Italian mental health supported accommodation services: the strengths and weaknesses

Background Different processes of deinstitutionalization across European countries have led to the development of a variety of residential services. According to international guidelines, the recovery-oriented approach should guide these services. In Italy, one of the pioneer countries of deinstitutionalisation, users should move from residential facilities (RFs) with more support to those with lower support as they acquire sufficient autonomy. However, different policy strategies and resources have been criticised internationally as leading to trans-institutionalisation and/or re-institutionalisation rather than rehabilitation. There are no studies that have explored in detail the strengths and weaknesses of the Italian residential system to support recovery for people with severe mental disorders (SMD). Aims This thesis aimed to investigate the strengths and weaknesses of Italian RFs to support recovery for people with SMD. The objectives were: 1) to synthesise information about recovery-oriented practices and rehabilitation, 2) to review the organization of RFs in Europe and in Italy 3) to hypothesize a recovery-oriented residential model 4) to investigate the quality of Italian RFs, including recovery-orientation and users’ perspectives 5) to evaluate whether supported employment might positively impact on users’ general outcomes 6) to assess whether individuals were placed appropriately in RFs and to facilitate their monitoring evaluating functional autonomy 7) to evaluate the use of a new organisational model in RFs 8) to investigate whether staff could be trained to deliver recovery-oriented care. Methods Recovery-oriented practice in mental health settings and its association with rehabilitation, and the RFs organization in Europe and Italy were described. A recovery-oriented residential model was hypothesised through: the translation of the Flexible Assertive Community Treatment (FACT) which provides a model of community-based care characterised by a well-organized recovery-oriented and outreach approach; the translation of a questionnaire, the Quality Indicator for Rehabilitative Care - Supported Accommodation (QuIRC-SA), which evaluates quality and recovery orientation of RFs; the description of a tool, the Mental health Recovery Star (MHRS), which assists the user to identify and evaluate his/her recovery facilitating shared-decision making; the validation of an instrument, the Monitoring of the Path of Rehabilitation (MPR) Form, that evaluates users’ functional autonomy. A sample of users of Verona RFs was studied via a cross-sectional survey and longitudinal study to investigate the quality and performance of RFs. A sample of users of a social enterprise in Verona was matched to users of local RFs to investigate whether supported employment could positively impact users’ general outcomes. A sample of RFs across Italy was evaluated using the QuIRC-SA, and associated with the assessment of users’ experiences. A longitudinal pilot study was conducted in services in Verona to investigate the feasibility of implementing recovery into everyday practice. The FACT model was adopted in a RF team in Verona. The MPR was validated and used to survey a sample of people living in Verona RFs. Results The shift to a recovery-oriented approach is necessary to avoid transinstitutionalisation and/or re-institutionalisation of users but represents a key challenge in mental health services. A recovery-oriented residential system might be a complementary set of instruments to implement recovery and quality of RFs and to promote satisfying lives for users. Italian RFs provide an acceptable environment and meet the fundamental needs of most users. Most users are appropriately placed in these services, which tend to work with those with higher needs, but some RFs lack the appropriate rehabilitative ethos to support individuals’ recovery. Users have stayed in the facilities for a long time and have difficulties in moving on to less supported settings. The FACT model might readdress the organisation of everyday practices. Tailored support to assist people to gain employment skills might facilitate recovery. The integration of recovery-oriented instruments in RFs might help to redefine their cultural frame towards recovery. Discussion and conclusions Our findings on quality, performance and functioning of Italian RFs provided by the studies conducted as part of this thesis suggest that the Italian residential system is not fully effective in implementing and integrating approaches that can assist users to optimise their recovery and autonomy, to gain the skills required for more independent living, and enable their successful progression to less supported settings. This evidence might be useful for decision-makers to rethink the organisation and the priorities of the Italian residential system.