Recovery

1. Recovery Miles Rinaldi Head of Recovery

2. What is recovery? Recovery is about getting your life back Building a new sense of self, meaning and purpose Hanging on to and/or rebuilding a meaningful, satisfying and contributing life Growing within and beyond what has happened to you Realising your ambitions “…a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and roles…The development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness’ (Anthony 1993)

3. There is no formula for recovery everyone must find their own way Hope Believing that a decent life is possible Hope-inspiring relationships Control and self-determination Getting back into the driving seat of your life: becoming an expert in your own self care, deciding what is important to you and where you want to go in life Opportunity and citizenship The opportunity to do the things you value and participate as an equal citizen in all facets of community life

4. What is recovery? Recovery is about getting your life back Building a new sense of self, meaning and purpose Hanging on to and/or rebuilding a meaningful, satisfying and contributing life Growing within and beyond what has happened to you Realising your ambitions “…a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and roles…The development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness” (Anthony 1993)

6. “Man’s search for meaning is the primary motivation in his life…and concern about a meaning of life is the truest expression of the state of being human.” Victor Frankl

7. Recovery People should be able to build a meaningful life for themselves, and should be supported to take control of and manage their own condition. Do the people you see through NHS mental health services… • Understand what is important to you in your life? 74% • Help you with what is important to you? 61% • Involve you as much as you want in discussing your care? 72% CQC (2017) Community Mental Health Survey: SWLStG

8. Care Planning… NICE (2011): Quality standard 8 • ‘People using mental health services jointly develop a care plan with mental health professionals, are given a copy with an agreed date to review it. • Care Plans should include things that matter to the person such as employment, education, leisure activities etc. • Provide support to help the person realisethe plan’. • However, care plans primarily focus on people’s risk, their illnesses, the problems they experience (Gould, 2013; Faulkner 2017).

9. Crisis planning…

10. Simon Simon has a diagnosis of schizophrenia and lives independently in his flat. He hears voices and describes them as being rude, critical and abusive. He has trouble keeping track of thoughts and conversations and finds it hard to concentrate. As a result he has difficulty interacting with people in social settings and tends to withdraw spending the majority of time on his own in his flat. Simon would like to gain more control over his life and has identified two recovery goals which are important to him: to give up smoking and to get a job. He receives support from his family and his care co-ordinator visits him every two weeks for an hour. Due to medication Simon finds he needs to sleep for approx12 hours a day.

11. Reality for Simon • 1 hour visit from care co-ordinator x 26 weeks a year = 26 hours • 12 waking hours per day x 365 days a year = 4380 hours • % of time receives support from care co-ordinator over a year = 0.6% • % of time Simon does not receive support over a year = 99.4% Simon spends just a few hours a year in contact with health and social care services. The reality is Simon is self-managing his mental health condition 99.4%of the time.

12. Self-management “What’s important to you?” Agenda setting, Action planning, Follow-up • Importance • Confidence • Ask before advise • Explore ambivalence • Problem solve

13. Adapted by Rinaldi & Potter (2010) from Baile, et al. (2000). SPIKES--A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. Oncologist, 5(4), 302-311.

14. South West London Recovery College • An educational facility providing recovery focused education and self-management training. • Empowering people to recognise, develop and make the most of their talents and resources to become experts in their own self-care and do the things they want to do in life. • Educational and coaching model – not a therapeutic model • Expert trainers: mental health practitioners & peer trainers • Fully integrated into the care pathways for people using mental health services

15. In 2017/18 • A total of n=1,029 students attended the Recovery College • 59% people using secondary MH services, 29% primary care MH services, 8% carers/families and 4% staff Most popular courses: • Five ways to wellbeing • Introduction to mindfulness • Introduction to Recovery • Taking Back Control (self-management training programme) • Introduction to relaxation and meditation

16. Processes occurring Who am I? 2. What are my strengths, values and dreams? 3. What is the context that I find myself in? 4. What kind of person am I seeking to become? 5. Bringing it all together

17. PROM: Hope, Agency and Opportunity N=280

18. Health Service Usage χ2  =  385.207,df=1, P = 0.00001 Impact: £1 invested in the Recovery College delivers £1.24 of savings

19. Care co-ordinators experience • Care Co-ordinators experience • 64% response rate (n=47) • 66% (n=31) had experience of service users from their caseload attending courses • Rated service user experience at a mean of 7/10 • No significant differences between those who had experience of service users from their caseload attending courses and those who had not by borough, profession, gender or length of time as a Care Co-ordinator.

20. Care Co-ordinators and self-management

22. Hope ‘My Psychiatrist suggested that I might find it useful to speak to an employment specialist about my situation. I don’t think that I had any idea of what to expect from this referral but simply being asked the question made me feel like I might still have a working future.’

23. Control and Hope I was diagnosed with schizophrenia two years ago. During the initial periods of my recovery I had very low self-esteem and no confidence. Despite that I told my key worker I wanted help to get into employment. My key worker introduced me to the employment specialist. I started meeting my employment specialist regularly. When I got an interview he helped me prepare for it . Throughout this period although I did not have much believe in myself and my skills, the belief that my employment specialist had in me kept me going.  I got the job.

24. Work? • Work is “…nature’s physician …essential to human happiness” - Galen AD172 • People need two things – love and work. Work “binds the individual to reality” – Freud, 1961 • “Work is the closest thing to a panacea known to medical science.” Szasz, 1974

25. Many people want to work but... • In comparison with other health conditions, people with mental health conditions are twice as likely to lose their jobs following the onset of problems (Burchardt, 2003) • 13% of people people using specialist mental health services are in employment (NHS Digital) • 45% people using mental health services were not offered help with finding or keeping work but would have liked help(CQC, 2017) • Getting a job is the number one personal recovery goal within care plans (Singh & Rinaldi, 2018)

26. In the last 12 months, did NHS mental health servicesgive you any help or advice with finding support for finding or keeping work? CQC (2004 - 2017) Community Mental Health Surveys

27. Cochrane Reviews… IPS, a form of supported employment, more superior for gaining and retaining employment compared to different types of vocational rehabilitation for people with mental illness. 2001 2013 2017

28. Individual Placement & Support (IPS) • IPS is a direct, individualised search for competitive employment • Avoids lengthy pre-employment preparation or training • Does not screen people for work ‘readiness’ or ‘employability’ • ‘Place and Train’ not ‘Train and Place’ • It’s evidenced-based • Assumes people can work in ordinary competitive settings • Directly tackles the lack of integration of mental health care and employment services and the disconnection of different specialists • IPS shifts the focus of the mental health system away from treatment onto employment, by demonstrating better employment outcomes. (OECD, 2012)

29. ‘Individual Placement & Support’ (IPS) • ‘Place and train’approach not‘train and place’... • Focus on competitive employment as a primary goal • Eligibility based on the individual’s choice • Rapid job search, minimal pre-vocational training • Integrated into the work of the clinical team • Attention to client preferences • Develop relationships with employers based on client preferences • Availability of time unlimited support • Benefits counselling should be provided to support transition (Bond, 2008)

30. Implementation... Strategy Practice

31. Implementation research An intervention is one thing Implementation is something else altogether Effective intervention Effective implementation Positive outcomes + =

32. Focus on implementation and outcomes Individual level intervention • Employment Specialist is integrated with the clinical team • ‘Part of the team not a resource for the team’ • Individualised approach with clients • Client preferences shape the vocational pathway • Individualised approach - active job development with employers

33. Focus on implementation and outcomes Team level intervention • Reduce opportunity for Employment Specialist role ambiguity • Changes the roles and behaviour of Health & Social Care staff • Changes the organisational structures, cultures, and climates • Changes systems and policies, as well as relationships with external partners • Shifts the focus from treatment outcomes onto employment outcomes • Process and outcome evaluation • Using IPS fidelity as a process evaluation and employment outcomes as outcome evaluation

34. Clinicians’ attitudes • Clinicians believed that many more people were capable of working than were actually doing so • However, 2/3 believed their caseloads either incapable of working or only able to do voluntary /sheltered work • Clinicians saw helping people get back to work as a core part of their role, but felt they had little relevant training and limited confidence in the vocational services currently available Marwaha et al, 2008

36. Clinicians ambivalence • Whether motivational interviewing(MI) directed at clinical staff addressed ambivalence about employment and improved client employment outcomes. • All teams delivered IPS but two were also trained in MI to improve clinicians skills in targeting young people’s ambivalence about work and study. • N=159 unemployed young people who made a commitment to consider returning to work or study were recruited.

37. Recovery • Everyone who experiences mental health problems faces the challenge of recovery • Not ‘recovering from’ an illness but ‘recovering a meaningful, valued and satisfying life’ • finding meaning in what has happened • finding a new sense of self and purpose • discovering and using our own resources and resourcefulness • growing within and beyond what has happened to us • pursuing our dreams and ambitions

38. Reframing mental health services? Away from ‘the person in our services’ towards ‘the person in their life’ and how what we do helps (or hinders) the person in living the life they want to live. The challenge for services – helping people to live the life they want to live and do the things they want to do: understanding the challenges they face their aspirations and dreams understanding the impact of what we do on their journey

39. Thank you Miles.Rinaldi@swlstg.nhs.uk