Outline 1. Position statements on the support of ‘recovery’ Working to support 'Personal 2. Historical context recovery': - The case of 3. Definitions of ‘recovery’ personality disorder 4. Problems Andrew Shepherd - NIHR Doctoral Research Fellow (UoM and 5. Working to understand recovery in different contexts GMW Mental Health), Higher Trainee in Forensic Psychiatry 6. Findings 7. Moving forward Personal Recovery Historical context Support of ‘personal recovery’ Recovery as ‘cure’ Recovery as survival of now defined as goal of modern invalidation NHS mental health services; with Enlightenment concept, notion substantial resource investment of distress as ‘disease’ in need Emergence of ‘recovery (e.g REFOCUS collaboration): of cure and treatment (c.f movement’ during process of Various accounts for deinstitutionalisation. Need for “New Horizons sets out the development of this mode of space for ‘the mad’ in society expectation that services to treat and care for people with mental (c.f disability rights movement) thinking Foucault, Lieberman, health problems will be accessible Scull) to all who need them, based on the best available evidence and focused on recovery, as defined in discussion with the service user .” New Horizons. A Shared Vision for Mental Health (2009). Department of Health London.
Defining recovery Researching recovery “ a way of living a satisfying, hopeful, and contributing life e.g REFOCUS intervention (Slade et al. 2015) even with limitations caused by illness . Recovery involves the development of new meaning and purpose Recovery conceptual framework - CHIME(S) (Leamy, Bird et al 2011) in one’s life as one grows beyond the catastrophic effects of mental illness .” (Anthony 1993, p527) 1. Connectedness 2. Hope “ The goal of the recovery process is not to become normal . The goal is to embrace our human vocation of 3. Identity becoming more deeply, more fully human . The goal is 4. Meaning not normalization. The goal is to become the unique, 5. Empowerment awesome, never to be repeated human being that we are called to be. ” (Deegan 1996, p92) 6. Spirituality Working to understand Problems? recovery in different contexts Recovery still requires greater conceptual clarity if it is to be Systematic review implemented in clinical practice. Conducted with aim of surveying existing literature in relation to Argument : - Greater understanding can be gained by considering understanding of recovery in marginal, liminal, states personality disorder and within forensic institutions. Example : - Personality disorder represents a complex experience with varying clinical conceptualisations and understanding by professionals. Providing sensitisation to existing practical and theoretical literature, Claimed prevalence of PD within forensic institutions raises this while allowing development of complexity further. framework understanding. Aim :- To explore lived experience of recovery in personality disorder as (Shepherd, Doyle, Sanders & Shaw described by individuals accessing care in both community and forensic 2016a, b) institutional settings. To develop understanding of the enactment of recovery orientated care by practitioners in these contexts
Individual interview phase Focus group interviews 1. Recruitment strategy 1. Recruitment strategy • 41 participants (21 Forensic and 20 Community) • 7 groups (30 participants) • Majority women (n=23 total, 13 in Forensic settings) • Homogeneous in membership (clinical teams accustomed to working together) • Mixed inpatient, prison, approved accommodation, community mental health team care settings 2. Interview conduct • Not diagnosis specific: - ‘as if’ one had a personality disorder of any type • Targeting varying clinical settings, length of contact with services etc responding to emergent • Semi-structured with initial elaboration findings of understanding of personal recovery before moving on to address individual 2. Interview conduct interview themes • Semi-structured, but with intent of supporting elaboration of participant narrative 3. Analysis 3. Analysis • Situational constructivist • Epistemology - Situational constructivist approach • Again considering reflexivity from role of conductor • Importance in considering reflexivity Findings - Recovery as a Diagnosis as representing ideas of understanding and hope process of identity work 1. Diagnosis as normalisation leading to Making sense of experience and the embodiment of distress 2. Diagnosis as problematic a hope for treatment “I got the understanding that people don't Participant narratives were replete with descriptions of childhood abuse, isolation, trust it [diagnosis] , or they say it’s a cop out, dislocation from their environment: “They gave me the diagnosis of but I don't care about it, I know I’m ill, I know emotionally unstable personality disorder. the things I’ve done, I know I wouldn't be in “I had a lot of depression and down days, when I think back now just not fitting in So I was put on, obviously, several this service if there was nothing wrong with even the foods that I liked were totally different I had nothing in common with the antipsychotic drugs and antidepressants me…” family that I lived with and brought up with. Not in the food, nothing.” which were linked with an anti-anxiety as well and I started going to a hearing 3. Moral contextualisation Means of communicating distress were presented as response to inability to voices group, which was near where I communicate through other means: lived, so that made things a lot easier “…if I don’t believe that I’m ill, if I can't knowing that I was with like-minded believe that this is an illness, and even “…to me it just felt like, everything did stop, and it just felt like a relief really. (Int: A personality disorder, if I can’t believe it’s an people.” relief of what?) Stopping all the pressure building up inside me and all the emotions illness then it makes it even worse. Because that I didn't know what to do with… I didn't know how to express them in other ways, it makes it that, I’m doing this to myself. That so by self-harming it kind of released those emotions and I guess in a way I was able for some reason I can’t control the way I feel to, after I’d done it, sort of take care of myself, in a way, in a way that I would normally and if it’s not an illness then, then I’m a really, never do.” really seriously bad person.”
Recovery and its social Professional understanding contextualisation of recovery Clinical support as a process of emotional labour Professional accounts of the “…I’m worried about going home, because people therapeutic process indicated will remember psycho-Samantha, people will that they too underwent an intense experience of emotional remember the Samantha who didn't give a shit… the labour in working with this client Samantha who’d do anything for anyone… I’m not group. that Samantha no more… I’ve really changed and I’m This led to complex descriptions worried about if they’d let me be this person…” wherein different professionals sought to make distinction between concepts of ‘ support’ versus ‘ dependence’. Professional understanding Moving forward - Recovery of recovery The need for clinical supervision Diagnostic uncertainty and the risk of Recovery as a social process of identity work stigmatisation Supervision was identified as an • How do we incorporate this understanding to develop adequate important means of addressing these Treatment options were often therapeutic spaces (c.f Nidotherapy - Tyrer, 2008)? difficulties. primarily seen as being driven by psychopharmacological approaches. • How do we capture the dynamic of social networks and their role in the Providing a manner in which the process (c.f Open Dialogue approaches - Aaltonen et al 2011, Seikkula emotional process, and uncertainty, Apparent failure to respond to these could be addressed. et al 2011)? medications led to ideas of ‘un- treatability’ and a desire to exclude Supervision was increasingly seen as • How do we gauge this process through audit or empirical research? individuals from clinical care. dominated by non-clinical material however. “ Once being ‘in recovery’ is under-stood as living a meaningful and self- Overall these were perceived as determined life in the community in the face of an enduring mental illness, it challenging individuals to work with, Supervision was also a restricted becomes obvious that this requires as much of a change in the community placing a great deal of strain on resource, squeezed out in a time of as it does in the person with the illness. ” (p306, Davidson, 2008) professionals budget and resource constraint.
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