Personal recovery is key to developing good mental health, and is an underlying principle of government policy.
A number of mental health charities provide useful resources about recovery including RETHINK , the Mental Health Foundation and Mind.
Despite the importance of recovery, it is difficult to embed the key principles of service user orientated recovery; hope, control and opportunity in services.
This study aimed to improve the recovery focus of staff working with service users in adult community based services and teams.
REFOCUS was a cluster randomised controlled trial of Community Mental Health Teams (CMHTs) which aimed to improve the recovery behaviours of staff.
The intervention was developed from a literature review and consisted of a number of components including training, coaching, telephone support and reflection groups with clinicians.
The primary outcome was the Questionnaire about the Processes of Recovery (QPR), although a range of other secondary outcome measures were also collected (n=14). Data was collected approximately one month before the intervention started, and then repeated afterwards.
- CMHTs were randomised to either:
- The intervention arm: usual care and REFOCUS (14 CMHTs) or
- The control arm: usual care (13 CMHTs)
- 403 patients were randomised and 297 were included in the final analysis:
- 153 patients (usual care and REFOCUS)
- 144 patients (control)
- There was no difference in QPR scores (the primary outcome) between the two arms:
- REFOCUS group 40·6 [SD 10·1]
- Control group 40·0 [10·2]
- Adjusted difference 0·68 (95% CI -1·7 to 3·1, p=0·58)
- Highly engaged teams had better staff scores for recovery-promotion behaviour at follow-up:
- Adjusted difference -0·4 (95% CI -0·7 to -0·2, p=0·001)
- Patient QPR interpersonal scores -1·6 (95% CI -2·7 to -0·5, p=0·005)
- Patients in the intervention arm incurred lower costs than those in the control group:
- After adjusting for baseline costs, the difference between the two groups was £1,062 (95% CI -£1,103 to £3,017)
The authors concluded:
Although the primary outcome was negative, supporting recovery might, from the staff perspective, improve functioning and reduce needs.
Implementation of REFOCUS could increase staff recovery-promotion behaviours and improve patient-rated recovery.
It is incredibly disappointing that this study appears not to have a significant impact on the recovery orientated behaviours of staff.
The authors have made a number of suggestions why the trial failed to have a significant impact, including:
- Poor implementation within teams
- The fact that recovery is a long-term outcome
- The effects of an unblinded study
- The fact that the primary outcome was not the best
It is clear that training mental health teams in order to bring about change is notoriously difficult. Total team training is virtually impossible and staff frequently move between services.
It is also interesting to see how the teams ended up being randomised, which was probably influenced by a lack of stratification in this study, for example all Assertive Outreach Teams and supported accommodation were in the control, and the majority of recovery teams were in the intervention arm. Whether or not this influenced the finds is debatable.
This study has been presented in some quarters as an “important milestone” in psychosis research. It will be interesting to see if other teams of researchers now pick up the baton by conducting further rigorous trials that help to refine the most effective programmes for supporting recovery-oriented behaviour and relationships with service users.
Slade M. et al (2015) Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial. Lancet Psychiatry DOI: http://dx.doi.org/10.1016/S2215-0366(15)00086-3
Le Boutillier C. et al (2011) What does recovery mean in practice? A qualitative analysis of international recovery-oriented practice guidance. Psychiatr Serv. 2011 Dec;62(12):1470-6. doi: 10.1176/appi.ps.001312011.
Department of Health (2011) No Health without Mental Health, HMSO, London https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf
@Mental_Elf Would it not standardised the person centred notion of Recovery?
@Mental_Elf Mind you that has always been the case since the concept was formalised and calibrated around meaningful activity.
@Mental_Elf Or employment.
Mental health recovery: does training staff help? http://t.co/A2zbw7qC5C #MentalHealth http://t.co/4nd52ZadOR
So training staff doesn’t seem to make them do ‘recovery’, my @Mental_Elf blog http://t.co/e7XFl8sM9z
Hi @Refocus2014 @Rethink_ We’ve blogged about the @LancetPsych REFOCUS study today http://t.co/DRg0BimPyL #recovery #psychosis
Thanks for this accurate summary of our study. A few points to add:
1. The theory base for the study is more extensive than ‘a literature review’ – in fact, my amazing team undertook 7 systematic reviews, qualitative validations studies and a national survey to inform the intervention and its evaluation. This theory base is described at http://www.researchintorecovery.com/refocus and summarised in a fortchoming paper:
Slade M, Bird V, Le Boutillier C, Grey B, Larsen J, Leamy M, Oades L, Williams J Development of the REFOCUS intervention to increase mental health team support for personal recovery, British Journal of Psychiatry, in press.
2. Recovery is an experience, not something the system ‘does to’ the person. We were therefore very mindful of the broad concern that recovery is being co-opted by the mental health system, and the specific danger that the REFOCUS intervention would be viewed by the mental health system as the means by which staff should ‘do recovery’. We used a number of strategies to address this concern, including employing people with lived experience as researchers, and evaluating the impact of a Lived Experience Advisory Panel on the study:
Slade M, Bird V, Chandler R, Fox J, Larsen J, Tew J, Leamy M (2010) The contribution of advisory committees and public involvement to large studies: case study, BMC Health Services Research, 10, 323.
Although characterising the resulting REFOCUS intervention as a staff training intervention is not unreasonable, we had intended it to be more than just staff training. The REFOCUS Manual 1st edition (i.e. the version we tested in the RCT) contained some non-training elements, such as the Partnership Project (to provide experiential learning opportunities for staff and service users) and the supervision form (to support recovery-related reflective practice). However, our process evaluation found that these were not widely implemented, and so they were removed in the final (second) edition of the REFOCUS Manual (downloadable for free at http://www.researchintorecovery.com/refocus).
3. What does the trial show? Whilst the primary outcome did not change overall, there was significant improvement in QPR Interpersonal scale for people using teams which more fully implemented REFOCUS. I interpret this to mean that the primary challenge is implementation. During the trial, major service re-configurations happened across both study sites (including disbanding of two participating teams) so doing anything different was always going to be an uphill struggle. We published a process evaluation of predictors of implementation:
Leamy M, Clarke E, Le Boutillier C, Bird V, Janosik M, Sabas K, Riley G, Williams J, Slade M (2014) Implementing a complex intervention to support personal recovery: A qualitative study nested within a cluster randomised controlled trial, PLoS ONE, 9, e97091.
Predictors were identified at three levels: organisational (stability and commitment), team (effective leadership, stability and composition, and current practice) and practitioner (attitudes, values, motivation). Overall we showed that REFOCUS does lead to improved recovery when implemented, and that it is most likely to be implemented within systems and teams which are stable and well-led, and by practitioners who already have some positive experiences of pro-recovery practice.
4. REFOCUS is being taken forward in a number of countries (e.g. http://www.med.monash.edu.au/scs/psychiatry/southern-synergy/health-services/pulsar.html), and within England through the Innovation Network of the Schizophrenia Commission.
5. More generally, it may be that the real legacy of the REFOCUS trial will be to challenge any lingering concerns that ‘supporting recovery’ and ‘evidence-based practice’ are incompatible. The REFOCUS trial adds to the growing empirical evidence base for pro-recovery interventions, which was summarised in 2014:
Slade M, Amering M, Farkas M, Hamilton B, O’Hagan M, Panther G, Perkins R, Shepherd G, Tse S, Whitley R (2014) Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems, World Psychiatry, 13, 12-20.
Thanks Mike Slade for adding in more detail,clarification, and references. It is really helpful to see how this one paper fits into a huge scheme of work. Implementation does appear key to this study, which is clearly problematic given continued re-configuration of services. I was interested in the intervention – given the difficulty in developing an intervention beyond training – was there a minimum threshold of attendance/team involvement needed to bring about change?
Great comment on our REFOCUS blog from lead author Mike Slade http://t.co/f5hw28DdvT @JohnBaker_Leeds @Refocus2014
We used a non-standardised participation scale to rank staff from each team on participation. The participation scale assessed engagement in the six implementation strategies (information session, personal recovery training, coaching training, team manager reflection sessions, team reflection sessions, supervision reflection). It is described in the supplementary materials for the trial report (http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366%2815%2900086-3/supplemental) and was called the REFOCUS Implementation Scale in the protocol paper:
Slade M, Bird V, Le Boutillier C, Williams J, McCrone P, Leamy M (2011) REFOCUS Trial: protocol for a cluster randomised controlled trial of a pro-recovery intervention within community based mental health teams, BMC Psychiatry, 11, 185.
For each team, we pooled the participation scale ratings for staff who did not move team and had baseline and follow-up data to produce a team-level score. We then used a median split to dichotomise intervention teams into high and low implementation.
This of course doesn’t address the ‘dose-effect’ question of how much of the intervention needs to be given for an effect. We tried and abandoned several attempts to analyse this, eventually concluding that because the intervention is complex (i.e. comprising several components, each of which may be independent or inter-dependent), it was not possible to identify a defensible approach to weighting participating in the different intervention elements (e.g. how much ‘team reflection session’ attendance is worth 50% ‘coaching training’ attendance?)
#Mentalhealth recovery: does training staff help? via @Mental_Elf http://t.co/SnuyCz0iTk #bizitalk
Hi @ImROC_comms @SaraMeddings @waldoroeg Any thoughts on our #REFOCUS #recovery blog? http://t.co/DRg0BimPyL by @JohnBaker_Leeds
Hi @julie_repper @sharongilfoyle1 Please read and comment on our #REFOCUS #recovery blog http://t.co/DRg0BimPyL by @JohnBaker_Leeds
Morning @ProfGeoffShep Interested in your thoughts on our #REFOCUS #recovery blog http://t.co/DRg0BimPyL by @JohnBaker_Leeds
Hi @simonsrn We’ve blogged about the #REFOCUS #recovery RCT http://t.co/DRg0BimPyL Any comments for @JohnBaker_Leeds?
Hi @JoinMQ @CjoyceMQ Have you read @JohnBaker_Leeds’ #REFOCUS #recovery blog yet? http://t.co/DRg0BimPyL Any thoughts/comments?
Interested in mental health recovery? Read this: http://t.co/DRg0BimPyL @JohnBaker_Leeds http://t.co/7kj7JTvJZv
@Mental_Elf @JohnBaker_Leeds Agree REFOCUS demonstrates that supporting recovery means supporting organisations not just training staff
@ProfGeoffShep @Mental_Elf @JohnBaker_Leeds http://t.co/RHEd3o4SrE Both organizations/staff need to be better equipped to help clients
Recovery hasn’t really been blogged about by @Mental_Elf see mine here on Mike Slade’s important work http://t.co/e7XFl8sM9z
The REFOCUS study has shifted the largely values based approach of recovery promotion in the UK firmly into a world of scientific rigour. The numerous outputs from this programme overall have been enormously helpful to our work in Scotland around recovery promotion, perhaps most notably the CHIME conceptual framework (Leamy et al 2014).
It is of course disappointing that this trial failed to show the desired effect but in some ways not that surprising. In addition to the clearly monumental challenges of implementation and the unfortunate timing (austerity-wise) there are I think other contributory elements, all of which we can learn from.
For me a potential weakness was the lack of emphasis on engagement with people in receipt of services. If recovery is at least in part characterised by hope and belief in its possibility then we need to look at new and different ways of disseminating and sharing that belief. This intervention was largely predicated on the belief that could be achieved via staff training and practices. While that is one part of the necessary shift, more direct work with people in receipt of services which was not ‘professionally’ driven would I suspect have been helpful. Shifting towards recovery requires we also shift power and that requires support and negotiation both for those giving up the power (practitioners) and also for those taking it on (people using services). These shifts are I believe negotiated out with traditionally expert-patient settings – in peer groups, in mutual support groups in recovery learning environments. Trying to achieve recovery approaches almost entirely through practitioner interventions is missing part of the story and puts too big an onus on practitioners who may themselves feel a reduced sense of hope and agency in a sea of service change and competing demands.
That said I am hugely grateful to everyone involved in the REFOCUS study for their massive contribution to the advancement of recovery based approaches in the UK and have great respect for their work and integrity.
Leamy, M., Bird, V.J., 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 http://www.researchintorecovery.com/
Is it possible to look at REFOCUS in isolation, although I’m passionate about “recovery” orientated services, I have to complete honos, care clustering, standardised outcome and assesment tools, with these days a focus on risk. I firmly believe that to “get ” recovery one needs to be able to have an understanding of how it applies personally ie to the clinician. There needs to be an enviroment of “recovery” for the staff to work in to aid the systems “recovery” eg as staff and the system how hopeful am I, how in charge am I, how empowered, in the increaseingly challenging times all these factors seem to be reducing. Training won’t help with this just increase frustration, or should we look at who we are training eg commissioners?
RT @Mental_Elf: REFOCUS RCT: supporting recovery in psychosis patients through care by community-based adult mental health teams http://t.c…
The REFOCUS RCT: an “important milestone” in psychosis research? http://t.co/DRg0BimPyL
No mention of relational security? @Mental_Elf: REFOCUS RCT: an “important milestone” in psychosis research? http://t.co/9IPSP16Xg3
“Mental health recovery: does training staff help?” http://t.co/OzBmtZsNdZ #psiquiatría #feedly
RT @Mental_Elf: Don’t miss: Mental health recovery: does training staff help? http://t.co/DRg0BimPyL #EBP
interesting study which shows why it is A good reason to investigate how we develop ourselves as recovery… http://t.co/XOXj7z6A2z
Last chance to add to the debate. Training staff to be more RECOVERY orientated, my @Mental_Elf blog http://t.co/e7XFl8sM9z
Mental health recovery: does training staff help? https://t.co/ZNvwi3trE8 via @sharethis
Mental health recovery: does training staff help? https://t.co/2KXsWOjxal via @sharethis
RT @Mental_Elf: There’s a brilliant discussion about mental health recovery taking shape here: http://t.co/DRg0BimPyL Please join in!
Mental health recovery: does training staff help? https://t.co/JYhi4mJYkT via @sharethis
Mental health recovery: does training staff help? http://t.co/UHrQCdTnFl via @theoldreader
Mental health recovery: does training staff help? http://t.co/GMt50HpYrv via @Instapaper
Does staff training help in #mentalhealth recovery? @Mental_Elf w/ a study here http://t.co/Y3NJFBoP8J @MHF_tweets @MindCharity @Rethink_
Mental health recovery: does training staff help? https://t.co/zfwjl7tp9U via @sharethis
2DO – read this: “Interested in mental health recovery?” via @JohnBaker_Leeds h/t @Mental_Elf http://t.co/Ng28213cFz http://t.co/cx9ynboLoz
#Mentalhealth recovery: does training staff help? New study results from @JohnBaker_Leeds https://t.co/UNEv2f8q6f
I do think this is a useful study, however I’m afraid it was never going to work very well. Simply training staff to do something different and then expecting them to do it is always ineffective (look at PSI training or MERIDEN) and this had been well demonstrated in the field of Recovery in an elegant study by Rob Whitely and his colleagues in the States looking at Mueser’s IMR programme (Whitley, R., Gingerich, S., Lutz, W.J. & Mueser, K.T. (2009) Implementing the Illness Management and Recovery Program in Community Mental Health Settings: Facilitators and Barriers. Psychiatric Services, 60, 202-209). Slade’s group was therefore in pretty good company in making this kind of mistake, everyone does it. From my prejudiced viewpoint, a much more organisational approach to helping organisations change so as to support recovery is to be found in the work of ImROC (e.g. Shepherd, G., Boardman, J., & Burns, M. (2010). Implementing recovery: A methodology for organisational change. London: Centre for Mental Health. http://www.imroc.org/wp-content/uploads/Implementing_recovery_methodology.pdf ) where the aim is to work with staff and organisations to release them from the shackles of bureaucracy to do what they know is right.
The REFOCUS trial also involved little in the way of true ‘co-production’, i.e. staff and service users being ‘trained’ (don’t like that word) together in sessions led by staff and service users. In our experience, the main implementation problem for staff lies in their low expectations of what service users can actually achieve in their lives (institutional stigma) and to counteract this requires direct contact between staff and the stigmatised group (service users) in a safe setting where both are present and this prejudice can be explored so that staff can re-evaluate their attitudes. We think that this process bears little relationship to ‘training’ as usually conceptualised.
Finally, the trial only involved two Trusts, both of which were really only starting on their journey of creating a more recovery-supporting culture. Quite apart from doubts about the generalisability of the results from such a small sample, given the conceptual distance the staff had to travel in both organisations, frankly I wouldn’t expect much in the way of effects for at least a couple of years, by which time the trial would just be ending.
I am sure that the REFOCUS group learned most of these lessons in the course of running the trial, but unfortunately this kind of 20/20 hindsight is not available when you are designing an NIHR funded RCT at least 5 years ago. We have certainly learned a lot about how to help organisations to change so as to better support recovery and there are lots of papers, films, DVDs and personal narratives on the ImROC website (www.ImROC.org ) testifying to the notion that this is possible and the results will genuinely benefit the lives of service users receiving these new services.
I also have to say that, while I completely agree with then need for more rigorous evidence, I don’t see this as being synonymous with RCTs. ‘Evidence’ comes in lots of forms and I hope that people who are interested in providing evidence that recovery can be supported remain open to all sorts of methodologies and designs to collect this evidence.
Thus, I do think this is a useful study. If nothing else it has provoked a rich discussion about how these kinds of studies could be done better. That is how scientific understanding progresses. I therefore hope that it does provoke a lot more research which benefits from the lessons that this trial gives us.
Centre for Mental Health
Fab comment from @ProfGeoffShep on @JohnBaker_Leeds mental health recovery blog http://t.co/Lou3FKCyFm Thanks Geoff!
Mental health recovery: does training staff help? https://t.co/ypwxdRomyr via @sharethis
[…] have done a fair amount of thinking about recovery, ranging from service user to staff concepts. A recent blog by fellow elf John Baker on a study trialling mental health recovery training for staff came up […]