The Wind Check: How to Adapt Recovery and Shared Decision-Making Across Cultures

Recovery-oriented practice and shared decision-making (SDM) are now mainstream expectations in mental health services. Yet clinicians know that you can use the same tools with the same intent, and still have the conversation go nowhere. One underdiscussed reason is that culture shapes what support, autonomy, expertise, and collaboration look like for each patient.

Recovery colleges (RCs) offer a window into how recovery-oriented mechanisms travel across contexts and the same tensions show up in routine psychiatric encounters. In a large international survey of RCs across 28 countries, most sites showed moderate to high fidelity to the original model, but some components (notably coproduction and tailoring to the student) varied by region, with some Asian sites reporting lower scores than England.¹ This does not mean these components are unimportant; it signals that how they are enacted may need cultural translation.

Findings from parallel work across the 28 countries examining associations between RC fidelity components and country-level cultural characteristics suggest that many components were associated with certain cultural characteristics (eg, higher country-level indulgence was associated with higher scores on some fidelity components).^2,3

SDM has accumulated a growing evidence base in recent years.⁴ A Cochrane review update of SDM interventions for individuals with mental health conditions found that SDM can increase service users’ involvement and does not necessarily lengthen consultations.⁵ A useful heuristic is “culture as wind.” Culture is not a fixed label on a person; it is the shifting set of norms and expectations that can push an intervention off course. A good clinician does not fight the wind; they trim the sail, keeping the same destination (recovery, dignity, participation), while adjusting how they get there.⁶

Case Example

“Ms B” is a 30-year-old graduate student who recently moved for work. She presents with depressive symptoms and panic attacks. In her first appointment, she is quiet, answers politely, and repeatedly asks, “What do you think is best?” Her partner, who is also present, looks to the psychiatrist for clear recommendations. The psychiatrist, committed to SDM, says: “There are a few options: medication, therapy, or both. It is your decision. What would you like to do?” Ms B freezes, looks down, and says, “I don’t know.” The psychiatrist repeats, “It is really up to you.” Ms B nods, agrees to “think about it,” and does not show up for the next scheduled visit.

What may have happened? The psychiatrist offered autonomy, but Ms B experienced it as a withdrawal of expertise and care. In some contexts, being asked to choose without scaffolding increases uncertainty, shame (“I should know”), or the sense that the clinician is avoiding responsibility. Family involvement can amplify this: A partner may interpret the clinician’s neutrality as a lack of competence, while the patient may feel caught between “choosing correctly” and “not disappointing others.”⁷

A culturally safer SDM approach in the follow-up visit looks different. The psychiatrist asks permission to be more directive (“Would it help if I make a recommendation?”), offers a recommendation with options (“Based on what you have told me, I suggest starting therapy and considering a low-dose selective serotonin reuptake inhibitor. We can also discuss nonmedication options”), then invites Ms B’s values and concerns (“What worries you most about medication?”). Provided Ms B wants this and there are no safeguarding concerns, the partner is explicitly included as support, not as proxy decision maker (“How can you support Ms B with whichever plan she chooses?”). Autonomy is preserved, but the burden is reduced.⁸

The Wind Check: 5 Quick Questions Before You Adapt

Before changing any SDM tool or recovery-focused approach, do a 60-second “wind check.” The goal is to prevent 2 common clinical errors: (1) labeling a patient as nonadherent when the intervention does not fit their context, and (2) stereotyping by assuming culture explains everything. See the Table for more information.

1. Who is the decision maker in practice (individual, family, team, community)?
2. What does good care look like here (directive expertise, collaborative exploration, or a mix)?
3. What is the main risk right now: loss of agency, loss of safety, or loss of relationship?
4. What support is needed to participate (language, literacy, time, peer coaching, advocacy)?
5. What signals respect and hope in this context (words, roles, rituals, pacing)?

Applying Wind Checks to Recovery-Oriented Practice

Recovery-oriented practice aims to strengthen connectedness, hope, identity, meaning, and empowerment,⁹ but these mechanisms are expressed differently across services and cultures.^10,11 One widely used educational model, RCs, draws on adult learning, strengths-based practice, and coproduction with people with lived experience. However, a cocreated scoping review suggests that although evaluations are increasing, meaningful cocreation in evaluation and governance can be variable or unclear.¹²

Related cross-cultural work in RCs focuses on language and implementation patterns. For example, RCs are advertised differently across England, Japan, and the Netherlands. Our corpus-based discourse analyses found that while the promotional texts of RCs in all countries emphasized lived experience, the texts in England highlighted self-management and skill acquisition, those in Japan highlighted learning together and lifelong learning, and those in the Netherlands described recovery in the context of daily life.^13,14 The same approach is presented very differently across cultures. Similar mismatches can occur in everyday psychiatric practice when concepts such as choice, autonomy, and empowerment are interpreted through different cultural expectations.

What You Can Do: Make Adaptation Measurable

If you adapt SDM or recovery-focused elements, decide what success looks like in observable terms. For example:

• After the visit, the patient can explain the plan in their own words (teach-back)
• The clinician offers a recommendation only after asking permission
• A brief values question is asked in every SDM conversation (“What matters most to you right now?”)^10,11
• Each care-planning discussion ends with a written “who decides what” summary (including safety boundaries)
• Patient-facing written materials (letters, leaflets, plan summaries) are checked for unintended meanings and stigma

From Evidence to Action

Cross-cultural data sets can help clinicians and service leaders avoid 2 extremes: assuming that one model fits all, or assuming that culture makes evidence irrelevant. The emerging pattern across RCs and SDM work is that there are shared principles (respect, learning, partnership) but variable pathways to express them. A global Delphi study is now underway to identify which RC components are cross-culturally applicable, and which require adaptation, providing a structured consensus route from field experience to practical guidance.¹⁵

Meanwhile, findings from cross-European survey work suggest that clinicians’ SDM preferences, including assumptions about autonomy, directiveness, and the extent to which to recommend explicitly, vary across countries.¹⁶ A wind check helps clinicians recognize and adjust for this variation without losing ethical grounding.

Concluding Thoughts

Recovery and SDM are ethical commitments that must be delivered in locally meaningful ways. The culture-as-wind metaphor offers a pragmatic stance: Do not overexplain behavior with culture, but do not ignore cultural headwinds either. Use a quick wind check, protect core mechanisms, and adapt delivery, so patients experience SDM as support (not abandonment) and recovery as possibility (not pressure).

Dr Kotera is an associate professor at the University of Nottingham in England, a collaborative researcher at the University of Osaka in Japan, and an honorary professor at Azerbaijan University in Azerbaijan.

References

1. Hayes D, Hunter-Brown H, Camacho E, et al; RECOLLECT International Research Consortium. Organisational and student characteristics, fidelity, funding models, and unit costs of recovery colleges in 28 countries: a cross-sectional survey. Lancet Psychiatry. 2023;10(10):768-779.

2. Kotera Y, Ronaldson A, Hayes D, et al. 28-country global study on associations between cultural characteristics and recovery college fidelity. Npj Ment Health Res. 2024;3(1):46.

3. Kotera Y, Ronaldson A, Takhi S, et al. Cultural influences on fidelity components in recovery colleges: a study across 28 countries and territories. Gen Psychiatr. 2025;38(3):e102010.

4. Francis CJ, Hazelton M, Wilson RL. Supported decision-making interventions in mental healthcare: a systematic review of evidence on the outcomes for people with mental ill health. Health Expect. 2024;27(6):e70134.

5. Aoki Y, Yaju Y, Utsumi T, et al. Shared decision-making interventions for people with mental health conditions. Cochrane Database Syst Rev. 2022;11(11):CD007297.

6. Kotera Y. Culture as wind: aligning the direction of mental health interventions with cultural values. Int J Ment Health Addict. Published online November 18, 2025.

7. Miyatake H, Ozaki A, Kotera Y, et al. Case report on the legal assurance of advance care planning in collective culture. Clin Case Rep. 2022;10(4):e05759.

8. Kotera Y. Three communication tips to integrate psychological and cultural determinants into everyday hospital care. Br J Hosp Med (Lond). 2026;87(3):51729.

9. Leamy M, Bird V, Le Boutillier C, et al. Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. Br J Psychiatry. 2011;199(6):445-452.

10. Kotera Y, Hara A, Ozaki A, et al. Refining the Global INSPIRE measure of recovery priorities: a qualitative, linguistic, and statistical approach. Research Square. Preprint posted online July 30, 2025.

11. Kotera Y, Hara A, Newby C, et al. Development and evaluation of a mental health recovery priority measure for cross-cultural research: Global INSPIRE. Soc Psychiatry Psychiatr Epidemiol. 2025;60(11):2695-2706.

12. Lin E, Harris H, Black G, et al. Evaluating recovery colleges: a co-created scoping review. J Ment Health. 2023;32(4):813-834.

13. Kotera Y, Antens M, Mulder CL, et al. The influence of quality-of-life orientation on recovery college advertising: a Dutch-English-Japanese corpus-based comparison. medRxiv. Preprint posted online August 14, 2025.

14. Kotera Y, Miyamoto Y, Vilar-Lluch S, et al. Cross-cultural comparison of recovery college implementation between Japan and England: corpus-based discourse analysis. Int J Ment Health Addict. 2025;23(6):4362-4386.

15. Kotera Y, Jebara T, Lawrence V, et al. Enhancing cross-cultural applicability in recovery colleges: a global Delphi study protocol. PLoS One. 2025;20(9):e0332729.

16. Kotera Y, Newby C, Kuzman MR, et al. Cultural impacts on shared decision-making: a cross-European study of psychiatrist preferences in 38 countries. Eur Psychiatry. 2025;68(1):e108.