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Relapse and Recovery

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Nicole Stokoe

on 21 April 2017

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Transcript of Relapse and Recovery

Overview of Session
- Introductions
- Group Task: What is relapse and recovery?
- Teaching:
1. Brief history of recovery conceptualisations
2.Current understanding and the recovery model


- Group Task: Why are client goals and values important?

Group task: What are the ingredients for recovery
- Role Plays: Talking about recovery with clients

Your name

Your area of interest

Have you used the Recovery Model
in your work before?

Group Task
History of the Recovery Model
From Asylums to Recovery, Strengths and Equality
Closure of Mental Health Hospitals and the Perception of Mental Illness

Things started to change with:
- Antipsychiatry movement
- Feminist criticism
- Ex-patient activism

Foucault (1926 - 1984) - We create the narrative around what is 'normal'

Rosenhan experiments (1973) - "On being sane in insane places"

Closure of mental health hospitals 1970s-1980s based on a mixture of financial reasons, the development of new anti-psychotics that could be taken at home, Goffman's (1961) theory of institutionalisation and reform campaigners.

Movement toward treating patients in the least restrictive environment, ideally in the community.

The Recovery Model
What is the Recovery Model?
The recovery model is an integrative framework combining evidence based practice, competencies for delivering psychosocial skills and the individualised/subjective experience of the service user. (Oades, Deane, Crowe, Lambert & Cavanagh, 2005).

What does it focus on?
"Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems" (Salisbury Centre for Mental Health)

What does it aim to do?
“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, 1993)

Recovery in this context does not necessarily mean cure
Andresen, Caputi and Oades (2006)

: a time of withdrawal characterised by a profound sense of loss and hopelessness

: realisation that all is not lost and that a fulfilling life is possible

: Taking stock of strengths and weaknesses regarding recovery and starting to work on developing recovery skills

: actively working towards a positive identity, setting meaningful goals and taking control of one’s life

: living a meaningful life, characterised by self-management of the illness, resilience and a positive sense of self
Is it for everyone?
Davidson & Roe (2007) suggest that many people may appear unwilling to engage with recovery because of the severity of their symptoms, their negative experiences of mental health care, the intolerable side effects of medication, or the simple fact that it is sometimes too painful and costly for them to begin to acknowledge that they need the kind of help that is being offered. (Salisbury Centre for Mental Health, p.4)
The Recovery Approach in Practice
Relapse and Recovery
Dr Nicole Stokoe
Community Adult Mental Health, Portsmouth

All the 1s, 2s and 3s get together in groups and discuss for 10 minutes:

Group 1
What is relapse? How do we know when a person has relapsed? At what point does this happen?

Group 2
What is recovery? How do we know when a person has recovered? At what point can we say someone is ‘recovered’?

Group 3
To whom do the terms relapse and recovery relate to? Is everybody 'recovering' in some way?
"Moral treatment" was introduced in 1790 by William Tuke
Medical/biological model of mental health - wide use of lobotomy, ECT, straight jackets, sedatives (such as bromides) as behaviour control mechanisms
The stages of change (Prochaska and DiClemente, 2005), motivation and motivational interviewing
Group Task

Why are goals and values important when talking about recovery with patients?
What will support a person in their recovery journey? How do the words hope, empowerment, opportunity and self-management/agency relate to recovery?
Seeing recovery examples
Self Management
"Therapists are there to be on tap not on top"
Social Inclusion
Meaningful activity
Rediscovering Identity
Role plays in threes

Practice talking to a client about the idea of recovery (10 mins)
Group Approaches

Wellness Recovery Action Planning
(Mary Ellen Copeland)

Participants come together to talk about:
Wellness Toolbox
Daily Maintenance Plan
Identifying Triggers
Identifying Early Warning Signs
Identifying When Things Are Breaking Down
Crisis Planning
Post Crisis Planning

Recovery College
872 AD first records - Institution in Cairo where music therapy was used.
Lost and neglected wanderers of society

Physically contained and restrained

Physically contained and biologically restrained

Community treatment

Community living/living with

Changes in the Perception of Mental Health
1 in 4 will experience a mental health difficulty in their life time

Recent survey of mental health staff in Solent showed approx 60% reported experiencing mental health difficulties themselves

There are a number of high profile people throughout history who had great achievements despite living with mental health difficulties for example:
Anthony W: Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal 16(4):11–23, 1993
The Recovery Model and Ownership
"The recovery model emphasizes that responsibility for and control of the recovery process must be given in large part to the person who has the condition." (Freese, Stanley, Cress & Vogel-Scibilia, 2001).
The Recovery Model cont
Frese, F. J., Stanley, J., Kress, K., & Vogel-Scibilia, S. (2001). Integrating evidence-based practices and the recovery model. Psychiatric Services, 52(11), 1462-1468.
Oades, L., Deane, F., Crowe, T., Lambert, W. G., Kavanagh, D., & Lloyd, C. (2005). Collaborative recovery: an integrative model for working with individuals who experience chronic and recurring mental illness. Australasian Psychiatry, 13(3), 279-284.
Stages of Recovery Instrument - STORI (Andreson, Caputi & Oades, 2006)
Andresen, R., Caputi, P., & Oades, L. (2006). Stages of recovery instrument: development of a measure of recovery from serious mental illness. Australian and New Zealand Journal of Psychiatry, 40(11‐12), 972-980.
Andresen, R., Oades, L. G., & Caputi, P. (2011). Psychological recovery: Beyond mental illness. John Wiley & Sons.
Research on the implementation of recovery models
- Recovery model training to professionals has been shown to increase the language of hope, recovery, ownership and multidisciplinary in care plans (Gilburt, Slade, Bird, Oduloa & Craig, 2013)
- Recovery orientated teams showed higher expectations of recovery, greater consumer involvement and goal directed content, less use of control mechanisms, conveying hope and choice. (Salyer et al, 2013)
Gilburt, H., Slade, M., Bird, V., Oduola, S., & Craig, T. K. (2013). Promoting recovery-oriented practice in mental health services: a quasi-experimental mixed-methods study. BMC psychiatry, 13(1), 167.
Salyers, M. P., Stull, L. G., Rollins, A. L., McGrew, J. H., Hicks, L. J., Thomas, D., & Strieter, D. (2013). Measuring the recovery orientation of assertive community treatment. Journal of the American Psychiatric Nurses Association, 19(3), 117-128.
......but does this translate into improvements for service users?
- How long do you see yourself being with mental health services?

- So what would recovery look like to you?
(But if you did know, what would it look like? Miracle question)

- What steps would we need to take to move towards you being more in control of your life?

- What steps would we need to take so that you wouldn't need us anymore?

- How does it feel when we talk about you leaving services?
Group 1 - new client – first episode of mental health difficulties

Group 2 – long term mental health difficulties

Group 3 – at the beginning of therapy

Group 4 – in the middle of therapy

Group 5 – at the end of therapy
In Pairs:
WRAP early warning signs exercise
The Five Stages of Recovery
Recovery College
A series of courses offering basic skills. For example:

1. Holding the hope
2. Working in partnership
3. Recovery star
4. Goal setting
5. Finding meaning and purpose
6. Personal responsibility
7. Self advocacy
8. Nourishing wellness
9. Environment and wellness
10. Being effective
The Continuum Model
(Keyes, 2005)
The Role of Relapse and Recovery

Keyes, C. L. (2005). Mental illness and/or mental health? Investigating axioms of the complete state model of health. Journal of consulting and clinical psychology, 73(3), 539.
Developing your own WRAP
- Wellness Wheel
- Triggers
- Early Warning Signs
- When things are breaking down
- Crisis Planning
- Mini WRAP

The Research
Your Wellness Toolbox
Developing your wellness wheel:

-What keeps you well day to day?
- What do you need to do each week to keep you well?
- What do you need to do each month to keep you well?
What are your Triggers?
What are your early warning signs?
Round the room there are some ideas about what your early warning signs might be
Crisis Plan and Mini Wrap
What is a crisis plan?

Completing your own mini WRAP
Post Crisis and Recovery
What top tips and advice would you give to someone in recovery?
The Research
Kings College London run a research programme on recovery in mental health: http://www.researchintorecovery.com/what-is-recovery-and-wellbeing

They also have a recovery network your can join.
RCT evaluation of outcomes for participants (n=519) at eight outpatient community mental health centres in an eight-week peer led intervention, compared with usual care and wait-list for WRAP, showed benefits in symptom profile, hope and quality of life
WRAP research
Cook JA, Copeland ME, Jonikas JA et al. Results of a randomized controlled trial of mental illness self-management using Wellness Recovery Action Planning. Schizophr Bull 2012;38:881-91
CHIME Framework
ope & Optimism
eaning & Purpose
Leamy M, Bird V, Le Boutillier C et al. A conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. Br J Psychiatry 2011;199:445-52
Recovery Colleges
Perkins R, Repper J, Rinaldi M et al. ImROC 1. Recovery Colleges. London: Centre for Mental Health, 2012
The REFOCUS intervention increases the recovery orientation of community adult mental health teams
Staff are trained and supported through reflection sessions and supervision to use three working practices
- Person centered care planning
- Standardised assessment
- Goal striving in the valued direction
The REFOCUS intervention is being evaluated in a multisite cluster RCT
Slade M, Bird V, Le Boutillier C et al. REFOCUS Trial: protocol for a cluster randomised controlled trial of a pro-recovery intervention within community based mental health teams. BMC Psychiatry 2011;11:185.
Current overview of empirical evidence and mis-uses of recovery:

Slade M, Amering M, Farkas M, Hamilton B, O'Hagan M, Panther G, Perkins R, Shepherd G, Tse S, Whitley R (2014) Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems, World Psychiatry, 13, 12-20.
1950's Reduction in the use of lobotomy and shock therapy

1960's Medication came into widespread use 'enabling' community treatment

1970's Women's movement, gay rights and disability rights movement

1980's The movement from passive patients to active consumers, self help and advocacy groups
Wellness Recovery Action Planning
Initial outcomes suggest improvements in symptoms, hopefulness, self advocacy and physical health (Cook et al, 2015)
Recovery Model Research Outcomes
Cook, J. A., Copeland, M. E., Hamilton, M. M., Jonikas, J. A., Razzano, L. A., Floyd, C. B., ... & Grey, D. D. (2015). Initial outcomes of a mental illness self-management program based on wellness recovery action planning. Psychiatric Services
Group Recovery Workbook Approach
Improved perceived sense of hope, empowerment and recovery (Barbic, Kruper & Armstrong, 2015)

Barbic, S., Krupa, T., & Armstrong, I. (2015). A randomized controlled trial of the effectiveness of a modified recovery workbook program: preliminary findings. Psychiatric Services.
Research is limited at present. So there is plenty of scope for undergraduate research opportunities.
Recovery Star and CROS
Measures for empowering recovery
(Dickens et al, 2012)
Dickens, G., Weleminsky, J., Onifade, Y., & Sugarman, P. (2012). Recovery Star: validating user recovery. The Psychiatrist Online, 36(2), 45-50.
The Anti-Psychiatry Movement Today

The role of social constructionism

Thomas Szasz: Founder of the anti-psychiatry movement over 60 years.
Full transcript