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 and led by 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.
What is the REFOCUS intervention?
The REFOCUS intervention is described in the second edition of the REFOCUS manual (here). 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) (here). The conceptual framework was validated with people currently using mental health services (here) and the cross-cultural validity of the conceptual framework was investigated (here). The CHIME Framework (Connectedness, Hope, Identity, Meaning, Empowerment) of recovery processes has been widely used internationally (citations listed here).
Four components of best practice in supporting recovery were identified in an international review of recovery guidelines (here). 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 (here). The final component of best practice – Organisational commitment – was investigated in a national survey (here).
The approach used in REFOCUS to assessing strengths is based on a systematic review of strengths measures (here). The experience of staff in supporting recovery informed the development of the REFOCUS intervention (here). The competing priorities identified by staff were contextualised in a systematic review (here). 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 (here). We also reported on the process of involvement (here).
All the above evidence which informed the REFOCUS intervention is brought together in the intervention development paper (here). In addition, the feasibility of recovery interventions was investigated (here) using a new measure called Structured Assessment of FEasibility (SAFE) (here), and the relationship between clinical and recovery outcomes was empirically tested (here).
The REFOCUS Model is a testable model of the expected impact of the intervention. It was published in the first edition of the REFOCUS Manual (here). The REFOCUS intervention is intended to be feasible for routine use (here). The evaluation of the impact of the REFOCUS intervention was informed by a systematic review of measures of recovery (here). We also published a systematic review of recovery support measures (here). This led to the development and evaluation of a new recovery support measure, called INSPIRE (here). 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 (here).
The REFOCUS Trial (ISRCTN02507940) evaluated the REFOCUS Intervention (first edition), as described in the trial protocol (here). The results of the trial were published (here). A process evaluation investigated the challenges of implementing a complex intervention to support recovery (here), and the experiences of mental health service users in the trial were investigated (here). An innovative approach to clinical end-point measurement was also evaluated (here).
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 2nd edition of the REFOCUS Manual (2nd edition) incorporates these changes (here).
The complete REFOCUS programme of work was reported (here).
The REFOCUS intervention is now being implemented and evaluated in a range of services in England and other countries. For example, the REFOCUS-PULSAR Study was conducted in Australia (here), and the REFOCUS-PULSAR trial found a positive effect for the intervention in secondary care (here) and preliminary evidence for a positive effect in primary care (here).
REFOCUS is one of a number of emerging evidence-based approaches to supporting recovery (here).
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
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