How can Mental health recovery be used to inform practice and improve outcomes for patients?
The Rethink.org website states, “Recovery can be defined as a personal process of tackling the adverse impact of experiencing mental health problems, despite their continuing or long-term presence. Used in this sense, recovery does not mean “cure”.
Recovery is about people seeing themselves as capable of recovery rather than as passive recipients of professional interventions. The personal accounts of recovery suggest that much personal recovery happens without (or in some cases in spite of) professional help.”
The introduction of recovery and its acceptance has been a gradual process but one which has gained much ground over the last few years. It is important to consider the strengths of individuals and work in partnership with them to support empowerment. Where once a service user may have been viewed as a series of maladies and symptoms and within the context of a primarily medical model, it is now recognised that each service users is different, with differing backgrounds, abilities, aspirations, desires, protective factors etc.
The recovery model grew out of substance misuse services around the world, particularly within the United States from the 1990s. By then, long term research studies had been completed which showed complete or partial recovery from psychiatric disorders and illnesses. Kilbride and Pitt said, “The overall research findings support the concept that recovery is a process rather than an end point or a cure… It is an uneven process without a definitive end and is a relative concept, meaning contrasting things to different people.” (p.20). With the concept of recovery in mind I applied myself to thinking about an innovative service which could be provided by my team.
Many of our service users experience social isolation. It is very common when speaking with patients that they describe a cycle of low mood, leading to a decreased desire to go out and be involved in community activities, leading to boredom and lack of identity, causing further low mood, and so on. I asked the service users with whom I work what sort of service they would like to see set up and overwhelmingly they told me that they would appreciate an opportunity to increase their social contact. Some of the service users I support experience a loss of self confidence following an episode of psychotic illness and can also experience difficulties with their self image when they have experienced personal reactions, feelings and ideas which were contrary to their premorbid behaviours. Rebuilding this self image and confidence in order to take account of this new information is an important part of recovery in many cases.
I decided therefore to think about an opportunity for service users to interact socially with others. When speaking with service users I was often told that while they would appreciate increased socialisation they did not feel very enthusiastic about doing so within an exclusively “mental health” environment. I was told that they wanted to demonstrate to themselves that they were able to form social relationships with people from the wider community, rather than simply ones based on the shared (and somewhat incidental) experience of being a user of mental health services. The people I spoke with seemed to feel that it was more “normalising” to be with a mixture of people, including some who have never used services or experienced significant mental illness.
The London Borough of Southwark, where my team is based, is an area which contains much deprivation and many socially excluded young people. A study, undertaken in three areas of England, and published in the Archives of General Psychiatry, (March 2006), found that, “The incidence of all diagnoses was greater in Southeast Londonthan Nottingham or Bristol after standardization for age andsex. These differences remained after further adjustment forethnicity, except for affective disorders. This suggests truly”psychotogenic” effects of that environment or population stratificationin terms of psychosis risk and needs exploring in further detail.” They also found a large discrepancy in rates of psychosis onset and ethnic background. “The observed 3-fold increased incidence of psychoses in the BME group compared with the white British group is important, particularly because this was found across study centres and broad diagnoses. A tendency to preferentially classify symptoms as schizophrenia in BME groups cannot have led to these findings”. The implications of this and similar studies are wide ranging for the planning of mental health and social services but may be at least partially addressed on a local level by services that bring local communities together and increase individual socialisation, an aspect of life often missing from deprived, urban environments.
Kawachi and Berkman’s journal article, Social Ties and Mental Health, states “…human relations consist of multiple layers extending out from the ego. These layers extend from the most intimate relations (e.g., marital ties), outward to social networks (e.g., connections to close relatives and friends), and to “weak” ties consisting of involvement in community, voluntary, and religious organizations. Participation in the last set of ties does not necessarily impose intense person-to-person interactions. Nonetheless, it provides a sense of belongingness and general social identity, which sociological theorists have argued as being relevant for the promotion of psychological well being.” (p. 463).
There are a limited number of places where young people can get together safely and enjoy activities and socialise. I therefore began thinking about a service along the lines of a youth club. I felt it should be somewhere that young adults from the community could attend but which would also be available to service users, along the lines of not being a mental health service per se but rather being “mental health friendly”.
It was felt important that the service be removed from the team base and away from a mental health hospital setting. There is still much stigma surrounding mental illness and it is unlikely that the wider community would be willing to attend services on site.
It is important to recognise that service users may easily feel that professionals are people who have great power over them and associate the team base or the hospital with having to “behave normally” in order to prevent admission or close scrutiny. There is also the tendency for professionals to become accustomed to the caring role and they may have trouble compartmentalising this within the new service. They may be tempted to use the extra time with service users to continue their regular work with them. It is anticipated that removing the project from the associated locations may help prevent both parties continuing their accustomed patterns.
A part of the proposed service is the inclusion of an executive board, made up of a combination of staff, service users and eventually users of the proposed service. It is envisioned that the service users will be supported to plan activities and take a hands on role in running aspects of the project, such as finance, advertising, hiring of the location etc. They are best placed to advise on the needs of the local community and to identify what steps should be taken to achieve success. There is also the added benefit of increased responsibility and activity on the part of the service user which can be very therapeutically important. This approach is already used in much of mental health services and can be easily built into this project. As Hall, Wren and Kirby (2008) said, “The voice of the service user will need to be at the centre of their own care, they will be seen as the expert on their experiences, deciding on the form of their care and support, whether it is social, medical, psychological and / or educational. The mental health professional’s role will shift from the traditional role of being the expert, to working alongside service users and carers as peers in supporting them to make these choices and decisions. This will give the service user hope and empowerment for their future.” (p.115).
Another aspect of this proposed service is the ability to adapt to both external and internal changes. Over time it may be possible that, for example, the service would change to become less focused on one particular community location. Rather than meeting once a week at the same time in the same place it is possible that specialised interest groups may be formed. A photographic group may take trips around London to photograph places of cultural or historical significance, a walking group may take ‘cheap day return’ trips to the coast or countryside, or a group with an interest in film may regularly meet to watch a film and then discuss it afterwards. I envisage these additional satellite communities would be facilitated by the service users themselves, perhaps with the assistance of a member of staff when required or requested.
I have made myself aware of groups which I may be able to work with to compliment the activities this project could provide. For example there is a group in the area which have a sound studio and forging links with this organisation may enable our users to access their equipment. Also, there is likely to be a cross over in terms of the users of the various services and we may be able to market our service within these groups. Finally, it may be useful to liaise with them in terms of sharing information, learning from their mistakes and getting tips on how to run the project successfully.
The first step in setting up the proposed service would be to contact Southwark Council. They would be able to advise on issues such as requirements for Public Liability Insurance, although after speaking briefly with them I understand that most venues would already have cover, which would apply to groups who rent the space. It would be necessary however to ensure that we made certain of this when securing a venue.
The service is designed to work with young people who are over the age of eighteen. It should therefore not be necessary to ensure that special Child Protection Procedures are in place, however Safeguarding Vulnerable Adults would apply and any members of staff are likely to require a Criminal Record Bureau clearance. Our staff already have Enhanced CRB clearances but it would likely be necessary to reapply with this project specifically in mind. If this were to be the case the CRB clearance should be applied for at least ten weeks before the proposed start of the project and I would be inclined to ask for a minimum commitment of six months from any staff involved.
With regard to funding, I will naturally attempt to gain funding from the NHS Foundation Trust at which I work but I will also be attempting to locate alternative ways of funding the project. For example, I intend to approach the National Lottery Community Fund and other community based projects. I do not anticipate difficulties with this aspect of the proposal as the initial and continuing costs are likely to be minimal.
In conclusion, I have designed a project which I believe would have make a positive contribution to the mental health and social functioning of both existing service users and people from the wider community.
I have not been able to identify many obstacles in successfully launching and maintaining this project. However it is important to bear in mind that the requirement of a CRB clearance application will require a small initial expense and will increase the lead time required.There is also the necessity of locating and renting a suitable venue and ensuring adherence to safeguarding policies and more general legal requirements. None of these issues are insurmountable and should not pose too onerous a burden upon volunteers.
There would be opportunities within a successful project to develop the service and expand beyond its original operational guidelines and the flexibility in this area is one of its core strengths. The proposed service is also designed to benefit the community, which is of particular importance given that it is based in one of the most socially deprived areas of the UK. Opportunities for socialisation in a safe and what might be termed ‘positive’ way are hard to find and over-subscribed in this area of London, and from my initial enquiries, both with proposed users of this service and with existing social groups, it seems likely that demand exists.
Rethink (3 June 2011). Recovery. [Online]. Available from: http://www.rethink.org/living_with_mental_illness/recovery_and_self_management/recovery/ [Accessed 12 July 2010].
Hall, A. Wren, M. and Kirby, S. (2008) Care Planning in Mental Health, Promoting Recovery. Oxford: Blackwall Publishing Ltd.
Kawachi, I. and Berkman, L. (2001) Social Ties and Mental Health, Journal of Urban Health: Bulletin of the New York Academy of Medicine, 78 (3), p. 463
Kilbride, M. and Pitt, L. (2006) Researching recovery from psychosis, Mental Health Practice, 9 (7), pp. 20-23
Nursing and Midwifery Council Code of Professional Conduct (2008) London: Nursing and Midwifery Council
Archives of General Psychiatry (March 2006). Heterogeneity in Incidence Rates of Schizophrenia and Other Psychotic Syndromes. [Online]. Available from: http://archpsyc.ama-assn.org/cgi/content/full/63/3/250 [Accessed 04 August 2010].