Individual Care Planning: Enabling the Paradigm Shift to Recovery Focused Care - Lessons from the National Mental Health

1. Individual Care Planning: Enabling the Paradigm Shift to Recovery Focused Care - Lessons from the National Mental Health Services CollaborativeBurlington Hotel 7th February 2012 Recovery Focused Practice Agnes Higgins PhD School of Nursing and Midwifery Trinity College Dublin Welcome Thanks to Rosemary for invitation Delighted to be sharing the same stage as Mike Watts, shared a journey together for past 4 year, process I have learnt a lot not only about recovery and about myself My presentation will focus on some of the guiding principle that should underpin recovery focused practiceWelcome Thanks to Rosemary for invitation Delighted to be sharing the same stage as Mike Watts, shared a journey together for past 4 year, process I have learnt a lot not only about recovery and about myself My presentation will focus on some of the guiding principle that should underpin recovery focused practice

2. Concept of recovery entered the lexicon of the mental health services in the 1970�s. Publication of a series of research studies and personal narratives that demonstrated that that the course of mental illness (such as schizophrenia), was not always one of inevitable deterioration and that people diagnosed with severe mental illness could reclaim or recover meaningful lives. Much of the disability was as a result of institutionalisation Impact of the total institution, stripped of identity, depersonalisation, batch living, over medication Adjustment to the environment: Career as a patient (Goffman, I 1963 Asylums: essays on the social situations of mental patients and other inmates) Concept of recovery entered the lexicon of the mental health services in the 1970�s. Publication of a series of research studies and personal narratives that demonstrated that that the course of mental illness (such as schizophrenia), was not always one of inevitable deterioration and that people diagnosed with severe mental illness could reclaim or recover meaningful lives. Much of the disability was as a result of institutionalisation Impact of the total institution, stripped of identity, depersonalisation, batch living, over medication Adjustment to the environment: Career as a patient (Goffman, I 1963 Asylums: essays on the social situations of mental patients and other inmates)

3. Recovery Within Ireland we were a bit slower, only entered our vocabulary officially in 2006 with the publication of Vision for Change in 2006 ( 6 years ago) Say takes about 10 years for evidence to be implemented into practice Peters (1992) notes that Lord Rothschild, speaking in 1968 to the WHO stated Within Ireland we were a bit slower, only entered our vocabulary officially in 2006 with the publication of Vision for Change in 2006 ( 6 years ago) Say takes about 10 years for evidence to be implemented into practice Peters (1992) notes that Lord Rothschild, speaking in 1968 to the WHO stated

4. Recovery Perennials Active process Individual and unique process Gradual process Non- linear process Trial and error process Life changing Stages or phases Can occur without professional help Aided by supportive healing environment Journey of discovery A review of individual and collective narratives , clear that certain core concept or similarities A review of individual and collective narratives , clear that certain core concept or similarities

5. Journey of discovery Discovery Identity Voice Hope Belief Meaning Belonging Strengths Personal control/agency Life long journey More than illnessMore than illness

6. Recovery Process/journey that person experiences Philosophy/Approach to care and service provision

7. Recovery: approach to care �Recovery offers a transformational ideology for services and suggests reform in how �mental illness� is understood and managed, as well as in how people living with mental illness are understood and helped. This guiding philosophy challenges ideas and beliefs about the etiology and treatment of �mental illness�, including the way in which mental health practice is organised and implemented to ensure that people living with �mental illness� lead meaningful and productive lives.� Boutillier et al (2011) What does recovery mean in practice? A qualitative analysis of International recovery-oriented practice guidance psychiatric services 62(11):1470-1476

8. Current narrative  Valuing of professional knowledge Privileging of biological or psychiatric narrative Colonisation of peoples stories Social death (Will Hall) Prescribed identity as service users, trumps all other status (partner, parent, lover, Narrative of �chronicity� Narrative of despair/hopelessness Compliance versus alliance Professional distancing Unequal power imbalance Risk adverse Valuing of professional knowledge Privileging of biological or psychiatric narrative Colonisation of peoples stories Social death (Will Hall) Prescribed identity as service users, trumps all other status (partner, parent, lover, Narrative of �chronicity� Narrative of despair/hopelessness Compliance versus alliance Professional distancing Unequal power imbalance Risk adverse

9. Narrative Synthesis of Recovery Processes Leamy and Slade kings college and institute of psychiatry N= 97 studies reviewed Leamy and Slade kings college and institute of psychiatry N= 97 studies reviewed

10. Recovery focused practice More than assimilating into current paradigm More than adopting language of recovery. A challenge to new ways of thinking and acting An invitation to fresh and new possibilities and new narrative Changing lives not bio-chemistry Changing lives not bio-chemistry

11. RecoveryNarrative Challenge the legitimacy and privileging of any one perspective Create a space and context for alternative narratives to be told Multiple �truths� and ways of understanding Illness not an end of life but a new beginning, an opportunity for growth Persons lived experience: their story and meaning at heart, hopes dreams beleive in authenticity and importance of persons story All aspects of person , bo/psych /socal /spirtitaul sexual, seen in context of my life role as �people as parents�, �people as sexual beings�, people with dreams of becoming parent, finding a job, returning to college, Collaboration (working with people as opposed against symptoms), all aspect of service provision , engaging in education Dialogue with demons rather than focusing on getting rid of them (Dr Rufus May interview with Dominic branagan), find meaning HOPE not a just a nice sounding euphemism but a matter of life and death (Deegan) Strengths and help people mobilise internal resources for recovery, confidence and self belief. Work creatively with tensions created between promoting safety and enabling risk ; I have a right to make mistakes Welless focused, autonomy. Self determination see problems and setbacks as part of the process help people learn form them and build on htem Eliminate social barriers to recover Capacity of society to create career �patient� Sick benefit v work Must be symptom free to return to work Must be able to return full time (school) Challenge the legitimacy and privileging of any one perspective Create a space and context for alternative narratives to be told Multiple �truths� and ways of understanding Illness not an end of life but a new beginning, an opportunity for growth Persons lived experience: their story and meaning at heart, hopes dreams beleive in authenticity and importance of persons story All aspects of person , bo/psych /socal /spirtitaul sexual, seen in context of my life role as �people as parents�, �people as sexual beings�, people with dreams of becoming parent, finding a job, returning to college, Collaboration (working with people as opposed against symptoms), all aspect of service provision , engaging in education Dialogue with demons rather than focusing on getting rid of them (Dr Rufus May interview with Dominic branagan), find meaning HOPE not a just a nice sounding euphemism but a matter of life and death (Deegan) Strengths and help people mobilise internal resources for recovery, confidence and self belief. Work creatively with tensions created between promoting safety and enabling risk ; I have a right to make mistakes Welless focused, autonomy. Self determination see problems and setbacks as part of the process help people learn form them and build on htem Eliminate social barriers to recover Capacity of society to create career �patient� Sick benefit v work Must be symptom free to return to work Must be able to return full time (school)

12. Shepherd et al 2008 In summary Shepar et all identifies 3 main principles underlying the recovery philosophy Hope Agency or personal control Opportunity for connectiiness In other words at the heart of recovery is a set of values about the persons right to Build a meaningful life for themselves, without or without the continued presence of mental health symptoms In summary Shepar et all identifies 3 main principles underlying the recovery philosophy Hope Agency or personal control Opportunity for connectiiness In other words at the heart of recovery is a set of values about the persons right to Build a meaningful life for themselves, without or without the continued presence of mental health symptoms

13. Insight and Internalised stigma People who accept that they have mental illness may feel driven to conform to an image of incapacity and worthlessness, becoming more socially withdrawn and adopting a disabled role. As a result, their symptoms may persist and they may become dependent on treatment providers and others. Thus, insight into one�s illness may be rewarded with poor outcome. Empowerment of people and helping them reduce their internalised sense of stigma are as important as helping them find insight into their �illness�. Until now, however, more effort has been expended on the last than on the former. Warner R. (2004).Recovery from Schizophrenia: Psychiatry and Political Economy (3rd edn). Brunner-Routledge,

14. Recovery: not anti medication �The biomedical model and medical treatments may have an important place for some people in their recovery, but as an invited guest, rather than an overarching paradigm� Higgins, A (2008) Recovery is about changing lives and not biochemistryRecovery is about changing lives and not biochemistry

15. �My journey of recovery is still ongoing. I still struggle with symptoms, grieve the losses I have sustained�I am also involved in self help and mutual support and I still use professional services including medications, psychotherapy and hospitals. However, I do not just take medications and go to the hospital. I have learned to use medications and to use the hospital. This is the active stance that is the hallmark of the recovery process.� Deegan, P (1996) Recovery as a journey of the heart Psychiatric Rehabilitation Journal 19, 3 91-97

16. Dinnins and Roberts Dream Staff and resident ratings of importance of factors.Dinnins and Roberts Dream Staff and resident ratings of importance of factors.

17. Staff and resident ratings of level of achievement of factor. *P<0.05, **P<0.01, ***P<0.001. Limitations; no psychometric testing 14 residents 26 staffStaff and resident ratings of level of achievement of factor. *P<0.05, **P<0.01, ***P<0.001. Limitations; no psychometric testing 14 residents 26 staff

19. Ten key organisational challenges Changing the nature of day-to-day interactions and the quality of experience Delivering comprehensive, service user-led education and training programmes Establishing a �Recovery Education Centre� to drive the programmes forward Ensuring organisational commitment, creating the �culture� Increasing �personalisation� and choice Changing the way we approach risk assessment and management Redefining service user involvement Transforming the workforce Supporting staff in their recovery journey Increasing opportunities for building a life �beyond illness� Sainsbury Centre for Mental Health 1 fundamental change in interactions , each interactions should be underpinned by hope, promoting personal agency, reducing power differentials, increasing opportunities for connection 2 need comprehensive service user led education , study just over 35% had service user involvement, but need to build capacity . 3 educate service users, to be educators, peer support workers. Triadic education process 4 recovery values need to be embedded at every level of organisation, mission , policies 5 self management, advanced directives shared decison making choice 6 accept risk as an intrinsic part of living with MH problem 7. Not simply about adding service users to menu, need to really address inclusion and barriers to inclusion 8 fundamental review of skill mix and professional /service user balance , ALSO review of involvement of peer support groups 9 Key carriers of Hope , cant nurture and support in some of current environments, as 10. Means opening up the organisation , turning it around to be outward looking rather than inward , so need to build alliances with employment, housing education services. Help people to connect with community problem of stigma and discrimination as many barriers collude to turn people into career mental patients1 fundamental change in interactions , each interactions should be underpinned by hope, promoting personal agency, reducing power differentials, increasing opportunities for connection 2 need comprehensive service user led education , study just over 35% had service user involvement, but need to build capacity . 3 educate service users, to be educators, peer support workers. Triadic education process 4 recovery values need to be embedded at every level of organisation, mission , policies 5 self management, advanced directives shared decison making choice 6 accept risk as an intrinsic part of living with MH problem 7. Not simply about adding service users to menu, need to really address inclusion and barriers to inclusion 8 fundamental review of skill mix and professional /service user balance , ALSO review of involvement of peer support groups 9 Key carriers of Hope , cant nurture and support in some of current environments, as 10. Means opening up the organisation , turning it around to be outward looking rather than inward , so need to build alliances with employment, housing education services. Help people to connect with community problem of stigma and discrimination as many barriers collude to turn people into career mental patients

20. Pillars of Recovery A Higgins TCD

21. Lasting change

22. Recovery: Thinking Differently �There are risks and costs to a program of action, but they are far less than, the long-range risks and costs of comfortable inaction� John F. Kennedy