SU1.1: Recovery begins with the hope of being free from clinical symptoms.

Service users and carers primarily understood recovery through a biomedical lens, equating improvement with the reduction or absence of clinical symptoms and emotional distress. Recovery was commonly associated with freedom from symptoms such as worry, depression, panic, suicidal ideation, and obsessive thinking, and was viewed as the necessary foundation for regaining happiness, stability, and a sense of normal daily life. Carers similarly gauged recovery through observable changes in mood, behaviour, and daily functioning, indicating that both subjective wellbeing and visible functional improvement shaped their understanding of progress.

HCP1.1: Clinical recovery must come first.

Healthcare professionals largely understood recovery as a process contingent on prior symptom stabilisation. Clinical stability was described in terms of behavioural control, the capacity to process and retain information, and the ability to communicate effectively with staff. Functional improvement and personal recovery were consequently positioned as sequential to rather than concurrent with symptom management, even from the point of crisis presentation.

“During the acute or crisis phase, it’s really not manageable. It’s beyond our capacity at the subdistrict health promoting hospital. The patient must go through the proper treatment process (in psychiatric hospitals) first. Only then we can start having meaningful conversations.”

- HCP02

HCP1.2: There is a strong alignment between functional and personal recovery.

Healthcare professionals conceptualised recovery not only as clinical improvement but also as the restoration of functional capacity. “Functional recovery” was consistently framed around independence in self-care, the ability to manage daily routines, and returning to employment for financial self-sufficiency and family provision. These accounts suggest that symptom reduction alone was not considered sufficient; recovery was evaluated through individuals’ capacity to resume socially expected roles and responsibilities. Recovery was therefore understood as the process of reintegration into valued social roles, rather than simply achieving clinical stability.

“At the very least, they should be able to take care of their basic daily needs. If it goes better, they might even help with family tasks. What we hope for is that they can live independently. Then they can work, take care of themselves, start helping their family. Some can even return to normal functioning we’d call it full recovery.”

- HCP05

JST1.1: Personal recovery could mean….

Personal recovery was described as closely associated with adaptability and resilience, enabling individuals with mental illness to feel content and maintain a sense of control over their mental health. Recovery was understood as being rooted in inner strength and the ability to manage one’s life despite ongoing mental health difficulties. It often began when individuals developed a more positive mindset, recognised the need for change, and set clear life goals with hope for the future. As one healthcare professional reflected, recovery started when a person realised, “I should be better”. Recovery did not mean the complete elimination of mental illness, but rather the ability to live independently, confidently, hopefully, and peacefully while continuing to manage ongoing symptoms and challenges. The ultimate goal of personal recovery was seen as successful reintegration into society and community life, where individuals could live meaningfully without creating recurrent difficulties for themselves or others.

Fig 1 presents a word cloud illustrating the most frequently occurring terms used by participants when describing personal recovery. This is not intended as a standalone analytical tool but offers a visual overview of dominant recovery-related concepts that complements the thematic analysis and contextualises participants’ shared understanding of recovery.

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Fig 1. Frequently used words in discussions of recovery.

https://doi.org/10.1371/journal.pone.0353706.g001

SU2.1: Staff are regarded with deference and authority.

Service users and carers consistently perceived healthcare professionals as the most legitimate source of knowledge and authority in mental health recovery. Doctors and healthcare staff were described as highly educated and competent, which fostered a strong tendency to trust professional judgement and follow treatment recommendations with limited questioning. Recovery was consequently positioned within a provider-led model, in which treatment compliance was understood as the primary route to improvement.

HCP2.1: Working in mental health care is challenging.

Healthcare professionals described workforce sustainability in community mental health care as constrained by limited specialist training and the emotional demands of practice. In Thailand, mental health nursing specialisation occurs only post-registration and recruitment remained difficult as many general nurses were reluctant to transition into psychiatric settings, largely due to fear, stigma, and uncertainty about managing the psychological demands of this work. Despite these challenges, compassion and a strong sense of responsibility towards mental health service users were identified as key factors sustaining staff engagement, suggesting that workforce participation was often driven more by personal commitment as much as formal preparation.

Participants also highlighted the complexity of supporting service users with substance misuse-related problems, which were perceived as particularly high risk. These cases intensified concerns about staff safety and heightened anxiety around community care delivery, particularly where there were fears of aggression or unpredictable behaviour.

“The main challenge is all about psychiatric patients here (in the community) who have issues with substance misuse. That makes our work risky and dangerous in providing care, because we don’t know what if the patient recovers and returns (from jail or substance rehabilitation hospital), they might harm (us) or what if they still hold resentment or anger toward us?”

- HCP01

HCP2.2: Multi-sectoral collaboration and shared responsibility for mental health care.

Healthcare professionals viewed mental health recovery as a shared responsibility requiring coordinated involvement from government agencies, community organisations, families, and other public services. Increasing awareness of the wider social determinants of mental health was seen as strengthening this collective approach. Initiatives such as the Serious Mental Illness (SMI) pathway were described as examples of effective multi-sectoral collaboration, enabling individuals experiencing acute psychiatric symptoms to be referred and admitted promptly without legal barriers. This was perceived as improving rapid access to emergency psychiatric care and strengthening inter-agency cooperation in crisis management.

HCP2.3: Belief in the possibility of recovery for all.

Healthcare professionals consistently emphasised that recovery was possible across all mental health conditions. While some staff considered recovery from substance misuse more challenging than from mood disorders such as depression, diagnostic category alone was not seen as determining recovery outcomes. Instead, they emphasised the importance of surrounding support systems, particularly family involvement, continuity of care, treatment adherence, and access to ongoing support. Recovery was therefore understood as contingent on enabling environments rather than illness severity.

“Regardless of which group of psychiatric patients they belong to, everyone has the chance to recover. It depends on the supportive factors. It is not just about medication. If someone stops taking meds, they can still recover. Or if someone has schizophrenia, even with the illness, if their family provides proper care and they take their medication and attend appointments, then all groups have the same chance.”

- HCP11

JST2.1: Mental health receives limited attention and prioritisation.

Participants described mental health as receiving lower institutional priority than physical health conditions, within the Thai healthcare system, particularly in subdistrict hospitals where community mental health services remained limited and underdeveloped. In contrast to areas such as non-communicable disease management, maternal and child health, vaccination programmes, and elderly care, mental health lacked clear performance indicators and formal evaluation mechanisms, reducing its visibility and organisational priority. Mental health responsibilities were consequently often assigned to general nurses without specialist psychiatric training, reinforcing the marginal status of mental health within routine service delivery.

“In my opinion, (community) mental health services are still quite limited and underdeveloped. As I mentioned, many people experience both physical and psychological symptoms, but most people including health personnel tend to focus only on physical health. […] Right now, (community) mental health services are still minimal and not comprehensive.”

- HCP11

SU3.1: ‘It’s more about how we carry ourselves’.

Service users frequently positioned recovery as shaped by personal attitudes and self-determination rather than clinical treatment alone. Acceptance of mental illness was described as an essential first step, involving recognition of the condition as part of life and learning to live alongside it rather than allowing it to define one’s identity. Recovery was associated with sustaining optimism and developing the capacity to move beyond distress rather than remaining fixed in the role of a patient.

“When we’re in society, it depends on how we behave. It’s not like, just because they say we have schizophrenia, we act all crazy and live without care. If we do that, we won’t be able to be part of society, right? I didn’t think that way. I don’t carry it with me. I think of myself as normal, just like anyone else. […] Just because the doctor said I had a mental illness doesn’t mean I have to act like a patient. Just be normal, like before I got sick.”

- PwM03

SU3.2: Feeling loved and supported.

Service users described love, encouragement, and trust from significant others as central relational conditions supporting recovery. Supportive family relationships characterised by care, respect, and emotional reassurance fostered a sense of belonging, safety, and personal value, which were seen as important for sustaining hope and gradual improvement in wellbeing.

Family harmony was particularly valued as a source of emotional stability, with the absence of conflict, criticism, and tension, especially within extended family relationships was considered essential for maintaining positive mental health.

SU3.3: Preserving self-worth and contributing to others.

Service users positioned financial stability and independence as important markers of recovery, linking the ability to work, earn an income, manage daily expenses, and repay debts with a sense of security, dignity, and reduced psychological distress. Economic independence was associated not only with practical stability but with self-worth, and the restoration of control over everyday life.

Recovery was also closely connected to the capacity to contribute to others and remain socially engaged. Helping others, participating in community activities, and undertaking voluntary or public work were described as meaningful sources of purpose and fulfilment, strengthened wellbeing by enabling individuals to give as well as receive support.

“Really, if you help others and do it with sincerity, anyone who has the heart to help others will feel happiness from it. It brings joy. It depends on the person and your intention too. If you genuinely want to help others, when you get to do it, it feels like you fulfilled that purpose […].”

- PwM09

SU3.4: Staying connected with people and nature.

Service users described recovery as supported by both social engagement and connection with nature. Regular interaction with others was viewed as important for maintaining a sense of normality, reducing preoccupation with illness, and preventing social isolation. Social participation was seen to relieve negative thinking, provide emotional distraction, and protect against distress, including suicidal ideation. Connection with nature was similarly described as a source of restoration and emotional balance. Activities such as caring for animals, walking in forests, and gathering herbs or mushrooms helped participants feel calm, grounded, and mentally refreshed. Recovery was therefore supported not only through interpersonal relationships but also through everyday engagement with natural environments that provided comfort, purpose, and psychological relief.

SU3.5: Feeling accepted and treated like everyone else.

Service users linked recovery to the preservation of autonomy and the ability to maintain an ordinary social identity beyond mental illness. Recovery was strengthened when individuals could manage daily activities independently, make their own decisions, and participate in everyday life without constant supervision or overprotection. Being able to go out, complete personal errands, and live without excessive monitoring reinforced feelings of competence and self-efficacy.

Equally important was how others responded to them. When family members and those close to them avoided treating them as different, fragile, or permanently defined by diagnosis, service users felt more respected, valued, and socially included.

“[…] because the people close to me didn’t treat me differently or specially. They treated me the same as before, nothing really changed. I could still go out, do my own errands, and live my life without needing anyone to constantly look after me. It wasn’t as if I had to depend on anyone or be supervised all the time.”

- PwM03

SU3.6: Reducing or stopping alcohol consumption.

For some participants, recovery was strongly associated with reducing or stopping alcohol use, particularly where alcohol was perceived to undermine daily functioning, emotional stability, and the ability to manage everyday life. Family support was identified as central to this process, with relatives playing an important role in encouraging abstinence, providing practical monitoring, and offering emotional guidance. Recovery from alcohol-related difficulties was therefore understood as both an individual and relational process, in which sustained improvement depended heavily on close family involvement.

“If he (patient) could just stop drinking, that’s the only thing, he would probably get better. […] The biggest worry is alcohol. If he quits, he can manage his own life. If alcohol is out of the picture, then I’m not worried anymore.”

- Carer01

SU3.7: Religious support as a source of recovery.

Spiritual and religious practices were identified as important supports for personal recovery, fostering mindfulness, acceptance, and a sense of purpose. Activities such as participating in rituals, listening to Buddhist teachings, chanting, and dedicating merit were described as promoting reflection, emotional regulation, and forgiveness, while helping individuals cope with past negative experiences or the consequences of karma. Religious practices were also linked to structure and behavioural self-regulation. Routine observances, such as abstaining from alcohol on holy days, were seen to strengthen self-discipline and support gradual positive change in everyday life.

“When I go to temples, pay respects to the Buddha, light incense, and make a vow in front of the main Buddha statue, then pour water to dedicate merit on holy days, I feel fulfilled. I feel content because I’ve done good deeds. The bad karma that affected me seems to ease and lessen. […] Once I felt that the merit I made helped me, it softened things. The karma that struck me eased up. Things got better.”

-PwM04

HCP3.1: ‘It has to start with patients themselves’.

Healthcare professionals positioned recovery as beginning with the individual’s recognition and acceptance of their mental health condition. Acknowledging illness was seen as a necessary first step that enabled engagement with counselling, medication, and other forms of support, allowing individuals to regain insight and develop a more hopeful and engaged orientation towards recovery. Without this initial acceptance, healthcare professionals felt that meaningful therapeutic progress was difficult to achieve.

However, willingness alone was not considered sufficient. Recovery was understood to require active engagement in treatment and recovery-oriented behaviours, rather than a passive acceptance of care. This reflects a view of recovery that prioritised personal responsibility and behavioural participation, in which improvement was closely linked to the individual’s readiness to change and openness to receiving support.

“I think it has to do with openness to accept help. Like I said, it depends on whether the patient wants to get better. If they want to be normal, it’s about whether they’re ready to open up. But even for psychiatric patients, if they open up, they could also recover.”

- HCP04

HCP3.2: Recovery requires collective community involvement.

Successful community reintegration was understood as requiring collaboration beyond formal healthcare services, particularly through partnerships with local leaders, village health volunteers, and the wider community. Village heads, subdistrict chiefs, and village health volunteers were described as key actors in monitoring wellbeing after discharge, providing updates on service users’ conditions and helping to coordinate responses when difficulties arose. This was especially important in community settings where limited staffing reduced the capacity for continuous professional follow-up.

For individuals experiencing alcohol misuse, restricting community access to alcohol through engagement with local retailers was also viewed as an important relapse prevention strategy. More broadly, participants emphasised that openness, understanding, and non-stigmatising attitudes within the community were essential for helping mental health service users feel accepted and supported.

HCP3.3: Staff must possess recovery-oriented knowledge, attitudes, competencies and skills.

Healthcare professionals described recovery-oriented care as dependent not only on clinical knowledge but also on relational and communication skills that supported trust, dignity, and engagement. Careful use of language and attention to recovery-oriented terminology were seen as important for reducing stigma and fostering respectful interactions with patients and families. Kindness, compassion, unconditional acceptance, and sustained belief in the person’s capacity for recovery were consistently identified as central to effective practice.

These interpersonal approaches were understood to strengthen therapeutic relationships and encourage greater participation from service users and carers in treatment discussions and future planning. In terms of structured goal setting, this was most commonly embedded within care pathways for people with alcohol dependence. However, some healthcare professionals described applying similar approaches more broadly, supporting individuals in identifying personal goals related to employment, daily functioning, and treatment engagement. This suggests that recovery-oriented care was understood as encompassing both supportive therapeutic relationships and practical collaboration around meaningful life goals.

JST3.1: Family as a central factor in recovery.

Participants consistently positioned family involvement as central to successful recovery. As the people in most continuous contact with the individual, family members were seen as essential in providing encouragement, emotional support, practical guidance, and ongoing monitoring of wellbeing. Effective family support depended on relatives having an understanding of the condition, maintaining open communication, and remaining actively engaged even during periods of frustration or exhaustion. Patients whose families actively mediated between them and their healthcare professionals were perceived to have stronger treatment engagement and better recovery outcomes than those living alone.

JST3.2: Peer support as a promising approach.

Participants identified peer support as a valuable component of recovery, particularly because individuals with lived experience could offer forms of understanding and guidance that professionals alone could not provide. Seeing someone who had experienced mental illness and progressed in their own recovery helped patients develop hope and recognise that improvement was possible. Peer supporters were also seen as able to provide practical advice on managing daily life, communicating with family, and navigating challenges that were often difficult to address through clinical support alone. Peer relationships helped normalise mental health difficulties, reduced feelings of isolation, and provided reassurance that individuals were not facing recovery alone. Healthcare professionals recognised that experiential knowledge offered a distinct form of credibility, particularly in fostering hope and helping patients feel genuinely understood.

“[…] Because sometimes, we ourselves haven’t been in their shoes. Sometimes we may not fully understand the patients the way someone with lived experience can, as their peer.”

- HCP05

SU4.1: Barriers that discourage recovery.

Service users identified multiple barriers to sustained recovery, encompassing both social and practical challenges. Stigma and embarrassment were described as significant factors delaying help-seeking, with some individuals avoiding mental health clinics due to fear of being seen, judged, or labelled by others. This suggests that concerns about social perception continued to restrict timely access to support.

Medication management also presented difficulties, particularly when psychiatric treatments caused excessive drowsiness that interfered with work, daily functioning, and independence, sometimes necessitating adjustments to balance symptom control with quality of life. Recovery was perceived as especially challenging for older adults, where age-related cognitive decline and the emergence of new symptoms complicated both treatment and self-care. Individuals living alone were additionally seen as more vulnerable to poor medication adherence and declining wellbeing due to the absence of family monitoring and everyday support. Together, these accounts illustrate how recovery was shaped not only by treatment but also by stigma, ageing, and the availability of practical and relational support.

SU4.2: Insufficient support for recovery.

Recovery was described as more difficult when carers received limited guidance from external services, leaving families to manage much of the caregiving responsibility alone. Relatives were often expected to monitor symptoms, supervise medication, and respond to complications such as alcohol-related poor nutrition, while relying on trial and error rather than clear professional guidance. This created significant uncertainty, emotional strain, and feelings of isolation, particularly when carers were unsure where to seek help and community services offered limited proactive outreach.

Participants also highlighted structural barriers within subdistrict hospitals, including limited medication availability, insufficient resources, and high patient volume, which undermined continuity of care and access to timely support. In some cases, referral to district hospitals created additional travel demands and financial pressure for both patients and families.

SU4.3: Mental health care remains distant from recovery-oriented practice.

Participants described recovery support within mental health services as predominantly centred on medication management, with limited ongoing dialogue, education, or collaborative guidance. Interactions with healthcare staff were often brief and focused primarily on prescription adjustments, while the structured self-management support commonly available for other long-term conditions, such as diabetes education was largely absent. As a result, patients and carers were frequently left to seek information independently and manage recovery with minimal professional support.

SU4.4: Inequality in healthcare service.

Carers described significant frustration with the perceived inconsistency and selectivity of disability and social welfare support, which often left families carrying the full burden of long-term caregiving. Many felt that formal support systems were unreliable or inaccessible, despite the substantial emotional, physical, and financial demands of caring for a person with mental illness. This reinforced a sense that recovery support depended on family capacity rather than equitable access to external assistance.

Some carers reported being advised by healthcare staff to simply continue providing care indefinitely, which intensified feelings of neglect, helplessness, and abandonment. Family members also perceived inequalities in how support was distributed, with those connected to health workers perceived as more likely to receive assistance, while their own evident needs were unmet. These experiences suggest that perceived institutional unfairness further undermined carers’ ability to sustain recovery within the family environment.

SU4.5: Challenges in addressing alcohol misuse.

Carers described alcohol misuse as one of the most persistent barriers to recovery, particularly when repeated advice, medical recommendations, and family efforts failed to produce behavioural change. Resistance to reducing alcohol use generated considerable frustration and emotional strain, with carers reporting that individuals often failed to recognise the impact of their drinking on daily functioning and recovery progress.

Financial management was a significant concern, as any money provided was frequently spent on alcohol, undermining household stability and treatment continuity. Social and cultural occasions including New Year, Songkran, and funerals were identified as high-risk situations where alcohol consumption was normalised and difficult to avoid, often precipitating relapse. These accounts highlight how recovery from alcohol-related difficulties was shaped not only by individual behaviour but also by broader social and cultural environments that normalised and sustained drinking practices.

HCP4.1: Patients’ lack of engagement in their own recovery.

Healthcare professionals frequently identified limited illness recognition and treatment engagement as major barriers to recovery. Many patients were described as not accepting their mental health condition, often leading to medication refusal, missed appointments, and disengagement from ongoing care, making recovery more difficult to sustain.

Among people experiencing substance misuse, these challenges were perceived as particularly pronounced. Healthcare professionals described how some individuals lacked awareness of the need to reduce or cease substance use and often acted impulsively, making continuity of care and follow-up especially difficult. Frequent disengagement, service avoidance, and premature discharge were identified as common obstacles, reinforcing the view that recovery depended heavily on insight, treatment acceptance, and sustained engagement with support.

HCP4.2: Family can’t provide care anymore.

Healthcare professionals noted that family support, although central to recovery, was not always available or sustainable. Some families experienced ongoing conflict, while others were constrained by demanding work commitments, financial difficulties, limited understanding of mental illness, or their own health problems, all of which reduced their capacity to provide consistent care. These accounts suggests that recovery could be significantly compromised when the family system itself was under strain or no longer able to fulfil a caregiving role.

“Most psychiatric patients have no family support. When their parents or caregivers die, how are they supposed to survive? This becomes a major issue. Many become homeless or wander the streets.”

- HCP08

HCP4.3: Community reluctance to reintegrate individuals with mental illness.

Healthcare professionals described community stigma and fear as significant barriers to recovery, particularly for individuals returning to the community following hospitalisation or those with histories of substance misuse or behaviours that had previously caused concern among community members. Reluctant to accept these individuals back, rooted in perceptions of unpredictable or risk, made social reintegration difficult even following treatment completion. Trust was especially challenging to rebuild where previous behaviours had caused harm within the community.

HCP4.4: Staff challenges in supporting patient recovery.

Healthcare professionals described significant organisational constraints that limited their ability to deliver recovery-oriented care, despite positive attitudes towards supporting patients. Staff shortages, heavy workloads, extensive administrative demands, and broad service responsibilities reduced opportunities for sustained mental health support and relationship-based care. General nurses and public health officers working in subdistrict hospitals also reported low confidence in managing mental health needs, particularly in the absence of specialist psychiatric training. The lack of psychiatrists within primary and community mental health services further restricted care options and clinical decision-making capacity.

“Treatment orders from a psychiatrist carry more authority. Doctors, by definition, have more decision-making power. We (non-physician) are here to assist, but without a psychiatrist, we’re limited as we can’t make those decisions ourselves […]. Our voice isn’t as strong […].”

- HCP05

JST4.1: Employment barriers for people with mental illness.

Participants reported that many employers were reluctant to hire individuals with mental health conditions, often perceiving mental illness as affecting work performance and reliability. Inconsistent attendance such as working for brief periods followed by repeated absence, were seen as economically disadvantageous, further limiting opportunities for stable employment. These barriers restricted not only financial independence but also social inclusion and personal confidence, given the close association between employment, dignity, purpose, and recovery.

JST4.2: Peer influence on relapse among people with substance use difficulties.

Participants described the social environment as a major influence on recovery from substance misuse, with peer and friendship networks seen as shaping everyday behaviours and decisions alongside family support. Recovery was considered particularly vulnerable to peer influence among young people, for whom returning to friendship groups associated with substance use was viewed as significantly increasing the risk of relapse and perpetuating harmful patterns of behaviour.