RECOVERY an overview

1. RECOVERYan overview Prof.dr. Chantal Van Audenhove KU.Leuven GAMIAN Budapest may 28th 2011

2. Content • Recovery: what is it ? • Why now? • New trends in society • Towards balanced care in mental health • What helps and what hinders in care ? • Evolutions to recovery-oriented mental health services and organisations • Challenges for the future

3. The concept of recovery 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 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. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s

4. The concept of recovery Recovery is what people with disabilities do. Treatment, case management and rehabilitation are what helpers do to facilitate recovery. Successful recovery from a catastrophe does not change the fact that the experience has occurred, that the effects are still present.. It means that the person has changed and that the meaning of these facts to the person has therefore changed. They are no longer the primary focus of one’s life. The person moves on to other interests and activities. Anthony, 1993. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s

5. Basic assumptions • Recovery can occur without professional interventions • A common denominator of recovery is the presence of people who believe in and stand by the persons in need of recovery • A recovery vision is not a function of one”s theory about the causes of mental illness • Recovery can occur although symptoms reoccur • Recovery changes the frequency and the duration of symptoms • Revovery does not feel like a linear process • Recovery from the consequences of mi is sometimes more difficult than recovering from the illness itself • Recovery from mi does not mean that one was not “really mentally ill”

6. Recovery as a process(Young & Ensing, 1999) Stabilisation Re-orientation Re-integration Control over symptoms and reducing the suffering Pharmaco-therapy Medication management Need for support and safety Exploring the consequences of illness Mourning process Psycho education Symptom management Making plans for the future Take on or restore meaningful relations of roles Return to a normal existence Practice skills Reinforce self-confidence Engage in activities

7. Key elements of the process: Personal aspects Person orientation : sense of self Person involvement : attitude change Self-determination : Choice Hope Role of society Social relations Social roles and functions in work and education Existential aspects Objectives at a higher level

8. Pat Deegan “The aspiration of people with disabilities is to live, work and love in a community in which one makes a significant contribution” (Deegan, 1988)

9. WHY NOW ?

10. New trends in care Offer • New care forms: • Alternatives to admission and transitional forms arise on top of the residential offer • Increasingly scientific focus of care (evidence-based) • Fading barriers between health care and social care • Position HCP: • Increased specialisation • Expert position • Decreased interest in general care professions • Increasingly equal accessibility of education • “Territorial wars”

11. International trends in mental health care since 2000 • Also: • Promotion of evidence-based psychiatry in pharmacological, social and psychological treatment • Increase in personal contribution in treatment and care • Emphasis on efficiency and cost reduction Deïnstitutionalisation comes to completion Decrease in number of hospital beds slows down Large institutions are being replaced by smaller ones Increased recognition of the role for families and concern about the balance between controlling the patient and their autonomy Re-allocation of health care providers to home care New emphasis on team work

12. “Balanced care” Equitable care with a large spectrum of health care organisations in society, to provide all care necessary without the negative impact of a hospital admission: in natural environment mobile oriented towards symptoms and limitations specific care for diagnoses and problems in accordance with the international convention on human rights focused on the users’ priorities coordinated

13. Example of balanced care Bron: Substance Abuse and Mental Health Services Association (www.SAMSHA.gov) Front line health care with specialised support, in which all areas of life and partners are given a place “Community integration and personal empowerment”

14. Trends in care and social wellfare • Younique: more differences between consumers • Power to the Patient: more do-it-yourself approach • The sky is the limit: high quality expectations • Afraid for care: anxiety by unsafety and complexity • Healthy Grey Societies: lifelong vitality • Everybody patient : more frequently chronic illness • Health as a choice : more attention for lifestyle • Prevention: high priority • Care without borders: globalising health • Googleritis: digitalisation of consumer-provider interaction • One-to-One: more direct treatment with medical technology • Caring is Sharing: more transparancy in knowledge and competency • Greener care: towards sustainable care • Saving lives, saving costs: more business, market and entrepreneur attitudes • Who cares for me? More demand, less provision on the labour market • Transition: reorganising the care chain • The bill please : more demand more costs … Idenburg en Van schalk 2010

15. Diversitity in care users and differing demands Bigger diversity Global 3 types • Less empowered users (49%): Difficulties with responsibility and choice • Pragmatic care users (41%): Trust in new technologies, empowered, high achievement motivation, wanting to make own choices or to participate • Society critical users (10%): Critical and assertive, against individualisation (Motivaction VWS Amsterdam 2005, in Idenburg en van Schalk)

16. An ideology ?

17. “The Diamond of Change”(M. Kmita 2005) Users of servicesrole of service providers accepted, self-actualisation, fight against stigma and powerlessness Citizenship Human rights, responsibilities, participation and inclusion in society Patients Victims, passive receptors of care and treatment, receive care from experts who know what is the right thing to do “The Mad”dangerous persons, excluded from society STIGMA

18. Implications for treatment Self-help and informal help (peer support) gain importance Professional support not necessary, but can be a facilitator Administrator of property home owner psychiatrist • Many other organisations potentially involved apart from mental health care day centre caregiver client PsyCoT domestic help pharmacist family support friend

19. Paradigms in the therapeutic relationship Chronicity Diagnostic category Pessimism Dysfunctions Fragmented model Paternalism Professional care Power and submission Articial environment Stabilisation Helplessness Herstel Individualisation Hope, realistic optimism Strengths, resilience Bio-psycho-social model User oriented Self help, expertise by experience Empowerment, choice Natural support, peer support Growth, calculated risk Self determination (Onken e.a., 2002)

20. Key components in helping relationships ‘Helping to keep hope alive‘ Balanced, client-oriented He didn’t have his own programs that I had to go through I was the one who decided what to talk about Human, respectful He was not afraid to tell me that he didn’t understand how I feel Available every day helpers I could talk about anything, not only problems I didn’t need much helpers, but a few good helpers over time, someone who can keep it up, who’s there, who stuck with me all these years Therapeutic With him, I found confidence, the charisma that he had made me dare to look at my life and talk about it

21. Key components in helping relationships But also: Breaking the rules He lent me some money over the weekend (because my welfare check would not come through the next Monday) he accepted my present (and allowed me the chance to offer something to someone else) Good chemistry We got on with each other very well, she was like a friend (Borg & Kristiansen, 2004)

22. Ten tips for recovery oriented practice 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? (Shepherd, Boardman & Slade 2008)

23. Barriers to recovery Loss of rights and equal treatment Discrimination in employment and housing Care systems that provide few possibilities of choice and undermine a sense of control and mastery

24. System standards • Mission: define the offer in terms of recovery • Evaluation: role functioning from different perspectives • Leadership: recovery not only in print and words but also in practice • Management: programmes, protocols, action-oriented processes of change, evaluations, ... • Integration: goals set by the users are the starting point for all organisations involved

25. System standards • Extensiveness: functioning in housing, work, school, social environment, ... • Involvement of patients and family: user-led organisations and self-help • Cultural relevance: appropriateness for other cultural groups • Advocacy: lobbying so that users can fully take part in life in society • Education and training: focused on introducing and implementing recovery-oriented practice • Financing: user needs-based, priority of patients: priority of processes • Accessibility: preference of patient is crucial

26. Challenges for the future • Paradigma shift in care • New organisational contexts • Research on recovery • Changes in society

27. New competencies • Patient centered practice • Shared decision making • Psycho-education • Promotion of selfhelp and illness management • … To help people on their way to recovery

28. New organisations • Guided by the recovery paradigm Combined with • Evidence based practice

29. Research on recovery • What helps people on the way to recovery? • How are interventions stimulating or hindering: • Shared decision making • Motivational interviewing • Self management • Matching the person of the counselor • Etc…

30. Changes in society • Accepting communities • Fight against stigma and self-stigma • Inclusion in work environments • Participation in care services

31. Leonard Cohen sings... Ring the bells that still can ringForget your perfect offeringThere is a crack in everything,That's how the light gets in Thank you for your attention