1. 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

2. Topics 1.What is personal recovery? 2.International policy 3.The international issue 4.Concrete actions and international examples

4. 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.

5. Long-term (>20 year) schizophrenia outcome TeamLocation Yr n F-upRecovered / sig. improved (yrs) (%) HuberBonn1975502 22 CiompiLausanne1976289 37 BleulerZurich1978208 23 TsuangIowa1979186 35 HardingVermont1987269 32 OgawaJapan1987140 23 MarnerosCologne1989249 25 DeSistoMaine1995269 35 Harrison18-site2001776 25 57 53 53-68 46 62-68 57 58 49 56

6. 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.

8. 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”

9. 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.

10. 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

12. Charcot’s presentation of a ‘case’ of hysteria at the Salpétriére in 1887

13. 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

14. Which type of recovery should be the goal of the mental health system? 1.Epistemological 2.Ethical 3.Empowerment 4.Effectiveness 5.Policy

15. 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.

16. 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.

17. 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.

18. 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

19. 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.

20. 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.

21. 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

22. 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.

23. Free to download: rethink.org

24. Free to download: www.centreformentalhealth.org.uk

25. Wiley-Blackwell, 2009Cambridge University Press, 2009

26. 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

27. 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 Personal Recovery Connectedness Hope and optimism Identity Empowerment Meaning and purpose

28. 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

29. The Personal Recovery Framework SOCIAL ENVIRONMENT IDENTITY-ENHANCING RELATIONSHIPS IDENTITY ‘Mental illness’ part Developing valued social roles Developing a positive identity Framing & self- managing

30. 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.

31. Support 1: Fostering relationships

32. 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.

33. Relationships…with professionals Traditional Detached Partnership Recovery-oriented Detached Partnership Real

34. 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.

35. Peace Ranch Caledon Ontario www.peaceranch.com

36. Support 2: Promoting well-being

37. 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.

38. 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.

40. Key We Waywww.wellink.org.nz/services/keyweway.htm

41. 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.

42. Support 3: Offering treatments

43. 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

45. The Villagemhavillage.org

46. 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.

47. Support 4: Improving social inclusion

48. 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.

49. Boston University Center for Psychiatric Rehabilitationbu.edu/cpr

50. 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

51. Cambridge University Press Free to download from rethink.org/100ways