Recovery and Rehabilitation in theory and practice

CONTEXTS - Royal College of Psychiatrists

Core Curriculum 2013 – Knowledge

• Define the clinical presentations and natural history of patients with severe and enduring mental illness

• Define the role of rehabilitation and recovery services

• Define the concept of recovery• Define the concept of quality of life and how it can

be measured• Awareness of disability/housing benefits that

patients may be entitled to claim

Core Curriculum 2013 - Skills

• Maintain hope whilst setting long term, realistic goals

• Develop long-term management plans• Act as patient advocate in negotiations with

services• Demonstrate skills in risk management in

chronic psychiatric disorders• Demonstrate skills in pathway care

management

Core Curriculum 2013 – Attitudes Demonstrated by Behaviour

• Treat each patient as an individual• Demonstrate an appreciation of the effect of chronic disease

states on patients and their families• Develop and sustain supportive relationships with patients

with severe and enduring mental illness• Demonstrate an appreciation of the impact of severe and

enduring mental illness on patients, their families and carers• Demonstrate an appreciation of the importance of co-

operation and collaboration with primary healthcare services, social care services, and non-statutory services

Core Curriculum 2013

• Understand the impact of stigmatisation – relating to both mental and physical illness – and its impact on the care of patients

• Develop an awareness of how established practices may perpetuate and reinforce stigma

• Be aware of strategies to enhance patient understanding and potential self - management

• Demonstrate awareness of methods to improve treatment concordance

Core Curriculum 2013

• Demonstrate an understanding of factors that influence the aetiology and course of mental disorder, including social deprivation

• Advise on environmental and lifestyle changes

CONTEXTS - NICE CG82

Interventions for people with schizophrenia whose illness has notresponded adequately to treatment

• For people with schizophrenia whose illness has not responded adequately to pharmacological or psychological treatment:– − review the diagnosis– − establish that there has been adherence to antipsychotic

medication, prescribed at an adequate dose and for the correct duration − review engagement with and use of psychological treatments and ensure that these have been offered according to this guideline. If family intervention has been undertaken suggest CBT; if CBT has been undertaken suggest family intervention for people in close contact with their families

– − consider other causes of non-response, such as comorbid substance misuse (including alcohol), the concurrent use of other prescribed medication or physical illness

Interventions for people with schizophrenia whose illness has notresponded adequately to treatment

• Offer clozapine to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least two different antipsychotic drugs. At least one of the drugs should be a non-clozapine second-generation antipsychotic.

• If symptoms have not responded adequately to an optimised dose of clozapine, review the diagnosis, adherence to treatment, engagement with and use of psychological treatments, other possible causes of non-response and measure therapeutic drug levels before offering a second antipsychotic to augment clozapine. The second drug should not compound the common side effects of clozapine. An adequate trial of augmentation may need to be up to 8–10 weeks.

Employment, education and occupational activities

• Provide supported employment programmes for those who want to return to work or find a job.

• These programmes should not be the only work-related activity offered when people are unable to work or cannot find a job.

• Mental health services should work with local stakeholders, including those representing BME groups, to enable access to local employment and educational opportunities. This support should take into account the person’s needs and skill level. It is likely to involve working with Jobcentre Plus, disability employment advisers and non-statutory providers.

• Routinely record the daytime activities and occupational outcomes of service users in their care plan.

RECOVERYre·cov·er·y /riˈkəvərē/Noun

Examples of use:• A return to a normal state of health, mind, or strength: "signs of recovery

in the housing market".

• The action or process of regaining possession or control of something stolen or lost: "the recovery of his sight".

Synonyms: • recuperation - convalescence

Recovery

• What do we mean by recovery in this context?• How do we aid recovery?

Recovery

• 'Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems

• Recovery represents a movement away from pathology, illness and symptoms to health, strengths and wellness

• A personal journey rather than a set of goals• Fuelled by deinstitutionalisation

What is Recovery?

William Anthony defines recovery as:• “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 the limitations caused by 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, W.A. (1993) Recovery from Mental Illness: The Guiding Vision of the Mental Health Service System in the 1990s Psychosocial Rehabilitation Journal,1993, 16(4), 11–23

History of Recovery

• Emphasis on personalisation, social inclusion and choice

• Arises from disability and civil rights movements

• Pinel – moral treatment• Dorothea Dix and Jane Adams, pioneers of

deinstitutionalisation

History of Recovery

• Erving Goffman (Stigma) and Franco Bassaglia • Crusading civil rights and race leaders,

including Martin Luther King • Humane psychiatrists Adolph Meyer and John

Strauss • Psychological and economic theorists, Lev

Vygotsky and Amartya Sen

Quality of Life

• WHO defines Quality of Life as individuals perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.

• It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of their environment.

Quality of Life Measures

• WHOQOL instruments – WHOQOL-BREF and WHOQOL-100 http://www.who.int/mental_health/media/68.pdf

• Recovery Star

Definition of Rehabilitation in Psychiatry

• Psychiatric rehabilitation promotes recovery, full community integration and improved quality of life for persons who have been diagnosed with any mental health condition that seriously impairs their ability to lead meaningful lives.

• Psychiatric rehabilitation services are collaborative, person directed and individualized.

Services

• Psychiatric rehabilitation services may include: workplace accommodations, supported employment or education, assertive community (or outreach) teams assisting with social service agencies, medication management, housing, employment, family issues, coping skills and activities of daily living and socialising.

• Psychiatric rehabilitation is illustrated by community models (e.g. Fountain House Model, MHA Village in Long Beach, CA)

Core principles of effective Psychiatric Rehabilitation

1. Respect for the client wherever they are in the recovery process

2. Empowering the client3. Providing hope even when the client lacks it4. Teaching the client wellness planning (eg

WRAP)5. Emphasizing the importance for the client of

developing social support networks

Areas of focus for Psychiatric Rehabilitation:

1. Psychiatric (symptom management)2. Health and Medical (maintaining consistency of care)3. Housing (safe environments)4. Basic Living Skills (hygiene, meals, safety, planning,

chores)5. Social (relationships, family, boundaries, communications

& community integration)6. Vocational and/or Educational (coping skills, motivation)7. Financial (personal budget)8. Community and Legal (resources)

Rehabilitation

• Comprehensive discharge planning• Outcomes measured

Recovery Star

Key elements of WRAP®:

1. Wellness Toolbox2. Daily Maintenance Plan3. Identifying Triggers and an Action Plan4. Identifying Early Warning Signs and an Action

Plan5. Identifying When Things Are Breaking Down

and an Action Plan6. Crisis Planning7. Post Crisis Planning

Some Common Wellness Tools1. eat three healthy meals per day2. take a nap3. exercise4. play with my dog5. write in a journal6. make my bed7. do something nice for someone else8. watch a video9. listen to music10. see my counsellor11. ask for a medication check12. make music

References• Enabling recovery for people with complex mental health needs: A template for

rehabilitation services. Edited by Paul Wolfson, Frank Holloway and Helen Killaspy. Faculty report FR/RS/1

Royal College of Psychiatrists Faculty of Rehabilitation and Social Psychiatry

• Wellness Recovery Action Plan (WRAP) – Mary Ellen Copeland. http://www.mentalhealthrecovery.com

• Recovery Star (One of a number of Outcome Stars available) - http://www.outcomesstar.org.uk

• http://www.mhpf.org.uk/resources/publications/the-mental-health-recovery-star-user-guide

• www.recoverydevon.co.uk

• NICE CG82 - www.nice.org.uk