This
post looks at Recovery in practice, first at what workers using the approach
actually do, and secondly at how services have sort to reorganise themselves.
In my local area I was on the receiving end, as a client, of two attempts aimed
at introducing Recovery focused care; one a largely bottom-up and partially
successful community movement, the other a top-down formal reorganisation by an
NHS Trust which made very faltering progress.
This
post on the Recovery movement should be read in conjunction with part one
(January 2010) and part two (November 2010).
From
2005 onwards, the Community Care Trust (CCT) began to adopt a Recovery approach and its
employees tentatively began to change their attitudes, if not at first their
actual behaviour. They signed-up to the national Support, Time and Recovery
Worker programme (STR or STaR) and during 2007-8 I undertook some STR training
too.
From
STR Worker to Recovery Coach
For
a brief description of the STR role go to NHS Careers. For more detailed
accounts see Huxley et al (2006) and the National STR Handbook (Hope 2008).
Before
the national programme ended approximately 400 people within the county of
Devon had received some basic STR or other form of Recovery training. At the
time the Community Care Trust employed the equivalent of 70 full-time staff
with a mix of STR and mental nurse training. Later an additional internal
programme of training in ‘recovery coaching’ was added. I was a client of CCT
between 1999 and mid-2007 and retain close links with some of the staff and
many of the clients. Today a few workers appear to pursue the Recovery approach
in the fullest sense envisaged by Shepherd et al (2008) and Slade (2009),
others barely at all - but they all speak the language of Recovery!
Huxley
et al (2006) in describing what his research subjects did, provides a useful
summary of the STR role as originally conceived.
‘..STR
workers achieve [..] through engaging in practical and emotional support to
increase people’s participation in daily life through accessing further
education and training, obtaining and holding down a job, participating in
leisure activities, coping with personal financial matters, or finding their
way through the welfare and health systems. One of the effective ways that STR
workers achieve these ends is, by dint of their maturity and personal
experience, teaching the service user to do practical things for themselves, so
they have the confidence to go and do it in the future.’ (para.3.2 p.9)
‘The
STR worker establishes (where appropriate) a pattern of activity, first working
for service users and then with service users…This leads to situations where
service users are ready, and/or want support with, and/or teaching of,
practical skills. This in turn leads to increased social skills and/or
activities which lead to independence and then greater interdependence with
other people.’ (para.3.3 p.10)
During
the time I’ve been able to observe CCT workers, the focus of support has
shifted away from the practical and interventionist, towards an emphasis (as
highlight in part two) on the idea of a non-directive worker, and a
self-managing client. (Workers remain particularly sensitive to how the
prescriptive nature of pre-Recovery ‘therapeutic’ interventions often appeared
to add to the problems faced by their clients.) Whilst STR practitioners are
confident of the effectiveness - plus the political, moral and ethical
appropriateness of their work - nonetheless they have great difficulty in
articulating their approach. They have problems in describing their one to one
interactions with the users of services; how they do what they do, from whom
they have learnt what they do, and what is effective in a given situation.
Equally, clients often cannot describe what ‘makes a difference’ to the
resolution of a crises. So although comfortable with the language of Recovery,
developed over more than twenty years, which most workers claim they apply in
practice, they seem unable to demonstrate its meaning in action.
The
test of any approach of course must be how far its values and ethos are embodied in the way its practitioners
actually behave. The Recovery workers I’ve met, like many occupational groups
in health and social care, play down or sometimes actively avoid interpersonal
skills training and any attempt to modify their own non-verbal communication.
Instead there is a huge bias towards explicit cognitive tools, especially
language use, which is presumed to lead to change.
My
abiding image is of an incongruence between the content of what is spoken by
workers and their body language (tone of voice, gestures, facial expression,
eye and head movement, posture and body movement). Nonverbally there is always
an urgency to empathise (feel what another person is feeling), not just to
establish an initial connection or rapport, but as a regular strategy - which
too often ends up with them mirroring the disconnectedness between emotion and
reason displayed by the client!
The
principal tools used by the Recovery worker today are; the Wellness Recovery
Action Plan (WRAP), personal stories, mindfulness, formalised peer support,
traditional non-directive counselling plus some group social activities.
However the emotional content of what Recovery workers do as expressed through
their body language remains not only tacit, but almost entirely unexamined. Yet,
workers put a premium on genuineness and sometimes claim not to be playing any
role at all other than being themselves. They also recoil at the idea that they
should teach, model or demonstrate any desired or more effective behaviour for
a client to follow. They believe they should and can work with almost anyone
who walks through the door. Equally, they feel that if only they can escape the
organisational constraints placed upon them, and just be themselves, then that
in itself is therapeutic for the client. They have an extremely ambiguous
relationship with their own training, believing that they can embody the values
and attitudes of Recovery without having practiced anything other than making
verbal affirmations of their approach.
This
can be a disaster for the client, who is desperate for practical help from
someone with whom they feel physically and emotionally safe, and from whom they
can gain confidence. Still today, workers often appear to want to climb into
the ditch with the client, empathising beyond establishing a connection (which
at most takes a few minutes), and help through reason and rational talk, whilst
their bodies display something other than the social competency and lack of
fear that their client craves.
When
assessing themselves workers ask the client to self-report using written
questionnaires which - in contrast to their claims about practice - are highly
directive, designed and targeted at what they presume to be the priorities and
concerns of clients. There is a tendency to drop the word Recovery into any and
all questions, as in: ‘How has such-and-such contributed to your Recovery?’
They seem to lack awareness of a loaded question, of when they do lead, leaving
one sceptical of their claim that they know how not to in practice!
Organisational
Recovery
The
Recovery approach began as a bottom-up community movement gradually seeping
into policy through word of mouth. In the case of CCT it began in an organic
way before becoming systemised, however as it was adopted as policy by the NHS
(Shepherd et al 2008, Slade 2009), a much more top-down, designed approach was
taken.
Traditional
occupational groups such as mental health nurses, psychiatrists, occupational
therapists, social workers and others have been asked to ‘unlearn’ or ‘let go’
of established professionalised practice (SCMH 2009).
In
my local area the principal statuary provider, Devon Partnership NHS Trust (DPT) adopted Recovery focused care in the context of trying to move workers
from being highly bureaucratised helpers and administrators to networking
coaches. Many responded as if this was an attempt to deskill them. Yet this
occurred in the context of community psychiatric nurses spending about fifty
per cent of their time on administrative tasks, and of ward nurses spending an even
greater proportion of their time at nursing stations! Even student mental
nurses are lucky if they can achieve two hours contact time with clients during
a seven and a half hour shift.
At
all levels there was a resistance to new learning; anything new was taken as
criticism of current practice, an encroachment of and threat to someone‘s
territory, someone’s job, and the defensive response was always the same -
experience tells us it is not practical to change (and it costs too much). And
besides, our clients are different than the model suggests and won’t respond!
Consultation,
and then implementation, was placed in the hands of managers who had first trained
as nurses many years before, often espousing a version of Recovery learnt from
reading policy documents rather than practice, to younger workers who daily met
with clients and were more in touch with their circumstances. There were a
number of ‘team leaders’ who bonded as students whilst ‘necking and decking’ in
the old asylums who appeared to undergo weekend conversions to the Recovery
approach. Much organisational change was put on hold whilst they were trained-up.
There
is a sense in which mental health workers are more risk averse than their
clients. I sat for eighteen months or so, on a DPT implementation committee for
my local area. After an initial false start however, an outsider was appointed
who didn’t carry the baggage of longer serving employees. However she was only appointed
on a one year contract and much of what she did was subject to both conscious
and unconscious obstruction – many simply did not appreciate that the Recovery
approach, whatever its weaknesses, nonetheless was a challenge to the
appropriateness of established practice and required a change in personal
conduct.
Committees
are often the death of change, the quasi-democratic structure of NHS management
based on professional group demarcations plus some user consultation gives all
interested parties their own five minutes, but when interests conflict, as they
must, the chair can reinforce the status quo whenever they choose. Authority in
hierarchy, rarely trumps professional demarcation and autonomy in practice.
Equally,
in the bureaucracy of mental health, where there is no clearly defined product
or outcome, then it is the amount of visible activity which is used as a
substitute for real achievement, success being measured by the size of a budget
and the number of staff employed.
Strangely
mental health organisations often operate in an information vacuum, this may
strike the outsider as incomprehensible since there has never been a period
when so much mental health information is so easily available, yet many
professionals are ignorant of it. In order for one professional group to assume
expertise in one particular area requires seeding authority to other groups in
other areas. This can be a disaster if there are no generalists left, how many
front line mental health workers, pursuing a Recovery approach or otherwise,
know that experimental psychology, neuroscience and forensic behavioural
science have made much of their work irrelevant and or potentially damaging to
their clients?
One
simple training initiative proposed by myself to allow those less experienced
in Recovery practice, though formally more senior, to see Recovery in practice
(me as client in interaction with an experienced Recovery worker) once a week
for forty-five minutes during a lunchtime at a local community mental health
centre was brushed aside as being only appropriate in a formal training
setting, run by trainers on official ‘away-days’, in other words costing
thousands of pounds instead of nothing at all. In such small ways does the NHS
forever expand, create needless jobs and financially become a bottomless pit.
In
recent years most service user participants have become explicitly incorporated into the hierarchy and bureaucracy
of DPT; as trainers on courses for clients rather than staff, as peer
supporters supervised by nurses - which becomes absurd since the whole point of
a peer supporter is that they do something a nurse cannot do, nor understand in
the fullest sense. Managers want the credibility of association with those with
‘lived experience’ without the need to fundamentally challenge their own
behaviour.
But
all this pales into insignificance alongside some of the larger absurdities.
The headquarters of DPT remains within the last local example of a Victorian asylum,
one of the ‘back wards’ has been used for many years as the showcase inpatient
Recovery unit where clients can stay for up to a year! Managers will tell you
they have been unable to do otherwise because of the way the building was
gifted to the Crown (for the expressed use of mental patients) way back in the
days of the formation of the NHS. But those senior managers, doctors and nurses
who push for a Recovery approach were not born and brought in Exeter. Digby and
Exminster hospitals may had been the long stay ‘bins’ from which your relatives
never returned, but Wonford House – the building in question - was the first
port of call for anyone taken off the streets, or from their homes. The
location, one word in fact, Dryden (as in Road/Lane/Clinic) was enough to
stigmatise anyone. Well over a million pounds must have been spent on Recovery
by now, but a lot more could have been done to aid the community, as well as
clients, by simply hiring a cheap suite of offices in the centre of the city.
Equally, the Trust had a free hand to develop a two hundred acre rural site a
few miles away on the coast, yet chose to take the Home Office’s money to build
a new secure hospital for the prison service.
Equally
it was the police service which insisted that the statuary provider finally do
something about providing a ‘place of safety’; a pilot scheme was initiated
(actually two rooms from an existing psychiatric ward), STR support laid on to
be alongside potential patients whilst they were being assessed and sure enough
the number of people actually admitted to hospital fell. After six months
however the money stopped and was diverted to pay for an extra approved mental
health professional (someone legally sanctioned to 'section' people). Now a couple
of years on a different scheme is being tried as an alternative to hospital,
but that’s prompted now by the shortage of beds.
It
was when someone within DPT said, ‘..it takes ten years to bring about real
organisational change’, that I knew it was time to absent myself from any
further involvement!
Conclusion
- the paradox of ‘control’
Now
the game has changed. DPT having attempted to manage change, rather than allow
it to evolve organically from the bottom-up, has seen what Recovery focused
care there was eroded by the external pressure of severe budgetary constraint.
The irony is that the Recovery approach only really costs money if you see it as
a top-down process of managing organisational change! CCT was also forced, late-in-the-day, to reduce the scale
of its activities due to a reluctance to compete for contracts. Recovery is on
hold.
In
day to day interactions between workers and clients the focus has become more
and more on the construction or reconstruction of an individual’s personal
story or emotional journey.
Some
people feel it is enough to vomit their personal distress over a keyboard, a
therapist or an audience; that others acceptance and validation is the
therapeutic goal. But that is not storytelling in the true sense, for there is
nothing necessarily useful in sharing for sharing’s sake, all it does is
attract the empathy of those who have been there too, who are equally
distressed. It offers nothing that makes it easier for the author or their
audience to get up tomorrow.
It
is now well established that each time we remember we update our memory within
the present context – what we are recalling from several years ago, is actually
the version we told ourselves a few weeks ago, the last time we recalled it! Your
carefully constructed personal story is always out of date. Much better to keep
a journal. Record a little regularly, then set aside. Going back to a journal
after a number of months or years gives a measure of change. The ‘making sense
of the world to yourself’ or ‘discovering what you’re thinking by writing’ is
of the moment, a process not of fixing, but of letting go.
Journals
take you back to a present moment, removing a large element of reconstruction,
illuminating what change has occurred, been forgotten, then occurred again –
all in a world of uncertainty where the resilience or robustness of a ‘personal
story’ is brittle and likely to collapse at any time.
Recovery
is based on an old existentialism as manifested in 1940’s humanist psychology,
updated with a 1980’s post-modern frame of reference. Large dosages of political
correctness, of rights and entitlements, but increasingly bureaucratised at the
same time as advocating social networking. There is certainly a phenomenon
which might be called Recoveryism, the assumption that the pursuit of a Recovery
approach is a virtue, in and of itself. An inward looking-ness, which hates
feedback as much as those traditional approaches it once criticised.