Health and Social Care in the Community (2011) 19(6), 602–616 doi: 10.1111/j.1365-2524.2011.01014.

Review
Self-care in mental health services: a narrative review
Mike Lucock PhD1, Steve Gillard PhD2, Katie Adams BSc
3
, Lucy Simons PhD
4
, Rachel White BSc
5

and Christine Edwards BA MSc FCIPD6

1
Centre for Health and Social Care Research, University of Huddersfield, Huddersfield, UK and Adult Psychological
Therapies Service, South West Yorkshire Partnership NHS Foundation Trust, Wakefield, UK, 2Division of Mental Health,
St George’s, University of London, UK, 3NHS Evidence, National Institute for Health and Clinical Excellence, City Tower,
Manchester, UK, 4School of Health Sciences, University of Southampton, Southampton, UK, 5Institute of Psychiatry, Kings
College London Denmark Hill Campus, UK and 6Kingston Business School, Kingston University, Kingston, UK

Accepted for publication 29 April 2011

Correspondence Abstract
Mike Lucock Self-care is an important approach to the management of
Adult Psychological Therapies Service long-term health conditions and in preventing ill-health
South West Yorkshire Partnership NHS by living a healthy lifestyle. The concept has been used to
Foundation Trust a limited extent in relation to mental health, but it over-
APTS, Fieldhead
laps with the related concepts of recovery, self-manage-
Ouchthorpe Lane
ment and self-help. These related concepts all entail
Wakefield
WF1 3SP, UK individuals having more choice and control over treatment
E-mail: [email protected] and a greater role in recovery and maintaining their health
and well-being. This paper reviews qualitative empirical
research that provides information on the nature of self-
What is known about the topic care in mental health from the perspective of people
d Self-care is an important principle underpinning experiencing mental health problems. Twenty qualitative
services for people with long-term health prob- studies were identified from a systematic search of the lit-
lems. erature. The methods used in these studies were critically
d For people with mental health problems, there is appraised and key themes across studies identified self-
currently limited empirical research to help us care behaviours and processes supporting self-care. The
understand what constitutes self-care. paper also highlights challenges to this approach in
What this paper adds mental health and provides a conceptual framework of the
relationships between self-care support, self-care
d The review identifies a range of self-care behav-
behaviours and strategies, and well-being for the
iours and processes that support the management
individual. It also highlights limitations in the current
of and recovery from mental health problems.
d It is important for services to provide the right evidence base and identifies areas for future research.
balance between providing care, support and
treatment when required and the autonomy of the Keywords: mental health, recovery, self-care, self-help,
individual. self-management
d A combination of ‘experts by experience’ and pro-
fessional expertise should be considered when
developing services to support self-care.

independently by an individual to promote and main-

Background to self-care in health and social
tain personal well-being throughout life. The World
care
Health Organization (WHO) defined self-care as ‘activi-
The importance of self-care has been highlighted in ties individuals, families and communities undertake
recent years as part of a patient-centred approach in the with the intention of enhancing health, preventing dis-
management of long-term health conditions and in pre- ease, limiting illness and restoring health. These activities
venting ill-health by living a healthy lifestyle. Orem are derived from knowledge and skills from the pool of
(1991) promoted the concept of self-care in nursing prac- both professional and lay experience. They are under-
tice and referred to it as those activities performed taken by lay people on their own behalf, either separately

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Self-care in mental health services

or in participative collaboration with professionals’ to improved health outcomes and more appropriate use
(WHO 1983). In the UK, self-care has become an impor- of health and social care services. They therefore recom-
tant principle underpinning services for people with mended that it is important to ‘…ensure that self-care
long-term health needs and includes greater choice and support becomes an integral part of an effective and effi-
control over care (Department of Health (DH) 2006a,b). cient healthcare system throughout the country’ (DH
The principles of choice, control and shared decision- 2007, page 3). Despite this, Chambers et al. (2006) point
making are also central to the new NHS strategy set out out that robust evidence of the cost-effectiveness and
in ‘Equity and excellence: liberating the NHS’ (DH 2010). impact on health outcomes of increased self-care by
Although self-care places an emphasis on the individ- patients is lacking. In relation to mental health, which is
ual’s own contribution to their well-being, a patient per- the focus for our review, they included a wide range of
spective on self-care highlights the role of health services psychological interventions that have been extensively
in supporting self-care: ‘The NHS cannot do self-care to researched (e.g. Roth & Fonagy 2005). The diverse nature
people, but what it can do is create an environment of these interventions illustrates problems understanding
where people feel supported in self care’ (DH 2006a,b, self-care and what should be considered a self-care inter-
page 2). vention in relation to mental health. We did not set out
It is important to acknowledge that self-care is a nor- to review the effectiveness of self-care interventions as
mal activity (Chambers 2006), and most people are moti- we argue that it is necessary to develop a clearer under-
vated to engage in self-care. For example, a recent standing of self-care in mental health before the scope of
DH ⁄ MORI survey in England (DH 2005a) found that such a systematic review can be defined. There is there-
82% of those who had a long-term health condition said fore a need for clarity about what self-care is in relation
they play an active role in caring for their condition, and to mental health and for a framework to inform future
that more than 9 in 10 people surveyed were interested service developments and research in this area. This is
in being more active self-carers. The same survey found particularly important because we argue that the nature
that more than 75% of respondents said if they had guid- of mental health problems and services means that sup-
ance ⁄ support from a professional or peer they would feel porting self-care for those with mental health problems
far more confident about taking care of their own health, presents particular issues and challenges that we high-
clearly suggesting scope for more professional support light in this paper.
to improve effective self-care. Despite this, more than To understand self-care in mental health, it is impor-
half of people who had seen a care professional in the tant to consider the experiences of those with mental
previous 6 months said they had not often been encour- health problems. This is self-evident in relation to self-care
aged to self-care, and a third said they had never been but is also consistent with the idea that an evidence base
encouraged by the professionals to self-care. This pro- for mental health services should be developed as a part-
vides some evidence of a mismatch between the desire nership of service users with expertise by experience and
of people to use self-care to manage long-term health expertise by professions (Faulkner & Thomas 2002). This
conditions and the self-care support provided by profes- approach is similar with the coproduction of scientific
sionals. It is therefore important to not only have a better knowledge which is a move away from conventional sci-
understanding of self-care but also to understand how entific research towards a model that involves a range of
services and professionals effectively support self-care scientific and non-scientific expertise (Gibbons et al.
(DH 2005b). These issues are particularly important 1994). The WHO definition also highlights the combining
given that some healthcare provision may not only fail to of knowledge and skills from both professional and lay
support self-care but may conflict with the principles of experience (World Health Organization 1983). Consistent
self-care. with this approach, our review of self-care focuses on the
experiences of those with mental health problems, which
we access through a review of qualitative empirical
Evidence base for self-care
research studies. This will help address the relative lack of
A review of the research evidence for the effectiveness of empirical literature describing self-care from the perspec-
self-care support across all health problems identified tive of service users, patients, survivors or consumers.
160 systematic reviews and 240 primary research studies
of self-care support interventions, covering a range of
Aim and scope of the review
health problems such as arthritis, asthma, cancer, depres-
sion, diabetes, mental health, obesity and pain (DH The aim of the review was to understand self-care
2007). Although at the time of writing this paper the from a mental health service user ⁄ patient perspective.
review was in progress, the authors concluded that the To achieve this, we carried out a three-stage review
evidence supports the view that self-care support leads process:

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M. Lucock et al.

1. A search of the literature on self-care, and related mental health have tended to include more formal inter-
concepts, and mental health. ventions such as guided self-help that is recommended
2. A review of qualitative empirical research studies by the National Institute for Health and Clinical Excel-
that provide information about self-care in mental lence (NICE) for mild to moderate anxiety and depres-
health from the perspective of people experiencing sion (NICE 2007, 2009a) and computerised cognitive
mental health problems.
behaviour therapy (NICE 2006). These self-help interven-
3. Identifying key themes across the studies to under-
stand the concept of self-care in relation to mental
tions are types of low-intensity interventions to be pro-
health. vided in the new Improving Access to Psychological
Therapies (IAPT) services and have been promoted to
We then developed a model of self-care in mental address long-standing problems of access (Richards et al.
health to inform future research and service develop- 2003). Reviews and meta-analyses of efficacy studies of
ments and to highlight and discuss how services can self-help interventions for anxiety and depression pro-
support self-care. vide support for their efficacy (e.g. Gould & Clum 1993,
We decided to focus the review on the broad range of Scogin et al. 2003). Although self-help and self-manage-
mental health problems, from mild to moderate common ment are very similar terms, self-management has
mental health problems to more severe and enduring tended to be used to describe strategies people use to
problems such as psychosis. The reason for this was to manage their lives and their health problems while self-
understand self-care across the range of mental health help has tended to be used to describe the more struc-
problems in terms of diagnoses and severity, to identify tured, professionally led interventions.
elements of self-care that apply across this range. We
focussed on working age adults, excluding studies
Literature review
with children and older adults because issues central to
self-care, such as autonomy and responsibility, are We undertook four separate, systematic searches of the
potentially different so self-care may differ in those literature using the terms self-care, self-management,
contexts. self-help, recovery and mental health or psychiatry. All
To identify relevant studies, we broadened the scope the searches, of papers in the English language, were car-
of our search, also looking at literature on the related ried out using Ovid Online and included the following
concepts of recovery, self-help and self-management, all databases: PsycINFO (from 1967), CINAHL (from 1982),
of which emphasise a principle similar to that in self-care AMED (from 1985), British Nursing Index (from 1994),
– of the individual having more control and autonomy Ovid Medline(R) (from 1996), EMBASE (from 1996). As
over their treatment, recovery and lives. This was justi- searches revealed a lack of papers preceding the mid-
fied from a preliminary look at the literature which indi- 1990s, later start dates were used in subsequent database
cated an overlap between self-care and these concepts, in searches.
terms of identified studies and in a conceptual overlap. Papers were excluded after reading abstracts if they
The understanding of these concepts in relation to men- were: not concerning self-care, self-management, self-
tal health is also more developed than is the case with help or recovery; primarily related to physical health
self-care. Recovery is a term that has been increasingly problems, including papers looking at physical health
used as an over-riding principle in mental health services problems where mental health was one of various out-
(e.g. DH 2001a) and reflects the desire to change negative come measures; not concerning adults (i.e. papers con-
perceptions of mental illnesses, so the prospect of recov- cerned with children, adolescence and older adults were
ery is acknowledged and supported. It emphasises discarded); primarily relating to drug misuse unless
empowerment of individuals to manage fulfilling and there was a clear focus on mental health problems. Self-
meaningful lives and a more positive outlook on restora- help books were also excluded because of the vast num-
tion, rebuilding, reclaiming or taking control of their ber of self-help books available (for example, a search of
lives. Self-management is mainly used in the context of ‘self-help’ and ‘depression’ on Amazon.co.uk revealed
managing long-term health problems and has led to over 5000 books). Empirical or review papers concerning
developments such as Co-creating Health which aims to self-care, self-management, self-help or recovery relating
embed self-management support within services (Health to adults with mental health problems were included.
Foundation, 2008). Rethink, a mental health membership Initial decisions about inclusion and exclusion were
charity, has developed a self-management programme made by members of the team undertaking the searches
and provided a definition of self-management as: ‘what- and were then checked by the first author. The first
ever we do to make the most of our lives by coping with author also reran all searches prior to submission of the
our difficulties and making the most of what we have’ paper to ensure a consistent end date, 2010. Searches
(Martyn 2002, page 3). Finally, self-help approaches in identified a total of 3285 papers. After reading abstracts

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Self-care in mental health services

and removing duplicates, 575 papers were retained (133 health problems, participants were recruited from a vari-
from the self-care search, 45 self-management, 268 self- ety of treatment and service provision settings, with
help and 129 recovery). recruitment processes described in the papers in varying
These searches revealed a very wide range of papers, degrees of detail. In most studies, participants were
the most frequent being evaluations of interventions ⁄ ser- recruited through the mental health service they used,
vices ⁄ approaches, using a range of qualitative, quantita- although in a number of studies, participants were peo-
tive and mixed methods. These included a range of ple who self-identified as being on a recovery journey, or
methodologies such as controlled trials (e.g. Anzai et al. of having recovered (e.g. Brown & Kandirikirira 2006,
2002, Rapee 2007), qualitative studies (e.g. Rogers et al. Nixon et al. 2010, Romano et al. 2010). It can be suggested
2004, Muir-Cochrane 2006), mixed methods (e.g. Lawn that self-selection of participants constrains the variation
et al. 2007) and some systematic reviews (e.g. Morriss in data elicited (Miles & Huberman 1994). However, it
et al. 2007). From these papers, twenty qualitative, empiri- might also be argued that, in the context of a review
cal studies of the views of people with mental health paper such as this, the inclusion of studies with popula-
problems were retained that identified important self-care tions ‘in recovery’ alongside those recruited on the basis
behaviours and strategies in a mental health context. This of diagnosis or treatment increases variation in the meta
final selection of papers was made by the first author and data set. This variation in sampling and recruitment
then checked by other members of the team. strategy limited our ability to specify the population to
whom the review findings apply while at the same time
enabled us to produce a model of self-care in mental
Review of qualitative studies identifying
health inclusive of elements of relevance across the broad
elements of self-care in mental health
spectrum of adult experiences of mental health prob-
Table 1 shows each of the twenty studies with the meth- lems.
ods, study population and main findings. To accurately Most studies used individual interviews to elicit data
reflect the findings and the methods used, standard prac- (exceptionally, Lucock et al. (2007) used focus groups,
tices for extracting data from papers into the table were Martyn (2003) used interviews, discussion groups and
employed (Britten et al. 2002), including retaining exact writing, Khan et al. (2007) synthesised the findings of
wording from papers where necessary. Data extraction existing qualitative research on depression management
was undertaken by the first author and then checked by in Primary Care, and Yurkovich et al. (1997) used partici-
other members of the team. Some researchers may resist pant observation alongside interviews). A number of
synthesis of qualitative research studies, arguing that studies indicated that they used extended, open-ended
each study is a unique representation of different reali- or narrative interview to enable participants to tell their
ties, but it is widely acknowledged that synthesis is personal stories of recovery or self-management (Smith
appropriate and will contribute to an understanding of 2000, Cunningham et al. 2005, Ridge & Ziebland 2006,
an underlying reality, consistent with the ‘subtle realism’ Borg & Davidson 2008, Kartalova-O’Doherty & Doherty
position (Hammersley 1992). In conducting a narrative 2010, Nixon et al. 2010). Some papers specified that inter-
review, we were interested in what the studies told us views sought to identify self-management strategies (e.g.
about the experiences of self-care in people with mental Cunningham et al. 2005) or to elicit understandings of
health problems and were able to identify key themes recovery (e.g. Borg & Davidson 2008). It has been noted
arising from the reviewed research. that ‘priming effects’ (Foddy 1993) – the way interview
questions are asked – can shape the responses of inter-
viewees, although not enough information is given in
Appraisal of studies
papers to enable us to evaluate the extent to which inter-
Mays & Pope (2006) discuss ways of improving validity view schedules might have shaped study findings.
of qualitative research, including triangulation, respon- Some papers provided details of the analysis process
dent validation, clear exposition of methods, data collec- (e.g. Borg & Davidson 2008, Kartalova-O’Doherty &
tion and analysis, reflexivity, attention to negative cases Doherty 2010 and Nixon et al. 2010). While all studies
and fair dealing. We included information on these ele- sought to organise understandings of recovery, self-care
ments of the studies reviewed under the methods col- and self-management strategies into themes, or elements,
umn in Table 1. It is clear from the table that some of the a range of approaches to analysis were described. While
studies provided limited information on the factors iden- many studies referred simply to ‘thematic analysis’, a
tified by Mays and Pope, making an evaluation of the number of studies (Yurkovich et al. 1997, Ridge & Zie-
quality of these papers difficult. bland 2006, Mancini 2007, Kartalova-O’Doherty & Doh-
While the inclusion criteria for the review ensured erty 2010, Romano et al. 2010) employed Grounded
that study populations were all adults with mental Theory in some form; an approach that seeks to derive

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Table 1 Details of 20 empirical qualitative studies of the views of people with mental health problems, identifying important self-care behaviours and strategies

Study Methods Population Findings

M. Lucock et al.

Yurkovich et al. (1997). Semi-structured interviews and participant 7 ‘chronic mentally ill The issue of control was central to the findings.
Loss of Control and the observation. Open-ended questions used to people’, 3 male, 4 Concluded chronic mentally ill clients prevent
Chronic Mentally Ill in a stimulate free responses about the views on the female. Variety of loss of control by using informal relationships to
Rural Day Treatment meaning of health and their health-seeking diagnoses adapt behaviours, attitudes and feelings within a
Center behaviours. Grounded theory analysis. supportive environment. If this fails, they turn to
Description of coding process. The ‘core formal sources of control such as therapists,
variables’ identified from the analysis were fed case workers, or other mental health providers
back to participants to check credibility
Yurkovich & Smyer A further analysis of Yurkovich et al. (1997) study. As in Yurkovich et al. Identified 4 properties related to preventing loss of
(1998). Strategies for Investigated strategies for maintaining optimal (1997) control: relationships, feelings, good attitude and
maintaining optimal wellness outside the hospital setting functional activity. These properties must be
wellness in the chronic examined within the context of the therapeutic
mentally ill environment as well as the nurse–patient
relationship
Faulkner & Layzell (2000). Individual interviews and thematic analysis Purposive sampling of 71 Key theme was the role and value of relationships
Strategies for living: a people with experience of with other people. Other themes included finding
report of user-led mental health problems meaning or purpose; the importance of
research into people’s acceptance and shared experience; finding ways
strategies for living with of taking control; and achieving peace of mind. A
mental distress range of helpful strategies were identified,
including medication, relationships with
professionals, self-help strategies, religious and
spiritual beliefs, complementary therapies, sport
and physical exercise and creative expression.
Smith (2000). Recovery Qualitative analysis of extended semi-structured 10 participants (aged Helpful factors in recovery were medication; a
from a severe psychiatric interviews relating personal stories of recovery. 38–60 years) ‘beset by group of supportive people; meaningful activities;
disability: findings of a Recruitment via newsletter advertisement persistent and severe a sense of control and independence; strong
qualitative study seeking participants to describe personal stories psychiatric disability’ determination to maintain recovery; positive
of recovery from severe psychiatric disability. outlook on the present; optimism about the
Thematic analysis future. Barriers to recovery were stigma,
symptoms, lack of financial resources and limited
access to services and occasional eruptive
responses to life’s pressures. Strategies for
recovery were accepting disability, believing in
recovery, being stabilised, accepting
responsibility for disability, establishing a
structure for daily life, seeking support, taking
care of yourself, keeping active, educating
yourself

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 Table 1 (Continued)

Study Methods Population Findings

Martyn (2003). Self- Thematic analysis of interviews, discussion 52 people with a diagnosis Identified five broad headings related to self-management:
Management. The groups and writing exploring self-management of schizophrenia a) maintaining morale and finding meaning; b) relationships
experiences and views of for people with a diagnosis of schizophrenia with other people; c) an ordinary life: coping; d) an
self-management of (extra)ordinary life: thriving; and e) managing ‘having
people with a diagnosis schizophrenia. Themes included occupation in its broadest
of schizophrenia sense, including education, voluntary work, art and creative
work and paid employment; relationships with other people;

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personal qualities, attitudes and beliefs involved in
maintaining morale; coping strategies for the experiences
of schizophrenia; managing medication; exploring and
understanding the experience labelled schizophrenia,
including getting information; religion and spirituality;
counselling and psychotherapy; complementary therapies;
and healthy living, such as diet and exercise
Rogers et al. (2004) Peoples’ Semi-structured interviews exploring patients’ 15 people who had People understand their problem as one of having
understandings of a primary care- understandings of the use of a UK primary attended the self-help lost an ability to cope, and that the ethos underlying
based mental health self-help clinic care-based self-help clinic. Thematic analysis clinic for one or more the clinic is well matched to restore a sense of
sessions coping, by motivating patients to re-establish and
retain control over their everyday lives
Cunningham et al. (2005). Qualitative narrative study aiming to identify the 13 Assertive Community CTT consumers were more likely to be engaged
Acceptance and change: illness management strategies used by mental Treatment (ACT) and 14 in the community, working, somewhat more likely
the dialectic of recovery health consumers transferred to less intensive Community Treatment to be attending church, and more likely to have a
services. Convenience sampling. Researchers Team (CTT) consumers clear understanding of their illness. Importance
coded the narratives, testing codes and coding (aged 27-70) of acceptance of illness and need for effective
assumptions to maximise inter-coder reliability strategies for managing it
Brown & Kandirikirira Individual interviews. Thematic analysis of Purposive sampling of 67 Identified six internal elements associated with a
(2006). Recovering recovery narratives. Use of semi-structured people who described recovery journey: Belief in self and developing a
mental health in Scotland narrative interview. Initial themes were checked themselves as ‘recovered positive identity; knowing that recovery is
with narrators after which interviewers and or in recovery from a possible; having meaningful activities in life;
principal researchers collaboratively constructed long-term mental health developing positive relationships with others and
broad interview themes. Transcripts double problem’ (aged 28-70) your environment; understanding your illness,
coded by the two principal researchers using the mental health and general well-being; actively
broad themes. Themes further refined through engaging in strategies to stay well and manage
inductive thematic analysis setbacks. Six external elements were: having
friends and family who are supportive, but do not
undermine narrator’s self-determination; being
told recovery is possible; having contributions
recognised and valued; having formal support
that is responsive and reflective of changing
needs; living and working in a community where
other people could see beyond your illness;
having life choices accepted and validated

607
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 608
Table 1 (Continued)

Study Methods Population Findings

M. Lucock et al.

Muir-Cochrane et al. (2006). In-depth interviews of experience of mental health 10 young people aged Medication use and management was a central
Self-management of and well being. Thematic analysis informed by 16-24, who were issue. Medication non-adherence influenced by
medication for mental Benner’s work in interpretive phenomenology. homeless and had unwanted side-effects, issues of access and
health problems by Participants offered the opportunity to review the experienced mental storage and lack of support from health and
homeless young people transcripts, but not taken up. The transcripts health problems social agencies. These problems were
were reviewed by the two researchers who had compounded by everyday stresses of
also conducted the interviews, and a conceptual homelessness. Medication adherence facilitated
map of the key issues was formulated. This by social support, consistent contact with
paper focuses on central issue of medication use supportive health services, and regular
and management medication supply
Ridge & Ziebland (2006). Modified grounded theory approach to analysis. 38 men and women who Identified various meanings associated with
‘The old me could never Open-ended, unstructured and semi-structured had previously recovery, including correcting chemical
have done that’: How interview phases with participants talking about experienced depression imbalances, types of insight, developing
people give meaning to their lives, living with depression and getting authentic self and living, assuming responsibility
recovery following better. Analysis was a cyclical process: the first for recovery and struggling with recover and the
depression author continually moved between reviewing the strategies deployed to revitalise life following
literature, data collection and coding, linking depression
codes and revising and reshaping the analysis.
The analysis was scrutinised by both authors
through regular meetings and electronic exchanges
Mancini & Rogers (2007). Critical discourse analysis of in-depth, Selected 2 interviews for Identified two phases of the recovery process:
Narratives of Recovery semi-structured interviews to demonstrate critical discourse Despair and anguish, marked by a sense of
from Serious Psychiatric the complexities of the recovery process. Coded analysis, from study of hopelessness and helplessness where the
Disabilities: A Critical each of the interviews for genre, discourse and 16 leaders in the person feels dominated by their condition and
Discourse Analysis style. These analyses included a content consumer provision of sees little hope for recovery; awakening
analysis for themes in the interviews, a mental health services. characterised by a sense of hope that recovery
contrastive, narrative analysis, and a critical Both had ‘psychiatric is possible and empowerment whereby a person
discourse analysis disability’ begins to recognise that they have some control
over their fate
Mancini (2007). A Grounded theory analysis of semi-structured 16 psychiatric survivors Participants played an active role with the help of
Qualitative Analysis of interviews. Participants asked to share their who were providers of supportive allies in initiating and sustaining their
Turning Points in the theories about what factors influenced their consumer- operated recoveries and that recovery consisted of a
Recovery Process recoveries and to discuss the key turning points services complex and ongoing struggle against multiple
influencing their recovery. To provide a reliability constraints to establish more positive identities
check and to mitigate biases of the researcher,
neutral outside reviewers were used to
triangulate and cross-check codes and
categories and debrief regarding the
development of interview questions and the
codes and categories that emerged from
analysis of the data

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 Table 1 (Continued)

Study Methods Population Findings

Pitt et al. (2007) User-led study using interpretative 7 people (5 male, 2 Recovery from psychosis found to be a complex
Researching recovery phenomenological analysis of individual female), with experience and idiosyncratic process, which often involved
from psychosis: a interviews exploring people’s experience of of psychosis, aged rebuilding life, rebuilding self and hope for a
user-led project psychosis and recovery. Initially, each researcher between 18 and 65 years better future (each of these themes consisted of
carried out thematic analysis independently for subthemes). Highlighted importance of continuity
each transcript. The two researchers then met of care, the need for greater choice in
jointly to agree the themes and members of the approaches, access to stories of recovery and

ª 2011 Blackwell Publishing Ltd

steering committee were then involved in encouragement, and the importance of more
deciding upon the final themes individualised recovery care plans.
Borg & Davidson (2008) Narrative, phenomenological approach involving 13 participants in recovery Four areas of everyday life experiences in
The nature of recovery in-depth interviews about the processes of interviewed twice, 10 had recovery were identified: (i) having a normal life,
as lived in everyday recovery. The research process also included a been treated for (ii) just doing it, (iii) making life easier and (iv)
experience reference group of five individuals with schizophrenia, 1 for being good to yourself. The findings suggest that
experience with recovery. A thematic and reactive psychosis, 1 for recovery unfolds within the context of ‘normal’
step-wise approach was taken to analysis of the manic depression, and 1 environments and activities. As one implication
interviews, involving analysis of individual for paranoia. of this study, everyday life expertise should be
interviews for units of meaning related to included in the practitioners’ agenda.
everyday life, analysis across individual
interviews, followed by grouping the material into
provisional thematic categories. Third step
involved returning to the interview transcripts to
verify and supplement key findings. Findings
continually discussed with reference group
Piat et al. (2009). What Semi-structured interviews exploring meaning of 54 mental health Two contrasting meanings of recovery emerged.
does recovery mean for recovery from the perspectives of consumers consumers The first definition strongly attached recovery to
me? Perspectives of receiving mental health services. Interviews illness and cure involving medication and
Canadian mental health coded independently by 2 members of the returning to former self. The second definition
consumers research team with inter-rater reliability of 80- linked recovery to self-determination, taking
90% and iterations of coding scheme. Efforts to responsibility for life recovery as a process and
ensure the trustworthiness of the study were evolving towards a new self. They discuss the
described such as shared process of analysis need to find common ground between these two
amongst research team and with an advisory perspectives
committee
Lucock et al. (2007) Thematic analysis of focus groups. The views 50 mental health service Identified the following self-management strategy
Service users’ views of recorded on the day were categorised under users themes: managing and structuring the day;
self-help strategies and themes. Initial themes were derived through empowerment; engaging others to help yourself;
research in the UK reviewing the views and discussion and analysis physical health and well-being; and spirituality
by planning team members. These themes were
used to provide a framework to review the
material again, and the themes were refined
through an iterative process, with full agreement
for the final themes by all planning team
members

609
Self-care in mental health services

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 Table 1 (Continued)

610
Study Methods Population Findings

Khan et al. (2007). Guided A meta-synthesis of published qualitative research Patients with depression Identified themes in literature such as patients’
M. Lucock et al.

self-help in primary care of patient experience of depression management and managed in primary understandings of self-help interventions,
mental health: Meta- in primary care to develop an explanatory care personal experience in depression; help-seeking
synthesis of qualitative framework and apply this to the development of in primary care; control and helplessness in
studies of patient a guided self-help intervention for depression engagement with treatment; stigma associated
experience with treatment. Patients reported the use of
coping strategies, such as distraction or use of
locations associated with feelings of safety and
control. Patients tended to seek help when their
own strategies were failing. Use of medication
could lead to a tension between the benefits and
perceived loss of personal control. Ambivalence
about the role of the therapist vs patients’ own
use of self-help. Control and the importance of
the restoration of social functioning were
important issues
Nixon et al. (2010). Interpretative phenomenological approach using a 17 participants, self- Found four major themes and seven subthemes
Recovery from psychosis: narrative interview method to explore recovery identified as having that described the experience of recovery from
A phenomenological from psychosis. Audiotape interviews transcribed recovered from some psychosis. The four major themes included the
inquiry and then reviewed with research participants for form of psychosis following: (i) pre-psychosis childhood traumatic
further clarification and input. Thematic analysis experiences, (ii) the descent into psychosis, (iii)
with 3 authors independently identifying surface paths to recovery and (iv) post-recovery
themes from each of the interviews from which challenges. Subthemes of the paths to recovery
higher order themes were agreed across were: a) working with traditional and non-
interviews. Procedures to enhance the overall traditional healers; b) embracing creativity and
reliability and validity included checking spirit; c) reaching out to others
interpretations for goodness of fit, and presenting
a coherent and convincing argument for the
themes. They checked how the themes
resonated with people who had similar
experiences, with willing participants and a
number of recovering people in the community
Romano et al. (2010). In-depth, semi-structured interviews. Charmaz’s Purposeful sampling of 10 Findings provided a theory of the process of
Reshaping an enduring constructivist grounded theory methodology. young adults who self- recovery from FES with the following phases:
sense of self: The Interview topics included impact of illness, identified as recovering ‘Who they were prior to the illness’; ‘Lives
process of recovery from support systems and coping strategies that from first episode of interrupted: Encountering the illness’; ‘Engaging
a first episode of influence recovery. Detailed description of data schizophrenia (FES). in services and supports’; ‘Re-engaging in life’;
schizophrenia analysis using constant comparison method. ‘Envisioning the future’; and a core category,
Included exploration of negative cases, ‘Re-shaping an enduring sense of self’, that
verification by members of the research team occurred throughout all phases.
and an audit trail of analytic transformation of
data. Reflexive stance throughout the research
process

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Self-care in mental health services

understandings of social phenomena that are grounded

with accepting a passive identity of a patient with
‘fighting to get better’. Giving up was associated
They identified two open codes of ‘giving up’ and

entailed substantial and sometimes risky effort

in the data rather than in existing literature or the per-

and required strong, self-sustained motivation

a chronic mental illness and a lack of intrinsic

against) dimensions. The fight for recovery

positive (fighting for) and negative (fighting
spectives of the researchers (Strauss & Corbin 1998).
motivation to get better. Fighting had both Another set of studies (Muir-Cochrane et al. 2006, Pitt
et al. 2007, Nixon et al. 2010) used Interpretive Phenome-
nological Analysis (Smith et al. 1995) or similar
approaches, designed to foreground the subjective expe-
riences of individual participants. Both these approaches
are appropriate for studies that are attempting to under-
stand individualised experiences of mental health and
mental health-care and, not surprisingly, generate
themes that are labelled and described in a wide variety
of ways. Despite this variety, it can be noted that those
Findings

studies – the majority of studies – that employed a com-

bination of semi-structured interview and thematic anal-
ysis generate themes that are largely descriptive of issues
of self-care and mental health; both the substantive
issues concerning self-care (e.g. medication management,
problems for two or more
peer support groups who

social support) and the personal challenges faced by

recurrent mental health
users or participants of
15 participants included
mental health service

individuals in their self-care (e.g. being in control, over-

years and consider
have experienced

coming barriers). The smaller numbers of studies that

themselves in

take a more narrative approach to interviewing and are

improvement

explicitly more constructivist in their approach to analy-

Population

sis (e.g. Mancini 2007, Romano et al. 2010) generate

understandings of the experience of self-care and mental
health that are more overtly conceptual (e.g. themes of
‘awakening’ and ‘lives interrupted’, respectively).
In some cases, themes were checked with people with
groups. More coding was performed and combined
A grounded theory study with individual open-ended

mental health problems or who had recovered (Borg &

of coding and labelling and agreed on labels of 13
interviews to understand the process of recovery.

health services, were living in the community and

notes of six interviews and performed line-by-line

containing definitions of recovery and the start of

participants. Second author independently coded

improvement. The two authors compared results

with the results of the first stage of the analysis

The first author studied the transcripts and field

Davidson 2008, Nixon et al. 2010) or neutral outside

participants, some of whom did not use mental

were participating in peer support or advocacy

under broader concepts and codes and were
coding. The emergent themes were grouped

constantly compared with a similar output of

reviewers (Mancini 2007). Respondent validation was

broad concepts. Further recruitment of nine
selected excerpts of the first six interviews

also described in Yurkovich et al. (1997), and some stud-

ies described analysis by more than one researcher
before agreeing common themes (Brown & Kandirikirira
2006, Muir-Cochrane et al. 2006, Pitt et al. 2007, Nixon
et al. 2010).

Summary of findings across studies

As Table 1 shows, the studies revealed strategies, sup-
ports and processes important in self-care, self-manage-
Methods

ment and recovery, with a number of themes featuring

across studies. A number of the studies identified a wide
range of strategies, including employment, education,
creative activity, physical exercise, healthy living, struc-
tured routine and spirituality (e.g. Faulkner & Layzell
problems: Giving up and

2000; Martyn 2003). The issue of control was a common

recurrent mental health
Kartalova-O’Doherty &

feature, including control over their lives, over treatment

fighting to get better
Table 1 (Continued)

and over their future (Yurkovich et al. 1997, Faulkner &

Recovering from
Doherty (2010).

Layzell 2000, Smith 2000, Mancini & Rogers 2007, Khan

et al. 2007). This supports the importance of control,
choice and joint decision-making in policy developments
Study

(DH, 2010) and confirms the assumptions that these are

central concepts in self-care. Support from others was

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M. Lucock et al.

another common finding, both professional, or formal, lifestyle and identity. Some developments, such as the
and non-professional, or informal, although expressed in expert patient programme (DH 2001b), personalisation
different ways (Brown & Kandirikirira 2006, Lucock et al. (DH 2009) and advanced directives have their origins in
2007, Mancini 2007). In the case of professional support, policy initiatives. Others, such as mutual support groups
it seems to be important that the support is flexible and and networks, have their origins in the service
responsive to changing needs (Brown & Kandirikirira user ⁄ survivor movements and may have no professional
2006), and Khan et al. (2007) highlighted the importance involvement. In some cases, consumer-led developments
of a balance between support from professionals and have been taken up and supported by professionals,
autonomy, which can vary over time. such as the Wellness Recovery Action Plan (WRAP,
Given that some studies explored the experience of Copeland 1997) that focuses on self-management of
recovery, it is not surprising that some findings related mental illness. A number of workbooks have also been
to the process of recovery over time (e.g. Nixon et al. developed to support self-management and recovery
2010), rather than strategies used at a particular time. from mental illness (e.g. Coleman et al. 2000, Ridgway
The importance of a developing sense of self is high- et al. 2002) and to support self-help for common mental
lighted (e.g. Romano et al. 2010) and described in differ- health problems such as anxiety and depression (e.g.
ent ways, such as an authentic self (Ridge & Ziebland Greenberger & Padesky 1995). Also, many of the wide
2006) and positive identity (Brown & Kandirikirira 2006, range of psychological and psychosocial interventions
Mancini 2007). Engagement with community activities provided for people with mental health problems
(Cunningham et al. 2005) and living and working in the included in the review of research evidence on the effec-
community where others could see beyond the illness tiveness of self-care support (DH 2007) are consistent
(Muir-Cochrane et al. 2006) were identified and linked to with the principles of self-care and recovery we have
the idea of living a normal, ordinary life (Borg & David- identified. They share common features such as empow-
son 2008; Martyn 2003). Other issues highlighted in the erment, a collaborative approach to understanding and
studies were the importance of coping (Martyn 2003, dealing with problems and the development of self-man-
Rogers et al. 2004), hope (Mancini 2007) and optimism agement strategies, particularly with cognitive behavio-
about the future (Smith 2000). A number of studies iden- ural therapies. To enable self-care within mental health
tified medication as important (Faulkner & Layzell 2000, services, it is important for staff to receive training con-
Smith 2000, Martyn 2003) with Muir-Cochrane et al. sistent with the principles of self-care and guidelines
(2006) highlighting the importance of adherence and have been developed to inform staff training. For exam-
professional support. ple, O’Hagan (2001) has developed recovery competen-
It is interesting to compare the elements of self-care cies for New Zealand mental health workers. The British
identified in these studies with professionally led Medical Association (BMA) has also acknowledged the
approaches. Lucock et al. (2007) pointed out that few of need for education on facilitating self-care in the medical
the themes they identified featured in the evidence-based curriculum (BMA 2007).
self-help interventions available up to now, the exception
being managing and structuring the day which is similar
Conceptual model
to behavioural activation approaches in cognitive
behavioural therapy. To conceptualise self-care, we developed a model, based
on our review and shown in Figure 1. The review sug-
gests that self-care in mental health is a broad, inclusive
Self-care support in mental health services
concept, not distinct from but encompassing those
Before we go onto develop a model of self-care based on related concepts of recovery, self-management and self-
the review’s findings, we will provide some examples of help, so the model should encompass these concepts.
the types of mental health services that have been devel- The model places the individual at the centre and shows
oped that are consistent with self-care. This will inform reciprocal relationships with self-care support, self-care
our consideration of how an empirically derived under- behaviours and strategies, and well-being and function-
standing of self-care and can inform the development of ing. Recovery is identified as a key process leading
mental health services supporting self-care. Relevant ser- towards well-being and functioning. Choice, control and
vice developments and interventions are clearly many engagement are shown as key processes determining the
and varied, but share common characteristics consistent individual’s appropriate and effective level and type of
with those identified in the review, such as increased self-care support. Knowledge (of self-care behaviours
control, shared decision-making, developing self-man- and strategies), self-efficacy (the person’s belief they can
agement strategies and engagement with community- achieve their goals) and capacity are identified as factors
based activities to improve integration into a ‘normal’ determining which self-care behaviours and strategies

612 ª 2011 Blackwell Publishing Ltd

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Self-care in mental health services

Self care support

• Support from
family/carers/friends Self care behaviours and
strategies
• Support groups
• Professional support Life situation • Establishing and maintaining
• Treatment/therapy positive relationships
• Self-help interventions • Coping/ self-help/ self
• Information management strategies
• Understanding & accepting self
Choice, • Adjusting to illness
control and The individual • Employment
engagement • Education
• Mental health • Creative activity
Knowledge
• Physical health • Physical exercise
self efficacy
• Beliefs/attitudes to self care • Healthy living
• Individual differences • Structured routine
• Motivation • Spirituality
• Perceived control
• Autonomy
Life situation

Recovery Life situation

Wellbeing and functioning

• Subjective wellbeing
• Positive, ‘normal’ sense of self
• Self esteem, confidence
• Level of functioning
• Physical & mental health
• Quality of life

Figure 1 A model of self care in mental health.

the individual adopts. We have placed these elements impede the widespread application of the concept of
within an overall context of the person’s life situation self-care to inform the development of mental health ser-
which will of course vary over time and influence all the vices.
other elements. The model reflects the complex, dynamic First, there is the difficulty of developing services
and reciprocal relationships between the elements. For that strike the right balance between providing care,
example, the appropriate level and type of self-care sup- support and treatment for the individual when required
port that a person can engage with will vary from time and the autonomy of the individual. There are concerns
to time for each individual depending on their physical that self-care approaches may on the one hand deny
and mental health, their beliefs and attitudes to self-care, the level of disability caused by mental illness, leaving
and their motivation, with personal choice being impor- individuals unsupported (Roberts & Hollins 2007), or
tant in enabling the individual to have some control over that they will be taken over by professionals and lose
the support. the user-centred focus, on the other (Davidson et al.
2006).
Certainly, there are potential contradictions and con-
Discussion
flicts in the idea and practice of professionally led self-
This review set out to understand the concept of self-care care. For example, services can undermine self-care and
in relation to mental health. Although the term self-care autonomy by being too prescriptive and controlling. It is
may not be a frequently used concept within mental clear from the research reviewed in this paper that,
health services, the principles of self-care underpin ser- although some key themes have been identified, self-care
vice developments which use self-management, self-help is a very individual thing, and so service users should be
and recovery approaches. The conceptual model sets out allowed to find the self-care activities that work for them,
a framework that might usefully inform the provision of rather than having them imposed. Self-care should there-
appropriate self-care support and highlight some of the fore provide choices to match the needs, capabilities and
complexities involved in ensuring the level and type of interests of individuals. In providing support, profes-
support is right at any given time. Although we have sionals should relinquish some control and work in part-
provided examples of a number of service examples that nership with the service user in a more enabling role
are consistent with the principles of self-care, there are a (Roberts & Hollins 2007). It is likely that self-care support
number of issues and practical difficulties that may will be unsuccessful if on the one hand it ignores the

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M. Lucock et al.

needs and autonomy of the individual or at the other Third, consideration should be given to the organisa-
extreme if it provides too little support. Successful self- tional, resource and change management implications of
care support will achieve a balance between these two providing effective self-care support. Achieving more
extremes. We acknowledge that this balance can be diffi- flexible partnership working with service users to enable
cult to achieve in practice, for example in risk manage- care to match their needs presents a challenge to health
ment where there is a tension between safety and services. Large-scale public organisations typically regu-
autonomy (Heyman & Huckle 1993). Despite concerns late and standardise services to enhance quality control,
about risk and litigation, positive risk-taking has been accountability and equity, to minimise risk and to realise
promoted (Titterton 2005). economies of scale (Cinate et al. 2009). Self-care on the
The medical model is often cited as the antithesis of a other hand requires flexible services that are responsive
self-care, recovery-orientated approach. The literature to individual needs. Self-care support also requires
suggests, however, that there is a place for a balance co-operation and collaboration across the different pro-
between the requirements of medical treatment and self- fessional groups and across organisations in the health,
care, for example in medication management where peo- social care and voluntary sectors (Ferlie et al. 2005, Currie
ple can understand and value the role of medication in et al. 2009). Thus, inter-professional and cross-organisa-
their own self-care (Roberts & Wolfson, 2004). Thus, the tional working presents challenges to the effective deliv-
implementation of self-care practice requires a re-orienta- ery of self-care, including issues of funding and
tion of the role of professionals from one of direction identifying who should provide the self-care support
towards that of partnership. (e.g. Morgan 2000, Laugh- and monitor changing needs.
arne & Priebe 2006, Schauer et al. 2007). Clarity and guid-
ance for professionals and users on what can be
Conclusion
expected of this new role, setting out boundaries and
expectations, would seem to be a fundamental require- This paper has identified and reviewed some of the exist-
ment for self-care to progress. ing research into important elements of self-care for peo-
The second issue impeding the widespread applica- ple with mental health problems. Although this enabled
tion of the self-care approach is the variable quality of us to develop a self-care model, we acknowledge limita-
the evidence available. Despite the large number of tions in the extent and quality of the available research.
papers identified in our review, there is limited system- We therefore recommend more research into service
atic empirical research underpinning practice and very users’ views of the key elements of self-care and what
few longitudinal studies that clearly demonstrate which constitutes effective self-care support. We have also high-
aspects of self-care support are most effective. Thus, lighted some of the challenges of self-care support in
there is insufficient evidence on the facilitators and barri- mental health and suggest more research is required into
ers to effective self-care on which to base policy and the barriers and facilitators to effective self-care at indi-
practice. Moreover, the philosophy of evidence-based vidual, service and organisational levels and more evalu-
medicine may also conflict with a self-care approach. In ations of the impact of self-care initiatives on well-being,
evidence-based medicine, a disorder is identified and the quality of life and functioning, including economic eval-
most effective treatments are revealed, primarily through uations. We hope the conceptual model provided in this
clinical trials. Treatment guidelines then guide the pro- review will support such further research.
fessionals in the treatments they provide. The self-care
approach, on the other hand, puts the emphasis with the
Acknowledgements
individual themselves, and the evidence that informs
this approach tends to be based on more qualitative Thanks to Karen Akroyd, Lucy Davies and Virginia Min-
research, personal narratives and the views of ‘experts ogue for their contributions to the literature review and
by experience’. This type of evidence is given relatively to Kati Turner for her helpful comments on drafts of the
low status in the development of NICE guidance paper.
although there is some acknowledgement of the value of
cross-sectional and qualitative research on patients’ expe-
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