Reader in Health Services Research
Institute of Psychiatry, King’s College London
Consultant Clinical Psychologist
South London and Maudsley NHS Foundation Trust, London
15 June 2011

1. What is recovery?
2. The REFOCUS Intervention
3. Recovery research challenges

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
Huber
Ciompi
Bleuler
Bonn
Lausanne
Zurich
Tsuang
Harding
Iowa
Vermont
Ogawa Japan
Marneros Cologne
DeSisto Maine
Harrison 18-site
Yr n F-up Recovered /
(yrs)
1975 502 22 sig. improved
(%)
1976 289 37
1978 208 23
1979 186 35
1987 269 32
1987 140 23
1989 249 25
1995 269 35
2001 776 25

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.

Recovery involves living as well as possible.
South London and Maudsley NHS Foundation Trust (2010)
Social Inclusion and Recovery (SIR) Strategy 2010-2015 ,
London: SLAM.

CLINICAL RECOVERY
- focus on professional imperatives
- partly operationalised
- not highly concordant with consumer views
PERSONAL RECOVERY
- focus on personal meaning and purpose
- not operationalised for research purposes
- ideological and oppositional, not empirical

Keep people safe, stop them coming to harm: versus let them be autonomous and make their own decisions.
People want help and advice, versus they want to be able to decide their own future
Society must be protected from mad people: versus vulnerable people must be protected from society
A wide range of treatment options should be available, versus everything must be regulated.
Whitwell D (2005) Recovery Beyond Psychiatry . London: Free Association Books.

1. Epistemological
2. Ethical
3. Empowerment
4. Effectiveness
5. Policy
Cambridge University Press, 2009

Personal recovery is established policy in most
Anglophone countries
Developing in German-speaking countries
Amering M, Schmolke M (2009)
Recovery in mental health – reshaping scientific and clinical responsibilities
London: John Wiley.

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

Slade M (2009) 100 ways to support recovery , London: Rethink.
Free to download: rethink.org/100ways

Funder: NIHR Programme Grant for Applied
Research RP-PG-0707-10040
£2m, 2009-2014
ISRCTN02507940

MRC Framework for
Development / Evaluation of
RCTs for Complex Health
Interventions
Exploratory
Trial
Modelling
Theory
Definitive
RCT
Long-term
Implementation
Pre-clinical Phase I Phase II Phase III Phase IV
Campbell M et al (2000) Framework for design and evaluation of complex interventions to improve health , BMJ, 321 , 694-696.

Define the problem
Optimise the intervention
Optimise the evaluation
Optimise trial parameters
Campbell N et al (2007) Designing and evaluating complex interventions to improve health care , BMJ, 334 455-459.

Mental health services are insufficiently recovery orientated, but the extent of the problem is unknown.
• Systematic review of recovery
• Document analysis of guidelines
• National survey
• Focus groups
• Individual interviews

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

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

Review the evidence for pro-recovery interventions using four criteria: a) clinical effectiveness b) cost-effectiveness c) meaningfulness d) feasibility for implementation in the NHS.
Develop a manualised intervention

Bird V et al (2011) REFOCUS: Promoting recovery in community mental health services , London: Rethink.
Free to download: researchintorecovery.com/refocus

 Understanding values
 Assessing strengths
 Supporting goal-striving
Process of care
 Developing recovery promoting relationships
 Service user partnership project
 Creating expectations among service users

Intervention
Practice change
Relationships
Service user experience
Service user outcome
Working practices
Values – Strengths - Goals
Values
Knowledge
Skills
Intent
Behaviour
Content
Process
Proximal
Hope – Empowerment - Quality of life
Distal
Personal recovery

1. Partnership strategies
2. Personal recovery training
3. Coaching and working practice training
4. Team manager reflection group
5. Team reflection sessions
6. Supervision reflection

• Two systematic reviews
– measures of personal recovery
– measures of recovery orientation
• Development of new measure
– researchintorecovery.com/recovery
• Psychometric evaluation of QPR and RSA
• PPO/GS

• Cluster randomised controlled trial
• 30 teams, psychosis diagnosis
• Fidelity assessment
• Process evaluation
• Outcome evaluation
– predefined primary and secondary outcomes
– resource consequences
– individualised outcomes

• Epistemological
– Paradigmatic clash
– Nomothetic vs idiographic knowledge
• Conceptual
– Positioning the study
– Manualising an individualised intervention

• Organisational
– Training is not enough
– Organisational buy-in
• Methodological
– Current measures
– Predefined clinical endpoint
– Incorporating lived experience
Slade M et al (2010) The contribution of advisory committees and public involvement to large studies: case study. BMC Health Services Research, 10 , 323.