Recovery Oriented Practice

1. Recovery Oriented Practice Julie Repper

2. 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

3. 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)

4. 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)

5. From a service user perspective Recovery is a process of rebuilding your life … “… a deeply personal, unique process of changing one’s 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 one’s life as one grows beyond the catastrophic effects of mental illness.” (Anthony, 1993)

6. 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 don’t 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’

7. 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

8. 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.

9. Facilitating Recovery and Social Inclusion (Repper and Perkins, 2003) Control Opportunity “Over the years I’ve worked hard to become an expert in my own self care…I’ve learned different ways of helping myself” (Deegan, 1993) “I don’t 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)

10. 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’. 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  Principles &   Practice

11. 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 …. Principles Practice

12. 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

13. 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)

14. 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)

15. Common Criticisms of Recovery(Shepherd et al, SCMH, 2007) • We’ve 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.

16. 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

17. 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 I’ve 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?

18. 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?

19. 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?

20. 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?

21. 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

22. Thank you!