Rachel Perkins BA, MPhil (Clinical Psychology), PhD, OBE
Implementing Recovery through Organisational Change (ImROC) Project Team
Co-author of ImROC briefing paper on recovery Colleges http://www.nhsconfed.org/Documents/imroc-recovery-colleges.pdf
Central and North West London NHS Foundation Trust (CNWL) is committed to increasing the extent to which its services promote the recovery the people it serves: the development of the Recovery College is central to these endeavours.
The Government’s mental health strategy ‘No Health Without Mental Health’ (Department of Health, 20111) identifies promoting recovery as a key outcome of services. CNWL and its partners were selected as one of the six national pilot sites of the national Implementing Recovery through Organisational Change’ (ImROC) programme: an initiative that forms one of the core work streams that has been established to support implementation one of the national mental health strategy2. The development of Recovery Colleges is an important component of the work within this programme. While Recovery Colleges/Education Centres have been central to the development of recovery-focused services in the USA, such as those in Boston, Massachusetts and Phoenix, Arizona (Ashcraft and Anthony, 20053) they have only recently begun to emerge in England.
CNWL and its partners have had a central role in pioneering the UK development of such colleges: officially opened in April 2012, the CNWL Recovery College is just the third in the country4.
Why is a Recovery College so important in the development of recovery-focused services?
Recovery is a personal journey of discovery that involves “making sense of, and finding meaning in, what has happened; discovering your own resources, resourcefulness and possibilities; building a new sense of self, meaning and purpose in life; growing within and beyond what has happened to you; and pursuing your dreams and ambitions.” (Repper and Perkins, 20125). The term ‘recovery’ is used to describe the process of ’recovering a life’ – rebuilding a meaningful, valued and satisfying life - not ‘recovering from’ symptoms and problems. Specialist assessment and treatment to alleviate problems and symptoms are important, but they represent only a small part of what mental health services do, and far more is required if people are to rebuild their lives, do the things they value and participate as equal citizens.
The challenge for services is to assist people in this journey, and if they are to do this then major changes in culture and practice are required. Shepherd et al (20106 ) identified ‘ten key organisational challenges’ facing organisations if they are to become more ‘recovery focused’. These form the basis of the ImROC programme and involve a redefinition of the purpose of services: from a primary focus on reducing symptoms to a primary focus on enabling people to rebuild their lives. All treatments, interventions and services must be judged in terms of the extent to which they help people in their recovery journey.
The Recovery College is specifically designed to enable people to rebuild their lives - to develop the skills they need for living and working. Recovery Colleges enable people to become experts in their own self-care and develop skills and confidence to manage their own recovery journey.
The change in culture and practice required if services are really to assist people in their journey of recovery also requires a transformation of the relationship between services/mental health practitioners and those whom they serve (Repper and Perkins 20124). This transformation involves:
a change in the role of mental health professionals and professional expertise
a recognition of the equal importance of both ‘professional expertise’ and ‘lived experience’ and a breaking down of the barriers that divide ‘them’ from ‘us’
a different relationship between services and the communities that they serve.
A Recovery College embodies this transformation and can be central to driving broader organisational change (see Perkins et al, 20127).
A change in the role of mental health professionals and professional expertise
In recovery-focused services, mental health practitioners need to move from being ‘on top’ to being ‘on tap’: supporting self-management rather than ‘fixing’ people by making their expertise and understandings available to those who may find them useful, rather than defining problems and prescribing remedies. This allows people using services to make their own judgements about how best to understand and move beyond what has happened, and what might be helpful in enabling them to do this.
An educational approach lies at the heart of recovery-focused services (Ashcraft and Anthony, 20053). An educational paradigm focuses on reinforcing and developing people’s strengths, enabling people to understand their own challenges, and how they can best manage these in order to do the things they value and pursue their aspirations. A Recovery College lies at the heart of an educational approach and provides much of what has traditionally been provided within a traditional therapeutic paradigm in the form of ‘individual work’ and ‘groups’. However, the relationship between mental health practitioners and those whom they serve is quite different.
In a Recovery College, mental health practitioners share their expertise in a range of workshops and courses. Those who provide courses become trainers, tutors or mentors, and those who attend move beyond the role of ‘mental patient’ or ‘service user’ and become ‘students’.
The College affords its students choice, control and self-determination. Students are not passive recipients of the ‘prescriptions’ of experts. Within a Recovery College there are no prescriptions: students select the courses that interest them from a prospectus, do their own research in a library, and attend courses that enable them to take control and pursue what is important to them. The range of workshops and courses available within the College help people to discover who they are, learn skills that promote recovery, find out what they can be, and realise the unique contribution they have to offer (Ashcraft and Anthony, 20053) … and thus gain the greater confidence and self-belief that come with recognising your abilities and potential.
A recognition of the equal importance of both ‘professional expertise’ and ‘lived experience’ and a breaking down of the barriers that divide ‘them’ from ‘us’
Recovery-focused services recognise the equal importance of two kinds of expertise - professional expertise and the expertise of lived experience (Shepherd et al, 20088; Repper and Perkins, 20125) – as well as the centrality of peer support in the recovery process (Repper and Carter, 20119). The expertise of lived experience and professional expertise must be brought together in working practices based on co-production and shared decision making at all levels, and the importance of both types of expertise must be reflected in a different kind of workforce (one that includes peer workers).
A Recovery College explicitly recognises the expertise of mental health professionals and the expertise of lived experience in a process of ‘co-production’.It is run by both peer trainers and mental health practitioner trainers. All courses are co-produced, co-delivered and co-received by staff, people facing mental health challenges and the people who are close to them.
The College breaks down the destructive barriers between ‘them’ and ‘us’ – barriers that perpetuate stigma and exclusion. The workforce of trainers includes both people with lived experience and mental health practitioners (who may themselves also have lived experience of subjects in which they provide training. Both Peer and Mental Health Practitioner trainers are employed on equal terms. Barriers between ‘them’ and ‘us’ are not only broken down in the provision of courses, they are also broken down within the student group. People with lived experience and those who provide their support (both informal carers and mental health practitioners) learn together and from each other. The transformation from ‘service user’/’client’ to ‘student’ affords a positive identity beyond that of ‘mental patient’.
Peer support is a central feature of the Recovery College. Co-produced, co-delivered courses enable students to see what people facing mental health challenges can achieve. The peer support offered by peer trainers and fellow students enables people to feel less alone, offers images of hope and possibility and allows people to learn from others who have faced similar challenges and use their lived experience to help others.
Group learning and mutual support replaces the disabling isolation engendered by a sole reliance on individual work. Recovery Colleges create a network of social opportunities among peers and the general community which can reduce the social isolation that so many people experience. Like any students, people attending Recovery College courses often form relationships that extend beyond the classroom.
A different relationship between services and the communities that they serve
The opportunity to be a part of, and contribute to, our communities is central to recovery and citizenship, yet the discrimination and social exclusion often deny these possibilities to people facing mental health challenges. Mental health services can, unwittingly, perpetuate exclusion in a kind of vicious cycle. People with mental health challenges can readily come to believe that experts hold the key to their difficulties. The people who are close to them – family, friends, colleagues, neighbours – can readily come to believe that the person they care about is not safe in their untrained hands – they should leave it to the experts. So communities, as well as individuals, become less and less used to accommodating people with mental health challenges, finding their own solutions and embracing distress as a part of ordinary life (Mary O’Hagan, 200710).
Recovery-focused mental health services need to develop a different relationship with the communities they serve. The challenge facing services is to work as part of communities. Recovery is not only about recognising the resources and resourcefulness of individuals – it is also about recognising the resources and resourcefulness of friends, families, communities. Recovery-focused services need to both use the resources available within communities, and share their expertise with those communities: support not only individuals, but also friends, families and communities.
A Recovery College can contribute to these endeavours in three ways. First, people from local organisations can be involved in providing courses. Second, individuals can attend courses that assist them to develop the knowledge and skills necessary to return to work, study, and participate in the community. Third, relatives, friends and neighbours can study alongside people facing mental health challenges. Together these help to promote inclusion and participation: break down the prejudice and discrimination that divide people facing mental health challenges from their friends, families and communities, and increase the understanding and confidence of those friends, families and communities in accommodating those with mental health challenges.
The Role of a Recovery College in Recovery-Focused Services
The Recovery College has a central role to play in the development of recovery focused services, but it cannot, and should not, replace all other services: it cannot, for example, offer specialist assessment and treatment, neither can it provide the outreach support that some people need to navigate their lives.
Neither can the Recovery College stand apart from these other facets of services. The Recovery College will be of little value if it is seen as ‘the place where recovery is done’ while all other parts of the service carry on as they have always done. Promoting recovery is everyone’s business. If the Recovery College it is to have a positive impact on the recovery journey of individuals the messages of hope and possibility, self-management and self-determination, must be reinforced and extended in other parts of the service that people use. If it is to have a positive impact on the development of recovery-focused services, it must be a fully integrated part of the organisation and its work. A wide range of staff and people with lived experience must contribute to its courses and workshops - not simply the ‘core staff’ of the college, but a wide range of practitioners and people with lived experience across the Trust and beyond. It must be a core part of ‘care pathways’ - perhaps these should be reframed as ‘recovery pathways’?
An important start has been made by establishing the CNWL Recovery College, but this is not the end of the road, it is the start of a journey.
The Recovery College needs to think about how it can accommodate the diverse range of people using all aspects of the Trust’s services, like older people, younger people, people who use forensic services, addictions services, eating disorder services ... It might also think about the role it has in the pre qualification training of mental health practitioners. Perhaps local training programmes might purchase places on College courses? Perhaps the College might constitute a placement for trainees?
Depending on the resources available, there are many possibilities to be explored as the College grows and matures.
The College could also play a far greater role in bridging the divide between mental health services and the wider community, making the resources of those communities available to people receiving mental health services and increasing the capacity of our communities to accommodate and address mental distress. This might be achieved by greater involvement of people from outside the mental health diaspora in providing courses (from colleges, community safety partnerships, job centres, housing associations, community groups ....). This would both increase the range of expertise available to students and provide people from external agencies with the contact with people who have mental health challenges that is so important in breaking down prejudice. The College could also become an important resource for the community. If one in four people face mental health challenges then there are many who might benefit from courses like coping with stress, living with depression, personal recovery planning, mindfulness and returning to work. If courses were available to a greater range of people (and those close to them) outside secondary mental health services then understanding of mental health conditions within our communities could increase substantially. And maybe there are people with other long-term health conditions – like diabetes, heart disease, stroke, COPD ... – who could benefit from a similar approach ...
2 http://www.nhsconfed.org/networks/mentalhealth/ourwork/imroc/Pages/NMHDU-Implementing-Recovery-Organisational-Change-Project.aspx and www.centreformentalhealth.org.uk/recovery/supporting_recovery.aspx)
3 Ashcraft, L. & Anthony, W. (2005) A story of transformation, Behavioral Healthcare Tomorrow, April, 12-22
5 Repper, J. & Perkins, R. (2012) Recovery: A Journey of Discovery for Individuals and Services IN Phillips, P., Sandford, T, & Johnston, C. (Ed) Working in Mental Health: Practice and policy in a changing environment, Oxford: Routledge