Usefulness of Recovery services promoting personal recovery among Adults living with Severe Mental illness – A Comprehensive Integrative Review CURRENT STATUS: REVIEW

Background: There is increasing call regarding recovery services but little review have been undertaken regarding such services. This integrative review aimed to identify and synthesize evidence on the usefulness of recovery services used to promote personal recovery among adults living with severe mental illness. Methods: A search of the published literature was conducted using: Medline, EMBASE, PsycINFO, CINAHL, Google Scholar, Web of Science, and Scopus. Mixed methods synthesis was used to analyse the data. The search was limited to papers published in English from January 2008 to January 2020. The review integrated both qualitative and quantitative data into a single synthesis. Results: Out of 40 included papers, 62.5 %( 25/40) used Quantitative data, 32.5% used Qualitative and 5 %( 2/40) used mixed methods. The review identified three recovery services such as integrated recovery model, vocational rehabilitation (Individual Placement Services), as well as recovery narrative photovoice and art-making services. The recovery services are useful in areas such as medication and treatment adherence, improvement in functioning, symptoms, physical health & social behaviour, self-efficacy, economic empowerment, social inclusion, household integration and access to support services. Conclusions: The evidence on recovery services focused largely on integrated rehabilitation and individual placement services, with a few studies implementing recovery narrative photovoice and art-making services. Mental health professionals are encouraged to implement the identified recovery services to improve the personal recovery goals of consumers.


Background
Recovery in mental health is defined as the process of restoration of functioning and well-being, improvements in quality of life of an individual diagnosed with longer-term mental health problems or emotional difficulties, using a whole system or an integrated approach (1,2). The concept of recovery has been defined according to two main categories -clinical recovery (eg. service-based, or objective definition) and personal recovery (subjective) (3)(4)(5)(6)(7)(8). The two forms of recovery-clinical and personal -are relevant in physical and mental conditions (9). The personal perspective considers recovery as a personal recovery journey of consumers. The evidence has largely addressed services used to foster integrated recovery services. Despite this, only a few studies have attempted to systematically review the literature regarding recovery services for adults with Severe Mental illness (SMI). The adult with serious mental illness (SMI) may suffer from a long term condition that requires a special integrated or whole system approach to treatment. A preliminary search we conducted showed that though some existing reviews have been conducted regarding recovery, they are limited to the general mental health population and some specific services, such as individual placement services (12)(13)(14).
Critically, no review study has been undertaken to aggregate a synthesis of both qualitative and quantitative studies regarding recovery services that promote the personal recovery journey of Adults living with Severe Mental illness. The review, therefore, aimed to: (1) identify existing evidence on recovery services; and to (2) synthesise evidence on the relevance of the recovery services for adults living with severe mental illness.
The review findings are significant for several reasons. The evidence is expected to inform policy decision making on the wellbeing of adults with serious mental illness. The evidence is also considered to be valuable to policymakers and mental health professionals to strengthen mental health services. Finally, the evidence can guide researchers and clinicians with regard to directions for future research and further inform the training of mental health professionals and students.

Methodology
An integrative review is an approach that allows simultaneous inclusion of diverse methodologies (e.g. qualitative and quantitative data) and varied perspectives to fully understand the phenomenon of concern (15,16). This review study aims to use diverse data sources to develop a holistic understanding of recovery services for adults with severe mental illness. This review method contributes greatly to evidence-based practice for mental health nursing. The review employed a fivestage process, including problem identification (developing and defining research question and study aim; searching literature (incorporating a comprehensive search strategy); evaluation of data (assessing for methodological quality); analysis of extracted data (data reduction, display, comparison and conclusions) and; presentation (mixed methods synthesis implications for practice, policy and research) (15).

Inclusion criteria
The review included studies that address recovery services for adults (eg 18 years and above) living with severe mental illness (eg. in-patients, out-patients, community-based residential services, homebased). The review defined individuals with serious mental illness as those with a mental, behavioural, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities (17). The adult with serious mental illness were individuals with schizophrenia, bipolar disorder, mania, or psychosis that has been diagnosed by a health professional and self-reported or by proxy (18). Studies that were included targeted services such as disability support, recovery services. The study also included papers that address the effect of recovery services on the lives of people living with severe mental illness.
The review included papers of all methods and designs. Papers included used mixed methods, quantitative, or qualitative methods. The quantitative methods included quantitative randomised controlled trials, quantitative non-randomized designs (analytical cross-sectional) and quantitative descriptive studies. Also, the qualitative papers used ethnography and participatory methodology, grounded theory, phenomenology, and narrative. The review considered only studies published in the English language. Studies published from January 2008 to January 2020, were considered for inclusion in this review. This year appears as the period where researchers' increasingly attempted to research into recovery services and interventions for an adult with mental illness.

Exclusion criteria
Papers that were excluded are based purely on general health services or clinical effectiveness of a particular intervention with no connection to recovery services and mental health rehabilitation. Also, papers were excluded if they address recovery services for children and adolescents, workplace mental health issues, recovery services in stroke patients as well as in traumatic injury. The review excluded articles published prior to 2008 as well as non-English language articles. Other general exclusion criteria were systematic reviews, conference abstracts, clinical case reviews, book chapters, papers that present opinion, editorials and commentaries.

Search strategy and selection procedure
We searched seven electronic databases; EMBASE, CINAHL (EBSCO), Web of Science, Scopus, PsycINFO, Medline and Google Scholar. The searches of published articles were conducted according to the Joanna Briggs Institute (JBI) recommended guidelines for conducting systematic reviews (19). A three-stage search strategy was utilised to search for information (see Table 1). An initial limited search was conducted in EMBASE and MEDLINE ( Table 1). The initial search was not restricted by limiters; field, language, timespan and type of publication. We analysed the text words contained in the title and abstract and of the index terms from the initial search results (19). A second search using all identified keywords and index terms was then conducted across all remaining five databases. These searches were restricted to title, abstract and keywords due to a plethora of references obtain by the initial search. Finally, the reference lists of all identified articles were handsearched for additional studies (19). Table 1 Search strategy and selection procedure

Stages
Search terms and keywords Stage 1 (Initial search in MEDLINE and EMBASE ( Disabilit*/ OR "psychosocial disability"/ OR Adult/ or Mental Disorders/ OR mental illness/ or mental condition.mp. ) AND ( Social Support/ or "Individual Support"/ or disability support.mp. OR "social inclusion"/ OR integration/ OR "community acceptance"/ or participation.mp. ) AND ( Nursing Homes/ OR Residential Facilities/ or residential care.mp. or "Rehabilitation Centers"/ OR community rehabilitation.mp. OR residential program.mp. or "Residential Care" OR Institutions.mp. or Residential Treatment.mp. ) AND ( "service model"/ or "service typology"/ or Rehabilitation/ or rehabilitat*.mp. or Disabled Persons/ or Rehabilitation OR Vocational/ or "Psychosocial Support Systems"/ OR "Psychosocial Deprivation"/ or psychosocial.mp. ) AND ( recovery OR effectiveness/ OR"Patient Reported Outcome Measures"/ OR "Treatment Outcome"/ or outcome.mp. OR "Patient Outcome Assessment"/ or functioning/ OR "quality of life"/ OR coping.mp. OR "Patient-Centered Care") Stage 2 (search across CINAHL, Web of Science, Scopus, and PsycINFO) ("Mental Disorders"/ OR "mental illness"/ OR "severe mental illness") AND TOPIC: ( The selection of eligible articles adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (20) (Figure 1). Firstly, three authors independently screened the titles of articles that were retrieved and then approved those meeting the selection criteria. The authors reviewed all the titles and abstracts and agreed on those needing full-text screening. The first author conducted the initial screening of titles and abstracts. The second and third authors conducted the second screening of titles and abstracts of all the identified papers. The authors conducted full-text screening according to the inclusion and exclusion criteria.

Data management and extraction
Endnote X8 (software) was used to manage the search results, screening, reviewing articles, as well as removing duplicate references. Three reviewers independently managed the data extraction process (19). The authors developed a data extraction form to handle all aspects of data extraction (Appendix 1). The data extraction form was developed according to Cochrane and the Joanna Briggs Institute (JBI) manuals (19) for conducting systematic reviews, as well as consultation with experts in methodologies and the subject area (19). The authors' extracted results of the included papers in numerical, tabular and textual format (19). The first author conducted the data extraction whilst the second and third authors conducted the second review of the extracted data. The data extraction focused on study details, (citation, year of publication, author, contact details of lead author, and funder/sponsoring organisation), publication source, methodological characteristics, study population, subject area (e.g., recovery service model, recovery concept, recovery intervention, period of project implementation, phases or component of recovery intervention, outcome or impact of intervention), as well as additional information and recommendation and other potential references to follow up.

Assessment of Methodological Quality
The authors developed a critical appraisal checklist using the Mixed Methods Appraisal Tool (MMAT) (21) and the Joanna Briggs Institute (JBI) (22) critical appraisal tool. The critical appraisal checklist was used by the authors (the first, second and third authors) to assess the methodological quality of the included papers. The critical appraisal tool was sub-divided into sections like study details, methodology (eg. categorized as qualitative, quantitative randomized controlled trials, quantitative non-randomized, including cohort study, case-control study, analytical cross-sectional, quantitative descriptive, and mixed methods) as well as overall quality score (Appendix 2). The methodological quality score was rated as low quality if the overall score was below 25%, medium quality if 50% and high quality 70% and above. The scores were computed by summing the number of 'Yes' counts in each sub-section of the methodological criteria. The total score was then expressed as a percentage (21).

Data synthesis
The extracted data were analysed using a mixed-methods synthesis (15,19). The mixed-methods synthesis seeks to develop an aggregated synthesis of qualitative and quantitative data (19). The process involves familiarization with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes and producing a thematic chart (23,24). The authors coded the quantitative and qualitative data together. Data display matrices were developed to document all of the coded data from each extracted data (15). Alphabets and colours were assigned to each of the coded ideas. The resulting codes from quantitative and qualitative data were used to generate descriptive themes (19). The descriptive themes were categorized into global and organizing themes (see Table 3). The themes have been discussed with the concepts and theoretical constructs that explain recovery services in mental health. The background information of included papers were analysed using STATA version 15.

Description of retrieved papers
The review retrieved 788 papers from all databases. Of these, 94 duplicates were removed. The titles and abstracts of 694 non-duplicate articles were screened for eligibility, after which 266 were excluded. A total of 428 full-text articles were assessed for eligibility (376 were excluded). The review extracted data from 52 full-text articles that met the eligibility. Of these, 2 articles were identified through hand searching of the reference list. Overall, 40 papers were included in the final synthesis ( Figure 1). Out of the 40 papers, 38 met the criteria for high methodological quality assessment, whilst only two papers had medium quality ( Table 2).

Characteristics of included articles
More than half of the papers (23/40; 57.5%) were interventional studies. Of these, more than a third  Table 1). A + represent the average, minimum or maximum age of participants Q ++ represent the quality assessment score for the papers ("H" indicate high score whilst "M" indicate medium score)

Environment for implementing recovery services
The review identified five environments where recovery services are implemented. The environment of implementing recovery services were community-based interventions, residential facility setting and services via psychiatric day hospital/primary health care settings (25)(26)(27)(28)(29)(30) (Table 3). Four papers suggested that recovery services can be offered through home-based cares (31-34) and a day centre structure programme (35)(36)(37).

Philosophy of Recovery services
An integrated recovery service model In this review, integrated recovery service model is described as any services that seek to promote and support restoration, 'remediation and reconnection. The concept employs both an overarching, inherently collaborative and integrated approach to mental health services. Sixteen of the included papers described the integrated recovery services model used to achieve recovery for adults with severe mental illness ( Table 3). Most of the papers suggested that integrated recovery service model can be delivered through illness management (38)(39)(40)(41)(42)(43)(44), mindfulness-based interventions (45), tasksharing or shifting approach (25,26), home visits concept (29,46,47), active leisure or recreational activities (32,37) and music therapy (27) (see Table 4). The reviewed papers highlighted that the integrated recovery services generally aim at developing independent living skills, improve quality of life, community mobilisation (39), reducing inpatient and crisis services, adhering to treatment and setting meaningful goals towards recovery (40,41,46).
The integrated recovery service model can be offered through training sessions (e.g. hours, days and weekly for several months) (25-27, 29, 40, 45). For instance, past study regarding integrated recovery model was enhanced with mindfulness group therapy sessions which were run for 60 minutes throughout 26 weeks (45) (see Table 4). Conversely, music-creation therapy used as recovery services were run for 32 weekly sessions, with a duration of 90 min for each session (27). Generally, the activities of recovery service model covers components such as cognitive behaviour therapy techniques, psychoeducation, relapse prevention, social and coping skills training (meals, guidance in activities of daily living, role-playing, hobby groups) (38,40,46), adherence support, family therapy, crisis management, household contribution and understanding medication (25,29,46). More specifically, Tjornstrand, Bejerholm (37) recommended that active leisure implemented as recovery services can take several activities, including playing sports, the opportunity to play games, eat, and socialize, embarking on excursions and relaxation (see Table 4).
Some studies further suggested that non-specialist are sometimes trained to deliver recovery services, through task-sharing or task-shifting approach. Some of the non-specialist professionals are auxiliary social workers (25,38).
Most of the included papers described the process of implementing individual placement and support.
The papers suggested that the IPS is implemented through phases such as initial vocational assessments (eg. to identify clients' personal strengths and work skills), job searching (eg. searching job sites, applying for work online and accompany clients to interviews), individual job development (eg. intensive supervision), work performance monitoring, support for employers and continuing postemployment support for clients (31,35,48,51,53). In addition, some papers recommended that Individual placement support workers receive training and regular supervision to provide effective services (50, 51) (see Table 4). The IPS employment can take several forms, including services(eg. cleaning, gardening, catering, clerical and administrative work) (30,37), training clients for labour market, agricultural production and creative projects (eg. painting, drawing, sculpture, ceramics and textiles, assembly lines, carpentry shops, computer repair centres, bicycle repair shops woodworking and furniture making) (54,55).

Recovery Narrative Photovoice, Art-making and exhibition
Five of the included papers recommended photovoice, art-making and exhibition as interventions used to construct recovery (56)(57)(58)(59)(60). The photovoice, art-making and exhibition are used to achieve recovery, empowerment, community integration (56,58,59) and share difficult experiences nonverbally (57). The intervention aims to explore, document and share ideas about recovery. It involves the construction of text with photographs through the exhibition and large group discussion (56,58,59). More importantly, the intervention helps to avoid the stigma that is associated with the conventional process of delivering mental health services (60). For instance, Clements (56) suggested that readers or audience of photovoice interventions become part of the construction of the meaning of recovery. The intervention allows people with serious mental illness to communicate their needs and ideas to the public, as well as to policymakers.
The photovoice, art and exhibition intervention are delivered through weekly class sessions and community outings (58-60) ( Table 3). The content of the class sessions focuses on writing exercises, psychoeducational handouts, and activities on how to construct empowering narratives of recovery and stigmatization (58, 59) (see Table 4). In addition, Ketch, Rubin (60) suggested that the class session begins with sharing previous experiences or knowledge about art-making. The final outcome of the photovoice, art and exhibition intervention are documented through the final recovery photo gallery or text pieces, art shows or public exhibition, creative arts (eg. painting, ceramics, silk screening, mosaics) and displays of art prints (56,57,59,60).
For instance, Lee, Liem (29) reported that recovery services have improved most outcome parameters such as bed days, re-admission episodes and days of missing psychiatric appointments.
Conversely, Malinovsky, Lehrer (39) suggested that the number of days spent in the hospital decreased by about 40% after initiation of recovery transformation. Furthermore, some studies suggested that the effects of IPS intervention on the time patients spend in competitive employment have had a significant effect on the clinical status, particularly a reduction of the need for psychiatric inpatient care (31,61). For instance, Kilian, Lauber (61) indicated that consumers who received an IPS intervention spent fewer days in the hospital.

Improve Functionality
Fourteen of the included papers concluded that recovery services have improved the functioning of adults living with severe mental illness (  (43) showed in a study that the intervention (eg. rehabilitation training programme such as day treatment, medication monitoring, biweekly rehabilitation training) group had a significant improvement in social and psychological functioning.

Reduce Symptoms
Most of the included papers suggested that recovery services have had a significant improvement in anxiety, psychosocial and mental symptoms of an adults with severe mental illness (25, 27-30, 33, 34, 40, 43, 45, 61). For instance, Chang, Chen (27) reported that the anxiety symptoms in an experimental group (music-creation programme) improved 6.22 points more than the control group (P < 0.001). Similarly, the mean symptoms (Positive and Negative Syndrome Scale PANSS) in a clubhouse group (eg. Open occupation or employment) decreased from 64.5 to 42.7 compared with the control groups which increased from 51.7 to 57.6 (p = 0.01) (30). More importantly, Lopez-Navarro, Del Canto (45) concluded that incorporating mindfulness intervention into integrated rehabilitation has the potential to reduce negative symptoms.

Improvement in Physical health & Social Behaviour
Six of the included papers reported that recovery services have improved the physical health and social behaviour of an adults with severe mental illness (26,33,34,39,45,46). In particular, the recovery services have had improvements in physical health, wellbeing, adaptation, appearance, (33,34,39,46), quality of life (psychological health) (45) and reductions in risk-taking behaviour (26). For instance, Lopez-Navarro, Del Canto (45) recommended that incorporating mindfulness-based intervention into recovery services have the ability to improve the psychological health-related quality of life. More specifically, the study indicated that the mindfulness intervention accounts for 38% of the variance in health-related psychological quality of life (45).
Three papers recommended that recovery narrative photovoice and art-making services have positively impacted on adults with severe mental illness. This recovery services have improved the lives of consumers in areas such as senses of identity, independence, tolerating uncertainty, feeling ownership of choices, learning from the past, and maintaining vigilance for relapse (57)(58)(59). In particular, art-making interventions provide opportunities for self-exploration and the development of new skills (57). More importantly, the art-making and exhibition help people living with severe mental illness to clearly express their feelings and communicate emotions and thoughts which could be difficult to express using words. In addition, recovery narrative photovoice intervention can also help to achieve recovery outcomes such as autonomy, readiness for change, inspiration, idealism, the transformation of self, acceptance of support, awareness of progress, hope, determination, passion, perseverance, introspection, strength, and sense of connectedness (58,59).
Moreover, four papers recommended that vocational rehabilitation interventions have impacted positively on the personalities (eg. sense of competence through participation in work), reduce boredom/loneliness, feeling anchored in reality and create strong internal motivation for change (49,52,55,62). The feelings and expressions of clients help them to develop a sense of selfdetermination and personal recovery (54,62).

Economic empowerment
Nineteen of the included papers reported that the recovery services, for instance, vocational participation have helped to improve the economic empowerment of adult with severe mental illness (see Table 3). More importantly, the vocational rehabilitation programmes provide livelihood and income-generating activities (26,46,49,52,53).
Most papers reported that adult living with severe mental illness who participate in vocational interventions gained competitive employment (28,33,37,50,53), returned to open employment (35) and receive vocational benefit (37,49,50,63). In particular, adult living with severe mental illness participating in vocational interventions are more likely to receive job-seeking assistance (eg. searching for jobs, filling application forms and practise for interviews) (38,49,50).
Most of the studies suggested that vocational intervention such as IPS is more effective than the conventional vocational services, particularly in every vocational outcome.The IPS clients are more effective to work competitively, returning to open employment (eg. working for at least one day), and longer duration of employment (eg. working for many hours and longer job tenure) and wages earned (28,35,48,49,51,61). Catty, Lissouba (51) reported that IPS clients were two times (214 days) more likely to work for a longer duration than vocational service clients (108 days). Conversely, 57% of IPS clients (a sample of 58 consumers with schizophrenia) worked competitively, compared with 29% of conventional vocational clients. Similarly, 70% of IPS participants obtained any paid work, compared with 36% of conventional vocational clients (48). More importantly, the vocational rehabilitation interventions have helped consumers to gain financial literacy skills (eg. managing finances) (25,26,31,46,52), become financial independence and financially stable (49) and improved recovery (28,46).

Social inclusion (Community integration)
Twenty-seven of the included papers reported that recovery services have increased social inclusion and community acceptance or integration of adults with severe mental illness (see Table 3).
Some studies reported that recovery services such as IPS recovery narrative photovoice and artmaking help an adult with severe mental illness to achieve or re-establish valued roles in the community (31,57,58). Whitley,Harris (42) recommended that consumers with severe mental illness can use the community as a place of safety, surrogate family, and as socialization and individual growth. In addition, vocational participation rehabilitation services increase the social contacts of adult with SMI with their supervisors and customers or clients, which subsequently break the feeling of social isolation (49,52,54,55,64).
Furthermore, some studies suggested that the social environment recovery services, (eg. clubhouse used as a community) have the ability to create an atmosphere of acceptance and inclusion and subsequently support each member's personal recovery journey (54,62). For instance, an adult with severe mental illness in a residential programme (clubhouse) had greater participation in recreational events, informal socialization with peers (44), social relationship, quality of life (30,43) and feeling valued, inclusion and belonging to a group (63). Further, De Heer-Wunderink, Visser (32) reported that supported independent living programs seemed to positively influence the level of social inclusion for consumers living with severe mental illness, in terms of their being active and receiving and making visits with others.

Household integration
Three of the included papers reported that recovery services have achieved integration of adult with severe mental illness into their families (25,33,46). Such recovery services have increased greater participation in the household task and family stability and care (25,46). For instance, Asher, Hanlon (46) reported that a recovery-oriented rehabilitation service has helped an adult with severe mental illness return home to address the basic needs of shelter and food. The services have also equipped family caregivers to develop some resilience to accommodate their relatives, including telling them of plans in advance, communicating calmly and avoiding stressors. Consequently, the service has helped to reduce caregiver burden as well as treating an adult with severe mental illness with dignity and effective caregiving (eg providing food, shelter and shelter) (46).

Social support
Seven of the included papers highlighted several support services used to implement recovery services for an adult with SMI (28, 31-33, 55, 59). Some papers highlighted that the support services originate from sources such as relatives, friends or peers (32,55) supervisor support and community peers (31,55). In particular, De Heer-Wunderink, Visser (32) suggested that more than 85% of clients in recovery-oriented rehabilitation service reported having received support from a partner, their family, or friends. Conversely, Harpaz-Rotem, Rosenheck (33) reported that clients receiving a residential treatment had a significantly higher social support on average (p < 0.001) after baseline.
Supervisors (staff) from recovery services provide practical and emotional support to adults with severe mental illness (42,55). Whitley,Harris (42) reported that most adults with severe mental illness considered supervisors or staff to be equally important members of the surrogate family.

Discussion
This review was conducted to synthesize evidence into the recovery services used to promote recovery among adults living with severe mental illness. The study specifically aims 1) to identify existing recovery services; 2) to synthesise evidence on the usefulness of recovery services on the recovery process of consumers. The review findings are discussed according to two emerging themes: (i) philosophy of Recovery services, (ii) usefulness of recovery services on the lives of adults living with a severe mental illness.

Philosophy of Recovery services
Recovery services are interventions that aim to provide person-centred mental health services. This approach of mental health services employs a whole system or holistic approach towards the recovery journey of consumers (8). The review findings identified several recovery services which include integrated recovery service model, vocational rehabilitation as well as recovery narrative photovoice and art-making exhibition. The integrated recovery service model, for instance, is offered through illness management, mindfulness interventions, task-shifting approach (eg. participatory based training), home visiting, active leisure and music therapy services. The Integrated recovery service model are mostly incorporated into conventional services and aim to achieve a holistic mental health services. The review findings encourage service providers to integrate mindfulness practices, active leisure, music therapy and spiritual healing practices as part of the integrated recovery service model (27,37,45). The inclusion of such components not only ameliorate the symptoms but are also useful in achieving a sense of agency and autonomy, taking personal responsibility and getting on with life (10). Conversely, the integrated recovery service model encourages the use of task-shifting and home visiting to promote the recovery journey (25,26,29,46,47). The home visiting and taskshifting can help consumers to take up a central role in managing illness (eg. regaining control), personal growth as well as establishing a fulfilling and meaningful life (3). The task-shifting and home visiting can help consumers and their families to set their personal goals towards the recovery journey. Our review findings encourage service providers to implement the integrated recovery service models to promote the personal recovery process of consumers.
The evidence suggests that vocational rehabilitation services are also increasingly employed to promote the recovery process of consumers This service is mostly offered through IPS, supported employment enterprises and social firms compared with conventional vocational services (eg. sheltered employment) (35,51). The vocational rehabilitation services that are used to support the recovery process of consumers are consistent with previous literature (12)(13)(14). In particular, the IPS interventions have proven to have the ability to improve the recovery journey. The IPS interventions identified in the current findings are mostly associated with agricultural production, creative projects, services and clients joining the labour market (30,35,49,51). The interventions are usually implemented through initial vocational assessment, job searching, individual job development, monitoring work performance, support for employers and continuing post-employment support for clients. The review findings encourage service providers to implement vocational rehabilitation services (eg IPS interventions) that are contextually respected by local service providers and communities. More specifically, researchers are encouraged to use interventional studies to measure the effectiveness of the different vocational rehabilitation services that aim to promote the recovery process of consumers.
Recovery narrative photovoice, art-making and exhibition interventions have recently been employed as recovery services to support the recovery process (56)(57)(58)(59)(60). The photovoice, art-making and exhibition services are implemented through text construction and photographs. This service is also presented through an exhibition and large group discussion. The service is particularly employed to achieve recovery, empowerment, community integration, expressing difficult experiences in nonverbal forms as well as avoiding the stigma associated with conventional mental health services. The review findings encourage researchers to use interventional studies to explore the effectiveness of recovery narrative photovoice and art-making exhibition services towards the recovery journey, particularly in multi-cultural settings, where there is increase stigmatization of mental illness. Such interventional studies could help consumers to develop culturally sensitive recovery goals.

Usefulness of recovery services
Recovery services necessarily focus on enhancing consumer's capacities for living with, managing, and pursuing a life in the presence of disability, as well as removing barriers around their environment (4). Consistent with earlier studies, the current recovery services are useful in enhancing psychiatric medication and treatment (clinical outcomes) of consumers (4,6). More specifically, such services increase access to psychiatric medication, antipsychotic medication adherence, decrease relapse, improve knowledge and decrease clinical contact (25,29,31,33,40,46,61). These services are not only about helping consumers to learn how to live a fuller and more satisfying life but also contributes to the reduction of the symptom itself. The review findings encourage service providers to promote holistic care that considers the individual's subjective appraisal of his or her functioning and satisfaction with life (9).
In addition, psychiatric rehabilitation has recently moved beyond the mere control of symptoms and prevention of relapse to incorporate a functional recovery and enhancement of the quality of life of the consumer (3). The ability of service providers to improve the quality of life of consumers could help to achieve a personal recovery process that is consumer-centred. The current review findings demonstrated that recovery services have supported the physical health and social behaviour of consumers. More specifically, such recovery services improves the physical health, well-being, adaptation, appearance, quality of life and reduction in risk-taking behaviour (26,33,34,39,45,46).
The improvement in the physical and social behaviour of the consumers could also help them to progress in developing self-efficacy, self-confidence, and gaining hope, improvements in self-care or practical skills. The interventions have specifically enhanced the recovery process through readiness for change, autonomy, inspiration, idealism, sense of connectedness and transformation of self.
Recovery services have also improved the economic empowerment of adult living with severe mental illness. The services provide livelihood and income-generating avenues that can facilitate access to competitive employment, returning to open employment and vocational benefits. It is apparent that the participation in income generation activities improves the financial literacy skills, financial independence and financial stability of adult living with severe mental illness. The improvement in finances through income-generating activities forms a major component of the recovery journey or process. The findings confirm previous literature which suggests that recovery services could empower adults with severe mental illness, through normative life participation such as education, social and political activities (3,5). The major strength of recovery services mostly relies on its ability to safeguard empowerment in the consumers through everyday living skills, accommodation, social networks, employment and education endeavours (5). Again, the review findings demonstrated that recovery services have the ability to aid the social inclusion and community acceptance of adult living with severe mental illness. Consistent with previous literature, recovery-oriented rehabilitation promotes the inclusion of adults with severe mental illness through increasing community participation, social contacts or social interactions, socialization, and supportive social environment (6). Such services support consumers to reconnect and re-establish a place in the community, and to explore opportunities that could help them live an independent life. Consequently, the services reduce social isolation, discrimination and stigmatization among consumers (5). In addition, the consumers are also integrated greatly into their individual families and so take an active role in family activities and also maintain family stability.

Limitations
The review has several limitations that need consideration. The limitations of the integrative review are largely pertinent to the search words, language limitations, and period of included papers. The review was only limited to papers published in English Language and those published from January 2008 to January 2020. In particular, limiting studies to only English Language articles published between January 2008 to January 2020 could miss relevant non-English Language articles as well as those published before 2008. The variation in search terms and keywords regarding recovery-oriented rehabilitation and recovery based interventions may miss some relevant articles. However, the combination of clearly articulated search methods, consultation with research Librarian, and reviewing articles with multiple experts as well as the quality assessment tool used to measure the methodological quality helped to address the various limitations.

Conclusion
The review findings showed that several studies have been undertaken regarding recovery services that can facilitate the recovery journey for adults living with severe mental illness. Most of the recovery services are implemented in developed western countries, particularly in the USA and Europe, with relatively few studies piloted in developing countries (for example Africa). The review findings demonstrated that most of the papers used quantitative data, with few studies employing both qualitative and quantitative data to achieve complementarity or convergence. The evidence showed that most recovery services are delivered through community-based settings. Also, studies on recovery services largely address issues on integrated recovery service model and vocational rehabilitation, with few studies addressing recovery narrative photovoice and art-making exhibition services. Furthermore, the recovery services are reported to be useful in areas such medication and treatment adherence, functioning, symptoms, physical health & social behaviour, self-efficacy, economic empowerment, social inclusion or community integration, household integration and increase access to social support services.

Relevance for Clinical Practice, Policy and Future Research
The recovery services identified are valuable for Mental Health Professionals. These findings may lead to an adaptation of rehabilitation interventions that would be helpful for the personal recovery goals for consumers.
Awareness and advocacy for recovery recovery services should be prioritised in national and international policy initiatives. Consumer associations, self-help groups and family caregivers could be empowered to take the leading advocacy role in the recovery services.
Research on recovery services should be prioritized in clinical practice and further directed towards interventional studies, which can provide sustainable and workable solutions in the recovery journey and outcome.
Recovery research mostly employs quantitative and qualitative methods, with relatively few studies using mixed methods. We recommend that future recovery research should attempt to use mixed methods to achieve complementarity and congruence in both methods.

List Of Abbreviations
Individual

Consent for publication
Not applicable

Availability of data and materials
All data generated or analysed during this study are included in this article and its supplementary information files

Competing interests
The authors declare that they have no competing interests.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.