Adult Mental Health Teams Research Articles

Sitting with uncertainty to create a rich nourishment for clinicians: Developing a systemic family therapy clinic for psychosis in community adult mental health team

PHOTO CREDIT: Priscilla Du PreezSystemic practice can be a rich source of fuel for services, nourishing clinicians and families. To us, systemic thinking supports the creation of space, taking pause, being with and seeing the bigger picture. It is about multiplicity, of idea, of voices, of people and cultures coming together to make sense together. In a culture which is struggling under the weight of austerity, the pandemic and ongoing limitations of practice due to staff shortages and limited resources at a time of extreme demand, we need something to open ourselves and our clients to new possibilities and build trust and safety.This paper will describe systemic family therapy within a secondary care community mental health team. You will hear the voice of Jo, a consultant clinical psychologist and systemic psychotherapist and Funmi, an assistant psychologist in the team. We will discuss decision-making in this work and explore the experiences of the reflecting team, highlighting the value of a systemic approach in secondary adult mental health. The straightest route is not always the most effective or nourishing, sometimes it takes the windy path to get the richest source of progress.

Service evaluation project: Evaluating and addressing staff training needs in relation to autism in an older adult mental health service

Autistic adults are at higher risk of experiencing mental health problems and commonly describe poor service experiences relating to a lack of understanding of autism by clinicians. Therefore, there is an increasing impetus in the National Health Service (NHS) for staff to receive autism training. However, there is a lack of understanding around training needs for older adult mental health teams. This service evaluation project used audit and survey methodologies to explore the autism training needs of an older adult mental health team. Whilst the audit identified that the team did see patients suspected to be on the autism spectrum, most patients did not have an official diagnosis. Most clinicians reported never having received any training in autism, and highlighted autism in older adults, and autism and mental health, as specific training priorities. A training programme based on these responses was developed, implemented, and evaluated using surveys. The training was rated as useful by attendees and resulted in non-statistically significant increases in self-rated knowledge. The findings of this study suggest that clinicians working in older adult mental health may particularly benefit from training specialised to their older adult context. Further research is required to better understand the area of older adulthood and autism, and to evaluate how to effectively enhance the capability of staff working in this area.

‘The role of encourager’: Exploring the experiences of mental health professionals working with older adults with hoarding disorder

Hoarding disorder affects 2–5 per cent of the population, with older adults making up a substantial proportion of that due to the chronic nature of hoarding behaviours and consequent clutter. Multiagency hoarding frameworks are being developed all over the UK, with mental health services working alongside other agencies to support an individual with hoarding difficulties holistically. Mental health clinicians have previously reported finding their role in this difficult. Therefore, this study recruited 30 clinicians working in an older adult mental health team and explored their experiences through a questionnaire. Thematic analysis identified six key themes detailing the clinicians experiences of working with hoarding: (1) contextual factors (time constraints, scale of clutter, previous negative experiences influencing current treatment, lack of skills); (2) assessment (risk, life story, beliefs and motives, MDT); (3) formulation (co-creation, motives and beliefs, helping staff understanding); (4) treatment (values based, support systems, discarding, meaningful activity, monitoring progress); (5) therapeutic relationship (trust, making the time, reinforcement); (6) multiagency working (skill profile, differing perspectives, coordination). The data highlighted the need for staff training and support, providing the necessary tools to deliver evidence-based assessment, formulation, and intervention. The challenges described suggest better links between different agencies is required. Meaningful interactions and success stories were linked to developing trusting relationships, introducing values and needs based approaches, and making use of the skill mix with the mental health team. Keywords: Hoarding; Older Adults; Multidisciplinary team; Multiagency working.

Improving the Appropriateness of Referrals From Primary to Secondary Care Confounded by the COVID Era: Student Status and Quality of Referral Evaluation in Oxford City Team (SQUARE-OCT)

AimsThe Oxford City and NE Oxon Adult Mental Health Team (AMHT) is an adult mental health team receiving referrals from GPs for most cases suspected to have a mental health illness requiring secondary mental health services’ input in Oxford city. In January 2020, the team was remodelled with care coordinators working in separate functions based on the duration AMHT support was required for, i.e. an assessment team and a treatment team, but with medics covering both functions of the team. This quality improvement project examines AMHT referrals over 2020/21, hypothesising a reduction in the proportion of inappropriate referrals following the remodelling compared to a 2018/19 pre-remodelling audit.MethodsThe project covers a total of 2803 referrals the team has received from 13/01/2020 to 12/01/2021. The outcomes measured included the number of inappropriate referrals returned to the GP, referrals only requiring a single assessment, the proportion of these referrals as university students in Oxford, and the diagnostic groupings of the referrals in students vs non-students. These outcomes were measured pre- and during the COVID-19 pandemic over 2020/21.ResultsA reduction in the total number of referrals to the team was noted over 2020/21 but this was compared to an 11 month audit in 2018/2019. During the study period, 19.5% (546/2803) of referrals were deemed inappropriate compared to 21% of referrals received in 2018/2019. Of 2803 referrals, 14.7% (97/658) were inappropriate pre-COVID-19 vs 20.9% (449/2145) during the pandemic. Of the total number of referrals, 32.9% were returned to the GP following a single assessment.The top 3 diagnostic categories in ‘non-students’ were mood/affective disorders (33.7%), anxiety/stress related disorders (17.2%), and neurodevelopmental disorders (7.8% total - ADHD was 3%). A significant increase in ADHD referrals and mood disorders amongst students compared to non-students is notable with the top 3 diagnostic categories for students being mood/affective (24.7%), neurodevelopmental disorders (19.5% - ADHD 17.7%), and anxiety/stress related disorders (13.4%). Students constituted 26% of the total number of referrals.It was notable that during the pandemic there was a higher proportion of inappropriate referrals.ConclusionOur project demonstrates a reduction in the proportion of inappropriate referrals sent to the AMHT following remodelling as compared to 2018/19. Further work is necessary to elucidate the contributing factors and reduce inappropriate referrals even further. An innovation is planned to automate the logging of referral outcomes to expedite a re-audit.

Integrated Family Approach in Mental Health Care by Professionals From Adult and Child Mental Health Services: A Qualitative Study.

ObjectiveA multiple case-study in which each case was evaluated by adult and child mental health professionals who used an integrated family approach in their treatments. In this approach, treatment focuses on the mental disorders of the parents as well as on the development of the young child and family relationships. This study evaluated the experiences of professionals from adult and child mental health services using this approach. The aim of the study is identifying key elements of this approach, processes involved in treatment, and barriers to its success, with the aim of contributing to the development of practice based integrated mental health care for the whole family.BackgroundParental mental disorders have an impact on parenting and child development. To stop detrimental cascade effects and prevent parent and child from being caught up in the intergenerational transmission of psychopathology, an integrated family approach in mental health care is needed. Methods: A qualitative case study design using a grounded theory approach. Data were collected through 19 group interviews of professionals (N = 37) from adult and infant mental health teams who worked together in the treatment of a family.ResultsProfessionals from the two services were comfortable coping with complexity and felt supported to perform their treatments by staying in touch with each other in multi-disciplinary consultations. They indicated that by attuning the treatment components to each other and tailoring them to the capabilities of the family, their treatments had more impact. A flexible attitude of all involved professionals and commitment to the interest of all family members was essential.ConclusionAccording to professionals, treatment with an integrated family approach in mental health care is of value for families by addressing the distinct roles, positions and relationships, by implementing a flexible complementary treatment plan, and by empowering professionals by multi-disciplinary consultations.

Working in older adult mental health teams: Reflections from trainee psychologists

Working in older adult mental health teams: Reflections from trainee psychologists

An audit to review the extent to which appropriate preconception advice is given to women being discharged from mental health wards on psychotropic medication, in line with NICE guidelines

AimsThe release of the Cumberlege Report in 2020 served as a reminder of the importance of informed consent for women when they are started on treatment that may affect their fertility or future pregnancies.Our aim was to evaluate current performance with regards to advice given to women of childbearing age around contraception, impacts of psychotropic medication on fertility and future pregnancies, and availability of preconception counselling.MethodStandard identified as NICE Guideline 192 (Antenatal and Postnatal Mental Health), sections 1.2 and 1.4.60 female inpatients were selected by looking at the most recent discharges prior to 03/11/2020 from 3 local acute adult wards. All females aged between 18 and 48 years were included.Electronic notes were reviewed for each patient. The discharge summary and last four ward round entries were reviewed, then key-word search of the patients’ records was performed using the terms “pregnan*”, “conception”, “contraception”, and “fertility”.The following information for each patient was documented in a spreadsheet:Discharge medicationIs there any discussion or advice around contraception?Have women taking antipsychotic medication been given advice regarding the possible impact on fertility?Has the potential impact of psychotropic medication on a future pregnancy been discussed?Has advice been given about the availability of preconception counselling should they plan a pregnancy in future?ResultOn discharge, a total of 33 women were taking one or more antipsychotics and 14 were prescribed a benzodiazepine. 24 women were discharged with antidepressants and 10 women were using a mood stabilising agent. 8 women were discharged without any psychotropic medication.Overall, 4 women received advice about contraception, and a further 8 women were already using contraception. The impact of taking an antipsychotic on fertility was not discussed with any patient. No women were advised about pre-conception counselling. The impact of taking psychotropic medication on a future pregnancy was discussed with one woman.ConclusionCurrent practice falls well below the standard set by NICE. Opportunities to inform women are being missed, and this has implications for the wellbeing of the patient and, potentially, future children.Action plan;Present findings at teaching.Deliver local teaching covering preconception counselling and the role of adult mental health teams when managing women of childbearing age.Produce a poster for inpatients wards and an information leaflet for women of childbearing age to aid with discussions.Create a poster for doctors’ offices to remind about NICE standards and documentation.Re-audit in 6 months.

‘The silent intermediary’: a co-authored exploration of a client’s experience of art psychotherapy for C-PTSD

ABSTRACT Background This article presents a client’s (art therapee’s) conceptualisation of his experience of art psychotherapy for symptoms of complex post-traumatic stress disorder (C-PTSD). Context He was receiving treatment through a community adult mental health team within the UK National Health Service. Approach The art therapee wrote about his art psychotherapy experience, and then he and his art psychotherapist identified key themes. They related his account to art psychotherapy theory and evidence and drew out implications of his experience for art psychotherapy research. Outcomes/Conclusions The art therapee found that an art psychotherapy approach was helpful in these ways: having control; expressing without words; distancing from trauma; being creative and playful. He identified some aspects of the art psychotherapy which seem to be under-represented in art psychotherapy literature: the importance of the therapist’s acceptance of the client’s artwork for building trust; the way in which artmaking bypasses the fear of ‘telling’ about past abuse; and the therapeutic value of creativity and play for accessing positive aspects of the child self. Implications for research It would be valuable to gain information from other clients with C-PTSD about their experiences of art psychotherapy. Research into the identified under-explored aspects of art psychotherapy practice, the use of artmaking for C-PTSD symptom management and how artmaking can be integrated within other approaches to C-PTSD treatment would be useful. Plain-language summary This article describes how a client (art therapee) with symptoms of complex post-traumatic stress disorder (C-PTSD) experienced art psychotherapy. The art therapee received therapy through a UK National Health Service community adult mental health team. The therapy sessions were on a weekly basis over an 18-month period. The art therapee wrote about his art psychotherapy experience, and then he and his art psychotherapist identified some themes. They related his account to art psychotherapy theory and evidence and drew out implications of his experience for art psychotherapy research. The art therapee found that an art psychotherapy approach was helpful in four main ways. It helped him to feel in control of the therapeutic process, and enabled him to express experiences of past abuse without having to use words. It gave him a sense of distance from his traumatic experiences. Finally, it helped him to connect with his creativity. He identified some particular aspects of his experience which seem to be under-represented in art psychotherapy literature: the importance of the therapist’s acceptance of the client’s artwork for building trust; the way in which artmaking bypasses the fear of ‘telling’ about past abuse; and how creativity and playfulness in art psychotherapy sessions can enable a more positive view of oneself as a child. The authors consider that it would be valuable to gain information from other clients with C-PTSD about their experiences of art psychotherapy and to undertake research into those aspects of the client’s experience which appear not to have been explored significantly so far. Research into how artmaking can help relieve C-PTSD symptoms and how artmaking might be used within other approaches to C-PTSD treatment would also be useful.

The Systemic Assessment Clinic, a Novel Method for Assessing Patients in General\xa0Adult Psychiatry: Presentation and Preliminary Service Evaluation

The traditional model of psychiatric assessment and diagnosis can be criticised as reductive. We developed an innovative model for psychiatric assessment of adult patients referred to our adult mental health team, the Systemic Assessment Clinic, incorporating the principles and techniques of systemic family therapy and dialogical practice into standard psychiatric assessment. We conducted a service evaluation, comparing prospective use of mental health services for patients assessed either in the Systemic Assessment Clinic or in standard assessment. Patients assessed in the Systemic Assessment Clinic had more favourable outcomes than those in standard assessment: they were significantly less likely to need multiple follow-up treatment appointments with a psychiatrist and to be re-referred to mental health services once discharged, indicating reduced healthcare costs. Satisfaction rates for participants attending the systemic assessment clinic were high. Our service evaluation gives preliminary evidence that the Systemic Assessment Clinic could be a potential new model for psychiatric assessment; further evaluation is warranted in a randomised controlled trial.

S239. EVALUATION OF A POINT OF CARE DEVICE IN IMPROVING PHYSICAL HEALTH CHECK UPTAKE IN TWO COMMUNITY MENTAL HEALTH TEAMS

BackgroundPatients with Severe Mental Illness (SMI) have a life expectancy 15–20 years below that of the general population, mediated predominantly by the complications of poor cardiovascular health. Physical healthcare for this population is shared between General Practice (GP) and Community Mental Health Teams (CMHTs) and encompasses a NICE-recommended annual physical health check, to screen for cardiovascular complications. Audit findings in 2017 across the South of England show poor physical health check completion (38%), typically because HbA1c and Lipid Panel blood tests were omitted. Traditionally, patients are advised to attend their GP surgery for these tests, which can be a challenge for patients with SMI.There is a growing market of POC devices able to calculate an HbA1c or Lipid Panel in rapidly from ‘fingerprick’ samples of blood at, or near the site of the patient. The Cardiovascular Monitoring in Mental Health (CARMEN) project hypothesised that test uptake would be improved by implementation of a ‘Point of Care’ (POC) blood testing device in two CMHTs.MethodsWe embedded the ‘Afinion’ device into an Early Intervention Team and an Adult Mental Health Team in Oxfordshire for six months. Training was provided to care coordinators with ongoing support to facilitate engagement with the device. We compared rates of blood test and full physical health check completion in the intervention teams to a matched early intervention team and adult mental health term in Buckinghamshire. We performed semi-structured interviews with patients receiving POC-augmented care and clinicians from the intervention teams.ResultsData showed that whilst the Adult Mental Health team did not engage with the device and saw no change in outcomes, the Early Intervention Team did engage and increased rates of physical health check completion from 22.6% to 40.3% of their caseload per 6 months. Completion in the control CMHT was 7.8%. Similar trends were seen in rates of HbA1c and Lipid Panel completion. Qualitative interviews revealed universal patient support for POC and diverse attitudes to the role of the mental health teams in providing physical healthcare. We explored how clinicians engaged and why they didn’t engage with the device, and how access to POC modulated the therapeutic relationship.DiscussionOur findings show that using POC for Physical Health Checks is acceptable to patients with SMI and mental health care clinicians, many of whom are from a non-clinical background. In teams where it is well adopted, POC testing can improve physical health check completion in the SMI population, although our qualitative findings highlight important considerations for maximising clinician engagement.

Consent to discuss participation in research: a pilot study

BackgroundEquitable access to research studies needs to be increased for all patients. There is debate about which is the best approach to use to discuss participation in research in real-world...

Autistic spectrum disorder without intellectual impairment in adult mental health services - fostering new perspectives and enhancing existing services.

Autistic spectrum disorder (ASD) is a neuro-developmental disability with multi-systemic impacts. Individuals with ASD without intellectual impairment (DSM-V) or Aspergers (DSM-IV) are often particularly vulnerable to mental health problems such as anxiety disorders including social phobia and generalised anxiety disorder, depressive disorders and psychosis. Adults with ASD without intellectual impairment suffer higher rates of physical and psychiatric morbidity, display a poorer ability to engage with treatment and have a lower chance of recovery compared with the general population. It is widely acknowledged that adults with suspected ASD without intellectual impairment and co-morbid mental health problems are often not best supported through adult mental health services and often require more tailored supports. This review seeks to (a) increase awareness in the area of undiagnosed cases of ASD without intellectual impairment in adult mental health settings and (b) highlights the importance of identifying this population more efficiently by referring to best practice guidelines. The value of future research to examine the benefit of having a team of specialist staff within adult mental health teams who have received ASD training and who are supported to work with the 'core difficulties' of ASD is discussed and a model for the same is proposed. It is proposed that a specialist team could form a 'hub' for the development of expertise in ASD, which when adequately resourced and funded could reach across an entire region, offering consultancy and diagnostic assessments and interventions.

A STARR is Born! A shining example of Integrated Care

In 2016, Queensland Health funded an innovative pilot for integrated care in a regional mental health service to improve consumer outcomes.(i) The STARR service model has funding for one year to determine the viability, applicability, and sustainability of integrated social and mental health services. Building on the international, national, and state strategies for integration, a service contract that required colocation, collaboration, agreed intent; and processes to coordinate services, was developed and implemented.(i) This abstract addresses integrated care between a regional Adult Mental Health Team and a Non-government organisation (NGO). The region provides case management and support to clients aged 18 or over, who have a severe and persistent mental illness; complex psychosocial needs, many requiring care co-ordination across sectors. Implementing collaborative, integrated shared care models is a challenge.(ii) Undertaking this in a regional setting presents the potential for sustainable and replicable service delivery frameworks. The Support Time and Rehabilitation Recovery Service (STARR), provided by a contracted NGO working with clinicians, aims to deliver better coordination of psychosocial supports to clients and their families. In devolving care coordination to the NGO, the intent of this pilot was to demonstrate increased capacity for clinicians to deliver therapeutic interventions to improve an individual’s health.(iii,iv) The first quadrimester has shown 15 referrals to STARR on the first day; with a total 79 referrals for this period with over 1260 hours of psychosocial supports delivered to mental health consumers.. Early indicators attest clinicians have decreased the time spent coordinating services, increased dedicated time for individual care by 5%, and increased therapeutic interventions by 2%. Collaboration has driven a range of holistic approaches in its first quarter with jointly developed care plans, case reviews, and targeted programs, including smoking cessation, a social recovery and carer program. Referrals to STARR have become routine practice for clinicians and the NGO has become an integrated part of the team. Co-location has been critical, in the early uptake of the service. Shared communication has been integral to develop shared intent. Engagement of clinicians, clients, and carers has been imperative and involvement from both organisations has reinforced shared intent. The early success of this pilot commenced with stakeholders documenting the service model inclusive of reorienting the role of case managers. Integration of an NGO into the clinical setting has increased consumer access to psychosocial and rehabilitation support services. STARR demonstrates that the challenges to implement an integrated model can be addressed.(iii,iv) The (STARR) Service, provides an innovative example of a NGO working in partnership with a public Mental Health Service delivering the key elements of integrated care, collaboration, coordination, and co-location. A STARR is born.(v)

Brief psychotic episode in a patient with chromosome 2q37 microdeletion syndrome

A 21-year-old woman with moderate learning disability secondary to chromosome 2 microdeletion at q37 was admitted to a general adult psychiatric ward following a period of agitation with incessant pressure...

Psychologically led multidisciplinary treatment streams within adult mental health teams

A model of integrated psychologically informed care within Multi Disciplinary Teams has been developed in Barnet Enfield & Haringey Mental Health Trust using psychologists in leadership positions within these teams.

A naturalistic evaluation of the financial benefits of employing a mental health pharmacist to work with child and adolescent mental health services

ObjectivesTo demonstrate that employing a mental health pharmacist in child and adolescent mental health services can significantly reduce medication expenditure, while assisting optimising medication use.MethodThe financial evaluation was undertaken by...

Recovery practice in community mental health teams: national survey.

BackgroundThere is consensus about the importance of ‘recovery’ in mental health services, but the link between recovery orientation of mental health teams and personal recovery of individuals has been underresearched.AimsTo investigate differences in team leader, clinician and service user perspectives of recovery orientation of community adult mental health teams in England.MethodIn six English mental health National Health Service (NHS) trusts, randomly chosen community adult mental health teams were surveyed. A random sample of ten patients, one team leader and a convenience sample of five clinicians were surveyed from each team. All respondents rated the recovery orientation of their team using parallel versions of the Recovery Self Assessment (RSA). In addition, service users also rated their own personal recovery using the Questionnaire about Processes of Recovery (QPR).ResultsTeam leaders (n = 22) rated recovery orientation higher than clinicians (n = 109) or patients (n = 120) (Wald(2) = 7.0, P = 0.03), and both NHS trust and team type influenced RSA ratings. Patient-rated recovery orientation was a predictor of personal recovery (b = 0.58, 95% CI 0.31–0.85, P<0.001). Team leaders and clinicians with experience of mental illness (39%) or supporting a family member or friend with mental illness (76%) did not differ in their RSA ratings from other team leaders or clinicians.ConclusionsCompared with team leaders, frontline clinicians and service users have less positive views on recovery orientation. Increasing recovery orientation may support personal recovery.

Clinician perceptions of sleep problems, and their treatment, in patients with non-affective psychosis

Aims and method: To assess clinicians’ views about their understanding and treatment of sleep problems in people with non-affective psychosis. An online survey was emailed to adult mental health teams in two NHS trusts.Results: One hundred and eleven clinicians completed the survey. All clinicians reported disrupted sleep in their patients, and endorsed the view that sleep and psychotic experiences each exacerbate the other. However, most clinicians (n = 92, 82%) assessed sleep problems informally, rather than using standard assessment measures. There was infrequent use of the recommended cognitive-behavioural treatments for sleep problems such as persistent insomnia, with the approaches typically used being sleep hygiene and medications instead.Clinical implications: Clinicians recognise the importance of sleep in psychosis, but the use of formal assessments and recommended treatments is limited. Barriers to treatment implementation identified by the clinicians related to services (e.g. lack of time), patients (e.g. their lifestyle) and environmental features of inpatient settings.

Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial

Mental health policy in many countries is oriented around recovery, but the evidence base for service-level recovery-promotion interventions is lacking. We did a cluster, randomised, controlled trial in two National Health Service Trusts in England. REFOCUS is a 1-year team-level intervention targeting staff behaviour to increase focus on values, preferences, strengths, and goals of patients with psychosis, and staff-patient relationships, through coaching and partnership. Between April, 2011, and May, 2012, community-based adult mental health teams were randomly allocated to provide usual treatment plus REFOCUS or usual treatment alone (control). Baseline and 1-year follow-up outcomes were assessed in randomly selected patients. The primary outcome was recovery and was assessed with the Questionnaire about Processes of Recovery (QPR). We also calculated overall service costs. We used multiple imputation to estimate missing data, and the imputation model captured clustering at the team level. Analysis was by intention to treat. This trial is registered, number ISRCTN02507940. 14 teams were included in the REFOCUS group and 13 in the control group. Outcomes were assessed in 403 patients (88% of the target sample) at baseline and in 297 at 1 year. Mean QPR total scores did not differ between the two groups (REFOCUS group 40·6 [SD 10·1] vs control 40·0 [10·2], adjusted difference 0·68, 95% CI -1·7 to 3·1, p=0·58). High team participation was associated with higher staff-rated scores for recovery-promotion behaviour change (adjusted difference -0·4, 95% CI -0·7 to -0·2, p=0·001) and patient-rated QPR interpersonal scores (-1·6, -2·7 to -0·5, p=0·005) at follow-up than low participation. Patients treated in the REFOCUS group incurred £1062 (95% CI -1103 to 3017) lower adjusted costs than those in the control group. Although the primary endpoint 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. National Institute for Health Research.

Supporting recovery from psychosis: assessment of REFOCUS

The argument that recovery from psychosis (and other severe mental illnesses) should be defi ned in terms of improved functioning and establishing a rewarding and meaningful life, rather than the permanent remission of symptoms and impairments, has gained traction since it was proposed more than 20 years ago. 1 Recovery for people with a serious mental illness is now broadly accepted as the legitimate goal of mental health ser vices, and is endorsed by high-level policy-makers in the UK and the USA. 2,3 Despite the growing enthusiasm for the vision of recovery and the hope imbued by the new defi nition, researchers have been reluctant to wade into the murky waters of recovery beyond exploratory, qualitative studies of the meaning of recovery to service users with mental health disorders. Mike Slade and colleagues 4 have broken new ground in their innovative study of the REFOCUS intervention, which was designed to foster recovery through changes in staff and team values, knowledge, skills, behaviour, and recovery-promoting relationships with patients. In a cluster, randomised, controlled trial, these investigators assessed the eff ects of usual care plus REFOCUS compared with usual care alone (control) in 27 community-based adult mental health teams providing care to patients with psychotic disorders. As might be expected owing to the sheer ambitiousness of the project, not everything worked out as hoped or expected. Outcomes were assessed in 403 patients at baseline and 297 at 1 year, who received care from 14 teams in the REFOCUS group or 13 in the control group. The primary endpoint, recovery, which was measured with the Questionnaire about Processes of Recovery (QPR), did not diff er between the two groups (REFOCUS group 40·6 [SD 10·1] vs control 40·0 [10·2], adjusted diff erence 0·68, 95%CI –1·7 to 3·1, p=0·58). Slade and colleagues suggest that an important reason for the lack of diff erence between groups was diffi culty in implementing parts of the intervention due to factors such as competing demands on staff members’ time. These hindrances led to substantial variation in participation levels of diff erent teams and changes in the recovery orientation of staff members. Staff turnover also diluted the potential eff ectiveness of the intervention on team recovery orientation, and patients dropping out from treatment and research reduced the statistical power to detect diff erences between patients in the diff erent study groups. In view of these diffi culties, it should be no surprise that REFOCUS did not lead to signifi cant diff erences from usual care alone. Despite this null result, some fi ndings suggest that the REFOCUS intervention is promising. Patients who received care from teams in the REFOCUS group improved more in overall functioning and unmet needs than those receiving usual care. Furthermore, compared with REFOCUS staff in low-participation teams, staff in high-participation teams reported more recovery-promoting behaviour (adjusted diff erence –0·4, 95% CI –0·7 to –0·2, p=0·001) and patients receiving care from higher-participation teams had improved overall functioning, quality of life, and scores on the QPR interpersonal subscale (adjusted diff erence in patient-rated interpersonal scores –1·6, –2·7 to –0·5, p=0·005). These results suggest that REFOCUS did improve recovery outcomes for patients receiving care from teams that more fully implemented the intervention. The REFOCUS trial represents an important milestone in research on recovery-oriented services. 5