18 September 2012 Antwerpen Belgium

Transcription

1 Marianne Farkas Professor Center for Psychiatric Rehabilitation Boston University Vlaams Geestelijk Gezondheidscongres 18 September 2012 Antwerpen Belgium

2 Historical Context..

3 What was the Historical context? Diagnosis implied life long deterioration Diagnosis implied only role available was that of service recipient/ client/ patient Categories of service limited (i.e. hospital vs. supervised housing; day programs vs. sheltered work) Farkas 2000

4 Current thinking Diagnosis does not predict success ( eg Razzano et al., 2005) Prognosis may be interaction of impairment process, local environment/treatment process, active agency of person ( Hopper et al., 2007) Medication alone does not promote community functioning and success (Swartz, Perkins, Stroup 2007) Farkas 2011

5 Current thinking People with serious mental illnesses want and have many roles- wife, homemaker, worker, student ( Ellison et al., 2008; Rogers et al, 1991) Service categories have to include a full range of options in the real world (Farkas & Anthony, 1989; Farkas 2006) Farkas 2011

6 Reducing mental illnesses does not mean increasing mental health Determinants of mental well being (produced socially) not same as determinants of mental illnesses (produced biologically/ environmentally etc) (Huppert, 2008; Primm et al, 2010; WHO 2009)

7 Findings About Health Promotion Added to Imperative to change our paradigm Mental illnesses are both a direct cause of mortality and morbidity and significant risk factor for poorer economic, health and social outcomes ( WHO 2005; 2006) Wellbeing/mental health also influences better physical health, improved recovery, higher educational attainment, greater productivity, better relationships, social cohesion, improved QOL ( WHO 2004; Barry & Jenkins, 2007; Primm et al, 2010)

8 Why did the field begin adopting Recovery as a legitimate vision? Known in the literature for at least 40 years (eg. Bleuler, 1972, Ciompi et al., 1976; Harding et al.,1987) First person accounts - much longer (eg. Deegan 1990; 1993; Ridgway, 2001; Spaniol et al, 1999) Research examining concepts of recovery, its process and its outcomes (eg. Davidson, Harding et al, 2005; Farkas 2007; Harding & Zhaniser, 1994; Liberman et al., 2002; Ridgway 2001; Silverstein & Bellack 2008 Farkas, 2011

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10 Recovery ideas in current literature of different countries UK, USA, Canada, Australia Claiming, reclaiming meaningful life; Home, health community, purpose Farkas 2007; SAMHSA 2010 Hong Kong Systematic review across countries 復元 (fu yuan) meaning regaining vitality, life force Tse et al., 2012 Processes related to ideas of connectedness,identity, meaning, empowerment Slade et al, 2012

11 Most used definition of Recovery Development of new meaning and purpose as one grows beyond the catastrophic effects of a psychiatric history and experiences of mental illness. ( Adapted from Anthony 1993) Or in summary- claiming or reclaiming a meaningful life ( Farkas, 2007)

12 What is Recovery A vision/ overall goal for services and systems Transformation of the paradigm with which services are delivered Farkas,2007, Anthony et al., 2002

13 What is Recovery? A process, an individual experience, Recovery is the process of reclaiming a meaningful life variety of multidimensional outcomes E.g. (re/)gaining a valued role; reducing symptoms; increased physical health, sense of well being, increased interpersonal connections etc. Farkas, 2007; Anthony, Cohen, Farkas et al, 2002

14 What does it mean at a personal level? Jean I spent 20 years in therapy and life experience trying to recover from a psychiatric disability. I began my formal recovery at the age of 15 in my first of a long line of hospitalizations at an area State Hospital and later in both private and public mental hospitals.

15 Jean s Story What does Recovery mean? I was afraid that my past history of trauma and hospitalizations had almost sealed my fate. School was my only area of competency A professor encouraged me, asked me to tell my recovery story and then to represent people in recovery at a conference slowly over time I realized I had something to offer

16 Jean s story I developed a career that helped me move from a shame based existence to now-making $45, a year-at the precipice of my new life. When my feelings and thoughts are being challenged by dissociation and flash backs, at 35, work is my lifeline and my support.

17 Jean s definition of her recovery Work, making real friends, literally having a place to live all these have been the great blessings in my life that for me, show me that I have indeed recovered from mental illness-- from internal stigma and the self-fulfilling prophecy of assuming that I had nothing to offer

18 Recovery Outcomes and Health Promotion: Compare these with measures of positive mental health Gaining/regaining a valued role, i.e. student, worker, family member, tenant Experiencing increased success and satisfaction in these roles Reducing/controlling symptoms Increased sense of selfefficacy Increased feelings of well being Increased number or quality of interpersonal connections Increased measures of physical health Increased sense of self-esteem (Farkas & Gagne, 2001) resilience, self esteem, optimism, life satisfaction, hopefulness, meaning in life, social integration ( eg Parkinson, 2008)

19 What do we know from Research? : Major Themes Recovery is possible and has been known for 40 years ( e.g. Buber, 1972; Harding et al., 1994; Hooper et al, 2001 Adapted, Anthony, Cohen,Farkas,Gagne 2002 Recovery is a complex, non-linear and multi-dimensional process and can be described Recovery is a highly individualized process with multiple explanatory models used Recovery can occur with or without professional intervention

20 So is Recovery different from just good practice? This question often is a global way of expressing concerns about the emergence of this concept and the challenges it can pose. Farkas 2012

21 How is it different from good practice? Some major differences are Good practice can be good rehabilitation, treatment, case management etc. These are services Recovery, on the other hand, is the person s experience of a journey which can be promoted or facilitated by services.or not Farkas 2012

22 So how is it different from good practice Interventions for mental illnesses often focus on controlling/ reducing/ fixing a problem or barrier through the role of person in authority/ person in charge of to reduce suffering and hopefully improve a person s life Farkas 2012 Interventions that are recovery oriented, look to promote person s own long term vision of a meaningful life through the roles of teacher, coach, consultant to the expert in the recovery process the person him/herself

23 What are some of the concerns about recovery as a concept.. Recovery is an irresponsible fad Recovery is old news Recovery happens for very few people Recovery means the person is cured Recovery can be implemented only through introduction of new services (Summarized by Davidson et al., 2006)

24 As an aside What is the major barrier to developing a recovery vision for systems? Many people think they are thinking when they are merely rearranging their prejudices.. William James

25 1. Recovery is an irresponsible fad: Is it a Fad? Recovery has been present in the literature for over 40 years People in recovery have written first person accounts detailing their recovery It is now the official policy of several countries Farkas 2012

26 2. Recovery is old news..so how come the stakeholders don t know it? If we are already doing it why is there consensus that mental health care is in serious need of reform, is not producing effective outcomes and that recovery should be the overall objective of the system? (e.g. in the U.S.--IOM, 2006; Surgeon General report, 1999; New Freedom Commission, 2003; MH Reform Commission in NZ., reform in Scotland, in England etc) Farkas 2012

27 2. Recovery is old news...so how come the stakeholders don t know it? In many countries, people with serious mental illness are still not well represented in the world of work; are not in post secondary education representational to their numbers in the population; are over represented in the criminal justice population If ½ to 2/3 of those with lived experience are not achieving a meaningful life how can recovery be old news? Farkas 2012

28 3. Is recovery only for the very few? Study Sample Size Length Outcomes Bleuler, % Huber et al., 1972 Ciompi & Muller, % % Tusuang et al.,1979 Harding et al, 1987 Ogawa et al, 1987 DeSisto et al, % % % % Harrison et al % Harding et al., 1994, Harrison et al., 2001)

29 4. Does it mean person is cured? Remember these outcomes identified by people themselves? Gaining/regaining a valued role, i.e. student, worker, family member, tenant Experiencing increased success and satisfaction in these roles Reducing/controlling symptoms Increased sense of self-efficacy Increased feelings of well being Increased number or quality of interpersonal connections Increased measures of physical health Increased sense of self-esteem Farkas & Gagne, 2001; Farkas 2007

30 5. Does recovery require the introduction of new services? Farkas, 2008 Organizational Recovery Vision? Do what we do now + Peers, EBP s Rec Ed. = Recovery Oriented Service

31 5. Recovery is introduction of new services Change vs Transformation We can change a system by promoting centralization, decentralization, coordination, adding services, selecting some services to improve their effectiveness We transform a system by changing the paradigm with which services are conducted Farkas, 2011

32 Why are services coordinated around a recovery vision so important?. Life lived within the confines of the human service [sic].is a life in which the freedom to become & make your own future is diminished..it is nearly impossible to make your own future when you are not part of the.[sic] fabric of the culture you live in (Patricia Deegan, Phd., World Congress Rehab International: Oslo, Norway June, 2004)

33 Example of Some Services and [Outcomes] Treatment [Symptom Relief] Crisis Intervention [Safety] Case Management [Access] Rehabilitation [Role Functioning] Recovery should be the integrative mission of all services (Adapted from Anthony, Cohen, Farkas et al., 2002) Recovery as overall mission Health Thoughts, Feelings, and Behavior X X Activity Role Performance Participation Opportunities (WHO, ICDF) X X X X X

34 Will Recovery replace rehabilitation?.. What is rehabilitation all about in a recovery era? Rehabilitation is a systematic approach that contributes to overall recovery by : Developing relationships where the individual is the expert regarding his or her own recovery Organizing interventions to ensure that people have a good chance to reach one aspect of their hopes and dreams i.e. valued roles-- the cornerstone of recovery Farkas 2012

35 Promoting recovery requires a transformation Creating services/systems that: a support a personal journey with an array of commonly identified outcomes, reflecting the (re)claiming of a meaningful life Facilitate this journey by basing service on a set of values expressed in the infrastructure and daily practice of services/system Facilitate this journey using a set of competencies within a partnership that alter the way in which any intervention is delivered Farkas, 2011

36 Transformation: Aligning Values to Promote Recovery Person not diseases, cases Choice Partnership Hope not coercion not compliance not helplessness Farkas, Gagne, Anthony, Chamberlin 2005

37 Transformation: Aligning competencies to promote recovery The skills of inspiring hope The skills of developing and maintaining partnership The skills of promoting self determined choices The skills of educating/teaching Farkas, 2011

38 Transformation: Aligning the system to promote recovery Macro issues Administrative Population wide interventions on health/mental health Examples policies, financing, credentialing, system evaluation etc) match recovery mission Strengthen community, community mental health/well being Farkas, 2011

39 More than old wine in new bottles?-point is rather-- make whatever wine it is using these fundamentals: Nothing about us without us - design, deliver, evaluate services with people in recovery Strengthening well being of communities provides resources for people to work on their own well being and recovery Investing in people rather than investing in buildings ( eg teaching; providing flexible support; respite ; recovery awards; developing and supporting peers etc) Researching/Evaluating progress using qualitative/quantitative methods to measure recovery outcomes (discussed earlier) to create recovery report cards Farkas 2012

40 Nothing will ever be attempted, if all possible objections must be first overcome. ~Samuel Johnson, Rasselas, 1759