Recovery

Prevention, Care, Rehabilitation: Recovery is possible

1. Mental health and wellbeing can be best described as the ability to establish appropriate and satisfying relationships and adopt adequate behaviours in order to deal with life's changes (environmental, relational and institutional). When these abilities are reduced, compromised or lost, the Mental Healthcare Services have the task of providing prevention, care and rehabilitation. In order to achieve these aims they must involve different settings, structures and persons, as well as different community actors and resources.
   Prevention, in its widest sense, must involve the entire social organisation, given that promoting health - and mental health in particular - means improving living conditions and responding to a person's basic needs, especially persons in weak or vulnerable social groups. Prevention means making social spaces more livable and promoting wellbeing and community development while respecting cultural, ethnic and religious diversity. It means facilitating access to education, training, information and culture and creating pathways to knowledge, communication and exchanges – not only among individuals but also among different social groups.
   Care must ensure that persons who find themselves in a state of difficulty, whether temporary or permanent, do not lose their rights, social abilities and qualifications, and their dignity and power in exercising their affective, relational, family, productive roles. However, in fighting against the risks of expulsion and marginalisation, there must also be a strong commitment to transforming attitudes and behaviours based on prejudice and intolerance, while at the same time recognising the problems and rights of family members and caregivers, or those who can be even indirectly involved or harmed. Actions, gestures and knowledge, the times and places, tools and programmes of care intervention should aim at giving value to the meaning and contents of suffering, the uniqueness of experience and life-stories, and utilise the need and demand for change which actually involve the relationships between persons and institutions, and between individuals and society as whole.
   Rehabilitation, which is the learning or recovery of capacities, abilities and social competencies, must seek to combine the different approaches that are best suited to the difficulties and obstacles present in each individual case. Its aims and implications extend well beyond the services themselves, for rehabilitation means promoting the use of resources and empowering persons so that they are capable of a full and meaningful exercise of citizenship.
   
2. But how can these criteria and principles of prevention, care and rehabilitation become tangible realities in the daily work and organisation of the Mental Healthcare Services? By means of what pathways, activities, programmes? And with what resources?
   Clearly, the answers to these questions are complex and open (and to which our WEBSITE seeks to provide a partial response), but in our view of fundamental importance the multiplicity of responses – of places, persons, cultures and resources which enables us to express more fully the demand for health, and which permits us as mental healthcare operators to face the problems linked to mental disorder with greater optimism. Indeed, the prospects opened up by the Italian Psychiatric Reform Act of 1978 has made it possible to overcome the prejudice of incurability/chronicity of the mental ill person, which only a few short years ago excluded recovery from mental illness as a viable attainable goal. By "recovery" we mean the experience of "regaining oneself", of "getting back on track" and regaining control of one's life. Each journey of recovery is personal and unique, enabling a person with a severe mental disorder to regain full autonomy, both as a person and a citizen, and making one responsible for oneself because capable of being responsible towards others, ultimately even helping others with similar problems and difficulties.
   Today, the possibility of recovery from a several mental disorder is often linked to adequate pharmacological and psychological treatments, which can alleviate mental suffering and reduce the destructive behavioural and relational consequences which sometimes result. But such treatments alone would be inadequate if the new community-based servces did not also work to empower users, family members and private citizens in order to reinforce the user's autonomy, and their ability to make choices and decisions which aim at achieving health and wellbeing and defending their own interests.
   
3. The main "discovery we"ve made in our many years of fighting against exclusion is that the person who suffers from a mental disorder must, above all, be helped in order to safeguard and preserve their rights within society: both in their own private, day-to-day lives as well as within the network of relations and exchanges of the community to which they belong. These rights cannot be sustained by abstract legal and administrative norms, but by resources which must be actively sought out and formalised, together with actions and interventions which guarantee access to such rights and their real, effective use and implementation.
   In other words, a right exists when it can be exercised, when it is recognised in a person's real life, in the forms of their social reproduction and in their emancipatory processes. Today, many people realise that this is at the heart of any therapeutic-rehabilitive work. Indeed, the originality of the Trieste experience probably consists in trying to invent – for more than 30 years now – on a day-to-day basis ways of gaining access to social opportunities and rights (housing, income, work, education and training, social networks and forms of belonging) through the use of resources and procedures which differ from those generally used in psychiatry.
   Today, many people with a mental disorder (or who have suffered from a disorder in the past) actively participate in groups and association that defend their rights, often supported by operators, volunteers and private citizens. Family members are likewise increasingly active in the services, and the various programmes for support, information and reduction of the family burden are helping to improve the quality of life for the entire family unit.
   However, the possibility of receiving help or activating process of healing and empowerment are still, in many cases, conditioned by prejudices and the forms of discrimination deriving from them. And while the closure of psychiatric hospitals has, in and of itself, produced major changes in the social image of persons with a mental disorder, manifestly improving their abiltiy to maintain social roles and capacities and holding out real prospects for recovery, there is still much that needs to be done in this area, in Trieste as elsewhere.
   
4. "Beliefs hurt, facts help": this is a key concept in a documented presented by WHO on Mental Health Day, April 7, 2001. Western countries currently make major investments in mental healthcare programmes, with countries like Norway and Germany allocating more than 10% of their total healthcare budgets to mental health. Nonetheless, the general image of mental illness, the stigma, prejudices and clichès which accompany it continue to persist, negatively impacting on access to services, care processes, social integration and, above all, recovery. The image of a mentally ill person who is not only "dangerous" but also incurable, irresponsible (in a legal and personal sense), incomprehensible and, ultimately, unproductive, likewise is on the increase. Fueled by these prejudices, significant resources are earmarked for social protection and security, resulting in the reproduction of places of confinement/exclusion, restrictive and invalidating procedures and the high human cost of tragic and irreversible outcomes.
   The supposed risk involved when we encounter a person with a mental disorder manifests itself in incomprehension, fear and a "sentence" of incurability. The mass media especially exploits this equation of mental illness and danger, sensationalising certain painful episodes and blowing them completely out of proportion. And this despite the fact that numerous studies have shown that, on the contrary, mentally ill persons commit far fewer crimes than the rest of the population. And yet mental healthcare policies and legislation continue to be conditioned by the concept of danger and violence, instead of seeking to provide for community services and effective care.
   In Italy, for example, there is a general misconception that infanticide is currently on the increase, even though there is absolutely no statistical evidence to support this commonly held belief. On the contrary, this crime has continued to occur with terrible but very limited regularity since the days of Medea, which is its mythical representation. This crime is often explained by "depression", and yet a psychiatric diagnosis will show that it is absolutely alien to and beyond the bounds of normal human behaviour, while at the same time we must acknowledge that the temporary rejection of one's child and a sense of alienation and incapacity is common to all women who become mothers and that these feelings are as natural as birth itself.
   The use of the word "depression" is emblematic here. In its common everyday acceptation it goes well beyond the specific clinical condition, which is actually limited to a very small percentage of the population, and is instead applied to an incredibly wide range of human experience: from nostalgia to sadness, melancholy to fatigue, frustration to grief, unemployment to the sense of incapacity and inadequacy which occasionally afflicts everyone. Clearly, the use of the word "depression" calls for a medical and biological explanation and justifies the widespread use of drugs. But most importantly, it subtracts meaning from our experience and can even result in irreconciliable breaks or ruptures in the continuity of our own lives, while also nurturing other commonplaces: for every human condition a diagnosis, for every diagnosis a drug, a psychologist or a psychiatrist to solve the problem.
   However, sometimes it is not possible to solve these problems, also because human behaviours cannot be simplified in this way, giving rise to the conviction of incurability. And yet in the case of a severe mental disorder like schizophrenia, the judgement of incurability is not borne out by the facts, given that one third of all persons recover completely and another third achieve so-called social recovery, or the ability to conduct a "normal" life with the aid of therapeutic support. And even the final third cannot be considered "incurable" and is in fact defined as "resistant to treatment". All of which encourages us in our desire to seek the right way forward and not surrender to the idea of an incurable illness.
   Persons with a mental disorder must undertake a journey of recovery and changes which are as unique as they are diverse. Today, many people can describe their own recovery without shame or embarrassment. Still, the idea of incurability remains the most insidious of commonplaces, precisely because it feeds fear, hides resources and possibilities for recovery and destroys hope.
   And yet living with schizophrenia did not keep John Nash from winning the Nobel Prize for economics or prevent Gianni from becoming a hotel porter, it has not stopped David Helfgott from giving worldwide concert tours or Marina from earning a degree in chemistry, doing her doctoral work in Sweden and work today as a researcher, it did not prevent Philip Dick from writing his novels and short stories or Nicole from going back to work and becoming the splendid mother she is.
   Even when living with a mental disorder condemns a person to the bleakest forms of isolation, delirium and hostility, so thhat they feel completely trapped, even then it is always possible to find a way out. But first we must free ourselves from the quagmire of beliefs and prejudices.
   
5. If there is one thing we are certain of, it is that information, knowledge and the aware participation of the general public are all indispensable in order to construct and keep renewing the system of mental healthcare services. At the same time, we realise that contacting the psychiatric services and formulating a request for help for the first time remains an extremely delicate and risk-filled moment. The time required for formulating the demand correctly and reaching the services, how the demand is transmitted and received and the first actions taken in response to the demand are all very important in determining outcomes in the short, medium and long term.
   One of the purposes of this Website is thus also to reduce this risk by facilitating access to the services while at the same time providing more effective forms of communication, exchange and knowledge among those who work in promoting mental health, and between the general public and the services.

Dr. Giuseppe Dell'Acqua
Director, Trieste Mental Healthcare Dept.