How we understand recovery
Over the last 10 years NHS mental health services have become more and more focused on the concept of “recovery”. For whatever reasons (changing views of psychiatry, service user voices, or simply a change in the climate of healthcare) we seem less in the business of cure and more about empowerment. But what is all this about and how does it apply to you if you have a mental health problem? And is it really happening or is the core business of mental health services still drugs and hospital? In the following short feature (5 minutes or so of audio with slides) I consider two recent papers which may help in understanding these questions: one by Mary Leamy and her colleagues from 2011 and the other by Rachel Perkins and Mike Slade from 2012. The first paper looks at the concept of recovery as personal journey and how service users define it. The second considers how mental health services are trying to support recovery and what the challenges are. Both these papers offer a valuable contribution to the understanding of recovery and how we go about implementing it practice.
(Note: File is .wmv. There is also a transcript of the audio below).
Mary Leamy and her colleagues begin their paper, published in 2011, with a much-quoted definition of recovery by William Anthony from 1993. He drew his definition of recovery from working closely with service users. He defines recovery as:
‘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 limitations caused by illness.’
He was emphasizing that it isn’t just about symptoms and cure. Recovery is much more. However, no one had yet pulled together the numerous studies in the English language that have actually asked people about their view of recovery, and that didn’t just focus on symptom reduction. This is what Leamy and her colleagues do in their 2011 paper. They found 97 papers that covered 87 different studies. Nearly all involved interviews with service users.
Recovery was viewed as:
- CONNECTEDNESS – Connecting with other people, for example people with similar experiences, or being involved in one’s community.
- HOPE – Seeing recovery as part of one’s future, valuing successes and having goals.
- IDENTITY – Thinking well of oneself and shaking off stigma.
- MEANING – Having valued roles in society, making sense of mental distress, a spiritual dimension to life.
So how can services support personal recovery?
A paper published in 2012 by Rachel Perkins and Mike Slade poses this question. But they also highlight a problem with viewing recovery as exclusively personal and individual. This ignores the role of prejudice and social exclusion. Perkins and Slade (2012) remind us that UK disability rights laws include people with mental health conditions. But neither service users nor services have been quick to demand these rights. What Anthony emphasized was that there may be ongoing disability, but recovery was about rebuilding a good life despite these.
>Perkins and Slade suggest that English mental health services still seem to focus too much on these deficits and disability, with only cure or care and containment as the goals. Services need to move towards “supporting self-management rather than fixing people” say Perkins and Slade (p. 33). They describe two major projects aimed at changing mental health services. One is called ImROC and the other REFOCUS.
ImROC stands for Implementing Recovery – Organizational Change. It addresses 10 challenges arising from work with 300 people with experience of working in mental health and social care and experience of using services and their relatives and friends. Here are a few of them:
- Implementing service user-led training for staff.
- Moving from risk management to supporting positive risk-taking with shared responsibility for risks.
- Transforming the work force by employing more people with lived experience of mental distress and valuing this experience.
- Supporting staff in safely disclosing their own expertise by experience.
- Recognizing service users’ strengths and any resources they have in the community to enable them to move towards their goals.
Both staff and service users decide which challenge to start with, and create an action plan. Progress is evaluated before the next challenge is attempted. The pilot was going to be six sites, but thirty-five signed up.
The REFOCUS project is about how staff relate to service users. A manual for working with service users was developed with input from people with expertise by experience. There are three working practices:
- Finding out who the service user is and what they want to achieve, using a topic guide, and helping them create a map of their life and their preferences.
- Finding out what strengths a person has, such as how they coped with something in the past, their connections in the local community, and so on. This uses a “strengths worksheet”.
- Supporting people in striving for their goals using a coaching approach.
The project also focuses on how staff relate to service users by:
- Service-user led training for staff.
- Follow-up training and reflective sessions.
- Staff and service users working together on projects of shared interest.
- Encouraging service users to expect staff to relate to them differently.
- Leamy and her colleagues summarised research on the views of people with lived experience on what recovery looks like from the personal perspective.
- There seem to be five main elements: connectedness, hope, identity, meaning and empowerment (CHIME).
- Yet Perkins and Slade (2012) remind us that recovery is not just an individual matter.
- It may require help from disability rights law to enable real social inclusion.
- Two ground-breaking projects are underway in a range of services in England.
- Perhaps they will lead to change.
- Many staff want to support personal recovery.
The findings could make a lasting impact on improving the prospects for people needing help for mental distress.
A longer version of this article appeared in Mental Health and Social Inclusion in their Research Watch feature, November 2012.
Holttum, S. (2012). Research watch: recovery as a personal journey: how mental health services are trying to support it, Mental Health and Social Inclusion, 16, 169 – 174.