A lecture for Mental Health Officer students at Strathclyde University in October 2019

1. Recovery and recovery
based approaches in
mental health
Dr Simon Bradstreet, Lecturer
University of Glasgow: Institute of Health and
Wellbeing

2. Who am I?
• Lecturer at University of Glasgow
• Trial Manager on EMPOWER study
• PhD focused on internal stigma
• Research interests digital, psychosis, recovery, peer
support, self-management
• Director of the Scottish Recovery Network 2004-2016
• Collaborate with Strathclyde on citizenship and
Nottingham University on NEON study
• Recovery research blogs for Mental Elf

3. What I hope to cover
• Some historical context
• Development of recovery approaches
• Examining characteristics of personal recovery
• The application of recovery approaches
• Critiques of recovery
• Evidence base for recovery approaches
• Implications of recovery for Mental Health Officers

4. Recovery
Personal recovery
Recovery approach
Recovery movement

5. Background history
• CAVEAT: There are many versions of this story – this is
mine
• Recovery and recovery-based approaches not new
• Often a means to challenge contemporary orthodoxy
• 1792 William Tuke, the York Retreat and moral treatment
• 1797 Jean Baptiste Pussin employing recovered patients
(via Pinel)
• 1800s rise of large asylums

6. Background history
• 1950s rise of biomedical psychiatry and
birth of anti drugs
• 1960s closure of large institutions (150,000
to 27,000 beds)
• 1980s care in the community

7. History of recovery approaches
• 1990s development contemporary recovery movement
• Some of the main historical influences:
– Activism and the rights based approach
– Sharing experiences and recovery narratives
– Social perspectives in mental health
– Long term outcome research

8. Long-term outcome studies
• Following people and measuring outcomes over time*
• Most studies relate to schizophrenia
• Prompted by community care
• Challenged traditionally bleak prognosis
• Vermont Longitudinal Study of Persons with Severe Mental
Illness (Harding & Brooks 1987)
– Two-thirds former long-stay patients improved considerably or
recovered
*See Dorrer (2006)

9. Long-term outcome studies
• Series of WHO cohort studies across 18 countries
• Early studies suggested outcomes consistently better in
‘developing’ countries
• Harrison et al (2001) 15 and 25 year follow up:
– Good long term outcomes overall and ‘late recovery’
– Better outcomes with early intervention
– Geographic variation in outcome
• Heterogeneity in course of schizophrenia and recovery by
location “challenges conventional notions of chronicity
and therapeutic pessimism” (Harrison et al. 2001, p.516)

10. Chronicity,
pessimism &
the clinicians illusion

11. Developing understanding of personal recovery
• The rise of first person narratives and sharing of lived
experiences tells us recovery is:
– A unique and individual experience
– An active process
– A non-linear process (often described as journey)
– Overcoming adversity and losses
– Living well with or without symptoms

12. Recovery as an active journey
‘My journey of recovery is still ongoing... I am also
involved in self-help and mutual support and I still use
professional services including medications,
psychotherapy, and hospitals. However, now I do not just
take medication or go to the hospital. I have learned to
use medications and to use the hospital. This is the
active stance that is the hallmark of the recovery
process. Recovery does not mean cure. Rather recovery
is an attitude, a stance, and a way of approaching the
day’s challenges. It is not a perfectly linear journey’
Deegan, 1996

13. Recovery is not…
• …just about symptoms
• …the same thing as cure
• …necessarily about being back
to ‘normal’
• …necessarily easy or
straightforward

14. Describing recovery
“Recovery is being able to live a meaningful and
satisfying life, as defined by each person, in the
presence or absence of symptoms. It is about
having control over and input into your own life.
Each individual’s recovery… is a unique and deeply
personal process.”
Journey’s of Recovery, Scottish Recovery Network, 2006
www.scottishrecovery.net

15. CHIME Conceptual framework
Leamy et al. 2011

16. Recovery in Scotland now
• From margins to mainstream
• Normal part of mental health discourse
• Recovery technologies* increasingly widespread:
– Peer Support Working
– Wellness Recovery Action Planning and self management
– SRI 2 and recovery policy and practice
– Professional training and education
– Recovery stories (narratives)
– Recovery Colleges
– Recovery communities
*Smith-Merry, J., Freeman, R. & Sturdy, S. 2010

17. Social movement to policy goal
‘Social movement to policy goal’ Smith-Merry et al. 2010

18. Recovery focused services
• From recovery walk to talk
• No lack of commitment and interest
• SRI 2 identified challenges in:
– Collaborative goal setting
– Involvement
– Self management and advance planning
– Strengths based practices
• Systemic barriers clearer

19. Summary so far
• Recovery outcomes challenge chronicity view
• Recovery moved from margins to mainstream
• Significant efforts to describe and evidence personal
recovery
• Recovery approaches and tools widely promoted
• Valuing lived experience is central to recovery

20. From margins to
mainstream…
Maybe too mainstream?

21. The recovery star
https://mentalhealthpartnerships.com/resource/recovery-star/

22. The UnRrecovery star
https://recoveryinthebin.org/unrecovery-star-2/

23. CHIME Conceptual framework
Leamy et al. 2011

24. Maslow’s Hierarchy of needs

25. Time for the bin?

26. Time for the bin?
• Isn’t this just a form of neo
liberalism?
• Blaming the victim?
• Colonisation of recovery
• Can’t I just be disabled?
• What about social determinants?
• Who controls the ‘story’?

28. https://www.patientopinion.org.uk/opinions/274911
Recovery is malleable

29. Mixed evidence for recovery approaches
• REFOCUS (largest UK recovery trial to date) failed to show an
effect (Slade et al 2015)
• PULSAR found small effect size with slightly altered method
(Meadows et al. 2019)
• Peer approaches at best as good as non-peer equivalents (Pitt et
al, 2013) but quality of research often poor (Lloyd-Evans et al.
2014)
• Largest UK trial to date of peer supported self-management
showed an effect (Johnson et al. 2018)
• Self-management approaches generally show promise (Lean et al.
2019)
• CHIME framework widely applied but may be overly optimistic and
non-inclusive (Stuart, Tansey & Quayle, 2017)
• Lack of critical investigation of how recovery narratives are
constituted and mobilised (Woods, Hart & Spandler, 2019)

30. Recovery in the real world
• 20 people with first episode of psychosis
1995-1999
• Used services 10 years prior to
‘recovery’ policy and legislative shift and
10 years after
• 10 ‘full functional recovery’ (10 not)
• Recovered groups felt services had
humanised
• Non recovered group felt abandoned
• Recovery potentially shifts responsibility
from services to individuals
O’Keefe et al. 2018

31. Should recovery be
consigned to the
dustbin of mental
health history?

32. In summary
• People can and do recover from even the
most serious mental health problems
• Learning can be applied in recovery
approaches
• Recovery is prone to misappropriation and
critiques must be taken seriously
• Moving from a social movement to a policy
goal is challenging
• Need to plug the evidence to policy gap
• Despite issues remains relevant to systems
and people

33. https://www.nationalelfservice.net/mental-health/

34. References
Bradstreet, S., & McBrierty, R. (2012). Recovery in Scotland: beyond service development. International Review of Psychiatry,
24(1), 64–9. http://doi.org/10.3109/09540261.2011.650158
Bradstreet, S., Dodd, A., & Jones, S. (2018). Internalised stigma in mental health: an investigation of the role of attachment style.
Psychiatry Research, Online. http://doi.org/10.1016/j.psychres.2018.03.047
Davidson, L., & Chan, K. K. S. (2014). Common Factors: Evidence-Based Practice and Recovery. Psychiatric Services, 65(5),
675–677. http://doi.org/10.1176/appi.ps.201300274
Deegan, P (1996) Recovery as a journey of the heart. Psychiatric Rehabilitation Journal 19 (3): 91-97
https://www.patdeegan.com/
Dorrer, N. (2006) Evidence of Recovery: The ‘Ups’ and ‘Downs’ of Longitudinal Outcome Studies. SRN Discussion Paper
Series. Report No.4. Glasgow, Scottish Recovery Network. Available from https://www.scottishrecovery.net/resources/
Harding, C. M., G. W. Brooks, et al. (1987). The Vermont longitudinal study of persons with severe mental illness: I.
Methodology, study sample, and overall status 32 years later. American Journal of Psychiatry 144(6): 718-726.
Harrison, G., K. Hopper, et al. (2001). Recovery from psychotic illness: a 15- and 25-year international follow-up study. British
Journal of Psychiatry. 178(6): 506-517
Johnson, S., Lamb, D., Marston, L., Osborn, D., Mason, O., Henderson, C., … Lloyd-Evans, B. (2018). Peer-supported self-
management for people discharged from a mental health crisis team: a randomised controlled trial. The Lancet, 392(10145),
409–418. https://doi.org/10.1016/S0140-6736(18)31470-3
Leamy, M., Bird, V., Le Boutillier, C., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental
health: systematic review and narrative synthesis. The British Journal of Psychiatry : The Journal of Mental Science, 199(6),
445–52. http://doi.org/10.1192/bjp.bp.110.083733
Lean, M., Fornells-Ambrojo, M., Milton, A., Lloyd-Evans, B., Harrison-Stewart, B., Yesufu-Udechuku, A., … Johnson, S. (2019).
Self-management interventions for people with severe mental illness: systematic review and meta-analysis. The British
Journal of Psychiatry, 1–9. https://doi.org/10.1192/bjp.2019.54
Lloyd-Evans, B., Mayo-Wilson, E., Harrison, B., Istead, H., Brown, E., Pilling, S., … Kendall, T. (2014). A systematic review and
meta-analysis of randomised controlled trials of peer support for people with severe mental illness. BMC Psychiatry, 14(1), 1–
12. https://doi.org/10.1186/1471-244X-14-39

35. References
O’Keeffe, D., Sheridan, A., Kelly, A., Doyle, R., Madigan, K., Lawlor, E., & Clarke, M. (2018). “Recovery” in the Real World:
Service User Experiences of Mental Health Service Use and Recommendations for Change 20 Years on from a First Episode
Psychosis. Administration and Policy in Mental Health and Mental Health Services Research, 0(0), 0.
https://doi.org/10.1007/s10488-018-0851-4
Pitt, V., Lowe, D., Hill, S., Prictor, M., Hetrick, S. E., Ryan, R., & Berends, L. (2013). Consumer-providers of care for adult clients
of statutory mental health services. Cochrane Database of Systematic Reviews, (3).
https://doi.org/10.1002/14651858.CD004807.pub2
Slade, M., Bird, V., Clarke, E., Le Boutillier, C., McCrone, P., Macpherson, R., … Leamy, M. (2015). Supporting recovery in
patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster,
randomised, controlled trial. The Lancet Psychiatry, 0366(15), 1–12. https://doi.org/10.1016/S2215-0366(15)00086-3
Smith-Merry, J., Freeman, R. & Sturdy, S. (2010). Recovery from Social Movement to Policy Goal, Report to the European
Commission. KnowandPol Orientation 2, Public Action 2 . Louvain-la-Neuve: Université Catholique de Louvain
Smith-Merry, J., Freeman, R. & Sturdy, S. (2011). Implementing recovery: An analysis of the key technologies in Scotland.
International Journal of Mental Health Systems, 5 (11). https://dx.doi.org/10.1186%2F1752-4458-5-11
Stuart, S. R., Tansey, L., & Quayle, E. (2017). What we talk about when we talk about recovery: a systematic review and best-fit
framework synthesis of qualitative literature. Journal of Mental Health, 26(3), 291–304.
http://doi.org/10.1080/09638237.2016.1222056
Woods, A., Hart, A., & Spandler, H. (2019). The Recovery Narrative: Politics and Possibilities of a Genre. Culture, Medicine, and
Psychiatry, 9–15. https://doi.org/10.1007/s11013-019-09623-y

36. Websites – further reading
EMPOWER Study: https://empowerstudy.net/
‘Mental Elf’ recovery research blogs: https://www.nationalelfservice.net/author/simon-
bradstreet/
Recovery in the bin: https://recoveryinthebin.org
Research into recovery (including NEON study: University of Nottingham):
https://www.researchintorecovery.com/
Scottish Recovery Network: www.scottishrecovery.net