1. Understanding the outcome of recovery Mike Slade Professor of Mental Health Recovery and Social Inclusion University of Nottingham 27 May 2016

2. This idea of recovery… 1.Where it’s come from 2. Where it is now 3. Where it might be going

3. Where has recovery come from? Version 1: Modernisation

4. 1813

5. Clinical Recovery Full symptom remission, full or part time work / education, independent living without supervision by informal carers, having friends with whom activities can be shared – sustained for a period of 2 years Liberman RP, Kopelowicz A (2002) Recovery from schizophrenia, International Review of Psychiatry, 14, 245-255.

6. Long-term (>20 year) schizophrenia outcome TeamLocation Yr n F-upRecovered / sig. improved (yrs) (%) HuberBonn1975502 22 CiompiLausanne1976289 37 BleulerZurich1978208 23 TsuangIowa1979186 35 HardingVermont1987269 32 OgawaJapan1987140 23 MarnerosCologne1989249 25 DeSistoMaine1995269 35 Harrison18-site2001776 25 Slade M, Amering M, Oades L (2008) Recovery: an international perspective. Epidemiology e Psichiatrica Sociale, 17, 128-137. 57 53 53-68 46 62-68 57 58 49 56

7. Long-term (>20 year) AN outcome TeamLocationYrn F-upRecovered / sig. improved (yrs)(%) LöweHeidelberg20018421 RatnasuriyaLondon19914120 51 Full 21 Partial 61 good / intermediate

8. Charcot’s presentation of a ‘case’ of hysteria at the Salpétriére in 1887

9. Current state of science 10-year follow-up study of first-episode psychosis (n=557) 213 (65%) no psychotic symptoms for past 6 months 140 (46%) no psychotic symptoms for two years The research relating to outcomes in schizophrenia and other psychoses, conducted before the more recent long-term course and outcome studies, has painted an overly pessimistic picture of the clinical course BUT 22% employed 32% in relationship 3.6 Standardised Mortality Ratio Revier C et al (2015) Ten-year outcomes of first-episode psychoses in the MRC ÆSOP-10 study, J Nerv Ment Dis 203: 379–86.

10. Where has recovery come from? Version 2: Stories

11. Stories Stories matter. Many stories matter. Stories have been used to dispossess and malign, but stories can also be used to empower and to humanise. Stories can break the dignity of a people, but stories can also repair that broken dignity Chimamanda Adichie

12. Different stories Flat. Lacking in motivation, sleep and appetite good. Discussed aetiology. Cont. LiCarb 250mg qid. Levels next time. Today I wanted to die. Everything was hurting. My body was screaming. I saw the doctor. I said nothing. Now I feel terrible. Nothing seems good and nothing good seems possible. I am stuck in this twilight mood where I go down into a lonely black hole. Where there is room for only one. O’Hagan M (1996) Two accounts of mental distress, In: Read J, Reynolds J (eds) “Speaking our Minds”, London: Macmillan.

13. Personal recovery A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and roles. It is a way of living a satisfying, hopeful and contributing life even with limitations caused by the illness. Anthony WA (1993) Recovery from mental illness: the guiding vision of the mental health service system in the 1990s, Psychosocial Rehabilitation Journal, 16, 11-23.

14. Recovery - a short definition Recovery involves living as well as possible. South London and Maudsley NHS Foundation Trust (2010) Social Inclusion and Recovery (SIR) Strategy 2010-2015, London: SLAM.

16. 2015 Slade M, Longden E (2015) Empirical evidence about mental health and recovery, BMC Psychiatry, 15, 285.

17. 1.Recovery is best judged by the person living with the experience 2.Many people with mental health problems recover 3.If a person no longer meets criteria for a mental illness, they are not ill 4.Diagnosis is not a robust foundation 5.Treatment is one route among many to recovery 6.Some people choose not to use mental health services 7.The impact of mental health problems is mixed. Seven messages

18. Where has recovery come from? Version 3: Social justice

19. Nothing about us without us

20. Which type of recovery should be the goal of the mental health system? 1.Epistemological 2.Ethical 3.Empowerment 4.Effectiveness 5.Policy 2009

21. Australia Priority area 1 Social inclusion and recovery...improved outcomes in relation to housing, employment, income and overall health and are valued and supported by their communities 2009

22. Canada Strategic direction 2 Foster recovery and well-being for people of all ages living with mental illnesses, and uphold their rights 2012

23. England Aim 2: More people with mental health problems will recover …ensuring that people with mental health problems are able to plan their own route to recovery, supported by professional staff 2011

24. Netherlands NGOs We use 'recovery' as a guiding principle in the care and treatment of the client...an active acceptance of problems and restrictions and a gradual transition in identity from patient to citizenship 2009

25. Hong Kong The vision of the future is of a person-centred service based on effective treatment and the recovery of the individual 2011

26. 2012 2015

27. Where is recovery now?

28. CHIME recovery processes Leamy M, Bird V, Le Boutillier C, Williams J, Slade M (2011) A conceptual framework for personal recovery in mental health: systematic review and narrative synthesis, British Journal of Psychiatry, 199, 445-452. Personal Recovery Connectedness Hope and optimism Identity Empowerment Meaning and purpose

29. Connectedness

31. Hope

35. The central importance of hope Hope predicts: Self-harm and suicide Klonsky D et al (2012) Suic Life Threat Behav 42, 1-10. Symptomatology Cheavens J et al (2006) Social Indicators Research 77, 61–78. Social network Connell J et al (2012) Health and Quality of Life Outcomes 10, 138. Quality of life Werner S (2012) Psychiatry Res 30, 214-9. Instilling hope is the first objective of self-management National Institute for Health and Clinical Excellence (2014) Psychosis and schizophrenia in adults: treatment and management. London: NICE. Interventions exist (collaboration, relationships, peers, control) Schrank B et al (2012) Social Science and Medicine, 74, 554-564.

36. Identity

39. Meaning

40. Mental health as a source of meaning Survivor testimony indicates that the process of surviving mental health challenges – including psychosis – can ultimately be transformative, enriching and a source of personal and social growth Slade M, Longden E (2015) The empirical evidence about mental health and recovery, MI Fellowship: Victoria. For example Post-traumatic growth Heightened capacity e.g. political engagement, creativity, fortitude, compassion, self-knowledge Survivor mission

41. 2010 2012

42. Empowerment

45. RCTs?Systematic reviews? 1 2 3 4 5 6 7 8 9 10 Slade M et al (2014) Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems, World Psychiatry, 13, 12-20. Approaches to supporting recovery Peer Support11Yes Advance Directives / JCPs4Yes WRAP1No IMR3No REFOCUS1No Strengths Model4No Recovery CollegesNoNo IPS18Yes Supported Housing1No TrialoguesNoNo

46. Slade M (2013) 100 ways to support recovery, 2 nd edition, London: Rethink Mental Illness Free to download: researchintorecovery.com

47. 2015

48. Where might recovery be going?

49. Where might recovery be going? Friendliness to multiple stories Enlightened self-interest Well-being

50. Macpherson R et al The relationship between clinical and recovery dimensions of outcome in mental health, Schizophrenia Research, in press.

51. Social marketing Interdisciplinary, strategic and multifaceted marketing based approach to facilitating or maintaining social good. Takes a citizen-centred approach, in which participant orientation is central French J, Gordon R (2015) Strategic Social Marketing, London: Sage.

52. New types of knowledge Academic disciplines Positive psychology Mental capital Well-being

53. Foresight five ways to wellbeing Connect Connect with the people around you…Think of these as the cornerstones of your life and invest time in developing them. Be active Go for a walk or run. Step outside. Exercising makes you feel good. Most importantly, discover a physical activity you enjoy. Take notice… Be curious. Catch sight of the beautiful. Remark on the unusual. Be aware of the world around you. Keep learning… Try something new. Rediscover an old interest. Sign up for that course. Set a challenge you will enjoy achieving. Give… Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a community group. Look out, as well as in.

55. Thank you More information at researchintorecovery.com Email: m.slade@nottingham.ac.uk