Remote mental health rehabilitation: Social Health Educators between experience and innovation

Introduction

Following the Covid-19 pandemic, in our country strict containment measures have been put in place. Firstly, such measures have aimed to safeguard vulnerable swathes of the population, including people affected by psychiatric disorders.

Unfortunately, this pandemic imperils treatment plans which have been laboriously built through time.

In compliance with the Decree by the Ministry of Health of 23 April, 2020, Mental Health Departments have implemented remote organizational systems in their facilities, especially in the community-based ones, such as Mental Health Centers. The outpatient center in Gravina in Puglia, belonging to the ASL Bari’s Mental Health Center 2, has continued working, guaranteeing necessary and/or emergency services in accordance with all measures to provide users and workers safe access and protection, thus allowing in-person services in such situations as therapy administration or direct examination.

The employment of means of telecommunication, including phone calls, has allowed to spread information about infection prevention behaviors but also, and above all, to monitor users who have been forced to stay home.

Nevertheless, a large part of territorial rehabilitation plans and activities, counselling sessions, aid and psychoeducational activities, social skills training, workshops, as well as family support, monitoring and network activities with rehabilitation centers workers and users have been rearranged in another modality. It has been an educational, therapeutic, training, preventive, informative and supporting work which has  been carried out through the so-called “remote modality” (Gabrielli et al. 2020).

We have observed how, after the initial difficulties were overcome, this “remote rehabilitation” has been appreciated and further implemented because of its efficacy, and how it has been necessary to extensively reflect on the necessity of adapting our technical work to such new social and cultural contexts.

Through the description of one of the therapeutic and rehabilitation activities which have been conducted in spite of the great difficulties in this challenging time, this report represents a summary of the actions that have been implemented to maintain the “relationship” which promotes treatment, rehabilitation and resocialization plans for people under the care of the Service.

The activity is mainly based on an ongoing Autobiographical Narration and Therapeutic Photography workshop which has been consistently conducted for about three years.

Through time it has been possible to teach participants to use narration and photography as tools for self-affirmation, so that they could use them as a language to convey their own condition and distress, but also positive feelings and their view of themselves, other people and the outer world, in order to possibly get-expressive confirmation and comparison which could lead to a conciliation or reconciliation with their consciousness, identity and structure (D’Elia 2018).

With the emergence and spread of the pandemic, particular attention has been paid to the workshop  participants who benefited from specific lines of communication which have allowed the continuation of 68 remote interventions, by the creation of virtual rehabilitation, psychoeducational, resocialization, support and mutual aid groups. During the Covid-19 health emergency period, the Project activity has intensified mainly during lockdown, by assisting all participants and their families in coping with difficulties, sense of dismay, abandonment and isolation that have posed a serious challenge to both their physical and mental health.

The remote activity has allowed to increase participation in the program, by aiming not only at the local Territory users but also at the surrounding Territory ones and at the patients of the rehabilitation centers belonging to such Territories, through the involvement of the representative Social Health Educators who have contributed to make the interventions even more effective.

Even in this unusual situation, we have been able to pursue the project objectives and purposes related to therapeutic continuity, not only by carrying activity contents forward, but also by identifying and understanding prodromal signs, by preventing the worsening of psychopathological symptoms and relapses, by maintaining autonomy through the recognition of early warning signs of a crisis in several everyday situations, as well as by sustaining families in the expressed emotions management.

The emergency period has witnessed the fulfilment of the greatly desired network among both public and private agencies that has managed to readjust and rebalance its intervention in view of users’ needs assessment, using flexibility as a pathway to provide rehabilitation in a new way.

Methodology and Materials

It should be remembered that the interventions implemented by psychiatric specialists have always been provided in community-based settings, thereby operating through territorial services made up of  multiprofessional and multidisciplinary teams that, when taking charge of the outpatient centers users, formulate therapeutic plans which consider both health and rehabilitation, education, and resocialization aspects.

All interventions, especially educational and rehabilitation ones, focus primarily on individuals and their relationships. The quantity and quality of relationships mainly represent the possibility to enhance wellbeing in everyday life. Self-awareness, the understanding of how one communicates, the knowledge and better expression of both positive and negative emotions, as well as the exchange and sharing of experiences are at the base of both individual and group proposed activities.

The system described above is where our Service works and, with the emergence and spread of the pandemic, particular attention has been paid to the participants of one of the most important territorial rehabilitation activities in our Service, who benefited from specific lines of communication which have allowed the continuation of remote interventions, by the creation of virtual rehabilitation,  psychoeducational, resocialization, support and mutual aid groups (Bellack et al 2003; Falloon 1992) and by the adoption of an approach conforming to the Illness Management and Recovery practices (Gingevich et al 103 2016). The scheduled activity Representative and Coordinator is the Mental Health Center Social Health Educator who, given his training and expertise, works on the motivational side with different professional approaches which are however complementary to other disciplines (Crisafulli et al 2010), offering a synergic cross therapeutic rehabilitation program, with the help of his team. The setting where the Project is conducted aims to boost participants’ Recovery conditions hence focusing on those which could lead them to live life to the best of their ability (Maone et al 2015). In this sense, we work in such a way that users have a concrete opportunity to become the promoters of their own skills recovery and maintenance, and the main characters of their treatment program, together with the rest of the cast (group), sticking to the cinematographic metaphor, that supports and motivates them by encouraging them to always do better. During in-person activity, the project could count on citizens’ engagement and active participation in events where both social and art works (photos, documentaries, short films) were displayed, or where participating Witnesses gave community-based accounts that helped participants to acquire knowledge in different subjects and develop both cross-disciplinary and civic skills. During remote activity, we have kept in line with such conditions as much as possible, even by taking part in the production of a short film that gathered stories from real life under lockdown, which were told to and  shared with the group during online meetings. Even during remote activity, it has been possible to keep using good practices that prompt competences exchange and mutual help not only among participants but also among and with workers, still in conformity  with the Recovery-oriented conditions according to which the worker’s knowledge, who is an expert by profession, is juxtaposed with the user’s knowledge, who is an expert by experience. The remote activity has been conducted by several means to manage interventions, and individual and group meetings. The total number of people currently participating in the activity is 24. The platform mainly used for scheduled group activities is jitsi meet where, for each session, about 8-12 users plus the involved Day Care Centers social educators and external experts and/or guests/witnesses log in. Skype, WhatsApp and phone calls are used, too.

The remote group activity consists in exploring value-related subject matters proposed or suggested by individuals which are included in a list that, in turn, becomes part of the meetings planning. Some examples of the subject matters explored are: “Care of the self and others”, “Self-esteem”, “Emotions”, “Communicative skills and relationships”, “Rules”, “Fear”, “Desires”. Other subject matters have concerned the community, like: “Place attachment”, “The dwelling”, “Welcoming territories”, “Active Citizenship”, “Politics”, “Past, present and future”. Some others have been about art and free time, such as: “Music”, “Cinematography” and obviously “Narration” and “Photography”. 

After re-assessing the needs that have emerged during lockdown, there has been the necessity to arrange some explanations of, reassurances and clarifications on Covid-19 and the related decrees, with a focus on the necessary measures to prevent the spread of the infection. Everyone in the small group is supported and bolstered during the identification of his/her own strengths and in the pursuit of his/her wellbeing. As for technical and rehabilitative aspects, such support is provided by Social Health Educators, but the therapeutic value is also sustained by experts’ and guests’ interventions through activities which develop psychophysical wellbeing, or by artistic mediators’ help, through ideas and suggestions or through the employment of several techniques or re-socializing and recreational activities.

But it is worth pointing out and highlighting the mutual help and support that participants have offered to one another, which could be defined as a mutual “peer to peer”, namely a form of care for each other. As a matter of fact, contacts among participants occur in autonomy or through the purposely created WhatsApp group that allows people to interact and socialize, by organizing meetings to spend some time together either on videocalls or, if possible, in-person. All this unequivocally defines the valuable labor workers have done to facilitate skills empowerment and abilities improvement, so that users could achieve a real personal transformation, with a methodology whereby everyone could recognize the limits imposed by his/her pathology but also see his/her potentialities, by activating a growth path based on empowerment and on an increase of self-esteem, self-efficacy, and self-determination. The creation of a “Cultural Club” – IN LUCE Stories – with a dedicated Facebook page is a further confirmation because it concretely represents participants’ interest in and passion for this activity, namely the desire to make it stable and more accessible than ever to the Territory beyond the Service-operating area. It also mirrors an excellent stage of individuals’ autonomy development, cognitive abilities, organizational and problem-solving skills, as they have decided to manage the initiative which makes them the protagonists of this single project but helps them to become the protagonists of a greater project, that is the life one. The micro-team devoted to this activity keeps in contact with doctors and workers who are responsible for remote users, and provides accurate update in order to account for the team work outcomes and to share intervention strategies, although being different.

Results and Discussion

Diverse research and assessment methods have repeatedly demonstrated that the benefits for the participants in the described workshop are numerous: “feeling watched with attention and appreciation, looking at oneself, and perceiving to be a story protagonist gently and effectively shows that narration and photography can be exceptional therapeutic tools”.

This activity also reveals a strong involvement by the workers devoted to this type of projects.

The workers have employed creativity, competence and effort to suggest and sustain a greatly innovative technological development that has had to be reinvented day after day, in the face of the continuous challenges posed by the fast evolution of the situation. And surely it represents grounded evidence where reflections on an absolutely necessary renewal can be founded on, so that actions in the mental health field could adequately meet current population real needs.

The cooperative work with the Day Care Centers colleagues has facilitated the fight against isolation and abandonment, the control of sense of loneliness, therefore the prevention of the clinical and psychopathological worsening and of its possible consequences (Emergency Room access, admission to the Psychiatric Diagnosis and Treatment Service, psychiatric visits and dedicated facilities crowding, etc.). Another positive aspect observed in the remote work has been the “grip” on users who are reluctant to meet in-person, which enabled a tout court integration in the program activity that boosted treatment compliance and, subsequently, eased the burden on families during the emergency period. Project-assessment indexes and tools have been used to record data regarding number of interventions, attendance and contacts, on both individual and group levels, as well as data concerning project evaluation and approval. Reference tools are: the V.A.D.O. and the Mental Health Recovery Star for assessments at T0, T1 and T2. Moreover, the micro-team, that is made up of the Day Care Centers representative Social Health Educators and the Mental Health Center Social Health Educator, periodically organizes updating meetings in order to identify, plan and verify individual and group interventions (Morosini et al. 1998; Burns et al. 2014). Remote Rehabilitation falls under the broader category of telemedicine services as indicated by the Ministry of Health that, in 2012, issued the national guidelines. Recent studies have pointed out that this kind of interventions are increasingly being appreciated by people affected by serious mental illnesses such as schizophrenia or bipolar disorder, as they are means that make them understand and manage their condition in a better way (Klein et al. 2018; Mueller et al. 2018; Biagianti et al. 2017). The remote Rehabilitation value lies in the Evidence-Based (EBM) nature of Psychiatric Rehabilitation techniques and in the way professionals can turn them into efficient and effective tools that conform to the users’ needs (EBP – Evidence Based Practice). In conclusion, despite the undisputed and essential value of human contact and face-to-face relationships, the work reported here shows the importance, for Mental Health Services, of employing communicative modalities, like the current alternative virtual ones, which have been widely used by now and should be combined with traditional modalities, because, in this particular case, they are convenient to face an emergency period but, on occasion, they might be useful to involve users that would otherwise be hardly reachable, gathering people who don’t need to travel anymore, thus overcoming organizational limits set by geographical distance. The emergency period has offered the opportunity to assemble the Social Health Educators micro-team, giving credit to the “active listening” as an exclusive means to reset their modus operandi which necessarily embraces dynamism and empathy, hence demolishing, both metaphorically and virtually, the limits (im)posed by social distancing due to Covid-19.

Acknowledgments

• For their advice and contribution:

Crisafulli Francesco – Professional Social Educator –Disability Unit Coordinator, AUSL BO – Professional Education Faculty Member at the University of Bologna – Professor of Continuing Education ECM.

• For their collaboration:

Squeo Carmen – Social Health Educator – Coordinator of “Questa Città” Day Care Center, Gravina in Puglia, Dimeo Emilia – Social Health Educator – Representative of “Questa Città” Day Care Center, Gravina in Puglia, Nolasco Anna – Social Health Educator – “Questa Città” Day Care Center, Gravina in Puglia, Derosa Domenico – Social Health Educator – Coordinator of “Auxilium” Day Care Center, Altamura, Abbadessa Filomena – Social Health Educator – Representative of “Auxilium” Day Care Center, Altamura, Facendola Angela – Social Health Educator – “Auxilium” Day Care Center, Altamura.

• For her supervision:

Santoro Maria Giuseppa – Representative Psychiatric Medical Director, U.O.S. Altamura – Gravina in P. – Poggiorsini C.S.M. 2 ASL BA.

• For their support:

Ferramosca Silvia – Psychiatric Medical Director, C.S.M. 2 Altamura ASL BA, Magnifico Giuseppe – Psychiatric Medical Director, C.S.M. 2 Altamura ASL BA, Pugliese Assunta – Psychiatric Medical Director,  C.S.M. 2 Altamura ASL BA.

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