Changing the culture of mental health service delivery

MHR article in the Irish Medical News, April 2013

By Orla Barry

The recovery principle set out in the Government’s mental health policy A Vision for Change represents a cultural challenge to reform of the mental health services. Pointing beyond issues of quality, scope and structure, the recovery principle evokes a new ethos to underpin service delivery. From the perspective of Mental Health Reform, the national coalition promoting improved mental health services, the culture change required includes five key practices: hope, listening, choice, partnership and social inclusion.

Hope: One hallmark of a recovery-orientated mental health service is a hopeful attitude conveyed by staff. People have described how the hopeful attitude of a key mental health worker or family member helped them to believe in their own capacity to recover.

Listening: Mental health professionals who work within a recovery ethos listen attentively to the individual who is seeking help. This listening involves three aspects:

1)                  Listening to the individual’s personal understandings of their condition. Individual service users may have different values to those of their treating clinician and these values should be respected. The individual’s interpretation of their experience may differ from the clinician’s and though it may not appear to be clinically significant, the individual’s interpretation may be equally important for determining appropriate support.

2)                  Listening to the individual’s aspirations and goals for his/her life. Only by understanding what the individual wants to get out of life can the mental health professional ensure that support is organised in a way that facilitates the person’s life goals, rather than hinders them.

3)                  Listening to the individual’s own knowledge about what helps them to recover and stay well. People living with a mental health condition develop an understanding of their condition over time. They often know from their own experience what works best for them in maintaining their mental health and what doesn’t. They know their experience of side effects from medications. They often know what triggers their mental distress. They know how they will define their own recovery. All of this self-knowledge is an important resource for recovery planning.

Family members and friends also need to be heard. Where permission has been given by the individual concerned, family members can provide useful information to mental health workers about what triggers the individual’s mental distress, the usual signs when the individual is starting to deteriorate and what has helped their loved one to recover in the past. Family members may need mental health support as well; listening to family members’ concerns may help to alert mental health staff to their mental health needs. The Mental Health Commission has stated that community mental health teams should provide support to family members, including on-going emotional support, respite care, assistance with accessing other types of services and education about mental health.[1]

Partnership: At a one-to-one level, working with service users as equal partners in their own care is key to redressing the traditional power imbalance between service users and professionals in the mental health services. A recovery-orientated approach demands equality between mental health staff and users of services.

Recovery planning involves a dialogue between the individual concerned, professional and carer (where relevant) in which meaningful communication about both the understanding of the ‘problem’ and the steps towards recovery takes place. Each participant has a valued role to play in this dialogue so that the combined expertise of clinician, person with a mental health condition and relative can be brought to bear on the perceived difficulty. And even though the ultimate decision must rest with the individual about his/her mental health treatment, the best outcomes are likely to come through shared learning between all parties.

Choice: People in Ireland have been calling for greater choice in mental health treatments for many years. People must be offered choices – of treatments and therapies, of who provides their care, of when and where supports are provided. To be able to make well-informed choices, individuals also need good quality, comprehensive and balanced information, including information about the risks and benefits of treatments.

Social inclusion:

A key aspect of the recovery ethos is the recognition that recovery is about more than reducing mental health symptoms – it concerns developing a meaningful life. Recovery-orientated mental health services have an important role to play in supporting people with a mental health condition to participate in their local community, have social relationships and engage in meaningful activities including education and employment.[2]

Implementing recovery in a time of economic crisis        

It would be tempting to consider this vision of a recovery-orientated service as ambitious. One could argue that current resource constraints imposed on the public mental health services make such a reform unrealistic. Certainly taking the time to listen to service users’ interpretations of their condition, life goals and self-management techniques requires resources. But one might well ask how efficient a service is that does not listen to its customers? When people receiving treatment are not listened to, they may ignore professional advice, or stop treatment. Just as bad, they may continue to endure unhelpful treatment for many years without recovering the quality of life and full citizenship that they could. Services that listen to their ‘customers’ are likely to produce better outcomes based on support that reflects the individual’s needs and life goals.

Adopting the recovery ethos may also equip services to survive and thrive in the future. With the focus on strengthening the individual’s capacity to manage and sustain their own mental health, mental health professionals become facilitators of self-care, rather than sole providers of care. Placing greater responsibility on people for their own recovery will facilitate them to be active participants rather than passive recipients of care. Mental Health Reform has heard from many people that recovery from mental health difficulties is a very personal journey and, alongside support from family, friends, peers and their community, recovery-orientated services will help people on that journey, step by step.


Mental Health Reform has recently produced an information leaflet for service users and family members/carers, called Recovery – what you should expect from a good quality mental health service. Copies are available from, from our website or by calling (01) 6121422.

[1] Byrne M, Onyett S. Teamwork within Mental Health Services in Ireland: Resource paper. Dublin: Mental Health Commission, 2010, p 14.

[2] Repper J, Perkins R. Social Inclusion and Recovery. London: Ballière Tindall, 2003.


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