Personal recovery is key to developing good mental health, and is an underlying principle of government policy.
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