Transcript Feedback of Outcome to Users and Staff: The FOCUS Study

Understanding and supporting
personal recovery
Mike Slade
Reader in Health Services Research
Institute of Psychiatry, King’s College London
Consultant Clinical Psychologist
South London and Maudsley NHS Foundation Trust, London
14 October 2010
Topics
1. What is personal recovery?
2. International policy
3. The international issue
4. Concrete actions and international examples
Recovery in schizophrenia
Full symptom remission, full or part time work /
education, independent living without supervision by
informal carers, having friends with whom activities
can be shared – sustained for a period of 2 years
Liberman RP, Kopelowicz A (2002)
Recovery from schizophrenia,
International Review of Psychiatry, 14, 245-255.
Long-term (>20 year) schizophrenia outcome
Team
Location
Yr
n
Huber
Ciompi
Bleuler
Tsuang
Harding
Ogawa
Marneros
DeSisto
Harrison
Bonn
Lausanne
Zurich
Iowa
Vermont
Japan
Cologne
Maine
18-site
1975
1976
1978
1979
1987
1987
1989
1995
2001
502
289
208
186
269
140
249
269
776
F-up Recovered /
sig. improved
(yrs)
(%)
22
57
37
53
23
53-68
35
46
32
62-68
23
57
25
58
35
49
25
56
Recovery in schizophrenia
Full symptom remission, full or part time work /
education, independent living without supervision by
informal carers, having friends with whom activities
can be shared – sustained for a period of 2 years
…we believe that it is now realistic to set as a goal
the feasibility of recovery from schizophrenia for half
or more individuals with first episode.
Liberman RP, Kopelowicz A (2002)
Recovery from schizophrenia,
International Review of Psychiatry, 14, 245-255.
But…
• What about the other 50%?
• Recovery indicators require ‘better than normal’
functioning
• You can’t return to how you were
• “I don’t want to be without my symptoms, I want
to live a valued life with them”
• “I don’t believe I’m ill – so I have nothing to
recover from”
What is recovery?
A deeply personal, unique process of changing one’s
attitudes, values, feelings, goals, skills and roles. It is
a way of living a satisfying, hopeful and contributing
life even with limitations caused by the illness.
Recovery involves the development of new meaning
and purpose in one’s life as one grows beyond the
catastrophic effects of mental illness.
Anthony WA (1993) Recovery from mental illness:
the guiding vision of the mental health service system in the 1990s,
Psychosocial Rehabilitation Journal, 16, 11-23.
One word – two meanings
CLINICAL RECOVERY
- focus on professional imperatives
- partly operationalised
- not highly concordant with consumer views
PERSONAL RECOVERY
- focus on personal meaning and purpose
- not operationalised for research purposes
- ideological and oppositional, not empirical
Charcot’s presentation of a ‘case’ of hysteria at the Salpétriére in
1887
Paradigm shift?
1. The central intellectual challenge comes from outside
the system of belief
2. The previous body of knowledge becomes a special
case
3. What was previously peripheral becomes central
Which type of recovery should be
the goal of the mental health system?
1. Epistemological
2. Ethical
3. Empowerment
4. Effectiveness
5. Policy
Australia policy
When a person’s mental health is at risk, service
systems should be equipped to intervene early…
These services should provide continuity of care,
adopt a recovery orientation and promote wellness.
A recovery orientation emphasises the development
of new meaning and purpose for consumers and the
ability to pursue personal goals.
Australian Health Ministers (2003) National Mental Health Plan 2003-2008,
Canberra: Australian Government.
New Zealand policy
To ensure that people with mental illness live in an
environment which respects their rights, provides fair
and equal opportunities, and have access to a fully
developed range of mental health services which is
provided by the right combination of people
responding appropriately to people’s needs in order to
achieve the best possible outcomes and recovery.
Mental Health Commission (1998) Blueprint for Mental Health Services
in New Zealand, Wellington: Mental Health Commission.
USA policy
Mental healthcare in the United States should be
recovery-oriented where recovery is defined as “the
ability to live, work, learn and participate fully in the
community”; for some that definition embodies living
“a fulfilling and productive life despite a disability,”
while it is “for others, a reduction or complete
remission of symptoms”
New Freedom Commission on Mental Health (2005) Achieving the promise: transforming mental health care in
America, Rockville, MD: US Department of Health and Human Services.
Ireland
The recovery model emphasises the centrality of the
personal experience of the individual and importance
of mobilising the person’s own resources as part of
treatment. It emphasises the development of
individualised self-management plans rather than
compliance with a standard treatment regime.
Mental Health Commission (2005) A vision for a recovery model in
Irish mental health services, Dublin: Mental Health Commission.
Scotland
www.scottishrecovery.net
England and Wales
We need to create an optimistic, positive approach to
all people who use mental health services. The vast
majority have real prospects of recovery – if they are
supported by appropriate services, driven by the right
values and attitudes.
The mental health system must support people in
settings of their own choosing, enable access to
community resources including housing, education,
work, friendships – or whatever they think is critical
to their own recovery
Department of Health (2001) The Journey to Recovery, London: HMSO.
International Policy
Personal recovery is established policy in most
Anglophone countries
Developing in German-speaking
Amering M, Schmolke M (2007)
Recovery - Das Ende der Unheilbarkeit
Bonn, Psychiatrie-Verlag.
Rehabilitation of the Mentally
Disabled in the Community Law
‘Basket’ of psychiatric rehabilitation services
- Employment
- Housing
- Adult education
- Social activity and leisure
- Families
- Dental care
- Coordination of treatment
Psychiatric rehabilitation services
Challenges in Israel:
• Providing person-centered services
• Training and supervision for service providers
• Integrate psychiatric services into a cohesive
recovery plan
• Involvement of service users and family carers
• The development of recovery-oriented services
Roe D et al (2009) The emerging field of psychiatric rehabilitation,
Israel Journal of Psychiatry, 46, 82-83.
Free to download: rethink.org
Free to download: www.centreformentalhealth.org.uk
Wiley-Blackwell, 2009
Cambridge University Press, 2009
Systematic review
Aim
To develop a conceptual framework for personal recovery
Sources
12 bibliographic databases, web, experts, ToC, hand searching
Data
5,208 identified, 376 full papers retrieved, 97 included
Analysis
Modified narrative synthesis
Recovery processes: The CHIME framework
Connectedness
Hope and
optimism
Identity
Personal
Recovery
Meaning and
purpose
Empowerment
Leamy M et al (2010) A conceptual framework for personal recovery in mental health: systematic review and
narrative synthesis, British Journal of Psychiatry, in press pending revisions
The Personal Recovery Framework
SOCIAL
ENVIRONMENT
IDENTITY-ENHANCING
RELATIONSHIPS
IDENTITY
Persistent characteristics
which make us unique and by
which we are connected to the
rest of the world
The Personal Recovery Framework
SOCIAL
ENVIRONMENT
Developing
valued social
roles
IDENTITY-ENHANCING
RELATIONSHIPS
IDENTITY
Developing a
positive
identity
‘Mental
illness’
part
Framing &
selfmanaging
RECOVERY SUPPORT TASKS
aka
The job of mental health professionals
1. Fostering relationships
2. Promoting well-being
3. Offering treatments
4. Improving social inclusion
Slade M (2009) The contribution of mental health services to recovery,
Journal of Mental Health, 18, 367-371.
Support 1: Fostering relationships
Types of professional relationship
1. DETACHED RELATIONSHIPS
Fully context-based: relationship is filtered by the clinician
through their own model
2. PARTNERSHIP RELATIONSHIPS
Defined by the mental health context, involves collaboration and
joint working. Requires activation of expertise-by-training and
expertise-by-experience
3. REAL RELATIONSHIPS
Genuineness (being who one truly is) and Realism (perceiving the
other in ways that befit him or her, rather than through a clinical
or in other ways distorting lens)
Gelso CJ et al (2005) Measuring the Real Relationship
in Psychotherapy, J Counsel Psychol, 52, 640-649.
Relationships…with professionals
Traditional
Detached
Partnership
Recovery-oriented
Detached
Partnership
Real
Communication styles
1. Mentoring
Deegan G (2003) Discovering recovery,
Psychiatric Rehabilitation Journal, 26, 368-376.
2. Co-learning
Bock T, Priebe S (2005) Psychosis seminars: an
unconventional approach. Psychiatric Services, 56, 1441-1443.
3. Coaching
Green LS, Oades LG, Grant AM (2006) Cognitive-Behavioural,
Solution-Focused Life Coaching: Enhancing Goal Striving,
Well-Being and Hope, Journal of Positive Psychology, 1, 142-149.
Peace Ranch
Caledon
Ontario
www.peaceranch.com
Support 2: Promoting well-being
Well-being – sources of knowledge
Source 1: Recovery
Source 2: Positive psychology
Source 3: Mental capital
Slade M (2010) Mental illness and well-being: the central importance of positive
psychology and recovery approaches, BMC Health Services Research, 10, 26.
Foresight five ways to wellbeing
Connect
Connect with the people around you…Think of these as the cornerstones of
your life and invest time in developing them.
Be active
Go for a walk or run. Step outside. Exercising makes you feel good. Most
importantly, discover a physical activity you enjoy.
Take notice…
Be curious. Catch sight of the beautiful. Remark on the unusual. Be aware of
the world around you.
Keep learning…
Try something new. Rediscover an old interest. Sign up for that course. Set a
challenge you will enjoy achieving.
Give…
Do something nice for a friend, or a stranger. Thank someone. Smile.
Volunteer your time. Join a community group. Look out, as well as in.
Key We Way
www.wellink.org.nz/services/keyweway.htm
RCT evidence: peer-led services
In-patient mental health services (n=393)
Consumer-operated unlocked service vs. locked inpatient unit
Improvements in symptoms and great improvement in satisfaction
Greenfield TK et al (2008) A Randomized Trial of a Mental Health Consumer-Managed
Alternative to Civil Commitment for Acute Psychiatric Crisis,
American Journal of Community Psychology, 42, 135-144.
Consumer-operated mental health services (n=1,827)
Drop-in / peer support / education & advocacy vs TAU
Improvements in empowerment, dose-effect
Rogers ES et al (2007) Effects of participation in consumer-operated service programs on both
personal and organizationally mediated empowerment: Results of multisite study,
Journal of Rehabilitation Research & Development, 44, 785-800.
Support 3: Offering treatments
Aims of recovery-focussed assessment
1. To validate development of personal meaning
2. To amplify strengths
3. To foster personal responsibility
4. To develop hopefulness
The Village
mhavillage.org
RCT evidence:
recovery-focussed service models
Demonstration sites re employment and crisis / outreach vs.
TAU (n=516)
Reduced hospital use (40% to 21%)
More employment (11% to 36%
Chandler D et al (1996) Client Outcomes in Two Model
Capitated Integrated Service Agencies, Psychiatric Services, 47, 175-180.
Savings of $650,000 over three years: re-invested!
Chandler D et al (2007) A Capitated Model for a Cross-Section of Severely
Mentally Ill Clients, Community Mental Health Journal, 34, 13-26.
Support 4: Improving social inclusion
What is social inclusion?
Social inclusion must come down to somewhere to
live, something to do and someone to love.
It’s as simple - and as complicated - as that.
Dunn S (1999) Creating accepting communities: report of the Mind inquiry into social
exclusion and mental health problems. London: Mind.
Boston University Center for Psychiatric Rehabilitation
bu.edu/cpr
Key pro-recovery values
• The primary goal of mental health services is
to support personal recovery
• Actions by staff primarily focus on
identifying, elaborating and supporting work
towards the person’s goals
• Mental health services work as if people are,
or (when in crisis) will be, responsible for
their own lives
Cambridge University Press
Free to download from
rethink.org/100ways