Transcript Slide 1

Recovery Oriented
Practice
Julie Repper
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
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)
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)
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)
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’
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
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.
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)
Recovery
Principles
&
Recovery represents a movement away from pathology,
illness and symptoms to a
focus on strengths and
possibility.
Hope is central and can be en
hanced 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 dis
covery - ‘on tap, not on top’.
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 relationship characterised by respect,
time, persistence and continuity.
Principles
Recovery is associated with being
able to take on
meaningful and satisfying roles within local commun
ities
.
Recovery is about discovering a
positive sense of personal identity, 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 sup
port is of prime importance fo
r many people with mental
health problems.
Practice
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 ….
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 personcentred goals, social roles etc
Amplify the power of people using the service
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)
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)
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.
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
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?
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?
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?
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?
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
Thank you!