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Report on the Trieste Action Learning Sets 2016

In 2016 Hywel Dda University Health Board, Wales  and ASUITS (Mental Health Deapartment) Trieste supported by the International Mental Health Collaborating Network (IMHCN) collaborated on  running a “Whole Person, Whole Life and Recovery into Practice” Joint Action Learning Set Programme. Co-facilitator and IMHCN Development Officer, Roberta Casadio describes what happened with the Action Learning Set in Trieste.


April - December 2016
In December 2016, we successfully completed the fifth and last meeting of the Action Learning Set Program in Trieste which started in April 2016 for a period of 9 months.

The Whole Person, Whole Life, Recovery into Practice Learning Set Program took place in the Administrative building of Trieste Mental Health Department (MHD), within the parco culturale “San Giovanni”, where the majority of training programs which are organised by the Department usually take place. The program was intended to be a participative and developmental experience to bring forward the thinking and practice within the community of Trieste.

The Action Learning Program was organised by IMHCN in collaboration with Trieste MHD to further develop the way of working with people with mental health issues alongside local communities, professionals and services. The five meetings have been planned nearly once every other month and were made up of committed mental health practitioners, service users, peer support workers, family members, community organisations and services who joined together to form trusting working groups. These groups embarked on a process of examining all aspects of the needs of people and how these needs were met throughout the facilitation of IMHCN trainers John Jenkins, Paul Baker and Roberta Casadio.

Three main themes were addressed in the five meetings:

  • “Knowing the person” (meeting 1 and 2),
  • “Working alongside the person” (meeting 3 and 4) and
  • “Whole person, whole life, whole system approach” (meeting 5)

The main objective of the program was to experience a new way of being together and to share responsibility in enabling people and local communities in facilitating recovery and resilience. Therefore we sought to develop trusting relationships with each other trough the Action Learning Set and learn from each others experiences. The importance of trusting relationships between a service user, their family members, practitioners and significant others was recognised as fundamental part of the learning experience.

During each meeting notes were taken and sent to the mailing list. At the end of each meeting participants agreed to experience an action and report back the following time.

Here is a summary of the Action Learning Set experience in Trieste.


1st ALS meeting : 6th of April, 2016
Theme: NOWING THE PERSON - Part 1
Participants: 36 people mixed group

Themes developed:

  • Essential importance of trusting reciprocal relationships;
  • Whole Life - Whole Systems development through partnerships with all community stakeholders;
  • Clinicalised, specialised, centralised, hospital-based services vs. integrated, comprehensive, decentralised, small-scale, low-threshold services;
  • Institutional resources vs. energies and opportunities from a community, if services are capable of capturing and activating them;
  • Whole Life Approach vs episodic life event approach;
  • Recovery Approach vs maintenance of individuals;

Summary:

Paul Baker, John Jenkins, Daniela Speh, Roberta Casadio and Roberto Mezzina welcome people and introduce them to the Action Learning Set program and twinning with Hywell Dda team, specifying how and why the initiative started and their role in guiding the group through the process of the 5 meetings.
The group was remanded about the guidelines and commitment necessary for the good outcome of the Action Learning Set experience.

Exercise 1 (1 hour): “Knowing each others”. Stand up and meet a person you don’t know or that you have seen but you don’t really know. Ask who he/she is and speak for 5 minutes and vice versa. Go back to the big group and introduce your partner.

Exercise 2 (1 hour): “Elements in favour and barriers to overcome a difficulty in your life”. Meet again with your partner and tell how you have overcome a difficult period in your life and vice versa. This difficult period could be due to relational, economical, health problems etc. Go back to the big group and tell the elements in favour and those which were a barrier for the recovery.

In the group we wrote a list of what emerged during the conversation in couples. Some examples:

What helps: responsibility, empathy with one worker, comprehension, feeling alive, be seen, helping the others, seek for help, tolerate uncertainty, take time and reflect, to dare, to understand the situation, money, to talk, been given the possibility to choose, age, work, sport etc.
What does not help: loneliness, socio economical status, to not have access to information, feeling fragile, not to face the situation, to not talk, rage, fear, guilt, shame, to not know the problem, feeling powerless etc.
Action: between today and the next meeting reflect on the list about the elements that helps and those that does not. How much do we give and receive of them? Share it with a partner, colleague or with a group.


2nd ALS meeting : 5h of May, 2016
Theme: KNOWING THE PERSON - Part 2
Participants: 25 people mixed group

Themes developed:

  • The shift from mental illness to mental health from a focus on institutional practice to the organisation of human focused services;
  • Interventions and programs that are valued by the service user based on trusting relationships provided by the whole communities’ resources;
  • Defining the pathways for the person for their mental health and wellbeing as a complete circuit of whole life, that values all human and personal experiences;
  • Professionals, organisations and the community participate and contribute to the common purpose of this paradigm shift in culture and belief;
  • The Whole Life Recovery approach is founded on human values and their application by the service user, families and the community, professionals and the service itself.

Summary: Introduction to the second meeting of the ALS. Reflection on the first meeting and the homework: the list has been discussed within the self help group led by peer support workers in a CBMHC (Community Based Mental Health Centre), a trainee psychiatrist has discussed the list with a colleague which is not trained in Trieste, an operator from a CBMHC has discussed it with a colleague etc.

Exercise 1 (30 minutes): from what has emerged the last meeting reflect on these themes in small groups:
“Assessment” vs “Knowing the person”:
How do I know the story of the person?
How can I know more about him/her?
Which information are important?
“Treatment” vs “Recovery plan”:
How can we find the right direction where to head to? How to overcome challenges?
“Review” vs “Celebrating success”:
How do I know whether the recovery plan is working?
How to introduce changes and overcome difficulties?

When we got back in the big group we have shared our story about the first impact with Mental Health Services from different perspectives. People that use or have used the services, a family member and professionals told their narrative on their first impact with mental health field.

From who have used the services: “(..) I was completely out of my mind. In the psychiatric clinic where I was hospitalised I was feeling very bad. A lot of people around me asking many questions. I felt like an object. In the Mental Health Centre I have never felt like this. I know it was impossible to communicate with me when I was sick. Now it is different and also the service is different”.

From a family member perspective: “(..) I was not in Trieste, we were all not prepared when it happen. We took my son to the hospital and suddenly we were send in a horrible place with big gates and dirty walls. It was a long time ago. That experience was horrible. We decided to move in Trieste because we knew it was different. After what I had experienced in the other city here I felt like in a grand hotel”.

From the professionals’ perspective “I was still a trainee psychiatrist, at the very beginning. That night I was ask to visit a person that was in crisis and perhaps to convince her to spend one night away from home. I went to her and by talking I managed to convince her to do it even though she did not like the idea at the beginning. We were walking in the street. It was freezing, the street was iced and there was the Trieste Bora wind. She recognised I was not from Trieste, eventually she said to me “pay attention I will support you in walking because you are not used to the Trieste bora, then we hug each other while walking through the iced street”. I felt she took care of me.”

Reflections: we can talk when we don’t feel judged by someone else. Talking is one way to give new meanings. Talking is therapeutic but it not always a liberating process. When a person arrive in a mental health service, this is the most important moment in which he or she start a journey. It is important how we start it. (This is true not just for the field of mental health). Some approaches enable the person to talk more in a open way even when they feel very bad; Open Dialogue is an example of it.

Action: Think about what you have heard today; ask to someone else about his/her first impact with mental health services. How trusting relationships were formed?


3rd ALS meeting : 27th of July, 2016
Theme: WORKING ALONGSIDE THE PERSON - Part 1
Participants: 25 people mix group

Themes developed

  • Recognition of the power of institutionalisation as reflected in stigma, practice and outcomes. Putting the person over the power of the institution is crucial;
  • We require a paradigm shift in thinking from pathology and illness to self-determination, self-management based on a narrative of the whole person and their needs;
  • We should all believe in the power of individuals to self-determine their Whole Life;
  • Peoples life stories, events and experiences are at the centre of unresolved problems and the means to find solutions;
  • Summary

Welcome and introduction to the 3rd meeting. Reflections on the second meeting and the homework:

From those who have used the services
“(..) I was very impressed by the theme of responsibility: in my workplace I could not talk about my distressing experiences. In the MHS in Trieste I found someone to talk to and I understood that I could be still responsible, therefore capable of my life. I would have liked to speak out about my problems in my workplace but there was too much stigma attached to those who suffer and still it is.”
“(..) Connect with the suffering of a user through our suffering. This connection with ones’ own feelings enable him/her to be in a real relationship and to really listen to the other.”
“ (..) I really appreciate to listening to the story of the workers and psychiatrist, they never speak about themselves or their personal experiences.”
From the professionals’ perspective
“ (..) Sometimes in the most difficult moments I feel I would like to step out from my role and express what I really feel. I think it is important to have supporting relationship between colleagues too. When I talk about myself with colleagues they ether say “thank you” or “ I didn’t want to hear this”.
“ (..) I am not sure that it is always right to talk about myself with the client. He or she is there to receive help not the contrary. We have similar feelings but different roles. Sometimes it is easier to connect with somebody and sometime it’s more difficult because your own life circumstances, being real does not necessarily means to talk about you with the client”.

John Jenkins: “To have a peer relationship does not necessarily means to mix roles. There can be a different way to collaborate together. A trusting relationship is one of the key factors in successful journeys to recovery. Could it be possible to not decide anything “on” the person but rather “with” the person? Are the dynamic always centred on/tailored to the person? Is there a real co-production?”

Roberto Mezzina: “Many people that arrive to mental health services don’t want to be there and didn’t choose to be there, it is unrealistic to think that we always have the same power because it is not. We should always tend to a balanced relationship thou. We feel the need to spread this considerations with those professionals that work everyday in the MHSs and face difficult situations daily.”

Simulation (30 min): welcoming a person that arrive for the first time in a MHS:

1st time: bad welcome (not trauma informed: hurry, lack of empathy, a lot of interferences, lack of choice for the person, the person is feeling not in control over the situation, powerlessness etc.)

2nd time: good welcome (trauma informed: time, attention, focus on the person, offering choice there for power and control over the situation, empathy etc).

Reflection and homework
Action: talk about co-production with a group, a partner or colleague. Change an action or thing in your own practice/experience toward a more co-produced way of working. How did it feel? What was the other person reaction?


4th ALS meeting : 21st of September, 2016
Theme: WORKING ALONGSIDE THE PERSON - Part 2
Participants: 10 people mix group

Themes developed

The importance of continuity of a consistent relationship and therapeutic approach across all parts of the services and communities;
The family and/or other significant people should be actively involved in the whole life program and the personal recovery journey;
The need to embrace individual and community strengths, resources and opportunities;
We should all believe that it is essential to enable individuals to continue or re-gain a whole life in all domains: wellbeing, health, social networks, education, work, housing, art & culture, faith, sport and leisure, treatments and therapies;
A health and social care system and services cannot achieve a Whole Life-Whole System Approach on its own;

Summary:

Introduction to the 4th ALS meeting. Brief summary of the previous meeting and welcome to few new people.

Key word: SPACE

What does it means?
. Time
. Opportunity
. Place where to create your own identity

From who have used the services:
- A person who has attended the hearing voices group speak about her experience in which she found the space to explore her experience in a different way “it is a space that is safe and respectful”.
“(..) I really like Enik Recovery College in Utrecth which I visited with the Trieste peer group. It is a space that is completely run by peers. They live that space in a respectful and open way. It is like if they were telling you “Come in, lets get to know each others, forget who they told you are and lets find out your talent”. Maybe one day it will be possible also here in Trieste to have something similar which is totally run by peers. Something that is not part of the institution but that relate to it openly.”
“(..) When I was in crisis the space for me was the bed. I could not see more than that. Now I feel my space it is my home, the city were I live. Feeling valued helped me to enlarge that space and feel a person again.”
“ (..) For me the rule “nothing about me without me” was not possible when I was in crisis. It was important that someone was taking the right decisions for me in that moment. After that difficult period I was able to take decisions for myself, but i was not really listened to until I found the right people. Everything changed when I found the true listening.”

From the professionals’ perspective
“(..) There have been similar experiences in Trieste in the 90s such as “Fuori Centro” initiative. Having a space means also to take a place, run it and create an identity through the use of that space. Do the operators have to be always involved?“

Paul Baker: “Most part of professionals’ training it is centred around theories, protocols and less around people. When we talk about recovery it means that there is always something to unlearn. A good question in psychiatry could be “what happen to you” rather than ”what’s wrong with you”.
In the “Whole person whole life” approach we try to:
- change the way we speak and act
- enable a free and open “space”
- change the objective from clinical recovery to personal recovery
- welcome and listen to the others toward a balanced partnership.

Roberto Mezzina: “are there any possible different way to approach a crisis for MHSs? When the person need to be hospitalised? Is it possible to deal with the crisis at home?! I think we can improve our approach further toward this direction”.

Action: think about the principle of “nothing about me without me” and try to apply it to your own practice.


5th ALS meeting : 14th of December, 2016
Theme: WHOLE PERSON, WHOLE LIFE, WHOLE SYSTEM APPROACH
Participants: 20 people mix group

Themes developed

  • It is fundamental that all people and organizations take responsibility for the part they can contribute to taking forward the necessary action required for this development and to be implemented;
  • This will require the wide spread ownership and leadership from all levels of management, all professional groups, support workers, service users, family members and community organizations and partners;
  • It requires leadership and passion from senior and middle management in all organizations involved;
  • A community Whole Life-Whole System needs to be developed with a common purpose that is understood and agreed formed with communities including family members, service users, community organizations and public bodies
  • It is crucial to move away from the preoccupation with security and risk to shared responsibility in decision making by the user, family, professional and the organization.
  • Recognition that social determinants are key causal factors to a persons’ mental health and assisting or impeding their opportunities for recovery. Therefore answers are to be found in the social, economic and cultural context.
  • The importance of learning from national and international good practice in Whole Life -Whole Systems and Recovery into Practice

Summary:
Paul Baker, John Jenkins, Roberta Casadio and Roberto Mezzina welcome everyone and introduce the group to the fifth and last meeting of the Action Learning Set 2016 Program in ASUITS Trieste. After a short summary of what has been discussed in the previous meetings we give time for reflections and feelings about the experience so far.

Roberto Mezzina: “(..) It is important to take the learnings and introduce them in the Departmental Objectives for 2017”.
“ (..) Sharing our experiences make me thing abut the important theme or taking care or care about the people that arrives in our services and also about how we have to welcome them. Which expectations? Which tools? How do we help the person to go out of the Mental Health System?”
“We need to decide how to better organise the peer presence inside the services, how can we help people to work toward their recovery and improve their wellbeing”
John Jenkins: The concept of “Whole Life” is inspired by the experience of Trieste. The three themes developed in this ALS program were “Knowing the person”, “Working alongside the person”, “Whole Person, Whole Life Whole System”. The core idea is to build a peer relationship between professionals, family members, people that uses services. We call it “co-production”. The experience of ALS in other Countries tell us about the importance of having a reflective space where people can feel free to reflect and talk openly. This is also about co-production.

Exercise (1 hour): split in two groups: in each of them there are at least two peers that will tell their story about been taken care of by MHSs. Reflect together on the elements of co-production.

From the professionals’ perspective
“(..) We can think about the MHSs with the metaphor of a coffee shop. How many coffee the bar attendant has to do in a given time? Why a client feels good in that place? Is it because the attitude of the bar attendant? Is it because the coffee is particularly good? Is it because the place is very nice and cozy? What make a person feeling comfortable to come back again?”
“(..) I would like to go in a coffee bar where the bar attendant tells me to sit comfortable somewhere and he will arrive to me not the contrary, I think in our “coffee bar” we serve too many coffee in a short time.”

From who have used the services:
“(..) in our group we spoke about listening, to give more time to the person, and to reduce all the kind of interferences such as telephone ringing etc. The role of peer is more and more valued by the professionals in the services and by the people that get to know us more and more. I think that the peers can play a great role in helping the person when he or she arrive in the service for the first time. It is a different approach the one of peer support workers because we have been there and we have overcome it. ”
“ (..) the person need to be reassured on the fact that she or he will not lose his/her identity when starting a journey in Mental Health Services. Often the crisis is about loosing part of your identity”.
“ (..) to receive trainings as peers is tricky. We need it but at the same time we don’t want to be empty receptors of information but rather to learn how to use our personal experiences and feelings to help the person”.
“(..) it is not too different from what the operators should do. It is about a process of learning and unlearning at the same time”.
“ (..) in Uk and other part of the world it happens that the peers are specialists but they have adopted a language and way of working with that is very far away from the experience of people”

We conclude the meeting with the purpose of (Acton) writing together guidelines of good practices, and to hold a conference for spreading the learnings from Asuits and Hywel Dda Action Learning Sets in 2017.

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