Are the rules contributing to the recovery of the service user?

Recently I have encountered several clinical situations in which unit rules compromised the recovery practices of clinicians and ultimately the care of service users.  The intent of this blog is to pose some ideas to you related to recovery and rules, with the hope to inspire you to reflect on your own experiences as a service user, healthcare provider and/or someone who is directly or indirectly impacted by mental health care services. I often have discussions with various colleagues locally and internationally in which we share our experiences and observations of clinicians who struggle on a daily basis to balance these so called ‘rules’ with recovery practices. It has been recognized that continuing to advance recovery-oriented mental health care requires a paradigm shift not just at the practitioner level but also at the organizational level which includes challenging and questioning commonly accepted, written or unwritten unit rules.

One of the founders of the recovery movement, Bill Anthony defines recovery as “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and roles. It is a way of living a satisfying, hopeful and contributing life, even with 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…” (Anthony, 1993).

It is common that unit rules are perceived to be in place to prevent or decrease “risk”.  However, we are learning from evidence and from experience that sometimes it is necessary for service users to take risks in order to learn and grow. Differentiating between risks that must be minimized such as self-harm or harm to others, and risks that people have a right to experience such as, participating in a consenting sexual relationship, becomes integral to recovery. Practicing with a recovery lens enables the practitioner to encourage a service user’s opportunities for growth and change in a responsible way, thus promoting ‘dignity of risk’.

Staff skills which enable recovery practices have been identified and include: openness, collaborating as equals, focusing on the individual’s inner resources, reciprocity and a willingness to go ‘the extra mile’ (Borg & Kristiansen, 2004).

Believing in providing recovery-oriented mental health care requires a practitioner to challenge antiquated practices and rules, promote ‘dignity of risk’ and integrate the characteristics and principles of recovery into his or her practice order to provide exemplary mental health care.

Here at Ontario Shores Centre for Mental Health Sciences we continue to advance our recovery practices which include supporting our interprofessional teams through the processes of challenging ‘rules’ if they arise in a clinical situation and working with our service users to determine what they perceive as effective or meaningful recovery practices. Recently, our Risk, Ethics and Professional Practice teams have joined  together to develop a framework to support the process of reviewing rules and creating new practices on the units to further advance our recovery practices. Mental health care internationally is on a journey towards this paradigm shift and ensuring service users are engaged within a recovery-oriented system, and it is extremely exciting to see Ontario Shores on this path. In June Ontario Shores signed the Mental Health Commission of Canada’s Declaration of Recovery , thus pledging to continue to promote awareness and greater understanding of recovery and to demonstrate our commitment on this journey to our service users, staff and community.

Lastly, as we continue to progress and enhance recovery-oriented care, I leave you with the following  questions that each mental health professional should ask themself before and after engaging with those in their care. I encourage you to adopt these for your practice and to share them with others.

Did I….
• Actively listen to help the person to make sense of their mental health problems?
• Help the person identify and prioritize their personal goals for recovery – not professional goals?
• Demonstrate a belief in the person’s existing strengths and resources in relation to the pursuit of these goals?
• Identify examples from my own ‘lived experience’, or that of other service users, which inspires and validates their hopes?
• Pay particular attention to the importance of goals which take the person out of the ‘sick role’ and enable them actively to contribute to the lives of others?
• Identify non-mental health resources – friends, contacts, organizations – relevant to the achievement of their goals?
• Encourage self-management of mental health problems (by providing information, reinforcing existing coping strategies, etc.)?
• Discuss what the person wants in terms of therapeutic interventions, e.g. psychological treatments, alternative therapies, joint crisis planning, etc., respecting their wishes wherever possible?
• Behave at all times so as to convey an attitude of respect for the person and a desire for an equal partnership in working together, indicating a willingness to ‘go the extra mile’?
• While accepting that the future is uncertain and setbacks will happen, continue to express support for the possibility of achieving these self-defined goals – maintaining hope and positive expectations?

(Making Recovery a Reality, Shepherd, G., Boardman, J. & Slade, M., 2008)