Recovery Oriented Practice

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Recovery Oriented Practice

• Julie Repper

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Today

• Brief consideration of Recovery focus on what
  it means in practice.
• Brief consideration of how service users have
  evaluated AO, what this says about AO value base
  and some of the ongoing challenges for AO workers
• Similarities between Recovery approach and what
  makes AO effective . and yet challenges remain
• Learning from experience
• the problems inherent in implementing a Recovery
  approach within an AO service.
• Ways of overcoming these problems

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Recovery, recovery, recovery

• International - DoH, WHO, EC, NZ, US, .
• Multi-professional - RCN, COT, RCP, BPS .
• Vol Sector - SCMH, Rethink, MIND .
• Research - SDO, NIHR
• Local application - Recovery services, Recovery
  workers, Recovery courses.
• (See SCMH Recovery Website for details of many
  initiatives)

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What is Recovery? Numerous interpretations.

• full symptom remission, full or part time
  work/education, independent living without
  supervision by informal carers, having friends
  with whom activities can be shared - sustained
  for a period of 2 years
• Liberman (2002)

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From a service user perspective Recovery is a
process of rebuilding your life

•  
• a deeply personal, unique process of changing
  ones attitudes, values, feelings goals, skills,
  and/or roles. It is a way of living a
  satisfying, hopeful and contributing life even
  with the limitations caused by illness. Recovery
  involves the development of new meaning and
  purpose in ones life as one grows beyond the
  catastrophic effects of mental illness.
  (Anthony, 1993)

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A journey of Discovery.(Repper, 2004)

• Discovering ways of understanding what has
  happened and that you are the expert
• Discovering that you are more than your illness
• Discovering ways of living a satisfying life
• Discovering that you dont need to rely on
  services/professionals
• Discovering that mental health problems are not
  totally negative
• Discovering that this journey continues even when
  services deem you to be recovered

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Recovery from

• Symptoms
• Treatment of those symptoms
• Negative prognoses of professionals
• Few people with skills to help rebuild life
• Devaluing, depressing services
• Prejudice
• Social exclusion

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5 stages of Recovery(Andreson, Caputi and Oades,
2006)

• Moratorium withdrawal sense of loss and
  hopelessness
• Awareness realisation that all is not lost and
  a fulfilling life is possible
• Preparation taking stock of strengths and
  weaknesses and developing Recovery skills
• Rebuilding - Actively working towards a positive
  identity, meaningful goals and taking control
• Growth living a meaningful life, self
  management, resilience, positive sense of self.

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Facilitating Recovery and Social Inclusion
(Repper and Perkins, 2003)
Control
Opportunity
Over the years Ive worked hard to become an
expert in my own self careIve learned different
ways of helping myself (Deegan, 1993)
I dont want a CPN, I want a life (Rose)
Hope
For those of us who have been diagnosed with
mental illness and who have lived in sometimes
desolate wastelands of mental health programmes,
hope is not just a nice sounding euphemism. It
is a matter of life and death. (Deegan, 1986)
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Recovery  Principles   Practice      

• Services define their purpose in terms of
  achievement of life goals rather than symptom
  removal.
• Services, interventions treatments are judged
  in terms of the extent to which they help people
  live the lives they wish to lead.
• Use life stories, peer support workers and staff
  with mh problems as inspiration
• Personal recovery planning, negotiated  safety
   plans  advanced  directives increasingly
  important
• Coaches work alongside in a relation-ship
  characterised  by  respect, time,  persistence
   and  continuity.

• Recovery  represents  a  move-ment  away  from
   pathology, illness  and  symptoms  to a focus on
  strengths and possibility.
•  Hope  is  central  and  can  be  enhanced  by
  taking more active control  over  our  lives  and
   by seeing  how  others  have   found  a
   way  through.  
• Self  management  is  encouraged and  facilitated
   
•  
• From clinicians  as experts towards clinicians as
  partners/ coaches  on  a  journey  of  discovery
  - on  tap,  not  on  top.  

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Principles Practice

• Recovery  is associated with  being able to take
  on meaningful  and  satisfy-ing  roles  within
   local  communities    .  
• Recovery  is  about  discovering a  positive
   sense  of  personal  id-entity,  separate  from
   illness  or disability.     
•  
• Recovery based services value the
  personalqualities  of  staff  as   much  as
    formal  qualifications,  
• Family  and  other  supporters   are partners  in
   recovery.  Peer  support  is  of  prime
   importance  for many people with mental health
  problems.   
•  

• The  individual  is supported to to  use
   community  resources rather than segregated
  activities.  
• Helping people re-tell their stories in language
  of empowerment and strength.
• Team processes reviewed language used,
  recruitment and selection, training, negotiated
  safety planning, partnership working, respect for
  individual choice, cultural awareness.
• Peer support workers are recruited to support,
  share mutual experiences and coping, inspire .

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7 Recovery Promoting Actions(Slade, 2008)

• Lead the Process
• Articulate the values use them and model them
• Training in specific skills (Recovery, Strengths,
  Solutions, Meaning, Control)
• Make role models visible life stories, peer
  support workers, staff with mh problems
• Evaluate success in setting and achieving
  person-centred goals, social roles etc
• Amplify the power of people using the service

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We are Recovery focused if we

• Help the person identify their personal goals for
  recovery.
• Demonstrate a belief in their existing strengths.
  
• Prioritise goals which take the person out of the
  sick role and enable them to contribute.
• Identify non-mental health resources to help
  achieve these goals.
• Facilitate self-management of mental health
  problems.
• Listen to what the person wants and show that you
  have listened.
• Convey an attitude of respect and a desire for an
  equal partnership.
• Go the extra mile to help the person achieve
  their goals.
• Identify real examples to inspire and validate
  hope.
• While accepting that the future is uncertain,
  continue to support the person in achieving these
  self-defined goals - maintaining hope.
• (SCMH 2008)

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Our Service is Recovery Focussed if we

• Help people build connections with their
  neighbourhoods
• Provide education to community about mental
  health.
• Involve significant others in care planning if so
  desired.
• Encourage service users to access own treatment
  records.
• Monitor progress towards service user defined
  goals
• Do not use threats, bribes or coercion to
  influence choices.
• Take risks and try new things
• Involve service users in staff recruitment and
  training
• Know about resources and opportunities in the
  community.
• Link people with peers who can serve as role
  models.
• Provide a choice of treatment options
• Believe people can recover and make their own
  treatment and life choices.
• Provide opportunities for service users, family
  members and staff to learn about Recovery
• (Repper, 2008)

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Common Criticisms of Recovery(Shepherd et al,
SCMH, 2007)

• Weve been doing this for years/our profession
  has been training us to work this way for years
  no, it is distinctive because user-led
• This just adds yet more to our work load should
  replace not add to
• Not evidence based it is based on personal
  narratives and RCT evidence may be helpful within
  a Recovery framework
• Undermines professional training no, it means
  using our professional skills in a different way
• Places professionals at risk as they get the
  blame when service user makes a bad decision we
  should develop negotiated safety plans where
  risks need minimising, and allow the dignity of
  risk where appropriate.

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Recovery and AO similar characteristics

• A social/community based model of care using
  least segregated/most acceptable setting
• Person centred, flexible, creative
• Support provided at the level/intensity required
  by the individual
• Engagement achieved by doing things in ways and
  places that are acceptable and meaningful to
  individual
• Build on strengths rather than just react/fire
  fight
• Co-working/shared responsibility allows careful
  safety planning
• Work with family so that they are enabled to
  provide acceptable support in the community
• Look for opportunities and resources in community
  to promote and provide positive role and
  activities

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User evaluation of AO (SCMH, 2005 Repper et al,
2004 Priebe, 2000)

• Improved continuity of care, quality of life,
  family relationships, mental health
• They do my forms for me
• They know how to handle me
• They get on well with my mum too
• They have taken me to football and Ive even
  thought about joining the club with them
• I understand my medication and I am more stable
  in my head now
• I have got much more benefits
• I feel much safer now, they sorted out my
  neighbours for me
• I have more contact with my family now
• They have helped my life get better and better!
• I trust them to let me know when they think
  things are going wrong again, to advise me about
  what might make my life easier.
• Could AO be more enabling/empowering?
• Could more of this support be provided by peers?

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Some of the challenges of AO Priebe et al, 2000
Repper et al, 2004 Grayling et al, 2005

• Boundaries friends vs workers
• Structures of AO clear (fidelity criteria, PIG)
  values/skills not so clear
• How to fit engaging client centred
  relationships into statutory structures
• Perverse incentive for clients to remain in AO
  if they improve they met get discharged to less
  supportive service
• Shortage of appropriate resources available in
  community and insufficient time to support
  people into existing community opportunities
• Shortage of skilled employment, education
  workers community bridgebuilders
• In UK PRiSM and UK 700 showed no difference in
  effects of AO versus TAU doing it wrong or
  measuring wrong things?

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Some of the difficulties with AO reflect
criticisms of Recovery

• AO and Recovery approach challenges traditional
  boundaries.
• AO and Recovery values do not fit easily into
  statutory structures and practices (e.g. problem
  centred care plans, locked doors, Ward
  Rounds/Review procedures etc)
• Biggest barrier to Recovery/success of AO is
  discrimination social inclusion is a new area
  of work that requires specific training (?who
  for)
• Shortage of gold standard evidence to support
  the effectiveness of AO in the UK.
• What else?

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A further problem? can Recovery always work in
AO?

• some people may appear unwilling to engage with
  recovery because of the severity of their
  symptoms, their negative experiences of mental
  healthcare, intolerable side effects of
  medication, or the fact that it is too painful or
  costly to acknowledge that they need the kind of
  help that is offered
• (Davidson and Roe, 2007)
• Unable? Unwilling? Frightened? Angry?
• Independent? Strong? Alternative supports?

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Learning from Experiences

• Brainstorm list of problems you have come across
  implementing Recovery in AO
• Select three to focus on
• Share experiences of tackling these problems
• Note responses and feedback overview

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Thank you!