Coteaching Recovery to Mental Health Care Professionals

Recovery has become policy in mental health services in the Capital Region of Denmark, as well as in other regions of Denmark and many Anglo-Saxon countries (1). In 2010, the Regional Council of the Capital Region of Denmark adopted visions for the future of mental health services. One vision endorsed mental health services based on personal recovery, rehabilitation, and the involvement of caregivers. The concept of recovery as described by William Anthony (2) includes “A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.”

Denmark’s efforts to bring a recovery orientation to its mental health services include a national policy in 2011 and the launch of several programs in 2012 in the Capital Region, including adopting a strategy for user inclusion and cooperation, hiring peer support workers, including personal goals in the treatment plans, encouraging consumer participation at organizational levels, and introducing a Recovery College, which offers recovery-oriented courses for service users, caregivers, and staff (3).

A cornerstone of Denmark’s reforms for recovery orientation is training mental health professionals in the concept of recovery. To that end, a key program for the Capital Region of Denmark’s reforms was a series of full-day workshops about recovery for all practitioner staff in mental health services. Research on recovery and mental health services has shown a need for a transition to a more collaborative partnership with the service user and services tailored to the needs and preferences of each service user (4,5). A review of the literature on service user and caregiver involvement in training and education of health professionals suggested that involvement of consumers in planning curricula and teaching mental health professionals enhances professionals’ interpersonal skills and emphatic understanding—skills that users prioritize (6). Originally, the role of the service user was often “guest speaker,” presenting personal and service user perspectives. However, that role has evolved, and the service user now often serves as a cotrainer. Cotraining—or including trainers with lived experience of mental disorders—was fundamental to the design of the recovery training workshops in Denmark.

Program Description

The purpose of the program was to establish a common ground for understanding and implementing personal recovery in existing clinical practice throughout the mental health services in the Capital Region of Denmark. Participants (approximately 3,700) in the workshops were employed in inpatient, outpatient, early intervention, community mental health, crisis, rehabilitation, forensic, and child and adolescent settings. Attendance was mandatory, and all categories of mental health professions were represented. The workshops took place locally at each hospital and supported-housing facility. A total of 148 workshops took place between spring 2013 and summer 2014.

The team of trainers included a project manager, two mental health practitioners with teaching experience and a postgraduate education in pedagogy, and three teachers with lived experience of a mental disorder who were also experienced in narrating their personal recovery stories. The team participated in a supervisory group to receive personal support and to improve teamwork. The team of teachers worked continuously to update the program in relation to the specialized units: eating disorders units, forensic wards, childhood and adolescent settings, and early intervention teams. The project manager, the teachers, and a steering committee comprising managers from the mental health services and stakeholders from consumer organizations collaborated in the development of the workshop content.

Each workshop was cotaught by two teachers: one with experience as a mental health practitioner and one with lived experience of a mental disorder. The definition of personal recovery and the historical and theoretical background of the concept of recovery were presented (2). The concepts of hope, opportunity, and empowerment were emphasized. Recovery research and theories about communication and discourses were presented. A personal narrative illustrated the process of recovering from mental illness, thereby linking theoretical concepts to lived experiences. Three exercises aimed to link theory and the personal recovery narrative to participants’ practice. In one such exercise, participants interviewed each other about how they had contributed to a patient’s journey toward recovery. The focus of the exercise was on the recovery-promoting abilities of the health professional. In another exercise, groups of participants were asked to identify barriers and difficulties in supporting patients’ hope, empowerment, and opportunities. In the third exercise, participants developed ideas of how to implement recovery-oriented methods for their clinical practice to promote patients’ experience of hope, opportunity, and empowerment.

Impacts of the Program

In all, 2,042 attendees responded to a questionnaire, and 1,700 answered all 17 questions. Four open-ended questions generated 200 pages of comments. Most of the participants indicated having gained increased knowledge regarding rehabilitation and recovery, as well as insight into methods concerning recovery-oriented culture. A total of 84% of the employees (N=1,884) felt some, a high, or very high degree of need to further develop a recovery-oriented culture. Moreover, the combination of the two teachers’ backgrounds (one a health professional and one with lived experience of a mental disorder) was an important educational element, as indicated by 68% of the participants (N=1,873). Several participants mentioned that the workshop ensured common knowledge about and understanding of recovery throughout their organization. Participants found it novel that service users participated in some workshops with health professionals in the mental health organization and noted that the language and choice of words became more positive.

On the other hand, some participants expressed a desire for a more tailored workshop, including methods, interventions, and the personal narrative. Participants from forensic and crisis teams observed that the narrative was too optimistic, and they had difficulties relating it to their practice. Others mentioned that the recovery narrative was superfluous, because they experienced narratives daily by listening to service users. The program was a “one-size-fits-all” workshop, with minor adjustments. Some participants felt patronized, as they deemed that they had already implemented recovery. It is a dilemma whether to present the same workshop to all, thereby establishing a common ground of understanding recovery throughout the organization, or to tailor the workshop for each specific practice. Remarks from the participants seemed to indicate that the impact of the program might have been larger if the workshops had been tailored to the specific teams and if there had been more focus on methods and implementation. This conclusion correlates with Tsai and colleagues’ (5) findings that staff receiving specific and practical training had a greater increase in positive recovery attitudes than staff receiving only general or inspirational training. Implementing recovery in an organization must, therefore, include tailored learning opportunities for staff and service users, including specific training in working practices.

The narrative and the different backgrounds of the teachers were effective ways of engaging participants. In alignment with Krawitz and Jackson’s (7) findings, 87% of participants (N=1,873) thought it important that the teachers were from two different backgrounds. Krawitz and Jackson found that the benefits exceeded that of training provided from one perspective only (7). This concept of coteaching can be pursued in the future planning of training and education of mental health professionals. Both Borg and Kristiansen (4) and Repper and Breeze (6) noted that recovery-oriented professionals and services involved the development of new roles and competences and that the concept of coteaching is an opportunity to change these roles (4,6).

The impact on services and service users remains to be determined. Studies of educating mental health staff about recovery generally focus on the impact on staff, with very little focus on the impact on services or service users. Wilrycx and colleagues (8) studied the impact of a recovery training program for staff on service users’ outcomes. They found that the service users could start their recovery journey in connection with the training of staff but that service users did not experience the relationship with the professionals as more recovery oriented.

Recommendations for Implementing Recovery-Oriented Services

With approximately 3,700 participants, this program was larger than any other recovery teaching scheme of which we are aware. The 200 pages of comments reflected participants’ engagement in recovery-oriented service provision. A program of this size can be the start of an organizational change toward a more recovery-oriented mental health organization. However, a follow-up will be needed, as indicated by the 84% of participants in our workshops who reported a need for further development of a recovery-oriented culture.

This initiative has been a stepping stone toward the vision of mental health services based on personal recovery in Denmark. The large number of program participants across the organization created a common ground for understanding the concept of recovery in mental health services in the Capital Region of Denmark. This primarily inspirational and theoretical program has had an impact on participants’ knowledge of recovery, and most participants recommended further development of a recovery-oriented culture. A one-day workshop is probably not sufficient to change services toward a recovery orientation. Introducing peer support workers, consumer participation at organizational levels, and the Recovery College has supported implementation of recovery-oriented services in Denmark.

Recovery has been on the political and governmental agenda in Denmark since 2015. A national strategy for user involvement and recovery-oriented practice is in preparation, with its launch expected in 2018. Projects concerning recovery and user involvement have received funding and are slowly changing the landscape of possibilities for service users, caregivers, and professionals in Denmark. The concept of a Recovery College is emerging in many forms throughout Denmark, as well as the hiring of peer workers in many organizations. There is a positive attitude toward the concept of recovery among professionals, but the demands of an organizational system that does not encourage an individual’s journey toward personal recovery presents a challenge (3). Korsbek (3) asked how organizational systems can recover so that services are designed to fit individuals rather than requiring individuals to fit predesigned services. As Le Boutillier and colleagues (9) found, health professionals struggle with competing priorities. There is a lack of alignment between the encouragement of staff to transform their practice toward more recovery orientation and the conflicting demands of organizational and financial imperatives.

The personal narrative, the synergy of the two different teachers, and the participation of service users in some workshops contributed to engaging participants in the program of workshops for mental health professionals in Denmark that we describe here. The program presented an opportunity for all participants to establish new roles for themselves, as well as for “the other.” The perspective of the service user is crucial in the concept of recovery and can be facilitated in many ways, including teaching mental health professionals and service users, learning together in programs, and involving service users in care and treatment planning. Mental health institutions must continue the work of transition, changing an attitude of “doing to” to “doing with.”