Recovery and forensics – a tricky balancing act | Submitted thoughts and stories

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Recovery and forensics – a tricky balancing act

Author: Susi Paden
Published: 10 June 2010

Susie Paden describes the remarkable journey of the Orchard Clinic, Lothian’s medium secure unit, towards recovery-focused practice. It’s a story characterised by persistence, energy and commitment in a challenging forensic service environment that should offer inspiration to all service providers seeking to develop their practice to better support recovery.

The Orchard Clinic is a medium secure mental health unit in Edinburgh. It opened in 2000 and comprises two rehabilitation wards and an acute ward, with en-suite accommodation for 45 people, and a therapy and recreation area. The people who live in the Orchard Clinic are there for a variety of reasons. All have experience of mental health problems. Some have involvement with the criminal justice system relating to offences from breach of the peace to homicide. Others simply need some intensive care and security before returning home or to their local hospital.

When the service was developed, staff were involved in everything from developing new policies and procedures, to choosing wall colours and room layouts. In the early days we were proud of our fresh new service. Then, in 2005, a charge nurse colleague and I attended ‘Recovery – Training for Trainers’, a course run by Karen Taylor and Ron Coleman. It was a unique and emotional experience and after a week of learning about recovery, and about ourselves, we felt as though we were looking at the same picture through different eyes. We returned to work determined to make our service more recovery-focussed.

But how could we give people choice and control over their lives and treatment in a service where restricted freedom is a central feature? The staff have keys and alarms, while your keys are locked in a safe and you don’t have an alarm. Access to belongings, and contact with family and friends, if indeed they want to maintain contact with you, is limited. Even access to tea and coffee is restricted at times. Sometimes the only fresh air you might get is in an enclosed garden. Your progress is discussed by a large team of staff without you being there, although you are brought in to hear the conclusions. For many, the power imbalances can feel frustrating.

We began, in early 2006, by holding an Orchard Clinic staff ‘recovery awareness’ session. We were encouraged at the number of participants, which included colleagues from psychiatry, and looking forward to delivering an interactive and varied day. But within thirty minutes we met our first obstacle when some of our audience took issue with the term recovery, saying that it implied a total cure, and was misleading and inapplicable to our service. We encouraged everyone to think about the principles of recovery, rather than dwelling on the term itself – but it was clear that some team members were not yet ready to think in a recovery-focussed way. We left the day feeling a little downheartened but no less determined to show that ‘recovery’ wasn’t just the latest buzz word. Over the following years, we gave presentations about recovery at the clinic’s annual conferences and talked about it at every other available opportunity.

Learning from New Zealand

In 2007 a colleague and I got a scholarship to go to New Zealand. Since 1998 government policy has required New Zealand’s mental health services to use a recovery approach (O’Hagan, 2007), and our task was to investigate how forensic services there meet this challenge.

On visits to 3 different forensic services we saw many inspiring examples of recovery-focussed practice. We saw service users developing a sense of community through helping to maintain gardens and cooking group meals, and gradually decreasing levels of security as people moved closer to going home. We were surprised to see open book cases, ward pets and free access to garden areas – if you’re a slightly institutionalised forensic practioner you can see a risk in the simplest of items! All of the services we visited highlighted the importance of relationships, encouraging regular contact with family and friends and providing family rooms for those who had travelled long distances. One service held an annual BBQ for residents, staff, family and friends. We also saw practices that were less than inspiring - the use of mechanical restraints for example - but all of what we saw helped us to build a clearer picture of both the strengths of our service, and how we could develop. Whilst waiting in one of many airport lounges, we decided that once we got back to the clinic, we would set up a working party, to begin translating what we had learned into action.

The Orchard Clinic Recovery Steering group
The Orchard Clinic Recovery Steering Group (RSG) is a working party with a difference, as its membership includes current and ex service-users, as well as staff from all disciplines. This precedent - of service user involvement - is now being seen in other forensic services. When we set up the group, we held a recovery awareness event for staff and service users to foster a shared understanding of what was meant by ‘recovery’. To create a sense of equality, the event was held outside the clinic, with everyone training, eating and socialising together - a simple and easy to arrange idea, but, for a forensic service, groundbreaking.

Today, the group has fourteen members, including three residents, and three subgroups. All members are treated equally and all contributions welcomed. We meet monthly and minutes are circulated to everyone who lives and works in the clinic. The Core principles subgroup updated the clinic’s mission statement, and acts as a ‘recovery lens’, ensuring that new and current policies and procedures are recovery-focussed. The Training and resources subgroup have carried out a skills audit for all staff and organise training events. Recovery is now embedded into the Knowledge and Skills Framework training for nurses, and it is hoped that other disciplines will follow suit. The group has created a recovery library for both staff and residents and recovery awareness sessions for residents - run by people with lived experience - are being planned. The Environments subgroup has raised issues around privacy and dignity, resulting in direct changes to the observation policy. It has also replaced clinical looking furniture with homely, modern furnishings, and set up a recycling system.

Sharing and learning
Over the last five years we have spoken at a number of conferences, including the 2008 International Association of Forensic Mental Health Services conference in Vienna - a daunting, but positive experience. Although our paper was the only one on recovery, it generated plenty of interest and discussion and it’s encouraging that the conference is attracting a wider audience and exploring a broader range of topics.

In 2009 Mary O’Hagan - a leading international expert in the field of mental health recovery-based services - conducted a ‘recovery assessment’ for the clinic. She spent a week in confidential meetings with carers, users, staff and other stakeholders, and asked some challenging questions, including, “do all the doors have to be locked all of the time”? Her visit ruffled feathers but was also a catalyst for change - people now have free access to their rooms, for instance. While the door locking issue had been considered before, Mary’s input added the weight needed to make the change. Her follow up report has given us ideas about where to go next, and has also helped us to acknowledge what we are already doing well.

Last year we made a 45 minute film: Recovering, which documented residents’ views on what has helped or hindered their recovery. It was shot by staff member Ewen Meldrum, who is also a keen amateur film-maker. The inspiration for the film came from my work with ex-residents. I had been struck by how candid they were about their experiences – but it seemed to me that this was only possible because they had left the clinic and so felt able to take control and talk on their own terms. This realisation led us to collect material from residents on an anonymous basis using questionnaires and interviews. We later reconstructed the contributions using volunteer actors. Staff were also invited to contribute - we are all on a journey of recovery.

The film has now been screened a number of times in the clinic and is proving to be a useful learning tool and stimulus for creative thinking. It has also been screened externally – including at the International Association of Forensic Mental Health Services Conference in Vancouver, and at an Edinburgh cinema, where feedback from the public suggested that hearing about what goes on behind locked doors had been an emotional, eye-opening experience.

Reflections and the future
Working towards recovery at the Orchard Clinic has certainly been a challenge. But while there have been obstacles here and there and at times it’s felt like treading water, nothing has been insurmountable and tenacity and determination are beginning to pay off. Accomplishments to date have been down to the staff and people who work and live in the clinic, especially those on the recovery steering group. Initiatives promoting service user involvement have been crucial in ensuring that we keep moving in the right direction, and the gradually increasing support of management has also been helpful.

Some feel that ‘too relaxed a regime’ has brought in unwelcome changes, and many have taken a while to get to grips with what recovery means to the individual. But initial feelings of defensiveness and resistance are a natural part of the process of reassessing practice. Many of us still have a way to go in terms of our understanding and application of recovery-focussed practice - me included; others have been happily surprised to realise that their practice was already recovery-focussed.

But, for me, this is still just the start of a longer journey. Next, we’ll use the Scottish Recovery Indicator to further examine and improve our practice. We’re also talking about using PATH to collect views and ideas from both residents and staff to help us keep on the recovery track. I personally would like to see employment of peer support workers - ie people with first-hand experience of receiving forensic care, and of recovery. We also need to do more around involvement – to make sure service users have a say in care planning and clinical team meetings. And we’d like to share more of what we’ve learned. Staff from the recovery steering group have already contributed to an external service, and, via collective advocacy networks, there’s scope for service users to do so as well. There is still so much more to be achieved!

If you’d like to share your thoughts or experiences of recovery then contact us on This e-mail address is being protected from spambots. You need JavaScript enabled to view it or 0141 240 7790 to discuss.

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Story disclaimer

The stories presented here are for information only. They are meant to inspire hope and show that recovery can and does happen. The stories highlight various examples of recovery and we do not advocate any of these experiences as the ‘right’ way to recover. Recovery is an individual and unique process, each person must decide for himself or herself what will work for them. Please carefully consider any decisions you make about your own recovery and consult with someone you trust if you feel unsure.

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