100 waysto supportrecovery.A guide for mental health professionalsby Mike SladeSECOND EDITIONRethink Mental Illness. 1
Who we areRethink Mental Illness is a charity that believes a betterlife is possible for millions of people affected by mentalillness. For 40 years we have brought people together tosupport each other. We run services and support groupsacross England that change people’s lives and wechallenge attitudes about mental illness.ContentsIntroduction5Section one: What is personal recovery?8Section two: The central importance of relationships11Section three: The foundations of a recovery orientedmental health service16Section four: Assessment18Section five: Action planning24Section six: Supporting the development ofself-management skills25Section seven: Recovery through crisis31Section eight: Recognising a recovery focus in mentalhealth services33Section nine: Transformation of the mental health system35Appendix one: Electronic resources to support recovery36Appendix two: References372 Rethink Mental Illness.
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ForewordAt Rethink Mental Illness we are working hard to improve the lives of peoplewith mental illness, and reforming the way mental health services are run is key.This book offers 100 practical ways in which mental health staff can work in aperson-centred and recovery-oriented way.Since the first edition was published in 2009, ithas been downloaded over 23,000 times from theRethink Mental Illness website (rethink.org/100ways)and been translated into several Europeanlanguages. This second edition references newemerging evidence and includes updated links torelevant resources.In the few years since the publication of the firstedition, attention to mental health recovery hasfurther matured. Recovery has become an integratedaspect of everyday practice in mental health serviceprovision, and new policy-driven developments suchas Personalisation and Personal Health Budgets havebeen introduced to support person-centred working.Professor Mike Slade, the report author, is aconsultant clinical psychologist with SouthLondon and Maudsley NHS Foundation Trust anda Professor of Health Services Research at theInstitute of Psychiatry, King’s College London. Histeam of researchers are in the final phase of theirfive year REFOCUS research trial (due to completein 2014), which is developing and evaluating amanualised recovery intervention for use within adultmental health community based teams in England.But still much needs to be done. In 2012 theSchizophrenia Commission reported their findingsbased on a comprehensive review of currentevidence and practice, and they identified areasthat need improvement to make sure people get thesupport and treatment that will make a real changein people’s lives (schizophreniacommission.org.uk).This updated second edition of 100 ways to supportrecovery offers a practical tool for mental health staffto support this work.Paul JenkinsChief Executive, Rethink Mental IllnessApril 20134 Rethink Mental Illness.
IntroductionThis is a guide for mental health staff, which aims to support the developmentof a focus on recovery within our services. It provides different ideas for workingwith service users* in a recovery oriented fashion.It is written on the basis of two beliefs: First, recovery is something worked towards andexperienced by the person with mental illness. Itis not something services can do to the person.The contribution of staff is to support the person intheir journey towards recovery. Second, the journey of recovery is individual. Thebest way of supporting an individual’s recovery willvary from person to person.Since there is no ideal or ‘right’ service, it is notpossible to provide step-by-step instructions for howrecovery can be supported by mental health staff.This guide therefore provides a map, rather than aturn-by-turn journey plan.At the heart of this report is a conceptual frameworkto identify what types of support may be useful.It is called the Personal Recovery Framework andis based on the accounts of people who havepersonal experience of mental illness. Translating thisframework into practice is the goal of this publication.* Whilst recognising the term is contested, we refer to ‘service users’ because our focus is on people with personal experience ofmental illness who are using services.Rethink Mental Illness. 5
Second editionSince the first edition of 100 ways to support recovery was published in2009, it has been downloaded over 23,000 times from the Rethink MentalIllness website (rethink.org/100ways).Not much has changed since 2009 in ourunderstanding of recovery which emerges frompeople’s stories – living a life beyond illness remainspossible for many people when active striving isaccompanied by good support. However, a newevidence base is emerging in the academic mentalhealth literature.For example, the Section for Recovery at theInstitute of Psychiatry has undertaken severalrecovery studies – see researchintorecovery.comfor more information. This has included systematicreviews (the most rigorous method for synthesisingevidence) which identified key recovery processesof Connectedness, Hope, Identity, Meaning andEmpowerment (the CHIME Framework)1, how toassess recovery2, how to identify strengths3, andhow to increase hope4.Mike Slade6 Rethink Mental Illness.It is now possible to identify best practice for mentalhealth services in supporting recovery5. Measures toidentify good recovery support have been evaluated6,leading to the development of a new free measurecalled INSPIRE (researchintorecovery.com/inspire).Interventions to support recovery are beingdeveloped7 and evaluated8, and national initiativesto transform mental health services are underwayacross England9. In all these developments, RethinkMental Illness has been a guide and a partner. Thissecond edition of 100 Ways to support recovery hasbeen updated to reflect this emerging evidence base.
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Section one: What is personal recovery?Recovery is a word with two meanings.Clinical recovery is an idea that has emergedfrom the expertise of mental health professionals,and involves getting rid of symptoms, restoringsocial functioning, and in other ways ‘getting backto normal’.Personal recovery is an idea that has emergedfrom the expertise of people with lived experiencedof mental illness, and means something different toclinical recovery. The most widely used definition ofpersonal recovery is from Anthony (1993)10: a deeply personal, uniqueprocess of changing one’sattitudes, values, feelings,goals, skills, and/or roles. Itis a way of living a satisfying,hopeful, and contributing lifeeven within the limitationscaused by illness. Recoveryinvolves the development ofnew meaning and purpose inone’s life as one grows beyondthe catastrophic effects ofmental illness.It is generally acknowledged that most mental healthservices are currently organised to meet the goal ofclinical recovery. Yet mental health policy around theworld increasingly emphasises support for personalrecovery. For example, in England a central goal ofthe 2011 national mental health strategy was “Morepeople with mental health problems will recover”.11How do we transform services towards a focus onpersonal recovery? This report identifies 100 differentways, starting with a conceptual framework tounderpin the transformation.8 Rethink Mental Illness.Box 1: Personal Recovery TasksRecovery task 1: Developing a positiveidentity The first task of recovery isdeveloping a positive identity outside of being aperson with a mental illness. Identity elementswhich are vitally important to one person may befar less significant to another, which underlinesthat only the person can decide what constitutesa personally valued identity for them.Recovery task 2: Framing the ‘mentalillness’ The second recovery task involvesdeveloping a personally satisfactory meaning toframe the experience which professionals wouldunderstand as mental illness. This involvesmaking sense of the experience so that it can beput in a box: framed as a part of the person butnot as the whole person. This meaning might beexpressed as a diagnosis, or as a formulation,or it may have nothing to do with professionalmodels – a spiritual or cultural or existential crisis(hence the quotes in the task title).Recovery task 3: Self-managing themental illness Framing the mental illnessexperience provides a context in which itbecomes one of life’s challenges, allowingthe ability to self-manage to develop. Thetransition is from being clinically managed totaking personal responsibility through selfmanagement. This does not mean doingeverything on your own. It means beingresponsible for your own well-being, includingseeking help and support from others whennecessary.Recovery task 4: Developing valuedsocial roles The final recovery task involves theacquisition of previous, modified or new valuedsocial roles. This often involves social roleswhich have nothing to do with mental illness.Valued social roles provide scaffolding for theemerging identity of the recovering person.Working with the person in their social contextis vital, especially during times of crisis whensupport usually received from friends, family andcolleagues can become most strained.
1.1 The Personal Recovery FrameworkSupporting personal recovery involves movingaway from a focus on treating illness and towardspromoting well-being. This will involve transformation,in which professional models become part of a largerunderstanding of the person. This understandingcan be guided by the Personal Recovery Frameworkwhich is based on the four domains of recovery thatemerge from accounts of people who have lived withmental illness12: Hope as a frequent self-reported componentof recovery Self-identity, including current and futureself-image Meaning in life, including life purpose and goals Personal Responsibility – the ability to takepersonal responsibility for one’s own life.The Personal Recovery Framework (shown inFigure 1) is based on four recovery tasks commonlyundertaken during recovery (shown in Box 1). Theseare loosely ordered, to suggest a general but notuniversal ordering from belief to action and frompersonal to social.The arrows indicate that recovery involves minimisingthe impact of mental illness (through framing andself-managing) and maximising well-being (bydeveloping a positive identity and valued social rolesand relationships).A personal recovery-oriented mental health serviceis organised to support individuals to undertake thefour recovery tasks, underpinned by an emphasison relationships. The central differences betweenrecovery-oriented and traditional practice have beenconsidered by several authors with experience oftrying to implement pro-recovery service change13-17,and some points of variation are shown in Table 1.Figure 1: The Personal Recovery FrameworkSOCIAL ‘Mentalillness’ partDevelopingvalued socialrolesDevelopinga positiveidentityFraming andself-managingRethink Mental Illness. 9
Table 1: Differences between traditional and recovery-oriented servicesTraditional approachRecovery approachValues and power arrangements(Apparently) value-freeValue-centredProfessional accountabilityPersonal responsibilityControl orientedOriented to choicePower over peopleAwakens people’s powerBasic ychopathologyDistressing experienceDiagnosisPersonal meaningTreatmentGrowth and discoveryStaff and patientsExperts by training and experts by experienceKnowledge baseRandomised controlled trialsGuiding narrativesSystematic reviewsModelled on role modelsDecontextualisedWithin a social contextWorking practicesDescriptionUnderstandingFocus on the disorderFocus on the personIllness-basedStrengths-basedBased on reducing adverse eventsBased on hopes and dreamsIndividual adapts to the programmeProvider adapts to the individualRewards passivity and complianceFosters empowermentExpert care co-ordinatorsSelf-managementGoals of the serviceAnti-diseasePro-healthBringing under controlSelf-controlComplianceChoiceReturn to normalTransformationSince personal recovery is something the individual experiences, the job of staff is to support the person intheir journey towards recovery. The remainder of this report describes what this means in practice.10 Rethink Mental Illness.
Section two: The central importance of relationshipsThis section begins to detail the 100 ways mental health staff can supportrecovery. It focuses on relationships – with peers, with staff and with others.2.1 Supporting peer relationshipsPeople with their own experience of mental illness(‘peers’) can directly contribute to the recoveryof others18-20. Meaningful peer involvement isassociated with innovative recovery-oriented servicesinternationally. There are three types of peer supportfor recovery.2.For other staff, their presence leads to increasedawareness of personal values. Interacting withpeer colleagues challenges stigmatising themand-us beliefs within services in a natural ratherthan forced way.3.For other service users, exposure to peersupport specialists provides visible role modelsof recovery – a powerful creator of hope. Theremay also be less social distance than with staff,leading to more willingness to engage withservices.4.For the mental health system, peer supportspecialists can be carriers of culture. There isoften less need to train and maintain a prorecovery orientation in recovered serviceusers and ex-users, because of their own livedexperience.1: Mutual self-help groupsMutual self-help groups give primacy to livedexperience, leading to structures based on theassumption that all participants have something tocontribute.2: Peer Support SpecialistsThe peer support specialist is a role in the mentalsystem for which personal experience of mentalillness is a job requirement. Creating peer supportspecialist r