1. Recovery domains for care planning and everyday practice: Clinicians’ views and service directions Terry J. Lewin, Ketrina A. Sly, Agatha M. Conrad, Barry Frost, Megan Turrell, Suzanne Johnston, Sadanand Rajkumar, Kerry Petrovic, Tirupati Srinivasan CTNMH

2. “Learning Objectives” (As stated in Abstract) Learning Objective One: Improved understanding of rehabilitation and recovery domains, and variation across service groups in recovery oriented practice. Learning Objective Two: Greater appreciation of potential collaborative client/clinician assessment tools for care planning (e.g., Recovery Star). While generalist and specialist mental health (MH) teams may differentially impact upon the various recovery domains, we need to develop a consistent, balanced, integrated, and consumer-focused approach to care planning across our services – hopefully using complementary measures.

3. Assessment and Evaluation Framework (1) A consensus is starting to emerge in the Mental Health literature that seeks to strike a better balance between “clinical recovery” (e.g., symptom reduction, relapse prevention, risk management) and “personal recovery” (e.g., promoting social and personal identity, goals, hope, and responsibility) (Slade, 2010). “… Quantitative approaches are needed to evaluate interventions that support recovery, and to understand the relationship between changes in recovery domains … and clinical domains of outcome” (Slade et al., 2012). “… More broadly, best available evidence drawn from international guidelines suggests that mental health systems can support recovery in relation to four domains of practice: promoting citizenship, organisational commitment, supporting personally defined recovery and working relationships (Le Boutillier et al. 2011)” (Slade et al., 2012).

4. Assessment and Evaluation Framework (2) “… Recovery is an individual and dynamic process, and [this review] is not intended to be a rigid definition of what recovery ‘is’, but rather a resource to inform future research and clinical practice … (Slade et al., 2012). Within the Australian context, preliminary attempts have been made to assess the value of existing recovery measures for routine use in mental health services, both as tools for “monitoring recovery status and change” (by individual consumers), and the “recovery orientation of services” (Burgess et al., 2011); however, gold standard measures are not yet available (Williams et al., 2012).

6. Considerable variability in domains assessed

7. Crawford et al. (2011) - Table II. Features of an appropriate outcome measure according to group members.  Should be based on patient rather than staff-rated judgements  Includes ‘positive’ as well as ‘negative’ items  Is comprehensive – neither too long nor too short  Avoids questions that are intrusive about private issues such as sex life  Makes note of the time and place where the outcome is measured  Includes space for ‘added comments’  Should be used by staff who have good interpersonal skills and have been properly trained in the use of the outcome measure  If self completed, is presented in a professional manner “Selecting outcome measures in mental health: the views of service users” Crawford et al. (2011) Journal of Mental Health, 20(4): 336–346 Service users views of outcome measures

8. Consensus Domains ? A decade ago, initial attempts were made to develop a comprehensive ‘consensus cognitive battery (for schizophrenia)’ for assessing cognitive change in clinical trials - Resulting in the selection of ten existing tests covering seven domains - Known as the MATRICS Consensus Cognitive Battery (MCCB) MATRICS domains:  Speed of processing (e.g., trail making, symbol coding, category fluency)  Attention/vigilance  Working memory (verbal and nonverbal)  Verbal learning  Visual learning  Reasoning and problem solving  Social cognition G REEN MF, N UECHTERLEIN KH, G OLD JM, B ARCH DM, C OHEN J, E SSOCK S, F ENTON WS, F RESE F, G OLDBERG TE, H EATON RK, K EEFE RSE, K ERN RS, K RAEMER H, S TOVER E, W EINBERGER DR, Z ALCMAN S, M ARDER SR. Approaching a consensus cognitive battery for clinical trials in schizophrenia: the NIMH-MATRICS conference to select cognitive domains and test criteria. Biological Psychiatry 2004;56:301-307. K ERN RS, N UECHTERLEIN KH, G REEN MF, L AADE LE, F ENTON WS, G OLD JM, K EEFE RSE, M ESHOLAM -G ATELY R, M INTZ J, S EIDMAN LJ, S TOVER E, M ARDER SR. The MATRICS consensus cognitive battery, part 2: Co-norming and standardization. American Journal of Psychiatry 2008;165:214-220.

9. http://www.researchintorecovery.com/

10. Slade et al. (2012).“International differences in understanding recovery: systematic review”, Epidemiology and Psychiatric Sciences, 21: 353-364.

11. Conceptual framework coding for recovery conceptualisations – by Country Slade et al. (2012).“International differences in understanding recovery: systematic review”, Epidemiology and Psychiatric Sciences, 21: 353-364.

12. Conceptual framework Slade et al. (2012).“International differences in understanding recovery: systematic review”, Epidemiology and Psychiatric Sciences, 21: 353-364.

14. Illustrative recovery goals identified by participants with ‘psychiatric disability’ (N = 144) Clarke, Oades & Crowe (2012). Psychiatric Rehabilitation Journal, 35:297-304 Conceptualization that includes: multiple domains, individualized processes, stages of change/recovery. MH Recovery – “Movement towards” well-being and meaning (versus avoidance of symptoms) Five stage model of psychological recovery based on Andresen et al. (2003) Seven overarching value domains (based on the Recovery Goal Taxonomy)

15. Illustrative recovery goals identified by participants with ‘psychiatric disability’ (N = 144) Clarke, Oades & Crowe (2012). Psychiatric Rehabilitation Journal, 35:297-304 Conceptualization that includes: multiple domains, individualized processes, stages of change/recovery. MH Recovery – “Movement towards” well-being and meaning (versus avoidance of symptoms) Five stage model of psychological recovery based on Andresen et al. (2003) Seven overarching value domains (based on the Recovery Goal Taxonomy)

16. Flexibility: Different goals for different stages of recovery Clarke, Oades & Crowe (2012). Psychiatric Rehabilitation Journal, 35:297-304 “… Individuals further along in their recovery set significantly more approach goals and types of goals set appear to reflect broader life roles” (p. 297) MH Recovery – “Movement towards” well-being and meaning (versus avoidance of symptoms)

17. Assessment and Evaluation Framework (3) In the Hunter region, we have begun to explore the utility of the Mental Health Recovery Star (MacKeith and Burns, 2010), both as a collaborative assessment and recovery planning tool for working with individuals, and as a framework for examining clinicians’ current views and practices. “The Mental Health Recovery Star was commissioned in the UK by the voluntary sector umbrella body the Mental Health Providers Forum (MHPF). … Considerable user involvement and extensive mental health service user feedback were integral to the development of the tool. … Recovery Star is predicated on an underlying model of a ‘ladder of change’ comprising five stages: being stuck, accepting help, believing, learning and self-reliance.” (Dickens et al., 2012)

19. Sample Ladder

20. (Detail)

21. Possible ‘higher-order clusters’ within Recovery Star Managing mental health Physical health & self- care Addictive behaviour Living skills Work Responsibilities Social networks Relationships Identity and self-esteem Trust and hope A: Mental/Physical Health C: Networks B: Activities & Functioning D: Self-image (Consistent with Factor 2 from Dickens et al. 2012)

22. Possible ‘higher-order clusters’ within Recovery Star Managing mental health Physical health & self- care Addictive behaviour Living skills Work Responsibilities Social networks Relationships Identity and self-esteem Trust and hope A: Mental/Physical Health C: Networks B: Activities & Functioning D: Self-image (Consistent with Factor 2 from Dickens et al. 2012)

23. Possible ‘higher-order clusters’ within Recovery Star Managing mental health Physical health & self- care Addictive behaviour Living skills Work Responsibilities Social networks Relationships Identity and self-esteem Trust and hope A: Mental/Physical Health C: Networks B: Activities & Functioning D: Self-image (Consistent with Factor 2 from Dickens et al. 2012) C onnectedness H ope and Optimism about the future & I dentity M eaning in life & E mpowerment “RECOVERY PROCESS” (CHIME) – Slade et al. (2012)

24. Recovery Star – Clinical Outcome Tool vs. Collaborative Care Planning Several Criticisms: IRR based on staff only ratings; Collaborative nature of tool not ‘unusual’ or a major limitation; Poor choice of comparator; Need different approaches to validation; Not designed to be an ‘objective outcome measure’ – but a tool for care planning and change.

25. “The ‘work’ item proved to be one of the least amenable to change … there may be a need to clarify the item descriptor to allow for a range of interpretations of ‘work’.” Responsive to change Two factors: internal vs. external management/ relationships (Likely to be highly dependent on nature of sample and timeframes)

26. Intermediate Stay Mental Health Unit (ISMHU) 20 bed non-acute inpatient unit located on the James Fletcher Hospital campus in Newcastle Opened: November, 2010 Stand alone unit – separated from acute unit by approx. 9 km Admissions planned and co-ordinated – utilising rehabilitation co- ordinators providing liaison across inpatient and community services Recovery/rehabilitation focused model of care – program based - approx. 6 week length of stay Recovery model underpinned by Recovery Star framework and associated, locally devised resources and training materials

27. ISMHU Evaluations – Components & Timelines

28. Participant Characteristics (1) Primary Role Baseline Survey (N = 194) Follow-up Survey (N = 200) Combined (N = 394) Clinical role Nursing74 (38.1%)71 (35.5%)145 (36.8%) Allied Health67 (34.5%)61 (30.5%)128 (32.5%) Other – Medical, Director25 (12.9%)24 (12.0%)49 (12.4%) Non-clinical role28 (14.4%)44 (22.0%)72 (18.3%) Note: 77.2% of participants were female (304/394) Average age = 44.1 years Moderate overlap across phases: At follow-up, only 32% reported baseline participation and 29% were ‘unsure’

29. Participant Characteristics (2) Primary Work Location (Clinician sub-categories) Baseline Survey (N = 166) Follow-up Survey (N = 156) Combined (N = 322) Long Stay Unit18 (10.8%)11 (7.1%)29 (9.0%) Acute Inpatient Unit44 (26.5%)45 (28.8%)89 (27.6%) Intermediate Stay Unit25 (15.1%)17 (10.9%)42 (13.0%) Community MH79 (47.6%)83 (53.2%)162 (50.3%)

30. Analysis Strategy The major analyses focused on overall comparisons between clinicians from different work locations, whilst statistically controlling for gender and clinical role effects. Three-step hierarchical regression analyses were used: o Step 1: Gender, Clinical Role (2 contrast coded variables) o Step 2: Survey Phase, Work Location (see below) o Step 3: Phase by Work Location interactions (To minimise the number of statistical tests) Three Work Location related planned orthogonal contrasts were examined: o Long Stay Unit clinicians Vs. the Rest; o Acute Inpatient Unit clinicians Vs. Intermediate Stay and Community MH clinicians; and o Intermediate Stay Unit clinicians Vs. Community MH clinicians Outcome variables: o Importance placed by unit/service on recovery-oriented practice [Follow-up Only] o Importance given to specific recovery domains in care planning o Perceived impact of current treatment practices Threshold for statistical significance: p < 0.01

31. Recovery-oriented practice Question 12 from Follow-up Survey: “How much importance does your unit/service place on recovery-oriented practice - e.g., encouraging self-determination and self management, strengths-based care, promoting personal goals and aspirations, addressing multiple factors impacting on wellbeing, carer involvement, supporting social inclusion and participation?”

32. High Considerable Moderate Some None Acute < Community MH and ISMHU (p < 0.001) Importance placed on recovery-oriented practice

34. On-line Survey (Zoomerang/Survey Monkey)

35. Importance for Care Planning

40. Comparison with Individual Interventions: p <.01; ** p<.001

42. Interventions Comprehensive Individualised rehabilitation program (together with a mixture of Group programs) that aim to enhance: Symptom control Resilience and coping skills Living skills Personal relationships Community integration Social inclusion Programs available across the whole week Key worker utilises a collaborative goal setting tool (Recovery Star) to assist in the development and implementation of the care plan

43. Intervention Log (using existing Code Sets) This log allows for the documentation and electronic recording of key interventions provided to each client admitted to ISMHU. Please tick all group programs that the client, carer or family member successfully participated in. For individual tailored interventions, tick only those interventions provided in addition to the group programs targeted at identified clinical goals or specific recovery domains.

44. Preliminary Recovery Star Outcomes (ISMHU, N = 102) 82% of consumers showed an improvement on the Recovery Star as a result of an admission to ISMHU. Of those who had shown an improvement, 61% had made a substantial improvement, and 21% a small improvement. Less than 1 in 5 showed either no improvement (11%) or a decrease (7%). The areas of need that showed the largest positive improvements were: Managing Mental Health (76%), Physical Health & Self Care (68%), Identity and Self Esteem (68%), Social Networks (66%), Living Skills (65%), Trust and Hope (65%), and Relationships (61%). The areas with the least number of consumers making a positive change were: Work (53%), Addictive Behaviour (50%), and Responsibilities (49%) – which correspond with the domains experiencing the least change reported by Dickens et al. (2012).

45. Conclusions - Rehabilitation and Recovery Domains: There is considerable variability in the domains assessed by current ‘recovery-related’ measures. We need to develop a ‘flexible consensus’ – a small number of broad (upper-level) domains (≤ 6), with a larger set of sub-domains that can adequately represent individualised (or system-level) recovery processes and goals, and different stages of change/recovery. Existing and proposed qualitative/quantitative measures can then be mapped onto those domains (and sub-domains) – and evaluated (e.g., acceptability, consistency, sensitivity, utility, etc). Measures may vary but the terminology and goals need to be coherent. Realistic timeframes need to be set for evaluating the effectiveness of programs – say, a minimum of 3- or 6-monthly assessments over 2 years (e.g., ‘hope’ and ‘identity’ may change relatively slowly).

46. Collaborative Client/Clinician Assessment Tools : The Recovery Star has been well-received by clients/clinicians within our health service and is reflecting improvements across the course of an ISMHU admission. Knowledge about its strengths and weaknesses is (slowly) accumulating. Particularly positive feature – underpins recovery model and interventions in ISMHU. Needs better integration with electronic records – across inpatient/community settings.

47. Survey findings : There was reasonable variation within our services in the ‘recovery orientation’ of clinicians – with a greater emphasis on recovery among our non-acute and community based staff. Not surprisingly, ISMHU affiliated clinicians tended to view all of the identified recovery domains as important for care planning; however, they only differed from Community MH clinicians in the importance attached to Living Skills and Self-Care & Physical Health. While generalist and specialist teams may differentially impact upon the various recovery domains, we need a consistent, balanced, integrated, and consumer-focused approach to care planning across our services – so that (at the very least) we are all talking the same language. Many of the recovery domains associated with the largest differences between clinician sub-groups could be viewed as elements of ‘personal recovery’ (e.g., Work, Social Networks, Identity & Self-esteem, and Trust & Hope) – suggesting that a greater (service-wide) emphasis may also need to be placed on these domains.

48. Survey findings (Continued) : The perceived impact of current treatment practices was lowest for the recovery domains of Addictive Behaviours and Work. Group interventions are perceived as less likely to produce positive changes (than individual interventions) – but not for domains relating to Managing Mental Health and Connectedness (social networks, relationships). Many clinicians (approx. 50%) also expressed a desire for additional skills training (beyond refresher courses) in providing interventions, particularly in relation to Addictive Behaviours, Trust & Hope, and Identity & Self-esteem. Thank you for listening, and to everyone who participated in the Rehabilitation and Recovery Surveys – and to the ISMHU Evaluation Committee/Team. Thank You CTNMH