Chris Newton - a tribute

A good friend has died, and how I feel about it is nobody’s business but my own. But the fact that he was a client of mental health services, on and off, for over forty years, yet managed to transform his life during his last twenty years is something that should be both acknowledged and celebrated. As his physical health declined, his mental state and that of many around him improved for the better. If asked for an explanation he would have named Jesus. For me, a non-believer but I hope an observant outsider, it was the church as a community which provided much of the answer.

We were unlikely friends, as different as chalk and cheese; he was from a working-class background with little formal education and had become a renowned biker; I’m middle class, over-educated and a believer in walking as the only proper means of movement! What we shared was a history of confinement. He often left the door of his flat open, so did I. He claimed it was to be welcoming to visitors - I once used that explanation too. But really it was a fear of not being able to get out of the door. What forged a connection between us however was a willingness to learn new things, and that requires an increasing openness towards others. It is the lack of such a capacity or willingness amongst those in mental distress, and perhaps their helpers too, which may account for the low success rate of mental health services.

Chris was in his early-fifties when we met in 2006 and never expected to reach sixty, he’d spent a total of twenty-five years either in prison or other secure environments - once sentenced to twelve years for aggravated assault, serving eight, five of which had been in Dartmoor. Son of Sergeant Robert ‘Tiger’ Newton, late of the Indian Army and sometime policeman, who installed discipline with his fists, Chris found himself on psychiatric drugs whilst still a child, diagnosed schizophrenic as a young man, and until he became a Christian, drank heavily and used street drugs. Workers were still telling him he would never live independently in the community up to a year before he achieved precisely that.

We first met at a regular social activity organised by the Community Care Trust (now absorbed into the charity Step One) when he moved to Teignmouth in south Devon. He hardly spoke at first and would often sit in a corner with his back to the rest of the group. Then one day he surprised me. Leafing through some photos he’d just picked-up from the printers, he mumbled something about a church event he had been to, saying: ‘If you don’t give, you’ll get nothing back’. I remember the first time he invited me to his flat. After ten minutes or so of intense talk he apologised and said he’d have to stop. I assumed it was because of the emotional nature of what we were talking about, but I was quite wrong, it was because he was not used to talking, full stop. The muscles that make speech needed a rest! Soon however he was talking to anyone, throughout the day.

Within a year or so of living independently in the community, our conversations on the street would be regularly interrupted by locals, with no connection to the world of mental health, who would enquire after his wellbeing. At first his life centred around the Baptist church, later he found greater acceptance with the Church of England. (On a practical level, Chris was often preoccupied at this time by how much he should cover-up, or not, the tattoos from his biker days as ‘Chopper’ Newton!) To me, his spirituality seemed to be all about letting go of that ‘preoccupation with self’ that comes with chronic mental distress. Once you have got yourself together you can start being of use to others. The writer Karen Armstrong argues that the spiritual is making others, or other things, the central focus of your life, allowing transcendent experiences which go beyond our usually limited perception of others, guided by what seems a ‘golden rule’ of all faiths - doing to others as you would have them do to you. Inevitably there came a point when Chris felt, perhaps for the first time in his life, the frustrations of giving more than he was getting back. After all, his God was a spirit within people, not an otherworldly presence looking down, and clearly not everyone felt that.

Early Good Friday morning 2009 saw us sitting in a bus shelter sharing our frustration at how, as we changed, others didn’t seem to want to follow, in particular two of our peers who lived just a stone’s throw away. One was clearly disabled by the system of care he had received over thirty years, the impact of which was noticed in the odd moments when his previous personality broke through. The other person just seemed to be on a ‘single track’, blocking-out anything that challenged or contradicted a set pattern of behaviour. Why wouldn’t they change? What had we done differently? It didn’t seem to be about a lack of capacity to act differently, rather that unwillingness to learn new things. An unwillingness to test or experiment, to risk and be prepared to look a fool from time to time. For example, Chris explained he had recently been through a bit of a crises, but hadn’t thought about drink at all, but a little later when all was well and he was socialising in a pub, he’d rapidly became agitated and had to leave.

Whilst he found that being supportive of other people with mental health problems was a strain, he felt he was much more effective working with the religious charity Prospects (and later the breakaway group Count Everyone In) which supported people with learning disabilities. Indeed, he had me join a sponsored walk and attend, for the first time in many years, a religious service which he helped put together specifically for people with various disabilities, the first of its kind to be held at Exeter cathedral. He also worked for a while with MENCAP, going into Doctor’s surgery’s and educating them on how to communicate more effectively with people with learning disabilities. Chris described himself as schizophrenic (for which he accepted a moderate level of medication) but regarded it as largely a thing of the past, more pressing were his learning difficulties, for now he knew beyond a shadow of a doubt he could learn a lot more. Nonetheless, he knew that it was his relatively minor ‘learning difficulties’ that allowed him to connect with, and be useful to, those with major learning difficulties. Furthermore, for the boundaries are always blurred, to help some others with ‘learning disabilities’.

Early on in our friendship he determined that he should finally learn to read and write in order to better study the Bible. More surprisingly still, he chose the ancient method of copying out those passages he had come to know from hearing them spoken. About a year into the enterprise (self-taught, but with the occasional help of a number of us who just happened to be around at the time) he became conscious of the quality of language in different versions of the bible. I found myself in the somewhat surreal situation of sitting with him in our favourite café trying to explain 16th century history and the appearance of English translations - he’d already worked-out for himself that it was the language of the King James that he wanted. This went hand in hand with his learning the basics of Makaton, to better aid communication with those with learning difficulties/ disabilities and his inclination to learn to draw. Now, by the time I met him he only had sight in his left eye, with the limits in depth perception that brings!

We undertook a number of trips together, two of which come to mind as important. First, in 2008 we visited Broadhempston Community Woodland. Transport was provided by a local mental health worker and as we skirted the edge of Channing’s Wood (an ‘open’ prison) Chris commented: ‘That’s one I was never in!’ From the start he enjoyed the undeveloped new woodland planted just twenty-five years previously. As we set off to climb Beacon Hill it soon became clear that he knew more about the trees than we did. For between spells of confinement he had clocked-up a total of twelve years as a casual agricultural labourer, migrating with the seasons on his bike from Cornwall to Scotland. The woodland was being developed as resource for people with all kinds of disabilities and disadvantages, but Chris was quick to point out that the rules and regulations that come with any money intended to help the disabled, often leads to the spoiling of the very experience on offer.

The other trip that sticks in my mind was to Paignton in 2009, for it seemed to mark some kind of transition. It was when we were sat having a meal in a relaxed ordinary way that I realised how unique it was for either of us to be comfortable enough to sit in a crowded café for forty minutes. There really is a thing called normality and those who have it often take it for granted so much, they come to deny its very existence.

Also, in 2009 Chris came top of the list for an allotment after a year of waiting. The location was between a housing project and an industrial estate, but its situation was different. Lifting one’s gaze from the ground, you could see to the southern part of the estuary, look to the west and you could see all the way up the valley to the moor, and an ever-changing horizon. He cultivated with a success that bemused his neighbours and quite without the orderliness that preoccupied them. It was on the few occasions when I helped-out, that, even more than being with him, one could see, spread out in front of one, almost like a map, his chaotic mind. Patches of temporary order emerging from place to place within a disorganised whole. Yet the whole was hugely productive, and produced flower and vegetable displays at a number of events. Most notably his displays for the annual flower festival of St. Michael’s church in July 2009 and 2010, displays which were conspicuous because they lacked the formality of style of all the others. They were personal and intimate, one depicted a flowing river, another; photographs of those people with learning disabilities who had helped on the allotment.

But Chris had another life of which I knew little. In time he became a frequent visitor to Bristol where his ‘family’ lived. He had lost contact with his remaining blood relatives many years before, but formed an attachment to two women, one of whom he came to think of as his mother, the other his daughter. I was lucky enough to attend the wedding of the latter and hear her account of Chris’s life since they had met over twenty years earlier.

He also had a life of physical illness. He had suffered from bowel cancer and had a total of six operations over the years, and also underwent various other invasive procedures for related complications. There came a point when he decided enough was enough and began to refuse most of the treatment being offered. He lived for more years than he expected. He’d fixated on sixty as a target age to be reached for several years before he actually achieved it. I myself felt the need to start writing this tribute before his sixtieth – he has died at the age of seventy-two.

For about five years from around 2010 we would talk for an hour or so two or three times a week in a local cafe. As he became more articulate, I demanded more of him. I watched as he became aware of how others, and therefore himself, had grossly underestimated his capacity for intellectual growth. I didn’t find it easy that he framed nearly all his talk in religious terms, over and over I pointed out that I disagreed and that somehow if he wanted to spread a message he had to take-on the reality of non-belief amongst so many of the community. Just as he’d learnt to control the anger that had got him into so many fights in the past, so now he learnt to temper his desire to spread the word to anyone who would listen.

In time his spiritual life deepened further, through the Church of England he connected with the Society of St Francis. In May 2018 he was ‘professed’ into the Franciscan Third Order. Now I don’t know what that means, but I know it meant everything to Chris.

Christopher Robert Newton 1952-2025

Note to self

Rational thought, followed by deliberate conscious intention, is such a weak tool for bringing about action - let alone change - that I have to carry instructions to myself on a cue card!

I doubt the below will mean anything to you, but then it’s not meant to!

(The more astute may realise some of these half sentences are cribs and at least one lifted in its entirety.)

Whatever happened to, ‘..the best is yet to come…’ (2011, 2019)

Human beings are notoriously bad at predicting. What we are good at, both instinctively and through the acquisition of further skill is anticipating in the short term, ‘the two second advantage’ [1] as some have called it. Many, unaware of how much of life is highly sensitive to initial conditions, boldly go in for futurology. The key to anticipation, having made one move, is how able are you to dump everything you think you know, and make a fresh assessment of the new, current and different situation? Think of all those sports where the ball travels so fast that you must start your move before it has been hit! And when you miss, how fast can you forget?

However, we are always being told by others to set aims, objectives, goals, plan and sign-up to mission statements. When I posted the following in 2011, I was playing that old trick, that rarely works, of hoping that a public declaration of intent would force me to get on with it and comply!

Screenshot

Things don’t turn out as we intend, the best attitude to ‘failure’ or indeed anything which might be regarded as a mistake, is to see it all as part of an inevitable process and an opportunity for new learning. You can even go so far as to regard depression in this way, as always reactive to something; you feel down in response to a loss (of any kind), is your response grounded in a real event where sadness or grief really is the right emotion, or is it that things just didn’t turn out the way you planned them? If the latter is the case, one legitimate response is to conclude that it was simply a lousy plan in the first place.

Events happen, change occurs around us whether we like it or not. I was a psychiatric inpatient for a brief period at the end of 2011, and for a month or so in the spring of 2012, the autumn of 2014 and the summer of 2016. My father died in 2014, he’d been the last of the previous generation, so his estate contained within it not only the possessions of many direct ancestors but their ‘life documents’ too [2]. In 2014 the sea wall outside my window collapsed and in 2016 I moved home. But I should confess, that all of this is by way of a distraction - for there is a sleight of hand in what I’ve written so far!

As stated in the post, all the writing was already half complete, I wouldn’t have had the nerve to assert their contents if they hadn’t been. Now, the first and last have already been posted, leaving just the meat in the sandwich. But, having had the pleasure of finding things out, the kick of discovery (to misquote Feynman) [3] I’m bored and face the tedium of laying out the argument and evidence step by step. (The answer to that kind of task is of course mindfulness!) Distraction is sorely tempting, like transcribing and publishing the audio recordings I have (conversations with 2 clients, a nurse, 2 support workers, a student and an educator.) The passage of time and an already tested form of presentation takes care of any confidentiality issues. Come to think of it, this is more than a Masters thesis, more like a PhD!

(I ought to hurry up though, because I want to claim for myself the phrase Ways Of Being With, and the concept of Social Craftsmanship.)

Of course, real intellectual confidence would be not feeling the need to do any of it. The most obvious recent example being flash Dave. In the course of doing a first degree you realise you’ve already proved to yourself your capability to do this kind of stuff and your attention shifts. Just how long does it take to become Prime Minster? And remember, political careers always end in failure, so at the first major mistake, get the hell out and find something better to do!

[1] Ranadive, V and Maney, K (2012) The Two-Second Advantage

[2] Plummer, K (1983 & 2000) Documents of Life

[3] Feynman, R. P (1999) The Pleasure of Finding Things Out 

Bibliography of the half-written!

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!

The Recovery Movement (part two)

This is the second of three posts on the Recovery movement (part 1 - 17th January) and offers a brief history of what I’ve come to regard as a social movement - an attempt to introduce a particular set of moral, ethical and political values into the behaviour of those in the world of mental health. Here I look at the nature of the Recovery approach itself, whilst the third part will deal with it’s impact on the day to day practice of individuals and organisations. For those entirely unfamiliar with Recovery please read part one and follow the links.

As far as I am aware, I am the only person locally, who having been a recipient or ‘product’ of Recovery-focused care, has then gone on to become a critic. Bemused workers and managers have responded to my observations almost as if they were acts of disloyalty - since my mental health obviously improved over that period. My contention, as hopefully the content of this blog has begun to show, is that it was factors other than those identified by the Recovery approach which were of real importance in improving my life. Nonetheless I believe the Recovery movement is important, not least because it helps to stop some of the damage psychiatry and clinical psychology continue to do.

It needs to be asserted at the outset that the Recovery approach to date has not generated any new theory of human behaviour, understanding of mental distress, of emotions or unusual behaviour, nor has it advocated specific therapeutic interventions. It is principally about the better management and delivery of care, but in this area too, it does not challenge the legitimacy of any of the existing occupational groups within mental health. In essence the Recovery approach sets out to change the way mental health services are organised and delivered in order to be more responsive to the stated needs of clients and their supporters. A set of Recovery values has emerged that are intended to inform the personal conduct of workers in their interactions with clients.

However the way the Recovery approach is experienced or encountered by the worker, client or supporter is self-reported in highly individualistic ways, only later do some appreciate the sources of their new insights or beliefs. Many talk about a journey of recovery, and of who or what placed them on that journey (see the recovery stories at http://www.devonpartnership.nhs.uk/fileadmin/user_upload/publications/Beyond_the_Storms.pdf ) in a way that is reminiscent of many narrative approaches throughout history, particularly the notion of spiritual or religious pilgrimage - albeit with a very secular favour - as if it were a novel and unique experience. But it was never that way for me. My growing ‘wellness’ made me increasingly an outsider looking-in on the Recovery movement, which seemed to be socially constructed by people talking a language of networking.

As yet there is only a very modest evidence base for Recovery-focused care and little that could be claimed as evidence based practice. But there are many ‘interested parties’, committed to Recovery values, who are only too anxious to create an evidence base. Equally there appears to be no systematic critique of Recovery other than the reassertion of more traditional approaches - extraordinary given how pervasive the ideas have become. It is also remarkable given the context of the highly contested nature of knowledge in mental health; within and between the disciplines of psychiatry, clinical psychology, nursing and now Recovery, between competing theories of learning, and the contrasting perceptions of the providers and users of services.

With the exception of the current UK REFOCUS research project ( http://www.iop.kcl.ac.uk/departments/?locator=1073 ) almost all investigations globally have been service evaluations, and almost exclusively quantitative. A recent local example being Alison Moores Report Of The Standards And Outcomes Pilot Project 2008/9 ( http://www.communitycaretrust.org/attachments/File/Standardsandoutcomes2008-9FINAL.pdf ). Qualitative data has been overwhelmingly restricted to collections of users’ writing. The involvement of service users as ‘researchers’ in such quantitative service evaluations is a sensitive and problematic issue in the UK and America. It remains to be seen how much influence they can assert over the current REFOCUS project.

The concept of Recovery may yet turn out to be an example of reification, but nonetheless many people do act ‘in the name of’ Recovery and in that sense it is having a very real impact on everybody’s ‘outcomes’.

Exceptional Clients and Disaffected Workers

The concept which became known as Recovery (in mental health) has its origins amongst a small number of individual consumers (users) in the US in the late 1980’s and early 90’s. Contrary to the folklore of Recovery they appear not to have rejected the medical or disease model itself, but the pessimistic prognosis offered by psychiatry. What they refused was the ‘sick role’ and the notion that they need be ‘disabled’ by mental illness. The client might continue to live with mental distress but it need not limit their ‘life chances’ or opportunities to fulfil goals or wishes. A few exceptional clients emerged who were able to wear as a ‘badge of honour’ both their ‘lived experience’ as well as their educational and work achievements. Readers may care to ‘google’ the following exceptional clients from the US - Patricia Deegan, Priscilla Ridgeway, Shery Mead and Mary Ellen Copeland. Deegan asserted in 1988 that:

‘Recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges. ..At times our course is erratic and we falter, slide back, regroup and start again. ..the aspiration is to live, work, and love in a community in which one makes a significant contribution’.

Even now, well over 20 years since it’s emergence there is only the broadest of agreed definitions of what Recovery is, allowing for a wide interpretation - and many welcome that. Ironically some also insist that Recovery is, what the individual decides it is. Last year Mike Slade, in the UK’s first textbook on the approach, Personal Recovery And Mental Illness ( http://www.amazon.co.uk/Personal-Recovery-Mental-Illness-Professionals/dp/0521746582/ref=sr_1_1?ie=UTF8&qid=1290062155&sr=1-1 ) selected the following quote from William Anthony in 1993 to serve as a working definition.

‘…a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/ or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness’.

Unlike the anti-psychiatry movement of the late 1950’s and 60’s however, which offered new theory and practice (though now largely rejected) and the user/ survivor groups of the 1970’s and 80’s, who in their complaining and campaigning focussed on rights and entitlements - Recovery approaches were, and remain highly individualistic. Not only is it assumed, in a moral or political sense, that individuals should be able to determine their own futures, but also in terms of theory - individual determinism is taken for granted, as opposed to more social forms of learning and agency. Part of the approach is for workers to be extremely client-centred with a clear moral imperative to take what clients say at face value. This is one of the senses in which the Recovery movement is best understood as a reaction against previous forms of care, rather than a positive assertion of new insights into mental distress. It emerged in the historical context of public perceptions of what constitutes abuse becoming much wider, and in parallel with a growing sensitivity of government and academia to the use of discriminatory and gender-based language, commonly referred to as ‘political correctness’.

Individual charismatic clients were joined by mental health workers who had gravitated towards community services, having become disaffected by the rigidity of the formal mental health system. The Recovery movement spread outwards from the USA to New Zealand (google Frank Bristol, Mary O’Hagan) and the UK (Ron Coleman). By the turn of the millennium, Recovery approaches were beginning to be considered for inclusion in the formal structures of health care in most western countries.

Recovery Values

From my observations of how the values and ethos of the Recovery approach have been embodied in practice, three underlying themes have emerged, and although their meaning is not made explicit or self-evident in the discourse of workers, they seem increasingly to be taken for granted in their actions. There is of course also a contrast between policy documents (again follow the links in part one) and practice. These are social processes, of working through different ways of being with clients.

What is explicit is the language of Recovery. In the UK, ‘hope’, ‘opportunities’ and ‘social inclusion’ seem to be the emerging concepts around which the Recovery dialogue is structuring itself - indeed advocates are often quite prescriptive about individual choice and freedom of action! From the general conversation of workers I would add; 'active listening’, ‘lived experience’, ‘empowerment’, ‘self-management’, ‘personal journey’, ‘goals’, ‘control’, ‘coaching’, ‘personal story’, ‘choice’ and ‘peer support’ as key words. But the underlying processes I observe are as follows:

Having a future orientation - (hope, goals, opportunities) the promise that tomorrow will be better than today and of acceptance, sometime in the unknowable future, by a society which has rejected them. Yet alarmingly workers often appear not to realise mental distress is only experienced in the present moment and must therefore be confronted today. Hopes and expectations need to be matched to the current situation and current capabilities, otherwise the expectations of others, come to be seen as further evidence of failure. Equally motivation can only come from others, and persists only as long as the client feels some emotional attachment to that person.

The pursuit of individualism - (self-management, personal journey, lived experience, choice, goals, peer support, social inclusion) an essentially anti-social bias; seeking equality in individual rights, entitlements and personal decision making and the formalising of relationships with peers. Clients are urged to set their own goals and needs and take responsibility - if they fail they appear to have ‘chosen’ and relieve others of responsibility. Wellbeing is judged not on the actual outcome of client’s activities, but the story or narrative they tell themselves. Individual merit and skill may be recognised but it is not given value or rewarded, everyone is made an expert to maintain an illusion of equally. Even those exceptional clients and workers who provide charismatic leadership - deny it! The social nature of learning goes unrecognised. Some claim Recovery is about social relationships, but when positive emotional attachments form between workers, clients and carers it is often seen as dependency and a failure to move on.

The illusion of a ‘self’ in control - (control, choice, empowerment, lived experience, self-management) it is one thing to argue that the client should take control back from mental health services and be in control, but this is what clients have always tried to do and been knocked-back by the reality of their situation - by evidence of not being in control. It is the ability to live with doubt, uncertainty, and not being in control, and be able to respond in a flexible way to change, that is mental health.

In short, Recovery values are the embodiment of our commonsense understandings about the place of individuals in modern western societies. They reflect the ideology of liberal democracies built upon a capitalistic economy. In so far as Recovery can be said to have intellectual antecedents then they lie in American humanistic psychology from the 1940’s and 50’s. Indeed at various times Recovery has made an uncritical use of Maslow’s ‘hierarchy of needs’! What the Recovery movement offers is highly conventional, but is offered to the one client group who are most psychologically and emotional alienated from society, the most aware of the difference between ideological valves and practical realities. The characteristics of the client continue to be seen, not as a reflection of modern society’s inability to genuinely accept difference, but of their failure to live within it. We are offered time and support to become more sophisticated conformists.

The clients I speak to every day do not speak the language of Recovery; if the subject is our own mental distress (and most often it isn’t) then we speak of the reality of the present moment and the inadequacies (or occasional virtues) of mental health services. We are suspicious of anything not grounded in the practicalities of everyday life. Workers in their stated attitudes often appear ignorant of our limited life choices. Workers wish to give hope, but do so in a situation where they get little back from the client. Equally they are anxious not to undermine the fragile confidence of the client. Yet in reality, as low paid, low status workers, they must be only too well aware of the limited opportunities of the client. As the number of workers with varying degrees of lived experience increases then the gap between potential life chances (as demonstrated by exceptional clients) and the reality of limited opportunities for most, can only become more visible.

A useful way of making sense of the activity of the Recovery movement is to see it as an example of ‘ideological work’. The late sociologist Bennett Berger ( http://www.amazon.co.uk/Survival-Counterculture-Ideological-Everyday-Communards/dp/0765808056/ref=sr_1_1?s=books&ie=UTF8&qid=1290063625&sr=1-1 ) introduced the concept - for him it was both his object of study and his method. Like myself he was initially personally involved with, and committed to, the subjects of his research, and like them wanting to provoke social change. He was interested in the tension between peoples ideals and the reality of their material existence. How the publicly stated goals of individuals or groups, realised themselves in actual behaviour. But he was also acutely aware of such a tension within himself; between his personal beliefs about the world, and what the results of his research told him. He argued that much of culture was becoming increasingly ideological, but that such symbolic structures were rarely translated into social structures. He studied people with ‘green’ values who wished to pursue a self-sufficient and communal lifestyle, but were confronted by the practical realities of agricultural labour and subsistence farming. He wanted to study the inevitable gap between what they professed and the way they behaved as they adapted to the changing circumstances of their lives.

‘…when groups are caught in contradictions between the ideas they profess to believe in and their day-to-day behavior, is their hurried ideological repair work best understood in an ironic, contemptuous, and cynical manner?’

In part three I consider how ideals have been turned into action in the Recovery movement.

Self-management - practical and emotional resources (updated 2014)

Practical resources I can usually organise for myself. They allow me to go where I want, when I want. They allow me to reach the emotional support and motivation I need - for that can only come from others.

My practical resources all centre around my leather satchel for which I paid almost £130 three years ago - an extravagant purchase you might think for someone on £91.80 per week benefits, but it’s intended to last a lifetime and it does the job required of it. It contains all I need to survive, it goes wherever I go!

So what’s in the bag?

It contains; diary/ address book, A-Z for Exeter, Torbay and Plymouth, several Stagecoach Devon timetables, a First Great Western timetable, A4 writing paper, pencil, red pen, yellow highlighter, post-it pad, red and black whiteboard markers, cloth for cleaning white board, extra tobacco and papers, spare lighter, re-usable cloth shopping bag, extra large plastic bag, sun glasses, reading glasses, benefits letter, CV, photocopy of some meditation techniques, my WRAP (on 2 sides of single sheet A4), bottle of tap water, Mac-in-a-Bag, sun hat, comb, spare key to my flat, Ventolin inhaler, 8 combined Aspirin/ Paracetamol/ Caffeine tablets, 6 low dose sleeping tablets, 2 condoms, 2 sticking plasters, 2 x 20p, a AAA battery, digital voice recorder, student ID and carrier, memory stick (back-up for my own computer, but also allows me to work on anyone else’s; contains hundreds of emails/ contacts, all my own writing, electronic versions of articles, bits of books, policy documents, reports, guides to everything that seems worth knowing about mental wellbeing!)

About my person I carry keys, coins, tobacco, papers and filters, lighter, tissues, wallet containing single debit card, driving licence, folding money, stamps, a couple of passport photos and my mobile. And last of all my go anywhere/ anytime Gold Mega Rider bus pass for Stagecoach Devon.

All the above gets me by bus/ train/ walking to my emotional resources and sources of motivation; and they in turn mark-out the limits of my territory (between Exeter and Plymouth with occasional forages as far as Bristol).

My only goal is the next horizon, my only need to meet someone there I care about - who will teach me something I don’t already know!

 

(..but now all that has changed. As of November 2014 I have a new satchel - there is nothing wrong with the old one I just want it exclusively for beachcombing - and there has been a lot of change to the contents too, brought on by my inevitable switch to a smart mobile device. The new bag cost just as much as the old one, and contains the further luxury of a proper leather bound Filofax to replace the diary/address book. Just as others are coming to depend on an electronic organiser, I take seriously the research that suggests that when it comes to memory and recall, then the hand/eye work of handwriting is much more likely to help than a keyboard/console with a screen. The A4 pad has also gone in favour of the back of the Filofax. The attraction of Google Earth plus maps plus GPS means I’m down to one local A-Z, and far fewer transport timetables! I still rely on the Bus Pass, though I can drive if I need to. Increasingly the smart device leads, it satellites around the laptop at home, plus relieving me of the need to carry a digital voice recorder, a calculator, a book…)