Resilience as Part of Recovery: The Views of Those with Experiences of Psychosis, and Learning for British Mental Health Social Work Practice. A Scoping Review

Abstract

There is a significant diversity in approach to ‘resilience’ in the context of mental health recovery following experiences of psychosis, varying from clinically measurable outcomes to a personal trait within a recovery ‘journey’. Given the contested nature of resilience within mental health literature, this study aimed to complete a scoping review to synthesise understandings of resilience by individuals with experiences of psychosis. Drawing on the holistic and person-centred principles that underpin social work approaches to mental distress, these perspectives are considered in the statutory, policy and critical contexts of British social work, establishing learning for practice. A meta-synthesis of qualitative studies was completed, drawing on searches of five databases (Social Care Online, APA PsychInfo, Cinahl, Medline and Web of Science), identifying twelve relevant papers. A thematic analysis identified three overarching themes (personal, social and professional factors) and eight associated sub-themes (personal responsibility, use of experience, coping strategies, peer support, social relationships, contribution, relationships with professionals and structured support). The study identifies systemic and life-course approaches as empowering service user engagements with psychosis, recovery and resilience, suggesting that the social work profession is well placed to engage with resilience enhancement in the context of mental health recovery.

mental health, psychosis, recovery, resilience

Introduction

Recovery, resilience and mental health practice

Mental health services and policy place significant emphasis on ‘recovery’ as both a goal of service provision and a principle of practice (Jaiswal, 2020). Perspectives on recovery vary across mental health services, from a measurable clinical outcome to representing a personal transformative journey (Piat and Lal, 2012). Clinical recovery in relation to psychosis, as outlined by van Os (2019), often reflects a ‘diagnosis symptom-reduction model’ that seeks to objectively return an individual to a previous ‘well’ state. In recent years, this view has been challenged by a conceptualisation of recovery as a personal resource and therapeutic process in a mental health context (Poloni et al., 2018). Commonly termed the ‘Recovery Model’ or ‘Recovery Approach’ (referred to throughout this article as the ‘Recovery Model’), this understanding of psychosis reimagines the outcome of clinical recovery through a framework led by individually formed meanings and values (Jacob, 2015). Such perspectives take a bio-psycho-social approach to mental health recovery, emphasising the uniqueness of individual experiences, goals and perspectives (Geekie and Read, 2009).

Such variety of outlook on recovery necessarily extends into debate around the meaning and purpose of resilience in mental health practice. There is significant conceptual variation across resilience studies, with Bolton et al. (2015) noting that the term is often ‘loosely conceptualised’ through ‘trait’ or ‘outcome’ paradigms. This is captured across mental health literature, with many studies understanding resilience as a trait that embodies the ways in which individuals adapt to adversity (Rutter, 2006). For perspectives rooted in clinical understandings of recovery, however, resilience is a measurable personality trait, with a number of resilience scales and measurement tools used to track and assess clinical ‘recovery’ (Connor and Davidson, 2003; Wagnild, 2009).

More recent conceptions of resilience in the context of mental health have promoted a ‘systems-oriented’ approach, in which genetic and neurobiological factors are considered alongside the experiences and contexts of individuals (Masten et al., 2021). Whilst this provides a conceptually comprehensive approach, Recovery Model perspectives promote sensitivity to potentially disempowering professional dominance in defining and addressing individual resilience. Indeed, for many critics, the measurement of ‘resilience’ through clinical scales, or significant emphasis on genetics and neurobiology, undermines person-centred perspectives and significantly shifts power from lived experience to professionals (Sartorius and Schulze, 2005). Service user-led views on recovery and resilience has, by contrast, been viewed as empowering individuals in understanding and defining their mental health experience away from a potentially deficit-based perspective on mental health to a strengths-based model of practice (Ayed et al., 2019). Indeed, multiple studies have argued that a focus on resilience is central to strengths-based approaches and brings the significance of resilience-promoting practice for social work into focus (Bonanno et al., 2015). Within a Recovery Model approach, recovery can be understood as a transformational journey where a person gains control over setting goals and finding meaning, with resilience forming an essential characteristic of this process (Friis-Healy et al., 2021).

For social work, a strengths-based approach that incorporates resilience resonates with the philosophy of the Recovery Model and conceptualises resilience as fundamentally formed through lived experience (British Association of Social Workers (BASW), 2014; Social Work England (SWE), 2020). A distinctive approach to mental health offered by the social work profession is outlined by Tew (2017) as systemic approaches to mental health, which foregrounds social, community and microsystemic factors. This is embedded in professional standards, with Social Work England emphasising the influence of social and cultural factors on the development of resilience (SWE, 2020, p. 3.14), whilst Windle (2011) and Feinstein et al. (2009) have also highlighted the socially embedded nature of resilience formation and maintenance. From this professional and conceptual basis, this article will explore service user understandings of resilience within experiences of psychosis recovery, drawing out learning points for practice within the professional and policy frameworks of social work.

Methods

The aims of this scoping review were to explore perspectives on, and the approaches to, resilience by adults with experiences of psychosis and to analyse these views in the policy and practice context of British mental health social work. This approach adopted a scoping review methodology, systematically searching key databases and completing a thematic analysis (informed by Braun and Clarke, 2006) of papers that met the inclusion criteria for the study (Table 1).

Table 1.

Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
Qualitative and mixed-methods research	Quantitative research
Peer reviewed and published research	Unpublished research
English language research	Non-English language research
Adult service user focus to research (aged 18 and above)	Professional-only focus to research
Research published no earlier than 2012	Research published pre-2012

A critical reference point for this research was Ayed et al.’s (2019) systematic review exploring understandings of resilience in mental health literature. Building on this research, scope remains for a specific synthesis of research in the context of psychosis and recovery. Moreover, two-thirds of Ayed et al.’s (2019) sources are published prior to 2012, meaning the inclusion criteria of publication since 2012 of this review also provides an updated synthesis of understandings of resilience in mental health practice and services.

Accordingly, the research question for this article is:

• How do service users with experience of psychosis understand and utilise resilience as part of their journey of recovery?

Advanced searches of abstracts, titles and keywords in key bibliographic databases were completed using the following search string: (recovery OR ‘recovery model’ OR ‘recovery approach’ OR ‘recovery framework’) AND (psychosis OR psychotic OR psychotic disorder) AND resilien* AND (experience OR view OR perspective OR understanding). Papers were identified from Social Care Online (one), APA PsychInfo (fifty-five), Cinahl (fifteen), Medline (thirty-eight) and Web of Science (sixty-nine). A small selection of papers (five) were added to the initial search findings through a ‘snowballing’ approach of scanning reference lists (Greenhalgh and Peacock, 2005).

From this initial search, duplicate papers were excluded and abstracts were screened against the inclusion criteria of the study. The remaining papers were read in full to ensure a final sample of papers that met the study’s inclusion criteria. This process is shown in Figure 1, drawing on Moher et al.’s (2009) PRISMA model.

Figure 1

PRISMA diagram of paper selection process.

Results

Paper designs and methods

The combined sample size for this review across the twelve papers was 179 participants. Gender was recorded in all but one of the papers, indicating an approximate 40–60 per cent female-to-male ratio of participants. From the data provided, the age range of the synthesised participant sample was 18–75.

Most studies used a purposive sampling method (n = 9), with convenience (n = 2) and a combined purposive and convenience (n = 1) sampling method also used. All studies collected data through one-to-one interviews, with ten collecting data through semi-structured interviews and two studies undertaking unstructured interviews.

Thematic analysis

A thematic analysis of these papers was completed, identifying three overarching themes constructed of eight sub-themes:

1. Personal factors

   • Personal responsibility

   • Use of experience

   • Coping strategies

2. Social factors

   • Peer support

   • Social relationships

   • Contribution

3. Professional factors

   • Relationships with professionals

   • Structured support

Personal factors

Personal responsibility

Recognising a personal responsibility in utilising and maintaining resilience emerged as a theme in five of the papers.

Participants in Ashman et al.’s (2017) study reported an increased alertness to their well-being through crisis planning within the Wellness Recovery Action Plan intervention which enabled a sense of control over responses to distress. Similarly, Henderson and Cock’s (2015) found that young people experiencing first episodes of psychosis found recognising distress and seeking support, through personal, social and professional resources, to underpin other resilience strategies and often represented the starting point for a changed understanding of their mental health.

Personal agency over resilience was also explored in a cognitive behavioural therapy (CBT) group setting by Ruddle (2017). Peer support was found to be a prompt for individual change, with one participant commenting that the course highlighted that ‘ultimately change has to come from yourself’. The ability to overcome negative stressors and triggers relating to the past and future was discussed by both ‘clinically recovered’ and ‘non-clinically recovered’ participants in O’Keeffe et al.’s (2021) study, with participants highlighting ‘living in the moment’ as taking control of experiences whilst not allowing their identity to be framed by diagnosis or medical histories.

Much like O’Keeffe et al.’s findings, participants in Mapplebeck et al.’s (2015) study discussed adopting an approach to distress that remained focused on the present, with one describing their resilience as being ‘imbued with a feeling of here and now’. A personal attitude that promotes and protects well-being was also linked to other, practical, activities of resilience and positioned as the basis for further resilience development.

Use of experience

In contrast to the emphasis on the present moment as a trait of resilience in the previous theme, the use of past experiences was also a consideration in seven studies.

The use of past experiences as a ‘rationalisation’ tool was identified as a key feature of resilience. Participants in Harris et al.’s (2019) study viewed resilience as reframing personal histories, with experiences of psychosis and suicidality an opportunity for growth and learning. One participant reflected that ‘unless you experience some deep problems, you don’t actually get to find out whether or not you’re resilient’, embedding past experiences in present and ongoing resilience. Participants in Mapplebeck et al.’s (2015) study also placed significant emphasis on the growth inherent in overcoming obstacles and challenges, explaining that they only realised their resilience capabilities through experiencing mental health distress.

Lawrence et al.’s (2021) study highlighted the interrelation of growth and experience as participants viewed crisis as an opportunity for distress to be better understood and contextualised. Notably, the study highlights differing experiences of accessing resources of resilience between White British and Black Caribbean participants, placing these findings in a comprehensive critical framework regarding the systemic factors that influence mental health service delivery.

Whilst symptoms of psychosis remained central to the lives of participants in Henderson and Cock’s (2015) study, embracing previous experiences enabled a sense of control over ongoing symptoms and distress, with one participant voicing their awareness of their resilience within their ongoing experiences of psychosis: ‘I haven’t recovered, I’m resilient’. A life-course perspective underpinned O’Keeffe et al.’s (2021) findings, with participants identifying ‘multiple recoveries’ as reflecting varying pressures at different phases of life (encompassing childhood trauma, periods of loss, addiction and psychosis), as opposed to a static experience of ‘ill health’ and recovery. Notably, Ruddle’s (2017) study highlights the collective experience of a group setting as providing a contextualising resource in periods of distress through the knowledge of the survival of others, promoting collective resilience over individual and clinical perspectives.

Coping strategies

Participants across six of the studies highlighted strategies and routines that had a shared thematic characteristic of being utilised as part of a planned approach to addressing distress and maintaining a personal homeostasis.

Participants in Gooding et al.’s (2019) study reaffirmed inner strength as a key characteristic of resilience in experiences of psychosis through phrases such as ‘getting on with it’ and ‘drawing on [inner] strength’. This was reflected through the emphasis on re-establishing emotional structure after an experience of psychosis in Lawrence et al.’s (2021) study; this included non-activity, such a relaxation and meditative techniques, as a legitimate tool of resilience during periods of heightened emotion and distress.

Jordan et al.’s (2020) study extends these approaches to psychotherapeutic strategies, finding that participants utilised positive reframing as a means of consciously searching for positive change following a first episode of psychosis, connecting the experience of psychosis to their personal development.

The synthesised data also provided significant evidence of coping strategies rooted in physical stimulation, with a participant in Sumskis et al.’s (2017) study noting it as the most important factor of their resilience, providing personal meaning and an outlet for frustration and stress. O’Keeffe et al. (2021) find that physical activity enables a re-establishment of self-connection, with one participant using sea swimming as a strategy for being ‘at one’ with themselves. Ashman et al. (2017) note a further benefit to the establishment of active routine as providing an early indicator of potential mental health crisis. Routine is framed as a ‘safety net’ by one participant in the study, who recognises distress through the breakdown of their routine and activities, whilst another participant describes an active routine as a ‘foundation’ for recovery through ubiquitous activity that provides stimulation and meaning alongside clear indicators for accessing early intervention support.

Social factors

Peer support

Seven of the synthesised studies noted peer support as a valuable tool of resilience for those with experience of psychosis.

Abram et al. (2020) considered the impact of peer research as a therapeutic intervention and found that participants felt significant benefit in sharing a space with people who have also experienced psychosis, with one commenting that they felt more aware of their own mental health through peer discussions as well as finding the sessions ‘good for morale’. Harris et al.’s (2019) study echoed this view, with three participants noting an emerging community through peer support and a developing confidence in managing periods of crisis: ‘the more I talked to people, the more I realised I weren’t on my own’. Indeed, participants in Ashman et al.’s (2017) found sharing experiences with peers emboldened them to identify with their mental health journeys. These peer support spaces, and subsequent identification with others, countered stigma and alienation associated with psychosis and increased hope in participants about their future. Similarly, three participants in Ruddle’s (2017) study noted that the social aspect of a CBT course had a greater benefit than the psychotherapeutic tools, with one participant noting the peer support experience as encouraging further social activity.

Gooding et al.’s (2019) and Sumskis et al.’s (2017) studies notably gathered perspectives of participants who identified their social networks as personally cultivated rather than formed through supported group settings. These studies found social support to often be entwined with shared experiences of psychosis, with Gooding et al.’s study noting these relationships as the most significant external tool of participant resilience.

For one participant in Lal et al.’s (2017) study, personal growth was viewed as necessitating an expansion of personal identity beyond relationships orientated to a diagnostic label and into wider social networks. This view highlights the potentially reductive approach to an individual’s social needs when they are framed solely through an experience of psychosis and the constraining impact on resilience. Ruddle (2017) further notes the potentially harmful impact of organised group settings where there is a perceived obligation to share experiences of psychosis, with one participant noting an escalation of anxiety and distress in this setting.

Social relationships

Participants in multiple papers valued the role of family relationships in normalising social interactions beyond a diagnostic context. This was found in Jordan et al.’s (2020) study to act as a grounding mechanism in times of mental health distress, with experiences contextualised in wider networks of family support and identity. Mapplebeck et al.’s (2015) study similarly emphasises the potential role of family in providing a sense of belonging and hope through having someone to talk to. Hope also emerged as a theme in Jordan et al.’s (2020) research, with family providing meaning in participants’ lives beyond experiences of distress.

Harris et al.’s (2019) and O’Keeffe et al.’s (2021) studies found that family and other significant relationships prompted a desire in individuals on recovery journeys to maintain a balance in their well-being in order to be there for their loved ones. This sense of responsibility represented a strong protective factor in managing the escalation of mental health and emotional crises. A participant in Harris et al.’s study described the consequence of their changed social role as their daughter ages as lessening their resilience to distress:

In the past when I’ve been psychotic and suicidal, I’ve always thought, ‘don’t do that, the kids are only young, and you can’t leave them without a mum’. […] But [daughter’s name] is twenty-three now and that’s why I think it was the worst.

The responsibility and meaning enabled by significant family relationships is shown to be a vital source and motive for resilience, with the study usefully documenting the impact on resilience when the responsibility of these roles lessens.

Four studies also note regulation and control over the type, and intensity, of support as an important caveat to the positive role of social relationships in building and maintaining resilience for those with experiences of psychosis. Exerting control over relationships is a notable finding of Lawrence et al.’s (2021) study, with one participant highlighting the importance of avoiding the emotional burdens of others in times of mental health distress. Similarly, a participant in Henderson and Cock’s (2015) study recognised the caring intentions of family in times of distress but developed confidence in asserting their own needs. A participant in Jordan et al.’s (2020) study noted a specific life-course aspect to managing family expectations, with parents failing to acknowledge the changing dynamics of relationships as participants age from a teenager to an adult, and the consequent difficulty of not being able to access desired practical and emotional support.

Familial understandings of mental health were also noted as a potential barrier to resilience, with a participant in Sumskis et al.’s (2017) study reflecting that the lack of awareness of mental illness in their family resulted in a risk-averse approach to their activities and identity. Poor understandings of psychosis and recovery journeys by family members were thus viewed as limiting potentially positive social relationships that maintain resilience to distress.

Contribution

Four studies identified fulfilling contributory social roles as significant elements of resilience in recovery journeys. A participant in Gooding et al.’s (2019) study noted their desire to utilise experiences of psychosis in a contributory manner, associating their engagement with those experiencing psychosis with personal development. This was similarly realised in Abram et al.’s (2020) study in which participants valued the opportunity to fulfil a role that was not directly related to their own experiences, but still enabled a contribution to understandings of psychosis whilst increasing confidence, self-esteem and alertness to their own resilience needs.

The use of a lived-experience facilitator in Ruddle’s (2017) study was noted as the most effective aspect of the psychotherapeutic programme, representing a ‘bridge’ between the group and the professional who co-led the course. Indeed, many participants felt that the sessions would have had a lesser benefit if they had been solely delivered by professionals. The relatable environment of this peer-led group represents a realisation of the perceived benefits of contribution outlined in Gooding et al.’s (2019) and Abram et al.’s (2020) studies.

Lawrence et al.’s (2021) study found participants looking beyond the realm of mental health for their contributory purpose, with employment described by one participant as an ‘anchor’ due its role in enabling a social contribution. It is notable, however, that the contributory role of work was only identified by ethnically White British participants in the study, something Lawrence et al. discuss in relation to systemic factors that make employment a more accessible tool of resilience for White participants in a British context (Khan, 2020).

Professional factors

Relationships with professionals

Five studies engaged with the role of professionals in the development and maintenance of resilience for those with experience of psychosis.

Harris et al. (2019) find that professionals play a particularly significant role for individuals with experience of psychosis during times of crisis. A participant in the study noted that contact with their Care Coordinator during mental health crises come at a point where other strategies of well-being and resilience are ineffective. Participants in Henderson and Cock’s (2015) study similarly positioned professionals as enabling change in periods of distress and noted a ‘control paradox’ in which the initial perceived loss of power in accepting the support of professionals becomes the first step in establishing sustainable strategies of resilience.

Lal et al.’s (2017) study finds that valued traits in professionals were utilised by participants in their recovery journey to maintain resilience. Emotional support was noted as a beneficial form of interaction with professionals, with empathy and respect also viewed as positively contributing to well-being. Underpinning these professional traits is an approach to the service user as an individual, echoed by a participant in Mappleback et al.’s (2015) study who described a valued professional relationship that looked beyond a mental health diagnosis in times of difficulty. Moreover, Sumskis et al. (2017) note the recognition of choice for service users as a resilience-enhancing professional trait. Participants in the study described a key difference between choosing to access professional support and it being imposed upon them, with this noted in relation to both medication and social support.

Participants in Lal et al.’s (2017) study commented on the damaging impact of generic approaches to psychosis by professionals that did not reflect their individual needs and goals. A ‘passive withdrawal’ from professional support is found to result from frustrating interactions, demonstrating the lost potential of professional support within recovery journeys through alienating practice approaches.

Structured support

Whilst organised support has been considered in relation to peer support settings, structured professional support was also a thematic consideration in three of the papers.

The multidisciplinary and varied support provided in formal settings, when coupled with empathic and compassionate engagement with psychosis and associated distress, was viewed by participants in Jordan et al.’s (2020) psychotherapeutic study as a notable part of their resilience. One participant in the study noted the varied approaches to their mental health, from clinical recovery to systemic approaches, provided an engagement with their life beyond their psychosis diagnosis, allowing other aspects of resilience, such as family support, to be integrated into discussions of resilience and recovery. Whilst many participants in Ruddle’s (2017) study found greater value in the peer support aspect of the course, the clarity of an organised programme was valued by one participant as ‘trusting the process’, with personal growth being identified through continued engagement with the programme and professionals. The experience of ‘trusting the process’ of organised support was, however, not universally shared across the studies, with a participant in Abram et al.’s (2020) study viewing their participation in a therapeutic intervention as a forced engagement with their mental health experiences in a manner that exacerbated distress.

Discussion

The thematic analysis identified service user perceptions of resilience that reflected personal, social and professional factors. These overarching themes embodied strategies and resources that promote and maintain resilience as well as identifying factors that impact the effectiveness of these approaches.

Personal factors

The differences between the ‘Use of Experience’ theme and the emphasis on being grounded in current experiences within the ‘Personal Responsibility’ theme are notable, particularly as both perspectives are found within Mapplebeck et al.’s (2015) and O’Keeffe et al.’s (2021) studies. These findings reflect the necessarily varied nature of resilience and recovery, both within participant sample groups and the wider literature. Extant perspectives on the Recovery Model share this view, with multiple studies promoting varied personal approaches to resilience in mental health contexts (Bonanno et al., 2015; Windle et al., 2011). These perspectives also have significant grounding in the frameworks of British social work, with person-centred principles embedded in professional standards with an emphasis on the strengths and skills of service users (BASW, 2014, p. 2.1; SWE, 2020).

The statutory duties of the profession further reflect the promotion of individual strengths as a vital component of practice. The 2014 Care Act identifies service users as taking an active role in co-producing resilience-enhancing interventions and services whilst also emphasising the role of professionals in adopting ‘appropriate, person-centred and flexible’ practice approaches (Department of Health and Social Care, 2014, p. 2.20). Such statutory duties emphasise a systemic coalescence of policy, professional practice and research in the promotion and empowerment of personal resilience in the context of psychosis. The variance of perspectives offered by these two themes, far from problematising social work practice, therefore empowers the principles of the profession to draw on the strengths of individuals to promote recovery and meaningful social participation.

Structure also emerges as a key factor of resilience for participants across the studies, taking on a variety of psychological, emotional and active forms, reaffirming strengths-based and person-centred principles as supporting individuals to identify their preferred form of coping strategies (BASW, 2014). Moreover, empowering service users to recognise and develop structures of coping as an indication of emerging distress allows personal strategies to become integrated in a wider network of support, in which mental health and other services can be accessed in a timely manner.

These findings demonstrate the flexibility required in promoting coping strategies that necessarily engage with the multifaceted structures of an individual’s life. Critical understandings of social work promote the profession as being excellently placed to negotiate this variety, with Howe’s (2014) ‘both-and’ perspective of social work embracing the necessary diversity and complexity inherent in engaging with people as socially and personally complex identities.

Social factors

Peer support was identified as a varied factor of resilience in seven of the studies in the literature review, framed around both mental health experiences and support outside of mental health structures. Promoting safe and productive peer support opportunities and spaces within mental health services is a notable finding, with multiple papers in the study noting that experiences of peer support outweighed the skills-development purpose of an intervention.

An important caveat is, however, offered in Lal et al.’s (2017) study, with participants commenting on the constraints of peer support that are centred wholly on diagnostic characteristics. In the context of existing research and understandings of psychosis and resilience, the bio-psycho-social underpinnings of recovery enlighten these findings, with a range of mental health and social factors integrated into approaches to lived experiences of psychosis, creating a co-produced and person-centred professional and service approach (Geekie and Read, 2009). Crucially for social work practice, enabling social identities and ‘peer’ networks beyond specific mental health frameworks promotes flexible and holistic approaches which recognise resilience as a diverse personality trait alongside the substantial evidence-base for specific mental health peer support opportunities.

Family and close personal relationships are evidenced as fundamental to resilience to distress for those with experiences of psychosis in seven of the papers. These findings resonate with systemic models of engagement with family and community circumstances that is embedded in holistic social work approaches. Bateson’s (1972) conception of the family as an ecosystem provides a valuable theoretical grounding to this approach, viewing the individual as formed through networks of relationships and power. Such critical perspectives point towards a pursuit of social and relational homeostasis as a valuable tool of resilience within a recovery journey. Indeed, research into the social nature of recovery by Schön et al. (2009) and Tew et al. (2012) has identified the establishment or reclamation of valued social relationships and roles (such as parent, sibling or friend) as the most important factor of recovery in a mental health context.

The scoping review reflects these research and theoretical positionings, with participants striving for control and balance in their meaningful personal relationships in order to utilise them as tools of resilience. Imbalance in these dynamics is identified as a factor in escalating distress and a significant absence of resilience in the context of psychosis.

There remains, however, a significant life-course aspect to these findings, with social relationships and roles being flexible and changing phenomena. For one participant in Harris et al.’s (2019) study, the role of ‘parent’ changed across the life course, with the lost dependence of a young child impacting the identity and homeostasis of the participant’s microsystem. Erikson’s (1998) cumulative, or ‘epigenetic’, approach to the life-course, which recognises the impact of past experiences and transitions on an individual’s identity, is valuable in this regard (Agronin, 2014). Identifying a ‘social role’ or relationship is not enough for effective person-centred practice, and social work engagement with relationships as a tool of resilience must remain alert to the complexity, and potential fragility, of necessarily dynamic and changing relationships within the microsystems of those they work with.

Anti-oppressive considerations

The findings, however, also indicate further systemic considerations for practice beyond the existing critical and policy understandings of resilience and experiences of psychosis. Lawrence et al.’s (2021) study notes a significant divide between identified opportunities for contribution between White British participants, who viewed employment as a viable contributory option, and Black British participants, who did not. The study links these findings to systemic barriers to employment relating to racial identity, offering a troubling finding in the context of resilience studies, with access to meaningful social roles a significant factor in resilience to mental health distress (Feinstein et al., 2009).

Anti-oppressive principles are embedded within international and British professional social work standards through an unambiguous commitment to social justice (BASW, 2021, p. 2.2; IFSW, 2021), whilst the Equality Act (2010) embeds racial and ethnic identity as a protected characteristic (s.9). Nonetheless, critical debate surrounding social care legislation has questioned the application of anti-oppressive principles, particularly in relation to matters of social justice and inequality. This has notably been explored through the lens of 2014 England’s Care Act, where person-centred approaches have been critiqued as foregrounding individual networks at the expense of systemic oppression and economic factors (Whittington, 2016). For Slasberg and Beresford (2017), this has ideological significance in distancing analysis away from political and economic factors of mental distress, instead assimilating notions of ‘resilience’ into a neoliberal reimaging of the responsibility of the state to its citizens.

This critical and policy framework, coupled with the findings of the literature review, points to a complex negotiation within social work practice of individual empowerment alongside critically contentious statutory frameworks in relation to the achievement of social justice and the fulfilment of anti-oppressive professional principles. The reflective nature of the profession, embedded in professional guidance, provides scope for social work to recognise oppressive contexts and lead in promoting equitable individual and community access to opportunities for social contribution and resilience.

Professional factors

The holistic role of professional support was a key finding of the thematic analysis, with organised psychological interventions valued alongside professional relationships. Nonetheless, the negative impact of perceived forced engagement with mental health experiences was notable, with many participants finding greater value in the social aspects of such support (Ruddle, 2017). These findings resonate with the ‘Peer Support’ theme, but should not, however, undermine the role of structured support and interventions in practice. Wilberforce et al.’s (2020) research into service user perceptions of mental health social work practice finds the consideration of the ‘whole life’ of the individual by the social worker to be a particularly valued characteristic; the varied perspectives on professionally structured support evidenced in this study point to such a dynamic understanding of resilience development, whether through direct benefits of interventions or the peer support enabled in these settings.

Implications: Flexible systemic approaches

The synthesised evidence in this literature review has found systemic understandings of personal, social and professional factors of resilience within psychosis recovery to resonate with professional and policy perspectives. Indeed, the thematic findings reframe the ‘systems-oriented’ approaches of current resilience research, instead emphasising the dynamic interrelation between individual and community factors that are engaged with, and empowered by, person-centred models of professional practice rather than biomedical and neurological vulnerability.

The life-course aspect of many of the themes indicate that resilience and recovery is a dynamic consideration to be addressed throughout an individual’s life, with changing social roles and identities reflecting the benefit, or otherwise, of specific strategies and experiences of resilience. Systemic models retain the scope to embrace such perspectives; Santrock (2007) identifies a ‘chronosystem’ as a valuable critical development for systemic approaches, emphasising the impact of life events and changing contexts on the homeostatic balance of an individual’s systemic role, identity and, in a mental health context, the accessibility and effectiveness of tools and strategies of resilience.

Such implications emphasise the complex interpersonal, service-led and political negotiations of effective and resilience-enhancing social work practice. It is notable, therefore, that current and ongoing mental health policy development acknowledges the need for increased systemic perspectives in practice, and the reflective underpinnings of the social work profession provide a framework for these systemic negotiations to take place (Garratt and Laing, 2022).

Limitations

As a scoping review, paper quality was not assessed in this study. Whilst this may have led to the inclusion of articles which lacked rigour, it enabled a valuable breadth of papers. Furthermore, despite Lawrence et al.’s (2021) study noting significant racial variance in accessing resources of resilience, the varied recording of demography data in the papers limited a broader exploration of these factors. The international nature of the synthesised data contributed to this, with the classification of race and ethnicity reflecting specific national contexts that could not be effectively synthesised.

Conclusion

In the context of mental health recovery, resilience is understood by individuals with experience of psychosis as a varied and multifaceted trait and resource. Personal, social and professional factors all inform an individual’s experiences of resilience which, crucially, must be viewed as a dynamic and changing perspective that can be fundamentally altered through life experiences. Empowering social work practice engages with varied perspectives on resilience through systemic approaches, recognising the longitudinal systemic influences on an individual’s understanding and utilisation of resilience. Social work must negotiate a complex role of meeting individual need through social approaches whilst embodying statutory and professional requirements and values. Health and social care policy frameworks in a British context provide scope for social workers to meet these practice demands, whether through the person-centred well-being principles of the 2014 Care Act or the conception of recovery and resilience as an ongoing and personally formed pursuit of social identity and meaning within NHS mental health policy (NHS England, 2017). The critically reflective and systemically minded professional approaches that define and underpin social work practice are, therefore, essential skills in empowering service users experiencing psychosis to identify and utilise varied personal, social and professional resources of resilience.

Funding

The author is in receipt of a PhD Studentship from the University of Bath.