Recovery:an international perspective

SUMMARY. Aims To review developments in recovery-focussed mental health services internationally. Methods Two forms of recovery which have been used in the literature are considered, and international examples of recovery-focussed initiatives reviews. A litmus test for a recovery-focussed service is proposed. Results Clinical recovery has emerged from professional literature, focuses on sustained remission and restoration of functioning, is invariant across individuals, and has been used to establish rates of recovery. Personal recovery has emerged from consumer narratives, focuses on living a satisfying, hopeful and contributing life even with limitations caused by the illness, varies across individuals, and the empirical evidence base relates to stages of change more than overall prevalence rates. Clinical and personal recovery are different. Two innovative, generalisable and empirically investigated examples are given of implementing a focus on personal recovery: the Collaborative Recovery Model in Australia, and Trialogues in German-speaking Europe. The role of medication is an indicator: services in which all service users are prescribed medication, in which the term compliance is used, in which the reasoning bias is present of attributing improvement to medication and deterioration to the person, and in which contact with and discussion about the service user revolves around medication issues, are not personal recovery-focussed services. Conclusions The term Recovery has been used in different ways, so conceptual clarity is important. Developing a focus on personal recovery is more than a cosmetic change it will entailfundamental shifts in the values of mental health services

Perceived barriers and facilitators to positive therapeutic change for people with intellectual disabilities: client, carer and clinical psychologist perspectives

Studies have highlighted successful outcomes of psychological therapies for people with intellectual disabilities. However, processes underlying these outcomes are uncertain. Thematic analysis was used to explore the perceptions of three clinical psychologists, six clients and six carers of barriers and facilitators to therapeutic change for people with intellectual disabilities. Six themes were identified relating to: what the client brings as an individual and with regard to their wider system; therapy factors, including the therapeutic relationship and adaptations; psychologists acting as a ‘mental health GP’ to coordinate care; systemic dependency; and the concept of the revolving door in intellectual disability services. The influence of barriers and facilitators to change is complex, with facilitators overcoming barriers and yet simultaneously creating more barriers. Given their potential impact on the psychologists’ roles and access to therapy for people with intellectual disabilities, findings suggest these factors should be formulated as part of the therapeutic process

Patients’ Preference and Experiences of Forced Medication and Seclusion

This study examined patients’ preferences for coercive methods and the extent to which patients’ choices were determined by previous experience, demographic, clinical and intervention-setting variables. Before discharge from closed psychiatric units, 161 adult patients completed a questionnaire. The association between patients’ preferences and the underlying variables was analyzed using logistic regression. We found that patients’ preferences were mainly defined by earlier experiences: patients without coercive experiences or who had had experienced seclusion and forced medication, favoured forced medication. Those who had been secluded preferred seclusion in future emergencies, but only if they approved its duration. This suggests that seclusion, if it does not last too long, does not have to be abandoned from psychiatric practices. In an emergency, however, most patients prefer to be medicated. Our findings show that patients’ preferences cannot guide the establishment of international uniform methods for managing violent behaviour. Therefore patients’ individual choices should be considered

“They can do whatever they want”: Meanings of receiving psychiatric care based on a common staff approach

This study deepens our understanding of how patients, when cared for in a psychiatric ward, experience situations that involve being handled according to a common staff approach. Interviews with nine former psychiatric in-patients were analyzed using a phenomenological–hermeneutic method to illuminate the lived experience of receiving care based on a common staff approach. The results revealed several meanings: discovering that you are as subjected to a common staff approach, becoming aware that no one cares, becoming aware that your freedom is restricted, being afflicted, becoming aware that a common staff approach is not applied by all staff, and feeling safe because someone else is responsible. The comprehensive understanding was that the patient's understanding of being cared for according to a common staff approach was to be seen and treated in accordance with others' beliefs and valuations, not in line with the patients' own self-image, while experiencing feelings of affliction

New Strategies for Research in Clinical Practice: A focus on self–harm.

This article suggests new ways of approaching clinical-based research in an era of evidence-based practice. Using the example of self-harm, we identify three distinct problems with current dominant approaches to research in this area. These include insufficient clarity about target issues, an overreliance on predetermined outcomes which prioritise behavioural measures (such as self-harm cessation) and an undue focus on treatment techniques. We argue that clinical research requires flexible, user-centred and practice-based methods, informed by a focus on principles instead of techniques. Therefore, we outline key practice-based principles that we argue need to be embedded within clinical research strategies. We then demonstrate how traditional behavioural approaches to research can be enriched with more qualitative cognitive and emotionally based data. We conclude that such strategies provide thickened, meaningful and context-specific research which is more relevant for service commissioners, clinicians and service users

Cigarette smoking, nicotine dependence and anxiety disorders : a systematic review of population-based, epidemiological studies

Background Multiple studies have demonstrated that rates of smoking and nicotine dependence are increased in individuals with anxiety disorders. However, significant variability exists in the epidemiological literature exploring this relationship, including study design (cross-sectional versus prospective), the population assessed (random sample versus clinical population) and diagnostic instrument utilized.Methods We undertook a systematic review of population-based observational studies that utilized recognized structured clinical diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD)) for anxiety disorder diagnosis to investigate the relationship between cigarette smoking, nicotine dependence and anxiety disorders.Results In total, 47 studies met the predefined inclusion criteria, with 12 studies providing prospective information and 5 studies providing quasiprospective information. The available evidence suggests that some baseline anxiety disorders are a risk factor for initiation of smoking and nicotine dependence, although the evidence is heterogeneous and many studies did not control for the effect of comorbid substance use disorders. The identified evidence however appeared to more consistently support cigarette smoking and nicotine dependence as being a risk factor for development of some anxiety disorders (for example, panic disorder, generalized anxiety disorder), although these findings were not replicated in all studies. A number of inconsistencies in the literature were identified.Conclusions Although many studies have demonstrated increased rates of smoking and nicotine dependence in individuals with anxiety disorders, there is a limited and heterogeneous literature that has prospectively examined this relationship in population studies using validated diagnostic criteria. The most consistent evidence supports smoking and nicotine dependence as increasing the risk of panic disorder and generalized anxiety disorder. The literature assessing anxiety disorders increasing smoking and nicotine dependence is inconsistent. Potential issues with the current literature are discussed and directions for future research are suggested