Development of Recovery-oriented Practice in Mental Health

复元导向实践在精神健康的发展

Optimizing Outcome through Occupational Therapy Intervention 透過职业治疗介入提高服务效果

31 March 2018

Maurice WanOccupational Therapist & Department Manager

United Christian Hospital(UCH), Hospital Authority (HA), Hong KongConvener, Working Group on Promotion of Recovery-oriented Practice in Mental Health , UCH

Former Convener and present member of the Specialty Group in Mental Health, Coordinating Committee in Occupational Therapy (OTCOC), HA

OTCOC Representative, Working Group on Mental Health Promotion, HA

International Occupational Therapy Conference 2018

Overview 內容

• Background for Recovery-oriented Practice (ROP) in Mental Health Movement

• Development of ROP Mental Health in Hong Kong• What is Recovery?• A Working Framework for ROP in Mental Health• Case illustration for transformative change in a local

psychiatric day hospital in Hong Kong• Optimizing ROP Outcome through Occupational Therapy

Intervention• Conclusion

Mental Health ServiceFrom Institutionalized Care to Recovery-orient Practice (ROP)

INSTITUTIONALIZATIONMedical Model- diagnosis, symptoms, and medication- clinical recovery - recovery FROM mental illness- patient restriction, separation from community

COMMUNITY-BASEDRehabilitation Model- deficits and life skills training- functional independence- Linking with Community

COMMUNITY MEMBERSHIPRecovery Approach- Empowerment- Self Determination- Personal Recovery - recovery IN Mental Illness- citizenship role- contribution to Community

De-insti

tution

alizati

onDe-s

tigmatizat

ion

由住院化到以復元為本 精神健康服務的轉変

Driving Forces for Development of ROP in Mental Health

• World-wide movement emerged since1980’s• recovery experiences of mental health service users • longitudinal research

Seven Long-Term Studies

Subjects Recovered and /or Improved significantly*

Sample Size Average Length in Years Study

62-68% 269 32 Harding et al. (1987a & b) Vermont

57% 140 22.5 Ogawa et al. (1987) Japan

49% 269 35 DeSisto et al. (1995 1 & b) Maine

*For Schizophrenia Subsamples

Get better Cope well with symptoms Re-establish self-identity Resume work and life roles

由住院化到以復元為本 精神健康服務轉変 的推�力

ROP in Mental HealthDriver in Hong Kong

Mental Health Service Plan (HA, 2010)

The vision of the future is of a person-centred service based on

effective treatment and the recovery of the individual.

Focus on recovery and social inclusion Inpatient care only when indicated

Patient-centred service delivery with engagement of the users

復元為本 香港精神健康服務的推�力

Personalized Care Program (PCP) for Persons with SMI since 2010嚴重精神病患者个案管理服�

• Re-focus from inpatient care to community & ambulatory services

• Facilitate patient’s recovery and re-integration into the community

• Enhance the continuity of care for discharged patients from hospitals to community setting through systematic needs, strengths and risk assessment

• PCP was established to provide intensive, continuous and personalized case management support

Personalized Care Program (PCP) for Persons with SMI since 2010

• Role of OT– Designated case manager– Provide need, strength and risk assessment for an

individualized recovery plan– Maintain contact with patients during the recovery journey– Coordinate and arrange appropriate services to patients,

including treatment upon sign of relapse– Collaborate with various service providers especially the

Integrated Community Centres for Mental Wellness (ICCMW) operated by NGO under SWD subvention to provide one-stop, integrated and accessible community support services

嚴重精神病患者个案管理服�

Enhancement of ROP for Psychiatric Inpatients since 2012

• Plan, implement and monitor illness management and recovery programme in psychiatric inpatient wards provided in psychiatric and general hospitals

• Facilitate early engagement of acute admitted patients, early discharge and better community re-integration

• Role of OT– Empower patients to take responsibility for their recovery and

mental well-being– To enhance patient’s ability in managing mental illness, mental

health and early daily living– Support patient’s recovery and better prepare for their

discharge

强化以復元為本 的住院病人服�

Recovery Programs developed by OT in HA

• Social Cognition Interaction Training Program

• Metacognitive Training Program • Illness Management and

Recovery Program (IMR)• Five Ways to Well-being• Peer Support (Job

Buddies) Program

以復元為本發展的治��划

What is Recovery or Personal Recovery?

Personal Recovery Clinical Recovery

reclaiming positive self-identity, meaningful and contributing life

reducing symptoms and deficits

Striving to reach full potential enhancing functional improvement

taking recovery as a process of personal growth & development (Recovery in)

targeting recovery as treatment outcome (Recovery from)

Taking responsibility by service users with peers and family support

relying on experts and professionals

SAMSHA, 2011William A. Anthony, PhD Professor & Director, Center for Psychiatric Rehabilitation, Boston University

Patricia Deegan, PhDUser & Research PsychologistAdjunct Professor, Dartmouth College School of Medicine and at Boston University

Ø Not a linear process

何謂復元?

Four Tasks of Personal Recovery復元的四項工作

1. Developing a positive identity

2. Framing the mental illness

3. Self-managing the mental illness

4. Developing valued social roles

Recovery Components �復元� 元素

希望Hope

全人 需要Individualized

自主自決

Autonomy

家庭

為本

Family

朋輩

支援

Peer

Support

起伏中 成長

Non-linear

個人獨特及有選擇Choices

積極參與

Participation

承坦 貴任

Responsibility

重視個人優勢Strength-based

融入

社會

Community

Personal Recovery in Practice – How ?

= Recovery Programs 服�?

= Recovery Activities活�?

Need to Operationalize the Concept of Personal Recovery…

復元的實踐?

复元運作概念?

Stages of Personal Recovery• Moratorium– Denial, confusion, hopelessness, withdrawal

• Awareness– Possibilities, hope

• Preparation– Stocktaking, gathering information, connecting

• Rebuilding– Setting goals, develop positive identity, taking responsibiliy

• Growth– Illness management, resilience, self-confidence, and

optimism, actualizing potential

Embedded Domains in Personal Recovery

Personal Recovery

Social Recovery/ Inclusion

Functional Recovery

Clinical Recovery

Personal Recovery• Hope• Strengths/ Resilience• Personal identitySocial Recovery• Community participation• Valued social roles• Citizenship and contributionFunctional Recovery• Assessment like work/ cognitive• Skills training• Adjustment• AdaptationClinical Recovery• Diagnosis• Treatment and medication• Symptoms/ illness management• Rely on experts & professionals

-

Process of Personal Recovery

Personal Recovery

Social Recovery/ Inclusion

Functional Recovery

Clinical Recovery

Com

mun

ity

Phas

e

Hos

pita

l Pha

se

Stages of Personal Recovery

ROP in Mental Health : A Working Framework

Structure

Process

Outcom

e

Recovery Components

As Service Guiding Principles

Social Inclusion (Recovery in an Ordinary Life as an Citizen)

Occupational Performance in Work, Education, Volunteer, Leisure, etc.

Functional and life skills enhancement

Focused Psychological Strategies

Positive Psychological Intervention (PERMA)

Use of Community Resources

Family Involvement

Peer Support

User Involvement

OT Intervention Participation

Clinical Functional Social Personal

Recovery Domains

(WAN, 2013)

Transformative Change in a local Psychiatric Day Hospital

through

Recovery-oriented Occupational Therapy Practice

STRUCTURE 架構

Psychiatry

Occupational Therapy

Health Resources

Center

Physiotherapy Department

Clinical Psychology KEC Working Group KEC Working Group

on on Promoting Promoting

Recovery-oriented Practice in Recovery-oriented Practice in Mental HealthMental Health

DeterminDeterminationation

TeamTeamworkwork

GovernanceGovernance

Involvement Involvement of PIRof PIR

STRUCTURE 架構

Services Working Groups

User Involvement復元人士參與

小組

Focused Psychological Intervention

心理介入

方法小組

Social Inclusion社會融合

服務小組

Modular Based

Program課程式

治療小組

Recovery Environment環境改善

小組

STRUCTURE 架構

User Involvement復元人士 的參與

Y UClub

Recovery 復元 360

提提供供「「復復元元」」人人

士士參參與與治治療療活活動動

過過程程機機會會

ChoicesChoices

由由「「復復元元」」人人士士提提供供意意見見，，策策劃劃及及負負責責推推行行治治療療活活動動User ParticipationUser Participation

付權及建立責任

Responsibility

Empowerment

YOUYOU Club - Club - Recovery Activities Organized by PIR

復元人士籌備活動

STRUCTURE 架構

Recovery Enhancement 「復元」支 友

Peer Mentor ProgramCollaboration with Health

Resources Center

朋輩導師計劃

PROCESS 過程

Recovery Support Service GuidelineRecovery Support Service Guideline「「復復元元」」為為本本 服服務務支支援援流流程程

Strength-Based Care Strength-Based Care

PlanPlan

優優勢勢為為本本 的的治治療療計計

劃劃

Recovery Support and Promotion – Recovery Support and Promotion – Community CollaborationCommunity Collaboration「「復復元元」」醫醫社社合合作作計計劃劃

Modular Treatment ProgramModular Treatment Program課課程程式式 治治療療活活動動

Users-led Programs

Users-led Programs

「「復復元元」」人人士士推推行行治治療療活活動動

Strength-Based Care PlanStrength-Based Care Plan優優勢勢為為本本 的的治治療療計計劃劃

Needs需要

Strengths優勢

Risks危機

治療目標治療計劃

個案討論Case ConferenceCase Conference

治療計劃

Recovery Support Service GuidelinesRecovery Support Service Guidelines 「「復復元元」」為為本本 服服務務支支援援流流程程

在社區中的適應

住院服務使用者

Inpatients

日間醫院服務使用者

門診使用者

社區資源

外展服務

臨床的復元

功能的復元

社會融入

社會融入及個人復元

Clinical Recovery

臨床的復元

Functional Recovery

功能的復元

Social Inclusion

社會融入

Personal Recovery

個人復元

Modular ProgramModular Program 課程式 治療小組

Family Involvement Family Involvement 家家人人參參與與計計劃劃

Social Collaboration與社署合辦愛家庭，愛鄰舍計劃

Recovery Journal Recovery Journal ��復復元元��日日誌誌

Recovery Environment 環環境境的的改改變變

Words of Wisdom on Recovery在環境中貼上復元及鼓勵的語句

Recovery Journey牆上的裝飾引進復元的旅程

Art work by PIR張貼復元人士的畫作

電視屏幕顯示

復元課程

Choices of Modular Programs

Peer Support Program朋輩支援計劃

Recovery Support and Promotion – Community Collaboration �復元� 醫社合作計劃

Recovery-oriented Mental Health Education�復元�為本 精神健康教育 - �有種經歷叫復元�

Create Opportunities創造復元人士與中學生接觸機會

Contribution as a Citizen復元人士 充分展現 對社會貢獻的角式

Recovery Stories & Experiences

活動，交談，分享復元

故事，文字記錄

復元人士和中學生相處

的經驗

Publishing into Story Book並编輯成書，以作推廣精神健康之用

Recovery Day Recovery Day ��復元�日之旅

2012-132012-13 重拾自我

2013-142013-14燃點希望

2014-152014-15 並肩同行

2015-162015-16醫社共翩復元路

分分享享復復故故事事

肯肯定定及及獎獎勵勵

提提供供參參與與機機會會持持續續實實踐踐

累累積積經經驗驗 團團隊隊建建立立

合合作作伙伙伴伴

建建立立復復元元文文化化

Culture

Practice

Reflection

Participation

Recognition

Story Sharing

Team work

Collaboration

Reclaiming Self Identity

Hope

Walking Together

NGOs Collaboration

OUTCOME 成效

Recovery Self Assessment (RSA, O’ Cornnell et al., 2005)Focused Interview of staff

and service users

OUTCOME- Quantitative 量

• Fifty-eight service users in 2013 and 2016 respectively have completed the Recovery Self-Assessment (RSA).

• The Mann-Whitney U Test showed significant improvement in the recovery domains including: - Life goals 定立及追求生活目標 (p=0.001), - Participation 復元人士的參與 (p=0.002), - Diversity of treatment 多元化的治療活動 (p=0.025), - choice 選擇活動 (p=0.004) - Individualized services 貼合個人化的治療服務 (p=0.005)

OUTCOME – Qualitative 質

Empowerment User Involvement Community Involvement

Higher autonomy of service users服務使用者能更大的程度的自主自決

Increased choices of activities增加活動的選擇

Increased training and promotion of ROP for staff and public令更多職員及公眾人士認識「復元」

Increased attention on service users’ strengths and talents能重視復元人士的優勢及才能

Increased opportunities for users-led programs增加復元人士帶領的活動

Collaboration with NGOs in promoting ROP in society與社福機構合作，在社區中推動「復元」為本服務

Mutual learning and trust between service users and staff復元人士及醫護人員之間的信賴及互相學習

Improved appreciation to service users能欣賞復元人士

Focused interview on 4 service users, 4 frontline staff, and 3 stakeholders

Continuity & Sustainability 持�性

HospitalComm

unityCommunity

Community

PIRPractitionerManagem

ent

Agency

AgencyPeers

Family

Optimizing Outcome of ROP in Mental Health through Occupational Therapy Intervention

• Align with the philosophy and practice of OT as an enabling profession

• Empower people to live their life again despite impairment or disabilities or handicaps

• In line with the Vision & Mission of OT in HA revised in the 1990s that – Vision: All our clients shall live a meaningful life of

their choice– Mission: empower people with various disabilities to

live a meaningful life of their choices through returning to their valued life roles at home, work and leisure

透過��治�介入提高服�效果

Optimizing Outcome of ROP in Mental Health through Occupational Therapy Intervention

• Beyond psychiatric disorder to recovery and well-being with emphasis on individualized care plan, strength-based intervention, user participation, and positive psychological intervention, etc

• ROP in Mental Health as an opportunity for further recognition of OT’s contribution in mental health

透過��治�介入提高服�效果

Personal Recovery Social InclusionPositive Identity

Challenges to Occupational Therapy Practice to Optimizing the Outcome of ROP in Mental Health

• Renew mind-set, knowledge and skills to enhance our role to support client’s recovery journey

透過��治�介入提高服�效果的挑�

Strength-based Intervention

• Principles– Users can recover, reclaim and transform their lives– focus on individual strengths– Community as a resource oasis– User as director of the helping process– The therapist-client relationship is essential– Community is the ultimate setting of Recovery

優勢為本的介入

Strength-based Intervention

• Assessment– Home/daily living– Financial/ insurance– Employment/ education/ specialized knowledge– Supportive relationship– Wellness/ health– Leisure/ recreational– Spirituality/ culture

• Individualized care plan/Recovery goals setting– Utilize of strengths identified

優勢為本的介入

Role Enhancement as a Coach教�技�

• Powerful coaching questions– preferred future of client– solution-focused– exceptions to every problem can be created– client’s strengths and resources– small change leads to larger change–meaning and experience are interactively

constructed– Client is the expert

Creative use of Occupational Therapy Environment

�境運用及改�

• Service structure and process• Activities design• facilitate integration of Recovery componants – empowerment, – user participation, –making choices, – taking responsibilities, – Instilling hope, etc.

Enhance Use of Occupations 作�活�的改善

• As positive psychological intervention strategy (the evidence-based model PERMA ) to support Recovery and Wellbeing –Positive emotion–Engagement and finding flow–Relationships and connection–Meaning and purposeful existence–Achievement and accomplishment

Center-based to Community

• Client’s preferred environment– Assessment of strengths/ resources– Facilitate appropriate support and skills transfer

• Social inclusion– employment– leisure activities– education– housing

• Citizenship – As an ordinary citizen in the community

社区化

Revisit Occupational Therapy Practice Model ��治�模式檢視

• Occupational doings Vs beings

• the Person-Environment-Occupation-Performance (PEOP) Model as a guiding framework for planning, implementing and evaluating ROP in mental health

Conclusion �論• Personal Recovery in mental health is a way of living an

ordinary, satisfying, hopeful, and contributing life despite having mental illness

• Self-direction, strength-based, taking responsibility, and maintaining hopeful attitude are the key dimensions of Recovery

• A transformation process of the client, the staff member, the organization and the community

• Enhancement of OT mind-set and intervention helps to optimize the outcome of ROP in mental health

• Ongoing journey for clients to lead an ordinary yet meaningful life of their choices

「懂得為何而活的人，

差不多任何痛苦都能忍受得住。」

尼采

能夠重拾生活的

目的和意義，

差不多任何精神病患

引致的困難都能面对!

Those who can regain the purpose and meaningof life can bear almost any difficulties from having mental illness

Reference

• Anthony, W.A. (1993). Recovery from mental illness: the guiding vision of the mental health service system in the 1990’s. Psychosocial Rehabilitation Journal,16, 11–23.

• Berg, I.K. (1994). Family based services: A solution-focused approach. New York: Norton.

• Berg, I.K., & Szabo’, P. (2005). Brief Coaching for Lasting Solutions. New York: Norton. 1-40.

• Chamberline, J. (1990). The ex-patients' movement: where we've been and where we're going. Journal of Mind and Behavior, 11, 323-36.

• de Shazer, S. (1985). Keys to solution in brief therapy. New York: Norton.• de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York: Norton• de Shazer, S. (1991). Putting difference to work. New York: Norton.• de Shazer, S. (1994). Words were originally magic. New York: Norton.• de Shazer, S., Berg, I.K., Lipchik, E., Molnar, A., Gingerich, W., & Weiner-Davis, M.

(1986). Brief Therapy: Focused solution-development. Family Process, 25(2), 207-222.

Reference

• Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11–19.

• Deegan, P.E. (1992). The independent living movement and people with psychiatric disabilities: taking back control over our own lives. Psychosocial Rehabilitation Journal, 15(3), 3-19.

• Davidson, L., Tondora, J., O'Connell, M.J. et al. (2009). A Practical Guide to Recovery-oriented Practice: Tools for Transforming Mental Health Care. Oxford University Press, New York.

• Davidson, L., Rakfeldt, J., & Strauss, J. (2010). The Roots of the Recovery Movement in Psychiatry: Lessons learned. Wiley-Blackwell, UK.

• Eaton, H.G. (1935). The Development of Psychiatry. California and Western Medicine, 43(2): 115–118.

• Hospital-Authority, (2010). Hospital Authority Mental Health Service Plan for Adults 2010-2015. Hospital Authority, Hong Kong SAR, PRC.

• Jackson, P.Z., & McKergow, M. (2007). The Solutions Focus – Making Coaching & Change SIMPLE. Nicholas Brealey International. UK. Second Edition. 137-1154.

Thank You

謝謝