Investigating the impact of the COVID-19 pandemic on recovery colleges: multi-site qualitative study.

BACKGROUND: During the COVID-19 pandemic, mental health problems increased as access to mental health services reduced. Recovery colleges are recovery-focused adult education initiatives delivered by people with professional and lived mental health expertise. Designed to be collaborative and inclusive, they were uniquely positioned to support people experiencing mental health problems during the pandemic. There is limited research exploring the lasting impacts of the pandemic on recovery college operation and delivery to students. AIMS: To ascertain how the COVID-19 pandemic changed recovery college operation in England. METHOD: We coproduced a qualitative interview study of recovery college managers across the UK. Academics and co-researchers with lived mental health experience collaborated on conducting interviews and analysing data, using a collaborative thematic framework analysis. RESULTS: Thirty-one managers participated. Five themes were identified: complex organisational relationships, changed ways of working, navigating the rapid transition to digital delivery, responding to isolation and changes to accessibility. Two key pandemic-related changes to recovery college operation were highlighted: their use as accessible services that relieve pressure on mental health services through hybrid face-to-face and digital course delivery, and the development of digitally delivered courses for individuals with mental health needs. CONCLUSIONS: The pandemic either led to or accelerated developments in recovery college operation, leading to a positioning of recovery colleges as a preventative service with wider accessibility to people with mental health problems, people under the care of forensic mental health services and mental healthcare staff. These benefits are strengthened by relationships with partner organisations and autonomy from statutory healthcare infrastructures.

Organisational and student characteristics, fidelity, funding models, and unit costs of recovery colleges in 28 countries: a cross-sectional survey.

BACKGROUND: Recovery colleges were developed in England to support the recovery of individuals who have mental health symptoms or mental illness. They have been founded in many countries but there has been little international research on recovery colleges and no studies investigating their staffing, fidelity, or costs. We aimed to characterise recovery colleges internationally, to understand organisational and student characteristics, fidelity, and budget. METHODS: In this cross-sectional study, we identified all countries in which recovery colleges exist. We repeated a cross-sectional survey done in England for recovery colleges in 28 countries. In both surveys, recovery colleges were defined as services that supported personal recovery, that were coproduced with students and staff, and where students learned collaboratively with trainers. Recovery college managers completed the survey. The survey included questions about organisational and student characteristics, fidelity to the RECOLLECT Fidelity Measure, funding models, and unit costs. Recovery colleges were grouped by country and continent and presented descriptively. We used regression models to explore continental differences in fidelity, using England as the reference group. FINDINGS: We identified 221 recovery colleges operating across 28 countries, in five continents. Overall, 174 (79%) of 221 recovery colleges participated. Most recovery colleges scored highly on fidelity. Overall scores for fidelity (ß=-2·88, 95% CI 4·44 to -1·32; p=0·0001), coproduction (odds ratio [OR] 0·10, 95% CI 0·03 to 0·33; p<0·0001), and being tailored to the student (OR 0·10, 0·02 to 0·39; p=0·0010), were lower for recovery colleges in Asia than in England. No other significant differences were identified between recovery colleges in England, and those in other continents where recovery colleges were present. 133 recovery colleges provided data on annual budgets, which ranged from €0 to €2 550 000, varying extensively within and between continents. From included data, all annual budgets reported by the college added up to €30 million, providing 19 864 courses for 55 161 students. INTERPRETATION: Recovery colleges exist in many countries. There is an international consensus on key operating principles, especially equality and a commitment to recovery, and most recovery colleges achieve moderate to high fidelity to the original model, irrespective of the income band of their country. Cultural differences need to be considered in assessing coproduction and approaches to individualising support. FUNDING: National Institute for Health and Care Research.

Evidence-based Recovery Colleges: developing a typology based on organisational characteristics, fidelity and funding.

PURPOSE: Recovery Colleges (RCs) have been implemented across England with wide variation in organisational characteristics. The purpose of this study is to describe RCs across England in terms of organisational and student characteristics, fidelity and annual spending, to generate a RC typology based on characteristics and to explore the relationship between characteristics and fidelity. METHODS: All RC in England meeting criteria on recovery orientation, coproduction and adult learning were included. Managers completed a survey capturing characteristics, fidelity and budget. Hierarchical cluster analysis was conducted to identify common groupings and generate an RC typology. RESULTS: Participants comprised 63 (72%) of 88 RC in England. Fidelity scores were high (median 11, IQR 9-13). Both NHS and strengths-focussed RCs were associated with higher fidelity. The median annual budget was £200,000 (IQR £127,000-£300,000) per RC. The median cost per student was £518 (IQR £275-£840), cost per course designed was £5,556 (IQR £3,000-£9,416) and per course run was £1,510 (IQR £682-£3,030). The total annual budget across England for RCs is an estimated £17.6 m including £13.4 m from NHS budgets, with 11,000 courses delivered to 45,500 students. CONCLUSION: Although the majority of RCs had high levels of fidelity, there were sufficiently pronounced differences in other key characteristics to generate a typology of RCs. This typology might prove important for understanding student outcomes and how they are achieved and for commissioning decisions. Staffing and co-producing new courses are key drivers of spending. The estimated budget for RCs was less than 1% of NHS mental health spending.

Who uses recovery colleges? Casemix analysis of sociodemographic and clinical characteristics and representativeness of recovery college students.

OBJECTIVE: Recovery Colleges support recovery for adults with mental health problems, through coproduction and education principles. This study aimed to determine whether students at three Recovery Colleges in England were representative of mental health service users. METHODS: Gender, age, ethnicity, diagnosis, involuntary detention, and inpatient admission were extracted from clinical records. Data for all service user students enrolled, and those who had attended 70% of a Recovery College course were compared to mental health services caseloads, using chi-square goodness-of-fit tests. RESULTS: Clinical records were identified for 1,788 students. Significant differences were identified for gender, age, and diagnosis (p < .001). In some Colleges, more students had recent inpatient admissions or involuntary detentions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Service user students were largely representative of mental health service users, although some groups were underrepresented. Further research is needed to understand why, so that Recovery Colleges can continue to address inequalities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Recovery Colleges Characterisation and Testing in England (RECOLLECT): rationale and protocol.

BACKGROUND: Recovery Colleges are a relatively recent initiative within mental health services. The first opened in 2009 in London and since then numbers have grown. They are based on principles of personal recovery in mental health, co-production between people with lived experience of mental health problems and professionals, and adult learning. Student eligibility criteria vary, but all serve people who use mental health services, with empirical evidence of benefit. Previously we developed a Recovery College fidelity measure and a preliminary change model identifying the mechanisms of action and outcomes for this group, which we refer to as service user students. The Recovery Colleges Characterisation and Testing (RECOLLECT) study is a five-year (2020-2025) programme of research in England. The aim of RECOLLECT is to determine Recovery Colleges' effectiveness and cost-effectiveness, and identify organisational influences on fidelity and improvements in mental health outcomes.  METHODS: RECOLLECT comprises i) a national survey of Recovery Colleges, ii) a prospective cohort study to establish the relationship between fidelity, mechanisms of action and psychosocial outcomes, iii) a prospective cohort study to investigate effectiveness and cost-effectiveness, iv) a retrospective cohort study to determine the relationship between Recovery College use and outcomes and mental health service use, and v) organisational case studies to establish the contextual and organisational factors influencing fidelity and outcomes. The programme has been developed with input from individuals who have lived experience of mental health problems. A Lived Experience Advisory Panel will provide input into all stages of the research. DISCUSSION: RECOLLECT will provide the first rigorous evidence on the effectiveness and cost effectiveness of Recovery Colleges in England, to inform their prioritising, commissioning, and running. The validated RECOLLECT multilevel change model will confirm the active components of Recovery Colleges. The fidelity measure and evidence about the fidelity-outcome relationship will provide an empirically-based approach to develop Recovery Colleges, to maximise benefits for students. Findings will be disseminated through the study website (researchintorecovery.com/recollect) and via national and international Recovery College networks to maximise impact, and will shape policy on how Recovery Colleges can help those with mental health problems lead empowered, meaningful and fulfilling lives.

Recovery Colleges After a Decade of Research: A Literature Review.

OBJECTIVE: Since the first recovery college (RC) opened in England in 2009, many more have begun operating around the world. The body of knowledge regarding the effects of RCs is growing, suggesting their benefit to recovery, well-being, goal achievement, knowledge, self-management, social support, reduced stigma, and service use. The objective of this review was to establish the state of knowledge about RCs from current empirical literature and to document the methods used to evaluate them. METHODS: In consultation with an international expert panel, two independent evaluators performed a literature review with no date limits on publications in the Medline and Scopus electronic databases. RESULTS: A total of 460 articles were found, and 31 publications were retained. RC attendance was associated with high satisfaction among students, attainment of recovery goals, changes in service providers' practice, and reductions in service use and cost. CONCLUSIONS: To our knowledge, this is the first literature review of peer-reviewed publications about original studies evaluating the impacts of RCs, including studies pertaining to students, health service providers' practices, education and management practitioners, and citizens. Quantitative studies with a high level of evidence were underrepresented and should be considered as a future evaluation design. Furthermore, outcomes such as empowerment and reduced stigma should be assessed with standardized tools. The impact of RCs on attendees, family, friends, and caregivers and on the everyday practice of health service providers who attend RCs for continuing education or as tutors should also be assessed.

Development and Evaluation of a Recovery College Fidelity Measure.

OBJECTIVE: Recovery Colleges are widespread, with little empirical research on their key components. This study aimed to characterize key components of Recovery Colleges and to develop and evaluate a developmental checklist and a quantitative fidelity measure. METHODS: Key components were identified through a systematized literature review, international expert consultation (n = 77), and semistructured interviews with Recovery College managers across England (n = 10). A checklist was developed and refined through semistructured interviews with Recovery College students, trainers, and managers (n = 44) in 3 sites. A fidelity measure was adapted from the checklist and evaluated with Recovery College managers (n = 39, 52%), clinicians providing psychoeducational courses (n = 11), and adult education lecturers (n = 10). RESULTS: Twelve components were identified, comprising 7 nonmodifiable components (Valuing Equality, Learning, Tailored to the Student, Coproduction of the Recovery College, Social Connectedness, Community Focus, and Commitment to Recovery) and 5 modifiable components (Available to All, Location, Distinctiveness of Course Content, Strengths Based, and Progressive). The checklist has service user student, peer trainer, and manager versions. The fidelity measure meets scaling assumptions and demonstrates adequate internal consistency (0.72), test-retest reliability (0.60), content validity, and discriminant validity. CONCLUSIONS: Coproduction and an orientation to adult learning should be the highest priority in developing Recovery Colleges. The creation of the first theory-based empirically evaluated developmental checklist and fidelity measure (both downloadable at researchintorecovery.com/recollect ) for Recovery Colleges will help service users understand what Recovery Colleges offer, will inform decision making by clinicians and commissioners about Recovery Colleges, and will enable formal evaluation of their impact on students.

Mechanisms of Action and Outcomes for Students in Recovery Colleges.

OBJECTIVE: Recovery colleges are widespread, with little empirical research on how they work and the outcomes they produce. This study aimed to coproduce a change model characterizing mechanisms of action (how they work) and outcomes (their impact) for mental health service users who attend recovery colleges. METHODS: A systematized review identified all publications about recovery colleges. Inductive collaborative data analysis of 10 key publications by academic researchers and coresearchers with lived experience informed a theoretical framework for mechanisms of action and student outcomes, which was refined through deductive analysis of 34 further publications. A change model was coproduced and refined through stakeholder interviews (N=33). RESULTS: Four mechanisms of action for recovery colleges were identified: empowering environment (safety, respect, and supporting choices), enabling different relationships (power, peers, and working together), facilitating personal growth (for example, coproduced learning, strengths, and celebrating success), and shifting the balance of power through coproduction and reducing power differentials. Outcomes were change in the student (for example, self-understanding and self-confidence) and changes in the student's life (for example, occupational, social, and service use). A coproduced change model mapping mechanisms of action to outcomes was created. CONCLUSIONS: Key features differentiate recovery colleges from traditional services, including an empowering environment, enabling relationships, and growth orientation. Service users who lack confidence, those with whom services struggle to engage, those who will benefit from exposure to peer role models, and those lacking social capital may benefit most. As the first testable characterization of mechanisms and outcomes, the change model allows formal evaluation of recovery colleges.

An evaluation of service use outcomes in a Recovery College.

BACKGROUND: Recovery Colleges offer educational courses about recovery and mental health which are co-produced by mental health professionals and experts by lived experience. Previous evaluations have found positive effects of Recovery Colleges on a range of outcomes including wellbeing, recovery and quality of life. AIMS: To evaluate service use outcomes for Sussex Recovery College students who use mental health services. METHOD: The study used a controlled-before-and-after design. It used archival data to analyse service use before and after participants registered with the Recovery College (n = 463). Participants acted as their own control. RESULTS: Students used mental health services less after attending the Recovery College than before. Students who attended the Recovery College showed significant reductions in occupied hospital bed days, admissions, admissions under section and community contacts in the 18 months post compared with the 18 months before registering. Reductions in service use were greater for those who completed a course than those who registered but did not complete a course. CONCLUSION: These findings suggest that attending Recovery College courses is associated with reduced service use. The reductions equate to non-cashable cost-savings of £1200 per registered student and £1760 for students who completed a course. Further research is needed to investigate causality.

Carers' experiences of assertive outreach services: an exploratory study.

BACKGROUND: Recent government policy has highlighted the needs of family and friends who provide support to mental health service users. Carers of assertive outreach (AO) service users may be particularly in need of support. However, little is known about their experiences and how services can support them. AIM: To explore the experiences of carers of individuals receiving an AO service. METHOD: Ten participants were interviewed using a semi-structured interview schedule. Interviews were transcribed and analysed using interpretative phenomenological analysis. RESULTS: Participants were positive about the service they and their relatives received from AO teams. They described the service as flexible and responsive to their needs and they had developed close collaborative relationships with AO workers. AO workers were considered by carers to be an extension of their family system. AO interventions helped their relatives to regain independence and enabled participants to feel less burdened by their caring role, thereby improving the carer's quality of life. CONCLUSIONS: The unique way in which AO teams engage and work alongside service users and their families is greatly valued by carers.

Interpersonal processes and hearing voices: a study of the association between relating to voices and distress in clinical and non-clinical hearers.

BACKGROUND: Previous research suggests that the distress experienced by clinical voice hearers is associated with the perceived relationship between voice and hearer, independent of beliefs about voices and depression. AIMS: This study aimed to replicate these findings and generate further hypotheses by comparing the voice hearing experiences of clinical and non-clinical hearers. METHOD: A cross-sectional, quantitative design was employed and used between-subjects and correlational methods. Thirty-two clinical voice hearers and 18 non-clinical voice hearers were assessed using the PSYRATS, the Voice and You questionnaire, the Beliefs About Voices Questionnaire - Revised, and the Beck Depression Inventory-II. RESULTS: For clinical voice hearers, distress was significantly associated with perceptions of the voice as dominating and intrusive, and hearers distancing themselves from the voice. However, these associations were not independent of beliefs about voices' omnipotence or malevolence. Non-clinical voice hearers were significantly less distressed than clinical voice hearers and voices were perceived as less dominant, intrusive, malevolent and omnipotent. Non-clinical hearers were found to relate from a position of less distance to voices perceived as benevolent. CONCLUSIONS: Findings from previous research were only partially replicated. Clinically, the development of less maladaptive relationships between voice and voice hearer may reduce distress.