1. Centre For Recovery And Social Inclusion 11 th June 2008 -TOWARDS A RECOVERY ORIENTED MODEL OF CARE- Dr Martin Lawlor Consultant Psychiatrist Carraigmor PICU HSE, Cork & Clinical Senior Lecturer, U.C.C.

2. Acknowledgements Dr Michael Kelleher Dr Mike Doyle PhD Dr Stephanie Kennedy & Dr Robin Ellis Mr Malcolm Rae FRCN OP 64, Irish College of Psychiatry, Nov 2007 Sainsbury Centre for Mental Health, (2008) Shepherd, Boardman & Slade

3. Learning themes Discuss recovery as a systematic, dynamic process Outline a framework for developing a recovery oriented care pathway-Practitioner, Team and Organisational level Highlight the proposed role of the CRSI in promoting service user, staff and organisational development

4. Discourse-performative effect of language Systemic use: language-has a power enforcing function You believe what clinician says, you give permission to operate, etc The language game of discourse expresses and enacts the authority of those who are empowered to use it within a social group It can be used to marginalise, exclude or subordinate those who are outside it Rational model - ‘Show me the evidence’ The importance of meaning, understanding and narrative Tension in developing a shared understanding.

5. Psychiatric perspective Prominent symptoms-cancer, multiple sclerosis, Rheumatoid arthritis improve with treatment but often d'ont recover to where they were when they became ill Focus on symptoms, severity, duration

6. Psychiatric perspective Integrated model gene enviroment interaction-including the social environment (Family and Childhood) Psychosis-final common pathway is dopamine dysregulation in CNS

7. Risk paradigm Risk v personal quality of ‘dangerousness’ Two components-Probability/Impact Structured Professional Judgement Multidisciplinary approach

8. RECOVERY Re-(dis)-cover a sense of personal identity separate from illness or disability a movement away from pathology, illness and symptoms to health, strengths and weaknesses Needs based approach

9. RECOVERY Recovery is not an end point, but a continuing journey People are ‘recovering’ MH staff, MH services cannot in themselves practice recovery This can only be lived by service users

10. RECOVERY MH staff can try to create the conditions In which individuals feel empowered And their sense of personal ‘agency’ can flourish Need clear models of service delivery Underpinned by Policy Implementation Guide

11. FAMILY & CARERS Family or other supporters are central to recovery should be included as partners whenever possible Peer support is crucial for many people

12. SELF MANAGEMENT is encouraged and facilitated no one size fits all Helping relationship between clinician and patient moves from Expert/patient to coach/partner

13. RECOVERY What kind of behaviours do staff need to display to create a recovery-oriented service? What kind of training programmes are required to produce those behaviours? What kind of organisational factors, promote or inhibit the uptake of these practices?

14. RECOVERY-Practitioner level OPENNESS COLLABORATION AS EQUALS A FOCUS ON THE INDIVIDUALS INNER RESOURCES RECIPROCITY-Give and take- A WILLINGNESS TO GO THE EXTRA MILE

15. RECOVERY-Practitioner level Empathy Positive expectation of the future Caring Acceptance Mutual affirmation ‘Hope’ inspiring relationships An encouragement of responsible risk taking

16. RECOVERY-Practitioner level Actively listen Help the person identify and prioritise their goals for recovery Show a belief in person’s existing strengths and resources Encourage self-management (Information, reinforce existing coping strategies) Discuss what the person wants in terms of therapeutic interventions Convey an attitude of respect Express optimism

17. RECOVERY-Individual Needs Based Assessments Diagnosis/ Co-morbidity Risk assessment-to inform therapeutic risk taking Recovery Factors Personal goals Hopes Aspirations Engagement with service Motivation for self management

18. RECOVERY-Individual Assessments Functional & Occupational skills Psychological well being Developmental model, early childhood, stressors, coping strategies Cognitive Functioning Physical Health Unmet needs Carer assessment

19. RECOVERY-Individual Assessments: Key steps Review history/collateral Engage service user and family MDT Assessment-SKILLS OF DIFFERENT PROFESSIONALS MUST BE INCORPORATED INTO CARE PLANS Holistic-Biopsychosocial assessment, Needs Led Shared view of service users difficulties and strengths Create a person centred formulation/care plan

20. RECOVERY-Team level Opportunity for service users to be employed in care giving roles Does the team encourage real user involvement? How do you know that this is happening? Job description/ Appraisal Clinical supervision

21. RECOVERY-Training 10 essential shared capabilities, Framework NIMHE (2004) Organisational rules and behaviour which promotes recovery oriented practice

22. RECOVERY-Strategic Level ‘Vision for change’ offers a template Assertive outreach : provision of individualised, focussed and proactive care to service user Minimise risk of disengagement Patient centred-evident in detailed individual assessments and carefully formulated care plans Practical/ Key worker / Liaison with other agencies

23. RECOVERY-Organisational Level Mission statement-goals and aims. Move form ‘excellence’ to ‘responsibility to positively improve the lives of others’ Commitment to involve service users in running the organisation at all levels Shift towards an educational Vs Therapeutic model Peer Professionals

24. Therapeutic relationship Organisational culture-what we do Power, role and task culture Mentoring Guided discovery Adult learning

25. Organisational culture Culture is the sum of shared, values and beliefs that people in the organisation hold Shared assumptions they make Shared philosophy they identify with Shared attributes are the foundations of organisational culture

26. Organisational culture Power Culture Role Culture Task Culture

27. Person centred culture The community is the organisation This organisation is service users, carers and professional coaches/mentors Order/structure-by mutual consent Emphasis on warmth, consideration and mutual support-Humanitarian

28. Centre for Recovery and Social Inclusion, C.R.S.I. ‘Open source’ templates-customisable; web-based support; Action Research Model Role of CRSI: Develop capacity for hope, creativity, compassion, realism and resilience-at practitioner, team, and organisational level Person centred culture-provide a service to a community (no ‘them and us’)

29. Social inclusion People do not recover in isolation Recovery is closely associated with social inclusion and being able to take on meaningful and satifying social roles within local communities as opposed to segregated services

30. Recovery-Summary Lived experience Unifying force for the organisation Break the traditional barriers between service users and staff Both are respected for what they can bring Power of organisation stems from central focus on service user & carer

31. HOPE is central to recovery can be enhanced by each person seeing how they can have more active control over their lives and by seeing how others have found a way forward RECOVERY EXPLICITLY VALUES A PERSON CENTRED CULTURE