This is the latest report on the progress of the Recovery House in Trieste. This article consider the challenges, the learnings and the achievements so far.
We understand the word recovery in mental health to mean “a deep and unique process in which one person with severe mental health problems (re)take ownership of his/her life”. In other words, for the person to be an active agent in their life in overcoming existential, social and psychological problems.
When we speak about recovery, we talk about something new, a new paradigm in mental health. Silvia Bon, who is a person with lived experience of distress and co-author of “Guarire si può”, states that the acknowledgment of the value of recovery, of the possibility to achieve a better wellbeing, is the next step after the revolution started by Franco Basaglia in fundamentally challenging institutionalisation, leading to the reform of the law and the closure of psychiatric hospitals in Italy.
If we agree that people with a severe mental health problem can recover, as is well supported both by scientific evidence and by people that have shared their stories, the question remains: What helps?
What are the elements, on an individual and social level that enable a person (for instance with a diagnosis of “schizophrenia”) to live a full life? How can they overcome the fear of symptoms such as distressing voices? How do they confront social stigma and to get back a full sense of their citizenship?
If we think about health, including mental health, in terms of an ongoing process that effects all of us, we will understand that we cannot separate it from the social context and relationships including those with the mental health service itself.
Starting from this premise, in April 2015 Trieste launched a Recovery Learning Community centered around a Recovery House, an innovative experience located within the services provided by the Mental Health Department. The objective was to foster recovery processes and significant changes in the lives of young people who already used mental heath services, but did not express a satisfactory quality of life because they still felt stuck in their suffering.
This experience, from its beginning, has had huge implications about the way we understand and promote mental heath. Firstly, a change in ourselves, a rethinking of our roles, and practices. Secondly, but no less important, was to promote mental health in all the people that are part of the experience or are just touched by it. This was because we believe this collaboration would bring a better sense of self, sense of belonging and autonomy. We regarded this as one way of fighting social discrimination and stigma toward people with mental heath problems, whilst simultaneously encouraging those who were part of the community to escape from their own loneliness and loss of sense of direction. The third objective was to overcome the maintenance of a “status quo” so often held by the person in identifying him/herself with his/her own illness but also by the service providers, family members and society.
The experience of establishing and developing a Recovery House in Trieste
In developing the Recovery House in Trieste, we learnt from the experience of recovery houses in Scotland and Italy and they provided a theoretical and methodological framework for our initiative.
The Recovery House experience is primarily for those people who hear voices or have other unusual experiences and that have a distressing relationship with these perceptions. On the whole they are young people that already had a relationship with the mental health services of Trieste for at least three years, but have not yet found the strength to gain full ownership of their life and to develop a successful path toward their desired goals.
The Recovery House was planned and developed by the Department of Mental Health in co-production with International Mental Health Collaborating Network (IMHCN), Associazione San Martino al Campo, Cooperativa Sociale Germano and family members. These partners gave life to this innovative experience with the broader objective of connecting/sharing this experience with the whole network of services within the Mental Health Department.
Brandesia House was chosen to be the place to establish the Recovery House. It is a house with a big garden (with fruit trees and a vegetable garden). The house is owned by the Associazione San Martino la Campo. This association had been working in the field of assisting people with social and psychological difficulties for more than 40 years. In Brandesia House there was an existing staff group, belonging to Cooperativa Sociale Germano. Since 2012, the cooperative had co-run, with the Department of Mental Heath, a centre for rehabilitative interventions paid for by Individualized Personal Health Budgets.
From the beginning of the initiative, three consultant trainers from the International Mental Health Collaborating Network worked with the partners to realise the project with the objective of facilitating the application of a Whole Life - Whole Person - Whole System - Recovery Oriented Approach that distinguishes the group in its international work.
The operators and case managers from the different Mental Health Centres in Trieste are an active part at both a managerial level and an operational level.
The experience is being evaluated in collaboration with ISTC-CNR through a participative research that has the aim of capturing both the salient processes and the long term outcomes.
The participation in the Recovery House activities is voluntary and each participant chooses to join according to his/her objectives. In some cases the person and his/her family members are invited to take part to the experience and will be introduced to the house through different channels of communication: by meeting the people who have undergone a similar journey, by experiencing the activities or through knowing people that are actively participating in the experience.
It is also possible to participate in the Recovery House in different ways, one of them is to live in the house. The length of time would be an average of 6 months but this varies according to their personal needs and individual plans. During this time, each person has the opportunity to take space and time to reflect on him/herself and on his/her story, without losing touch with the reality next to him/her to find new meanings. This opportunity is also given by the relationship with other people: operators, volunteers, and others involved. The idea is to shift the attention from the pathology to the personal experience of individual and family with a deep focus of whole needs and wishes.
The Recovery House offers an environment where it is possible:
collaborate with one or more operators that are chosen to be partners in a journey of reciprocity with which to explore personal stories and narratives about life, challenges and hopes.
involve from the very beginning family members, supporters and other important people/agencies that (can) play a crucial role in the personal journey.
build and strengthen resilience. Helping the person to face with serenity life difficulties, and fears.
explore, find meaning to voices and other unusual experiences that play a role in diminishing quality of life and wellbeing of the person.
strengthen the social network with the objective of feeling a major sense of belonging,reciprocal trust and mutual support.
The Experience of the Recovery Learning Community centered around a Recovery House has been one of the most important happenings of the year in Trieste Mental Health Department and that was co-created by all the people involved though a democratic, bottom-up process. The pilot period lasted till November 2015. Today, another group of young people have joined the experience and some people of the previous group have been employed as peer workers.
Now lets examine some elements that have contributed to the value of this experience:
Principles and key elements of the Recovery House
1. A guess on ourselves: the opportunity for a group of young people and their families to be at the centre of an experience that is co-produced. The house of Brandesia is the place where the mayor number of activities take place but also represents the symbol of a different philosophy of dealing with mental health. The residential element is therefore secondary in importance.
2. Recovery as a personal and collective journey. The group becomes the element that foster change and challenge the status quo. Shared responsibility is at the core of each decisional process regarding daily life in the house, activities, organizational aspects of the project. Individual journeys are discussed with the person according to the principle “noting about me without me”. The person is always included in the decision making processes: protagonism become a way forward to negotiation and development. The space and time dimensions that are present in the context of the Recovery House invite the person to dream and plan actions to define a journey which include all the people that can be active supporters. One person who is living at the house at the third month says about himself:
“I like the house, i wasn’t autonomous as I am now, I wouldn’t been able to find my place in the world. I have found friends. I feel more confident now and I don’t get hurt that much by the things that used to hurt me so badly before. Now my family is listening to me more, and I am more open and I try to understand them too. I am grown up and I have managed to become more stable”
3. A third element of this experience is the new ability to cross contradictions. All the subjects co-produce the experience of the recovery House and are involved in a journey in which day after day we ask to ourselves: “where are we going?”. The project in all its aspects can be adjusted and revised in every moment by all the people. This will help who live in the house to better define what they need, the operator to tolerate uncertainties and to break usual patterns of behavior, families to redefine their time, their needs and to lessen control over their children. In this perspective, we all are experts of a dynamical process that adapt to the people rather then the contrary.
4. Seeking for a language that is near to the experience of the person as defined by themselves, avoiding the use of a technical - clinical language. For instance, in the beginning it has been discussed how to define ourselves: collaborators? partners? guest? operators? Another aspects deal with the individual experience of having unusual belief or perceptions: those experiences that in a clinical language are called auditory hallucinations, are considered real voices because they are real for the person who is living them. It is important to respect the person and his/her truth. Meaningful/problematic experiences are depathologized and not considered as symptoms to be eradicated or suppressed rather phenomenon to be understood.
5. In this sense, it is given full right and respect of the knowledge of the expert by experience. This mean to acknowledge and to give value of the experience of the person so that he/she is the first expert of its own experience. Consequently, in the Recovery house people, thank to their motivation and their choice of moving forward in a process of learning and discovery, are the real protagonist of their journey. This aspects is not that easy to interiorize for the operators that are not used to work in this way because it requires that they will stop from thinking what is right or not for the person. This will enable them to to be in a real relationship with the person, overcoming barriers and to better respect person’s time and way forwards. Not less important is the presence of peer workers in the experience of the Recovery House: the strengths that is drown by their experience contribute to the process by offering a support to those who are in their journey of recovery.
6. Last but not least, is the development of an ongoing mutual learning process: the willingness by all - people who live or have lived in the Recovery House, families, operators of the cooperative or the department, volunteers, consultants - to co-produce, through an ongoing process of sharing, exchange, research of a new sense of community. The Recovery Learning Community centered around a Recovery House is characterized by another particular feature. With respect with other Recovery Houses in Italy and across the world, the experience in Trieste starts from a need that lie in the network of services offered by the Department of Mental Health. Therefore, values and principles that represent the foundation of this experience trigger refection that can arise from different perspectives. A family member state:
“it has been interrupted the chronicization process to which my son was going toward, here the focus wasn’t what was wrong with him but rather what’s good. It has been changed the axis from the Mental Heath Centre. It is like an unconscious process there, the person is expected to act like a patience and so he does.”
Conclusive notes
We have tried to describe briefly what is the experience of a Recover House in Trieste, being aware that this was not an easy task.
We can add, as a conclusive note, that the experience has an high cultural purpose: to foster different comprehensions and vision of reality as a mean to overcome any form of reductionism. The idea is to keep on stimulating a change in culture around mental health difficulties. Suffering is just one of the way of expression of human beings and not just a pathology or something to be fixed. We believe that this culture should be spread like a wave form. Some implication of this approach regards: focus on narratives and stories of the person and significant others (families, friends, relatives, operators etc.) rather than diagnosis and clinical story. More attention given to the use of medication and its negotiation with prescribers with the scope to find minimum doses that enable the person to be more in touch with feelings and at the same time not being overwhelmed by them. The attention to stories of people who have overcome difficulties and successfully undergone a recovery process. This is important to reactivate a sense of hope that is often lost, hope that is possible to recover and to find meaning in stressful perceptions such as distressing voices. As previously said, the collaboration with families since the very beginning was a central part of the program: this means the active listening to their stories and needs and the help in identifying existing resources and develop new ones together with the person in a framework of mutual growth.
Finally, the deep value given to the community. It is the community that changes together with the people that are part of it. It is the community that take care of individual journeys of people, families, services, and territory in which meetings are the ground in which change happens through the dialogue.
Izabel Marin
Social worker - REFERENTE DSM of the project
Roberta Casadio
psychologist and consultant for International Mental Health Collaborating Network
Paul Baker
Consultant for International Mental Health Collaborating Network