Post-traumatic growth in mental health recovery: qualitative study of narratives

Objectives Post-traumatic growth, defined as positive psychological change experienced as a result of the struggle with challenging life circumstances, is under-researched in people with mental health problems. The aim of this study was to develop a conceptual framework for post-traumatic growth in the context of recovery for people with psychosis and other severe mental health problems. Design Qualitative thematic analysis of cross-sectional semi-structured interviews about personal experiences of mental health recovery. Setting England. Participants Participants were adults aged over 18 and: (1) living with psychosis and not using mental health services (n=21); (2) using mental health services and from black and minority ethnic communities (n=21); (3) underserved, operationalised as lesbian, gay, bisexual and transgender community or complex needs or rural community (n=19); or (4) employed in peer roles using their lived experience with others (n=16). The 77 participants comprised 42 (55%) female and 44 (57%) white British. Results Components of post-traumatic growth were present in 64 (83%) of recovery narratives. Six superordinate categories were identified, consistent with a view that post-traumatic growth involves learning about oneself (self-discovery) leading to a new sense of who one is (sense of self) and appreciation of life (life perspective). Observable positively valued changes comprise a greater focus on self-management (well-being) and more importance being attached to relationships (relationships) and spiritual or religious engagement (spirituality). Categories are non-ordered and individuals may start from any point in this process. Conclusions Post-traumatic growth is often part of mental health recovery. Changes are compatible with research about growth following trauma, but with more emphasis on self-discovery, integration of illness-related experiences and active self-management of well-being. Trauma-related growth may be a preferable term for participants who identify as having experienced trauma. Trauma-informed mental healthcare could use the six identified categories as a basis for new approaches to supporting recovery. Trial registration number ISRCTN11152837

circumstances'. 2 Other terms for this phenomenon have also been used, such as benefit-finding, 3 both a coping profile and a coping outcome, 4 and positive illusions. 5 This range of terms points to the complexity of the phenomenon, with different theorists emphasising change in identity and narrative (i.e. the sense of self), 6 change in eudaimonic wellbeing (i.e. subjective quality of life), 7 and change in social/psychological resources (i.e. broadening response repertoires). 8 11 There is some evidence of a curvilinear association between depression and post-traumatic growth, for example two studies of assault survivors (n=270 in total) found survivors with low or high post-traumatic growth reported more symptoms of post-traumatic stress (both studies) and depression (one study) than those with intermediate growth levels. 12 Longitudinal research is needed to fully understand how reports of post-traumatic growth interact with depression in the recovery from event trauma.
Post-traumatic growth has relevance to health care, for example liver transplantation 13 and stroke. 14 There are several reasons why post-traumatic growth may also be relevant to psychosis and other severe mental health problems. 15 First, abuse incidence is high. In particular, childhood adversity is strongly associated with increased risk of psychosis. A meta-analysis of 18 case-control studies (n=2,048 psychosis, n=1,856 controls), 10 prospective studies (n=41,803) and 8 populationbased cross-sectional studies (n=35,546) found significant associations between adversity and psychosis across all designs (OR2.78, 95%CI 5 2.34-3.31). 16 Second, comorbid depression, which is implicated in post-traumatic growth, is common. For example, around 50% of people with a diagnosis of schizophrenia also experience depression. 17 Third, both the experience of psychosis itself and the consequent experiences of societal discrimination and re-traumatisation caused by mental health system responses 18,19 may generate trauma. Finally, some people with personal experience of psychosis report post-traumatic growth. 20 There is strong evidence that positive changes can be experienced after first-episode psychosis. A systematic review, 22 published initially as a scoping review, 23  There is only limited evidence about the frequency and types of post-traumatic growth in people living long-term with psychosis and other severe mental illness experiences. 24 A quantitative study of 121 people with severe mental illness using community mental health rehabilitation centres in Israel found high levels of trauma, 25 and that meaning-making and coping self-efficacy mediated post-traumatic growth experiences. 26 Three small (n=7, 27 n=7, 28 n=10 29 ) qualitative studies using interpretative phenomenological analysis of semi-structured interviews all identify themes of personal growth. Current evidence indicates that growth is integral to recovery, and involves both restoration of existing aspects of identity and construction of new aspects. 30 The extent to which (a) the five growth processes identified from event trauma research and (b) the more preliminary early psychosis-specific restorative and Integration of these two sources of evidence is needed, as is investigation of the experiences of a broader range of people with long-term psychosis, including underresearched groups. The aim of this study is to develop a conceptual framework for post-traumatic growth in the context of recovery for people with psychosis and other severe mental health problems.

Methods
This research was undertaken as part of the NIHR Narrative Experiences Online (NEON) study (ISRCTN11152837, information at http://www.researchintorecovery.com/neon) between March and August 2018. Ethical Committee approval was obtained (Nottingham 2 REC 17/EM/0401). All participants provided written informed consent.

Participants
A purposive sample of under-researched populations took part. Inclusion criteria common to all groups were: aged over 18; willing to discuss experiences; able to give informed consent; and fluent in English.
Group A (Outside the system) comprised people having had self-identified experiences of psychosis and not using services. Psychosis experience prevalence estimates in the general population range from 7% 31 to 13%, 32 yet lifetime rates of psychosis, determined through contact with services, range from 0.2% (narrowly defined criteria) to 0.7% (broadly defined). 33 The experience of the many individuals who have psychosis without using services may therefore illuminate growth Group B (BAME) comprised people who identified as being from Black and Minority Ethnic (BAME) populations. Ethnic minority groups often have problematic relationships with services, 34 and research about recovery in these populations identifies a strong emphasis on the post-traumatic growth concepts of connectedness 35 and spirituality. 36 Additional inclusion criteria for Group B were: currently using mental health services; Black, Asian and minority ethnic community member.
Group C (Under-served) comprised people who were not well engaged with mental health services. This was operationalised for three under-served groups: people from lesbian, gay, bisexual or trans (LGBT+) communities; 37 from rural communities; 38 or with multiple complex health and social care needs. 39 Additional inclusion criteria for Group C were: experience of mental health problems in previous 10 years; no or mainly unsuccessful interactions with formal mental health services; member of LGBT+ communities OR living in an area with less than 10,000 population OR experience of at least two of homelessness, substance misuse issues or offending.
Group D: (Peer) comprised people with experience of working in statutory or voluntary roles for which lived experience is a requirement, e.g. peer support workers, trainers or researchers. Addition inclusion criteria for Group D were: working in statutory or Recruitment for all groups used snowball sampling.

Procedures
A preliminary coding framework (Online Supplement 1) was developed in advance of interviews, by merging existing post-traumatic growth dimensions identified in trauma populations 40 and in previous studies of post-traumatic growth in psychosis. 22,23,28 The preliminary coding framework was intended to establish the link between existing research and participant narratives, and comprised the code name, definition and examples drawn from the source references. An 'Other' category was added to allow the emergence of new themes.
Interviews using a narrative approach were conducted by four researchers from sociology, advocacy, public health and health psychology backgrounds. Each given options to pause or discontinue if they became distressed. Interviews were recorded, and pseudonymised transcripts were made after interviews. After the interview the researcher wrote field notes, which were included in the analysis.
Interviews were conducted until theoretical saturation was achieved.

Analysis
The four coders comprised three interviewers plus one non-interviewer with an interdisciplinary background in sociology and mental health nursing. Thematic analysis was undertaken using NVivo version 11. 41 Coding was initially according to the preliminary coding framework and informed by field notes, but coders remained open to the identification of additional themes in the data. Coding involved identification and allocation of text relating to the coding framework, enabling related text to be grouped and compared, allowing identification of themes occurring within and across sources. Regular discussions between analysts explored how themes of post-traumatic growth were expressed and related to each other, allowing lower order themes to be recognised. 42 Each coder independently coded and compared the same initial transcript. Remaining transcripts were then coded separately (25% per coder).
The coding framework was then iteratively refined in meetings between the four primary coders and a wider group of four other non-interviewer analysts with expertise in collection and analysis of data. 43 To enhance trustworthiness, an audit trail was kept, and an interim coding framework is shown in Online Supplement 3. The conceptual framework, i.e. the final coding framework, was agreed by all coders and analysts.

Results
The sociodemographic and clinical characteristics of the 77 participants are shown in Table 1.
Insert Table 1 here Post-traumatic growth components were coded in 64 (83%) of the 77 transcripts. The conceptual framework for post-traumatic growth in psychosis and other severe mental health problems is summarised in Table 2 with a complete version including more example coding in Online Supplement 4.
Insert Table 2  This was like taking a step back and looking at almost re-engineering life to take into account self-care, self-preservation and also building myself up… (D08)

Sense of self
The development of a more positive sense of self involved integration and valuing of illness experiences. A repeated theme was pride in oneself as a person.  The relationship between mental health recovery and post-traumatic growth is unclear, as is the extent to which they are the same or overlapping but distinct phenomena.

Patient and Public Involvement statement
Patients were involved in acquisition of funding, both through a Lived Experience Advisory Panel informing the design and through involvement as applicants. Several interviewers and analysts had their own lived experience of mental ill-health and recovery, in addition to their professional training. The NEON Lived Experience Advisory Panel (LEAP) comprising ten members with lived experience of mental illhealth and recovery informed the ethics application, trained the interviewers, informed the topic guide and supported access to Group D. A LEAP member was involved in interpretation of the findings and as a co-author of this paper. The LEAP are leading the writing of a guide to sharing stories, which will be informed by this research.

Competing interests statement None declared
Author statement MS and LB made a substantial contribution to the conception or design of the work. All authors contributed to the acquisition, analysis, or interpretation of data for the work. All authors were involved in drafting the work or revising it critically for important intellectual content, and gave final approval of the version to be published. All authors agree to be jointly accountable for all aspects of the work.

Data sharing statement
Data available from corresponding author.
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Where the Submitting Author wishes to make the Work available on an Open Access basis (and intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative Commons licence -details of these licences and which Creative Commons licence will apply to this Work are set out in our licence referred to above.     Discovering or re-discovering how to access, accept and be mindful of inner emotional life and difficult feelings 1.2 Self-knowledge Knowing oneself better, being more authentic and not being as shaped by the expectations of others 1.3 Self-acceptance Grieving and letting go of the past, and developing self-compassion 1. Increased determined to stay well, self-manage and not return to a bad situation 4.2 Being active More engagement in the arts, music, sport, nature and learning

Relationships
More actively choosing and valuing relationships with others 5.1 Choosing relationships Actively choosing relationships to continue, to re-start or to end 5.2 Valuing relationships Placing more value on relationships with others 5.3 Empathy Enhanced ability to empathise with others 6 Spirituality Deeper engagement with spirituality, religious and existential endeavours 6.1 Spiritual awareness Increased awareness of the presence of something greater than oneself making a positive contribution by providing meaning 6.2 Spiritual engagement New or renewed engagement with spiritual or religious practices, helping with meaning-making and providing comfort and security Integration of experience of psychosis into identity Psychosis experiences as shaping who the person is now, psychosis being part but not all of identity, more insight or clarity 9 Selfacceptance More self-acceptance and awareness More self-compassion, positive sense of self 10 Other Other forms of post-traumatic growth not coded above

START OF TOPIC GUIDE Preparation
Before the participant arrives, allocate a unique identifier (UID) to the participant, and write it into a blank Informed Consent Form.

Introduction
• Introduce the interviewer facilitator • Ensure the participant has read the information sheet and understands that participation is voluntary and that they are free to withdraw at any time • Explain the aims and purpose of the activity and give a brief description of the interview structure. Tell the participant they can decide whether their story is used in the later part of the NEON study, emphasising that this may mean other people beyond the study team may see it.
• Provide an opportunity for participant to ask any questions, and then obtain written consent through the Informed Consent Form • Describe digital recording of the interview. Clarify whether the participant wants to be video-recorded or audio-recorded.
• Turn on the recorder. Read out the UID so that it is recorded.

Questions Part 1
Ask the participant to describe their own story of recovery. Do not use language (e.g. 'psychosis') which might be leading -refer to e.g. 'mental health difficulties'. Give them plenty of time, listen carefully. Reply if asked (e.g. "Is this okay?" -"Yes, you're doing great") and use minimal prompts if needed (e.g. "Do go on") but try to let the participant tell their story in their own words.

Part 2
Follow up with questions about the narrative, e.g. 1. Who have you shared your story with, and why? 2. What was the impact on the recipient and on you? If there was a particularly powerful part of their narrative, ask specifically about the impact of that part of their story. 4. Do you sometimes hold back some aspects of your story? If so, how do you decide what and when to hold back? If the participant becomes distressed during the interview, ask if they would like to take a break or stop. If the participant reveals information which is of concern and may need reporting i.e. potential risks to another person or to themselves, or criminal behaviour, then continue the interview if you feel comfortable to, but discuss these with the PI at the earliest opportunity and where appropriate report accordingly.

End of interview
Explain the interview is now over and ask if the participant has any final questions. Give information about timeline for the study and how publications can be accessed. Thank the participant for their participation.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59   Integration and sense-making of experience of mental health issues into identity Mental health experiences as shaping who the person is now, psychosis or other mental health experiences being part but not all of identity, more insight or clarity, re-framing experiences, choosing other explanatory frameworks to make sense of experiences 9 Selfacceptance More self-acceptance and selfcompassion

END OF TOPIC GUIDE
More self-compassion, positive sense of self, less internalised stigma 10 Other Other forms of post-traumatic growth not coded above There was just a point where I was just like I forgot how to feel, I forgot how to be hungry, I forgot how to feel tired, I forgot how to be exhausted, I forgot how to feel fear and then I realised oh my fuck I need to feel fear, you know, I need these things, these things are really fucking important, you know that a human being needs fear, we need tiredness, we need hunger…I moved to Hong Kong and it found me again and I realised it wasn't really my situation, it was me, it was something inside me that was drawing this energy towards me and there I, unless I changed the noise inside, the noise outside is never going to go away. (B25) And I think that is the key to everything isn't it, accessing your emotions, not running away from them, which a lot of people in mental suffering with mental health are trying to do because it is overwhelming and painful. So it is about yeah feeling and not feeling somebody else's or not, following somebody else and not being scared to be who you are and be different I think. (C19) Grieving and letting go of the past, and developing selfcompassion I grieve all the hopes that are not there, you know things that haven't worked out, and I try to accept what is there and say well this is it, this is the thing that is real, maybe the other things were a little fantastical… And so I still talk to myself a lot but it's not now, it's, it's, it's me comforting myself and actually communicating with me, you know, just sort of, um it's that thing of having learned to love myself. (A08) I started going to loads of classical music concerts which I'd really shunned because I felt like I'd really failed as I'm not playing the violin anymore, I should be, I've really failed, I'm not good as the other people who have made it their profession. Suddenly I was like, God that doesn't matter, that is just so irrelevant, like classical music and music generally is so beautiful I just want to go and listen to it. (A10)  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  The key word is accepting the situation that I was in, um, and being honest with myself. (C03) 1.4 Selfresponsibility Taking (back) responsibility for one's own life Yeah, because in my own mindset and recovery…I had to become interested in the problem because prior to that my outlook on recovery in mental health was based on seeing a Consultant Psychiatrist and they will have the answer because that is the predominant feeling, patient/doctor relationship, you see a doctor, you trust what they say and then I had to become interested after I realised that the doctors can't fix me. So when I became interested I became open to learning. (A21) The one thing he did when he came, when he saw, he said, 'I'm not going to help you do one thing in this flat unless you start doing it for yourself. If you make a start yourself, I will help you. If you don't do anything, I'm gone. And that hit me like a, er, thunderbolt, knowing that, knowing I, that if I'm not going to help myself, no one else will help me. And that was the beginning, really, of my recovery. Maybe sometimes we need to go through that process, in order to think, I don't need to go back there, to where I was ten years ago, thinking about that experience anymore. But you can think about it, but have a different sort of attitude to it. (B06) I tend to be living the moment, that's part of my new self, this post-near death experience self is to really be living in the moment as much as possible, not worry about the future or churn over the past. (D04) This was like taking a step back and looking at almost re-engineering life to take into account self-care, self-preservation and also building myself up rather than saying rotten  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46 If there was a big red button on the table and somebody said would you like to switch off your diagnosis I would say no because I have accepted it now. Although it was horrid, it was horrible, I can't take anything away from that, but I have accepted that it has become part of my personality and I am happy with that and that's me. What they were calling symptoms that must be eradicated, were actually part of me and so I looked behind that and said that is where, that is where my creativity comes from. This is where, this is how I am able to take a photograph, this is how I am able, when I am sitting at a piano to think of a tune. (A19) Whereas before I felt ashamed to have these mental health issues, I now feel really proud in a way because I know that I can use it for good and I can make a difference in my community. (B01) There is a liberation that comes through all of this, a personal kind of yeah, not sure it's full blown self-actualisation, but it's somewhere up close to the top of the pyramid. (D04) I am still me but I am a different me and I am stronger. (D05)  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46 o n l y I kind of thought that that was the best I could ever hope for and that was fine because I kind of really internalized my label of I am an anorexic, I am a you know a broken person who needs a lot of support and actually it was seeing the people who were talking about their lived experience with lots and lots of confidence and taking lots of responsibility and um being empowered to, to self-manage and use their difficulties in a really positive way which kind of opened my eyes to like gosh maybe I am more than my label, maybe I am, maybe I could do more than just function or survive, maybe I could thrive. I have kind of realised that I am not in a position to dictate the terms of life: "it should be like this and I expect this and why is it not like this". Just, I am alive, I appreciate that I am alive and that I have got so many hours each day to gain something from, some joy or some inspiration or blessings and gifts everywhere that I can and the number one thing is to just keep going, I am a mother and I have to keep going. (C19) 3. And so, you know, I felt like I was becoming something. Erm, I could identify with more, kind of, politicised…the personal was political and I was beginning to become aware of that on a deeper level. So, I thought right, that's it and, I'm going to set up my own thing. (B09) And then as I came back out it was just like no, I wanted to help, I wanted to do something, I wanted to use this story, I wanted to actually like you know... I wanted, that's when I started studying psychology and then I applied to go study in <place>…what's helped me recover was I find life, you know, I've got stuff I want to do, I want to help people, I want to, I want to do psychology. (B25) I've been looking forward to sharing my experience because um, by people sharing theirs has really helped me and you know, and that makes it feel like talking about it is a  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46 really worthwhile thing to do, because its gonna allow somebody else to grow, or just take a little bit from it that you know, it might benefit them or it might not, maybe they need to hear a different story but, you know, somebody might, you know, might hear it and think well I'm really pleased that I've heard that because that's, that's gonna help me.  Actively choosing relationships to continue, to re-start or to end He (counsellor) used a waiter analogy where the waiter is trying to please the clients but then more and more people come in and he is still trying to please them all but the quality of the food comes down and then people start complaining and then it is mad, so basically just concentrate on what you can do and don't try to please everybody…I also now try to mix with people who are just happy and positive and try to stay away from people who aren't. (A09) But you need the right quality of people around you, network, for you to be able to stay in your mental health, going forward. I'd also come to realise before then that the relationship I was in was not quite what it was as he told me lots of things that were untrue that I discovered so I ended that as well and that was having a clean slate but it took me a long time to get literally over it. (B17) 5. It's been a process of learning that I needed, I need desperately, I desperately needed family, you know, people I feel safe with, to be myself. And I needed people to help me normalise my feelings rather than be freaked out and hiding and terrified of expressing.
Now I do feel a lot more stable than I did back then, and then when I go to these kinds of experiences you know, I've started to like, connections have become my thing because connections are what saved me from like, connections with people, a spiritual connection Although the experiences were horrendous, and they were horrendous, there's no other way of describing the agony, it has been necessary because I couldn't do it on my own, so it still feels, and maybe this is just you know the spiritual aspect of my life but it still feels as though I do have like something watches over me and is helping me um and I survived. ( A08) I kind of relived stuff and at the same time just physically I wanted to let go of loads of things, I just kind of clutter cleared my whole house, really cleaned it, I got rid of loads of bits and pieces that I didn't need any more and as I went through that whole process it was like this massive opening, just kind of spiritual opening again…I felt very very free, I felt like I was being guided with everything, I felt very, very spiritual. Um lots of things happened that were very healing I suppose, played a lot of music…when I relived it and  But when you kind of realise that there is something bigger than you, you start to realise don't hurt yourself, have more respect for yourself, and you also don't harm others in a sense, not but everything falls into place. The world has meaning, has greater meaning. (C19) 6.2 Spiritual engagement New or renewed engagement with spiritual or religious practices, helping with meaningmaking and providing comfort and security Like wow so I ran over to them and they kind of just guided me so I was just being guided by all of the spirits and stuff and they guided me up the hill into the woods. (A02) …was actually, uh, around all of this I was sort of meditating and looking at the more spiritual aspects of my life and you know, just looking for, I was looking and seeking that help and I was, I was meditating. It, it, it brought a lot of pain but I was looking at that. (A08)  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44 45 46 I became very um sort of what's the word, like spiritual as well. I found the church very comforting and kind of a place I would be, to trust and yeah, it just gave a sense of security for some reason. (A14) So, you know, if it wasn't, if it wasn't for yoga, my Buddhist practice and community, who get, who don't, who, who see that there's something valuable from raw emotion, that there's energy in raw emotion…My understanding of Buddhism had, had grown. Erm, I'd been introduced to it, to the practice of chanting [inaudible], to reveal your own courage and compassion and wisdom and create, create more humane connections with people. And, I thought it was amazing energy to, to nourish, 'cos it wasn't based on any gods or idols or who was, you know, who was, who was cool and who wasn't. It's universal. It's a universal truth….the long and short of it, Buddhist practice helped [laughs]. More harmonious with myself and other people. (B09).
Every morning I put my hand on my heart and I pray and I meditate and I go into that space where it's myself…Now I feel like now I do feel a lot more stable than I did back then and then when I go to these kinds of experiences you know, I've started to like connections have become my thing because connections are what saved me from like, connections with people, a spiritual connection and this connection between people, there's interconnection between people is essentially what saves people. (B25) I was still a Quaker at this point so that was really helpful, so I would go each week to have silent worship and that was really good, I saw it as an opportunity to kind of pause and have my brain calm down and yeah that was really lovely. (C15) …think also a lot, mental health is to do with emotion, for me I can only find the emotional vocabulary within church. And many things that we are struggling with are deep spiritual psychic rooms and you can't find that power and that passion in a, in anything other than a spiritual context… So for me recovery is about spirituality, it is about God, that is me and that's what works for me, it might not be the same for everyone…just pray, pray. (laughs) It works, do it, don't be scared. (C19)

Design
Qualitative thematic analysis of cross-sectional semi-structured interviews about personal experiences of mental health recovery.

Setting
England.

Participants
Participants were adults aged over 18 and: (i) living with psychosis and not using mental health services (n=21); (ii) using mental health services and from black and minority ethnic communities (n=21); (iii) underserved, operationalised as lesbian, gay, bisexual and transgender community or complex needs or rural community (n=19); or (iv) employed in peer roles using their lived experience with others (n=16). The 77 participants comprised 42 (55%) female and 44 (57%) White British.

Results
Components of post-traumatic growth were present in 64 (83%) of recovery narratives.
Six superordinate categories were identified, consistent with a view that post-traumatic growth involves learning about oneself (Self-discovery) leading to a new sense of who one is (Sense of self) and appreciation of life (Life perspective). Observable positivelyvalued changes comprise a greater focus on self-management (Wellbeing) and more importance being attached to relationships (Relationships) and spiritual or religious engagement (Spirituality). Categories are non-ordered and individuals may start from any point in this process.

Conclusions
Post-traumatic growth is often part of mental health recovery. Changes are compatible with research about growth following trauma, but with more emphasis on selfdiscovery, integration of illness-related experiences and active self-management of wellbeing. Trauma-related growth may be a preferable term for participants who identify as having experienced trauma. Trauma-informed mental health care could use the six identified categories as a basis for new approaches to supporting recovery.

Key words
Post-traumatic growth, mental health, recovery

Trial registration
Conducted as part of the NIHR NEON Study (ISRCTN11152837).    Post-traumatic growth has relevance to health care, for example liver transplantation 13 and stroke. 14 There are several reasons why post-traumatic growth may also be relevant to psychosis and other severe mental health problems. 15 First, abuse incidence is high. In particular, childhood adversity is strongly associated with increased risk of psychosis. A meta-analysis of 18 case-control studies (n=2,048 psychosis, n=1,856 controls), 10 prospective studies (n=41,803) and 8 populationbased cross-sectional studies (n=35,546) found significant associations between adversity and psychosis across all designs (OR2.78, 95%CI 2.34-3.31). 16 Second, comorbid depression, which is implicated in post-traumatic growth, is common. For example, around 50% of people with a diagnosis of schizophrenia also experience depression. 17  There is strong evidence that positive changes can be experienced after first-episode psychosis. A systematic review, 22  There is only limited evidence about the frequency and types of post-traumatic growth in people living long-term with psychosis and other severe mental illness experiences. 24 A quantitative study of 121 people with severe mental illness using community mental health rehabilitation centres in Israel found high levels of trauma, 25 and that meaning-making and coping self-efficacy mediated post-traumatic growth experiences. 26 Three small (n=7, 27 n=7, 28 n=10 29 ) qualitative studies using interpretative phenomenological analysis of semi-structured interviews all identified themes of personal growth. The concept of recovery in mental health has come to mean living as well as possible, whether or not symptoms are present. Recovery thus differs from the traditional clinical priorities of symptom remission and functional restoration, 30 and a systematic review identified five recovery processes: Connectedness, Hope, Identity, Meaning and Empowerment (CHIME Framework). 31 Current evidence indicates that growth is integral to recovery, and involves both restoration of existing aspects of identity and construction of new aspects. 32 The extent to which (a) the five growth processes identified from event trauma research and (b) the more preliminary early psychosis-specific restorative and constructive identity processes are characterising the same changes is unknown.
Integration of these two sources of evidence is needed, as is investigation of the experiences of a broader range of people with long-term psychosis, including underresearched groups. The aim of this study is to develop a conceptual framework for post-traumatic growth in the context of recovery for people with psychosis and other severe mental health problems. Group A (Outside the system) comprised people having had self-identified experiences of psychosis of sufficient frequency or duration that they identify as someone with experience of psychosis, and not using services. Psychosis experience prevalence estimates in the general population range from 7% 33 to 13%, 34 yet lifetime rates of psychosis, determined through contact with services, range from 0.2%

This research was undertaken as part of the NIHR Narrative Experiences
(narrowly defined criteria) to 0.7% (broadly defined). 35 The experience of the many individuals who have psychosis without using services may therefore illuminate growth processes. Additional inclusion criteria for Group A were: self-identified lifetime experience of psychosis; no use of secondary mental health services over the previous five years.
Group B (BAME) comprised people who identified as being from Black and Minority Ethnic (BAME) populations. Ethnic minority groups often have problematic relationships with services, 36 and research about recovery in these populations identifies a strong emphasis on the post-traumatic growth concepts of connectedness 31 and spirituality. 37 Additional inclusion criteria for Group B were: currently using mental health services; Black, Asian and minority ethnic community member.
Group C (Under-served) comprised people who were not well engaged with mental health services. This was operationalised for three under-served groups: people from  41 and in previous studies of post-traumatic growth in psychosis. 22,23,28 Duplicates were removed, dimension names were made consistent, and then thematic options to pause or discontinue if they became distressed. Interviews were recorded, and pseudonymised transcripts were made after interviews. After the interview the researcher wrote field notes, which were included in the analysis. The four coders comprised three interviewers plus one non-interviewer with an interdisciplinary background in sociology and mental health nursing. Thematic analysis was undertaken using NVivo version 11. 42 The study had a predetermined focus on developing a conceptual framework starting from a synthesis of empirical evidence derived from event trauma research as described above, which was then developed through analysis of interview data. An approach akin to framework analysis was adopted 43 . Framework analysis involves applying a priori codes and categories to qualitative data to explore specific questions of interest to the research aims, with attention also paid to inductive analysis of data relating to topics which were not anticipated in advance, and to responsive revision of the coding frame as analysis progresses and in the light of regular discussion within the research team.

Analysis
Coding was initially according to the preliminary coding framework and informed by emergent understandings captured by field notes, but coders remained open to the identification of additional themes in the data. Coding involved identification and allocation of text relating to the coding framework, enabling related text to be grouped and compared, allowing identification of themes occurring within and across sources.
Regular discussions between analysts explored how themes of post-traumatic growth were expressed and related to each other, allowing lower order themes to be recognised. 44 Each coder independently coded and compared the same initial transcript. Remaining transcripts were then coded separately (25% per coder).
The coding framework was then iteratively refined in meetings between the four primary coders and a wider group of four other non-interviewer analysts with expertise in healthcare technologies, qualitative research, recovery research and clinical psychology. Several of the interviewers, coders and analysts also had lived experience of mental ill-health and recovery, to enhance the role of lived experience in collection and analysis of data. 45 To enhance trustworthiness, an audit trail was kept, and an interim coding framework is shown in Online Supplement 4. The conceptual framework, i.e. the final coding framework, was agreed by all coders and analysts.

Results
The sociodemographic and clinical characteristics of the 77 participants are shown in Table 1.
Insert Table 1 here Post-traumatic growth components were coded in 64 (83%) of the 77 transcripts. The conceptual framework for post-traumatic growth in psychosis and other severe mental health problems is summarised in Table 2 with a complete version including more example coding in Online Supplement 5.
Insert Table 2 here Major themes Theme 1: Self-discovery The self-discovery theme involves a fuller and deeper understanding of oneself. This involves the ability to access, accept and be mindful of difficult feelings:  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   22 merit further investigation. These were not dissenting voices or competing accounts, but statements about types of change which were not judged by analysts to be posttraumatic growth. Examples which were not coded as post traumatic growth include alternative methods of getting well, escapism, knowing where to access support, cultural differences and environmental factors. Recovering from 'trauma' was not the language or frame of reference used by many participants in telling their stories, so this represents a researcher framing of experiences. However, many of the changes identified by participants were clearly describing growth arising directly out of their experiences. Relatedly, the extent to which participants attributed changes to posttraumatic growth, and the extent to which their formulations were derived from cultural understandings, were not explored. Our data are consistent with a view that the development of trauma-informed mental health services, with consequent changes in language and constructs used to describe experiences, will lead to an increase in individuals using post-traumatic growth concepts in their own recovery narratives. An alternative analysis approach would have involved wholly inductive coding followed by comparison with existing research. This would be more applicable to an interview study using a topic guide to assess previous experiences of trauma and identifying specifically post-traumatic growth experiences, rather than the current topic guide which was focussed on recovery narratives and did not specifically ask about previous trauma experiences. The wide diagnostic spread of participants and high proportion (36%) who preferred not to give a diagnosis could be seen as a limitation. The standard health research approach would be to use a standardised assessment to confirm research diagnosis, but recovery research tends to have a more transdiagnostic focus. Finally, the cross-sectional coding inevitably abstracts from complex  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  peer support, 69,70 and a greater focus on human rights. 71,72 The current study supports the case that trauma-informed approaches to mental health care should be added to this list of recovery-supporting innovations. 73 The conceptual framework provides a theoretical foundation for work to support posttraumatic growth in mental health. Encouraging post-traumatic growth is an important contribution to supporting recovery. For example, a study of post-traumatic growth and recovery in 34 people experiencing first episode psychosis concluded that 'people with early psychosis may benefit from disclosing their experiences of psychosis, including those aspects that were traumatic, as this may support the processes of recovery and post-traumatic growth' (p.213). 74 A clinical implication is that it is important to reinforce efforts by service users to find their own personally satisfactory meaning of their experiences, rather than simply encouraging the adoption of a clinical explanatory model. Similarly, supporting service users to engage in wellbeing self-management,  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y Licensing statement I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance with the terms applicable for US Federal Government officers or employees acting as part of their official duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   31 Publishing Group Ltd ("BMJ") its licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the Work in BMJ Open and any other BMJ products and to exploit all rights, as set out in our licence.
The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to the Submitting Author unless you are acting as an employee on behalf of your employer or a postgraduate student of an affiliated institution which is paying any applicable article publishing charge ("APC") for Open Access articles.

Relationships
More actively choosing and valuing relationships with others 5.1 Choosing relationships Actively choosing relationships to continue, to re-start or to end 5.2 Valuing relationships Placing more value on relationships with others 5.3 Empathy Enhanced ability to empathise with others 6 Spirituality Deeper engagement with spirituality, religious and existential endeavours 6.1 Spiritual awareness Increased awareness of the presence of something greater than oneself making a positive contribution by providing meaning 6.2 Spiritual engagement New or renewed engagement with spiritual or religious practices, helping with meaning-making and providing comfort and security

Guidelines for promotional material
All promotional material produced to support recruitment in NEON Phase 1, for both activities 1 and 2, will incorporate the following: 1. A summary of the objectives of the project as a whole, e.g. "The NEON Study looks at whether experiencing online stories of personal recovery ('recovery narratives') told by peers improves quality of life for people with psychosis." 2. A summary of the objectives of phase 1, e.g. "The aim of phase one is to develop a theoretical understanding of how recovery narratives (personal stories of mental health problems and recovery) can be of benefit to other people with mental health problems." 3. A summary of the group which the promotional material is aiming to recruit, e.g. "We are seeking to recruit 30 participants who are working in statutory or voluntary roles where having lived experience of mental health problems is a requirements, and where sharing personal experiences is a normal part of the work of the role"

4.
A summary of what participation would require, e.g. "Each participant would engage in a single one-hour interview, where they will be asked to talk about their experience of recovery". Integration of experience of psychosis into identity Psychosis experiences as shaping who the person is now, psychosis being part but not all of identity, more insight or clarity 9 Selfacceptance More self-acceptance and awareness More self-compassion, positive sense of self 10 Other Other forms of post-traumatic growth not coded above

Introduction
 Introduce the interviewer facilitator  Ensure the participant has read the information sheet and understands that participation is voluntary and that they are free to withdraw at any time  Explain the aims and purpose of the activity and give a brief description of the interview structure. Tell the participant they can decide whether their story is used in the later part of the NEON study, emphasising that this may mean other people beyond the study team may see it.  Provide an opportunity for participant to ask any questions, and then obtain written consent through the Informed Consent Form  Describe digital recording of the interview. Clarify whether the participant wants to be video-recorded or audio-recorded.  Turn on the recorder. Read out the UID so that it is recorded.

Questions Part 1
Ask the participant to describe their own story of recovery. Do not use language (e.g. 'psychosis') which might be leading -refer to e.g. 'mental health difficulties'. Give them plenty of time, listen carefully. Reply if asked (e.g. "Is this okay?" -"Yes, you're doing great") and use minimal prompts if needed (e.g. "Do go on") but try to let the participant tell their story in their own words.

Part 2
Follow up with questions about the narrative, e.g. 1. Who have you shared your story with, and why? 2. What was the impact on the recipient and on you? If there was a particularly powerful part of their narrative, ask specifically about the impact of that part of their story. 4. Do you sometimes hold back some aspects of your story? If so, how do you decide what and when to hold back? If the participant becomes distressed during the interview, ask if they would like to take a break or stop. If the participant reveals information which is of concern and may need reporting i.e. potential risks to another person or to themselves, or criminal behaviour, then continue the interview if you feel comfortable to, but discuss these with the PI at the earliest opportunity and where appropriate report accordingly.

End of interview
Explain the interview is now over and ask if the participant has any final questions. Give information about timeline for the study and how publications can be accessed. Thank the participant for their participation. Mental health experiences as shaping who the person is now, psychosis or other mental health experiences being part but not all of identity, more insight or clarity, re-framing experiences, choosing other explanatory frameworks to make sense of experiences 9 Selfacceptance More self-acceptance and selfcompassion

END OF TOPIC GUIDE
More self-compassion, positive sense of self, less internalised stigma 10 Other Other forms of post-traumatic growth not coded above There was just a point where I was just like I forgot how to feel, I forgot how to be hungry, I forgot how to feel tired, I forgot how to be exhausted, I forgot how to feel fear and then I realised oh my fuck I need to feel fear, you know, I need these things, these things are really fucking important, you know that a human being needs fear, we need tiredness, we need hunger…I moved to Hong Kong and it found me again and I realised it wasn't really my situation, it was me, it was something inside me that was drawing this energy towards me and there I, unless I changed the noise inside, the noise outside is never going to go away. (B25) And I think that is the key to everything isn't it, accessing your emotions, not running away from them, which a lot of people in mental suffering with mental health are trying to do because it is overwhelming and painful. So it is about yeah feeling and not feeling somebody else's or not, following somebody else and not being scared to be who you are and be different I think. (C19) 1.2 Self-Knowing oneself I feel like I know myself quite well, you know I can heal myself. And uh, these are things Grieving and letting go of the past, and developing selfcompassion I grieve all the hopes that are not there, you know things that haven't worked out, and I try to accept what is there and say well this is it, this is the thing that is real, maybe the other things were a little fantastical… And so I still talk to myself a lot but it's not now, it's, it's, it's me comforting myself and actually communicating with me, you know, just sort of, um it's that thing of having learned to love myself. (A08) I started going to loads of classical music concerts which I'd really shunned because I felt like I'd really failed as I'm not playing the violin anymore, I should be, I've really failed, I'm not good as the other people who have made it their profession. Suddenly I was like, God that doesn't matter, that is just so irrelevant, like classical music and music generally is so beautiful I just want to go and listen to it. (A10) It's all about self-accepting, getting to know me and it helped. (A17) The key word is accepting the situation that I was in, um, and being honest with myself. (C03) 1.4 Selfresponsibility Taking (back) responsibility for one's own life Yeah, because in my own mindset and recovery…I had to become interested in the problem because prior to that my outlook on recovery in mental health was based on seeing a Consultant Psychiatrist and they will have the answer because that is the predominant feeling, patient/doctor relationship, you see a doctor, you trust what they say and then I had to become interested after I realised that the doctors can't fix me. So when I became interested I became open to learning. (A21) The one thing he did when he came, when he saw, he said, 'I'm not going to help you do one thing in this flat unless you start doing it for yourself. If you make a start yourself, I will help you. If you don't do anything, I'm gone. And that hit me like a, er, thunderbolt, knowing that, knowing I, that if I'm not going to help myself, no one else will help me. And that was the beginning, really, of my recovery. Maybe sometimes we need to go through that process, in order to think, I don't need to go back there, to where I was ten years ago, thinking about that experience anymore. But you can think about it, but have a different sort of attitude to it. (B06) I tend to be living the moment, that's part of my new self, this post-near death experience self is to really be living in the moment as much as possible, not worry about the future or churn over the past. (D04) This was like taking a step back and looking at almost re-engineering life to take into account self-care, self-preservation and also building myself up rather than saying rotten stuff about myself and focusing on what I couldn't do and what I should do and should be  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46 was horrible, I can't take anything away from that, but I have accepted that it has become part of my personality and I am happy with that and that's me. (A21) I think for a long time I was just existing with the mental health, getting to know, getting to understand it…Because there's very much negativity around it and I felt ashamed. What they were calling symptoms that must be eradicated, were actually part of me and so I looked behind that and said that is where, that is where my creativity comes from. This is where, this is how I am able to take a photograph, this is how I am able, when I am sitting at a piano to think of a tune. (A19) Whereas before I felt ashamed to have these mental health issues, I now feel really proud in a way because I know that I can use it for good and I can make a difference in my community. (B01) There is a liberation that comes through all of this, a personal kind of yeah, not sure it's full blown self-actualisation, but it's somewhere up close to the top of the pyramid. (D04) I am still me but I am a different me and I am stronger. (D05) I kind of thought that that was the best I could ever hope for and that was fine because I  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46 kind of really internalized my label of I am an anorexic, I am a you know a broken person who needs a lot of support and actually it was seeing the people who were talking about their lived experience with lots and lots of confidence and taking lots of responsibility and um being empowered to, to self-manage and use their difficulties in a really positive way which kind of opened my eyes to like gosh maybe I am more than my label, maybe I am, maybe I could do more than just function or survive, maybe I could thrive. ( 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  And so, you know, I felt like I was becoming something. Erm, I could identify with more, kind of, politicised…the personal was political and I was beginning to become aware of that on a deeper level. So, I thought right, that's it and, I'm going to set up my own thing. (B09) And then as I came back out it was just like no, I wanted to help, I wanted to do something, I wanted to use this story, I wanted to actually like you know... I wanted, that's when I started studying psychology and then I applied to go study in <place>…what's helped me recover was I find life, you know, I've got stuff I want to do, I want to help people, I want to, I want to do psychology. (B25) I've been looking forward to sharing my experience because um, by people sharing theirs has really helped me and you know, and that makes it feel like talking about it is a really worthwhile thing to do, because its gonna allow somebody else to grow, or just take a little bit from it that you know, it might benefit them or it might not, maybe they  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43 44 45 46 When I came out of hospital I was like "I can't go back there again so I've got to sort myself out and I've got to build a better relationship with me and the girls", you know, they'd been through so much. (D05) It was also about sort of about finding activities that I enjoyed much more, rather than just aimlessly sort of treading water and doing things that I felt I was sort of having to do or other people were you know were saying I should do, you know, sort of planning about things that actually I enjoyed… One of the things I did was I joined the choir and you know it's one of [inaudible] gospel choir in South London for about, ever since I got there really and it's a very, very supportive environment, so that's been really critical and I've been able to sort of go there when I've been in every kind of mood state possible. (D13) 5. Relationships More actively choosing and valuing relationships with others 5.1 Choosing relationships Actively choosing relationships to continue, to re-start or to end He (counsellor) used a waiter analogy where the waiter is trying to please the clients but then more and more people come in and he is still trying to please them all but the quality of the food comes down and then people start complaining and then it is mad, so basically just concentrate on what you can do and don't try to please everybody…I also now try to mix with people who are just happy and positive and try to stay away from  I'd also come to realise before then that the relationship I was in was not quite what it was as he told me lots of things that were untrue that I discovered so I ended that as well and that was having a clean slate but it took me a long time to get literally over it. It's been a process of learning that I needed, I need desperately, I desperately needed family, you know, people I feel safe with, to be myself. And I needed people to help me normalise my feelings rather than be freaked out and hiding and terrified of expressing. (B09) Now I do feel a lot more stable than I did back then, and then when I go to these kinds of experiences you know, I've started to like, connections have become my thing because connections are what saved me from like, connections with people, a spiritual connection and this connection between people, there's interconnection between people is essentially what saves people…That power of coming together is so powerful, that is worth fighting for, worth dying for, it's worth me giving my time for. (B25) Having the friendship, the respect that built up over that in learning from each other, you Although the experiences were horrendous, and they were horrendous, there's no other way of describing the agony, it has been necessary because I couldn't do it on my own, so it still feels, and maybe this is just you know the spiritual aspect of my life but it still feels as though I do have like something watches over me and is helping me um and I survived. ( A08) I kind of relived stuff and at the same time just physically I wanted to let go of loads of things, I just kind of clutter cleared my whole house, really cleaned it, I got rid of loads of bits and pieces that I didn't need any more and as I went through that whole process it was like this massive opening, just kind of spiritual opening again…I felt very very free, I felt like I was being guided with everything, I felt very, very spiritual. Um lots of things happened that were very healing I suppose, played a lot of music…when I relived it and the emotion that was associated my voice really did, like it changed, it kind of opened out and it became much more free and liberated and um at the same time I felt like I went into a completely different reality, it was really incredible, it was like intensely spiritual and a feeling that everything was connected and it was though lots of chakras opened or something happened in my body and my mind. (A10)  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44 45 46 F o r p e e r r e v i e w o n l y Now I'm sort of growing older I know they're spirit animals, I still have them and so it's the wolves that are the most powerful so I do feel protected by those. Um and the other one is [inaudible] spiritual as well I always used to feel some [inaudible] egocentric, sort of like, wounds, [inaudible] kind of reaching out to people because I've always felt like I'm [inaudible] ever since I was really little which has why I have gone into mental health, to help people. (A18) But I think the longer deal is this, this, internal shift, they call it a psychic shift, an internal psychic shift, which is more about that spiritual experience and I don't know anything else that, that would work with me, do you know what I mean. And so, erm, since about 2009, that's what I've been kind of exploring in a, in a sort of ad hoc way. (B04) But when you kind of realise that there is something bigger than you, you start to realise don't hurt yourself, have more respect for yourself, and you also don't harm others in a sense, not but everything falls into place. The world has meaning, has greater meaning. (C19) 6.2 Spiritual engagement New or renewed engagement with spiritual or religious practices, helping with meaningmaking and providing comfort and security Like wow so I ran over to them and they kind of just guided me so I was just being guided by all of the spirits and stuff and they guided me up the hill into the woods. (A02) …was actually, uh, around all of this I was sort of meditating and looking at the more spiritual aspects of my life and you know, just looking for, I was looking and seeking that help and I was, I was meditating. It, it, it brought a lot of pain but I was looking at that. (A08) I became very um sort of what's the word, like spiritual as well. I found the church very comforting and kind of a place I would be, to trust and yeah, it just gave a sense of security for some reason. (A14) So, you know, if it wasn't, if it wasn't for yoga, my Buddhist practice and community, who get, who don't, who, who see that there's something valuable from raw emotion, that  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44 45 46 F o r p e e r r e v i e w o n l y there's energy in raw emotion…My understanding of Buddhism had, had grown. Erm, I'd been introduced to it, to the practice of chanting [inaudible], to reveal your own courage and compassion and wisdom and create, create more humane connections with people. And, I thought it was amazing energy to, to nourish, 'cos it wasn't based on any gods or idols or who was, you know, who was, who was cool and who wasn't. It's universal. It's a universal truth….the long and short of it, Buddhist practice helped [laughs]. More harmonious with myself and other people. (B09).
Every morning I put my hand on my heart and I pray and I meditate and I go into that space where it's myself…Now I feel like now I do feel a lot more stable than I did back then and then when I go to these kinds of experiences you know, I've started to like connections have become my thing because connections are what saved me from like, connections with people, a spiritual connection and this connection between people, there's interconnection between people is essentially what saves people. (B25) I was still a Quaker at this point so that was really helpful, so I would go each week to have silent worship and that was really good, I saw it as an opportunity to kind of pause and have my brain calm down and yeah that was really lovely. (C15) …think also a lot, mental health is to do with emotion, for me I can only find the emotional vocabulary within church. And many things that we are struggling with are deep spiritual psychic rooms and you can't find that power and that passion in a, in anything other than a spiritual context… So for me recovery is about spirituality, it is about God, that is me and that's what works for me, it might not be the same for everyone…just pray, pray. (laughs) It works, do it, don't be scared. (C19)  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60