Mental Health

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• Mental Health
• Acute Transformational Conference
• Tuesday 19 May 09

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Recovery-focused Practice and Inpatient Care

• Rachel Perkins
• Director of Quality Assurance and User Experience
• South West London and St Georges Mental Health
  NHS Trust

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Mental health problems admission to psychiatric
hospital a devastating and life changing
experience

• They are all very nice to me here, but I dont
  think they understand what a big deal this
  schizophrenia is for me.
• Strange and often frightening symptoms
• Unthinkable things may happen to you
• Prejudice, discrimination, exclusion
• in a wider society
• the newspaper headlines apply to you or your
  mother, father, daughter, son
• risk losing everything you value jobs, homes,
  friends
• in mental health services them and us
  barriers
• sometimes subtle not being believed, not having
  your views and wishes taken seriously
• sometimes gross separate staff cups, cutlery,
  toilets
• Loss of confidence and self-belief
• Feel very alone and very frightened

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The experience of coming in to a psychiatric ward

• "I was scared to move. I just sat there petrified
  - too scared to move.
• I'd never been to a place like this before. I
  was terrified."
• "It was horrible. I was dragged here by the
  police. I was scared. I didn't know I was going
  to a psychiatric hospital.
• "It was alarming - I didn't expect it.
• I don't know what is happening to me - the
  uncertainty - I feel I must have done something
  very bad
• I felt embarrassed I didnt want anyone to see
  me there.
• Last month I was a regular mum walking down the
  street with my kids in their push-chair now Im
  just a mental patient.

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Everyone with mental health problems faces the
challenge of recovery ... but what does this mean?

• Recovery is about getting your life back
• rebuilding a meaningful, satisfying and
  contributing life
• Recovery is a way of living a satisfying,
  hopeful and contributing life even within the
  limitations caused by illness a deeply personal,
  unique process of changing ones attitudes,
  values, feelings, goals, skills and rolesThe
  development of new meaning and purpose in ones
  life as one grows beyond the catastrophic effects
  of mental illness (Anthony 1993)
• Recovery involves
• building a new sense of self, meaning and
  purpose
• growing within and beyond what has happened to
  you
• Recovery is NOT the same as cure ... NOT a
  professional intervention ... NOT a linear
  process ... NOT restricted to a particular theory
  of mental health problems
• Recovery is possible for everyone

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What helps people in their recovery
journey? There is no formula for recovery each
persons journey is unique and deeply personal
... but 3 things do appear to be important
Taking back CONTROL Recovery means I try to
stay in the drivers seat of my life. I dont
let my illness run me. Over the years I have
worked hard to become an expert in my own
self-care (Deegan, 1993)
OPPORTUNITY accessing the roles, relationships
and activities that are important to you I
dont want a CPN, I want a life. (Rose,
2001)
HOPE and hope inspiring relationships The
turning point in my life was where I started to
get hope. Dr. Charles believed that I could. And
Rev Goodwin believed that I could. Certain
people believed that I could and held that
belief even when I didnt believe in myself.
(Donna in Vincent 1999)
Adapted from Repper Perkins (2003)
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People often feel pretty hopeless when they come
into our wardsRecovery is impossible without
hope

• The turning point in my life was where I
  started to get hope Dr Charles believed that I
  could. Rev Goodwin believed that I could.
  Certain people believed that I could and held
  that belief when I didnt believe in myself.
  (Donna, cited in Vincent, 1999)
• If you cant see the possibility of a decent
  future for yourself you cannot rebuild your life
• Relationships are central to hope
• When you find it hard to believe in yourself you
  need others to believe in you
• It is difficult to believe in yourself if
  everyone around you thinks you will never amount
  to very much ... low expectations become
  self-fulfilling

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Recovery involves taking back control getting
back into the driving seat of your life

• To me, recovery means I try to stay in the
  drivers seat of my life. I dont let my illness
  run me. Over the years I have worked hard to
  become an expert in my own self-care Over the
  years I have learned different ways of helping
  myself. Sometimes I use medications, therapy,
  self-help and mutual support groups, friends, my
  relationship with God, work, exercise, spending
  time in nature all of these measures help me
  remain whole and healthy, even though I have a
  disability. (Deegan, 1993)
• Control over your problems enhanced
  self-management
• Control over the help you receive a different
  kind of relationship between people using
  services and those providing them
• Control over your recovery and deciding what you
  want to achieve in life

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Recovery is impossible without opportunityYou
cannot sustain hope, you cannot rebuild your life
if everywhere you are debarred from doing the
things

• I dont want a CPN, I want a life.
• (Rose, 2001)
• Social inclusion is important for recovery ...
  access to those things that all citizens should
  take for granted
• Being a part of our communities
• Being a valued member of those communities
• Having access to the opportunities that exist in
  those communities
• Having the opportunity to contribute to those
  communities

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The challenge for acute inpatient services ...

• How can we
• Foster hope?
• Enable people to use their personal
  resourcefulness and take back control over their
  problems , their lives and the help they receive?
  
• Help people to access the opportunities they
  value and do the things they want to do in life?
• In a setting where
• people are scared of psychiatric services they
  dont know what goes on or what to expect
• people are often very distressed when they come
  into services they may find it difficult to
  express themselves
• people dont want to need services they may
  feel demeaned and diminished because they need
  help to do things others do for themselves

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Fostering hope - creating an environment that
promotes recovery

• Hospitality the way we welcome people and make
  them feel valued
• The language we use
• Language that recognises a persons strengths and
  assets not whats wrong but whats strong
  ... beyond manipulative, attention-seeking,
  non-compliant ....
• Language that is empowering rather than language
  that robs people of power ... beyond you
  should, you must, you need to, my advice to
  you is, the best way is
• I statements rather than you statements I
  was scared of you rather than you were
  aggressive, You statements
• sound blaming and judgemental like pointing the
  finger at the person
• sound absolute like my way of seeing things is
  the only right way
• make the other person feel cornered and defensive
  in the situation
• less likely to co-operate and less likely to
  look at their own part
• inspire destructive power struggles

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Fostering hope creating relationships that
inspire hope

• Valuing people for who and what they are
• Believing in their worth
• Seeing and having confidence in their skills,
  abilities and potential
• Listening to and heeding what they say
• Believing in the authenticity genuineness of
  their experiences however unusual they may seem
• Accepting and actively exploring a persons
  experiences beyond you should never collude
  with a delusion, delusion busting, humouring,
  distraction .
• Not believing that I feel, see or hear the
  things that trouble me thats what makes me
  really lonely. People say things like dont
  worry, its in your imagination, of course
  no-one is talking inside your head and at your
  ears, its just not happening. Well all I can
  say is Yes it is happening, mores the pity,
  and yes it is difficult but they dont
  understand.
• (cited in Repper and Perkins, 2003)
• Seeing problems and set-backs as part of the
  recovery process
• Tolerating uncertainty about the future
• (see Woodside et al, 1994, Russinova, 1999,
  Repper Perkins, 2003)

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The challenge helping people to come to terms
with what has happened Appreciating the
devastating impact of what has happened, AND helpi
ng people to make sense of it and fostering a
positive vision of the future

• Be fully present there with the person and
  actively listen
• Ask open-ended questions
• Use reflective statements
• Pause for the person to think and speak
• Recognise the challenges that the person has
  faced/is facing and use empathy
• Ask permission e.g. Do you mind if
• Validates their strengths and assets
• Invite/provide choices
• Point out progress
• Remind them that they are the experts
• Support the person in taking the lead and not
  telling them what to do and what is good for them

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Fostering hope helping people toaccommodate
what has happened, make sense of the experiences
and believe the possibility of a decent future
for themselves

• Helping people to make sense of what has happened
  - grieving what you have lost and making sense
  of what has happened
• the importance of telling your story
• keeping a diary
• finding meaning in your experience Why me?
  Whats the point
• Helping people to see that they can get through
  it that a decent life is possible with mental
  health problems ... different narratives of life
  with mental health problems to counter the common
  assumptions of doom and gloom
• a focus on strengths and possibilities
• sharing recovery stories
• The importance of peer support seeing what
  people who have been there themselves have
  achieved in their lives

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Expertise of lived experience is central to
recovery ...

• Feeling less alone
• The gift of hope that people can give each
  other - images of possibility, role models
• Sharing experiences and different ways of
  understanding what has happened
• Sharing experience of different treatments and
  support
• Working out ways of dealing with problems
• Support from someone who understands what you are
  going through
• Using the experience and expertise you have
  gained to help others facing similar challenges
  a reciprocal relationship

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What is peer support?

• A relationship based on mutuality and a shared
  journey - offering support, companionship,
  empathy, sharing and assistance to counter
  feelings of loneliness, rejection, hopelessness,
  frustration and rejection (Stroul et al, 1993)
• Models of peer support
• Naturally occurring mutual support
• Consumer run services/support groups
• Informal arrangements for helping people to share
  experiences
• Service user led/co-facilitated training for
  service users
• (e.g. self-management programmes, hearing voices
  network)
• Formalised/intentional peer support (employed,
  trained, supervised) (e.g. Ashcroft Anthony
  2005, Mead 2001)

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Peer support workers on an acute admission
ward Just two workers two days per week employed
trained and supervised by local voluntary sector
user organisation
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What did you find useful about spending time with
a peer support worker?
The peer support worker understands what it is
like. She listened and was sympathetic because
she had been through things herself. You cannot
always rely on the doctors for help as they do
not understand how it feels - the peer support
worker does. Being able to discuss my personal
issues and also doing a comparison with her own.
Realising that there is life after mental
illness. Chatting about our problems - being
with someone who has been through it
themselves. It helped me to feel more hopeful
and believe I could still do things because I
could see they had.
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• But we have only just begun to scratch the
  surface ...
• Recovery Innovations (META), Phoenix,
  ArizonaAcute inpatient unit, living room
  crisis unit, recovery centre, community teams
  Over 50 of staff are Peer Support
  Specialists(Ashcroft and Anthony 2005) Peer
  support is about being an expert at not being an
  expert and that takes expertise.
• Peer support is
• A way of sharing our personal story
• A way of being in a relationship that empowers
  people to recover
• A way of offering help and support as an equal
• A way of teaching, learning and growing together
• An attitude that values each persons experience
• Decreased frequency and duration of
  hospitalisation, decreased readmission rates,
  elimination of seclusion and restraint (Ashcroft
  Anthony 2004, Martin 2008)

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Taking back control ... Acute inpatient wards can
be very controlling places
I believed in my job as a psychiatric nurse I
could have justified everything I did. But now I
was a patient I was horrified to discover just
how terrifying and restricting it is to be on the
receiving end the psychiatrist and the nurses
were in total control of everything. They not
only dictated the treatment I would receive but
also how I would spend my day. I felt utterly
powerless. (Coles, 2007)
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Taking back control a different relationship
between mental health workers and those whom they
serve

• Traditionally one set of experts them and
  us the experts and the patients/clients/users
• Assumed that the expert professional has
  access to a body of knowledge that cannot be
  understood by non-experts therefore it is mental
  health workers job to tell people what they
  should do
• Aim compliance getting people to do what we
  think is best for them
• Recovery focused practice and self-directed
  support two sets of experts
• Experts by profession, qualification and degrees
• Experts by lived experience
• Aim Co-creation of understanding - Shared
  decision making - Self-defined outcomes
• Mental health professionals should be on tap
  rather than on top

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Mental health professionals on tap not on top

• A coaching approach using questioning
  techniques to identify their own solutions,
  rather than directing what they should do
• (see, for example, www.coachingnetwork.org.uk)
• An education based framework an educational
  approach emphasises strengths and developing a
  persons expertise erather than
  curing/fixing them ....how much of what we
  currently provide as therapy and groups could
  better be framed within an education model? Could
  we organise seminars/courses instead?
• Shared decision making care planning, treatment
  , support etc

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Taking back control fostering real involvement

• Bridging the information gap - providing
  information in a way that people can take it in
  giving information is not a one off exercise
  but a process of becoming an expert
• information about what will happen
• information about the choices available
• information about problems and treatment
  available
• information about your own treatment and support
• Helping people to do their own research
• Information and intelligence from peers
• Developing care plans with the person and
  offering as many choices as you can
• Helping people to take part in the decision
  making process developing negotiation skills

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Taking back control becoming an expert in your
own self-care

• Enhanced self-management
• self-management materials
• individual assisted self-help
• self management courses/seminars ... the
  importance of lived experience
• Advance Directives
• Planning your own recovery Personal recovery
  plans, Wellness and Recovery Action Plans
  (WRAP) (NB Not the same as care plans, owned by
  the person)
• keeping well
• managing ups and downs triggers, early warning
  signs, signs that a crisis is looming ... and
  what the person can do
• moving on after a crisis
• pursuing ambitions

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Helping people to access the opportunities they
value

• The role of inpatient/crisis care
• Relieving people of responsibility for social
  roles and expectations when they are not able to
  fulfil these is important in preserving access to
  these roles
• BUT what too often happens is that with every
  crisis, a person loses more valued roles and
  activities until they become nothing but a mental
  patient
• Challenge
• How to maintain these roles over the crisis
  period?
• How to enable people to resume their roles and
  responsibilities as the crisis resolves?

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Maintaining roles during the crisis

• Finding out what responsibilities a person has
  (you cannot help a person to maintain their roles
  unless you know what they are)
• Day to day responsibilities
• Family responsibilities
• Work, education, day time activities
• Leisure and social activities
• Friends and people who are important to the
  person
• Faith and religious activities
• Working out how you can help the person to
  maintain their roles during the crisis
• Who can take care of day to day responsibilities?
• Letting friends and families know what has
  happened a letter, a phone call, an e-mail, a
  text message ...
• Cancelling appointments/engagements
• A sick note to an employer or college
• Supporting people who are important to the person
  to understand and accommodate what has happened
• What/whether to tell other people about your
  mental health problems

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• Resuming roles and activities as the crisis
  abates
• Dont wait until the person is discharged or
  fully better ... start gradual process of
  resuming roles as soon as the person is able (the
  longer you are out the more difficult it is to
  get back).
• Making apologies/saying thank you
• Sorting out problems caused by the crisis
• Making a plan to gradually resume activities
• Deciding on what help you will need
• Helping people to take stock and decide how they
  want to move forward in life - explore new
  ambitions, roles and sources of value Some
  people have already lost many of the roles ,
  relationships and activities that gave their life
  meaning so we need to help them to explore new
  possibilities

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But what about those who are compulsorily
detained?... there should be no recovery-free
zones in our services.

• The therapeutic purpose of detaining someone and
  treating them against their will is to achieve
  the gradual handing back of choice and control in
  ways that are safe and to enable them to resume
  responsibility for themselves. Roberts et al
  2008

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And what about risk?

• The challenge how to do develop an approach to
  risk assessment and management that
• Fosters hope
• Enables a person to take back control
• Helps people to access the opportunities they
  seek
• Suggested principles
• Consider EVERYONES view of the risks service
  user, staff, relatives/friends (if appropriate)
• Involve people in their risk assessment and
  developing their risk management plan safety
  plan
• Share responsibility for risk two experts
  rather than one involve service users in risk
  assessment
• Focus on ways of helping people to do the things
  they want to do while minimising risk
• Consider the advantages and disadvantages pros
  and cons of all different possible courses of
  action a problem solving approach

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References risk and recovery

• Langen and Lindow, 2004 Living with risk,
  Joseph Rowntree
• Perkins Goddard, 2008 Sharing responsibility
  for risk and risk-taking, NHS Education for
  Scotland (www.nes.scot.nhs.uk/mentalhealth -
  Realising Recovery Learning Materials)
• Roberts et al (2008) Detained whats my
  choice? Advances in Psychiatric Treatment
  14,172-180
• An independent investigation into the care and
  treatment of Daniel Gonzales, January 2009

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But most of all we must foster and maintain
Images of Possibility

• One of the biggest barriers to recovery and the
  development of recovery-focused services is low
  expectations
• If people are to rebuild their lives we must
  believe in the possibility of a decent future
  ourselves
• If mental health workers are to facilitate
  recovery and develop services that help people in
  their journey we must possibility of a positive
  future for those whom we serve
• Beyond being realistic ... daring to dream
• the value of dreams and ambitions lies not in
  their realism but in their ability to motivate us
  give us a reason to get up in the morning

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• Mental Health
• Acute Transformational Conference
• Tuesday 19 May 09

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(No Transcript)
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The six key factors driving the successful
spread, its speed and the sustainability of
Releasing Time to Care

• Leadership
• Strategic alignment
• Governance
• Measurement
• Capability and Learning
• Resources

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Questions and Answers

• Panel