What recovery can look like

Like many people working in mental health, I have always been motivated by a desire to reduce people's distress. I wasn't sure exactly what form this should take and so I followed my interests, studying A-levels in Biology, Chemistry and Maths (perhaps with the implicit drive towards medical science) before a BSc in neuroscience. Over time, I discovered I was more interested in the complexities of people's behaviour than their biochemical compositions. Thus, I began to angle towards clinical psychology. 

My understanding of clinical psychology began with textbooks and statistics: 'treatment' follows rigid protocols, recovery is measured by symptom reduction on standardised tests, and evidence-based practice means adherence to manualised therapies. Perhaps my background in the hard sciences biased me to a particular view of psychology. Yet this medicalised approach seemed to be reflected in much of the prescriptive work my newly graduated colleagues undertook in statutory psychology services. Their jobs seemed to involve delivering semi-scripted interventions and aiming to meet neat target numbers of recovered patients.

These colleagues described a lack of humanity in their work. Many of them lost touch with the motivations that brought them into the field in the first place. Some colleagues left their jobs due to emotional fatigue. The problems with these target-based rigid protocols and emphasis on throughput were articulated well for me in James Davies' (2021) Sedated, a book that got me thinking that there must be something missing from how mental health interventions are commonly delivered. It wasn't until I began working as a recovery practitioner with the Devon Mental Health Alliance (DMHA) that I saw an alternative approach.

In what follows, I would like to share six lessons from my time working at the DMHA that have taught me about what recovery from 'severe mental illness' can look like and how I've seen a service do it differently.

What does the Devon Mental Health Alliance do?

The DMHA was formed at the introduction of the Community Mental Health Framework, a 2019 NHS program aimed at facilitating community-based, person-centred approaches to mental health care. Recovery practitioners within the DMHA work on a 1:1 basis with individuals diagnosed with severe mental illnesses, individuals that often do not meet the neat criteria for primary or secondary statutory care. Recovery practitioners use skills such as those in Dialectical Behavioural Therapy (Linehan, 1993) to help clients develop a toolkit for emotional regulation. Yet rather than adhering to a fixed curriculum, these skills are shared through a responsive, relational approach – one that starts with trust.

Lesson 1: The therapeutic relationship

An early lesson – which may have been difficult to learn in a classroom – was the importance of the therapeutic relationship. At 10 a.m. on my first day, I sat opposite my first client, notes in hand: a basic formulation and worksheets on mindfulness and breathing skills. But after I welcomed them, they launched into a detailed account of how their life had unravelled. My materials stayed on my lap. I listened and found my humanity roused. The empathy that brought me into the field in the first place emerged. In true Rogerian fashion, the simple act of sitting in the professional's chair and hearing my client's story facilitated their self-acceptance and confidence. I hadn't appreciated the significance of simply meeting a client with sincere empathy and fostering human connection.

Before this, I'd seen psychological interventions as a structured delivery of techniques. My science background and classroom education on protocol-heavy services had shaped a view of recovery as score improvement after specific intervention delivery. Yet research corroborates the centrality of therapeutic relationship to recovery. For example, a meta-analysis of 295 studies found it to be significantly associated with positive outcomes (Flückiger et al., 2018). Indeed, this effect is found independent of the type of therapy (Ardito & Rabellino, 2011). Thus, the therapeutic relationship is central to the intervention. As one client put it: "Being seen, validated, and understood is life-changing".

For recovery practitioners, that relationship is facilitated both through the lack of rigid scripts or protocols but also through the culture created by the DMHA. Central values of the DMHA include listening, respect and honesty. My first lesson had been its particularly radical approach to listening.

Lesson 2: The person-centred approach

Placing the client's subjective experience at the centre of the intervention is another lesson which would be difficult to truly grasp in a classroom. It is something to which recovery practitioners take a radical approach. Whilst interventions aimed at treating diagnoses often use a highly prescriptive approach (Bracken et al., 2012), the logistics of the DMHA allow recovery practitioners to put the experiences of the individual at the centre of their work. For example, after a client disclosed to their practitioner that they had a fear of sea swimming, a colleague of mine drove to the beach with them to work on practising techniques by the sea. This was not about reducing their GAD-7 score but ensuring that this client could return to enjoying days at the beach.   

The effectiveness of the person-centred approach lies in its ability to foster autonomy, self-efficacy, and engagement – factors that have consistently been associated with improved outcomes in recovery (Ryan & Deci, 2000a; Slade, 2009). Practitioners can empower individuals by being allowed to use the meaning made by the client to inform practical components of their work. Again, this approach is created through the culture of the DMHA. Yet the logistics of the service that recovery practitioners offer is also geared towards empowering individuals.

Lesson 3: Freedom for clients to return

In 2024, I conducted a systematic review of meta-analyses investigating factors predicting the efficacy of CBT for treating bipolar disorders. One factor I investigated was the most effective number of sessions for symptom reduction. I hadn't appreciated that intervention sessions are not drugs for which you can discover a dose-response relationship. I had missed how disempowering it might be to tell an individual that they have come to the end of their sessions, particularly at a time when they may have experienced a distressing downturn in their mental health due to any number of unpredictable factors. 

Empowerment is a key component of recovery (Leamy et al., 2011). This means returning personal responsibility and control to individuals. Whilst DMHA recovery practitioners generally offer 6–10 sessions to their clients, clients are then given the power to decide to return back to working with their practitioner if they feel it is necessary – reflecting that fact that recovery is rarely a linear process (Leonhardt et al., 2017). This came as a surprise to a client of mine who had previously been placed under a section 2 on a psychiatric ward. For this individual, knowledge that they were able to return as required empowered them to return to work, testing their toolbox of Dialectical Behavioural Therapy-based emotion regulation skills with the possibility of returning if they experienced a downturn. In addition to reducing the 'need to recover' for the individual, this takes pressure off practitioners who know that their clients will be back in touch if they require.

Lesson 4: Practitioner autonomy is important

Just as client autonomy supports recovery, practitioner autonomy is equally vital to foster their own motivation and wellbeing. Most individuals working in mental health are propelled by a desire to reduce distress. The fundamental motivator for our work is seeing clients improve, facilitated by the effort we put in. Seeing clients decline is hard enough without being reprimanded for declining standardised scores, particularly if the decline is affected by factors beyond practitioner's control (a scene I witnessed for a friend of mine working in a statutory service).

Research indicates that rigid, target-driven systems often create ethical dilemmas for professionals, potentially leading to moral injury – the distress caused by actions that violate one's ethical code (Griffin et al., 2019). For example, practitioners may be under pressure to collect standardised measure scores even when their judgement tells them the questions would presently be inappropriate or intrusive. This is compounded by burnout, also exacerbated when practitioners lack control over their work (Maslach & Leiter, 2016; O'Connor et al., 2018). Self-Determination Theory argues that fostering practitioners' autonomy and competence results in greater fulfilment and helps sustain their therapeutic effectiveness (Martela et al., 2021; Ryan & Deci, 2000b).

The DMHA's approach achieves this by avoiding strict performance-based targets. While we collect anonymised ReQoL-10 (Keetharuth et al., 2018) outcome measures (as well as qualitative feedback), practitioners are not held to meeting particular standardised score changes. This flexibility has been crucial in my own work. Being able to focus on what matters most for each individual, rather than meeting targets on sometimes irrelevant metrics, has preserved my professional wellbeing while facilitating better care. Studies confirm that such autonomy reduces burnout and improves outcomes (O'Connor et al., 2018). Supporting practitioners ultimately benefits clients too.

Lesson 5: The importance of cross-service communication

Perhaps the most commonly taught alternative to the medical model of mental health is the biopsychosocial model. Four years of neuroscience gave me a good grasp of the bio and psycho components of this model. Yet it wasn't until I sat with a client facing eviction, their anxiety overwhelming them, that I grasped what 'social' truly meant. This was not a deficiency of available serotonin in their synapses or disordered thinking. Our social environments are crucial contributors to mental health. Indeed, individuals in low-income groups are 2-3 times more likely to develop a severe mental illness (Sareen et al., 2011), indicating how important environment is.

A key aim of the Community Mental Health Framework was to ensure that mental health care was embedded in communities. For recovery practitioners, this means we may be assisting with PIP applications and liaising with housing services but also attending community music and gardening groups with clients. Indeed, the DMHA employs Community Mental Health Development Leads, whose job it is to connect relevant services. Helping clients solve these problems avoids the need for highly skilled medical and psychological professionals delivering complex interventions but solves the problem where it is truly located.

Challenges

The DMHA is not perfect. Indeed, it faces similar challenges to many other mental health services. The most pertinent challenge is the rapidly increasing waiting list and wait times for referred clients. A second (though attached) challenge is ensuring that the most appropriate individuals are referred, as referrals rely on local services understanding this novel service. Thirdly, it takes time for practitioners to become effective in their role as they develop relationships with local services and an understanding of how to work effectively. Yet my final lesson comes from the DMHA's ability to grow in response to challenges. 

Lesson 6: Freedom for learning

The DMHA fosters a culture which is adaptable in response to new challenges. The lack of overly rigid protocols allows space for learning at different levels of the hierarchy. On the ground, the within-session freedom for me as a practitioner meant that I could spend more time assisting universal credit transitions when benefits laws changed. For management, this means the freedom to pursue novel avenues like group interventions and new training days. I hadn't appreciated the need for this adaptability until working in the real world in which social environments are rapidly changing. This was a strange story to share with friends in statutory services who work in the confines of established structures which struggle to adapt to change. 

A different way of doing mental health?

I entered the mental health field driven by a simple desire to reduce distress. But working with the DMHA has reshaped how I understand that aim. Recovery isn't just about reducing symptoms or delivering interventions, it's about relationships, autonomy, and meeting people where they are. It's about shifting from "what treatment should I deliver?" to "what matters to this person, right now?"

This is not a blueprint for how every service should operate. Statutory services carry the immense responsibility of supporting vast numbers of people, often under the weight of growing waiting lists and limited resources. Indeed, the ability of those services to offer accessible and effective care to the majority of people with mental health problems is what creates the space for services like the DMHA to work more creatively with individuals who fall outside standard criteria. This article is not a critique of those systems but simply a story of my own personal growth: how I've come to see a different way of doing mental health to that which I'd heard about in the classroom.

Each of the six lessons I've shared came from stepping away from rigid frameworks and into a space where human connection, flexibility, and collaboration were not just allowed but encouraged. This experience has not only deepened my understanding of recovery but fostered my motivation for this work. The DMHA has shown me that with the right values and structure, we can rediscover the heart of why most of us entered this field in the first place.

References

Ardito, R. B., & Rabellino, D. (2011). Therapeutic Alliance and Outcome of Psychotherapy: Historical Excursus, Measurements, and Prospects for Research. Frontiers in Psychology, 2, 270. 

Bracken, P., Thomas, P., Timimi, S., Asen, E., Behr, G., Beuster, C., Bhunnoo, S., Browne, I., Chhina, N., Double, D., Downer, S., Evans, C., Fernando, S., Garland, M. R., Hopkins, W., Huws, R., Johnson, B., Martindale, B., Middleton, H., … Yeomans, D. (2012). Psychiatry beyond the current paradigm. The British Journal of Psychiatry, 201(6), 430–434. 

Davies, J. (2021). Sedated: How Modern Capitalism Caused our Mental Health Crisis. Atlantic Books.

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. 

Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral Injury: An Integrative Review. Journal of Traumatic Stress, 32(3), 350–362. 

Keetharuth, A. D., Brazier, J., Connell, J., Bjorner, J. B., Carlton, J., Taylor Buck, E., Ricketts, T., McKendrick, K., Browne, J., Croudace, T., & Barkham, M. (2018). Recovering Quality of Life (ReQoL): A new generic self-reported outcome measure for use with people experiencing mental health difficulties. The British Journal of Psychiatry, 212(1), 42–49. 

Leamy, M., Bird, V., Boutillier, C. L., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. The British Journal of Psychiatry, 199(6), 445–452. 

Leonhardt, B. L., Huling, K., Hamm, J. A., Roe, D., Hasson-Ohayon, I., McLeod, H. J., & Lysaker, P. H. (2017). Recovery and serious mental illness: a review of current clinical and research paradigms and future directions. Expert Review of Neurotherapeutics, 17(11), 1117-1130. 

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Publications.

Litz, B. T., & Walker, H. E. (2025). Moral Injury: An Overview of Conceptual, Definitional, Assessment, and Treatment Issues. 

Martela, F., Gómez, M., Unanue, W., Araya, S., Bravo, D., & Espejo, A. (2021). What makes work meaningful? Longitudinal evidence for the importance of autonomy and beneficence for meaningful work. Journal of Vocational Behavior, 131, 103631. 

Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry, 15(2), 103–111.

O'Connor, K., Neff, D. M., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53, 74–99. 

Ryan, R. M., & Deci, E. L. (2000a). Intrinsic and Extrinsic Motivations: Classic Definitions and New Directions. Contemporary Educational Psychology, 25(1), 54–67. 

Ryan, R. M., & Deci, E. L. (2000b). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. 

Sareen, J., Afifi, T. O., McMillan, K. A., & Asmundson, G. J. G. (2011). Relationship Between Household Income and Mental Disorders: Findings From a Population-Based Longitudinal Study. Archives of General Psychiatry, 68(4), 419–427. 

Slade, M. (2009). Personal Recovery and Mental Illness: A Guide for Mental Health Professionals. Cambridge University Press.