Secure Recovery

Approaches to Recovery in Forensic Mental Health Settings

Gerard Drennan, Deborah Alred, Gerard Drennan, Deborah Alred

• Publisher: Willan
• Year: 2013
• Print ISBN: 9781843928379
• eBook ISBN: 9781136472480
• Edition: 1
• Topic: Social Sciences
• Subtopic: Criminology
• Index: Social Sciences

Secure Recovery is the first text to tackle the challenge of recovery-oriented mental health care in forensic services and prison-based therapeutic communities in the UK.

Recovery as an emergent paradigm in the field of mental health presents a challenge to all services to embrace a new clinical philosophy, but nowhere are the implications more profound than in services that are designed to meet the needs of mentally disordered and personality-disordered offenders, both men and women. The chapters collected together in this book represent a cross-section of experiences in high, medium and low secure services and prison-based therapeutic communities in England and Scotland that have begun to implement a recovery orientation to the rehabilitation of offenders with mental health needs.

Secure Recovery sets out a road map of guiding principles, practical and evidence-based strategies for promoting service user participation in their care and treatment and further demonstrates the adaption of traditional treatment approaches, and the development of innovations in rehabilitation, as well as tackling training for staff teams, and the evaluation of service delivery.

This book provides a valuable resource and an inspiration to practitioners working across forensic mental health settings, increasing understanding of contemporary challenges and suggesting ways of moving forward.

1 Recovery in forensic mental
health settings

From alienation to integration

Gerard Drennan and Deborah Alred

‘Contemplating the loss of reason as pre-eminent in the catalogue of human afflictions; and believing that the experience of the Retreat throws some light on the means of its mitigation, and also that it has demonstrated, beyond all contradiction, the superior efficacy, both in respect of cure and security, of a mild system of treatment in all cases of mental disorder, an account of that experience has long appeared to me, due to the public.’

(Tuke, [1813] (1996), p. vi)

In this chapter we introduce and describe the evolution of recovery in mental health services. We make the case for why we consider that the development of recovery concepts and their implications for practice is an emergent and new paradigm in mental health work generally, and forensic mental health work in particular, and that the interpretation of recovery principles in forensic mental health settings requires an adapted approach to how they are promoted in mainstream services. We will review four facets of recovery – clinical, functional, social and personal recovery – and introduce ‘offender recovery’ as a fundamental additional recovery task for forensic service users. In order to set out our case for recovery in forensic settings we will make links with the development of desistance in the arena of offender rehabilitation. Finally, we will suggest that a new synthesis of the elements drawn from mental health and criminal justice settings offers a way of understanding the complex recovery tasks forensic patients need to address in order to navigate a return from a state of alienation from family, society, the care system and all too often themselves, to a state of integration in which a safe and satisfying life becomes possible.

From psychiatric rehabilitation to recovery

The recovery movement as we have come to know it today benefited in the UK from the 2007 publication of a Joint Position Paper by the Care Services Improvement Partnership (CSIP), the Royal College of Psychiatrists and the Royal College of Nursing entitled ‘A Common Purpose’. This paper set outs what was meant by recovery, the importance of embracing its concepts and the many ways in which this process would challenge service providers to rethink what it meant to be a service delivery organisation. Recovery as a guiding principle brought with it a set of themes rather than hard and fast directives for service change. Recovery emphasised values in practice, the fundamental importance of hope, a shift away for emphasising pathology to an emphasis on strengths and wellbeing. Meaning in life, choice, empowerment and a positive sense of personal identity were other key elements for someone to be in recovery.

Roberts and Wolfson’s (2004) publication of ‘The rediscovery of recovery: open to all’ in Advances in Psychiatric Treatment also made a key contribution to the recognition of new meaning to the term recovery, although they were sanguine about whether this was a new paradigm as they traced the origins of these concepts back to the establishment of ‘moral treatment’ at the Quaker Retreat in York, described by Samuel Tuke’s grandson (Tuke, [1813] 1996). Roberts and Wolfson (2004) describe moral treatment as based on kindness, compassion, respect and hope of recovery. There were many elements at the Retreat that would be recognisable to today’s practitioners, notably the therapeutic use of occupation, resulting in a varied programme of outdoor activities, gardening, farming, exercise and indoor activities such as dressmaking, reading, writing and maths (Wilcock, 2001).

Jacobson (2004), in her historical and anthropological analysis of the emergence of recovery in the USA, suggests that Tuke distinguished between ‘cure’ and ‘recovery’, and that he preferred the word ‘recovered’ – the above quote notwithstanding – because of the emphasis on recovery of social function and humility in recognising that their approach supported natural healing processes rather than effecting a cure directly. The recovery principles of the Retreat considered the potential for recovery to lie in the individual, the extent to which they could rediscover a sense of control and their ‘desire for esteem’ (Tuke, [1813] (1996), p. 157, quoted in Jacobson, 2004, p. 34).

The word recovery has therefore been a feature of health and mental health practice for a considerable time, and indeed the word recovery is ubiquitous in our culture, with everything from the economy to the environment needing to recover. Reference to the goal of recovery has also been prominent in the paradigm of psychiatric rehabilitation as it developed in the last three decades. In their seminal texts on the psychiatric rehabilitation model, William Anthony, Robert Liberman and colleagues in America (Anthony and Liberman, 1986 ; Anthony, Cohen and Farkas, 1990 ; Pratt et al., 1999) and Wing, Bennett and Shepherd in the UK (Shepherd, 1984 ; Watts and Bennett, 1991) encouraged practitioners to recognise that they were not only ‘doing rehabilitation’ but also achieving what they called therapeutic benefits for the patient. While not without its critics (BPS, 2000), the psychiatric rehabilitation model did seek to be progressive through addressing the clinical and social aspects of rehabilitation. The model set out four dimensions to the negative impact of severe mental illness. These were impairment, dysfunction, disability and disadvantage. Impairment was defined in terms of the traditional symptoms of mental illness, such as hallucinations and delusions. Dysfunction was defined as the restriction or loss of ability to perform an activity or tasks such as activities of daily living, work skills and social skills. Disability was defined as the incapacities that resulted in unemployment, homelessness, and other social roles. Finally, disadvantage was defined as the lack of opportunity to engage in an activity or role as a result of discrimination, poverty, and so on (Anthony et al., 1990). In this model, recovery from severe mental illness was seen as multifaceted and incorporated a range of social elements.

The sophistication of the psychiatric rehabilitation model lay in its comprehensiveness. Besides formal medical treatment, it conceptualised the need to address psychosocial rehabilitation through skills training, interventions to promote social inclusion, and service user empowerment. Even the importance of hope, a cornerstone of recovery, is present in many early rehabilitation texts and in practice (Bachrach, 1992 ; Geller, 2000 ; Watts and Bennett, 1983; Menninger, 1959). However, it has been our experience in trying to develop recovery in our forensic service that the degree of common language between the psychiatric rehabilitation model and recovery has led to a difficulty in conveying how recovery as a paradigm could mark a fundamental break with the psychiatric rehabilitation model. In spite of texts that have provided clarification of the meaning of recovery as distinct from rehabilitation (e.g. Repper and Perkins, 2009; Shepherd, 2006) this has arguably not yet penetrated into mainstream understanding and so Lloyd et al. (2008), Meehan et al. (2008), Slade et al. (2008) have all noted the ongoing confusion in terminology.

Recovery: a new paradigm?

Accounts of the emergence of new concepts of recovery, and recovery as a distinct set of meanings, trace its genealogy throughout the history of mental health services through a number of sources. The critique of the medical model and the ‘modernisation’ agenda that it suggests can be seen in the Normalisation movement starting in the 1970s (Flynn and Nitsch, 1980 ; Brown and Smith, 1992), deinstitutionalisation in the 1980s (Geller, 2000 ; Maclean, 2000) and the Consumer/Survivor movement in more recent times (Deegan, 1988, 1993 ; Mead and Copeland, 2000).

However, it is Patricia Deegan’s (1988) paper that is most often attributed with being the first mouthpiece of a groundswell of change. Patricia Deegan, a psychologist diagnosed with schizophrenia, described her experience as a journey of personal recovery and linked this to the empowerment discourse that had emerged from physical disability empowerment. The shift in any recovery vision was towards the recognition that all the efforts to ‘treat’ on the part of the healthcare system were of limited value, if not iatrogenically harmful, if they did not progress a service user on a personal recovery journey.

Anthony (1993), in another seminal paper, takes up the contrast between a traditional rehabilitation approach and a recovery-orientated approach at the level of the organisation by proposing:

recovery-orientated system planners see the mental health system as greater than the sum of its parts. There is the possibility that efforts to affect the impact of severe mental illness positively can do more than leave the person less impaired, less disabled, and less disadvantaged. These interventions can leave a person not only with ‘less’, but with ‘more’ – more meaning, more purpose, more success, and more satisfaction with one’s life. The possibility exists that the outcomes can be more than the specific service outcomes of, for example, symptom management and relief, role functioning, services accessed, entitlements assured, etc. While these outcomes are the raison d’etre of each service, each may also contribute in unknown ways to recovery from mental illness.

(Anthony, 1993, p. 530)

And further that:

Recovery-oriented health systems must structure their settings so that recovery ‘triggers’ are present.…The mental health system must help sow and nurture the seeds of recovery through creative programming.… Helpers must have a better understanding of the recovery concept in order for this recovery-facilitating environment to occur.

(Ibid, p. 534)

In Jacobson’s (2004) anthropological account of the introduction of recovery into mental health services in Wisconsin, she observed the many facets or ‘complexes of meaning’ of the concept that she encountered, and described this as a kaleidoscope. One of the older meanings is that of recovery-as-evidence, referring to the history of treatment and institutional care with all the applied knowledge and scientific evidence of what can bring about recovery. Jacobson (2004) also identified recovery-as-experience, in which she included the recovery stories of service users, carers and services themselves. Jacobson goes on to describe recovery-as-ideology, which refers to when the coming together of economic factors, the evidence base for treatment, and experiences of recovery give rise to support for certain service models and specific approaches to treating mental illness. Jacobson suggested that when a third aspect of recovery – recovery-as-ideology – became established in the minds of professionals it became a driving force for mental health system reform. Inevitably, political factors have entered into the recovery arena and so Jacobson identified two further aspects – recovery-as-politics and recovery-as-policy. In Jacobson’s account of what she saw in Wisconsin, it was clear that the development of recovery during a period of economic downturn had a significant impact on how services responded to the challenge represented by the experience and evidence of recovery. This is surely very pertinent for UK forensic services at the start of this decade.

It is also important for our purposes here to highlight that all of these different ways in which recovery has meaning expand the concept of recovery from simply being an aspect of a person’s response to illness to potentially a form of political struggle with roots in the anti-psychiatry, critical psychiatry and survivor movements; to a set of principles by which mental health services can be modernised and reformed and, as a result, a model for service delivery. The chapters in this volume will describe how this kaleidoscope of meaning in the recovery paradigm has found expression in UK forensic settings.

Meanings of recovery for the person

Over and above the ways in which Jacobson has described the meanings of recovery, there are four principal meanings of recovery for the individual person, and we have summarised these below.

Clinical recovery

This is usually the first and most commonsensical meaning of recovery. It applies to all disease and illness conditions and refers to the absence of the signs and symptoms of these illnesses or diseases. In mental illness this could mean the absence of disturbances of perception or belief, suicidal feelings or impulses, inappropriately elated mood, disorganised thinking and a whole raft of other similar such indicators of mental health disturbance.

In this sense, clinical recovery implies a return to a state of health that preceded the onset of clinical symptoms; however, clinical recovery can be full or partial. After a long period in the history of madness, when there was considerable scepticism about the prospect of clinical recovery in conditions such as the schizophrenias, longitudinal studies reignited hope for clinical recovery, when the potential for recovery was measured in decades (Harding et al., 1987 ; Harrison et al., 2001 ; Jobe and Harrow, 2005). It is very important that the goals of clinical recovery remain a hope and aspiration, for the sake of the service user and their carers. Indeed, much of the energy and enthusiasm for recovery in services and carers of people with severe and enduring forms of mental illness was reignited by discoveries of clinical recovery in patients with whom this had not been expected or anticipated (Bellack, 2006 ; Davidson et al., 2006).

The notion of clinical recovery can be controversial for patients who suffer from the features of personality disorder, since sufferers will often respond that they cannot ‘return’ to a state of wellness as this state had never previously existed for them.

The notion of clinical recovery is controversial for another reason. Clinical recovery is the aspect of a broader approach to recovery from mental illness or emotional disturbance that is most likely to be described in outcomes defined by others, whether they be professional or non-professional, and this may detract from self-acceptance processes (Repper and Perkins, 2003) and valuing the transformative power of such personal experiences (Repper, personal communication).

Functional recovery

Functional recovery (Lloyd et al., 2008) does not require the absence of all experiences associated with illness. Rather, the achievement in this dimension of recovery is the restitution of functional capabilities for undertaking life tasks, whether daily routines of living or more demanding tasks such as holding down a job, staying in a partnership or parenting. Getting on with life and enjoying what it has to offer does not require the complete absence of discomfort. So mental health service users may still experience hearing voices, have feelings of paranoia, conduct compulsive rituals or have urges to self-harm, and may yet lead full and enriching lives. This form of recovery is most closely linked to the aims and objectives of skills training in the psychiatric rehabilitation paradigm. However, there is much overlap with social recovery.

Social recovery

This aspect of recovery has been embedded in the psychosocial rehabilitation approach to recovery from mental illness from the outset. However, the tenets of social recovery have moved on to be synonymous with the vast sweep of issues linked to social inclusion. Repper and Perkins (2003) have made a substantial contribution to the field and set out in considerable detail the indivisible link between recovery, taken as a whole, and the means of social inclusion. Their position on the social exclusion of me...

Table of contents

• Front cover
• About Book
• Issues in Forensic Psychology
• Title Page
• Copyright
• Contents
• Foreword
• Preface
• List of Contributors
• 1 Recovery in forensic mental health settings: From alienation to integration
• 2 Recovery and risk: Accepting the complexity
• 3 ‘Nothing for us without us either’ – forensic service user involvement
• 4 Recovery in the forensic organization
• 5 Giving voice to recovery: Perspectives from within a high secure hospital
• 6 Recovery for men with cognitive difficulties and impulsive challenging behaviour in a high secure hospital: What does it mean and how do we promote it?
• 7 Recovering personhood: Using recovery principles on a long-stay medium secure ward
• 8 Harnessing hearts and minds for change
• 9 ‘Supporting recovery’ and ‘moving on’ – the recovery approach applied to group intervention programmes in in-patient settings
• 10 The seesaw of recovery in women’s secure care
• 11 Recovery within a prison therapeutic community: Setting the scene
• 12 Embedding recovery into training for mental health practitioners
• 13 Recovery evaluation: The Scottish Forensic Services
• 14 Evaluating recovery at a forensic mental health service using the Developing Recovery Enhancing Environments Measure (DREEM)
• Index