National Recovery-Oriented Mental Health Practice Framework Project. Discussion Paper

Transcription

1 National Recovery-Oriented Mental Health Practice Framework Project Discussion Paper Prepared for Safety and Quality Partnership Subcommittee of the Australian Health Ministers Advisory Council, Mental Health Standing Committee Date 8 March 2012

2 Table of Contents TABLE OF CONTENTS... 2 INTRODUCTION... 4 OVERVIEW OF THE NATIONAL RECOVERY-ORIENTED MENTAL HEALTH PRACTICE FRAMEWORK PROJECT... 7 Key project dates and actions... 7 EXECUTIVE SUMMARY... 8 LANGUAGE THROUGH A RECOVERY LENS THE CONCEPT OF RECOVERY THROUGH THE EYES OF LIVED EXPERIENCE THE CONCEPT OF RECOVERY IN THE CONTEXT OF MENTAL HEALTH PRACTICE AND SERVICE DELIVERY Toward a shared understanding of what recovery means in mental health practice and service delivery The recovery journey in practice and service delivery Key components of recovery-oriented mental health practice for individual practitioners Key components of recovery-oriented practice at a service and organisational level EXAMPLES OF FRAMEWORKS OR GUIDANCE FOR RECOVERY-ORIENTED MENTAL HEALTH PRACTICE AND SERVICE DELIVERY Australia - Nationally Australia - In the states and territories Internationally - New Zealand Internationally - England and Wales Craze Lateral Solutions Page 2 of 64

3 Internationally - Scotland Summary EXAMPLES OF APPROACHES TO MEASURING RECOVERY-ORIENTED MENTAL HEALTH PRACTICE AND SERVICE DELIVERY MH-CoPES Developing Recovery Enhancing Environment Measure (DREEM) Recovery Self-Assessment (RSA) Recovery oriented service evaluation (AACP ROSE) Recovery Oriented Systems Indicators Measure (ROSI) Summary SOME CHALLENGES AND ISSUES Limitations of this literature review Aboriginal and Torres Strait Islander peoples and recovery The applicability of recovery-oriented mental health practice REFERENCES Craze Lateral Solutions Page 3 of 64

4 Introduction While a recovery orientation in mental health has largely been championed and driven by people with lived experience, their families, friends and peers as well as the non- government community mental health sector, mental health clinicians and policy makers in recent years have increasingly supported their calls for cultural change. The increased recognition of the role mental health services and individual practitioners in creating environments supportive of recovery, is reflected in Action 4 identified in the Fourth Australian National Mental Health Plan: an agenda for collaborative government action in mental health (the Fourth Plan): the promotion and adoption of a recovery oriented culture within mental health services. (Action 4 the Recovery Action ) 9v2.pdf The Fourth Plan intends that the attitudes, expectations and good practices that underpin a recovery orientation are adopted by individual practitioners, service leaders and policy makers whether they be in the public, private or non- government sector and irrespective of the practice setting. Though people with lived experience of mental illness, their families, individual practitioners and service providers welcome this direction, it is not without concern. Whilst every Australian state and territory has embedded the concept of recovery in their policy and reform platforms, the criticism is often voiced that there is too much rhetoric and insufficient change in practice. Some describe recovery as the latest aerosol term in mental health sprayed on liberally but not applied. Further, mental health consumer organisations express the concern that the concept has been colonised to the detriment of its integrity. Many practitioners and services providers are concerned by the profusion, or as some might say, a cornucopia of different recovery approaches. Whilst some of the emerging approaches are similar, others advocate vastly different language, terms, themes, principles, values and practice guidance. Craze Lateral Solutions Page 4 of 64

5 While many mental health professionals promote person- led recovery, and have embedded a recovery- oriented approach in their practice, many are keen to have an overarching national guiding document to support recovery oriented service delivery and practice in Australia. The National Recovery- Oriented Mental Health Practice Framework Project is occurring against this backdrop. The project seeks to provide the opportunity for all mental health sectors to contribute to the development of a shared national framework for recovery oriented mental health service provision. It is intended that the framework will span all levels of service delivery and guides national mental health system change. It is also intended that the framework will provide guidance to both individual practitioners and service leaders. It further envisaged that the framework will compliment existing professional standards and competency frameworks. This Discussion Paper is to be viewed as an interactive starting point. To assist, the Internet link to each major resource is provided as it is discussed. Readers are invited to follow the link, go to the original document, read it in full and consider its relevance or usefulness. The links to key references and resources used have also been placed on the Project s website: It is acknowledged that in trying to balance the demands of rigour with brevity, the overview of the literature in this Discussion Paper is neither exhaustive nor definitive. Undoubtedly, the Discussion Paper will have failed to mention numerous resources that people in different settings and locations have found useful and instructive. Advice concerning these further resources is welcomed. This Discussion Paper comprises the following sections: The concept of recovery through the eyes of people with lived experience The concept of recovery in the context of mental health practice and service delivery Examples of frameworks or guidance for recovery- oriented mental health practice and service delivery Examples of approaches to measuring recovery- oriented mental health practice and service delivery Craze Lateral Solutions Page 5 of 64

6 Some challenges and issues Two other documents accompany this Discussion Paper: the first, Examples of Recovery- Oriented Frameworks and Guidance; and the second, Summary & Consultation Questions. Craze Lateral Solutions Page 6 of 64

7 Overview of the National Recovery- Oriented Mental Health Practice Framework Project The Safety and Quality Partnership Subcommittee (SQPS) of the National Mental Health Standing Committee (MHSC) is responsible for progressing the Recovery Action and is providing oversight to this project. If this project is to successfully develop a shared framework, the active involvement of people who are experts by experience, family and other supporters, states and territory mental health directorates, the different service sectors and individual practitioners is critical. A phased process of framework development and national consultation is planned to ensure that stakeholders are informed, involved and able to respond at each stage. The Discussion Paper and each consecutive draft of the framework are to be viewed as work in progress. The phased consultation will support the step- by- step identification of the key characteristics of recovery oriented practice guidance. The information acquired will then be progressively synthesised into an overarching framework to aid the translation and embedding of recovery guidance into practice and for reshaping service delivery. Key project dates and actions Mid March Discussion Paper and Online Survey released & strategic discussions commence 30 April 1 st Consultation Draft of the Recovery Framework released Mid late May Consultation forums in capital cities 22 June 2 nd Consultation Draft launched at the Inaugural National Recovery Forum June- July Consultations 30 August National Mental Health Recovery Framework finalised Craze Lateral Solutions Page 7 of 64

8 Executive Summary By providing a summary of relevant Australian and international experience, research and literature, this Discussion Paper seeks to: Foster discussion between groups with different views about what a recovery orientation to mental health service delivery means and requires Promote discussion about the contents of a national mental health recovery framework including for example key concepts, elements and practices Identify key issues and questions needing to be addressed during the course of the project. The Discussion Paper invites people with lived experience of mental illness, their families and other supporters, practitioners, mental health service providers and other Australian mental health stakeholders to collaboratively and progressively sift through and discuss seminal or ground shifting threshold writings and research. People are also invited to assess the relevance of current recovery- oriented practice frameworks. Questions are progressively posed throughout the Discussion Paper to elicit people s views and ideas as well as their responses to key issues. The questions also provide an opportunity for people to identify helpful articles and resources that have not been referred to in the Discussion Paper. Services and practitioners are encouraged to assist by making hard copies of key resource documents available for people who may otherwise having difficulty in accessing them. Recovery through the eyes of lived experience Common themes described by writers and researchers with lived experience of mental illness including the following. Recovery is a unique and highly personalised experience Recovery is an individually defined journey or process of growth and personal wellbeing emotional, mental health and social Recovery is non- linear, a process including ups and downs, periods of growth as Craze Lateral Solutions Page 8 of 64

9 well as setbacks Recovery is a pathway informed by a person s unique strengths, preferences, needs, experiences and cultural background Relationships with family, friends, peers and practitioners can foster hope that in turn is a catalyst for recovery. A starting point for understanding what recovery means in mental health practice and service delivery As a starting point for developing a shared understanding of what recovery means in practice and service delivery, the following statement is provided. In this document, the term recovery is considered to be an overarching philosophy that encompasses notions of self- determination, self- management, personal growth, empowerment, choice and meaningful social engagement. It is an overarching philosophy that does not equate with a particular model of care, phase of care or service setting. It can be used to guide practice across the full range of clinical and non- clinical services The concept of recovery is understood to refer to a unique personal experience, process or journey that is defined and led by people in relation to their wellbeing and mental health. Recovery is about building a meaningful and satisfying life, as defined by the person, whether or not there are any ongoing or recurring symptoms or difficulties. While recovery is owned by and unique to each individual, mental health services have a role in creating an environment that facilitates clinical recovery and supports people s individual recovery efforts. An important goal of mental health services is minimising service system barriers to recovery. Mental health services also have a role in supporting people with the effects of discrimination and other possible social consequences of the experience of mental illness including loss of self esteem, and limitations to social, housing and employment opportunities that might impede recovery. Craze Lateral Solutions Page 9 of 64

10 A starting point for understanding the key components of recovery- oriented mental health practice for individual practitioners A synthesis of the research and literature suggests that key components of recovery- oriented practice for individual practitioners include: Collaborative relationships with people to understand each person s strengths, wishes and opportunities Responsiveness to the particular strengths, preferences, concerns, needs, goals and values of individuals Responsiveness to the things, people, activities and roles that people identify as important to their wellbeing and recovery (and ensuring that mental health care enhances rather than interferes with these) Promoting decision making led by people accessing the services in accordance with each person s values, needs, circumstances and resources Encouraging and promoting self- determination and self- management of mental health and wellbeing Demonstration of empathy and resourcefulness in communicating with and responding to people Active challenging of stigmatising attitudes within the service and the broader community utilising people s existing support networks Use of interventions that promote people s personal agency, self- esteem and overall wellness Active listening and responsiveness to people s views, understandings of their experiences and advice on what they find helpful Use of person- centred and optimistic language that promotes hopefulness Practice that is trauma- informed and promotes safety Practice that is responsive to and inclusive of family, friends and peers Craze Lateral Solutions Page 10 of 64

11 Practice that is responsive to gender, sexuality, culture and community The offering of professional training, knowledge, expertise and experience as a resource for recovery A starting point for understanding the key components of recovery- oriented mental health practice at service delivery and organisational level A synthesis of the research and literature suggests that key components of recovery- oriented practice at an organisational level include the following. Organisational culture and commitment to facilitate a reorientation to a recovery approach and the embedding of recovery principles in practice Inclusion of recovery principles in all management processes, such as recruitment, professional development, supervision, appraisal, audit, service planning and operational policies Incorporation of recovery values and language into all key organisational documents and publications A degree of risk tolerance in encouraging people s choice, balanced with duty- of- care obligations Routine documentation of people s preferences, ambitions, resources and support networks ongoing provision of information in multiple forms to people regarding rights, complaint processes, treatment options, advocacy support options and access to records A peer support workforce Involvement of people with lived experience and their significant others in processes such as recruitment, education, training and development, and quality- improvement activities responsiveness to people s feedback, for example, through using outcome- measures, surveys, quality audits, complaints, service planning and evaluation activities and training led by people with lived experience Providing evidence- based interventions that assist in achieving the best outcomes Craze Lateral Solutions Page 11 of 64

12 for people s mental health and wellbeing Using practice models compatible with a recovery approach such as strengths- based approaches and individual recovery planning Fostering partnerships between the service, people accessing services and their significant others Partnerships between different service providers for integrated and coordinated care Partnerships with community to aid social inclusion of people in communities of their choosing A starting point for identifying the key components of a recovery- oriented mental health practice framework A review of existing frameworks and guidance for recovery- oriented practice suggests that at a minimum, the components of a new national framework might comprise the following. 1. Statements reflecting shared understandings of what recovery means in the contexts of practice and service delivery 2. Guiding principles 3. Domains of practice 4. Capabilities for each practice domain at both an individual practitioner level and service/organisational level 5. Indicators 6. Measurement approaches and processes 7. Examples of good practice at an individual practitioner level 8. Examples of good practice at a leadership level 9. Examples of good practice at a service delivery level 10. Workforce development strategies or pathways Craze Lateral Solutions Page 12 of 64

13 11. A research agenda to build the knowledge and evidence base and to inform ongoing improvement in practice and service delivery In view of our National Apology to the Stolen Generations by the Australian Parliament in February 2008, the New Zealand experience and achievements demand consideration. Particularly pertinent, is the way in which Maori culture, history and language as well Maori expectations and preferences have been integrated into a generic and overarching recovery- oriented framework. (Te Pou, Let s get real get- real- working- with- maori- learning- module) Specific consideration is also required as to how the new national framework ensures it is applicable to different age groups as well as to population groups with specific needs. Consideration is further required as to how the new framework ensures its applicability to difficult settings where choice and responsibility are most compromised or where services are most limited. Craze Lateral Solutions Page 13 of 64

14 Language through a recovery lens Words and language are critically important in the mental health field where people battle with self- stigma arising from issues of identity, loss of self- esteem and discrimination. Language powerfully shapes sense of self by influencing how people describe themselves and are described by others (Slade, 2009b). Recovery paradigms increasingly advocate the adoption of people first language whereby: descriptions like person in recovery, person who is expert by training, or person with lived experience, rather than previous descriptions which focused on deficits or relationships to services (Mental Health and Language, Recovery Devon, in- action/162- language- and- mental- health#importance This paper adopts a similar approach. Consistent with the language of recovery, the terms person, people with lived experience and experts by experience are used wherever possible rather than terms such as consumers, clients, service users or patients. For similar reasons, this paper uses terms such as family and support people rather than the term carer. The author acknowledges that many people identify as both an individual with personal lived experience of mental illness and as family member or support person. Despite taking this approach, the author acknowledges that many people find a depth of personal meaning in the terms consumers and/or carers. Their preference for the use of these terms is also respected. Craze Lateral Solutions Page 14 of 64

15 The concept of recovery through the eyes of lived experience The concept of recovery having emerged from the consumer movement in the 1970s continues to be further advanced internationally by people with lived experience. This section discusses the concept of recovery as seen through the eyes of people with lived experience. There are many different understandings of what recovery means, including that of a journey for some people and an outcome such as wellness for others. Recovery as a unique and personal journey The NSW Consumer Advisory Group takes up the theme of recovery as a unique and personal journey : The personal view of recovery is viewed as a journey that is a unique and personal experience for each individual. It has often been said to be about: gaining and retaining hope, understanding of ones abilities and limitations, engagement in an active life, personal autonomy, social identity, meaning and purpose in life, and a positive sense of self. Essentially, the personal view of recovery is about a life journey of living a meaningful and satisfying life. CAG- MHCC- Project- Recovery- Literature- Review.pdf Recovery as living well Commentators and researchers with lived experience also emphasise living well irrespective of any limitations arising from mental illness.... 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 within 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) Self defined and not the same as cure The distinction between clinical recovery and personal recovery is frequently described. For example, Slade (2009a) suggests that clinical recovery is defined by mental health Craze Lateral Solutions Page 15 of 64

16 professionals and pertains to a reduction or cessation of symptoms and a restoring of social functioning, while personal recovery is self- defined and refers to an ongoing holistic process of personal growth, healing and self- determination. Pat Deegan, a psychologist who is in recovery with schizophrenia, reflects on what this distinction means in every day life. Recovery is not the same thing as being cured. Recovery is a process not an end point or a destination. Recovery is an attitude, a way of approaching the day and facing the challenges. Being in recovery means recognizing limitations in order to see the limitless possibilities. Recovery means being in control. Recovery is the urge, the wrestle, and the resurrection My journey of recovery is still ongoing. I still struggle with symptoms, grieve the losses I have sustained... I am also involved in self- help and mutual support and still use professional services including medications, psychotherapy, and hospitals. However, I do not just take medications or go to the hospital. I have learned to use medications and to use the hospital. This is the active stance that is the hallmark of the recovery process. (1996, p.91) No straight lines Deegan also discusses the non- linear nature of recovery and how recovery is frequently interspersed with both achievement and setbacks. Recovery is not a linear process marked by successive accomplishments. The recovery process is more accurately described as a series of small beginnings and very small steps. Professionals cannot manufacture the spirit of recovery and give it to consumers. Recovery cannot be forced or willed. However, environments can be created in which the recovery process can be nurtured like a tender and precious seedling. To recover, psychiatrically disabled persons must be willing to try and fail, and try again. (Deegan 1988, p. 11) Craze Lateral Solutions Page 16 of 64

17 Recovery and relationships Other commentators with lived experience of mental illness emphasise the theme of relationships with family, friends, peers and practitioners (Brown & Kandirikiria 2008, pp75-79). [It is]. important for people in recovery to feel as if they are supported and cared for and identify being there and available as a factor within friendships that seemed to help people in recovery. For professionals or caregivers, to go the extra step, to take a risk, to reach out and make a connection and be there was important (2008, p. 75) Boydell et al (2002) take up the theme of the importance of peers and refer to an enhanced level of understanding, support and acceptance that peers bring to each other. Also emphasised is the role of peers in alleviating alienation and loneliness. This brief discussion of how writers and researchers with lived experience of mental illness have described recovery identifies a number of common themes including the following. Recovery is a unique and highly personalised experience Recovery is an individually defined journey or process of growth and personal wellbeing Recovery is non- linear, a process including ups and downs, periods of growth as well as setbacks Recovery is a pathway informed by a person s unique strengths, preferences, needs, experiences and cultural background Relationships with family, friends, peers and practitioners can foster hope that in turn is a catalyst for recovery. It is vital that the new national recovery- oriented mental health practice framework remains true to what recovery means to people who are living it. Though recovery cannot be standardised, there is a growing conviction that it can be viewed as an overarching philosophy to guide practice and service delivery. Craze Lateral Solutions Page 17 of 64

18 Recovery through the eyes of lived experience Question 1 Are there any other important themes, identified in descriptions of recovery provided by people with lived experience, that should be included here? Question 2 What is your response to the statement that, the concept of recovery can be viewed as an overarching philosophy to guide practice and service delivery? Craze Lateral Solutions Page 18 of 64

19 The concept of recovery in the context of mental health practice and service delivery Though personal and unique and though the notion of recovery is not constrained to any particular model or service setting, in order for recovery- oriented approaches to be implemented, we all need to know what we are talking about. A common or shared understanding, even it is a starting point, is required. If recovery is to have the impact it deserves, people accessing mental health services and people working in mental health need to be confident that they are talking about the same thing. A shared understanding will enable all parties to actively work together to support the framework s implementation across services. Having reached an initial shared understanding of recovery, the task remains to identify from the literature the range of practices and behaviours at both an individual practitioner level and a service level that can guide practice and foster environments supportive of people s recovery. This section of the Discussion paper seeks to promote an initial shared understanding of the following: The concept of recovery in practice and service delivery The concept of recovery as a journey Key components of recovery- oriented practice for individual practitioners Key components of recovery- oriented practice at a service or organizational level. Toward a shared understanding of what recovery means in mental health practice and service delivery A number of different approaches to describing recovery may assist movement toward a shared understanding of what recovery means in mental health practice and service delivery. Helpful descriptions are provided. The salient features of each description are identified in turn. Craze Lateral Solutions Page 19 of 64

20 The Victorian Department of Health in its Framework for Recovery- oriented Practice (2011b) adopts the following approach to the question of what recovery means in practice. In the paradigm of mental health, the concept of recovery is understood to refer to a unique personal experience, process or journey that is defined and led by each person in relation to their wellbeing. While recovery is owned by and unique to each individual, mental health services have a role in creating an environment that supports, and does not interfere with, people s recovery efforts. (p.1) In this document, the term recovery is considered an overarching philosophy that encompass notions of self- determination, self- management, personal growth, empowerment, choice and meaningful social engagement. (p.2) It is an overarching philosophy that does not equate with a particular model of care, phase of care or service setting but that can be used to guide practice across the full range of clinical and non- clinical services. recovery- oriented- practice.pdf This description emphasises the personal and individualistic nature of recovery as a person seeks wellbeing. Recovery is viewed as an overarching philosophy can be used to guide practice across the full range of clinical and non-clinical services. The role of practitioners and services includes doing all they can to support a person s recovery, wellbeing and mental health. The Mental Health Coordinating Council of NSW in noting the absence of a shared working definition of recovery in Australia, proposes that: Recovery in a broad sense is about finding a way to get back on track after experiencing illness. Recovery from the consequences of mental health problems can sometimes be more difficult than recovering from actually being unwell. Issues such as discrimination, loss of self- esteem, and limitations to social, housing and employment opportunities, can all be very real barriers to recovery. Viewing recovery as a normal human process demystifies the process of recovery from mental health problems and puts people in a better position to support someone in their recovery journey. (MHCC 2008, p.14) revised.pdf Craze Lateral Solutions Page 20 of 64

21 This approach adds the dimension of viewing recovery as a normal human process. It also raises the importance of services supporting a person with the effects of discrimination and other social consequences of the experience of mental illness, all of which may impede recovery. The Mental Health Advocacy Coalition of New Zealand in providing guidance for non- government services adopts a similar approach in their paper, Destination Recovery. We define recovery as achieving the life we want in the presence or absence of mental distress. The right conditions for recovery are the strength and interrelationships of our self- determination, personal resources, supports, therapies, and our social and economic opportunities. The role of recovery- based practices and systems is to ensure all of these factors are maximized. (NZ Mental Health Advocacy Coalition: 2008, 18) Living the life one is seeking to achieve and living well irrespective of the presence or absence of mental illness are further helpful emphases. Davidson et al (2006b), while acknowledging the difference between clinical recovery and personal recovery, argue that the two types of recovery are complimentary and supportive of each other. For example, Davidson et al., suggest that on one hand, symptom alleviation can contribute to personal recovery and on the other hand, an increased sense of wellbeing regardless of continuing symptoms can contribute to a reduction in those symptoms or in their severity. Wood et al (2010), from the Greater Manchester West Mental Health NHS Foundation Trust, in a recent study conducted by researchers with lived experience, explored views of people with psychosis about recovery. The research team reports: All participants highlighted symptom change as an indicator of their recovery, and change in symptoms was often accompanied by alleviation of distress and personal change. (2010, p. 468) There is general agreement in the research that while recovery is much broader than symptom improvement, alleviation of distress associated with symptoms makes an important contribution. Wood et al., state: Craze Lateral Solutions Page 21 of 64

22 Improvements in psychotic symptoms may be important to recovery, but only in conjunction with a range of other factors. Furthermore, the findings in relation to the need for change within symptoms may indicate that although full symptom alleviation or removal may be important for some service users, for others, changes in the nature of the symptoms may be just as important. For example, recovery may mean the continued presence of symptoms but without their negative impact. (2010, pp ) The findings of this research project may have particular relevance to acute inpatient settings and to other settings where there are high levels of acuity. The study points to the need for recovery approaches to not underestimate the importance of symptom alleviation to the promotion of wellbeing and self- management. Drawing together all of the identified themes, the following definition is provided as a starting point of a shared or common understanding what recovery means in the context of mental health practice and service delivery. Craze Lateral Solutions Page 22 of 64

23 Toward a shared understanding of what recovery means in mental health practice and service delivery In this document, the term recovery is considered an overarching philosophy that encompasses notions of self-determination, self-management, personal growth, empowerment, choice and meaningful social engagement. It is an overarching philosophy that does not equate with a particular model of care, phase of care or service setting. It is an overarching philosophy that can be used to guide practice across the full range of clinical and non-clinical services The concept of recovery is understood to refer to a unique personal experience, process or journey that is defined and led by people in relation to their wellbeing and mental health. Recovery is about building a meaningful and satisfying life, as defined by the person, whether or not there are any ongoing or recurring symptoms or difficulties. While recovery is owned by and unique to each individual, mental health services have a role in creating an environment that facilitates clinical recovery and supports people s individual recovery efforts. An important goal of mental health services is minimising service system barriers to recovery. Mental health services also have a role in supporting people with the effects of discrimination and other possible social consequences of the experience of mental illness including loss of self esteem, and limitations to social, housing and employment opportunities that might impede recovery. Question 3 What is your response to this statement as a starting point for developing a shared understanding of what recovery means in mental health practice and service delivery? How might it be improved? Craze Lateral Solutions Page 23 of 64

24 The recovery journey in practice and service delivery Davidson & Roe (2007) suggest that while recovery is possible for everyone, for many engaging with recovery is a struggle. The struggle might stem from the severity of symptoms or from, trauma and pain arising from their personal experiences of mental illness and/or services and treatment. Compounding the struggle might be insufferable side effects of medication. Would a conceptual approach for understanding the recovery journey assist practitioners and services to support those who are struggling? By studying personal accounts of recovery, Australian researchers based at the Illawarra Institute for Mental Health, Andresen, Caputi and Oades, sought to develop a conceptual model of recovery to guide research and training and to inform clinical practice (2003 & 2006). As a result of their research, Andresen et al identified four key processes of personal recovery. Finding and maintaining hope believing in oneself; having a sense of personal agency; optimistic about the future; Re- establishment of a positive identity finding a new identity which incorporates illness, but retains a core, positive sense of self; Building a meaningful life making sense of illness; finding a meaning in life, despite illness; engaged in life; Taking responsibility and control feeling in control of illness and in control of life. Leamy et al (2011) researchers at the King s College Institute of Psychiatry in London, identified similar, however differently worded, processes. They added a fifth process, connectedness (peer support, relationships, support from others and being part of a community). Additionally Andresen et al proposed the following five stages of personal recovery: Moratorium a time of withdrawal characterised by a profound sense of loss and hopelessness; Craze Lateral Solutions Page 24 of 64

25 Awareness realisation that all is not lost and that a fulfilling life is possible; Preparation Taking stock of strengths and weaknesses regarding recovery and starting to work on developing recovery skills; Rebuilding actively working towards a positive identity, setting meaningful goals and taking control of one s life; Growth living a meaningful life, characterised by self- management of the illness, resilience and a positive sense of self. According to Andresen et al., the stages should not been seen as a linear. Nor should it be assumed that everyone will travel through each stage. Andresen et al suggest that the stages are better understood as aspects of a person s engagement with the recovery process. Models that seek to describe different processes, tasks and stages of the recovery journey may provide useful practice guidance for involuntary, forensic and other secure settings where choice and responsibility is often most compromised. In these settings a person s illness may be at its severest and a person might appear least able or least motivated to engage in recovery. As a result of the difficulties or constraints that can be encountered in these settings, practitioners might be pessimistic about recovery and might struggle to see how people can be supported toward greater self- determination and self- management. Understanding recovery in terms of processes and stages, might assist practitioners to look beyond the acuity or chronicity of the setting and to embrace the challenge of utilising evidence- based, innovative, individually- tailored interventions to help a person move from being disengaged to engaged, from withdrawn or hostile to having a sense that there is hope for improvement. To look beyond the current severity of a person s illness also requires a practitioner to actively seek to ensure that any limitations on a person s choice, autonomy and self- determination are removed as soon as possible and to the extent that is consistent with duty of care and safety. A person s steps toward awareness, preparation and rebuilding (or however recovery phases might be variously described) would be encouraged by a progressive restoring of choice, if only minimally in the first instance. Recovery gains would also be promoted and consolidated through opportunities for greater self- determination and informed risk taking. Craze Lateral Solutions Page 25 of 64

26 By providing these conceptual approaches, Andressen et al and Leamy et al assist understanding of what a recovery journey might entail. They also enhance understanding of what recovery means in the context of mental health practice and service delivery and of how practitioners can assist. Toward a shared understanding of recovery journeys in mental health practice and service delivery Question 4 In viewing personal recovery as a journey, is it helpful to seek to identify, without being prescriptive, key processes and stages of that journey? Question 5 Does viewing recovery as a journey comprising processes and stages also provide a conceptual basis for understanding the importance of recovery-oriented practice in involuntary, forensic and other secure settings where choice and responsibility might be most compromised? Question 6 What is your response to the Andresen, Caputi & Oades (2003 & 2006) conceptual approach to the processes and stages of personal recovery? Question 7 Are you aware of different approaches to understanding what the concept of recovery as a journey means in mental health practice and service delivery? Key components of recovery- oriented mental health practice for individual practitioners A literature review conducted by the Victorian Department of Health, Recovery- oriented practice, provided the following summary: The term recovery- oriented practice in the literature is viewed as encompassing principles of self- determination and personalised and holistic care. A Recovery- practicing professional emphasises hope, social inclusion, community participation, Craze Lateral Solutions Page 26 of 64

27 personal goal setting and self- management (2011a, p.4) d%20practice%20literature%20review_web.pdf Others have added that recovery- oriented practice involves looking beyond the pathology of a person s mental illness and adopting a holistic approach to wellbeing that builds on individual strengths (Davidson The literature on recovery- oriented practice general promotes a coaching or partnership- based relationship between people accessing mental health services and mental health professionals. A recovery- practicing professional views people with lived experience as experts on their lives and experiences. The recovery- practicing professional seeks to compliment a person s lived expertise with their own professional expertise and their knowledge of available treatment, therapies, services and supports. (Victorian Dept Health, 2011a, p.2) d%20practice%20literature%20review_web.pdf Roberts & Wolfson envisage a two- way learning relationship. offering their professional skills, knowledge and experience, while learning from and valuing the person and their family members and supporters, as experts- by- experience (2004, p.37) A key aim of the recovery- practicing professional identified in the literature is to provide people with the resources information, skills, networks, services, support, treatment, therapies and rehabilitation to manage their own condition as far as possible and to help people access the resources they think they need to live their lives. Supporting self- management is important because if people can achieve greater control over their symptoms and how they are managed, particularly during times of crisis, they can begin to grow in confidence and take control over other aspects of their life. Repper and Perkins (2003) describe this change as professionals being, on- tap, not on- top and having a two- way, partnership- based relationship with the people who are using their services. It is a relationship which fuses together the skills and experience of both the person with the mental illness and the professional. Craze Lateral Solutions Page 27 of 64

28 The research and literature also emphasises the importance of mental health practice being inclusive of and responsive to families, friends, peers and others who have a significant and important role in supporting a person s recovery. Working effectively with a person s family and support network involves establishing rapport and trust, and using evidence- based practices to help support their recovery as well as the recovery of their relationships. Working effectively with families also requires an understanding of the tension that can occur at times between a person s rights and the rights of families and significant others. (Brown & Kandirikirira 2007) Le Boutillier et al (2011), based at the King s College Institute of Psychiatry, conducted a comprehensive review of the literature to synthesise guidance concerning how practitioners might support the recovery journey of a person with mental illness. As a result of their research, the team identified four practice domains. Promoting citizenship meaningful life, social inclusion, meaningful occupation Organisational commitment ensuring that the work environment and organisational culture are conducive to promoting recovery- oriented practice Supporting personally defined recovery personally defined recovery at the heart of practice rather than an additional task Working relationship a partnership- based working relationship A synthesis of the research and literature suggests that key components of recovery- oriented mental health practice for individual practitioners include: Collaborative relationships with people to understand each person s strengths, wishes and opportunities Responsiveness to the particular strengths, preferences, concerns, needs, goals and values of individuals Responsiveness to the things, people, activities and roles that people identify as important to their wellbeing and recovery (and ensuring that mental health care enhances rather than interferes with these) Craze Lateral Solutions Page 28 of 64

29 Promoting decision making led by people accessing the services in accordance with each person s values, needs, circumstances and resources Encouraging and promoting self- determination and self- management of mental health and wellbeing Demonstration of empathy and resourcefulness in communicating with and responding to people Active challenging of stigmatising attitudes within the service and the broader community utilizing people s existing support networks Use of interventions that promote people s personal agency, self- esteem and overall wellness Active listening and responsiveness to people s views, understandings of their experiences and advice on what they find helpful Practice that is trauma- informed and promotes safety Use of person- centred and optimistic language that promotes hopefulness Practice that is responsive to and inclusive of family, friends and peers Practice that is responsive to gender, sexuality, culture and community The offering of professional training, knowledge, expertise and experience as a resource for recovery. Toward a shared understanding of key components of recovery-oriented mental health practice for individual practitioners Question 8 What is your response to the list of key components of recovery-oriented practice for individual practitioners provided in this Discussion Paper? What changes or additions would you suggest? Craze Lateral Solutions Page 29 of 64

30 Key components of recovery- oriented practice at a service and organisational level The aim of a recovery approach to mental health service delivery is to support people to build personal identity and to maintain a meaningful and satisfying life, that is self- defined and self- determined, regardless of whether or not there are ongoing symptoms of mental illness (Shepherd et al The literature has increasingly discussed the implications for services supporting self- determination, including provision for positive risk taking. The balancing of risk is identified as an important task for services that are actively promoting choice and self- management. This tasks requires services to confront the tension between empowering people and supporting positive risk taking on one hand and duty of care and promoting safety on the other hand. The Victorian Department of Health provides this guidance: in supporting people s recovery efforts, it is necessary for services to articulate the threshold of risk appropriate to the particular service setting. Accordingly, services should consider providing guidance, training and support to staff on how to reconcile flexibility and responsiveness to people s unique circumstances and preferences with appropriate risk management obligations. 2011b, p. 3) The Victorian Framework for Recovery- oriented Practice, based on a synthesis of research findings and extensive consultation, suggests that key components of recovery- oriented practice at organisational level include the following. Organisational culture and commitment to facilitate a reorientation to a recovery approach and the embedding of recovery principles in practice Inclusion of recovery principles in all management processes, such as recruitment, professional development, supervision, appraisal, audit, service planning and operational policies Incorporation of recovery values and language into all key organisational documents and publications A degree of risk tolerance in encouraging people s choice, balanced with duty- of- care obligations Craze Lateral Solutions Page 30 of 64

31 Routine documentation of people s preferences, ambitions, resources and support networks Ongoing provision of information in multiple forms to people regarding rights, complaint processes, treatment options, advocacy support options and access to records A peer support workforce Involvement of people with lived experience and their significant others in processes such as recruitment, education, training and development, and quality- improvement activities Responsiveness to people s feedback, for example, through using outcome- measures, surveys, quality audits, complaints, service planning and evaluation activities and training led by people with lived experience Providing evidence- based interventions that assist in achieving the best outcomes for people s mental health and wellbeing Using practice models compatible with a recovery approach such as strengths- based approaches and individual recovery planning Fostering partnerships between the service, people accessing services and their significant others recovery- oriented- practice.pdf Also important are partnerships between different service providers for integrated and coordinated care as well as partnerships with community to aid social inclusion of people in communities of their choosing. Craze Lateral Solutions Page 31 of 64