Framework forrecovery-oriented practice4 Clinical review of area mental health services 1997-2004Framework for recovery-oriented practiceIf you would like to receive this publication in an accessible format, pleasephone 03 9096 7873 using the National Relay Service 13 36 77 if required.This document is also available in PDF format on the internet at:www.health.vic.gov.au/mental healthPublished by the Mental Health, Drugs and Regions Division, Victorian GovernmentDepartment of Health, Melbourne, Victoria© Copyright, State of Victoria, Department of Health 2011This publication is copyright, no part may be reproduced by any processexcept in accordance with the provisions of the Copyright Act 1968.Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne.Print managed by Finsbury Green.August 2011 (1104012)AcknowledgementsThis framework has been developed with the support and active participation of many people. In particular,the Mental Health, Drugs and Regions Division would like to acknowledge the valued contribution of AssociateProfessor Alex Cockram, Chair of the Advisory Committee, who was instrumental in advancing this project.Advisory CommitteeMs Jodi BatemanMr Neil BrewerMs Michela CardamoneDr Prem ChopraAssoc. Prof. Alex CockramMs Maureen CuskellyDr Paul DenboroughAssoc. Prof Carol HarveyMr Peter McKenzieMs Dannielle McLeishMr Lei NingMr Arthur PapakotsiasMs Glenda PedwellMs Sherilyn PhillipsMs Cath RoperMs Wendy SmithMr Martin TurnbullMr Joel WickhamProject LeadMs Tracy BeatonProject ManagersMs Imogen EdesonMs Amy SzczygielskiAcademic AdvisorDr Bridget HamiltonProject TeamMs Silvia AlbertiMs Leanne BeagleyMs Brigid ClarkeMs Nicola FarrayMs Joyce GohMs Emma MontgomeryMs Petrina O’ConnorMr Graham RoddaMr Keir SaltmarshMs Amber ScanlonDr Ruth VineDr Sally WilkinsMinister’s forewordThe intention that specialist mental health practitioners work with people towards their self-definedpersonal recovery has gained momentum in the mental health sector over recent years. The recoverymovement, as it has become known in mental health, has evolved from the work of the physicaldisability sector from the era of deinstitutionalisation. People accessing services and communitypartners have long advocated for the rights of people with a disability to be supported to take upfull citizenship and participate in community life.The early voices for recovery orientation in mental health were clearly those of people with livedexperience, who actively advocated for the wellbeing and recovery of people with experiences ofmental illness. More recently, the voices of health professionals and policymakers have increasinglyjoined those of advocates in calling for health services to facilitate recovery and to systematicallydismantle barriers to full engagement and recovery.The orientation of service delivery towards recovery involves the need to focus on strongpartnerships in decision making between people and providers. It also requires partnerships withpeople’s significant others. In order to forge genuine partnerships, practitioners must do the workof listening closely to the experiences of people accessing services and their support people.This necessary work can be very challenging, especially when listening means acknowledgingpeople’s distress associated with accessing services.Recovery orientation requires that service models and practitioners favour collaborative practicesin everyday work. This involves supported approaches to decision making across the full spectrumof service provision, from assessment and acute treatment to therapeutic programs, long-termrehabilitation, accommodation and employment. This requires careful negotiation and collaboration.A number of efforts are underway across the Victorian specialist service system to work in recoveryoriented ways. This framework is intended to pull these activities and efforts together. As a livingdocument, the Framework for recovery-oriented practice will be adapted over time to suit theevolving system.This framework presents an invitation of the specialist mental health workforce to continue todevelop and enhance practice in line with recovery principles. It offers an opportunity for servicesand individual practitioners to reaffirm the aspirations they held when entering the mental healthsector and, most importantly, to create more positive experiences for people accessing the services.I look forward to working with mental health practitioners, managers and service leaders as weensure that Victorians who live with a mental illness are able to access services that respond totheir strengths, wishes, needs and circumstances.Hon Mary Wooldridge MPMinister for Mental Health ContentsPurpose 1Definitions 2Recovery 2Recovery-oriented practice 2Balancing risk 3A note about language 3Background and method 4Policy analysis 4Literature review 4Consultation 4Broad literature findings 4Organisational practice 4Individual practice 5Framework for recovery-oriented practice 6Domain: Promoting a culture of hope 7Domain: Promoting autonomy and self-determination 9Domain: Collaborative partnerships and meaningful engagement 11Domain: Focus on strengths 13Domain: Holistic and personalised care 15Domain: Family, carers, support people and significant others 17Domain: Community participation and citizenship 19Domain: Responsiveness to diversity 21Domain: Reflection and learning 23Conclusion 25References 26 1PurposeIn the paradigm of mental health, the concept of recovery is understood to refer to a unique personal experience,process or journey that is defined and led by each person in relation to their wellbeing. While recovery is ownedby and unique to each individual, mental health services have a role in creating an environment that supports,and does not interfere with, people’s recovery efforts. To this end, the Framework for recovery-oriented practiceexplicitly identifies the principles, capabilities, practices and leadership that should underpin the work of theVictorian specialist mental health workforce. As such, the framework is intended to provide broad guidance toboth individual practitioners and service leaders, spanning different practice settings and age ranges throughoutthe specialist mental health service system, specifically clinical and PDRS services. It is intended to complementexisting professional standards and competency frameworks.2DefinitionsRecoveryThe concept of recovery emerged from the consumer movement in the 1970s and 1980s and continues to be utilisedand further developed by people with lived experience internationally (Anthony 2007; Slade 2009). The term also hasincreasing currency in mental health policy and service systems internationally but is employed in a variety of ways.Consequently, there is some ambiguity around its definition. To overcome this ambiguity, a distinction is sometimesmade between what can be termed clinical recovery and what can be understood as personal recovery. Clinicalrecovery is primarily defined by mental health professionals and pertains to a reduction or cessation of symptomsand ‘restoring social functioning’, while personal recovery is defined by the person and refers to an ongoing holisticprocess of personal growth, healing and self-determination (Slade 2009). In this document, the term ‘recovery’ isconsidered an overarching philosophy that encompasses notions of self-determination, self-management, personalgrowth, empowerment, choice and meaningful social engagement.As an ongoing process or journey, recovery is not concerned with ‘achieving’ a state of being ‘recovered’ viatreatment of mental illness. Indeed, recovery can be considered a multidimensional interplay between people’sexperience of their mental health and their circumstances. The literature suggests that recovery is a non-linearprocess of continual growth whereby the pathway is informed by the person’s unique strengths, preferences, needs,experiences and cultural background (US Department of Health & Human Services 2011). Therefore, recovery canbe understood as a highly personalised journey unique to and led by the individual and thus cannot be ‘provided’,standardised or replicated within a service context. Similarly, as an ongoing journey of personal growth and wellbeing,the notion of recovery does not equate with a particular model of care, phase of care or service setting. However, theliterature on recovery outlines a range of practices and behaviours at both organisational and individual practitionerlevels that create an environment supportive of people’s recovery and that can be used to guide practice acrossclinical and non-clinical services.Recovery-oriented practiceThe aim of a recovery-oriented approach to mental health service delivery is to support people to build and maintaina (self-defined and self-determined) meaningful and satisfying life and personal identity, regardless of whether ornot there are ongoing symptoms of mental illness (Shepherd, Boardman & Slade 2008). Thus a recovery-orientedapproach represents a movement away from a primarily biomedical view of mental illness to a holistic approach towellbeing that builds on individual strengths (Davidson 2008).The term ‘recovery-oriented practice’ describes this approach to mental health care, which encompasses principlesof self-determination and personalised care. Recovery-oriented practice emphasises hope, social inclusion,community participation, personal goal setting and self-management. Typically, literature on recovery-oriented practicepromotes a coaching or partnership relationship between people accessing mental health services and mental healthprofessionals, whereby people with lived experience are considered experts on their lives and experiences whilemental health professionals are considered experts on available treatment services.3For the purposes of this framework, recovery-oriented practice is understood as encapsulating mentalhealthcare that:• encourages self-determination and self-management of mental health and wellbeing• involves tailored, personalised and strengths-based care that is responsive to people’s unique strengths,circumstances, needs and preferences• supports people to define their goals, wishes and aspirations• involves a holistic approach that addresses a range of factors that impact on people’s wellbeing, such ashousing, education and employment, and family and social relationships• supports people’s social inclusion, community participation and citizenship1.Balancing riskGiven that a recovery approach involves promoting people’s choice, agency and self-management, a degree ofrisk tolerance in services becomes necessary. As such, services can empower people – within a safe environmentand within the parameters of duty of care – to decide the level of risk they are prepared to take as part of theirrecovery journey. In supporting people’s recovery efforts, it is necessary for services to articulate the thresholdof risk appropriate to the particular service setting. Accordingly, services should consider providing guidance,training and support to staff on how to reconcile flexibility and responsiveness to people’s unique circumstancesand preferences with appropriate risk management obligations. This involves working with the inherent tensionbetween encouraging ‘positive risk taking’ and promoting safety (Department of Health 2007).A note about languageThere are a number of terms employed throughout international mental health policy, legislation and literatureto refer to people accessing mental health services, such as consumers, clients, service users and patients. Inthis document, wherever possible, the terms ‘person’, ‘individual’, ‘people with lived experience’ and ‘peopleaccessing mental health services’ are used to model humanistic language in line with a recovery approach.Similarly, because many people do not identify with the term ‘carer’ and the kind of relationship this term denotes,this document uses terms such as ‘support people’, ‘support networks’ and ‘significant others’, to recognise theplurality of relationships of importance to people.1 Citizenship in this context is understood to refer to people’s full inclusion and participation in all aspects of public, social and cultural life.4Background and methodPolicy analysisA policy analysis examined a number of Victorian and national policies, projects and legislation relevant torecovery. Recovery has featured as a core component in a range of Victorian policy documents that guide reformacross the mental health service system. Recovery is also embedded in the Fourth national mental health plan(Commonwealth of Australia 2009) and the National standards for mental health services 2010 (Department ofHealth and Ageing 2010). In addition, principles of recovery are included in a range of other national policies.As such, a recovery orientation has emerged as a key feature of contemporary reform to mental health servicedelivery.Literature reviewA literature review was undertaken of Australian and international literature pertaining to recovery-oriented practice.The primary objective of the literature review was to provide an overview of relevant literature that defines goodpractice mental health care within a recovery paradigm. To this end, the literature review focused on practice atorganisational and individual practitioner levels. However, the literature review did not examine broader systemic issuesthat impact on mental health practice and people’s experiences of care. Additionally, the literature review primarilyfocused on recovery-oriented practice in services working with adults because available literature on recovery ispredominantly adult focused. The literature that does pertain specifically to child and youth mental health emphasisesresilience, hope, strengths and growth, while the literature regarding older people’s mental health highlights theneed to support people to participate in valued activities, to preserve a sense of personhood and to celebrate lifeachievements (Boardman et al 2010).ConsultationIn addition, an advisory committee comprised of consumer, carer, clinician and psychiatric disability rehabilitation andsupport (PDRS) service representatives with expertise across the age ranges was established to provide ongoingguidance towards the development of the framework.Broad literature findingsOrganisational practiceThe literature outlined the following as being important components of recovery-oriented practice at anorganisational level:• organisational culture and commitment to facilitate a reorientation to a recovery approach and the embeddingof recovery principles in practice• inclusion of recovery principles in all management processes, such as recruitment, professional development,supervision, appraisal, audit, service planning and operational policies• incorporation of recovery values and language into all key organisational documents and publications• a degree of risk tolerance in encouraging people’s choice, balanced with duty-of-care obligations5• routine documentation of people’s preferences, ambitions, resources and support networks• ongoing provision of information in multiple forms to people regarding rights, complaint processes, treatmentoptions, advocacy support options and access to records• a peer support workforce• involvement of people with lived experience and their significant others in processes such as recruitment,education, training and development, and quality-improvement activities• responsiveness to people’s feedback, for example, through using outcome-measures, surveys, quality audits,complaints, service planning and evaluation activities and training led by people with lived experience• providing evidence-based interventions that assist in achieving the best outcomes for people’s mental healthand wellbeing• using models of care compatible with a recovery approach such as strengths-based approaches and individualrecovery planning• fostering partnerships between the service, people accessing services and their significant others; partnershipsbetween different service providers for integrated and coordinated care; and partnerships with community toaid social inclusion of people in communities of their choosing.Individual practiceThe literature suggested the following as being important components of recovery-oriented practice for individualpractitioners:• collaborative relationships with people to understand each person’s strengths, wishes and opportunities• responsiveness to the particular strengths, preferences, concerns, needs, goals and values of individuals• responsiveness to the things, people, activities and roles that people identify as important to their wellbeing andrecovery (and ensuring that mental health care enhances rather than interferes with these)• promoting decision making led by people accessing the services in accordance with each person’s values,needs, circumstances and resources• demonstration of empathy and resourcefulness in communicating with and responding to people• active challenging of stigmatising attitudes within the service and the broader community• utilising people’s existing support networks• use of interventions that promote people’s personal agency, self-esteem and overall wellness• active listening and responsiveness to people’s views, understandings of their experiences and advice on whatthey find helpful• use of person-centred and optimistic language that promotes hopefulness• practice that is responsive to gender, sexuality, culture, family and community.6Framework for recovery-oriented practiceThe framework utilises findings from the literature review and advice from the advisory committee to crystalliseguidance to the specialist mental health workforce on recovery-oriented practice.While recovery is understood as a unique personal journey that belongs to individuals, mental health professionals canpractice in ways that encourage and support people’s recovery journeys and improve people’s experiences of mentalhealth care. To this end, the framework is intended to align the practice of all people working in the Victorian specialistmental health system, across clinical and non-clinical practice settings and spanning the age ranges, with principles ofrecovery. In addition, the framework describes the key capabilities necessary for the specialist mental health workforceto function in accordance with these principles.The framework is intended for use at both individual practitioner and governance/leadership levels across theworkforce including the peer workforce, clinicians, workers, service managers and leaders. As such, the frameworkis targeted at all people employed in the Victorian specialist mental health system, regardless of their role, healthprofession, degree of contact with people accessing the service or level of seniority. The framework clarifies theprinciples that should underpin practice to ensure the quality of people’s experiences of mental health care. In as much,the framework is intended to complement existing professional standards and competency frameworks.The framework is structured into domains that reflect key fields of recovery-oriented practice. There is some overlapbetween the different domains, which are intended to be used concurrently to inform the ongoing provision of mentalhealth care. The order of the domains does not reflect their importance.The domains include:• Promoting a culture of hope• Promoting autonomy and self-determination• Collaborative partnerships and meaningful engagement• Focus on strengths• Holistic and personalised care• Family, carers, support people and significant others• Community participation and citizenship• Responsiveness to diversity• Reflection and learning.Within each domain, there are four sections.1. Core principles that should govern all practice, decisions and interactions in the provision of mental health carewithin the relevant domain.2. Key capabilities required to enact these core principles including the behaviours, attitudes, skills andknowledge consistent with recovery-oriented practice.3. Good practice examples, intended to support individual practitioners to translate principles of recovery intotheir daily practice. Some examples may be more relevant to clinical settings, while others are more applicableto PDRS staff.4. Good leadership examples, directed at service leaders and managers, that describe activities and governancestructures that could be expected of a recovery-oriented organisation.7DOMAINPromoting a culture of hopeCreating and sustaining a service culture of hope is essential to ensuring an organisational environmentthat encourages and supports people’s recovery efforts. Everyone participates in creating and maintainingorganisational culture through the perpetuation of behaviours and attitudes. However, governance/leadership rolesare responsible for leading efforts to establish a positive and hopeful culture conducive to people’s recovery.Key capabilities Mental health professionals:• actively uphold a culture of hope by using optimistic language, supporting people, their significant others andcolleagues, and celebrating people’s recovery efforts• understand and work to create the environment, conditions and practices that support people’s recovery efforts.• sustain and express hope, optimism and the conviction that people can, will and do recover.• use hopeful recovery-oriented language in all interactions and documentation.• understand and effectively communicate recovery principles, emphasising hopefulness and optimism towardspeople’s recovery• have knowledge of up-to-date research on recovery outcomes and can express this to colleagues, people accessingthe service and their significant others. Core principlesMental health services promote principles of hope, self-determination, personal agency, social inclusion and choice.A service environment supportive of people’s recovery is one that sustains and communicates a culture of hopeand optimism and actively encourages people’s recovery efforts.The physical, social and cultural service environment inspires hope, optimism and humanistic practices for all whoparticipate in service provision.BehavioursAttitudesSkillsKnowledge8Good practice• Actively seek, celebrate and share (with permission) people’s stories of recovery.• Emphasise achievements and successes, highlighting progress using affirmative language.• Note behaviours and events that signal improvements and remind people of these.• Sustain hope for people’s recovery, especially when people feel unable to carry hope themselves.• Understand the philosophical underpinnings of the concept of recovery and its origin in the consumermovement.• Keep up to date with research on positive outcomes.• Recognise that team relationships impact on people’s wellbeing.• When working with older people, celebrate life achievements and support people to retain their sense ofpersonhood (such as through interests, hobbies, habits and preferences).Good leadership• Provide avenues for people to gather and share their lived experience and stories of recovery (such asthrough monthly on-site gatherings).• Model recovery-oriented behaviours and language in case conferences and case reviews.• Foster a culture of high expectations of recovery and hope.• Celebrate rights of passage and achievements.• Recognise when a person has developed effective coping strategies for stressful situations.• Support people to become advocates or peer support workers, where appropriate.• Work to showcase mental health as an exciting area of innovation and positive outcomes in the broaderhealth context.• Broadcast research on recovery outcomes and create opportunities for service-wide discussions of theresearch.• Use outcome-measures data to promote positive messages of recovery among staff and clients.• Ensure treatment and recovery planning involves routine conversations about people’s aspirations andhopes.9DOMAINPromoting autonomy and self-determinationAlthough the human rights of people accessing mental health services may be impacted by mental health andother legislation, the principles outlined in this domain are applicable regardless of people’s legal status. In this way,practices should always be directed towards facilitation or resumption of people’s own decision making in all areasof life. Where a person is unable to self-advocate at any time, services should ensure that the person’s views areproperly represented in all decision-making processes.Key capabilities Mental health professionals:• provide all the necessary information to support people to make decisions about their mental health care• inform people of their rights and actively protect and promote these rights• support people to exercise their rights• remove barriers that unnecessarily limit people’s rights• make every effort to ensure people’s safety, comfort and wellbeing at all times• consider people’s varying levels of vulnerability and resilience at different times.• recognise and support people’s rights of self-determination and choice• are committed to facilitating the involvement of people accessing the service and their significant others in all aspectsof service delivery• acknowledge and value people’s lived experience and expertise.• are informed and skilful in supporting people’s self-determination, decision making and informed risk taking, withoutcompromising safety• are able to support people’s self-advocacy and to advocate on people’s behalf when required with a view tofacilitating a restoration of people’s self-advocacy as soon as possible• continue to develop the skills and capacity to support people to exercise their rights and make decisions about theirmental health, wellbeing and lives.• have knowledge of human rights principles and relevant frameworks• are aware of consumer and carer movements and advocacy groups, and support their involvement in service deliveryand service improvement• have knowledge of relevant legislation and policies on consumer rights and consumer and carer participation in arange of processes. Core principlesMental health services have a responsibility to involve people as partners in their mental health care.Mental health care aims to promote people’s self-determination and to support people’s capacity to manage theirmental health.Lived experience and expertise is recognised, elicited and acted on in all decision-making processes.Every person should have access to high-quality recovery-oriented mental health care that is responsive to theirparticular needs.Recovery-oriented mental health care encourages informed risk taking2 within a safe and supportive environment.The safety and wellbeing of people accessing the service and their support networks is central to the provision ofmental health care and the service environment is organised to ensure people’s safety and optimal wellbeing.BehavioursAttitudesSkillsKnowledge2 See next page (14) for footnote.10Good practice• Assist people to make informed decisions about their mental health care by providing information, resourcesand other support.• Sit down with people to explain their rights upon admission or initial contact and regularly throughout theperiod of service and using different media to ensure that people are well informed of their rights.• Engage in ongoing dialogue and enquiry about people’s needs, wishes and experiences.• Use advanced directives, advanced statements or equivalent.• Develop the required knowledge and understanding of the Victorian Charter of Human Rights andResponsibilities Act 2006 and understand principles of self-determination, privacy and informed consent.• Take care to create a safe and supportive environment in which people feel safe and secure; this includesavoiding practices that people may experience as traumatic.• Recognise the shared responsibility of staff and people accessing services to maintain an environment thatfeels safe and secure for everyone.• Seek feedback from people accessing the service and their significant others to inform ongoing practice.Good leadership• Ensure that systems are in place to inform people of their rights at all times and through a variety of differentmedia; this information should be routinely communicated upon admission or initial contact and regularlythroughout the period of service.• Set up systems to actively seek lived experience and expertise from people accessing the service and theirsignificant others.• Make it easy to provide feedback and make complaints (for example, provide open access for families andclients to make complaints in multiple forms).• Ensure consumer and carer consultants are represented in feedback and complaints processes (such as onpanels or review teams).• View feedback and complaints as opportunities for service improvement and set up systems to ensure thatfeedback and complaints are translated into service changes and that these are communicated to staff andclients.• Review local policies and procedures to incorporate principles of autonomy, self-determination and choice.• Ensure that position descriptions reflect the requirement to understand and be able to communicate rightsand to enact people’s rights in practice.• Support staff to work well with informed risk taking as an important part of promoting people’s choice andself-determination.• Engage in an active and ongoing discussion with staff about risk.• Be clear about people’s responsibilities as well as rights.• Encourage staff to communicate transparently with people.• Ensure that wherever there are limitations on a person’s choice, autonomy and self-determination, that theselimitations are removed as soon as possible.2 (from previous page) Informed risk taking here refers to what is documented in literature on recovery as dignity of risk or positive risk taking.Informed risk taking involves optimising informed choice and consumer-led decision making, even where this involves a degree of perceived risk.Consumer-led literature on recovery highlights the importance of self-determination, self-responsibility and supporting people to decide the level ofrisk they are prepared to take with their health and wellbeing. However, in the context of a mental health service setting, practitioners and serviceleaders are required to balance the need to encourage informed risk taking with the need to create a safe environment and adhere to duty-of-careobligations. Nevertheless, risk management processes should always be oriented towards promoting consumer choice and restoring choice assoon as possible if it is limited in any way.11DOMAINCollaborative partnerships and meaningful engagementThis domain details how mental health professionals can engage with people at all times in ways that areconducive to supporting their recovery efforts. Central to recovery-oriented practice is the development ofcollaborative partnerships between mental health professionals and people accessing the service, which areinclusive of their support networks and significant others. These partnerships involve health professionals providinginformation, skills, networks and support to people to maximise their choices, manage their mental health andwellbeing and get access to the resources they need. This relationship is characterised by openness, equality, afocus on people’s strengths, reciprocity and power sharing (Shepard, Boardman & Slade 2008).Key capabilities Mental health professionals:• work in partnership and engage meaningfully with people and their significant others• demonstrate genuine care, warmth, consideration, honesty, transparency and empathy in their interactions withpeople• communicate respectfully and sensitively with people at all times, using non-judgemental, positive and affirminglanguage• respond to people’s self-defined goals and aspirations in their practice• listen, reflect and respond to people’s lived experience and expertise.• value collaborative approaches to working with people and their support networks• acknowledge, value and respond to people’s lived experience and that of their support people and significant others• are committed to promoting people’s choice and personal agency by eliciting and responding to people’s uniquewishes, needs, cultural values and circumstances.• utilise well developed interpersonal skills to successfully build positive collaborative relationships with people and theirsignificant others• use their professional expertise to fully inform people of the complete range of options available to them• actively seek and incorporate people’s preferences and expertise in the provision of mental health care• support people to make decisions about their lives
