Understanding and supportingpersonal recovery

Mike Slade

Reader in Health Services ResearchInstitute of Psychiatry, King’s College London

Consultant Clinical PsychologistSouth 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 F-up Recovered /sig. improved(yrs) (%)

Huber Bonn 1975 502 22Ciompi Lausanne 1976 289 37Bleuler Zurich 1978 208 23Tsuang Iowa 1979 186 35Harding Vermont 1987 269 32Ogawa Japan 1987 140 23Marneros Cologne 1989 249 25DeSisto Maine 1995 269 35Harrison 18-site 2001 776 25

575353-684662-6857584956

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.

…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.

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

PERSONAL RECOVERY - focus on personal meaning and purpose- not operationalised for research purposes- ideological and oppositional, not empirical

CLINICAL RECOVERY- focus on professional imperatives- partly operationalised- not highly concordant with consumer views

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.

IrelandThe 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.

Scotlandwww.scottishrecovery.net

England and WalesWe 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 PolicyPersonal recovery is established policy in most Anglophone countries

Developing in German-speakingAmering M, Schmolke M (2007)

Recovery - Das Ende der UnheilbarkeitBonn, 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 servicesChallenges 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

AimTo develop a conceptual framework for personal recovery

Sources12 bibliographic databases, web, experts, ToC, hand searching

Data5,208 identified, 376 full papers retrieved, 97 included

AnalysisModified narrative synthesis

Recovery processes: The CHIME framework

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

PersonalRecovery

Connectedness

Hope and optimism Identity

EmpowermentMeaning and purpose

The Personal Recovery FrameworkSOCIAL

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 FrameworkSOCIAL

ENVIRONMENT

IDENTITY-ENHANCING RELATIONSHIPS

IDENTITY‘Mental illness’

part

Developing valued social

roles

Developing a positive identity Framing &

self-managing

RECOVERY SUPPORT TASKSaka

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-learningBock 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: RecoverySource 2: Positive psychologySource 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 wellbeingConnect

Connect with the people around you…Think of these as the cornerstones of your life and invest time in developing them.

Be activeGo 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 unitImprovements in symptoms and great improvement in satisfaction

Greenfield TK et al (2008) A Randomized Trial of a Mental Health Consumer-ManagedAlternative 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 TAUImprovements in empowerment, dose-effect

Rogers ES et al (2007) Effects of participation in consumer-operated service programs on bothpersonal 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 ModelCapitated 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 PressFree to download from rethink.org/100ways