Recovery Oriented Practice
description
Transcript of Recovery Oriented Practice
Recovery Oriented Recovery Oriented PracticePractice
Julie RepperJulie Repper
Today …Today …Brief consideration of Recovery – focus on what it means Brief consideration of Recovery – focus on what it means in practice. in practice.
Brief consideration of how service users have evaluated Brief consideration of how service users have evaluated AO, what this says about AO value base and some of the AO, what this says about AO value base and some of the ongoing challenges for AO workersongoing challenges for AO workers
Similarities between Recovery approach and what makes Similarities between Recovery approach and what makes AO effective …. and yet challenges remainAO effective …. and yet challenges remain
Learning from experience – Learning from experience –
the problems inherent in implementing a Recovery approach the problems inherent in implementing a Recovery approach within an AO service. within an AO service.
Ways of overcoming these problemsWays of overcoming these problems
Recovery, recovery, recovery…Recovery, recovery, recovery…
International - DoH, WHO, EC, NZ, US, ….International - DoH, WHO, EC, NZ, US, ….
Multi-professional - RCN, COT, RCP, BPS ….Multi-professional - RCN, COT, RCP, BPS ….
Vol Sector - SCMH, Rethink, MIND ….Vol Sector - SCMH, Rethink, MIND ….
Research - SDO, NIHRResearch - SDO, NIHR
Local application - Recovery services, Recovery Local application - Recovery services, Recovery workers, Recovery courses….workers, Recovery courses….
(See SCMH Recovery Website for details of many (See SCMH Recovery Website for details of many initiatives)initiatives)
What is Recovery? Numerous What is Recovery? Numerous interpretations….interpretations….
““full symptom remission, full or part time work/education, full symptom remission, full or part time work/education, independent living without supervision by informal independent living without supervision by informal carers, having friends with whom activities can be carers, having friends with whom activities can be shared - sustained for a period of 2 years” shared - sustained for a period of 2 years”
Liberman (2002)Liberman (2002)
From a service user perspective From a service user perspective Recovery is a process of rebuilding your Recovery is a process of rebuilding your
life …life …
“… “… a deeply personal, unique process of changing a deeply personal, unique process of changing
one’s attitudes, values, feelings goals, skills, one’s attitudes, values, feelings goals, skills, and/or roles. It is a way of living a satisfying, and/or roles. It is a way of living a satisfying, hopeful and contributing life even with the hopeful and contributing life even with the limitations caused by illness. Recovery involves limitations caused by illness. Recovery involves the development of new meaning and purpose the development of new meaning and purpose in one’s life as one grows beyond the in one’s life as one grows beyond the catastrophic effects of mental illness.” catastrophic effects of mental illness.” (Anthony, (Anthony, 1993)1993)
A journey of A journey of Discovery….Discovery….(Repper, 2004)(Repper, 2004)
DiscoveringDiscovering ways of understanding what has happened – and ways of understanding what has happened – and that you are the expertthat you are the expert
DiscoveringDiscovering that you are more than your illness that you are more than your illness
DiscoveringDiscovering ways of living a satisfying life ways of living a satisfying life
DiscoveringDiscovering that you don’t need to rely on services/professionals that you don’t need to rely on services/professionals
DiscoveringDiscovering that mental health problems are not totally negative that mental health problems are not totally negative
DiscoveringDiscovering that this journey continues even when services that this journey continues even when services deem you to be ‘recovered’deem you to be ‘recovered’
Recovery from…Recovery from…
SymptomsSymptomsTreatment of those symptomsTreatment of those symptomsNegative prognoses of professionalsNegative prognoses of professionalsFew people with skills to help rebuild lifeFew people with skills to help rebuild lifeDevaluing, depressing servicesDevaluing, depressing servicesPrejudicePrejudiceSocial exclusionSocial exclusion
5 stages of Recovery5 stages of Recovery(Andreson, Caputi and Oades, 2006) (Andreson, Caputi and Oades, 2006)
MoratoriumMoratorium – withdrawal sense of loss and – withdrawal sense of loss and hopelessnesshopelessnessAwarenessAwareness – realisation that all is not lost and a – realisation that all is not lost and a fulfilling life is possiblefulfilling life is possiblePreparationPreparation – taking stock of strengths and – taking stock of strengths and weaknesses and developing Recovery skillsweaknesses and developing Recovery skillsRebuildingRebuilding - Actively working towards a positive - Actively working towards a positive identity, meaningful goals and taking controlidentity, meaningful goals and taking controlGrowthGrowth – living a meaningful life, self – living a meaningful life, self management, resilience, positive sense of self. management, resilience, positive sense of self.
Control Opportunity
Hope
“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)
“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)
Facilitating Recovery and Social Inclusion (Repper and Perkins, 2003)
Recovery Recovery PrinciplesPrinciples && PracticePractice
Recovery represents a move-ment Recovery represents a move-ment
away from pathology, illness away from pathology, illness and symptoms to a focus on and symptoms to a focus on strengths and possibility.strengths and possibility.
Hope is central and can be Hope is central and can be enhanced by taking more active enhanced by taking more active control over our lives and by control over our lives and by seeing how others have seeing how others have found a way through.found a way through.
Self management is encouraged Self management is encouraged and facilitated and facilitated
From clinicians as experts towards From clinicians as experts towards
clinicians as partners/ coaches clinicians as partners/ coaches on a journey of discovery - ‘on on a journey of discovery - ‘on tap, not on top’. tap, not on top’.
Services define their purpose in terms Services define their purpose in terms of achievement of life goals rather of achievement of life goals rather than symptom removal. than symptom removal.
Services, interventions & treatments are Services, interventions & treatments are judged in terms of the extent to which judged in terms of the extent to which they help people live the lives they wish they help people live the lives they wish to lead. to lead.
Use life stories, peer support workers Use life stories, peer support workers and staff with mh problems as and staff with mh problems as inspirationinspiration
Personal recovery planning, negotiated Personal recovery planning, negotiated safety plans & advanced safety plans & advanced directives increasingly important directives increasingly important
Coaches work alongside in a relation-Coaches work alongside in a relation-ship characterised by respect, time, ship characterised by respect, time, persistence and continuity. persistence and continuity.
PrinciplesPrinciples PracticePractice
Recovery is associated with being Recovery is associated with being able to take on meaningful and able to take on meaningful and satisfy-ing roles within local satisfy-ing roles within local communities communities . .
Recovery is about discovering a Recovery is about discovering a positive sense of personal id- positive sense of personal id-entity, separate from illness or entity, separate from illness or disability. disability.
Recovery based services value the Recovery based services value the
personalqualities of staff as personalqualities of staff as much as formal qualifications, much as formal qualifications,
Family and other supporters are Family and other supporters are
partners in recovery. Peer partners in recovery. Peer support is of prime support is of prime importance for many people importance for many people with mental health problems. with mental health problems.
The individual is supported to to The individual is supported to to use community resources rather use community resources rather than segregated activities. than segregated activities.
Helping people re-tell their stories in Helping people re-tell their stories in language of empowerment and language of empowerment and strength. strength.
Team processes reviewed: language Team processes reviewed: language used, recruitment and selection, used, recruitment and selection, training, negotiated safety training, negotiated safety planning, partnership working, planning, partnership working, respect for individual choice, respect for individual choice, cultural awareness. cultural awareness.
Peer support workers are recruited to Peer support workers are recruited to support, share mutual support, share mutual experiences and coping, inspire experiences and coping, inspire ….….
7 Recovery Promoting Actions7 Recovery Promoting Actions(Slade, 2008)(Slade, 2008)
Lead the ProcessLead the Process
Articulate the values – use them and model themArticulate the values – use them and model them
Training in specific skills (Recovery, Strengths, Training in specific skills (Recovery, Strengths, Solutions, Meaning, Control)Solutions, Meaning, Control)
Make role models visible – life stories, peer support Make role models visible – life stories, peer support workers, staff with mh problemsworkers, staff with mh problems
Evaluate success in setting and achieving person-Evaluate success in setting and achieving person-centred goals, social roles etccentred goals, social roles etc
Amplify the power of people using the serviceAmplify the power of people using the service
Help the person identify their personal goals for Help the person identify their personal goals for recovery.recovery.Demonstrate a belief in their existing strengths. Demonstrate a belief in their existing strengths. Prioritise goals which take the person out of the ‘sick Prioritise goals which take the person out of the ‘sick role’ and enable them to contribute.role’ and enable them to contribute.Identify non-mental health resources to help achieve Identify non-mental health resources to help achieve these goals.these goals.Facilitate self-management of mental health problems.Facilitate self-management of mental health problems.Listen to what the person wants and show that you Listen to what the person wants and show that you have listened.have listened.Convey an attitude of respect and a desire for an equal Convey an attitude of respect and a desire for an equal partnership. partnership. ‘‘Go the extra mile’ to help the person achieve their Go the extra mile’ to help the person achieve their goals.goals.Identify real examples to inspire and validate hope.Identify real examples to inspire and validate hope.While accepting that the future is uncertain, continue While accepting that the future is uncertain, continue to support the person in achieving these self-defined to support the person in achieving these self-defined goals - maintaining hope.goals - maintaining hope.
(SCMH (SCMH 2008)2008)
We are Recovery focused if we:
Help people build connections with their neighbourhoodsHelp people build connections with their neighbourhoodsProvide education to community about mental health. Provide education to community about mental health. Involve significant others in care planning if so desired.Involve significant others in care planning if so desired.Encourage service users to access own treatment records.Encourage service users to access own treatment records.Monitor progress towards service user defined goals Monitor progress towards service user defined goals Do not use threats, bribes or coercion to influence choices.Do not use threats, bribes or coercion to influence choices.Take risks and try new things Take risks and try new things Involve service users in staff recruitment and training Involve service users in staff recruitment and training Know about resources and opportunities in the community.Know about resources and opportunities in the community.Link people with peers who can serve as role models.Link people with peers who can serve as role models.Provide a choice of treatment options Provide a choice of treatment options Believe people can recover and make their own treatment Believe people can recover and make their own treatment and life choices.and life choices.Provide opportunities for service users, family members Provide opportunities for service users, family members and staff to learn about Recovery and staff to learn about Recovery
(Repper, 2008)(Repper, 2008)
Our Service is Recovery Focussed if we:
Common Criticisms of RecoveryCommon Criticisms of Recovery(Shepherd et al, SCMH, 2007)(Shepherd et al, SCMH, 2007)
We’ve been doing this for years/our profession has been We’ve been doing this for years/our profession has been training us to work this way for years –training us to work this way for years –no, it is distinctive no, it is distinctive because user-ledbecause user-ledThis just adds yet more to our work load – This just adds yet more to our work load – should replace should replace not add tonot add toNot evidence based – Not evidence based – it is based on personal narratives it is based on personal narratives and RCT evidence may be helpful within a Recovery and RCT evidence may be helpful within a Recovery frameworkframeworkUndermines professional training – Undermines professional training – no, it means using our no, it means using our professional skills in a different wayprofessional skills in a different wayPlaces professionals at risk as they get the blame when Places professionals at risk as they get the blame when service user makes a bad decision – service user makes a bad decision – we should develop we should develop negotiated safety plans where risks need minimising, and negotiated safety plans where risks need minimising, and allow the ‘dignity of risk’ where appropriate. allow the ‘dignity of risk’ where appropriate.
Recovery and AO: similar Recovery and AO: similar characteristicscharacteristics
A social/community based model of care – using least A social/community based model of care – using least segregated/most acceptable settingsegregated/most acceptable settingPerson centred, flexible, creativePerson centred, flexible, creativeSupport provided at the level/intensity required by the individualSupport provided at the level/intensity required by the individualEngagement achieved by doing things in ways and places that are Engagement achieved by doing things in ways and places that are acceptable and meaningful to individualacceptable and meaningful to individualBuild on strengths rather than just react/fire fightBuild on strengths rather than just react/fire fightCo-working/shared responsibility allows careful safety planningCo-working/shared responsibility allows careful safety planningWork with family so that they are enabled to provide acceptable Work with family so that they are enabled to provide acceptable support in the communitysupport in the communityLook for opportunities and resources in community to promote and Look for opportunities and resources in community to promote and provide positive role and activitiesprovide positive role and activities
User evaluation of AO User evaluation of AO (SCMH, 2005; Repper et al, 2004; Priebe, 2000)(SCMH, 2005; Repper et al, 2004; Priebe, 2000)
Improved continuity of care, quality of life, family relationships, mental health…Improved continuity of care, quality of life, family relationships, mental health…
““They do my forms for me”They do my forms for me”““They know how to handle me”They know how to handle me”““They get on well with my mum too”They get on well with my mum too”““They have taken me to football and I’ve even thought about joining the club They have taken me to football and I’ve even thought about joining the club with them”with them”““I understand my medication and I am more stable in my head now”I understand my medication and I am more stable in my head now”““I have got much more benefits”I have got much more benefits”““I feel much safer now, they sorted out my neighbours for me”I feel much safer now, they sorted out my neighbours for me”““I have more contact with my family now”I have more contact with my family now”““They have helped my life get better and better!”They have helped my life get better and better!”“ “ I trust them to let me know when they think things are going wrong again, 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”. to advise me about what might make my life easier”.
Could AO be more enabling/empowering? Could AO be more enabling/empowering? Could more of this support be provided by peers? Could more of this support be provided by peers?
Some of the challenges of AO Some of the challenges of AO Priebe et al, 2000; Repper et al, 2004; Grayling et al, 2005;Priebe et al, 2000; Repper et al, 2004; Grayling et al, 2005;
Boundaries – friends vs workersBoundaries – friends vs workersStructures of AO clear (fidelity criteria, PIG) values/skills not so Structures of AO clear (fidelity criteria, PIG) values/skills not so clearclearHow to fit ‘engaging client centred relationships’ into statutory How to fit ‘engaging client centred relationships’ into statutory structures structures Perverse incentive for clients to remain in AO – if they improve Perverse incentive for clients to remain in AO – if they improve they met get discharged to less supportive servicethey met get discharged to less supportive serviceShortage of appropriate resources available in community – Shortage of appropriate resources available in community – and insufficient time to support people into existing community and insufficient time to support people into existing community opportunitiesopportunitiesShortage of skilled employment, education …workers Shortage of skilled employment, education …workers ‘community bridgebuilders’ ‘community bridgebuilders’ In UK PRiSM and UK 700 showed no difference in effects of In UK PRiSM and UK 700 showed no difference in effects of AO versus TAU – doing it wrong or measuring wrong things? AO versus TAU – doing it wrong or measuring wrong things?
Some of the difficulties with AO Some of the difficulties with AO reflect criticisms of Recoveryreflect criticisms of Recovery
AO and Recovery approach challenges traditional AO and Recovery approach challenges traditional boundaries. boundaries.
AO and Recovery values do not fit easily into statutory AO and Recovery values do not fit easily into statutory structures and practices (e.g. problem centred care plans, structures and practices (e.g. problem centred care plans, locked doors, Ward Rounds/Review procedures etc)locked doors, Ward Rounds/Review procedures etc)
Biggest barrier to Recovery/success of AO is discrimination – Biggest barrier to Recovery/success of AO is discrimination – social inclusion is a new area of work that requires specific social inclusion is a new area of work that requires specific training (?who for)training (?who for)
Shortage of Shortage of ‘gold standard’‘gold standard’ evidence to support the evidence to support the effectiveness of AO in the UK. effectiveness of AO in the UK.
What else? What else?
A further problem? can Recovery A further problem? can Recovery always work in AO? always work in AO?
“ “ some people may appear unwilling to engage with some people may appear unwilling to engage with recovery because of the severity of their symptoms, their recovery because of the severity of their symptoms, their negative experiences of mental healthcare, intolerable negative experiences of mental healthcare, intolerable side effects of medication, or the fact that it is too painful side effects of medication, or the fact that it is too painful or costly to acknowledge that they need the kind of help or costly to acknowledge that they need the kind of help that is offered” that is offered”
(Davidson and Roe, 2007(Davidson and Roe, 2007))
Unable? Unwilling? Frightened? Angry? Unable? Unwilling? Frightened? Angry?
Independent? Strong? Alternative supports? Independent? Strong? Alternative supports?
Learning from ExperiencesLearning from Experiences
Brainstorm list of problems you have come Brainstorm list of problems you have come across implementing Recovery in AOacross implementing Recovery in AO
Select three to focus onSelect three to focus on
Share experiences of tackling these problemsShare experiences of tackling these problems
Note responses and feedback overviewNote responses and feedback overview
Thank you!Thank you!