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How can Psychiatrists (Clinicians) support Recovery
Copenhagen - Tuesday 15 May 2012
Jed BoardmanConsultant Psychiatrist/Senior Lecturer in Social Psychiatry, London.
Recovery Programme, Centre for Mental Health
Overview
What is Recovery?
What is it relevance for Clinicians? (practice and mental health services)
What do we need to change?
Recovery is for All
What is Recovery?
What is Recovery?
Living a life beyond illness
“… a deeply personal, unique process of changing one’s attitudes, values, feelings goals, skills, and/or 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, 1993)
• ‘Recovering your life’ – building a meaningful life ‘beyond illness’, based on self-defined goals, not the ‘realistic’expectations’ of professionals (e.g. Employment)
Personal Recovery (Social Recovery)
Clinical recovery
“We define recovery as achieving the life we want in the presence or absence of mental distress.”
Mental Health Foundation of New Zealand (2008)
Recovery is a process
And a Civil Rights movement
What is Recovery?Key ideas
What is Recovery?Key elements
Ideas of Recovery come from service users stories
Key elements:Hope
Agency (Control)
Opportunity
‘Recovery’ refers to a set of narratives (stories) written by individuals living with mental distress about their lives. These are their stories and only they can make ‘recovery’ happen‘
Recovery is therefore not a new method of ‘treatment’. Staff can’t make people recover.
Professionals and services can (and do) influence these stories – sometimes helpfully, sometimes unhelpfully
Recovery-orientated practice and services
Significant changes to practice, services and culture in order to be more supportive of recovery processes
Recovery and Recovery-oriented services
What is its relevance for clinicians?
Recovery – Why should we be interested?
Recovery Orientated Practice and services
Opportunity
Changing professions
Policy
International interest
Improving outcomes
Extending our horizons
Carers and families
Economic and social benefits
Transformation of mental health services – practice, services and culture
New Zealand (1998)
England and Wales (2001 / 11)
Australia (2003)
Scotland (2004)
USA (2005)
Ireland (2005)
Canada (2009)
National Policy
Current Mental Health Policy (Department of Health, 2011)
6 Key Objectives
1. Emphasis on early intervention, prevention and promotion of ‘well-being’
2. Expectation that more people with MH problems will ‘recover’
3. Aim to improve physical health of people using MH services
4. Improve experience of care (subjective satisfaction) and regularly measure it
5. Minimize avoidable harm
6. Reduce stigma and increase public understanding
No Health Without Mental Health
Most professional bodies now support Recovery ideas
Royal College of Nursing
College of Occupational Therapy
British Psychological Society
Royal College of Psychiatrists
Social Work
But there is still some resistance from some professionals ‘on the ground’
Professional support and resistance
Support from the Royal College of Psychiatrists
Fits in with other RCPsych policies
Changing Professional Roles
Profession of Medicine changingMore collaborative – greater emphasis on partnership
Greater emphasis on self-care and patient choice
Greater recognition of contribution of patients as experts in their own conditions
Change in the professional contract
Professional and Healer(Cruess & Cruess, 2009)
Professional guidanceGeneral Medical Council 2006 “Good Medical Practice”
The duties of a Doctor registered with GMC
”Patients must be able to trust doctors with their lives and health. To justify that trust, you must show respect for human life and you must:
….Work in partnership with patients
Listen to patients and respond to their concerns and preferences
Give patients the information they want or need in a way they can understand
Respect patients’ right to reach decisions with you about their treatment and care
Support patients in caring for themselves to improve and maintain their health”
Professional guidanceGeneral Medical Council 2006 “Good Medical Practice”
Good Clinical Care
“Supporting Self-Care
4. You should encourage patients and the public to take an interest in their health and to take action to improve and maintain it. This may include advising patients on the effects of their life choices on their health and well-being and the possible outcomes of their treatments”
Relationships with patients
“The Doctor-Patient Partnership
21. Relationships based on openness, trust and good communication will enable you to work in partnership with your patients to address their individual needs”
Anxieties about change
Professionals influence. Some users accept this – and some don’t!
We still haven’t fully identified the contribution of carers and families (but we are working on it!)
Support and resistance from service users and families
From the beginning, many managers said, ‘All this sounds OK, but what does it really mean? How can we tell if we are doing it ornot?’
We recognised this and have spent a lot of time on trying to clearly formulate and describe the organisational implications of ‘Recovery-oriented’ services
As part of this we have worked closely with the staff organisation that represents senior managers in mental health services (the ‘NHS Confederation’ MH network)
Support and resistance from organisations (managers)
What do we need to change?
Practice, Services and Culture
Practice – staff and professional training
Service Organisation and Delivery
Culture of Services
These 3 areas should be addressed in parallel
Practices and services should be based on best available evidence
The key themes of a recovery-oriented approach include a practical emphasis on:
Hope, control and opportunity
Coherent and shared vision
Person-centred and personalised care
Stories and narrative skills
Meaningful measures of outcomes
Support for active engagement and responsibility
Transforming practice and practitioners: engaging with peer perspectives and partnerships
Based on: Schrank B, Slade M (2007) Recovery in psychiatry, Psychiatric Bulletin, 31, 321-325.
Changes to practicePromoting Relationships
Aim to improve hope, control and opportunity
More emphasis on the quality of relationships
Staff and service users recognising and valuing what they have in common. Respect their knowledge and expertise as different, but valued
Meeting of experts – by training – by experience
Working in partnerships, sharing knowledge and expertise, with mutual respect.
Viewing staff as a resource (coach/mentor) ‘on tap’, but not ‘on top’
Developing user involvement – partnership work/co-production
Put service users at the centre of planning their own care (e.g. WRAP) including risk assessment and planning
Professionals need to support service users in the pursuit of their personal life goals (‘personalisation’), conveying a belief that this is possible. They have a key role as the ‘carriers of hope’
Build on their strengths, rather than listing their problems
Changes to practice, how can we ensure that every interaction .........
Supports service users in the pursuit of their personal life goals, maintaining a consistent belief that they are possible
Builds on their strengths, rather than listing their problems
Respects their knowledge and expertise as different, but valued
Uses educational approaches, as well as therapeutic models
Increases their opportunities for employment, education and community integration – using existing networks wherever possible
After each interaction, ask yourself did I…
• actively listen to help the person make sense of their mental health problems?
• help the person identify and prioritise their personal goals for recovery
• demonstrate a belief in the person’s existing strengths and resources?
• identify examples from my own ‘lived experience’ which inspires and validates their hopes?
• pay particular attention to the importance of goals which enable the person actively to contribute to the lives of others?
• identify non-mental health resources relevant to the achievement of their goals?
• encourage self-management?
• discuss what the person wants in terms of therapeutic interventions, respecting their wishes wherever possible?
• behave at all times so as to convey an attitude of respect for the person and a desire for an equal partnership, indicating a willingness to ‘go the extra mile’?
• while accepting that the future is uncertain continue to express support for the possibility of achieving these self-defined goals – maintaining hope and positive expectations?
‘10 Top Tips’ for recovery-oriented practice (Shepherd, Boardman & Slade,
2008)
Changes to practiceWorking Practice
Educational approaches, e.g. ‘Illness Management and Recovery’programmes (Mueser et al., 2004) may be particularly useful.
Shared decision-making (Torrey & Drake, 2009) for medication management
‘Joint crisis plans’ (Henderson et al., 2004) for crisis management and relapse prevention
Increase opportunities for employment, education and community integration – using their existing networks wherever possible
Encouragement for self-help, development of Personal Recovery Plans
Recovery is for All
Jed Boardman
Montreal 11 April 2011
Why is all this good for psychiatrists?
Increasing job satisfaction
Developing partnership - placing greater value on personal knowledge of the individual
Greater emphasis on personal priorities of service user
Balanced and evidence-based approach to treatment
Reminds us about promoting social justice for people with mental illness
What have we learned?
Doctors are part of the solution not the problem
Work with service users and carers
Work out the benefits of a Recovery-orientated approach
Get support from professional organisations
Work with other organisations
Recovery is for All
Benefits to clinicians
Benefits to service users
Covers all mental health specialisms
Placing greater value on personal knowledge of the individual
Greater emphasis on personal priorities of service user
Balanced and evidence-based approach to treatment
Readdress the historically subordinate interests of people with mental illness
Recovery means a new relationship between ‘them’ and ‘us’
A true partnership
Based on a recognition of
our common humanity and
what unites us, rather than
what divides us
Peer support Workers in Uganda
