Electronic supplementary material
Regional opportunities and imperatives
Recovery possibilities and needs
Service delivery frameworks and models
Clinical Rehabilitation (CR) within MH services
CR principles and priorities
Planning and Diagnosis
Intervention and Review
Transfer of Care/Discharge
Clinical Review or Recovery-focused Tracking
Aspirations - Hope of a better life may include: wellness enjoyment, participation, contribution and opportunity.
Personal - working with an individual’s goals no matter how well grounded, is pivotal in fostering commitment to recovery processes.
Self-identified – imposing goals that are incongruent with the individual’s is simply counter-productive and diametrically opposed to the tenants of CR.
Well formulated - using assessment toolsa that have credibility with a person may assist in discussing and formulating recovery goals.
Comprehensive – thorough and holistic, not adopting a pathological view of SMI, but unashamedly a comprehensive appraisal of relevant factors to assist in the formulation of a collaborative recovery plan.
Multiple domains - may include: medication, treatment, co-morbidity, substance-use, physical & cognitive issues, coping, daily living skills, living arrangements, education & employment, family interactions, social, sexual and existential needs & stage of change.
Function oriented – may include an array of issues in domains of functioning, activity & participation, role & impact on environmental and personal factors.
Promoting hope – the knowledge gleaned assists clinicians to work effectively with clients & their family in generating and validating hope.
Collaborative – may be developed using tools such as the MHRSa. Recovery-oriented plan outlines individual recovery needs and develops strategies dependent on motivation for change in specific domains.
Evidence-based - guiding access to a range of interventions (e.g., cognitive remediation, skills training, family interventions, employment & education strategies), as well as support & environmental adaptation.
Delivery methods - interventions may be detailed as concurrent, sequential, in individual or group settings, as well as identifying who participates (family, carers, friends, support workers).
Coordinated – across clinical and non-clinical interfaces, as well as addressing the interaction of CR & pharmacological intervention.
Goal focused - related to a range of personal, social & environmental factors, not diagnosis dependent. Interventions assist in achieving goals & improving mental & physical health.
Individually tailored –interventions are individually tailored but, to assist clinicians in recovery-oriented service provision, core interventions may be linked with domains of recovery (e.g., using the MHRSa).
Integrated programs – provide a foundation for developing strategies and interventions. Core & elective programs operate in individual, group, milieu/residential and community settings.
Structured – collaborative, goal focused, evidence-based and motivational to promote generalisation, and accommodate different learning styles and abilities. To support achievement, higher level therapy programs are run in parallel to compliment activity-based programs.
Aim to ensure the highest level of care & that:
1. Strategies are comprehensive, responsive & positive;
2. Support is available to the CR clinician at every step;
3. Continuity maintained through information sharing;
4. Concurrent interventions are implemented and monitored;
5. Early intervention strategies are available;
6. Multidisciplinary team skills are available;
7. Risks are quickly identified & resolved;
8. Interventions are evidence &/or practice-based;
9. Positive recovery-oriented outcomes are shared;
10. Care coordination facilitates high quality service;
11. Opportunities exist to build service networks and linkages;
12. Key performance indicators are discussed and reviewed.
The review provides a forum to oversee, support & co-ordinate service delivery & maximise recovery possibilities.
Time demands - time intensive due to complexity of issues & need to ensure a positive and productive milieu. Recovery trajectories are complex & dynamic. Work contexts can be demanding, particularly when the time course is extensive & progress minimal.
Processes – innovative, recovery-focused, inclusive & holistic. Review should be led by a senior CR clinician due to complex processes & time-frames, & include client, family, peer-support & relevant agencies. Feedback informs goal development & collaborative interventions.
Recovery pathways - may be simple & linear or interspersed with minor setbacks, even relapse. Incremental recovery in some domains & profound in others. Gains may be interdependent. Numerous reiterations of CR processes may be required to trigger a decision to adopt a more inclusive & adaptive approach (e.g., for SMI & substance misuse).
Achievements – Clinical review can objectively affirm achievements; facilitate development of options &/or determine when another strategy is warranted; & aid making complex decisions regarding level of service need. Achievement of self-determination in several domains may require minimal short-term interventions accompanied by follow-up & review.
Integrated Recovery-oriented Model (IRM)
Illustrative IRM scenario
If a client advised of an escalation in their early warning signs and…
it had become evident, after review by the CR team, that coping strategies and environmental supports were not sufficiently robust to prevent a relapse.
➮ A brief admission may be considered, particularly if safety was a concern.
➮ In consultation with the acute community team, client and family, an admission plan would be developed that reassured and affirmed the client’s role in working with clinicians (e.g., in regard to identification of warning signs).
➮ The plan would also be designed to reinstate hope by building a range of coping strategies and supports.
➮ Identification of triggers &/or vulnerabilities would be central to this process. Although the initial focus would be on MH remediation, the degree of involvement of the other IRM service components would be dependent on the vulnerabilities identified by the client in the clinical review.
If medications were a primary concern and further adjustments required.
➮ This could be managed safely in a recovery-oriented sub-acute inpatient unit, with follow-up review by the CR psychiatrist, working in conjunction with a GP.
If, on the other hand, adherence was a concern.
➮ Strategies could be developed by the CR clinician and, depending on the accommodation arrangements, supported by the accommodation provider.
➮ The frequency of clinical reviews would be increased to support the client and monitor effectiveness of the intervention strategies.
If additional coping strategies were required to manage stress in the residential or employment arena
➮ These could be developed and implemented, with the support of relevant CMOs/NGOs.
If issues emerged around substance misuse:
➮ The CR team would engage specialist MH services, as well as setting up risk management strategies.
If high levels of expressed emotion in the family were a factor.
➮ CR could develop a family intervention and education plan.
If the CMO/NGO indicated that there were sexual safety, antisocial or substance misuse issues in the living situation.
➮ Strategies could be developed to improve safety (before consideration of a disruptive change in location). Clinical experience would suggest that quite often a complex of vulnerabilities impacts on wellness.