The Recovery approach and Western Australian community based mental health services A discussion paper for individuals

and organisations

Prepared by the Western Australian Association for Mental Health 25 October 2011

Background- why recovery? Mental health is receiving significant attention in Western Australia (WA) and the State Government has made a strong commitment to reform. The State Government has undertaken wide spread consultation to develop the WA Mental Health Strategic Plan 2010- 2020. The consultation paper, WA Mental Health Consumer, Carer and Community Consultation Review (the Review) released in March 2010 and the recently released Everybodys Business- Community Consultations Summary Report (Everybodys Business) iterate the beginning of this reform agenda in the form of consumer and carer feedback. Key ideas coming out of these papers include that services need to be recovery focussed and holistic with ...a stronger recovery focus and; services to help individuals live independently (the Review). Also ...Key themes for reform include the importance of prevention and early intervention; more person centred and recovery focused services with the engagement of families and carers and access to a more comprehensive range of community based supports... (Everybodys Business 2011) Recovery has been the broad underlying principle for health in New Zealand, Ireland, Scotland and the United States since as early as 1993 (USA) and 1998 (in NZ). While embraced in the community based mental health sector, recovery, hand in hand with more personalised approaches to care is now beginning to gain traction in government consultations, policy development and program delivery. What is Recovery? A good starting point in gaining an understanding of recovery is the following definition from Anthony1. a deeply personal, unique process of changing ones 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 ones life as one grows beyond the catastrophic effects of mental illness.

W.A Anthony, Recovery from Mental Illness: The Guiding Vision of the Mental Health Service System in the 1990s, Psychosocial Rehabilitation Journal, 1993, 16(4), 1123

The nine common elements of recovery This definition is expanded on in various texts on recovery and Professional Psychology: Research and Practice2 has identified the nine common elements that regularly come up when talking about recovery.
1. 2. 3. 4. 5. 6. 7. 8. 9. Renewing hope and commitment Redefining self Incorporating illness Being involved in meaningful activities Overcoming stigma Assuming control Becoming empowered and exercising citizenship Managing symptoms Being supported by others

In this paper we have aligned these elements of recovery with the five stages of recovery identified in the Sainsbury Centre for Mental Healths paper Making Recovery a Reality3 to explore these stages in greater detail. The Sainsbury Centres five identified stages Moratorium Awareness Preparation Rebuilding Growth Although moratorium is not identified in Davidson it is critical when thinking about the entire experience of recovery. I.e. that the journey starts with the diagnosis (self or otherto this end, awareness or the gaining of knowledge is likely a more accurate explanation of the experience) and; from this knowledge a process of grieving for what has happened, what may be lost or changed.

Recovery in serious mental illness: A new wine or just a new bottle? L. Davidson, M. OConnell, J. Tondora, M.R. Staeheli, and A.C. Evans. Professional Psychology: Research and Practice, 36(5), 2005, pp. 480487. 3 (2008) Shepard, Boardman, Slade, Making Recovery a Reality, Sainsbury Centre for Mental Health

Table 2: The five stages of recovery explored in details against the nine common elements of recovery
Moratorium A time of withdrawal characterized by a profound sense of loss and hopelessness 1. Renewing hope and commitment Having a sense of hope and a belief in the possibility of a new sense of self and purpose- this hope and faith may come from others at first. Desire and motivation are also critical parts of this element 2. Redefining self Getting beyond the initial crisis to see yourself as more than a consumer- Its only one part, not all of who you are 3. Incorporating illness A first step- accepting the limitations that may be imposed by an illness but having an open minded approach to new and exciting gifts and talents you didnt see before! Taking stock of strengths and weaknesses regarding recovery and starting to work on developing recovery skills Preparation Realisation that all is not lost and that a fulfilling life is possible Awareness

4. Actively working towards a positive identity, setting meaningful goals and taking control of ones life

5.

6.

7.

8. Living a meaningful life, characterised by self management of the illness, resilience and positive sense of self

9.

Being involved in meaningful activities The experience of social exclusion (what tends to happen organically as you fall out of your regular networks of school, work or friends) and the countering experience of social inclusion, getting back into those regular roles that express social functioning, are a cornerstone of recovery Assuming control The individual is the person best placed to guide the treatment they receive and there is links in this element to the more personalised services to be delivered in WA. But more than this an individual has to be the one to assume the power in the transformation from an individual with a disability to an individual in recovery. Families, friends and clinicians must also ensure the individual is afforded opportunities to succeed and fail. Managing symptoms Recovery is living well in the absence or presence of symptoms. So complete clinical recovery or symptom remission is not required to be in recovery rather managing with resilience the good and bad times, the ups and downs with a treatment of choice to maintain some level of functionality. Being supported by others Recovery is not done in isolation. Friends, family and co-worker networks provide encouragement and support through the hard times and help you celebrate the good. Overcoming stigma Social exclusion can lead to stigma as people you once saw everyday wonder where you disappeared to. Recovery is reconnecting with those networks and actively challenging stigma or just building resilience to the sometimes hard-tohandle negative attitudes toward mental illness in the community Becoming empowered and exercising citizenship As this power and control grows, individuals want the same rights (where to live, what treatment to receive and how to spend time) and responsibilities as everyone else

Growth

Rebuilding

So, here in WA we can say that we define recovery to be An individuals journey from crisis to finding a way(s) to live well is best supported by tailored programs that are based on the wishes of the individual. An individual in recovery practices self-care, is resilient, has hope and experiences being part of their community and making meaningful contributions to it and is supported where needed by an agency in their journey. Services that are recovery oriented are holistic, encourage self-management and provide individual supports based on the persons plan and are considerate of the diversity in our community. This includes young people, older people, and the needs of people who are homeless or living without secure accommodation, Aboriginal cultural perspectives and the experiences of persons from other cultural and linguistic backgrounds. Recovery oriented organisations As organisations committed to working in recovery we talk about it often but incorporating recovery principles into routine practice4 takes a concentrated effort. The question is: How do we go from being organisations that provide some recovery- oriented services and organisations that talk about the importance of recovery and promoting recovery for individuals to Organisations that demonstrate the principles of recovery in every aspect of our business (recovery not just in the programs we deliver but in polices we write, in our leadership, in our planning and evaluations, our human resources, marketing etc.) . Why would we do this? Recovery Oriented Leadership (ROL) is a leadership and organisational tool developed by a group called Community Activators based in the United States. The premise of their tool (and indeed the case for a mental health organisation making recovery implicit in all their business) is ROL is a leadership and organisational development tool whose benefit comes from exploring how the principles and processes of recovery can be used by an organisation to improve its own health and the quality of services it provides. By emphasising four primary recovery principles5 as a basis6 The four primary recovery principles ROL uses are 1. Hope: Having a vision that is worth working towards. Believing that things can improve and the vision is achievable 2. Healing: To acknowledge the parts of us that need healing and receive compassion and encouragement as we work towards finding wholeness and health 3. Community engagement: being a part of the community we live in- making our contribution and being accepted for who we are 4. Authority: We have the power to decide our future and take meaningful action based on our beliefs and desires
4

(2008) Shepard, Boardman, Burns, Implementing Recovery, Sainsbury Centre for Mental Health (2004) G and B Anderson, Recovery Oriented Leadership: A beginning dialogue, Community Activators and MHA Village

More information can be found on this methodology here. Challenges and the recovery oriented organisation The Sainsbury Centre for Mental Health has developed a methodology to address what it has identified as the 10 key organisational challenges to becoming more recovery oriented. Table 3: The 10 key organisational challenges to becoming a more recovery oriented service

Increasing opportunities for building a life beyond illness

Changing the nature of day to day interactions and the quality of experience

Delivering comprehensive, user led education and training programs

Supporting staff in their recovery journey

Establishing a recovery education unit to drive the programs forward 10 key organisational challenges Ensuring organisational commitment, creating the culture. The importance of leadership

Transforming the workforce

Redefining user involvement Changing the way we approach risk assessment and management

Increasing personalisation and choice

It is recommended that at the outset staff and service users familiarise themselves with the challenges by identifying where in a three stage classification the organisation sits currently in implementing them. This will develop a sort of baseline for comparison as the organisation progresses in its implementation of the challenges.

Table 4: The three stages in implementing the 10 key organisational challenges to achieve recovery in an organisation Stage one Stage two Stage three Engagement Development Transformation The organisation is clearly engaged in its intent to deliver recovery-oriented services Action is being taken with some evidence of significant developments in practice policy and culture The vision for achieving significant change has been fully realised

More information can be found on this methodology here and more on the 10 key organisational challenges can be found in the original position paper here Final remarks Recovery is an idea whose time has come. At the heart is a set of values about a persons right to build a meaningful life for themselves, with or without the continuing presence of mental health symptoms76 Recovery is a personal journey, prescribed by the individual. It is not linear nor does it neatly fit one definition- one persons recovery is unique as the individual itself and it morphs and changes as the journey progresses. However the common elements of recovery that we have identified here- experiences like hope and healing, processes like social inclusion, self- management and the personal strengths that get re/discovered along the way like resilience, do not just have individual application. For organisations to truly be recovery-oriented, for an organisation to improve its own health and wellbeing, it must too, tread the recovery path. Recovery is a key part of the National Mental Health Standards and the WA Mental Health Commission is also committed to recovery. The WA community managed mental health sector has also indicated a strong commitment to recovery oriented service delivery. This is a positive step and one that is important as the reforms to the mental health both at a state and national level commence. Further reading http://www.mhcc.org.au/documents/Projects/NSW-CAG-MHCC-Project-RecoveryLiterature-Review.pdf

(2008) Shepard, Boardman, Slade, Making Recovery a Reality, Sainsbury Centre for Mental Health