The need for a fair deal
‘Recovery’ has been used in two ways
in mental health.1,2 First, recovery is the intended
consequence of the skilful application of medicine, nursing and
social care on a specific illness. Second, recovery is where
individuals actively build a meaningful life for themselves while
either continuing to experience mental health problems, or
following a period of poor mental health.
A recovery-based approach is not
primarily about returning to a pre-illness state, but is a process
where the individuals and professional collaboratively work towards
a meaningful and satisfying life. It is one where people with
mental health problems regain active control of their lives, and
where services support this through negotiated decisions about the
best ways of meeting a person’s medical, social and personal
needs.1,3
Social inclusion is the goal we all
share for people with mental health problems. A recovery- based
approach is fundamental for this to be achieved.
What we are calling for
- The formulation of a clear UK
rehabilitation policy.
- Recovery to become a better understood and
accepted approach across all mental health specialties.
- Clear and practical guidance and standards
on how mental health services can be recovery
orientated.3
- Further research on successful methods of
supporting self-management and recovery.
Examples of what the College will do
- The College, with its partners, will work
to develop guidance, advice and audit to support recovery-oriented
practice in local mental health services.
- We will ensure that training for
psychiatrists promotes the recovery approach.
- We will press for the formulation of a
clear UK policy on the provision of rehabilitation services for
people with long-term mental health problems.
Recovery: what is the evidence?
People can and do recover from severe
mental health problems. Research studies have followed the progress
of individuals with different mental health problems over several
years. A large review of longitudinal research studies of those
with schizophrenia found that complete recovery (a return to
pre-illness levels of functioning) occurred in 20–25% of
participants, and social recovery (regaining economic and social
independence) in 40–45%.4,5 Studies of individuals with
bipolar disorder suggested that around 40% of participants did not
experience detectable inter-episode psychosocial
impairment.6
An important finding is that personal
outcomes may depend on considerably more than effective treatment –
social and cultural factors play an important role, as do personal
commitment, hope and peer support.
Case study
1
James
Wooldridge
My army career ended the day I went on
parade in my pyjamas at Sandhurst. Within 24 hours I was sectioned
and pinned to a bed while a sedative was injected into my arm. For
the next 20 years, I was in and out of acute wards, and in 2003 I
committed an offence and was transferred to a medium secure
hospital. It was here that I, along with excellent hospital staff,
was able to recover and work towards maintaining my mental health
and well-being. I now use my experience of living with mental
distress and my commitment to recovery as the basis for my
successful business as a freelance trainer, speaker and
motivator.
Dr Glenn Roberts, member of the
RCPsych
We frequently do
not know what is possible until we try.
Rehabilitation services
Rehabilitation services include the
community rehabilitation team, which will often work closely with
crisis resolution teams, community mental health teams, assertive
outreach, residential services and acute in-patient
facilities.7 They will also cultivate a network of
connections with ordinary services and resources that promote
social inclusion. However, psychiatrists report that specialist
rehabilitation services are often not available across the UK or
are under threat and that a clear strategy for their development is
lacking.8 They are critical of the large distances their
patients have to travel from their homes to receive rehabilitation
services.9 Out-of-area treatments also affect many
thousands of long-term in-patients who are, as a consequence,
likely to experience social exclusion.
Case study
2
The Development of
Recovery in Devon
Devon has been developing
recovery-orientated services across the whole health and social
care community since 2003. The Devon Partnership NHS Trust has
declared one of its key aims as to ‘put recovery at the heart of
everything we do’, and underpinned that with a requirement that ALL
staff have awareness of the recovery approach and appropriate
skills, leading to a whole workforce training strategy. Similarly,
the Joint Health and Social Care Commissioners have developed a
recovery-orientated commissioning strategy and set in motion a
year-long exploration of how to embed recovery outcome measurement
in routine practice. The Commissioners, the Trust and the third
sector have agreed on a set of ten core standards for
recovery-orientated services.
Recovery: a common purpose for services and users
Recovery features prominently in public
discussion and in the national mental health policies of all four
UK countries. The importance of putting patients at the centre of
their care is the main tenet of the new government approach in
England and Wales. It includes an expansion of social measures such
as individual budgets and self-assessment, including widening of
direct payments.10–12 The principles of recovery are
being put into practice across mental health and social care
services including specialist rehabilitation services in the
community and hospitals.
Placing recovery at the centre of mental
health services requires change in the way organisations operate
and individuals practice their profession. Patients will expect
professionals to listen to them on general life issues and provide
them with the information, skill and support needed to manage their
condition and become active and responsible in their own recovery;
they will expect help to access what they think they need to live
meaningful lives. Recovery is an important means of promoting
social inclusion and challenging marginalisation, stigma and
discrimination within health services and in the wider society.
Social inclusion is important for recovery and it is not possible
without the opportunity to be part of a community, to be a valued
member of that community, to have access to opportunities and to
contribute.
Although improvement in individual symptoms
and clinical outcomes is important and may play a key role in a
person’s recovery, the overall quality of life, as judged by the
individual, is central. There is a necessary shift of emphasis from
being clinically and professionally centred to being user- or
person-centred. With this comes an increased emphasis on the need
for satisfactory housing, employment, education, personal finances
and participation in ‘mainstream’ community and leisure activities:
each or any of these areas could become central objectives.
This approach does not undermine
professionals’ opinions nor require them to pretend that something
is possible when they genuinely believe it is not. However, they
should support people in trying to achieve the goals they set for
themselves, even if they believe the goals are not realistic. The
hopes and expectations for recovery held by service providers are
potent mediators of the opportunities of recovery for
individuals.
Confusion about the meaning of recovery,
concerns about a perceived lack of evidence about recovery-based
services and fears about risk13 have impeded the
development of recovery-orientated services.1 These need
to be addressed. We must differentiate between risks that must be
minimised (self-harm, harm to others) and risks that people have a
right to experience. In a recent report on risk management, the
College has expressed concern about forms of clinical practice that
attempt to eliminate risk.14 It is felt that
preoccupation with risk and a consequential tendency towards
risk-averse practice is stifling creativity and innovation. The
report emphasised that constructive and creative risk-taking is a
vital part of a patient’s rehabilitation and that risk-averse
practice is detrimental to this process.
Case study
3
National Initiatives on Recovery – Scotland
The
Scottish Recovery Network (SRN) is developing recovery ‘audit
tools’ for mental health nurse leads. This will complement the NHS
Education Scotland recovery training initiative for mental health
nurses. To achieve this, SRN is adapting an existing international
assessment tool – the Recovery-Oriented Practices Index – to assess
the extent to which practice is focused around the promotion of
recovery.
Case study
4
National Initiatives on Recovery – Wales
The Powys Equals Partnership have drawn
on local, national and international stories of personal recovery,
service development, tools and training to create a framework for
the inclusion of skills associated with acknowledged lived
experience (ALE) within recruitment practice of statutory and
voluntary organisations (for example, support time and recovery
workers). Day services, within the county, are developing their
capacity to support personal recovery, based on a pilot, Active
Lifestyles, in Welshpool, that draws on the themes above, and
supports people to be more active in their own
communities.
Case study
5
National Initiatives on Recovery – England
Initiatives include that of the South
London and Maudsley Foundation Trust. Their social inclusion,
rehabilitation and recovery strategy has been recently adopted. It
states that 'recovery is something the individual defines and
experiences. A mental health service cannot make someone recover,
though it can support the process. The primary aim of SLAM in its
work with service users is to support them in their
recovery'. A training programme has been developed,
field-tested and funded for roll-out and evaluation across Lambeth
and Southwark.
Case study 6
National Initiatives on Recovery – Northern
Ireland
Rethink has established a self-help
programme to support and facilitate people’s endeavours to take
active steps towards their own recovery. It is run by people who
have experienced mental illness, and people on the courses can
either self-refer or be referred by a social worker or community
psychiatric nurse. The programme operates from six centres across
South Belfast, with the intention for it to be extended to
other parts of Northern Ireland.
Making recovery a reality: developing policy implementation
guides
The Royal College of Psychiatrists is
committed to a recovery-based approach to mental health services.
In 2007, the report A Common Purpose: Recovery in Future Mental
Health Services was published with the Social Care Institute
for Excellence and the Care Services Improvement
Partnership.1 In 2008–2009, the Sainsbury Centre for
Mental Health will take this forward, with College input, in their
work programme Making Recovery a Reality. This will involve the
development of implementation guidance for NHS
trusts.1,3 Measures of recovery-orientated practice are
being developed, standards proposed and training needs identified,
and guidelines will be produced at individual, team and service
level. The College supports these initiatives.
References
1 Care Services Improvement Partnership, Royal
College of Psychiatrists & Social Care Institute for Excellence
(2007) A Common Purpose: Recovery in Future Mental Health Services.
CSIP, Royal College of Psychiatrists & SCIE.
2 Bonney, S. & Stickley, T. (2007) Recovery and
mental health: a review of the British Literature. Journal of
Psychiatric and Mental Health Nursing, 15, 140–153.
3 Shepherd, G., Boardman, J. & Slade, M. (2008)
Making Recovery a Reality. Sainsbury Centre for Mental
Health.
4 Warner, R. (1994) Recovery from Schizophrenia:
Psychiatry and Political Economy. Routledge.
5 National Institute for Clinical Excellence (2002)
Schizophrenia. Core Interventions in the Treatment and Management
of Schizophrenia in Primary and Secondary Care. NICE.
6 MacQueen, G. M., Young, L. T. & Joffe, R. T.
(2001) A review of psychosocial outcome in patients with bipolar
disorder. Acta Psychiatrica Scandinavica, 103, 163–170.
doi:10.1034/j.1600-0447.2001.00059.x
PMid:11240572
7 Killaspy, H., Harden, C., Holloway, F., et al (2005)
What do mental health rehabilitation services do and what are they
for? A national survey in England. Journal of Mental Health, 14,
157–165.
doi:10.1080/09638230500060144
8 Mountain, D. & Holloway, F. (2007) Rehabilitation
Services in the UK and Ireland: Current Status and Future Need.
Royal College of Psychiatrists.
9 Holloway, F. (2005) The Forgotten Need for
Rehabilitation in Contemporary Mental Health Services. A Position
Statement from the Executive Committee of the Faculty of
Rehabilitation and Social Psychiatry. Royal College of
Psychiatrists.
10 Department of Health (2006) Our Health, Our Care,
Our Say. Department of Health.
11 Department of Health (2006) Supporting People with
Long-Term Conditions to Self-Care: A Guide to Developing Local
Strategies and Good Practice. Department of Health.
12 Department of Health (2007) Mental Health: New ways
of Working for Everyone, Progress Report. Department of
Health.
13 Davidson, L., O’Connell, M., Tondora, J., et al
(2006) The top ten concerns about recovery encountered in mental
health system transformation. Psychiatric Services, 57,
640–645.
doi:10.1176/appi.ps.57.5.640
PMid:16675756
14 Royal College of Psychiatrists (2008) Rethinking
Risk to Others in Mental Health Services. College Report CR150.
Royal College of Psychiatrists.