A multidisciplinary expert consensus for enhancing recovery-oriented clinical practice in schizophrenia: The RECOVERY project

Abstract

Background and objectives

Recovery‑oriented care has become a central paradigm in schizophrenia treatment, yet gaps persist between evidence and clinical implementation. The RECOVERY project aimed to identify unmet clinical needs and propose practical initiatives to enhance recovery‑oriented practice within the Spanish mental health system.

Methods

A structured, three phase expert consensus was conducted (2022–2024), involving a Scientific Committee and two Multidisciplinary Working Groups. Participants reviewed evidence, identified needs, and developed actionable recommendations through iterative meetings.

Results

Ten key needs were identified, including individualized treatment planning, improved training in recovery principles, implementation of shared decision making, reduction of stigma, rational pharmacotherapy, attention to physical health, coverage of basic needs, access to psychological treatments, strengthened community support, and integration of new technologies. For each need, practical and evaluable proposals were formulated.

Conclusions

This consensus provides a realistic, adaptable framework for advancing recovery-oriented care in Spain. Adoption of these recommendations could improve functional outcomes, quality of life, and the alignment of mental health services with patient-centered values.

Introduction

Schizophrenia is a severe and complex mental disorder characterized by notable clinical and etiological heterogeneity, typically emerging in late adolescence or early adulthood.^1,2 Its estimated lifetime prevalence is around 1 % of the general population.¹ The illness course is variable, and relapses, particularly in the initial years following a first psychotic episode (FEP), are common and associated with a higher risk of chronicity, functional impairment, and poorer clinical outcomes.^3–6 Current evidence underscores the critical importance of early detection and intervention in the initial phases of psychotic disorders to improve long-term outcomes, reduce relapses and hospitalizations, and promote symptomatic and functional recovery.^7–10 Traditionally, the therapeutic approach to schizophrenia has focused on reducing symptomatology, primarily positive symptoms, and preventing relapse.¹¹ However, recent decades have witnessed the strong emergence of the recovery paradigm. This multidimensional concept extends beyond symptomatic remission to encompass the restoration of personal and social functioning, quality of life, and the ability to live a meaningful and satisfying life, despite the presence of the illness.^12–16 Functional recovery is a complex goal influenced by biological, psychological, social, and environmental factors.^17–20 Although its definition and measurement still pose challenges,^21,22 there is a growing consensus among clinicians, researchers, patients, and caregivers regarding its relevance as a central therapeutic objective.^21,23 In Spain, the recent update of the National Health System's Mental Health Strategy (2022–2026) and increased social awareness of mental health provide a favourable context for driving improvements in schizophrenia management.²⁴ Nonetheless, significant gaps persist between the scientific evidence on recovery and its practical implementation in clinical services. The RECOVERY project was initiated in this context, aiming to identify, through a multidisciplinary expert consensus, unmet clinical needs and propose practical, implementable, and evaluable initiatives to enhance recovery-oriented clinical practice for individuals with schizophrenia in Spain.

Materials and methods

The RECOVERY project utilized an expert consensus methodology developed between December 2022 and October 2024. The process was led by a Scientific Committee (SC) and facilitated by a technical secretariat (Eversheds Sutherland Salud Advisory). This approach is conceptually aligned with established consensus methods used in medical and health-services research when the available evidence is incomplete, heterogeneous, or must be translated into context-specific recommendations — namely the nominal group technique and modified expert-panel formats — as distinct from the anonymous, questionnaire-based Delphi process.^32,33 Consistent with recommendations for the transparent reporting of consensus exercises,³⁴ we describe below the participants, the number and type of meetings held, and the decision rules applied.

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  Participants:

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    Scientific Committee (SC): Comprised four Spanish psychiatrists with recognized clinical and academic expertise in schizophrenia (M. Bernardo, M. Bravo, J. Domper, G. Lahera). Their role was to lead the project, oversee clinical and technical content, and coordinate the working groups.

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    Multidisciplinary Working Groups (MWGs): Two MWGs were formed to represent the diverse stakeholders involved in the recovery process. They included professionals from mental health nursing (J.A. López), healthcare management (S. García-Heras), clinical psychology (Ó. Vallina), social work (J.I. García), a volunteer patient expert (A.M. Martínez), and a representative from patient organizations (S. García Márquez). Each MWG was mentored by two SC members. Working Group 1 comprised the mental health nurse (J.A. López-Cocera), the social worker (J.I. García-Gimeno), and the volunteer expert patient (A.M. Martínez-García); Working Group 2 comprised the clinical psychologist (Ó. Vallina), the healthcare manager (S. García-Heras), and the representative of patient organizations (S. García Márquez). This distribution ensured that each group integrated a clinical, a managerial/social, and a lived-experience perspective. The SC mentors facilitated the discussions without substituting for the group’s judgment.

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  Procedure: The project unfolded in three phases:

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    Phase 1 (December 2022 - Early 2024): The SC conducted a preliminary literature review on recovery in schizophrenia. In an initial meeting, project objectives were defined, preliminary clinical needs were identified as a basis for subsequent work, the reference bibliography was updated, and profiles for MWG members were selected. A baseline document outlining detected needs was prepared for discussion with the MWGs.

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    Phase 2 (February 2024): A joint meeting of the SC and MWGs was held to formally present the project, the baseline document, and the working methodology. Specific tasks were assigned to each MWG, and a timeline was established. The MWGs began their work separately, mentored by SC members. Specifically, each MWG was tasked with: (i) critically reviewing the baseline needs document from the standpoint of its constituent disciplines and experiential perspectives; (ii) refining and prioritizing the preliminary list of clinical needs; and (iii) formulating, for each retained need, concrete initiatives that were considered implementable within a reasonable timeframe and potentially evaluable within the Spanish healthcare context.

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    Phase 3 (Mid-2024 - October 2024): Each MWG held meetings (in parallel) to discuss preliminary clinical needs, debate, and propose practical initiatives that were implementable within a reasonable timeframe and potentially evaluable, considering the perspective of each discipline and stakeholder represented. Subsequently, in a joint online meeting, the conclusions and initiatives proposed by both MWGs were consolidated and validated, generating a draft consensus document. This document was reviewed by the SC and validated in a final joint (in-person) meeting of the SC and MWGs, resulting in the project's final report.

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  Analysis: The process relied on structured deliberation and qualitative consensus among participants to identify key needs and formulate practical recommendations. The Scientific Committee (SC) held an initial scoping meeting (December 2022) and maintained ongoing coordination throughout the project. Two joint plenary meetings involving the SC and both MWGs were convened — a kick-off meeting (February 2024) and a final in-person validation meeting (October 2024) — together with one joint online meeting to consolidate the groups’ conclusions. In addition, each MWG met independently on two occasions during Phase 3. No formal quantitative voting or Delphi-style numerical rating was applied; in keeping with the deliberative, qualitative design, consensus was operationalized as the absence of sustained substantive objection following structured discussion. Divergences were resolved through moderated deliberation facilitated by the SC mentors, and contested statements were iteratively reformulated until they were acceptable to all participants. All ten needs, together with their associated initiatives, were endorsed by every participant at the final validation meeting; no need was excluded and no formal dissent was recorded. The needs are presented thematically rather than in a ranked order of priority.

Results

The multidisciplinary consensus process identified 10 fundamental needs for improving recovery-oriented clinical practice for people with schizophrenia in the Spanish context. Specific practical initiatives were proposed for each need. These needs and a summary of the key initiatives are presented in Table 1.

Table 1.

Identified needs and proposed initiatives from the RECOVERY consensus for enhancing recovery-oriented clinical practice in schizophrenia.

Identified Need	Key Proposed Initiatives
1. Comprehensive, individualized, and intensive treatment plan	Implement continuity of care plans with multidisciplinary teams; ensure care continuity and case management; assign a care coordinator; promote patient leadership in their own plan.
2. Enhanced training for professionals in the recovery paradigm	Incorporate recovery workshops into specialized training (psychiatry, psychology, nursing residencies) and continuing education; promote professional self-assessment (see Table 2 ^25); foster collaborative methodologies and facilitator roles.
3. Incorporation of a Shared Decision-Making (SDM) model	Promote and train in SDM models; implement advance care planning and advance directive documents; record and minimize coercive measures; provide training in verbal de-escalation techniques.
4. Raising awareness about the possibility of recovery	Disseminate recovery messages via media and social networks; combat self-stigma (patient education); activate peer support; conduct workshops with personal testimonies in secondary education and healthcare settings.
5. Striving for the minimum effective dose in pharmacological treatment	Evaluate prescribing patterns against CPGs; avoid non-justified polypharmacy and megadoses; implement prescribing alerts; conduct anonymized analyses of prescribing patterns.
6. Addressing physical health and promoting healthy lifestyles	Systematically monitor physical health parameters; promote healthy habits (exercise, diet, substance avoidance); provide continuing education for professionals; ensure coordination with Primary Care (PC). Apply structured metabolic monitoring and cardiovascular risk screening in line with international standards^38^,^39; formalize shared-care pathways with Primary Care.
7. Coverage of basic needs (income, housing, employment)	Sensitize public authorities and the scientific community on the importance of meeting basic needs; strengthen the social worker's role as a liaison; systematically incorporate basic needs assessment into clinical practice.
8. Offering recovery-oriented psychological treatment	Survey access to psychotherapy; ensure professional training in evidence-based interventions; include validated family interventions; incorporate peer perspectives.
9. Adequate social and community support network	Promote support networks (self-care, social skills, leisure, employment, housing); coordinate rehabilitation interventions with individual plans; foster user-friendly and non-stigmatizing community environments.
10. Incorporation of new technologies into clinical practice	Create/facilitate access to interactive websites (info, self-help); enable online psychotherapy resources; develop a universal access resource library; produce podcasts; utilize open-access knowledge models. Prioritize digital tools with empirical support and ensure data-protection/GDPR compliance and equity of access.

The most relevant aspects of each identified need are briefly detailed below:

Comprehensive Plan: Emphasis was placed on overcoming care fragmentation through individualized plans coordinated by a designated professional (e.g., specialist nurse, social worker) with active patient participation.

Professional Training: A specific training need in the recovery paradigm was identified, both in initial training (residency programs) and continuing education, including self-assessment²⁵ and adopting more collaborative roles.²⁶

Shared Decision-Making (SDM): Implementing SDM models, advance planning, and advanced directives was deemed crucial to respect patient autonomy and minimize coercion.

Awareness and Stigma: The importance of combating stigma and self-stigma by promoting messages of hope and the possibility of recovery was highlighted, targeting society, patients, and families, using personal testimonies.

Pharmacological Treatment: Adherence to clinical practice guidelines¹¹ was recommended, seeking the minimum effective dose and avoiding practices like unjustified polypharmacy or megadoses, which can have stigmatizing adverse effects.

Physical Health: People with schizophrenia have a markedly reduced life expectancy — on average approximately 14.5 years lower than the general population³⁶ — largely attributable to physical comorbidity, particularly cardiovascular and metabolic disease.³⁷ Given this excess morbidity and mortality, the consensus stressed the need for systematic physical-health monitoring and active promotion of healthy lifestyles, coordinated with Primary Care. In particular, the group endorsed adherence to established metabolic monitoring standards and structured cardiovascular risk screening — including baseline and periodic assessment of weight/body-mass index, waist circumference, blood pressure, fasting glucose, and lipid profile — in line with international recommendations for the physical-health care of people with severe mental illness^38,39 and emphasized formalized coordination and shared-care pathways between mental health services and Primary Care.

Basic Needs: It was acknowledged that functional recovery is difficult without meeting basic needs like housing, income, and employment (supported or mainstream), requiring social policy involvement and strengthening social work's role.

Psychological Treatment: The need to actively offer recovery-oriented, evidence-based psychotherapeutic interventions for both patients and families, incorporating peer perspectives, was identified.

Social Support: The importance of a robust, coordinated community support network to prevent isolation and facilitate social, occupational, and residential integration was highlighted.

New Technologies: Leveraging digital technologies to improve access to information, training, peer support, self-monitoring, and psychotherapy was proposed, using open-access knowledge models. Examples with a growing (though still maturing) evidence base include smartphone applications for symptom self-monitoring and relapse prevention, ecological momentary assessment, digital psychoeducation, and therapist-supported (blended) online psychological interventions. The evidence should nonetheless be interpreted with caution: a recent systematic review and meta-analysis of digital health interventions in schizophrenia found no statistically significant pooled effects across core clinical outcomes, with more promising signals for human-supported (rather than fully self-guided) formats.⁴⁰ Implementation also raises specific risks that must be actively managed, including data protection and confidentiality (compliance with the EU General Data Protection Regulation), informed consent for data use, clinical safety and oversight, and the risk of widening inequities through the digital divide.⁴¹ Digital tools were therefore framed as a complement to, not a replacement for, face-to-face care.

Discussion

The RECOVERY project, through a structured and multidisciplinary consensus process, has generated a framework of needs and concrete action proposals to advance towards more recovery-oriented clinical practice in schizophrenia within the Spanish healthcare system. The results reflect broad agreement among different professionals and stakeholders (including patients) on the key elements that must be addressed.

The 10 identified needs span clinical, functional, social, and structural dimensions, consistent with the multidimensional nature of the recovery concept.^12,14,21,23 The need for comprehensive, individualized plans (Need 1), enhanced professional training (Need 2), and the implementation of SDM (Need 3) are aspects repeatedly highlighted in international literature as pillars of recovery-oriented services.^15,16,25,26 The proposal to include patient perspectives and collaborative models^27,28 is fundamental for moving beyond traditional paternalistic approaches. Combating stigma (Need 4), rational use of pharmacotherapy (Need 5), and attention to physical health (Need 6) are also critical areas with a direct impact on the quality of life and functioning of individuals with schizophrenia.^11,29,30 The explicit inclusion of meeting basic needs (Need 7) underscores the importance of the social determinants of mental health.^17,19 The recommendation to enhance access to evidence-based psychological treatments (Need 8) and community support networks (Need 9) aligns with clinical guidelines and community care models.^12,15,31 Finally, the proposal to integrate new technologies (Need 10) reflects a necessary adaptation to contemporary tools for improving accessibility and support. The primary value of this work lies in its pragmatic approach, contextualized to the Spanish system, and its inclusive methodology integrating diverse professional perspectives and the lived experience of patients. This enhances the relevance and potential applicability of the proposals. The inclusion of an annex for professional self-assessment provides a practical tool for individual change (Table 2).

Table 2.

‘Ten Top Tips’ for recovery oriented practice²⁵ After each interaction, the mental health professional should ask her / himself, did I….

Actively listen to help the person to make sense of their mental health problems?

Help the person identify and prioritize their personal goals for recovery – not professional goals?

Demonstrate a belief in the person’s existing strengths and resources in relation to the pursuit of these goals?

Identify examples from my own ‘lived experience’, or that of other service users, which inspires and validates their hopes?

Pay particular attention to the importance of goals which take the person out of the ‘sick role’ and enable them actively to contribute to the lives of others?

Identify non-mental health resources – friends, contacts, organizations – relevant to the achievement of their goals?

Encourage self-management of mental health problems (by providing information, reinforcing existing coping strategies, etc.)?

Discuss what the person wants in terms of therapeutic interventions, e.g. psychological treatments, alternative therapies, joint crisis planning, etc., respecting their wishes wherever possible?

Behave at all times so as to convey an attitude of respect for the person and a desire for an equal partnership in working together, indicating a willingness to ‘go the extra mile’?

While accepting that the future is uncertain and setbacks will happen, continue to express support for the possibility of achieving these self-defined goals – maintaining hope and positive expectations?

The present consensus should be read in relation to, rather than as a substitute for, established international frameworks. Comprehensive clinical guidelines such as the United Kingdom’s NICE guideline on psychosis and schizophrenia in adults,³⁵ and the recovery paradigm articulated in the international literature,^18,22 define what recovery-oriented care should achieve. The specific contribution of the RECOVERY Project is complementary and implementation-oriented: it translates these principles into concrete, evaluable initiatives, and it does so through a process that explicitly integrates multidisciplinary professional perspectives with the lived experience of patients and patient organizations. Several features of the Spanish mental health system justify a tailored framework. Care is organized within a decentralized National Health System in which the seventeen autonomous communities hold competencies for service planning and delivery, producing substantial territorial heterogeneity in resources and models of care. The recent National Health System Mental Health Strategy 2022—2026²⁴ provides a policy window for reform, while the central roles of community mental health teams, specialist mental health nursing, social work, and coordination with a strong primary-care network shape both the opportunities for, and the barriers to, recovery-oriented practice. A framework developed and prioritized by Spanish stakeholders is therefore more likely to be adopted than a direct transposition of recommendations designed for differently organized systems.

However, the study has several limitations. As an expert consensus, the proposals derive from qualitative deliberation and existing evidence rather than from a clinical trial directly evaluating their effectiveness; rigorous implementation and evaluation will be the crucial next step. Experts were selected purposively on the basis of recognized clinical, academic, or experiential expertise rather than through random or exhaustive sampling, which may introduce selection bias and may not capture the full range of professional and experiential viewpoints. Territorial representation was limited, as participants were drawn from a subset of autonomous communities and did not encompass all regional realities of the Spanish system. Finally, the consensus did not employ quantitative agreement metrics: because no Delphi-style ratings or predefined agreement thresholds were used, we are unable to report numerical indices of consensus (e.g., percentage agreement), and the strength of agreement for individual items cannot be quantified. These methodological choices, appropriate for the deliberative and translational aims of the project, should be borne in mind when interpreting and generalizing the recommendations.

The implications of this work are significant. It provides a roadmap for clinicians, managers, and policymakers interested in improving mental health services for people with schizophrenia. Implementing these recommendations could contribute to improving functional outcomes, reducing the burden of the illness, and aligning clinical practice with recovery principles and patient rights. Future research should focus on developing effective implementation strategies for these initiatives and evaluating their impact on clinical and functional outcomes using measurable indicators.

Conclusions

The RECOVERY project has identified, through a multidisciplinary expert consensus, 10 key areas of need and proposed specific initiatives to foster recovery-oriented clinical practice in schizophrenia in Spain. This framework encompasses aspects from treatment planning and professional training to addressing basic needs and utilizing new technologies. Adopting these recommendations, based on a strategic, realistic, and inclusive vision, represents an opportunity to significantly enhance the care and quality of life for individuals affected by schizophrenia, promoting their capacity to live full and meaningful lives.

Funding

This paper was funded by unrestricted support from ROVI. The company had no influence on article content.

Ethical considerations

This study did not involve human participants or patient‑level data and therefore did not require ethics committee approval.

Acknowledgements

We gratefully acknowledge the collaborative efforts of the multidisciplinary panel of experts who participated in the consensus-building meetings: José Antonio López, (enfermero especialista en salud mental), Susana García-Heras (Directora de la Fundación Sociosanitaria de Castilla-La Mancha - Consejería de Sanidad), Óscar Vallina (Psicólogo Clínico del Hospital Sierrallana-Tres Mares, Torrelavega, Cantabria), Jesús Ignacio García (Trabajador Social), Ana María Martínez (Voluntaria del Programa Ments Despertes del Grup SOM VIA para la prevención y promoción de la salud mental integral y la lucha contra el estigma en salud mental) y Silvia García Márquez (Directora del Programa Paciente Experto del Grupo SOM VIA). Their diverse perspectives and critical insights significantly shaped the final recommendations.