A Strengths Approach - Principles and Frequent Reactions

A Strength Approach has been adapted from the original ‘Personal Strengths Model of Case Management’ developed by Professor Charlie Rapp and colleagues at Kansas University in the early 1980’s. I was part of the original UK case management initiative that Professor Charlie Rapp and Wally Kisthardt presented their ideas to in 1991.

This approach has underpinned all of my work as a practitioner, supervisor, writer, trainer, and developer of other teams from 1991 onwards, and is the core philosophy of Practice Based Evidence.

PDF: Principles and Frequent Reactions

‘Personalisation revisited’

The article linked within was first published in Openmind 159, Sept/Oct 2009) and is made available as a PDF with their kind permission.

Excerpt: The conundrum

The current driver for the transformation of all UK public services is the concept of personalisation.

But haven’t we been here before, and if so what have we failed to learn? Case management, the National Service Frameworks, Valuing People in learning disability services, and recovery are but a few of the recent designs on service delivery sharing some common characteristics. They all lay claim to service user-focused or person-centred ways of working, and all are intended to transform the way services are delivered. Personalisation may just be he latest catchphrase for the same messages. If so, is it the aims or the message that we are getting wrong?

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Getting Personal

As the National Service Framework (Department of Health, 1999) completes its 10 year plan there is cause for cautious optimism that the path has been set for a national standard in delivering responsive mental health services through functional teams. However, this is tinged with concerns when we scratch the glossy surface and examine the depth of quality and consistency. The focus of attention has been about getting structures and systems consistent, but at the ground level it is arguable just how much attention is being paid to nurturing and developing the complex arrangements we call multidisciplinary teams.

The framework, and accompanying NHS Plan (Department of Health, 2000) set the scene for establishing a national network of assertive outreach teams, crisis resolution & home treatment teams, and early intervention teams to complement the existing network of in-patient psychiatric units and community mental health teams that constituted the statutory sector service provision. These are now largely in place, and underpinned by the overarching mantra of ‘working to principles of recovery’ and ‘promoting social inclusion’.

This latter statement can be used to illustrate the gap between the rhetoric of policy and the reality of practice, as many practitioners and service users express anything from confusion to concern about what these statements mean; particularly where teams are re-branded as ‘support and recovery teams’ with little to illustrate what the change actually means. For some service user activists this has come to represent yet another usurping of their good ideas, as the service providers find another change of language to liberally sprinkle over their latest policy initiatives.

Pockets of good practice have undoubtedly flourished, providing a genuine service user-focused approach to delivery, and this has to be a tribute to determined practitioners and team managers who have finely tuned their values and attitudes to shape the way they provide a service, even while being bombarded with an avalanche of initiatives, targets and measures. We need to hear more of the voice of the service users experiencing these types of services, so that the new policy agenda can be driven by good experiences rather than the more usual need for change predicated on failures in services.

The next step in UK policy seems to raise the profile of what I would consider to be good practice in isolated initiatives, seeking to set a service user-focused agenda for all public services (not just social care and health, but housing, leisure and welfare benefits, etc) under the banner of personalisation. It is an agenda supported by all major political parties, and is already being seen as the picture of what the 21st century service imprint will look like. However, it is worryingly caged in grand gestures about ‘radical reform’ and ‘workforce transformation’; not particularly motivating mantras to people on the ground already giddy from the constant process of change proffered by the policy makers. The following sets out ideas and challenges underpinning this concept of personalistion.

What is personalisation? (1)

• A shift of emphasis from the service at the centre with the person fitting in, to the person at the centre with flexible services adjusting to the needs of the individual
• An over-arching philosophy of seeing the individual as a person with strengths and preferences, and networks of personal support [something I have long seen as being the ‘strengths approach’]
• Recognising the person as an ‘expert of their own experience’, who knows their own needs and the best ways to meet them
• Seeing people as being able to exercise choices, take responsibility for decisions, taking more control through expressing their needs, wishes and aspirations, but needing information and support in order to do so effectively
• Early intervention and prevention as priorities
• Developing individual budgets to provide genuine purchasing power
• Finding new collaborative ways of working and developing local partnerships
• Transformation of the whole system and culture of thinking, so that it becomes the outcome of a reformed service, not the process of reform itself

What are the potential barriers to implementation? (2)

• Fear of the volume of change represented by phrases such as radical reform and workforce transformation
• Is the current workforce sufficiently geared towards delivering services in these ways (professionals trained to manage will often struggle with the role of enabling)?
• Is there really a full menu of options to choose from? Where is the investment in a wider range of alternative services and treatments?
• Eligibility criteria for many services are being progressively tightened!
• Service users and/or carers taking on employer status, and all the legal and financial implications associated with this development
• Shared responsibility is not about leaving people to decide then blaming them if it goes wrong
• Adequate funding, more so at a time of economic recession
• Is the political will for the outcomes matched by the political will for the process? Is it all about destinations with little or no thought for the actual details of the journeys?

1. Carr, S. and Dittrich, R. (2008) Personalisation: a rough guide. Adult Services Report 20. London: Social Care Institute for Excellence.
2. Bird, A. and Wooster, E. (2008) Personalise this! Openmind, 153: 6-9.

'Practice Development' in Mental Health

The article was below was written by me in 2001, which is a long time in mental health (it's quite a long time full stop!) But I am include it here as it was an important piece for me at the time and remains pertinent today, I think.

The Need

The education and training of the mental health workforce needs to change in order to keep pace with how modern mental health services need to be delivered. The Workforce Action Team has produced a Capable Practitioner report, which outlines a framework of capabilities that broadly encompass the knowledge, skills and attitudes required by the workforce of mental health practitioners. Many organisations have commissioned the growing range of flexible post-graduate education courses, which seek to target and customise training to meet local need. These have achieved a limited success at credentialing practitioners, through successful attendance levels and completion of set assignments. However, transferring the dissemination of information (the evidence) into routine clinical practice remains the next challenge.

Practice Development has now become an essential challenge to the workforce, of linking the research-based evidence of clinical theory with the practice-based evidence of clinical reality. Training initiatives should no longer stand-alone, they need to be the initial stage of a fuller package of education and support. The aim of developing high quality services will be achieved by going beyond just delivering the message, to close modelling and supervision of its implementation within the available resources and creativity of the personnel in local services.

The on-going credibility of the trainers will be sustained by closer contact with the point of service delivery, and the publishing of ideas and evidence from routine clinical practice, not just artificially resourced research programmes. Credibility for local and national services requires a move on from the theoretical frameworks of a Capable Practitioner, to the practical realisation of Creative Capability (David Juriansz). The individual practitioner, team and wider network of support are clearer about effective ideas, and in the effectiveness of how they function.

The Idea

‘Practice Development’ is an outcome-driven process supporting the implementation of recognised good practice into the routine daily functioning of individual practitioners and teams. Its overall aim is the improved quality of care and support offered to service users. Specific goals include:

• Identifying and translating the ideas from ‘evidence-based practice’ (messages through training programmes) into the realities of ‘practice-based evidence’ (realities of routine clinical practice).
• Recognising and supporting elements of existing good practice.
• Raising individual and collective standards of practice, through managing, modelling and supporting the implementation of changes in practice.
• Examining individual and collective attitudes underpinning the philosophy of care, specifically the implementation of real service user involvement.
• Promoting an understanding of the links between, and co-ordination of, the different components of comprehensive mental health services.

Training is an essential component for supporting effective contemporary mental health practice, but its focus on dissemination of messages only partly achieves the aim of changing practice. Even the very well evaluated training workshops offer no clear guide as to how the ideas, thoughts and discussions will be subsequently incorporated into changes in practice beyond the workshop setting. Informing service managers of the ideas, and reviewing practice in the workshop setting, are further methods of promoting good practice, to a limited degree; but offer no further evidence of how the people attending the event are likely to bring about real change. Portfolios of evidence to support developments in individual practice provide a better snapshot, but are often only a picture of one person’s chosen examples of what they wish to divulge; rarely offering a guide to the practice across a team.

It is the philosophy of ‘Practice Based Evidence’ that truly effective changes to clinical practice, in line with the messages from the research, can only be achieved through the sharper focus offered by a presence alongside practitioners and teams in their daily routines. This requires much the same approach as would be expected in the work with individual service users:

• Engaging a trusting relationship with practitioners and teams.
• Establishing a baseline of current knowledge, skills and attitudes.
• Reflecting existing strengths and good practice.
• Suggesting, modelling and supporting ideas for change.
• Monitoring and measuring changes.

The Practicalities

'Practice Development' requires a flexible responsive approach to the needs identified in a particular individual and team. Like most innovations, a certain amount of the challenge in the process is about working it out as you go along. Standardisation is necessary to implement the perceived wisdom of good practice from national and international research studies, but too much negates the reality of the local circumstances and constraints in which people have to operate. The trick is not to lose the important elements of the messages about effective practice in the balance of evidence and practice.

The challenges for successful implementation require the manager of the process to perform many of the following functions (not an exhaustive list):

• Being a regular presence, working alongside people, as time and consistency are essential elements in the change process.
• Supporting all functions of the team and all team members, managerial and clinical (supporting the team leader, not taking over), and providing a trusting impartial conscience and inquisitor within the team.
• Chairing meetings, to propose changes through constructive discussion e.g. implementing a strengths approach within a broadly problems-orientated culture.
• Shadowing and co-working a range of planned and unplanned interventions (assuming the roles of guide and mentor, as required); what are the aims of a specific contact? What if it doesn't go to plan? What contingency plans do you have in place? What have you learned after the event?
• Encouraging active personal reflection through a process of in vivo supervision.
• Reviewing the administrative process of care e.g. note-keeping and other forms of required documentation.
• Reviewing existing policies and procedures e.g. Care Programme Approach and risk management, defined client groups and caseload management.
• Identifying and working with resistance.
• Providing copies of relevant educational materials e.g. articles, references, clinical tools.
• Providing in vivo training that responds to the immediate needs of the individuals or teams in a client-centred way, rather than planning a series of training workshops to fulfil a pre-determined programme in a service-centred way.
• Promoting service user involvement and evaluation, as well as Practice Development Manager reports of progress and evaluation.

Steve Morgan
Practice Based Evidence
October 2001.

Positive risk-taking: an idea whose time has come

Update: Originally the PDF was missing (and our thanks to an eagle-eyed visitor for letting us know). The PDF has now been added. The article is from 2004 and is a forerunner of 2 other articles, published in 2010, which can be found here.

This was the first of Steve's dedicated articles to the concept of positive risk-taking, and is produced here with kind permission from the publishers of Health Care Risk Report.

PDF: Positive risk-taking: an idea whose time has come