Recovery Communities of Practice: An Innovative Strategy for Mental Health System Transformation

The concept of recovery in mental health is understood as a unique process of personal change leading to a satisfying, hopeful, contributing life, even within the limitations of mental illness (1). Recovery-oriented services build on the strengths and resources of people with mental illness, enhancing self-determination and control (2). They promote collaborative relationships between service users and providers, shared decision making, use of joint well-being and crisis plans, employment of peer support workers, and a fight against stigma (3,4).

Recovery is the dominant paradigm in mental health and the focus of mental health plans in G8 countries, notably Canada, the United Kingdom, the United States, Australia, and New Zealand. The rationale for the shift to recovery-oriented services is compelling. Traditional services typically emphasize clinical outcomes and symptom management, relapse prevention, and reduction of mortality and morbidity, and professionals exert control over the therapeutic process (5). Traditional services may exacerbate patients’ dependency and self-stigma (6). Recovery-oriented practices embrace recognized behavioral health theories and approaches, such as empowerment, capabilities theory, the strengths model, and person-centered practice (7,8). In promoting a life in society, not in services, recovery meets a vital ethical obligation to honor the personhood of people with mental illness.

Numerous strategies have been developed to promote the uptake of recovery-oriented practices. Systematic reviews have produced conceptual frameworks of recovery. Research has examined measures of personal recovery, recovery-oriented services, provider competencies, and standards and guidelines for service provision (9,10).

In the United States, the Recovery to Practice initiative created an online recovery hub (www.samhsa.gov/recovery-to-practice). System transformation efforts are under way in the United Kingdom; IMROC (Implementing Recovery Through Organizational Change), a new organization focused solely on system change, has been launched and the first randomized controlled trial is being conducted. In Australia, the National Framework for Recovery-Oriented Mental Health Services has developed practice guidelines for practitioners, consumers, and caregivers (11). The Mental Health Commission of Canada, a nonpartisan body created in 2007 to improve services, released the Canadian Recovery Guidelines in May 2015 (12).

Despite these initiatives, implementing recovery-oriented care remains a challenge. Clinicians and managers struggle with how to implement recovery in practice in the face of competing priorities (13,14). Translating recovery into practice may not be a question of identifying a particular service (such as case management or housing) but may involve integrating recovery values and principles into organization and staffing.

“Communities of Practice” to Promote Recovery

“Communities of practice” (CoPs) is a specific strategy that can be used to promote implementation of recovery-oriented practices, although no research on their use for this purpose has been published. CoPs are “groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis” (15). CoPs originated in the business sector and have been used primarily as a managerial tool to promote knowledge sharing and innovation. More recently, CoPs have become popular in the health sector and are used to facilitate clinical practice improvements and support implementation of evidence-based practices (16). CoPs have also been used to influence health policy, improve public health outcomes, and reduce health inequalities (17).

Membership in CoPs depends on the group’s specific purpose, but CoPs often involve individuals from a variety of professions and organizations (18). Most CoPs in health care involve only professionals and are thus limited in scope. Recently, there have been calls to develop CoPs that bring together clinicians, managers, services users, caregivers, and researchers. In some contexts, CoPs play an important role in improving health care performance, reducing professional isolation, and facilitating new technology implementation (19). Factors that support and hinder the success of CoPs in the health care sector remain to be investigated. Promoting implementation of recovery-oriented care through CoPs may be a promising strategy.

A Recovery CoP in Quebec

Brought together by a meeting grant in 2012, researchers, practitioners, managers, and service users created the first CoP to address recovery of people with mental illness. The goal of this initiative was to develop a variety of sustainable recovery implementation strategies in Quebec. Initially, a group of 33 stakeholders began meeting around a shared goal: making recovery a reality in Quebec and moving toward full participation in civic life for people with mental illness. The objectives were to create a common neutral space to share and transfer knowledge; support diverse practices, strategies, and solutions; develop a culture of collaboration; mobilize opportunities for quality improvement; and influence decision-making bodies.

Membership and Functioning

Membership is open, and participants can join or leave the CoP at any time. Any person or organization expressing an interest in the CoP’s mission and objectives is welcome. To promote constructive dialogue, all members are asked to leave corporate issues aside to allow for expression of diverse experiences and opinions. Members include 38 participants from a variety of community and public organizations, including service users, practitioners, family members, agency administrators, and researchers. On average, 18 participants attend monthly meetings and participate on special committees. CoP meetings are conducted face to face, although videoconferencing is available for those in other sites in the province of Quebec. A voluntary executive committee of five CoP members facilitates decision making and planning between meetings.

Activities

At monthly meetings, the focus is on knowledge translation and sharing local recovery practices. The innovative work of CoP members, or recovery champions, is showcased. Several methods are used to engage CoP members: literature is e-mailed before the meeting, members are invited to present their area of expertise or experience, and outside experts are invited. An array of topics is discussed, such as risk management and shared risk taking; quality of services and recovery measures; role of peers in clinical and organizational decisions; shared decision making; and hiring peers. As members learn about the various recovery initiatives, they are motivated to translate knowledge gleaned from meetings into their local contexts.

The CoP also discusses broader-based transformational strategies: creating a recovery college; providing recovery training for physicians, administrators, service providers, and service users; introducing recovery “change agents” within organizations; replacing intervention plans with recovery plans; recognizing peer-support workers in public organizations; and advocating for a long-term plan to implement recovery into services.

Outcomes

Since 2012, the CoP has met some of its initial objectives. It created a neutral space where people from different professional affiliations and personal identities now meet and develop a culture of collaboration. It has achieved significant recognition on the political front and has influenced decision-making bodies. Staff from the Ministry of Health have attended several CoP meetings to better understand the CoP’s work and focus. The CoP participated in provincial consultations, advocating for recovery to be designated as a priority in the new Quebec Mental Health Action Plan. Such efforts have been successful: the provision of recovery-oriented services is the primary focus of the 2015–2020 plan.

The CoP has also been successful in sharing and transferring knowledge. It played an important role in the 2014 Annual Provincial Mental Health Conference. The CoP led a keynote presentation and panel discussions about recovery, an event that validated the CoP’s leadership role in knowledge dissemination in this area. Subsequently, the CoP was invited to be on the organizing committee for next year’s conference, thus increasing its capacity to influence the public agenda and promote the uptake of recovery-oriented practices. Although CoP members have initiated numerous discussions on quality improvement and implementing evidence practices, there is no hard evidence that these activities are taking place in CoP member organizations.

Challenges

Sustaining the CoP is not without challenges. Maintaining participant engagement is challenging, because some members are primarily interested in recovery-oriented practices, whereas others expect the discussions to address system aspects of such care. Efforts must be taken to balance meeting agendas. In addition, working collaboratively in a context of scarce resources and “silos” is a source of tension. Corporate rivalries emerged when some members believed that their organizations might incur budget cutbacks as the CoP was gaining prominence. Concrete efforts were taken to prevent members from feeling threatened. It was important to consistently remind members about their shared passion and beliefs in order to dismantle corporate rivalry and promote group cohesion. In addition, transcending corporate agendas to achieve collective action and to function as a cohesive entity has been challenging. Some members felt disloyal to their organizations when the CoP advocated for issues that were seen as inconsistent with their employer’s orientations. For example, some members were uncomfortable with the CoP’s lobbying of the Ministry of Health. Unable to reach consensus on this issue, the CoP encouraged individual members to support specific actions simply as individual citizens.

Questions related to the CoP’s structure and leadership have been the object of recurrent discussions. Under whose jurisdiction will the CoP evolve? Should the group be led by a specific organization? Should the government financially support the CoP? Until now, the CoP has chosen to remain independent. However, governance issues will need to be resolved if the CoP is to flourish. Not being affiliated with any organization means that the CoP functions without a budget. Coordination of activities is assumed on a voluntary basis. The lack of funding limits the CoP’s potential to expand its membership across the province. Solutions are needed to support sustainability of the CoP’s activities.

Future Work

Looking ahead, the goal of the CoP is to consolidate its efforts and pursue its mission to promote implementation of recovery-oriented care in Quebec. The CoP envisions developing a network of smaller and more locally based recovery CoPs dispersed throughout the province, inspiring others to build their own entities. The Quebec Recovery CoP was recently invited by the Mental Health Commission of Canada to present its work to a pan-Canadian group of stakeholders from the mental health sector. That the CoP is serving as a model for others to develop their own CoPs to promote recovery-oriented practices is evidence of the potential of recovery CoPs to bring about system transformation from the bottom up.