REFOCUS was a five year, £2 million programme of research, funded by the NHS National Institute for Health Research (Programme Grants for Applied Research), from 2009 to 2014 at King’s College London. The aim of REFOCUS was to find ways of making community-based adult mental health services in England more recovery-orientated.
This page gives updated information about publications and resources from the REFOCUS programme. You can download free outputs from REFOCUS on our Downloads page.
What is the REFOCUS intervention?
The REFOCUS intervention is described in the second edition of the REFOCUS Manual 2nd edition. The intervention has two components:
Component 1: Working relationships
The working relationship between staff and people who use the service is central to personal recovery. The intervention addresses the working relationship by skills training in coaching
Component 2: Supporting personally-defined recovery
Supporting personally-defined recovery is addressed by training and supporting staff behaviour change in relation to three specific working practices:
1. Understanding values and treatment preferences
2. Assessing and amplifying strengths
3. Supporting goal-striving by the service user as a primary focus for staff action.
Evidence base for the REFOCUS Intervention
The development of the REFOCUS intervention followed the Medical Research Council Framework for the evaluation of complex health interventions.
The understanding of recovery is based on a systematic review of personal recovery (which identified the CHIME Framework):
Leamy M, Bird V, 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.
The conceptual framework was validated with people currently using mental health services:
Bird V, Leamy M, Tew J, Le Boutillier C, Williams J, Slade M (2014) Fit for purpose? Validation of a conceptual framework for personal recovery with current mental health consumers, Australian and New Zealand Journal of Psychiatry, 48, 644-653.
The cross-cultural validity of the conceptual framework was investigated:
Slade M, Leamy M, Bacon F, Janosik M, Le Boutillier C, Williams J, Bird V (2012) International differences in understanding recovery: systematic review, Epidemiology and Psychiatric Sciences, 21, 353-364.
The CHIME Framework (Connectedness, Hope, Identity, Meaning, Empowerment) of recovery processes has been widely used internationally – citations are listed here.
Four components of best practice in supporting recovery were identified in an international review of recovery guidelines:
Le Boutillier C, Leamy M, Bird VJ, Davidson L, Williams J, Slade M (2011) What does recovery mean in practice? A qualitative analysis of international recovery-oriented practice guidance, Psychiatric Services, 62, 1470-1476.
The REFOCUS intervention addresses two of these components: Supporting personally defined recovery and Working relationships. A third component – Promoting citizenship – was not used in REFOCUS but was reviewed:
Tew J, Ramon S, Slade M, Bird V, Melton J, Le Boutillier C (2012) Social factors and recovery from mental health difficulties: a review of the evidence, British Journal of Social Work, 42, 443-460.
The final component of best practice – Organisational commitment – was investigated in a national survey:
Leamy M, Clarke E, Le Boutillier C, Bird V, Choudhury R, Macpherson R, Pesola P, Sanger K, Williams J, Williams P, Slade M (2016) A national survey of recovery practice in community mental health teams, British Journal of Psychiatry, 209, 340-346.
It is also being addressed by the ImROC programme.
The approach to assessing strengths is based on a systematic review of strengths measures:
Bird V, Le Boutillier C, Leamy M, Larsen J, Oades L, Williams J, Slade M (2012) Assessing the strengths of mental health service users – systematic review, Psychological Assessment, 24, 1024-1033.
The experience of staff in supporting recovery informed the development of the REFOCUS intervention:
Le Boutillier C, Slade M, Lawrence V, Bird V, Chandler R, Farkas M, Harding C, Larsen J, Oades L, Roberts G, Shepherd G, Thornicroft G, Williams J, Leamy M (2015) Competing priorities: staff perspectives on supporting recovery, Administration and Policy in Mental Health and Mental Health Services Research, 42, 429-438.
The competing priorities identified by staff were contextualised in a systematic review:
Le Boutillier C, Chevalier A, Lawrence V, Leamy M, Bird V, Macpherson R, Williams J, Slade M (2015) Staff understanding of recovery-orientated mental health practice: a systematic review and narrative synthesis, Implementation Science, 10, 87.
To increase the extent to which REFOCUS was consistent with recovery principles, we evaluated 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.
We also reported on the process of involvement:
Slade M, Trivedi P, Chandler R, Leamy M (2016) Developing involvement during a programme of recovery research, Journal of Mental Health Training, Education and Practice, 11, 244-255.
All the above evidence which informed the REFOCUS intervention is brought together in the intervention development paper:
Slade M, Bird V, Le Boutillier C, Grey B, Larsen J, Leamy M, Oades L, Williams J (2015) Development of the REFOCUS intervention to increase mental health team support for personal recovery, British Journal of Psychiatry, 207, 544-550.
In addition, the feasibility of recovery interventions was investigated:
van der Krieke L, Bird V, Leamy M, Bacon F, Dunn R, Pesola F, Janosik M, Le Boutillier C, Williams J, Slade M (2015) The feasibility of implementing recovery, psychosocial and pharmacological interventions for psychosis: comparison study, Implementation Science, 10, 73.
And the relationship between clinical and recovery outcomes was empirically tested:
Macpherson R, Pesola F, Leamy M, Bird V, Le Boutillier C, Williams J, Slade M (2016) The relationship between clinical and recovery dimensions of outcome in mental health, Schizophrenia Research, 175, 142-147.
The REFOCUS Model is a testable model of the expected impact of the intervention. It was included in the first edition of the REFOCUS Manual:
Bird V, Leamy M, Le Boutillier C, Williams J, Slade M (2011) REFOCUS: Promoting recovery in community mental health services, London: Rethink Mental Illness.
The REFOCUS intervention is intended to be feasible for routine use:
Bird V, Le Boutillier C, Leamy M, Williams J, Bradstreet S, Slade M (2014) Evaluating the feasibility of complex interventions in mental health services: standardised measure and reporting guidelines, British Journal of Psychiatry, 204, 316-321.
The evaluation of the impact of the REFOCUS intervention was informed by a systematic review of measures of recovery:
Shanks V, Williams J, Leamy M, Bird V, Le Boutillier C, Slade M (2013) Measures of personal recovery: systematic review, Psychiatric Services, 64, 974-980.
We also published a systematic review of recovery support measures:
Williams J, Leamy M, Bird V, Harding C, Larsen J, Le Boutillier C, Oades L, Slade M (2012) Measures of the recovery orientation of mental health services: systematic review, Social Psychiatry and Psychiatric Epidemiology, 47, 1827-1835.
This led to the development and evaluation of a new recovery support measure, called INSPIRE:
Williams J, Leamy M, Bird V, Le Boutillier C, Norton S, Pesola F, Slade M (2015) Development and evaluation of the INSPIRE measure of staff support for personal recovery, Social Psychiatry and Psychiatric Epidemiology, 50, 777-786.
More information about INSPIRE, including downloadable versions, is available here.
The trial uses the Questionnaire about the Process of Recovery (QPR) measure as the primary outcome, so we evaluated the psychometric properties of QPR:
Williams J, Leamy M, Pesola F, Bird V, Le Boutillier C, Slade M (2015) Psychometric evaluation of the Questionnaire about the Process of Recovery (QPR), British Journal of Psychiatry, 207, 551-555.
The REFOCUS Trial (ISRCTN02507940) evaluated the REFOCUS Intervention (first edition). The trial protocol has been published:
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.
The results of the trial have been published:
Slade M, Bird V, Clarke E, Le Boutillier C, McCrone P, Macpherson R, Pesola F, Wallace G, Williams J, Leamy M (2015) Supporting recovery in patients with psychosis using adult mental health teams (REFOCUS): a multi-site cluster randomised controlled trial, Lancet Psychiatry, 2, 503-514.
A process evaluation investigated the challenges of implementing a complex intervention to support recovery:
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.
The experiences of mental health service users in the trial were investigated:
Wallace G, Bird V, Leamy M, Bacon F, Le Boutillier C, Janosik M, Macpherson R, Williams J, Slade M (2016) Service user experiences of REFOCUS: a process evaluation of a pro-recovery complex intervention, Social Psychiatry and Psychiatric Epidemiology, 51, 1275-1284.
An innovative approach to clinical end-point measurement was also evaluated:
Pesola F, Williams J, Bird V, Freidl M, Le Boutillier C, Leamy M, Macpherson R, Slade M (2015) Development and evaluation of an Individualised Outcome Measure (IOM) for randomised controlled trials in mental health, International Journal of Methods in Psychiatric Research, 24, 257-265.
Learning from the REFOCUS Trial
The effectiveness of the REFOCUS Intervention (1st edition) was evaluated in the REFOCUS Trial, which ended in 2014. The process evaluation for the trial investigated each element of the original intervention. The REFOCUS Intervention was modified in the light of these findings.
The basic structure of the intervention – recovery-promoting relationships and three working practices – is unchanged. The intervention content has been simplified, with less emphasis on for example the history of the recovery movement, and a stronger focus on the link between coaching and the working practices. Implementation was identified as a specific challenge, so the major changes from the REFOCUS Manual (1st edition) relate to supporting practice change, with some approaches dropped (e.g. Partnership Project, Supervision Form), some modified (e.g. reflection groups) and some added (e.g. Recovery and REFOCUS Workshop). Evidence is also emerging that the REFOCUS Intervention is applicable to in-patient settings, so the focus specifically on community services has also been reduced.
The REFOCUS Manual (2nd edition) incorporates these changes to the REFOCUS Intervention:
Bird V, Leamy M, Le Boutillier C, Williams J, Slade M (2014) REFOCUS (2nd edition): Promoting recovery in mental health services, London: Rethink Mental Illness.
The 2nd edition of the manual can be downloaded here.
The complete REFOCUS programme of work has been reported:
Slade M, Bird V, Chandler R, Clarke E, Craig T, Larsen J, Lawrence V, Le Boutillier C, Macpherson R, McCrone P, Pesola F, Riley G, Shepherd G, Tew J, Thornicroft G, Wallace G, Williams J, Leamy M (2017) REFOCUS: Developing a recovery focus in mental health services in England, Nottingham: Institute of Mental Health.
This report can be downloaded here.
The REFOCUS intervention is now being implemented and evaluated in a range of services in England and other countries, such as the PULSAR Study in Australia:
Shawyer F, Enticott J, Brophy L, Bruxner A, Fossey E, Inder B, Julian J, Kakuma R, Weller P, Wilson-Evered E, Edan V, Slade M, Meadows G (2017) The PULSAR Specialist Care protocol: a stepped-wedge cluster randomized control trial a training intervention for community mental health teams in recovery-oriented practice, BMC Psychiatry, 17, 172.
The PULSAR trial found a positive effect for the intervention:
Meadows G, Brophy L, Shawyer F, Enticott J, Fossey E, Thornton C, Weller P, Wilson-Evered E, Edan V, Slade M (2019) REFOCUS-PULSAR recovery-oriented practice training in specialist mental health care: a stepped-wedge cluster randomised controlled trial, Lancet Psychiatry, 6, 103-114.
REFOCUS is one of a number of emerging approaches to supporting recovery:
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.
There are many ways in which the REFOCUS Intervention could be provided. Based on the process evaluation from the REFOCUS Trial, we recommend a four-stage approach to implementing REFOCUS:
1. Recovery and REFOCUS Workshop
2. Working Practices training
3. REFOCUS Coaching for Recovery training
4. Development of approaches to support practice change
Contact us for information about accessing trainers.