# Survey identifying commonality across international Recovery Colleges

Toni King (Solent NHS Trust, Portsmouth, UK) (ImROC, Nottingham, UK)
Sara Meddings (Department of Education and Training, Sussex Partnership NHS Foundation Trust, Worthing, UK) (ImROC, Nottingham, UK)

ISSN: 2042-8308

Article publication date: 6 June 2019

Issue publication date: 19 July 2019

## Abstract

### Purpose

The purpose of this paper is to provide a preliminary outline of the international presence, commonality and differences between Recovery Colleges.

### Design/methodology/approach

This study used a short e-mailed survey to create a map of Recovery Colleges internationally and review Recovery Colleges outside the UK. Questions gathered descriptive and qualitative data to gain an overview of the mode of delivery and aspects respondents felt were noteworthy.

### Findings

This paper identifies Recovery Colleges in 22 countries in five continents (including the UK). Participants described wide variance in their context. Despite adaptations, the operational models and inherent principles of each were closely aligned to those developed in the UK.

### Originality/value

This paper provides the first baseline of Recovery Colleges on an international scale. It provides evidence of a high degree of commonality despite variance in setting and highlights the internationally valued transformational power of this model.

## Citation

King, T. and Meddings, S. (2019), "Survey identifying commonality across international Recovery Colleges", Mental Health and Social Inclusion, Vol. 23 No. 3, pp. 121-128. https://doi.org/10.1108/MHSI-02-2019-0008

## Publisher

:

Emerald Publishing Limited

## Introduction

The growth of the Recovery College model has increased significantly. The first pilot was in London in 2009 and by 2017, 85 were identified in the UK (Anfossi, 2017). Using a 31-item questionnaire Anfossi gathered operational detail and application of recovery principles in Recovery Colleges. The development of Recovery Colleges was inspired by but different from the expert patients programme in the UK and recovery education programmes in the USA.

Perkins et al.’s (2012) original ImROC conceptual paper outlined ten defining features of Recovery Colleges which were condensed to six in 2018 (Perkins et al., 2018): educational approach; coproduction, co-facilitation and co-learning; recovery-focused and strengths based; progressive; integrated with the community and services with transformational potential; and inclusive and open to all. Similarly, the RECOLLECT study identifies that coproduction and adult learning underpin Recovery Colleges (Toney, Knight, Hamill, Taylor, Henderson, Crowther, Meddings, Barbic, Jennings, Pollock, Bates, Repper and Slade, 2018). They function through creating empowering environments that connect people in new types of relationships, facilitate personal growth and shift the balance of power (Toney, Elton, Munday, Hamill, Crowther, Meddings, Taylor, Henderson, Jennings, Waring, Pollock, Bates and Slade, 2018).

Publications about Recovery Colleges internationally demonstrate growing interest and practice in this area. Several countries share literature reviews and local needs analysis prior to commencing (Australian Healthcare Associates, 2018; Collins et al., 2016) and the ambition and realisation of transformational change beyond the Recovery College (Lucchi et al., 2018; Grard et al., 2017; Arbour and Stevens, 2017). The unique value of coproduction is frequently emphasised (Sasaki, 2018; Sommer et al., 2018; Skolen for Recovery, 2016).

Perkins et al. (2018) suggest benefit in local variation and growth. International variations include adjusting to limited resources in Uganda (Baille et al., 2015) and targeting wider student audiences including young people (Hopkins et al., 2018), those with housing instability (Chung et al., 2016), people with diverse ethnic and spiritual needs and people with alcohol or other drug issues (Australian Healthcare Associates, 2018).

Evaluations show positive student experience and outcomes from Australia to Europe to Japan (Sommer et al., 2018; Hall et al., 2018; Hopkins et al., 2018; Lucchi et al., 2018; and Yuki Myamoto, personal communication, 8 November 2018). This builds on the evidence from the UK (see Perkins et al., 2018; Meddings et al., 2016; Toney, Elton, Munday, Hamill, Crowther, Meddings, Taylor, Henderson, Jennings, Waring, Pollock, Bates and Slade, 2018).

There is a gap in the literature in identifying the global prevalence of Recovery Colleges and comparison of how these function within very different contexts.

This paper has two aims: it maps countries which currently host a Recovery College. It reports on a preliminary overview of Recovery Colleges internationally, their commonality and differences, despite variation in context and locations.

## Methodology

### A two-step approach was adopted

In order to establish the global prevalence of Recovery Colleges two strategies were employed. Using a snowballing technique, e-mail contact was made with fellow members of two international networks with links to Recovery Colleges (Recovery College International Community of Practice and ImROC). They were asked to confirm details of the Recovery College they were linked with and inform us of any other known Recovery Colleges in order to contribute to the mapping exercise. An internet search was also undertaken to identify Recovery Colleges in all continents. Different browsers were used to search for the terms “Recovery College”, “recovery education centre” and “discovery college” plus translated terminology, linked with major cities, countries and continents.

### Confirmed responses were used to map the location of Recovery Colleges

Second, all identified Recovery Colleges were surveyed (questionnaire available from the authors). We excluded UK Recovery Colleges in acknowledgement of Anfossi’s (2017) thorough review. The threshold for inclusion was all self-defining Recovery Colleges. We did not seek to measure fidelity with the defining features.

Part one captured key contextual factors in the respondent’s location. This included ratings using a likert scale of the wider public’s perception of mental illness, how mainstream the recovery approach is and the legal framework in relation to mental health within that country. Part two gathered descriptive quantitative data about the operational models of Recovery Colleges. Part three gathered qualitative data. Open questions asked respondents to note aspects they were proud of, challenges they had faced and adaptations made to accommodate local context. Major themes in this data were identified and explored.

## Results

### Mapping Recovery Colleges

We initially contacted 18 Recovery Colleges, outside the UK, identified through the Recovery College Community of Practice and ImROC networks. Through snowballing and internet searches this increased to 28. A response rate of 89 per cent (25/28) was achieved within the two week time frame.

A further five colleges were confirmed to exist (therefore included in the mapping) but contact details were not available within the study period.

In September 2018, we identified Recovery Colleges in 22 countries (including UK) over five continents (Figure 1). We confirmed the existence of 33 Recovery Colleges operating or planned outside the UK. During the process of writing this paper more Recovery Colleges have started developing in these countries and we are now aware of at least 44 colleges outside of the UK. Countries such as Australia, Canada, Japan and Ireland have five to ten Recovery Colleges each and increasing.

Results captured the year the first course started in the first Recovery College in each country (Figure 2). These show continued growth. In three of these countries they reported work toward opening their Recovery College in 2019.

### Recovery College survey (excluding UK)

People rated stigma in their country as high: 91 per cent of respondents rated medium to high agreement with the statement “A majority of people view those who experience a mental illness as fundamentally different – creating an us and them demarcation”. People rated use of recovery approaches as low: 100 per cent rated low to medium agreement with the statement “Recovery approaches are widely used”. In total, 100 per cent confirmed there is “mental health legislation which means people can be treated against their will”.

Respondents talked about their context and the variation of factors individual Recovery Colleges grapple with. These included healthcare approaches with a high level of psychiatric bed use “We have 0.35 million psychiatric beds in our country (269 beds per 100,000 people), which is the largest number among OECD and EU members”; limited resource “2–3 qualified nurses per 100 patients”; and variable access to and quality of services.

The political or social context was noted by four respondents from four continents. These included high stigma “stigma levels […] have remained consistent regardless of ‘progressive’ initiatives to date”; rhetoric about change not matching practice “[…] there exists deep-seated politics and power plays between community and inpatient psychiatry […]” and opposition to and/or absence of peer workforce.

Specific population needs were commonly identified across continents including age of targeted students, cultural diversity, socio-economic deprivation, housing instability, isolation and comorbidities. Physical geography including rurality, size of area and population was shared.

### Reasons for developing a Recovery College

The three most common reasons for developing a Recovery College were:

1. Transforming the organisation and changing attitudes and culture (n=10):

We expect Recovery College to be an initiating agent to create the recovery culture.

We would like to promote peer workforce, coproduction and transform our organization.

2. Serving the needs of the community (n=8):

In response to needs analysis research that was carried out in our geographical region.

To address the need for meaningful programming (as requested by our service users).

3. Being inspired by visiting other Recovery Colleges (n=3):

Visits to Recovery College in England.

We have had to rely on experience from Recovery Colleges offshore who were great in sharing.

### Operational model

Information was gathered about the model of delivery in each Recovery College. Providers frequently cited partnership working, for example, one identified eight other affiliated parties. The most frequent main provider was identified as health (52 per cent). Second were third sector, non-governmental organisations (NGOs), charities or social welfare corporations (38 per cent) and 10 per cent were led by education providers.

Funding was provided primarily via the government (43 per cent). A combination of funding sources was second most common (29 per cent). This included initial grants to set up the college then moving to government funding on the basis of positive outcomes achieved in three examples. Philanthropy was cited by 14 per cent. Examples of “other” (14 per cent) and “combination” sources of funding included via a national disability insurance scheme, personal budgets, research grants, student contributions and the UK Department for International Development.

Geographical networks of Recovery Colleges were identified in Canada, Ireland, Australia and Japan with shared learning and support a prominent feature.

All Recovery Colleges engaged a combination of staff with lived and professional expertise in their workforce. Variations in interpreting this question were evident, with some describing their core team and others their whole workforce. Answers ranged from 40–100 per cent of those working in Recovery Colleges having lived experience.

Eligibility to attend the Recovery College was entirely open to anyone in the geographic region in 68 per cent of responses. The remainder operated more focussed criteria related to accessing the mental health service or specific age groups. All cited access for staff and carers.

A majority of respondents said they did not need to adapt “the Recovery College model developed in the UK” for their specific area or country. Adaptations that were made included location, for example, situating the Recovery College within an established mental health service; completely separate from the mental health system, or operating a hub and spoke approach to engage people in more rural settings. Six (27 per cent) from three different continents identified they had made adjustments to their curriculum or approach to coproduction in order to proactively engage with specific groups within their community (e.g. people with unstable housing, LGBTQ+, ethnic and spiritual diversity).

Several respondents noted needing to pay particular attention to aspects of their Recovery College development due to differences in their starting point. For example, noting their country had a “tend-to-hide culture” requiring more preparatory discussions to enable trust to talk openly about lived experience and expertise (n=4) or in other countries to develop a recognition of peer expertise by mental health staff and organisations. Two expressed intent to prioritise carers and families.

Finally research was highlighted (n=5) as an important strand of the work undertaken by Recovery Colleges.

## Qualitative themes

Three open questions asked about challenges, one thing they were most proud of and top tips for other Recovery Colleges.

Themes were identified separately by the authors. On comparison six matched. Following discussion, a seventh theme was identified by combining sustainability and resourcing. Themes were common across colleges and continents. Numbers denote numbers of comments in this theme.

The most frequent themes which emerged were:

1. Recovery (n=44):

This was an overarching cross-cutting theme prevalent across all responses.

2. Culture change (n=34):

The recovery college has been important in spreading recovery issues in our organization and in making recovery and coproduction keywords of our work.

3. Coproduction (n=26):

[…] to make a difference (to create innovation) we have to co-produce for real.

4. Lived experience and peers (n=17):

The value of knowledge from lived experience is getting more appreciated.

Our peers are willing to share, try and integrate their experience. It takes courageous to make it happened. Their personal success provide HOPE and learnable skills and knowledge for others.

5. Education and learning (n=17):

We were anxious to foster a clear and unambiguous educational and community identity.

Learning with each other ⇒ Every student (including mental health professional) learn importance of his or her own self-care.

6. Inclusivity (n=16):

We have expanded the program to engage different cultures i.e. LGBTIQ, Arabic, Aboriginal.

7. Sustainability (n=13):

Sustainability. High level of demand – meeting that demand.

Securing organisational commitment especially in terms of resources and spending.

## Discussion

This survey took place over two weeks. The high response rate, content and care taken to provide full answers, often with follow up questions and suggestions indicate a high degree of enthusiasm.

Recovery Colleges were identified in 22 countries across five continents.

Recovery Colleges have developed in countries with quite different contexts. They differ in health models and resources: health spending ranges from $133 per person per year in Uganda to$5,182 in Germany and over \$9,000 in USA. They are in economically more unequal countries like USA and UK and more equal countries like Denmark and Japan. Education provision and school leaving age differs across countries. They also differ in terms of geography, population size and density or rurality; and in social and political contexts. Most respondents felt stigma was moderate to high – some giving particular emphasis to this. Recovery approaches were not felt to be dominant in any areas, however, some Recovery Colleges are emerging as part of national or regional commitments to change the focus of mental health services.

Significantly, despite this variance in context, the operational model is similar across countries. A majority of Recovery Colleges are led by health providers and funded by government bodies – this is similar to the UK identified by Anfossi (2017). Compared with the UK, more Recovery Colleges around the world are led by NGO or education providers, whereas in the UK many are jointly led by health plus an NGO or educational partner. Educational bodies lead 10 per cent of Recovery Colleges emphasising intention to highlight this aspect of the model. Government funding was more common in the UK (92 per cent compared with 43 per cent), reflecting the different funding and organisation of health services. Partnership, as in the UK, is very common and includes a number of open public consultation groups. Funding routes including research grants, student contribution, health insurance and philanthropy demonstrate the creativity and determination of Recovery College leaders to adapt and deliver across contexts. There was a high degree of commonality in the delivered model with all respondents citing the peer workforce and open eligibility.

This study identified themes of recovery, coproduction, education and learning, inclusivity, and sustainability as well as culture change. These themes correspond well with the defining features identified by Perkins et al. (2018) and Toney, Knight, Hamill, Taylor, Henderson, Crowther, Meddings, Barbic, Jennings, Pollock, Bates, Repper and Slade (2018). This finding emerged despite the intentional omission within the survey of features of a Recovery College and purposeful development of open questions which did not explore these as discrete concepts. Internationally, the significance of the recovery approach and valuing of lived experience, coproduction, education and inclusivity within Recovery Colleges is demonstrated.

This study highlights that the introduction of a Recovery College is most frequently used to achieve the outcome of system transformation and that it is achieving this across the global arena. This may be understood as an outcome of the growing evidence base now available. All respondents have or intend to evaluate and many to publish their findings.

There are limitations to the extent that these findings can be extrapolated. The time frame of the study served to omit a proportion of potential participants. Although several participants were able to create time and identify resource to translate the survey from English, this may have limited or excluded some for whom English was not their first language.

## Conclusions

This paper presents the findings from a survey carried out in September 2018. It provides a reference point from which to map Recovery College developments across the world and identifies Recovery Colleges in 22 countries over five continents. At the time of the survey, 32 Colleges were identified outside of the UK and the number has grown beyond this since. More intend to open in 2019.

Despite multiple differences in context, Recovery Colleges are demonstrated to be visibly alike and distinct from the dominant model of healthcare in each country. The significance of the Recovery College as a vehicle of system transformation is universally recognised. The features of a Recovery College identified in UK literature are found to be fundamental and translatable across all participating settings. This supports Perkins et al.’s (2018) suggestion that embracing principles rather than enforcing fidelity is an effective approach to enabling the continuing development of Recovery Colleges. Although more research is needed, Recovery Colleges do seem to be one of only a few approaches which translate across different contexts and cultures across the world.

## Figures

#### Figure 1

Recovery Colleges were identified in 22 countries (September 2018)

#### Figure 2

Increasing number of countries with Recovery Colleges

## References

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## Acknowledgements

With thanks to ImROC and Recovery College International Community of Practice members and those who helped the authors map and contact Recovery Colleges around the world. Particular thanks to those who took part in the survey or enabled others through their translation skills. Thanks to Julie Repper, Geoff Shepherd and Dawn Fleming for support with the project.

## Corresponding author

Toni King is the corresponding author and can be contacted at: toni.king@nhs.net

Toni King is seconded from her role as Trust Lead for Recovery and Peers at Solent NHS Trust to a Consultant Practitioner trainee post with Health Education Wessex. She is an Occupational Therapist and is a Consultant with ImROC.

Sara Meddings is Psychology and Psychological Therapies Consultant lead for recovery and wellbeing at Sussex Partnership NHS Foundation Trust and is a Consultant with ImROC.