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June 16, 2011 Volume 2 Issue 22
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The recovery movement is not only a national phenomenon in the United States. Its scope is global. For example, some work supported by the British Department of Health is similar in aim and content to the Recovery to Practice (RTP) Initiative.

In this week’s Highlight, four recovery leaders from England—Geoff Shepherd, Rachel Perkins, Julie Repper, and Jed Boardman—describe what they have been doing to bring recovery and its implications into the practice of behavioral health professionals in their own country. As RTP evolves, we will share lessons learned with these British colleagues, as well as with others engaged in similar work around the world, in hopes that we will all benefit from one another’s creativity and innovation. Readers interested in more details about the British agenda in particular are encouraged to contact Dr. Shepherd directly.
Implementing Recovery – Organizational Change (ImROC)
by Geoff Shepherd, Rachel Perkins, Julie Repper, and Jed Boardman
The provision of mental health services in England is organized around local National Health Service (NHS) trusts. There are currently just over 50 mental health trusts in England, each serving an area with an average population of around 1 million people. NHS services consist of: (1) primary care, with general practitioners, specialist nurses, and others, usually in group-based practices, serving people with mild/moderate conditions, plus some longer-term follow-up of people with more severe conditions; (2) secondary care, consisting of specialist community teams, outpatient clinics, and day treatment, serving people with more severe and complex problems; and (3) tertiary care, consisting of inpatient beds, with short and long stays for those with the most severe conditions. The NHS is a national service, funded through taxation and free at the point of access. There is very little private provision.

From 1955 until now, the number of beds in mental institutions has gradually declined from more than 150,000 to less than 5,000. They have been replaced by a range of specialist community teams in each locality providing crisis resolution/home treatment services, assertive outreach (or ACT), and early intervention for young people with a first episode of psychosis. These teams were created through a National Service Framework (Department of Health, 1999) which, most people agree, has provided a comprehensive structure for community-based, local services across the country (Appleby, 2007).

In addition to NHS provision, the local government also commissions a range of local social care services (e.g., housing, day care, employment programs) that are increasingly provided by the independent, not-for-profit sector, such as charities and nongovernmental organizations (NGOs). There is a clear separation between providers and commissioners in both health and social care services, although the relationship between local health and social services is now much closer than it used to be. It is now common for them to be commissioned jointly (sometimes by the same person). The split between health and social care services expenditure on mental health is approximately 80:20. Within health services, a little more than 60 percent is spent on community services and just less than 40 percent, on hospitals.

Policy is formulated nationally but, historically, the national Government has exerted a relatively weak influence on local services (with the exception of the implementation of the National Service Framework). Its strongest contribution is to set the funding parameters, and recently these have become increasingly restricted. All public services in England are currently facing 10 percent to 20 percent cuts in budgets over the next 2–3 years.

Recovery policy. The objectives of recovery are now well established in mental health policy in England. The most recent strategy document from the Department of Health, “No Health Without Mental Health,” contains six key objectives, of which one is “More people with mental health problems will recover” (HMG/DH, 2011, 7). It goes on to state, “More people who develop mental health problems will have a good quality of life—greater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates, and a suitable and stable place to live.” In addition, all the major professional organizations in England and Wales—nursing, psychology, occupational therapy, social work—have voiced their support for recovery ideas, including the Royal College of Psychiatrists (Royal College of Psychiatrists/Social Care Institute for Excellence/Care Services Improvement Partnership, 2007).

In England, as in many other parts of the world, we have been working to ensure that recovery ideas are articulated sufficiently clearly that we can agree on a common definition and a common language to communicate these ideas. We have also been trying to describe and formulate the process of recovery so that its effectiveness can be improved and staff helped to practice in a more recovery-oriented way (Bird, Leamy, Le Boutillier, Williams, & Slade, 2011). Relatively less attention has been paid to the question of how to change services so that they are more supportive of recovery. It is agreed that a new kind of training is required, in which staff and service users (consumers) can learn together new ways of relating to each other and the different ways in which professionals can help service users pursue their goals and ambitions. But, training will not be sufficient on its own.

A methodology for change. We know from other studies about embedding recovery principles into services that, in addition to training, we need to take account of the organizational context: management and supervision of staff, leadership, and the organizational culture within which this training is delivered (Whitley, Gingerich, Lutz, & Mueser, 2009). At the Centre for Mental Health in London, England (formerly The Sainsbury Centre for Mental Health, an independent, not-for-profit research and consultancy center), we have been struggling with these organizational change issues and have just embarked on a national project to test out a new methodology. The project is called “Implementing Recovery – Organizational Change” (ImROC), and the methodology was developed through a series of workshops held with mental health service providers in England who were already attempting to change their organizations to make them more supportive of recovery-oriented practice. These workshops were attended by more than 300 health and social care professionals, managers, and representatives from local independent organizations, plus extensive input from service users and caregivers.

Each workshop attempted to explore a set of organizational issues arising from trying to help services become more supportive of recovery. These included training, leadership, risk assessment and management, the role of peer professionals, and building opportunities for a life beyond illness (employment, housing, community integration, etc.). After each event, the steering group collected its impressions and refined its list of key organizational challenges. Eventually, this was reduced to 10, which were published in a position paper, “Implementing Recovery – A New Framework for Organizational Change” (Sainsbury Centre for Mental Health, 2009).

The 10 key organizational challenges are
  1. Changing the nature of day-to-day interactions and the quality of experience
  2. Delivering comprehensive, user-led education and training programs
  3. Establishing a Recovery Education Center to drive the programs forward
  4. Ensuring organizational commitment, creating the culture and leadership
  5. Increasing personalization and choice
  6. Transforming the workforce (training and deployment of peer professionals)
  7. Changing the way we approach risk assessment and management
  8. Redefining user involvement to achieve a true working partnership
  9. Supporting staff in their recovery journey
  10. Increasing opportunities for building a life beyond illness
The framework covers themes that have been derived from—and are specifically relevant to—an English health service context (although we believe that many can be generalized to other countries). It takes a systems approach to implement change; that is, it explicitly aims to include all the stakeholders in the local system, which includes the main NHS mental health service provider, together with local independent sector organizations (such as NGOs), commissioners, service users, and caregivers.

This framework was then used to develop a simple methodology for organizational change, based on an internal audit cycle. This is described in a second paper, “Implementing Recovery: A Methodology for Organizational Change” (Shepherd, Boardman & Burns, 2010). Local providers and stakeholders first sit down and review the local mental health service. They then agree upon the current state of development regarding each challenge. Challenges are rated using a simple three-point scale:
  • Engagement. Service is just beginning to engage with this challenge.
  • Development. Service has begun to engage and make improvements against this challenge, but with limited or uneven progress.
  • Transformation. Service has already made significant progress in addressing the organizational challenges inherent in this topic.
Each scale point is clearly defined with textual descriptions. The stakeholders then prioritize actions across a manageable number of challenges (usually about four to six) and agree on targets, together with indicators for assessing outcomes. Once the goals are agreed upon, the process of change is implemented, progress is monitored, goals are adjusted, new goals are set, and the cycle is repeated. This form of internal audit loop (or “Plan–Do–Study–Act” cycle) has been recommended as the most effective process for producing sustained organizational change (Iles & Sutherland, 2001).

The ImROC project. The Department of Health has now funded the Centre for Mental Health, in collaboration with the Mental Health Network of the NHS Confederation (an organization for senior managers in NHS mental health services and composed of chief executives and board members), to test out this methodology in a national demonstration project. The aim is to assist NHS mental health services, together with their local independent sector partners and user and care provider groups, to improve the quality of local services to support people with mental health problems lead meaningful and productive lives (that is, recover). It is one of the key implementation programs that follow from the most recent government strategy document (HMG/DH, 2011).

The project team consists of Professor Geoff Shepherd, senior policy adviser, Centre for Mental Health, and project lead; Dr. Rachel Perkins, OBE, freelance consultant, formerly director of quality assurance and user experience, SW London & St. George’s NHS Trust; Dr. Julie Repper, associate professor, Institute of Mental Health, Nottingham University, and recovery lead, Nottinghamshire Partnership NHS Trust; and Dr. Jed Boardman, consultant psychiatrist, South London and Maudsley NHS Trust, and social inclusion lead, Royal College of Psychiatry. We are all experienced mental health professionals with several years' experience working in, and trying to change, mental health services. We also have an established track record of research and publications in the recovery field (e.g., Repper & Perkins, 2003; Shepherd, Boardman, & Slade, 2008).

The project began on April 1, 2011. Sites were invited to apply to join the program through the NHS Confederation (managers) network. It was made clear that applications would only be accepted from local systems—that is, not from a single NHS or independent sector provider unless it could demonstrate active partnership working on their local site. Sites were also aware that, if accepted, they would be required to make a financial contribution to the training and technical consultancy they would receive from the team. More than 30 sites—which included more than half the NHS trusts in England—applied, and they were assessed using a combination of written applications, site visits, and interviews. Those accepted were assigned to one of three categories:
  1. Demonstration sites (n=6). These were deemed to have already made significant outstanding progress regarding the 10 key challenges and successfully embedding recovery principles into the organization. They will receive up to 10 days’ expert consultancy on topics of their choice.

  2. Pilot sites (n=6). These had made some progress in addressing the key challenges and embedding the principles, but less than the demonstration sites. They showed good, local working partnerships and were keen to develop their services. They will receive 20 days’ consultancy, plus 5 additional days provided by the team with support from expert peer trainers who have been recruited to help develop local, user-led training initiatives. While some direct training of staff and service users will be undertaken, the emphasis will be on building local capacity.

  3. Network sites (n=17). These were not as advanced as either the demonstration or the pilot sites in terms of progress against the key challenges and/or organizational embedding, but they were keen to do more.
In addition to the personalized consultancy supplied to the pilot and demonstration sites, each site will have the opportunity to send six to eight people to local “learning sets” (n=6 1-day workshops over 2 years). These will comprise mixed groups consisting of demonstration, pilot, and network sites, and will provide the opportunity to share ideas and experiences and to gain support from others who are working on similar issues.

Outcomes will be monitored primarily using the internal data generated by the successive audit cycles. There will also be retrospective interviews with key service managers (including independent sector partners), service users, and care providers regarding the implementation process and perceived changes in care. We are additionally encouraging sites to consider using a standardized measure of quality of patient experience (called INSPIRE), developed by Mike Slade and colleagues at the Institute of Psychiatry as part of a larger research program to evaluate the effectiveness of recovery training. This measure assesses the extent to which care received from the key worker is judged to conform to recovery principles. Sites will be expected to collect specific outcomes that follow from the new strategy (e.g., placement in stable and secure housing, numbers in paid employment, reduced time in hospital).

Progress so far. A steering group consisting of the main sponsors (Department of Health, Centre for Mental Health, and NHS Confederation) has now been established, together with a larger advisory group with greater user and caregiver representation. An expert peer trainer reference group (n=8), consisting of experienced peer trainers from all over the country, has also been recruited. The group will advise on the joint training and will be assigned in pairs to each of the pilot sites.

Meetings have now been held on all the pilot sites and most of the demonstration sites, and initial plans have been formulated. These contain a number of common themes:
  • Support for the delivery of local training events, run jointly by project staff and peer trainers, aimed at developing staff/user knowledge and awareness of recovery principles
  • Parallel events for senior managers in organizations (board level) plus key clinical leaders (psychiatrists, psychologists, professional leads) in teams
  • Active consideration of plans to establish local recovery centers
  • Review of key clinical policies and procedures (individual record-keeping, risk assessment and management, etc.)
  • Plans to develop training for peer specialists to work in local teams
  • Consideration of how best to involve family, friends, and other caregivers in the process.
These programs are now ongoing. Dates for the first learning sets have also been fixed and will be complete by the end of June. The first event will consist of an examination of the recovery journey of each organization, focusing on how they got to where they are, what helped, and what hindered. These will be led by senior managers from each site.

Conclusions. We are excited about this new project. We have an opportunity to influence the next phase of development of mental health services in England after the undoubted successes of the structural reforms undertaken as part of the National Service Framework implementation. We see this next phase as concentrating on improving service quality and acceptability to consumers by supporting them and their personal hopes for the future, giving them greater control over their treatment, and helping them build lives beyond simply being “a patient.”

We have been supported in these endeavors by several friends and colleagues in the United States, particularly Gene Johnson and Lori Ashcraft in Phoenix, Ariz.; Marianne Farkas and Bill Anthony in Boston, Mass.; and Yale University’s Larry Davidson. We would like to take this opportunity to thank them publicly for their inspiration and wisdom. We look forward to making new friends and colleagues in the United States and to receiving further help and support. All comments are therefore welcome. We look forward to hearing from you.

Appleby, L. (2007). Breaking down barriers – The clinical case for change. London, England: Department of Health. http://www.dh.gov.uk/mentalhealth.

Bird, V.; Leamy, M.; Le Boutillier, C.; Williams, J.; & Slade, M. (2011). REFOCUS – Promoting recovery in community mental health services. London, England: Rethink.

Department of Health. (1999). National Service Framework for Mental Health – Modern standards and service models. London, England: Department of Health. http://www.dh.gov.uk/mentalhealth.

HMG/DH. (2011). No health with mental health. Retrieved from http://www.dh.gov.uk/mentalhealthstrategy.

Iles, V., & Sutherland, K. (2001). Organisational change – A review for health care managers, professionals and researchers. London, England: National Coordinating Centre for NHS Service Delivery and Organisation (NCCSDO) and London School of Hygiene and Tropical Medicine.

Royal College of Psychiatrists/Social Care Institute for Excellence/Care Services Improvement Partnership. (2007). A common purpose: Recovery in future mental health services. London, England: Social Care Institute for Excellence. http://www.scie.org.uk.

Repper, J., & Perkins, R. (2003). Social inclusion and recovery. London, England: Balliere Tindall.

Sainsbury Centre for Mental Health. (2009). Implementing recovery – A new framework for organisational change. London, England: Sainsbury Centre for Mental Health. http://www.centreformentalhealth.org.uk.

Shepherd, G.; Boardman, J.; & Slade, M. (2008). Implementing recovery: A methodology for organisational change. Policy Paper. London, England: Sainsbury Centre for Mental Health. http://www.centreformentalhealth.org.uk.

Shepherd, G.; Boardman, J.; & Burns, M. (2010). Implementing recovery: A methodology for organisational change. London, England: Centre for Mental Health. http://www.centreformentalhealth.org.uk.

Whitley, R.; Gingerich, S.; Lutz, W.J.; & Mueser, K.T. (2009). Implementing the illness management and recovery program in community mental health settings: Facilitators and barriers. Psychiatric Services, 60, 202–09.

Webinar Announcement
The RTP Resource Center is pleased to announce
the third Webinar in a four-step series:
Step 3 in the Recovery-Oriented Care Continuum:
Promoting Recovery Through Psychological and Social Means
Thursday, July 28, 2011

2:00–3:30 pm E.T.

This Webinar will describe a few approaches to promoting recovery that involve psychological and social interventions. A first speaker will update participants on the state of the art in cognitive–behavioral psychotherapeutic approaches to serious mental illnesses (schizophrenia and bipolar disorder). A second speaker will describe the key common elements of psychiatric rehabilitation approaches that involve in vivo support (supported employment, education, housing, etc.). A third speaker will describe the role of consumer-run programs and businesses as offering alternatives to traditional programs and settings (e.g., clubhouses).

To Register

Please share this announcement with friends and colleagues who may be interested in learning more about recovery-oriented practice in behavioral health services. For more information on SAMHSA’s Recovery to Practice project, please contact the Recovery to Practice Technical Assistance Center at
recoverytopractice@dsgonline.com, or 1.877.584.8535.

NIMH Seeks Proposals for its Outreach Partnership Program
The National Institute of Mental Health (NIMH) invites applicants to submit proposals for consideration as an NIMH Outreach Partner for the following States: Colorado, Connecticut, Florida, Georgia, Idaho, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York and New York City, Ohio, South Carolina, Tennessee, Texas and Texas border area, Utah, Vermont, Virginia, and Wisconsin. Nonprofit organizations that conduct outreach on mental health are invited to submit proposals for participation in the NIMH Outreach Partnership Program, which is designed to facilitate and increase the use of science-based information on mental disorders nationwide. Organizations with experience in child and adolescent mental health and/or mental health disparities are encouraged to apply.

Applicants are selected as NIMH Outreach Partners through a competitive process. Outreach Partners receive an annual stipend of $7,500 to: a) conduct statewide dissemination of NIMH research and educational materials; b) implement a special outreach project(s) with a targeted focus on mental disorders in children and adolescents, or mental health disparities that occur by race or ethnicity, age (e.g., older adults), education or income, disability status, geographic location, risk status related to sex and gender, and among other populations identified to be at-risk for health disparities such as immigrants and military service members and their families; and c) promote NIMH clinical research. Participation in the Outreach Partnership Program provides organizations with numerous opportunities to stay abreast of the latest advances in mental health research, interact with leading researchers in the field, and become involved in clinical research efforts. The program also is an opportunity for Outreach Partners to dialogue with NIMH about the public health needs of communities within their States. Other program benefits include networking opportunities with other State and national organizations, sponsored participation in an annual meeting, and dedicated access to NIMH publications.

Funding under this solicitation is awarded for 1 year and renewable for 2 more years for organizations that meet all program requirements, contingent upon continued funding for the program. The Outreach Partnership Program supports 55 Outreach Partners, one in each State, the District of Columbia, and Puerto Rico. The States of California, New York, and Texas each have two Outreach Partners.

Important Dates
June 9, 2011, 10:00 a.m. ET – Solicitation posted
June 30, 2011 – Deadline for inquiries
July 21, 2011 – Response to inquiries posted
Aug. 23, 2011, 4:00 p.m. ET – Proposals due
End of 2011 – Outreach Partner selection

Eligibility Criteria
  • Organizations located in one of the States listed in the current solicitation
  • Organizations that are tax exempt, with a nonprofit status, under any section of the United States tax code
  • Organizations that have an active record in the Central Contractor Registration (CCR) database
  • Organizations that demonstrate experience and capacity to disseminate information statewide and conduct State or local outreach
  • Organizations that meet Federal Equal Employment Opportunity requirements
Inquiries about this solicitation are being addressed through a formal question-and-answer process. To keep the process as fair as possible, we will not be responding to questions individually or by phone. Questions about this solicitation must be sent by June 30, 2011, to NIMHPartners@mail.nih.gov. Responses will be posted on July 21, 2011, on the Web.

How to Apply
  • Download solicitation (PDF).
  • Complete Organization and Contacts Form (Word version) [Word version of this form will be available until Aug. 23, 2011].
  • Register organization in Federal Central Contractor (CCR) database.
  • Submit proposal to NIMH by 4:00 p.m. ET on Aug. 23, 2011.
For More Information

SAMHSA ADS Center FREE Training Teleconference
Forging a Path Toward Social Inclusion
To register now, please visit the following page:

Please note
Registration will close at 5:00 p.m. ET on Tuesday, June 21, 2011.

3:00–4:30 p.m. ET, Thursday, June 23, 2011

Webinar Description
The Substance Abuse and Mental Health Services Administration (SAMHSA) Acceptance, Dignity, and Social Inclusion With Mental Health (ADS Center) invites you to a free training teleconference to learn how consumers/survivors of mental health and substance use conditions are working together with private and public officials to make socially inclusive systems across many dimensions of community life: housing, employment, education, arts and culture, transportation, civic and entrepreneurial leadership, health, and recreation.

Speakers will provide strategies for building diverse collaborations to map community assets and discover individual capacities that benefit communities and the delivery of social services. As a participant in this teleconference, you will see that social inclusion is achievable and learn how you can be part of the change.

Target Audiences
Individuals with the interest, ability, or influence to achieve social inclusion in a community and public systems, including consumers/survivors/peers of trauma, mental health problems, and addictions; families; community development organizations; policymakers or public officials; leaders of community- and faith-based organizations; educators; employers; social service providers (e.g., health, housing, transportation, welfare); criminal justice officials; cultural or arts organizations; and behavioral health providers.

Learning Objectives
As a result of this teleconference, participants will learn about these topics:
  • The dynamics and impact of marginalizing people with mental health and substance use problems, as well as the courage it takes for them to reintegrate into society
  • The six assets of an individual and a community that promote social inclusion
  • Successful strategies for assessing your community's strengths and capabilities, and ways to mobilize community involvement to shift systems and achieve social inclusion
Jacki McKinney, MSW, is a survivor of trauma, addiction, homelessness, and the psychiatric and criminal justice systems. Among her many roles, she is co-founder and director of the National People of Color Consumer/Survivor Network, co-director of the Trauma Knowledge Utilization Project, and co-director of Philadelphia's City-wide Trauma Initiative. She is the first African American woman to receive Mental Health America's Clifford Beers Award.

Lindsey Dawson, M.S., is the health policy advisor at the Centre for Economic & Social Inclusion – U.S., as well as a contractor with the Kaiser Family Foundation's Medicare Policy Project. Ms. Dawson has expertise in evidence-based policy, qualitative methodologies, and research ethics. An example of her work includes presentations on community-based reparations and on methods by which lesbian, gay, bisexual, and transgender people cope with antigay political atmospheres in ways conducive to mental health.

John (Jody) Kretzmann, Ph.D., is the co-founder and co-director of the Asset-Based Community Development (ABCD) Institute of the School of Education and Social Policy at Northwestern University. The ABCD Institute works with community-building leaders around the world to conduct research, produce materials, and support community-based efforts to rediscover local capacities and to mobilize citizens' resources to solve problems. The institute continues to build on the stories and strategies for successful community building reported in Mr. Kretzmann's popular book, Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community's Assets, which he wrote with longtime colleague John McKnight.

Read more about these speakers at http://promoteacceptance.samhsa.gov/teleconferences/archive/training/teleconference06232011.aspx.

Training Sponsor
This teleconference is sponsored by the SAMHSA ADS Center, a project of the Center for Mental Health Services (CMHS). CMHS is a center within SAMHSA, U.S. Department of Health and Human Services.

Please explore the SAMHSA ADS Center Web site for more information, at http://www.promoteacceptance.samhsa.gov.

Invitation to Submit Personal Stories
Personal stories are a powerful way to share information, influence others, and advance recovery-oriented practice. The RTP team would like to hear from military family members about your recovery-oriented experiences.

We're also interested in receiving your personal stories about how healthcare reform has affected your recovery journey.

We will add your stories to our library of resources that will soon become available to our ListServ subscribers.
To submit personal stories or other recovery resources, please contact
Stephanie Bernstein, MSW, at 1.877.584.8535,
or email recoverytopractice@dsgonline.com.

The RTP Resource Center Wants to Hear From
Recovery-Oriented Practitioners!
We invite practitioners to submit personal stories that describe how they became involved in recovery-oriented work and how it has changed the way they currently practice.
The RTP Resource Center Wants to Hear From You, Too!
We invite you to submit personal stories that describe recovery experiences. To submit personal stories or other recovery resources, please contact Stephanie Bernstein, MSW, at 1.877.584.8535,
or email recoverytopractice@dsgonline.com.

We welcome your views, comments, suggestions, and inquiries.
For more information on this topic or any other recovery topics,
please contact the RTP Resource Center at
1.877.584.8535 or email recoverytopractice@dsgonline.com.

The views, opinions, and content of this Weekly Highlight are those of the authors and do not necessarily
reflect the views, opinions, or policies of SAMHSA or the U.S. Department of Health and Human Services.