What follows below is an original version of the WhatsApp conversational review that began with an invitation statement from the teacher and each participant critically appraised and reviewed the Qualitative study. As the discussion progressed, dialogue between the moderator students and a professor centred around study, and a review report was summarized (the moderator is indicated by the title “teacher” and/or initials (R.B.) and student reviewers are indicated by their initials).
VP: TITLE: A Complexity Perspective on Narrative Identity Reconstruction in Mental Health Recovery
ABSTRACT: The issue of complex nonlinear change processes is one of the least-understood aspects of recovery and one of the most difficult to apply in recovery-oriented healthcare. The purpose of this article is to explore the recovery stories of 17 mental health peer support workers to understand their narrative identity reconstruction in recovery using a complexity perspective. Using the Life Story Model of Identity (LSMI), a narrative thematic analysis of interviews suggests that self-mastery as part of personal agency is an important component of participants’ narrative identity reconstruction. Self-mastery is particularly evident in redemptive story turning points (positive outcome follows negative experience). A complexity perspective suggests that participants realised their adaptive capacity in relation to self-mastery as part of recovery and that its use at story turning points critically influenced their evolving recovery journey. Further exploring self-mastery as adaptive growth in narrative identity reconstruction appears to be a fruitful research direction.
VP: CASP-Qualitative-Checklist-2018.pdf (file attached)
CASP-Qualitative-Checklist-2018
VP: This is a casp check list for qualitative study
RB: I'll invite our clinical psychologist here to this group. He also has a PhD
RB: Please note that in the event of the rejection of this paper, in conjunction with the author’s decision to refer their manuscript, it may be transferred for consideration in another SAGE journal. Your referee comments may also be transmitted as well. Your identity will remain confidential to the author but will be disclosed to the editor.
The criteria for acceptance consists of evaluating both the substantive contribution and technical excellence of the article. Please consider each of these questions when reviewing the manuscript. **You may copy and paste these questions into the “comments to the author” box at the end of the form. Or, you may paste them into a new Word document, which can be attached to the review**
These recommendations are for modification/improvement for the author:1. Importance of submission: Does it make a meaningful and strong contribution to qualitative health research literature? Is it original? Relevant? In depth? Insightful? Significant? Is it useful to reader and/or practitioner?2. Theoretical orientation and evaluation: Is it theoretically clear and coherent? Is there logical progression throughout?3. Methodological assessment: Appropriate to question and/or aims? Approach logically articulated? Clarity in design and presentation? Data adequacy and appropriateness? Evidence of rigor?4. Ethical Concerns (Including IRB approval and consent).5. Data analysis and findings: Does the analysis of data reflect depth and coherence? In-depth descriptive and interpretive dimensions? Creative and insightful analysis? Linked with theory? Relevance to practice/discipline?6. Discussion: Results linked to literature? Contribution of research clear? Relevance to practice/discipline?7. Manuscript style and format: Please evaluate writing style: Length (as short as possible], organization, clarity, grammar, appropriate citations, etc.); presentation of diagrams/illustrations?8. Does the article fit with QHRs publication mandate? Has the author cited the major work in the area, including those published in QHR?9. Additional Comments for the Author(s).
MS: Does this mean instead of following CASP tools they want us to grade the paper as such sir?
RB: No I guess it's their checklist but they should be fine with our using CASP too. Vivek already shared that pdf with her following which she sent me a direct link to access this PDF
AVK: this paper is amazing sir👌
AVK: 1- Was there a clear statement of the aims of the research? -*yes* - "The purpose of this article is to explore the recovery stories of 17 mental health peer support workers to understand their narrative identity reconstruction in recovery using a complexity perspective"
2- Is a qualitative methodology appropriate? - *yes* - _
qualitative Methods < Research Design, Interviews < Research Strategies, Thematic Analysis_
Q- why questionnaire is not provided?
50 Questions per session and out of 90 min. 60 min for these questions where all concepts or themes are repeated multiple times.
is time to less to speak a question, think and answer correctly for Identity Reconstruction where subject is not aware of questions already and have to look back and generate insightful narratives for themself to speak quickly in realtime?
AVK: given that they are peer worker in the field of mental health care & patient too (who may be a better observer in pt. perspective).. and not the professional psychiatry doctors/researcher (who may be better on clinical signs/symptoms and their variations) and summarize important features quickly/correctly.
RB: I'm not sure if it is clear.
What is a recovery story? What is a mental health peer support worker? What is narrative identity reconstruction? What's complexity perspective and how does it become a tool for narrative identity reconstruction?
RK: Sir, I have gone through the paper. I will answer..
RK: The paper describes about the recovery stories of the 17 patients who had some kind of mental disturbance in their lives...
RK: Recovery story is the narrative described by the recovered patients and the insights achieved by them just before recovery happened..
RK: Narrative identity reconstruction is the explaining of the events (larger and smaller) in the lives of the people and the positive turns taken by them during certain pivotal moments
RK: The complexity perspective explains the dynamic nature of the narrative process since the recovery is not linear but mixed with various twists and turns taken in the recovery process by the insights they achieved for the recovery...
RK: I do not agree with the sudden insights of the patients since the paper itself says about the dynamic nature involved and the complexity of the recovery process.....
RK: sudden insight is linear process and the complexity is dynamic process. This is a contradiction in itself...
RK: An insight of a patient is achieved through a complex process of psychotherapy involving the application of various therapeutic approaches by an experienced psychotherapist......
RK: each therapy is customized dynamically to suit and help the patient to achieve the insights....
RK: For eg., for a patient with obsessive compulsive disorder, we use Cognitive behaviour therapy
RK: For an Anti social personality patient, we may use Rational emotive behaviour therapy...
RK: For Somatic symptom disorder we use CBT along with Gestalt....
RK: For a person distressed in life and does not find a direction, we may use logotherapy....
RK: From the perspective of approach taken by the therapist which is dynamic in nature, an insight is found by the patient by looking deep within the layers of the unconscious and subconscious minds in a safe therapeutic environment....
RK: As explained by the paper, i am of a contradictory view that the sudden insight is not practical nor can be prophylactic
RK: Sudden insight is like a miracle happening and the probability of this happening in a patient is extremely low.....
RK: This is because of the organic causes in the brain due to the imbalances in the neurotransmitters, personality factors, Genetic factors, extreme distressing environmental factors......
RK: Finally, a person can achieve insight in a less distressing situations like making a choice between remaining at home or moving out of the home...or dealing with inter personal disturbances....
RK: But the insight cannot be practically applicable to mental disorders like Schizophrenia, border line personality disorders, dependent personality disorders, somatic syndrome disorders, disassociate disorders, obsessive compulsive disorders....i cannot give a whole lot of list here....discussing them itself would require months of effort......
RK: Sudden motivations and insights cannot be achieved in neurotic patients itself.......let alone psychotic patients....
RK: If one needs more information, one needs to read the psychological theories of the last hundered years by Sigmund freud, otto rank, albert bandura, bf skinner, jean piaget, jean paul sartre, irwin d yalom, carl jung, viktor frankl, carl rogers, james williams, ivan pavlov....
AVK: yes sir.
AVK: wow. thanks!
AVK: patient narrate their journey from sick to getting healthy..but here its question answer it seems and not really a detailed story.
AVK: people who had suffered mental health issues once but then recovered and got employed as peer group to help other's by supporting or motivating with their story etc.
AVK: narrative is the story and narrative identity reconstruction is like story of getting back to normal or better mental health, a pt. to normal identity of self and not in an affected mental state like depressed or hopeless or suicidal etc.
AVK: complexity perspective - to visualize the key elements of efficient, information-based, collaborative decision making.
AVK: sir, as i couldn't find any direct /unique definition of the terms, i tried to find their meaning and this is what i got to understand ahead
RB: Good. We are inching toward the climax.
AVK: this title is also interesting for our conversational reviews/decision making.
AVK: thanks sir!
RB: Let's look into the detail of how and why the study formulated this theory of "sudden insight?"
AVK: took story by questionnaire interview with short q&a and called it narrative, then used to analyse points repeated, etc. for finding keywords/phrases for the complexity perspective /analysis.
RB: So "a mental health peer support worker" is aka patient? 🤔
AVK: yes sir. now working as peer group and had been a pt
RK: The question comes as to why these 17 patients were not supported by former patients who achieved insight and got well...
RB: Yes did this idea come later? Did one of these 17 patients suggest this idea? Is one of them among the study authors?
AVK: may be they were sir..perhaos that's not clarified in article that they didn't had patient support group help.
AVK: no idea as we are blinded sir.. but even if one is in author's no one will know unless they specify specifically.
RB: Yes this needs to be specified by the authors even if one of them is in their author team. Also would be clear if we can clarify their methodology
RK: Sir, from the paper it can be inferred from various stories narrated, that the patients got motivated to act differently now when compared to their previous actions which were not fruitful...
RB: What led to the motivation?
RK: The root cause of the motivation is not mentioned in the paper sir..that is why it is referred to as sudden insight which is absurd from a practical point of view. There needs be a catalystic agent....
RB: Very point in our review that will constitute author feedback. So we need to tell the authors to identify the root cause of their motivation
RK: Yes sir, also it is mentioned that the patients recovered from " severe and persistent mental illness"
RK: The definition of what constituted that "severe and persistent mental illness" is not given anywhere....
RK: if the mental illness was severe and persistent, what are the causes of this illness is not given...
RK: Also how the questions are drafted for obtaining data from the control group is not given in the paper... when each mental illness suffered by the individual members are different considering that severe and persistent illnesses endured are unique to each person...
RK: my point is how the unique set of questions(application to all 17) are drafted to collect data from the sample of 17 people who suffered from different "severe and persistent mental illnesses". When they suffered from different mental illnesses, the set of questions should be customized to each individual as per his/her recovery from that particular illness....
RK: For eg., if a person suffered from schizophrenia, his mental state is psychotic and the recovery is a different process when compared to a neurotic person with anxiety disorder...
RB: Excellent points for the authors to address. Avinash, Vivek, Madhava please take note of these as we need to incorporate these in our review comments.
Also as previous we can create a blog with our entire conversational review taking care to deidentify the journal, article and other relevant areas.
RB: From what I am understanding from the conversations (even without having found the time and energy to go through the article myself) is that perhaps the authors are trying to show the power of collaborative learning as the patients couldn't have gotten any insights on their own but it was a product of collaboration between all of them who were untrained patients engaging in peer to peer learning as an interventional tool. I would suspect that they also were trained by the authors who may have been professionals unless the patients themselves have written this paper as part of a "participatory action research" in which case it should have been mentioned in the methodology
While the concept of collaborative learning in a naive patient user driven manner is laudable (and our group is actually studying this phenomenon as evidenced by our past publications) it would be very important to critically appraise and validate or invalidate this work
RK: Collaborative learning between patients with severe and persistent mental illnesses is like interactions between two different people from two different planets....they do not understand each other's language...
RK: Sir, when the patients lack insight, then one cannot expect them to speak rationally, let alone collaborate dialogue and actions..
RK: Peer to peer learning can be a possibility if the patient has attained some kind of a personal improvement and shares the same with a person or group who are in need of help being in the same situation as the patient....this happens regularly in our DAC
RK: When I say lack of insight, I mean loss of touch with reality which is seen in psychotic conditions...
RB: Great point I agree. Similar point made by a US based psychiatrist who contributed to our book and you will find his chapter here https://www.igi-global.com/book/user-driven-healthcare-narrative-medicine/41908
Scroll down to chapter 23
RB: Here's another one written by one of our patients https://www.igi-global.com/chapter/user-driven-psychiatry/67732
MS: After reading half of the paper, I remember a TV series called Elementary which is a crime fighting background and hero of it Sherlock holmes but it is based on USA unlike UK. He was addicted to drugs and for recovery he used to visit a mental health group. Here also U just visit there and sit in the group and share ur story. There u can ask people who has recovered from mental illness to guide us (who are seniors to them and recovered sucessfully) If u are sucessfully recovered and donot go the habit the group they give you coins as a reward and congratulates you.
MS: I suppose paper is about getting inspired at some point of time by looking at the peers and comparing similar life style, problems with others and getting motivated from it.
RB: Yes something like Alcoholics anonymous for deaddiction. 👍
RB: Thanks Madhava very good insight. 👍Dr Raj Kumar any inputs on this?
RK: Yes sir.I agree with getting inspired at some point of time at random to address an individual's shall mental disturbances. But in no way related to addressing "serious and persistent mental illnesses" which are mentioned in the paper...My view is that "serious and persistent mental illnesses" cannot be addressed with the approach mentioned in the paper....
RB: What are those seventeen individual stories suggesting? Are these stories about how each one of these individuals obtained insights into their mental well-being? Are their individual stories believable? Let's say if among all of us five reviewers one found it believable and others didn't then perhaps these stories are not that great. This method of pluralistic evaluation is also known as triangulation in qualitative research (and come to think of it our review process itself is using the methodology of qualitative research).
MS: Sample size was chosen according to principles of data saturation.
What does this mean?
17 individuals from 5 centres are taken
Why only 17?
I suppose the authors selected these 17 recovering individuals and selected for the study and wanted to show this kind of approach for the treatment.
Havent read the entire paper yet but by using only this method, can a complex disease like schizophrenia and bipolar can be recovered?
To some extent I agree for depression and anxiety can be recovered.
Apart from this they didnot state if they are on any medication or therapy.
If they are on therapy or medication then this appraoch may be benefited.
MS: The authors needs to state these points to give some more clarity and understanding the situation much more better.
RB: Yes and let's google and find out and share here what principles of data saturation mean
MS: Theoretical saturation of data is a term in qualitative research, mostly used in the grounded theory approach. Theoretical saturation of data means that researchers reach a point in their analysis of data that sampling more data will not lead to more information related to their research questions.(1) No additional data can be found to develop new properties of categories and the relationships between the categories are disentangled. Researchers see in their data similar instances over and over again and that make them empirically confident that their categories are saturated, the descriptions of these categories are thick and a theory can emerge. Researchers are allowed to stop sampling data and to round off their analysis.
Explicit guidelines for determining theoretical saturation are lacking and therefore researchers have to support their claims of saturation by an explanation of how they achieved saturation including clear evidence.(2) The application of the term saturation beyond the grounded theory approach is a topic of debate.(3)
MS: Again, This is stated in the text:
Sample size was chosen according to principles of data saturation. This entails an iterative process of sequentially conducting interviews until all concepts or themes are repeated multiple times without new ones emerging and additional interviews are unlikely to provide additional insights (Trotter, 2012). Emphasis was on the richness (quality) of data elicited from participants’ narratives with variation of responses valued over the number of times something was stated (Morse, 1995). Data saturation was facilitated by using an interview protocol structured to facilitate asking participants the same questions (Fusch & Ness, 2015).
MS: So more number of interviews were conducted but how many more are conducted and how did they come to conclusion that they are repeatative. All this information may be required in the supplementary information of the paper.
MS: Because to believe by following only this apprach with out any treatment from outside (given or not given we yet dont know ) is slightly difficult.
RK: Agreed with this...As mentioned in the paper and the stories narrated...the problem with which the patients were dealing were very shallow and day to day challenges which cannot be categorized into mental illnesses and that too, "serious and persistent illness"....
RK: Moreover mental illnesses is a big word to define a spectrum of disturbances which cannot be cured without the intervention of advanced psychotherapy and psychopharmacology...
RK: We have many people coming to in psychiatric ward and every one has different mental illness. In spite of they being at a place, they do not even know what the other person's illness is....because they do not have any knowledge about their psychiatric condition or mental illness....let alone helping each other.....
MS: Also sir, they have taken only 4 diseases: Schizophrenia, anxiety, depression and bipolar.
Are these 4 are not representative of entire mental health?
Also the number in each disease group is so less to come to any conclusion
VP: But is this paper trying to represent whole mental health and I think that would be difficult?
MS: Yes, the title itself is stating as such
A Complexity Perspective on Narrative Identity Reconstruction in Mental Health Recovery
RK: May not be applicable to any of them...for eg...depression is again categorized into mild, moderate and severe....and if it is severe, there might be suicidal thoughts and attempts due to imbalances in dopaminergic and serotoninergic neurotransmitter mechanisms.....which would definitely require intervention of a trained medical professional
RK: in this paper, there can be two conclusions if the points are to be valid.....First, the mental disturbances are very narrow which does not require the intervention of anybody like a mental health professional.....Second, the group members are themselves well versed with indepth mental health concepts and know how to treat each other by talking to each other....
RK: We are not in 1850s to accept such a concept or a paper.....if this paper was published in around 1860,this would have been definitely valid....we have come so long with understanding of human brain in last 150 years.....with advanced talking therapies, psychopharmacological interventions etc....
RK: Sorry to be little harsh with these wordings but as an advanced psychotherapist myself i cannot accept such kind of a purely illogical concepts such as those mentioned in the paper.....
RB: Absolutely agree. This is a good point to ask the authors to address
RB: Very important point again. Perhaps we should cite specific examples from the text for the authors to appreciate which problems and why they appear shallow to us and why addressing them may not have had much impact on the patient's overall mental health outcomes
RB: Agree. Did they define what kind of mental illness was identified in each patient?
Yes sir.
They have
MS: Participants self-reported disorders as schizophrenia (3 males, 2 females), bipolar disorder (3 males, 2 females), depression (3 males, 1 female), and anxiety (1 male, 2 females).
MS: From the text
MS: Can we think of this atleast useful as an adjuant therapy along with the medications or not?
RK: There are lot of points missing to ask the author of review since our discussion since last night
RB: Agree. 🙂👍
MS: 1.Was there a clear statement of the aims of the research?
The aim of the study is to explore participants’ narrative identity reconstruction during recovery, as described in their recovery stories, and understand it from a complex adaptive system (CAS) perspective.
This is the aim of the paper. So how to give scoring sir whether is correct or not.
RB: As mentioned before the statement as an aim didn't appear to be clear
MS: So the answer is No
RB: No more action here? Have we finished the critical appraisal check list for this?
RB: If yes then let's prepare a point wise review summary for the authors and a blogged description/draft illustrating our review methodology here.
MS: 2.Is a qualitative methodology appropriate?
The researchers used a very broad term which is mental health ( and included only 4 diagnosis on it Depression, Schizophrenia, Bipolar and Anxiety) So Qualitative methodology is not appropriate
MS: Is it worth continuing?
3.Was the research design appropriate to address the aims of the research?
The researchers failed to provide proper AIMS of the study and the methodology is not appropriate
MS: So No
MS: Hence I would like to stop my review here. If anyone wants to still continue the review, please do that I will also join u people or else I will stop here.
RB: Why? Why should not a broad term include the four and why shouldn't that be appropriate to qualitative methodology?
RB: Elaborate 🤔
RB: Stopping is fine but we need to better define why
The above article shows the types of mental health disorders, but the authors only two subsections included in the entire paper. So using a broad term is not appropriate.
MS: Sorry for the delay in response.
RB: Using the broad term where?
MS: In the title
A Complexity Perspective on Narrative Identity Reconstruction in Mental Health Recovery
RB: What is the problem if they use that broad term when they are targeting specific conditions? I guess it means they are not focused properly? I agree that every mental disorder may have different outcomes with peer social media intervention and most user driven healthcare sites use websites that are disease specific like one for multiple sclerosis one for itp and so on. However would this be a big negative?
MS: Sir, then we should suggest change in the Title from mental health to Anxiety and Mood diaorders
MS: Disorders*
MS: But wouldnt this broad term create confusion in the readers mind
MS: ?
VP: In think broad term is fine and looks good to me in the title. like we entitled optimize precision medicine that doesn't mean we are trying to cover all and everything of the precision medicine disciplines.
RB: Yes agree 👍
RB: Can we quickly collate whatever we have done till now?
FINAL RECOMMENDED REVISIONS FOR THE AUTHORS WHICH TRANSPIRED FROM CONVERSATIONAL REVIEW BY THE TEAM:
FINAL RECOMMENDED REVISIONS FOR THE AUTHORS WHICH TRANSPIRED FROM CONVERSATIONAL REVIEW BY THE TEAM:
Our recommendation for the Qualitative study that you sent to us for review is that it is fair and require further revisions as pasted below:
1. Complex nonlinear change processes: The definition is not given how it is applicable to the present context of research in recovery-oriented healthcare is not clear.
2. Whom did 17 mental health peer support workers work with for participants’ narrative identity reconstruction?
3. Are these 17 peer support workers the first batch who are to help another batch if there is any through their reconstructive stories?
4. Non linear, heterogeneous trajectories are basically mathematical terminology in describing mathematical equations. How are these quantified in the present papers if they are applicable to the present research?
5. what are the "processes" in recovery and how they are measured here?
6. what are dynamic psychological states when narrating stressful and traumatic experiences and how they are quantified here in the article?
7. what is nonlinear dynamic processes of adaptive growth?. The article referring to recovery from severe and persistent mental illness. Where does the adaptive growth fit into and what is the process of growth? Is the article referring to recovery or growth?
8. "The possibilities for recovery are created by the inherent strength and capacity of all people experiencing mental health issues"
· This statement refers to the possibilities. If it is referring to the possibility only then it is also possible that the person may not recover. How can the article claim that the probability of the recovery is there and how do you quantify the probability of the recovery happening?
· Patients with severe mental illness such as schezophrenia and bipolar disorders are psychotic disorders in which the patient loses a sense of touch with reality. How can patient do the "Narrative Identity Reconstruction" when the patient has lost a sense of touch with reality in such "prolonged psychiatric disability" and "severe mental disorders".
· please give more details of the psychotic disorders as it is not possible for any patient with "prolonged psychiatric disability with severe psychotic sympoms" recover through narration.
· If it is possible then please provide the scripts of the narration and at which point of their statements did they receive their insights to get well.
9. " In recovery, there is often an internal conflict between the individual’s illness self and healthy self? what is the proof that there is an individul illness self and healthy self? Looks like a qualitative statement which cannot be scientifically prove and does not provide any argument for its existence in the article.These kind of statements are to be removed from the article which cannot be quantified or cannot be proved to be in existence.
10. who are the consumers word relating to in the paper?
11. who are the 17 people in participation. Did they recover on their own discussing among themselves or was there any outside factor?
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