The Recovery Movement (part three)

What looks and feels radical to those attempting to bring about change from within an organisation often appears to outsiders as the mildest of reforms. As a general rule, groups - which share a collective self-interest - do not correct errors and the world of mental health is no exception. Groups self-perpetuate until external pressures cause them to collapse.

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.

The desire for control by workers, clients and carers - achieved through rational, cognitive tools - to deal with emotional uncertainty - leaves everyone just as vulnerable to inevitable external change as ever before.

The Recovery Files - in need of editing and re-filing!