The following is a consideration of the status of ‘collaborative working’ and ‘co-production’ from an organisational level within Irish Mental Health Services.
The term ‘Organisational Level’ refers to the operationalisation of collaborative work and co-production at the level of the health service (e.g. hospital, community service, university and school systems). The following account will detail where as a society we are progressing well in terms of the real-life integration of these philosophies into our mental health services and wider understanding of mental health conceptually.
The organisational strength of collaborative working in Ireland can be evidenced through the evolution of the ‘recovery’ themed ethos that has been promoted in most mental health services and organisations over recent years. “Recovery is what people with mental illness do, and treatment, interventions, person centred approach are what organisations do to facilitate recovery” (Anthony 1993). The Recovery model is based on how mental health services view service users’ experience and voice, recognising the centrality of the uniqueness of each person’s experience, story and narrative in constructing meaning rather than clinical diagnosis (Mental Health Commission 2008). Existing practice framework within organisations in Ireland which promote collaboration include; Relapse prevention, Wellness Recovery Action Plan, Crisis Planning, and Advanced Directives. The significant roll out of these philosophical approaches can be observed across most mental health services and this can be illustrated in the mission statements of most organisations. The recovery ethos places real value on hearing the voice of the service user and promotes the need for collaborative decision-making around the table regarding care-planning, treatment initiatives etc. This is a considerable departure from historical approaches which failed to recognise the need to in-corporate the service user’s views into any aspect of their treatment. The Recovery ethos is also evident in how it is currently embedded in the under-graduate and post graduate curriculum for most mental health training programmes. The recognition of the need for collaborative approaches and its endorsement of co-production and peer mentoring makes these concepts part of the everyday discourse of Irish mental healthcare settings.
The organisational challenges of collaborative working can be that the philosophical underpinnings described in the section above do not always pollinate down into the coal face or front line of mental health care and treatment. Sometimes it may be that these philosophies (i.e. Recovery) become no more than signs on the wall or inscriptions over the door. The weakness may therefore be that Recovery becomes no more than a ‘branding exercise’ which has limited impact on the service user experience. The weakness therefore is that these phrases are tokenistic and are exercises in lip service which are not well informed or fully endorsed. Translating the principles of collaborative mental health care into actual practice can be the biggest obstacle. Any changes that the hospital administration wishes to make regarding future practice may face opposition from the staff on the ground. Reasons for resistance can be varied and the hospital administration must be able address these reasons. If they are unable to address the reasons, then staff will just superficially follow any new policies created and continue their work in the same ways as before.
Since the movement of mental health care services from institutionalisation to deinstitutionalisation of service users during the late 1980s in Ireland, community-based care is on the rise. The burden of care now rests primarily on families. This provides opportunities for mental health services and organisations to adopt approaches that collaborate with families as well as service users (through consent of both service users and families). Through family psychoeducation, families can be more fully informed about the diagnosis of various mental illness, psychotropic medications, early warning signs, triggers, and early signs of relapse. In this way families can be taught to intervene earlier in order to prevent re-hospitalisation. This opportunity increases service user’s support system for service users. Families on the other hand can feel empowered through psychoeducation as they feel as part of the team of care and more integrated in care plan decision making.
There are real opportunities for services and organisations to embrace the idea of collaborative working and provide meaningful opportunities for ‘experts by experience’ to have an actual impact on ongoing service development. This would be evident by further expansion of the Recovery Colleges across the country and more emphasis and further development of the peer mentoring programmes across universities. This is a unique opportunity to introduce the culture of collaboration and co-production into Irish healthcare settings where these interventions are embraced for their potential value rather than resisted due to their potential threat.
The threats to collaborative working is that the ideology morphs into something that is not in keeping with the origins of the idea. This can happen if perhaps the organisations create a recovery or collaborative model that is less about collaboration and more about coercion or inequitable decision making. This is held by the fear that recovery can be done ‘to’ someone rather than ‘with’ them and this is a considerable departure form the core concepts of the model. It is also a threat that Recovery, Collaboration and Co-Production will continue to exist in ‘pockets’ or ‘silos’ of mental health services and not successfully infiltrate service delivery across the national span of services. Views that collaboration is just a fad or that some patients are “too ill” for such treatments can also occur. Achieving collaboration requires infrastructure to support it, the hospital administration must be willing to ensure that the changes to care they wish to make are supported, otherwise it will only exist in a piecemeal fashion and be as successful as it should.
In summary, organisationally we have come a long way from where we were 20 years ago. The emergence of Youth Advocacy and Empowerment Networks and the collaboration of service users in the recruitment of staff and the development of services and organisational strategies and the representation of service users on Board of Directors etc. are all positive developments. However, the authenticity of organisations to truly embrace the culture of collaboration and instil these value systems into the ‘on the floor’ service delivery etc. (via peer mentoring roles etc.) remains to be seen. It is important that this tide has turned but organisations will be responsible for continuing to maintain its momentum and integrity.