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Recovery Oriented Recovery Oriented Practice Practice Julie Repper Julie Repper

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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 - PowerPoint PPT Presentation

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Page 1: Recovery Oriented Practice

Recovery Oriented Recovery Oriented PracticePractice

Julie RepperJulie Repper

Page 2: Recovery Oriented Practice

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

Page 3: Recovery Oriented Practice

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)

Page 4: Recovery Oriented Practice

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)

Page 5: Recovery Oriented Practice

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)

Page 6: Recovery Oriented Practice

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’

Page 7: Recovery Oriented Practice

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

Page 8: Recovery Oriented Practice

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.

Page 9: Recovery Oriented Practice

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)

Page 10: Recovery Oriented Practice

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.

Page 11: Recovery Oriented Practice

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 ….….

Page 12: Recovery Oriented Practice

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

Page 13: Recovery Oriented Practice

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:

Page 14: Recovery Oriented Practice

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:

Page 15: Recovery Oriented Practice

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.

Page 16: Recovery Oriented Practice

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

Page 17: Recovery Oriented Practice

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?

Page 18: Recovery Oriented Practice

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?

Page 19: Recovery Oriented Practice

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?

Page 20: Recovery Oriented Practice

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?

Page 21: Recovery Oriented Practice

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

Page 22: Recovery Oriented Practice

Thank you!Thank you!