to shared treatment planning and decision making all fostered empowerment. Participants appreciated having choices over their practitioner’s discipline (e.g., nursing, social work) and whether appointments were face-to-face or via telehealth. They felt empowered through sharing experiences without fear of judgement. Being provided with tools, information, strategies, and resources was also helpful. For example, one participant found their mental health practitioner to be effective in “helping me be a bit more assertive … having my wants and needs communicated more clearly” (P1). Reframing a prior experience or situation diminished shame and guilt, making way for self-acceptance and self-compassion.

Feeling disempowered was associated with similar factors to disconnection: a lack of communication, abrupt closures, a lack of a clearly articulated treatment plan, feeling unheard, and long practitioner wait times. The intake and assessment stage could be a “bit invasive and overwhelming” (P18). A follow-up phone call the next day was recommended to reduce the impact of this potentially triggering process.

Beyond CHIME

Participants shared experiences not encapsulated within the CHIME framework, which were predominantly socioeconomic in origin. In describing contributing factors that led to contacting the mental health service, participants recounted long periods, often years, of mental health challenges, marked by distress, confusion, and coping strategies, they understood to be unhealthy and unsustainable. Stories of past trauma, such as sexual assault and family violence, were woven into participant accounts of what led them to requiring mental health support. Previous attempts to access mental health supports had been stifled by barriers, financial cost being the predominant factor. One participant, a migrant from a non-English speaking background, related her concerns when COVID-19 restrictions impacted on face-to-face service delivery:

I was scared … absolutely scared. And I thought, how will we make the connection by phone, when … my accent, my limitation, and vocabulary … Plus, the situation, a personal situation that is hard to open yourself [to], when you don’t know the other person. (P2)

However, being a rural cohort, issues of visibility, privacy, and confidentiality also were prominent. The latter shaped participant preferences for mode of service delivery. For two participants, being employed locally within the mental health sector elevated their concern for anonymity and they were relieved the service model accommodated referrals to practitioners from different locations who provided telehealth consultations. Parenting issues were an important consideration for some participants who sought support and strategies for responding to challenges with their children.

Discussion

In this article, the ways in which service users of a newly developed mental health service in a rural primary health setting described the recovery-oriented aspects of their experience are highlighted. In the light of the recent Royal Commission into Victoria’s Mental Health System (State of Victoria, 2021), more could have been done to implement and embed recovery elements within structures. While longstanding mental health services have attempted to retrofit recovery-oriented features into existing hierarchical medical models, the development of new services presents an opportunity to do something different. However, there were missed opportunities, potentially due to inadequate planning and lack of design inputs from multiple stakeholder perspectives, including lived-experience perspectives. Examples include poor collaboration and treatment planning with service users and GPs, and inadequate family-focused and carer support options. In the rush to activate an urgent response to the COVID-19 pandemic mental health crisis, most components of Australia’s ubiquitous individualistic clinical MHS approach, with associated limitations, were replicated. More recovery-focused features could have been integrated had those designing the model heeded the wise words of African Elders, often shared by Bayo Akomolafe, “the times are urgent, let us slow down” (2014).

Recovery practices were undertaken to a greater or lesser degree by practitioners, depending on their knowledge, experience, and therapeutic approach. It is not clear if these practices are attributed to the model and service structures or were inherent in the practitioners’ own approach. The findings suggest the CHIME personal recovery framework (Leamy et al., 2011) provides a lens to view recovery processes of a primary care mental health model. Participants emphasised the significance of connectedness and empowerment in shaping their episode of care and promoting recovery. A smooth entry supported participant service connection and a free service was of great assistance. The “check-ins” enhanced participants’ sense of belonging and helped them feel valued.

The importance participants placed on the physical space along with the role of non-clinical staff in creating a welcoming, safe, and inclusive environment speaks to the operationalisation of trauma-informed care (TIC). TIC is founded on safety, trustworthiness, choice, collaboration, and empowerment (Fallot & Harris, 2008). The data reinforced how participants perceived safety in the physical environment as an extension of treatment. Isobel et al. (2021) found participants wanted trauma to be raised and discussed and participants in our study concurred; a sense of empowerment and hope transpired when their thoughts, emotions, and behaviour were explained in the context of past traumatic experiences.

While we are unaware of other studies applying the CHIME framework to MHS in the primary care sector (Brijnath, 2015), it has been utilised in other settings such as aged care (McKenna et al., 2014), forensic mental health (Senneseth et al., 2022), and inpatient units. Previous researchers have found adjustments would be required to modify the framework to the predominant recovery needs of people in these diverse settings. CHIME also was tested with Anglo and Indian Australians in a community context (Brijnath, 2015). Findings indicated that although the five categories were relevant, there were nuances, such as experiences of stigma within connectedness, spirituality being strongly related to hope for Indian Australians, and socioeconomic stability being an important prerequisite for empowerment. The Brijnath study (2015) illuminated ways social and economic drivers of health influence recovery possibilities.

The lack of family-focused practice and/or carer support represents a missed opportunity to promote connectedness, hope, identity, and meaning through strengthening relationships and support systems, deepening family members’ understanding of the service users’ mental health challenges, and providing support and resources for those impacted, including children. Embedding family-focused practice in recovery models has met with multiple barriers despite dedicated resourcing (Allchin et al., 2020; Maybery et al., 2015b). Price-Robertson et al. (2017) described how relational recovery could enhance the CHIME framework (Leamy et al., 2011), bringing intimate interpersonal relationships to the fore and considering key relational roles including parenting.

Undermining recovery was the lack of collaboration between practitioners and service users in relation to setting treatment goals and determining priority needs. Choices were not fully outlined and explained to service users and thus participants were vague about the direction their treatment was taking. Furthermore, high staff turnover hampered recovery progress. As self-management and self-determination are key principles underpinning Australia’s national recovery (Australian Health Ministers’ Advisory Council, 2013), these elements are crucial. Collaboration with and referral to GPs and other health practitioners involved in the participants’ care also was deficient. Case coordination or planning activities are undermined by a private funding model that only recognises the time practitioners spend with clients.

These deficits reduced participant choice, trustworthiness, collaboration, and empowerment, which are key elements of trauma informed care (TIC) (Fallot & Harris, 2008). The consumer movement has embraced the slogan “nothing about us without us” and collaboration with the whole care team, privileging the priorities and perspectives of service users, is an area of service delivery which requires improvement (Bradley et al., 2015).

The rural MHS, which was the setting for this research, was established hastily, in the midst of a pandemic to address a rapid increase in demand (Maybery et al., 2022). There was little opportunity for detailed planning. Notwithstanding, national frameworks on recovery-oriented practice need to be incorporated into all mental health services and this was a missed opportunity. Transparency and accountability structures for monitoring recovery-oriented practice and challenging cultures and models that undermine recovery, are inadequate (Dawson et al., 2021). There are no mechanisms for national monitoring or accreditation of services against either recovery-oriented or TIC principles. Given the substantial government investment in private MHS, and the significant role these services play in mental health treatment, more attention needs to be directed towards ensuring recovery-oriented practices are embedded within this sector.

This research used broad recruitment strategies. Interviews were conducted with a cohort who had recently accessed this mental health service; a key strength was the diversity within this sample in relation to age, gender, socioeconomic dimensions, and cultural backgrounds. The interview depth captured the contexts of each participant’s experiences, and researchers were confident saturation was reached for service users.

Limitations

With only two carers represented, a limitation of these findings relates to carer experiences as these cannot be generalised to other populations or settings. Sampling bias also may be present. Participants had the time and inclination to participate and they may be a sample who had experiences they wanted to share. Future research should follow similar patient-oriented recovery lenses and delve into key components of treatment, in particular, initial engagement and intake, and the use of telemedicine for delivery of services.

Conclusion

Recovery-oriented practice has been endorsed as the overarching framework for MHS within Australia. However, there are substantial deficits in its integration into structures, policies, and practices. Although the CHIME framework provides a useful overview of key processes facilitating recovery, structures need to be developed to support and monitor implementation of recovery-oriented practice in private and primary care settings. Key areas for improvement include implementing family-focused practice to foster connectedness; more collaborative decision making with service users; and attention to the holistic experience including referrals, administration, communication, and the physical environment. Trauma-informed care principles emphasising safety, choice, and self-determination are congruent with recovery-oriented practice. Social workers ideally are placed to demonstrate leadership and drive practice change in this realm of recovery-oriented practice with its emphasis on strength-based, trauma-informed practice and specialised theoretical knowledge about family function and dynamics.

Acknowledgements

We would like to thank the participants of this study for sharing their experiences.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by evaluation funding from Gippsland Primary Health Network.

Appendix 1:

Themes and sub-themes

Table

Theme	Sub-theme	Example quotes
Fostering connectedness	Opportunities for family focus	I would have liked to have had a chat to the counsellor on my own first, without [my daughter] there. Yeah, I was surprised we didn't have that opportunity.
		there was (sic) some things that I'd spoken with her about that I hadn't spoken to anybody else about and … she encouraged me to start to talk to … my close family about some of the things that were going on, so that I could, you know, extend my support network and hopefully get on the right track
	Engagement and continuity	There was nothing clinical about it. And if you're early for an appointment, you get offered a cup of tea. Well, that's lovely. You feel like you're visiting a friend instead of, you know, a professional with a degree. Yeah. It is the reception staff, everyone, a friendly, welcoming place.
		They were very understanding, very empathetic, so supportive … They asked me if there were any triggers, and why I felt suicidal? What had led up to me feeling that way? And they explained what they could do for me to support me …
	Disconnection	A lot of the time the appointments didn't happen, because you didn't have the zoom link and no one was there at reception to answer the calls or they were so busy you didn't hear from them for a few days. So that was disappointing …
		But then the psychologist I was allocated to left. And they couldn't find anyone else to allocate me to. So I just kind of had no one for a long time.
Hope and optimism	Hope renewed	… by the end of this phone call with someone I've never met before, I was smiling. I thought, I have help. I have somewhere to go.
		I knew I needed it, so kind of something in me was like—this might be the answer because I was about ready to give up on asking for help.
	Looking forward	… she will say, what's your next step? … So it's, all pretty possible. But she's not reflecting on the past or if I relapse. I am of the opinion, if I do slip up, there's no blame.
	Losing hope	because they're so overwhelmed with clients, it would sometimes be like five to six weeks between appointments, which is really too long when you're struggling.
Influences on identity	Parenting	I went to find some help because I was (at) the tipping point as a mother that I can't manage, even manage my daughter, teenager, then I … maybe I didn't realise how much she was suffering as well.
	Vocational	And us as musicians, also, it's terrible, because you know, all our gigs have been cancelled. And again, it's really, you know, soul destroying, you know, you book all these gigs, and then one o'clock lockdown on Saturday, and that's it your gig for that night, you know, all your rehearsal and preparation to gig …
		… one of the things at intake that I discussed with them (was) that I had to know the name of the counsellor and see a picture to know if it was someone that I had worked with or known because I obviously didn't want to see someone that I knew personally.
		I’ve had to become the carer but it's a different sort of care when he doesn't quite realise what's going on within denial.
	Changing identity	it was hard for me to open. I think this is the hard part when you have to say, yes, I've got a problem. And I need some help.
		I've grown my hair long, I've shaved my head completely, I've gotten rid of the beard, I've worn pink clothes to go to doctor's appointments. I've done everything I can not to make myself look intimidating or not to come across as aggressive
		your life revolves around alcohol and so forth. I don't go to the pub anymore. I avoid parties. And going to the local cricket. It's just drinking sessions.
		I said … “I think I'm a bad person”. And she said, “what's a bad person?” And I went, “huh, paedophile murderer, you know?” And she said, “you think you're one of them? I wouldn't know” … It was like 40 years of guilt disappeared in one conversation … it has taken 40 years for me to walk out and think I'm not a bad person. Yeah, yeah. I did it for survival, for preservation.
	Describing finding self	… psychologists use different ways and techniques to adapt with their patients. And I find that definitely(the service) adapts to their patients a lot more than other places. Which is definitely good because obviously, they see people of all different natures, whereas my other psychologist didn't really do that. It was just the same technique.
		I wanted someone to get to know the real me … So they can understand the entire me. So I'm not getting misdiagnosed. So I can finally get the help I need. Speaking to a different person each time does nothing.
Meaning in Life	Being a good parent	I went through a hard divorce and I have to raise my daughter by myself. And it was good and bad, but more good things than bad. Because she was always my motor or my battery to keep going and keep moving.
		… my kids are first, like, I'm not the type of parent and I know this with every fibre of my being, I would never hurt my kids. No matter how bad I was inside my own head.
	Understanding the meaning of past events	… things that I hadn't discussed with anybody else. And so, you know, it was, like, pretty confronting and upsetting at the time to discuss those sorts of things, but I did. I did feel as though it was necessary to and that was, you know, part of the reason why I was seeking that appointment, it was to try and help to, you know, come to terms with some of those things and be able to discuss
	Seeing positive change	… I have to think glass half-full and I get stronger. That was the main thing that you are getting stronger through your life.
	Gaining resources	I keep a notepad with all the key points that my therapist touched on with me, that helped me look back, and I sit and I go through the dot points of certain stuff that was said, and I go, okay, am I doing this? No, I'm not doing that. When, yes, I am doing this, this is how I fix it.
Empowerment	Having choice, accessible options	I do prefer in person, I get distracted very easily, especially over the phone. Speaking to people over the phone, all I'm looking at is a blank screen on my phone, or I'm just looking at my hands … in person … it is more obvious that I'm feeling very comfortable with what I'm speaking about.
		I can build rapport and stuff with the psych perfectly fine over the phone. I'm not a big fan of zoom sessions, I just find it really awkward … I just get tired having to like maintain a fake smile during a session
		… if I felt like my next appointment was too far away, I can say, “can I please have a check in” and that way I still feel like, I don't know the right word, but it made me feel like I was able to talk to people all the time.
	Feeling confident/safe to share	And every now and then, over the last month, I have felt good in the fact that I can go there and spill it all and get … a bit of direction which is really, really good stuff.
		… she let me talk. She was directed by, you know what I was saying. And she just let me talk … it's just allowing me my space to talk.
	Shared planning, collaborative decisions	we did discuss, I guess, yes, somewhat of a treatment plan in terms of, you know, what I needed to do to get certain referrals from my doctor … whether I needed different medication or whatnot. And then we spoke about how regularly I should be speaking to her and speaking to the psychologist …
		you didn't have that sort of feeling of pressure to like, get everything achieved in 10 sessions. But I suppose it might have been nice to have a little bit of an idea of what they were thinking.
		We did talk about what my goals were and what my aims were of coming to counselling. So I guess I probably did have one. But it just wasn't something I wrote down on paper type thing
		it would have been nice if all the various people talked, just like came up with a collaborative kind of plan, rather than me having to kind of constantly advocate for myself.
	Gaining information, resources and skills	I feel much, like I said before, empowered, and I'm learning strategies. I've been receiving emails, some paperwork from my current counsellor, and she's been helpful in strategies for me to be more assertive without being inflammatory towards getting myself heard … she's been giving me breathing stuff, too, in case I'm starting to get feeling anxious
		She explained everything to me, how to cope when I can't, why my body reacts the way it does and I've never had that before. You know every, all my emotions and my reactions are a direct result from trauma and I didn't understand that at all and she explained it to me but without making me feel stupid, without making me feel confronted, without making me feel like what I was saying was wrong.
		I think she's probably picked up that I’m the sort of person who, if I've got information and if I've got resources, I'm very capable of sort of taking all that up.
	Receiving validation	He was helpful in in me assessing that, you know, that I shouldn't feel guilt for, you know, what had been done and all this sort of stuff. So it was a bit of empowering stuff for me, which was good.
		I felt like my mental health got a lot better, I stopped being so hard on myself about guilt and shame and emotions that I'd been having about things that had happened in my situation. Because I just felt like the counsellors supported me and understood me … weren't judging me, they were like, very, sort of empowering and encouraging of me, and the decisions I was making.
	Changing mindset	things happen for a reason. And, yeah, I have to be focusing on the positive things and the good things that we got … understand that mistakes sometimes have to be done. But the main thing is you're learning from the mistakes the lesson from life.
		at one point you have to reach that moment, you have to analyse and you have to stop and make a clear idea what is the best for you and sometimes what we are doing is not the best way so we have to learn.
	Disempowering processes	I feel like am I getting that reputation as being the person who doesn't like this and that? So now, this feeling iffy about actually asking for what I want, advocating for myself
		I'm almost feeling like I would do better managing my own mental health on my own than seeing head to help. It's just been such a wild ride and so much causing more stress than it's helping to reduce.
		they asked you about family violence or sexual assault or something they would ask you for more detail. And I kind of felt for an intake assessment process that was a little bit uncomfortable, because it was the kind of stuff you want to wait to talk to the counsellor about.
		there wasn't enough time allocated for the amount of information I was trying to cover and the amount of questions so sort of when I left the first assessment session, I felt really overwhelmed. Like it brought up a lot of trauma, and a lot of things and then it's like you just go home and wait for a counsellor.
	Abrupt closures	they told us that it's closed down in (our town) and there are no places in (the next town) for us to go. Which is a shame. And they said that initially, they'd been given five years funding and then they've just cut it off. So which was really disappointing.
		… we were told that's it, sorry. See you later … they told us, we would have to go and get private … pay for it privately, yourself.