RECOVERYan overview

Prof.dr. Chantal Van Audenhove

KU.Leuven

GAMIAN

Budapest may 28th 2011

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

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

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

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”

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

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

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)

WHY NOW ?

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”

New trends in care

Demand

Growing demand for care

Increase in chronic conditions

More critical consumers and assertive clients who are organising themselves

Personal patterns of expectations towards care

Multi-cultural dimension of care

Offer Policy

Deïnstitutionalisation and increased focus on society

Fading barriers between health care and social care

Commercialisation of health care

Cost effiency rules the debate

Increased focus on science and internationalisation

International trends in mental health care since 2000

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

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

“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

Example of balanced care

Front line health care with specialised support, in which all areas of life and partners are given a place

“Community integration and personal empowerment”

Bron: Substance Abuse and Mental Health Services Association (www.SAMSHA.gov)

Trends in care and social wellfare

1. Younique: more differences between consumers2. Power to the Patient: more do-it-yourself approach3. The sky is the limit: high quality expectations 4. Afraid for care: anxiety by unsafety and complexity 5. Healthy Grey Societies: lifelong vitality6. Everybody patient : more frequently chronic illness7. Health as a choice : more attention for lifestyle8. Prevention: high priority9. Care without borders: globalising health10. Googleritis: digitalisation of consumer-provider interaction 11. One-to-One: more direct treatment with medical technology 12. Caring is Sharing: more transparancy in knowledge and competency 13. Greener care: towards sustainable care14. Saving lives, saving costs: more business, market and entrepreneur

attitudes15. Who cares for me? More demand, less provision on the labour market16. Transition: reorganising the care chain17. The bill please : more demand more costs …

Idenburg en Van schalk 2010

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)

Diversitity in care users and differing demands

An ideology ?

“The Diamond of Change”(M. Kmita 2005)

“The Mad”dangerous persons, excluded from society

STIGMA

Users of servicesrole of service providers

accepted,

self-actualisation, fight against stigma and powerlessness

CitizenshipHuman rights, responsibilities, participation and inclusion in

society

PatientsVictims, passive receptors of care and treatment, receive care

from experts who know what is the right thing to do

Implications for treatment

Self-help and informal help (peer support) gain importance

Professional support not necessary, but can be a facilitator

Many other organisations potentially involved apart from mental health care

psychiatrist

caregiver

domestic help

family support

friend

pharmacist

PsyCoT

day centre

home owner

client

Administrator of property

Paradigms in the therapeutic relationship

ChronicityDiagnostic categoryPessimismDysfunctionsFragmented modelPaternalismProfessional carePower and submissionArticial environmentStabilisationHelplessness

HerstelIndividualisationHope, realistic optimismStrengths, resilienceBio-psycho-social modelUser orientedSelf help, expertise by experienceEmpowerment, choiceNatural support, peer supportGrowth, calculated riskSelf determination (Onken e.a., 2002)

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 throughI was the one who decided what to talk about

Human, respectfulHe was not afraid to tell me that he didn’t understand how I feel

Available every day helpersI could talk about anything, not only problemsI 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

TherapeuticWith him, I found confidence, the charisma that he had made me

dare to look at my life and talk about it

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 chemistryWe got on with each other very well, she was like a friend

(Borg & Kristiansen, 2004)

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)

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

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

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

System standards

Challenges for the future

1. Paradigma shift in care

2. New organisational contexts

3. Research on recovery

4. Changes in society

New competencies

Patient centered practice Shared decision making Psycho-education Promotion of selfhelp and illness

management …

To help people on their way to recovery

New organisations

Guided by the recovery paradigm

Combined with Evidence based practice

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…

Changes in society

Accepting communities Fight against stigma and self-stigma Inclusion in work environments Participation in care services

Leonard Cohen sings...

Ring the bells that still can ringForget your perfect offering

There is a crack in everything,That's how the light gets in

Thank you for your attention