There is very little point in criticising our present system if there is no alternative to put forward. I argue that there is a viable alternative way in which people with mental health problems can recover. Like any other journey, the recovery journey has an itinerary. The itinerary I will be using is called the C.O.P.S. recovery programme. COPS stands for choice, ownership, people & self. The programme is based on the elements that I believe were responsible for my own recovery. COPS is not a programme of clinical or social recovery though there may be outcomes that equate with these models of recovery rather it is a programme for personal recovery.
Recovery is essentially a personal thing and as such is experienced differently by each individual. There are however some stepping stones that are consistent amongst people who successfully recover and it these that are the stepping stones that make up the COPS programme.
Most people in our society regard choice as a fundamental right and rightly so, indeed one can argue that the level of sophistication of a society can be measured by the level of choice an individual can make within society. Within democracies politicians go to great lengths to foster the notion of choice as the bedrock of society. The commission on social justice in the UK in their report "Social Justice strategies for national renewal"(1994) gave as one of their four propositions on social justice the following;
"We must promote real choices across the life-cycle, in the balance of employment, family, education, leisure and retirement."
Promoting these choices for every citizen is essential if a society is to be regarded as just argues the commission. I would agree with this argument and would argue further that for society to deny citizens these choices would make a society unjust. When the state uses its power to deny psychiatric patients’ choice then the state is acting unjustly by denying them a chance of recovery.
Choice is one of the central themes that is time and time again misconstrued by services to mean that they make the decisions. Even where there is an element of choice it is often only cosmetic in that rarely are the choices offered really meaningful. Two good examples of this are in the areas of treatment and accommodation. All too often the notion of choice is lost in these areas with clients being offered only the choice between one drug or other in terms of treatment, despite the fact that the patients charter clearly states that all alternatives should be discussed with the client. The problem here is one that both the client and the medical staff jointly share the responsibility for resolving. There is no doubt that many doctors have no idea what alternatives are available to them beyond medication and they and their professional bodies must take the responsibility for rectifying this situation. Clients and their advocates must also take the responsibility for challenging the medics by pointing out the rights that clients have under the charter and asking why alternative treatments have not been considered.
Choice in accommodation is the other area where frankly we never learn any of the lessons from past mistakes. In the inner cities it is still the normal practice to move vulnerable clients out of acute wards back into poor housing or into run down estates that only increases their vulnerability and expedites their return to the acute unit. In many mental health services there is little or no choice offered in accommodation that develops the recovery potential of the client.
Indeed one could surely argue that often when we discharge clients back to the environment from which they came we do nothing more than set them up for relapse.
Real choice is not only having the ability to pick from a number of predetermined options it is also about having the power to add that which you as a consumer want, to those options. The professional perception of the things that people need is one of the greatest barriers to choice, since much of their perception is coloured by their professionalism. In order to achieve real choice it is essential that we start without preconceptions as to the real desires of the client.
More important than professional perception is the voice of the client if choice is to become a reality then service users must begin to exercise their voices they must make clear to professionals exactly what they want. One of my own memories of seeing the consultant in the ward round was how I always went into the ward round with lots of questions and came out with no answers. The main reason I never got any answers was that I always forgot the questions in the heat of the meeting. This was resolved when I finally agreed with my advocate to write down my questions before I went into the ward round. Though most of my questions still went unanswered I at least had the satisfaction of knowing I had asked them.
Much of the supposed choice in services revolves around the workings of the care programme approach (CPA) or case management approach (CMA). These two assessment tools would if used properly not only identify what professionals think the client needs but also what the client’s aspirations are. All too often CPA has become nothing more than a medication review controlled by the medic. For this reason I believe that there is a need to be more direct in planning the recovery journey.
Making good plans will enable clients to plot their own journeys to recovery and ensure that they stay on course during the journey. There are many ways of planning that can be used which are person centred, the one that I prefer is a personal development plan much like the ones that most professionals use in their own workplaces. The reason for my preference is that the focus of this type of plan is very much on development rather than on care. This does not mean that we reject the concept of care indeed in my opinion working in this way can only enhance the quality of care provided by adding the notion of ‘caring about’ to the existing ‘caring for’ framework.
Like most planning the personal development plan requires the person to answer a series of questions, the following are a selection the types of questions that may be asked:
- What areas of your life do you consider have gone particularly well over the last six months?
- What can be done by yourself or others to build on your successes?
- What areas of your life have not gone so well in the last six months?
- Have there been any particular barriers, difficulties or problems that have caused these parts of your life not to go so well?
- What can you do by yourself to resolve these problems?
- What can others do to help you resolve these problems?
- What do you want to achieve over the next six months?
- Which of these goals can you achieve on your own?
- Which of these goals do you require help to achieve?
- Who can help you achieve these goals?
All of the above questions may appear straight forward but when was the last time we were asked them by others or indeed asked ourselves any of them. These questions are fairly open-ended in that they can relate to health, social activities, employment or training. They also allow the client to look at the strengths, weaknesses, opportunities and threats in their personal life. This SWOT analysis can if used properly by all concerned lead the recovery process by allowing the client to monitor their own progress against the goals they have set themselves.
One of the most important aspects of choice is in choosing the people that support the client. The usual practice of appointing a key-worker to work with the client without consulting the client is not only wrong but can in some circumstances be dangerous both to the client and the professional. How often do we ask both the client and the key-worker whether they are happy working together? Even if we did ask them and found that they were unhappy, would we act on the answer? I would hope so, though I fear the system would not respond in an appropriate way. This danger has nothing to do with the threat of violence posed by the client but the mess that will occur if there is no positive relationship between the client and the professional.
In services that do allow the client to choose their own support workers both the clients and the workers agree that this system of appointing staff eliminates many of the relationship problems that the traditional system creates. The other identified benefit was that a trusting relationship was established much more quickly using this system thereby speeding the recovery process. Even if the system cannot adopt a method that allows the client to choose their paid supports it must at the very least find a way to allow the client to change their paid supports if they wish to do so. If this simple step could be achieved then it is my opinion that the benefit in terms of recovery will far outweigh any loss of face that may occur amongst professionals.