Progress Report on the Slí Eile Housing Project (Villa Maria) May 2007
by Lydia Sapouna – Department of Social Studies: University College, Cork

1. The Evaluation Process

This is the first progress report on the Sli Eile housing project, combining an analysis of data from the baseline and the interim evaluation. The report presents the key initial findings of the evaluation and aims to provide a tool for discussion on the progress of the project and the extent to which its original objectives are being met. A number of recommendations are also included in areas where further action is considered appropriate.

Most sections of this document provide a full discussion on findings. However, due to time constraints, some sections provide a summary of findings. Priority for discussion is given to the sections presenting the qualitative data on the tenants’ experiences of the project.

1.1 Discussion on Methodology

As outlined in the original evaluation document, the main methodological tool employed for this research is qualitative in nature. This is considered a suitable approach for this project as qualitative research is concerned with how people understand a given topic, in this case a therapeutic, community-based approach to responding to mental distress.

Baseline data

The first part of baseline data was collected in September & October 2006 and involved:

documentary analysis
individual, semi-structured interviews with four members of the project’s board of directors
individual interviews with the staff team
Baseline on tenants could not be collected until they had made a decision to stay in Villa Maria. The question of ‘the appropriate timing’ to interview tenants and the ethical issues regarding consent were important in the process. Due to the nature of the relationship of the service user group with the mental health services, the priority was for the staff team to establish a trusting relationship with participants and then introduce the evaluator.

In October 2006, the two first tenants of Villa Maria were interviewed. Two further tenants joined the project in December 2006. They were interviewed in March 2007 and, at that point, interviews collected both baseline and interim evaluation data. These interviews were largely focused on the way tenants describe (a) their own needs and expectations at the initial point of engagement with the project and (b) their experience of their participation in the project.

Interim report-methods of data collection
In January, March and April 2007 the following interviews were held:

individual interviews with 4 tenants
individual interviews with the staff team
individual interview with the strategic development officer
individual interview with one member of the board of directors
Feedback from a student who completed a social work placement in the project was initially received through a questionnaire, and was then followed by discussion.

Confidentiality in data presentation

All interviewees were guaranteed confidentiality in the presentation of the report findings. Therefore staff, tenants and members of the board of directors are not named in the report. As some interviewees have a distinct role (i.e. strategic development officer; student social worker) they are also referred to as ‘staff’ in the report for reasons of confidentiality and consistency.

2. Baseline-Stakeholders’ Expectations of Sli Eile

2.1 Tenants’ Expectations

Tenants’ expectations varied significantly. Some tenants articulated clear plans for the future while others appeared to be unclear about a ‘sense of purpose’ associated with living in Villa Maria.

Recovery

While not necessarily focusing on specific plans, most tenants expressed a hopeful vision for the present and the future. During the baseline data collection, one tenant mentioned her expectation ‘to recover’; however, she did not wish to elaborate further on her understanding of recovery. Another tenant described the project as a ‘stepping stone’ to getting better, while a further tenant spoke extensively about her hope to “be more pacifist, find peace with myself face up my fears, have a go with family life…learning to trust them [family] again ” .

Independence

Independence is a central component of the recovery process. Two of the tenants talked about the need to ‘get back on their feet’ again. They both made a direct reference to loss of independence since becoming unwell. One tenant acknowledged how difficult it would be to make plans and stand on her feet again “I don’t know [what my expectations are] because this is the situation for me at the moment – before I went into hospital I had a little job, and I was living on my own, and I had kind of settled myself…And I was coping ok … and then I went into hospital and I unsettled myself again, and I lost my little job that I had. Now I’m here and I feel that it’s very hard to get back up on my feet again”. Another tenant made reference to becoming more independent by catching the bus and not getting lifts or taxis.

Getting a job

Some tenants viewed getting a job as a way of regaining their independence. Since moving to Villa Maria one tenant has been actively preparing her CV and has been applying for jobs. Another tenant who was satisfied with her employment in the past said that she would like to find a job again but acknowledged that at the moment she needs to mind herself first.

Getting fitter and more active

Three tenants made direct reference to plans to become more active and get fitter, by being involved in a exercise regime.

Deciding to stay

Tenants associated their decision to stay in Villa Maria with experiencing the house as a nice, relaxed place, which gives them a sense of support and companionship. One tenant said “ ….the people in the house, the company, we look after each other and you know it’s good company really”. Tenants also made reference to forming friendships as motivation to stay. Another tenant talked about liking the opportunity to do things such as shopping, cooking and gardening as something different from previous experiences of services.

But also anxiety about the next step

Two tenants expressed quite high levels of anxiety about what they will do after Villa Maria. They suggested that moving on with their lives might mean that they will have to move out of the house.

Recommendation:

There is a need for more clarity in relation to the ‘tenure contract’, particularly in relation to whether ‘moving on’ means ‘moving out’.

2.2 Staff and management expectations for tenants (summary)
It was anticipated that Sli Eile will provide opportunities for tenants to:

recover in a safe, therapeutic and non critical environment
be facilitated to find what they want to do with their lives and ‘move on’
focus on the future rather than where they were before
become independent, full of dignity and confidence
regain their self esteem
stand up on their feet
be happy, have their basic needs met
eventually become involved in supporting Sli Eile
3. Interim evaluation

This part of the evaluation discusses three main themes (a) understanding and practice of the Sli Eile Approach to recovery, (b) the impact of the project on the tenants and (c) management and organisational structures. The data is based on in-depth interviews with tenants, staff and management.

3.1 Articulating the Sli Eile approach to recovery

“I can see a difference in the service users already. I was here first day when people moved in and I was surprised at how withdrawn they were, and quiet, and even their posture very closed…. and how far they’ve all come individually. At times it can be frustrating, things can go backwards, but overall I think it’s positive so far” (staff, March 2007)

The aim of Sli Eile is to provide a safe therapeutic environment conducive to recovery. However, staff and management agreed that, at the initial stages of the project, there was a lack of focus and sense of purpose. As a result a need to develop a common vision in relation to recovery for both tenants and workers was identified. “To take on board the vision, a shared vision and to create a culture that will be there and that people can almost taste and sense when they walk into the house, which isn’t there at the moment, that must still happen” (management member, January 2007).

This situation has improved significantly since January with the employment of the new Strategic Development officer, who also provides individual and group staff supervision. As one staff member put it “ I think the project is a lot more steadier now [March 2007]… we are a lot more focused, we know where the project is going, and I think that is because of the training we did and we all did the same training so we’re all singing from the same hymn sheet I suppose”. Furthermore, staff described the project as being ‘strengths-based’, ‘built on trust’ and on ‘being real’.

The recovery approach seems to appeal to the staff team. As one person put it “I can’t see how any other approach would work, because it’s the whole point of living together and learning from each other and moving on, I mean that’s real life – I mean people live in houses and share each other’s company but also share the responsibilities and whatever else, so it just seems the most common sense way to recover your mental health, and I think that’s the basis of it you know people – anybody who comes through the recovery system would want to live in some domestic sense …in their future whatever choice that would be, so it makes sense to recover in a domestic environment”.

Developing a shared sense of purpose has had a positive affect on the tenants. Tenants are perceived by staff and management as becoming increasingly comfortable within the house, “ they are not referring to us as nurses anymore which is a good sign…” (staff member, March 2007).

Tenants themselves described Villa Maria as a homely, friendly environment where they feel respected by the staff team.

Recommendation:

– Focusing further on developing a shared vision for recovery for tenants and staff.

3.2 Tenants’ experiences of life in Villa Maria

“I like living here because I’ve my own privacy and I’m with really nice people. Everyone has their ups and down days you know, but lately I’ve had all ups – ya – I have so much to gain by living here really” (tenant, March 2007).

In relation to measuring ‘successful outcomes’, a significant factor to be taken into account is the long history of tenants within the mental health system. All tenants, despite their young age, have been affected by institutionalisation. As a result they seem to have lost a sense of hope for the future as well as the confidence in their own abilities. They have also been deprived of opportunities to take responsibility for their own lives. Being in an environment where they are encouraged and expected to make plans and take responsibilities is a new and challenging experience. Therefore small steps towards building their confidence and independence at their own pace are central. At the same time it is important to be clear that living in Villa Maria has a purpose; it is focused on recovery. This requires a commitment from tenants towards involvement and engagement with this process. Significant support is required to achieve this involvement in ‘looking forward’. “… They feel that their dreams and their aspirations have been trampled upon, and they’re not sure where they want to go to next, because what they thought was going to be their life picture hasn’t happened, so I think someone needs to help them and listen to try and develop what their life picture is going to be because they’re not sure…” (staff member, March 2007).

Staff and management acknowledged that, while change is a slow process, and while you can often make one step forwards and three backwards, the tenants have gone a long way. The importance of capturing small changes such as finding one’s voice in a meeting or going to the local shop was stressed. A point was also made that a possible re-hospitalisation of a tenant should not necessarily be viewed a setback as, given the new recovery context, it might be short and purposeful and help the individual move on. Staff also recognised that tenants have more skills and strengths than initially expected.

Recommendation

The impact of institutionalisation needs to be taken into account in evaluating tenants’ ‘progress’.

It is important to capture ‘small steps’ towards confidence, engagement and independence.

Relationship- building; interaction and communication skills

Tenants talked about becoming more comfortable being part of a group, and valuing the support they receive from other tenants. Some tenants made direct reference to developing their social skills further. “I suppose mingling with people, I’ve learned how to interact with people better, when I was at home…we usen’t get many people calling to the house, or I used to go out maybe once or twice a month, I just I find here it’s more active, I’ve more things to do, I feel more relaxed and I participate with everything with the girls and they’re really nice girls so I’m really, really lucky” (tenant, March 2007).

Staff also mentioned changes in communication and interaction patterns; for example one tenant who would not have sat down for a meal before joined tenants and staff team in a restaurant for a meal.

Becoming more involved and engaged was also an achievement recognised by staff. “One tenant who would never sit down and get involved in conversation or anything…where now we’d sit and watch a whole film maybe with her and talk about it, that wouldn’t have happened before, that’s positive” (staff member, March 2007).

“ [Tenant name] would have been very withdrawn, she might make a statement and walk out…and now she kind of discusses it, and kind of get her to evaluate it, you know she kind of thinks about it more rather than just makes a statement, and I found it difficult at the start because she was very withdrawn, into her room and things like that, now she’ll stay out… she’s coming out of her room a lot more” (staff member, March 2007)

Two tenants specifically talked about building friendship and how important that is for their wellbeing. The improved interaction and relationship building between tenants was also recognised by the staff team. “I just remember at the start if we were all sitting around the table it would be me to [tenant A] me to [tenant B], me to [tenant C], conversation you know, it wasn’t among themselves and now they’re chatting among themselves and it’s all different directions you know, so they’re building on the relationships with each other as well and I think they help each other out as well in a way you know, if everybody agrees to go to something and somebody pulls out another tenant would say – go on sure you’d be brilliant at it why don’t you go, rather than always the staff trying to encourage the tenants, they are doing it to each other now as well” (staff member, March 2007).

An important point was made in connection with relationship building – the normality of having tenants arguing with each other. “…even watching them sometimes having an argument in the kitchen over silly things and they wouldn’t have done before, you know but they feel really comfortable I suppose with themselves even arguing over the washing up, like we do at home, any of us would do” (staff member, March 2007). As another staff member put it, tenants learn how to cope with difficulties in relationships, “which is the basis of most problems for most people here”.

The development of positive relationships was not limited to interactions between tenants. Tenants recognised how important it was for them to feel supported by staff. “…ya very supportive…the staff are very nice and it seems to be, the staff are very helpful and I seem to get on well with them” (tenant, March 2007). They also said they are treated with respect by the staff team; as one tenant put it “they think we have potential”.

Building confidence

Staff and tenants talked about tenants becoming gradually more confident in themselves. An example was given of a tenant “…who wouldn’t up until now go shopping on her own, would want an assistant or maybe support all the time, and I’ve noticed now the last few weeks this same girl is going down and doing things on her own, taking her responsibilities” [staff member, March 2007]. A tenant talked about how she is now more confident using public transport rather than depending on lifts from family members or taxis. She associated this step with becoming more independent. The issue of confidence is ultimately connected with all the steps taken by tenants so far, particularly with ‘finding their own voice’ in the house.

Gradual ability to voice opinions; opportunities for participation

Tenants and staff were asked about tenants’ participation in decision-making and whether tenants ‘speak up’ then they need to. Interestingly there are different views on this matter between staff and tenants. While tenants overall indicated that ‘they don’t say much’, staff noted a significant change in tenants finding a voice for themselves.

Two tenants said that they keep to themselves and only voice their opinion if they really feel very strongly about an issue. “No, I usually keep to myself so I don’t have to voice my opinions very much. Only sometimes now, say if somebody was really getting annoying, you know I’d just say to them look I just want to be by myself for a bit like, or else I’d say go on nag them, (laugh) but otherwise I wouldn’t” (tenant, March 2007).

This is not necessarily a reflection of fear of voicing their opinion. It can be connected with previous experiences of mental health settings where people felt that their opinion was not valued, or where they were penalised for expressing ‘controversial’ views. Another possibility is that tenants themselves have not evaluated their progress in that regard. This is something to be considered, for example by giving more explicit feedback to tenants and creating opportunities for self-evaluation. Furthermore, in order to encourage more participation the structure and timing of house meetings can be considered. For example, one tenant who described herself as “not really assertive” said that in order to “encourage participation there should be meetings in the evening to plan activities and holidays and things like that”. The need to open up opportunities for tenant involvement in more ‘serious issues’, such as staff and tenant selection, was also mentioned by some staff members.

One tenant said that she would speak up if she wants to. What is worth noting is that all tenants felt that their voice is heard and respected by staff.

On the other hand, staff talked extensively about how tenants developed skills to voice their opinions, particularly their dissatisfaction. “I think it’s [the model] useful because it’s empowering, it’s gives the tenant a voice, you know if they are not happy with something that they have that safe environment to say ‘I’m not happy with the way things are going’, or if something is being forced on them, you know it’s a bottom-up approach rather than a top-down approach, and it’s meeting their needs, and they know what they need to recover and they know their body so it gives them a voice. And I suppose building on that relationship, the trust and that they can talk to us about something and it will be confidential and non-judgemental…” (staff member, March 2007).

This is evident in the “… interaction of the tenants with each other and with the staff. They are lot more verbal and even people stand up for themselves…” (staff member, March 2007). An example was given of a situation where there was “a bit of bullying and one tenant wasn’t standing up for herself, she was going into her room and staying there for the night, and now she’d say – ‘I really don’t like the tone you’re speaking to me in, I think it’s very disrespectful’; It was important that the individual found their voice and stood up for themselves”.

On a similar note, making reference to a particular tenant a staff member said “when she first came she was very quiet, if you asked her something it would take so long to get an answer and in a way you’d think she was just ignoring you…but now she’s a lot more – as if she’s a lot more alert or focussed or something…. she talks a lot more. And [in relation to the chores rota]… if somebody said to do something and somebody might say ‘[tenant name] will you do it’ – and she’d be like ‘no I have my jobs here on this’ – you know she speaks up as well” (staff member, March 2007).

A staff member, who became aware that a particular tenant had confided to another staff member that she found her ‘intense’, also identified tenants’ growing ability to express their concerns. The staff member about whom the complaint was made brought this up at the house meeting, explaining “I am open to hearing if something I’m doing is not helping tenants. The tenant who had brought up the issue went on to explain how she has had people controlling her for years in the psychiatric system and she wants now to do her own thing and not be put under scrutiny or pressure by staff, who she pointed out are only paid to be in the house! I think this was a very significant piece of work and was glad that the tenant was comfortable to be openly critical of what she saw as faults in the way I was dealing with her. It was also an opportunity for her, and other tenants, to outline what other problems they were experiencing. After the meeting we agreed to write down in the diary that two named tenants wanted more space in the evening and needed time to relax before getting involved in the activities or any discussion in the house. And one tenant expressed that it’s enough to write down the daily chores on the board, that it annoyed her when staff checked if she had done her chore. This meeting was also an opportunity to introduce that there may be some discomfort in the way we are communicating openly in the house, but that any issue between housemates (by that I refer to tenants and staff) can be brought up as long as it’s done respectfully (staff member, March 2007).

From the above it appears that critical feedback from tenants is appreciated by the staff team and is regarded as a positive indicator of tenants’ assertiveness.

Recommendations :

-Facilitate tenants to identify and evaluate their own progress in relation to becoming ‘more vocal’.

-Create opportunities for more joint planning of activities between tenants and staff. House meetings do not always offer such opportunities

-Consider involving tenants at a broader level of decision-making (e.g. tenant or staff selection process).

A sense of responsibility, ownership and collaboration

All tenants talked about the importance of having a sense of responsibility and collaboration in the running of the house. “We have a rota for all the work that goes on in the house, and we all sit down and chat, and we chat about what we’re doing, all the courses we’re doing, you know the daily chores if anyone wants to swap, and everyone’s hobbies and what people want to do by themselves…it is very good” (tenant, March 2007).

Another tenant, making reference to what helped her settle in the house, said that doing chores and shopping did. The therapeutic element of this practice was also recognised: “It’s going OK you know… we share things, we cook together and we take turns in doing things. We’ve our own house chores to do… and that’s good therapy, that’s good practice” (tenant, March 2007).

The sense of normality associated with such responsibility was also articulated: “…I like the idea of cooking for yourself…it is just normal life…” (tenant, March 2007).

A different side of ‘normality’, i.e. the ‘negative side’ of house duties, was articulated by another tenant who said that she likes the daily chores; however “I’m afraid not to do the jobs here and I wasn’t like that in [previous accommodation]”.

Staff also recognised the importance of tenants taking responsibility for collective (e.g. saving money for a concert) and personal finances. Collective tenant responsibilities also provide tenants with opportunities to negotiate, learn to be flexible and appreciate the contribution of ‘others’ to the house.

Engaging with Activities

Opportunities to engage with various social activities were appreciated by tenants.

“I’m more outgoing and I thrive an awful lot more. I’ve a lot of courses – I’ve an awful lot of things to do which is brilliant. I’m interested in badminton I’ve a course every day, Monday to Friday, music, everything, and it’s just brilliant….I think if I didn’t have them I’d be really, really – I’d be constantly thinking about my family or my friends, you know I would be much more upset, so I’m grand that I have them hobbies ” (tenant, March 2007).

Another tenant spoke with a sparkle in her eyes about how much she likes ‘going places’ and being involved in gardening. An interesting point came up when she was asked whether she did any gardening in her previous accommodation (hostel). She said that she did not and after a while thinking about it said “I couldn’t have done it if I wanted to but I didn’t”.

Staff also acknowledged that tenants were gradually becoming more confident in trying new things: “I suppose little things like, you know one tenant had a fantastic camera thrown under her bed, never used, you know I brought that out – a digital camera, put it on the computer, made slides out of the photos that were on it, got her going on that and got her out to Doneraile Park to take new photos and laminated them and put them on the wall, so that was positive because it made her aware of what you could do with it, and it led to another tenant getting a camera and getting some great interests, and so I think that was positive” (staff, March 2007).

Another example of engagement in activities was given by staff – “ we went to the cinema there last week, about four of us – we went to see ‘Becoming Jane’ and initially there was one tenant who didn’t want to come, and she wouldn’t normally have got involved, but we kind of just said come on it will be great crack and we’d love if you could come, and we all went and we had a great night and she even said afterwards that she was delighted that she came”.

Two staff members noted that tenants smoke less since moving into Villa Maria and acknowledged this as a positive development. “When [tenant] first moved in here you’d hardly never see her, she was always out the back, now she comes in, she’ll sit down, she watches the soaps, she stays in the evening time in the kitchen talking or even if she’s not talking, like she’d stand next to the chair, like she mightn’t sit down but she’d stand next to the chair, and then it would go from there to sitting down, like she’s making that move the whole time” (staff, March 2007).

Recovery

– Making plans; hopes and possibilities

“…there is hope for the future and there is another way to do it” (staff, March 2007).

Since moving to Villa Maria tenants have begun to look into the future and to slowly identify wishes, goals and plans. “[Tenants now say] ‘I’m looking to coming to reducing my medication’, ‘I’m looking forward to’ – which is great, because a few months ago nobody would have said that and I can see people looking to the future a little bit, I suppose looking to the possibilities, whereas before they wouldn’t have maybe thought about possibilities” (staff, March 2007).

However, in the broader context of the project, concerns have been expressed about a lack of a shared vision for recovery among tenants and staff. This issue is discussed in section 3.1. As already discussed, this situation has been improved with the employment of the new Strategic Development Officer and the introduction of the WRAP (Wellness Recovery Action Plan) program. The WRAP program is further considered in the following section.

Staff also identified the need to know more about the future plans that tenants have for themselves and suggested that a formal space needs to be created “where to say: we’re not just renting here we are doing something more” (staff, March 2007). The same staff member also recognised that “I might be expecting too much too soon”, which highlights the balance that needs to be struck between setting goals and pacing the work according to tenants’ needs.

A similar point was made by a member of the management board “…our aim is to work closely with the people who have kind of stuck in the mental health service, the traditional one, and give them an opportunity to grow, to re-skill themselves, to gain confidence in their own abilities, and to help them along their path, but working within certain principles… there are certain responsibilities if you sign up to this particular project. It’s not a question of oh it sounds good and then enter the house and stay in bed for the rest of your life, there has to be a commitment for something, but it’s about empowering, about engaging, about discussing, about sharing, about choices” .

– Recognising the holistic nature of their lives

When trapped in the mental health system, people’s identity is primarily associated with the role of the ‘patient’. This is the way individuals are viewed by others and as a result this is the way they view themselves. Thinking about possibilities requires individuals to take a broader view of their lives, to move from being a ‘patient’ and to consider aspects of their identity that were possibly neglected or unrecognised in the past. As one tenant put it, “it’s just basically like I’ve started a new cycle of everything, … saved up to buy clothes, you know you always have the materialistic side as well, well like you have kind of spiritual and health finding in your life it’s more interesting really, but like I do try for both and sometimes like you can only have one or the other really”.

– A safe place to express genuine emotion

This is also an important part of the recovery process. Staff said that tenants are opening up more and that they seem to feel safer to express genuine emotion, for example “say that ‘such and such wasn’t feeling great today’, or ‘I wasn’t feeling great’, or ‘we did this and we enjoyed it’…”

An example was given of a tenant who expressed a sense of loss about her future and as a result engaged in an exploration of these emotions with a staff member – “… she might make comments like – ‘I’ll never get married’, and I [staff] started to say to her ‘what’s your sense of that like, you know how would life be different if you did get married’ …and it brought up some very interesting [issues] …”

– Tenants’ mental health

Tenants were specifically asked about how their own mental health has been affected since moving to Villa Maria. Overall, tenants described improvements in this area. A tenant who has experienced a series of bereavements in recent times said “I find myself cheering myself up every now and then”. Another person said that “I feel better and I am getting more active”. A further tenant wasn’t happy to discuss this question with the evaluator saying that she only talks to her doctor about recovery. She did say however that since she moved to Villa Maria she feels better.

Another tenant said that she is not ‘great at that moment’ but acknowledged that she feels better than she did while in hospital. “I don’t know I just feel better – when I was in the hospital I was kind of you know – not that – I was very quiet and I wouldn’t speak and…..ya [I am] stronger [now]”.

Again, it is important to remember that through their encounter with the mental health system tenants have been disempowered and as a result never considered the possibility of their own recovery. As a staff member put it, “I suppose sometimes the difficulty is that some clients wouldn’t see recovery as something that is going to happen for them, but I just feel that by talking about recovery and hope, and positive things for the future, and what would you like to do, where would you like to go and that sort of thing, it’s kind of getting positive back from them that kind of way I’ve been working on it” (staff member, March 2007).

Recommendations:

Consider the development of a specific ‘space’ where staff and tenants discuss tenants’ goals and plans for the future

A balance between facilitating tenants to identify goals for themselves and encouraging them to achieve them at their own pace needs to be struck. This is particularly true as the current group of tenants have long histories of institutionalisation, where the idea of taking responsibility or even having their ‘own’ vision for the future was alien to them.

A striking difference from previous experiences of the mental health system“in a house you’re actually living”

Tenants clearly articulated a new sense of possibility and prospects, particularly when comparing Villa Maria with other residential and hospital settings they had experienced in the past. Freedom of choice, a sense of responsibility and ownership as well as the opportunity to do ‘normal life things’ were viewed as new and welcome experiences.

“In a hostel they make your own schedule, here I have to make my own” (tenant, March 2007).

“Well like in a hospital you’re just – everything is done for you and you just stay there and it’s like a routine, you get up in the morning, you go through the day, you have your meals, you go to occupational therapy, it’s just – it’s a routine as such, but in a house you’re actually living, you know you an watch television, you can talk to each other, you can – you know it’s – you’re actually living ” (tenant, March 2007).

“Here I am self-medicating, they can be over-protective [at the hostel]” (tenant, March 2007).

“…in [name of hostel] we only had the opportunity to go to the day centre or go home” (tenant, March 2007).

“…in [name of hostel] there was not as much pressure to get out of bed, I felt there wasn’t anything for me to do there…It is different here” (tenant, March 2007).

Issues of quality of life were also identified. “There’s less people about, you aren’t scrutinised as much, you don’t have to be waiting for doctors or nurses to come and tell you this or tell you that, you’re not months in there by yourself just lying on a bed practically having nothing to live for really being so depressed” (tenant, March 2007).

Being among people of the same age group was also important for tenants. “…walking around [hospital name], and I had no friends or no-one to talk to and I used to get really nervous of all the old men there, and in comparison to here like – that’s what I disliked about [hospital name] the age difference as well, I just couldn’t get used to them because they were all much older, but here everyone is my own age and we all come and go as we please and it’s great” (tenant, March 2007).

“In [hostel] – it was really nice, I loved it there. [But]…I felt the time go really slow. The people there were pretty old – fifty plus – I felt that they used get tired so much, and it used put pressure on me trying to amuse everybody…” (tenant, March 2007).

Staff also talked about the open communication and the lack of divisions between staff and tenants. “We don’t have that in Sli Eile, everything is open, we all eat together, we use the same facilities, we sleep in the same place… Yes, one of the big differences is that we don’t keep notes separate from the tenants – the tenants are involved in writing in the diary the same as ourselves… that in some ways might be seen as risky but then if we’re trying to develop some sort of a therapeutic community I think we have to have an openness and transparency, and I think it’s important that tenants don’t feel that we’re writing about them behind their backs, so anything that needs to be said, I think, is being said to them” (management staff, March 2007).

Interaction with the community

Since moving to Villa Maria, tenants’ contact with the community has gradually increased. Tenants have taken considerable steps in that regard; for example individuals who previously would not go out on their own, now go out to do their shopping or use the public transport to go to training courses in Mallow.

There are different views and experiences about the advantages and limitations of tenants being from the local community. For example one tenant spoke extensively about how relaxed she feels in town “I seem to be much more outgoing – before I used to be very, very shy and I used to talk to hardly anybody, and every since I moved to Villa Maria everybody in Charleville like they’re always hello, hello, hello and you know I say hello to them like…” (tenant, March 2007).

For another tenant, however, a staff member said “the stigma is a huge thing for her because she is from the local community…” and does want to be seen with staff and tenants in town, while she likes getting involved in activities outside the local community.

This is an issue that may need to be considered in the referral process, as being from the locality has different meanings for different individuals. For some people it can be a source of support while for others a stigmatising experience.

In relation to the broader level of community mental health services, the experience so far has been varied, but there is a commitment to support the project.

Staff initially identified the possible limitations posed by the lack of resources in the local community. Since the beginning of the project, however, the staff team has become quite active in developing links with the community and accessing resources. Staff members also identified the importance of involving tenants in the development of community resources.

The involvement of local groups, such as the transition year students, has been a positive step forward for both the tenants and the community. Awareness about the project was raised, young minds were informed and tenants were given the opportunity to interact with people from their community. While the project was not always planned with a gardening outcome in mind, it allowed for interaction, conversation and inclusion. The students involved have seen what the project is all about and they acknowledged that the reality of Sli Eile is different from the initial negative perceptions in the community.

In relation to generating broader community support, an interesting point was made by one staff member who recommended more community involvement in the management of the project. “I think it would be helpful if some members of the board were located within the community of Charleville. There are people in the town with influence who feel passionate about the service and their inclusion could lead to greater support, even possible understanding”.

Reflecting on the opposition Sli Eile faced by sections of the local community in the past, the importance of community support and involvement is clearly demonstrated. However, a differentiation needs to be made between ‘community involvement’ and ‘consultation with’ local communities. As a member of the Board of Directors put it “there is no need to keep people informed when all you do is buying a house like anybody else”. An over-emphasis on consultation and information may undermine the aim of the project which is to provide a normal home environment.

Recommendations:

– Consider greater participation of members of the local community to the board of directors

– Community involvement should not be confused with consultation when buying a house.

– Consider what it means for present and prospective tenants ‘to be from’ the local community. For some people it can be a source of support, while for others it can be a stigmatising experience.

Issues and concerns arising from the interviews

– A possibility of complacency/dependency

“It’s all done for you”

While staff and tenants acknowledged that a part of the house rules is the significant level of responsibility that tenants have for house matters, concerns were also raised by staff and management about the possibility of tenants viewing Villa Maria as a halfway house where the main responsibilities lie with staff. The potential of such a trend is evident in the following quotation from a tenant: “As an organisation it is brilliant, because I wouldn’t have been able to afford a house or to live in a house with such – like the house must be worth a lot but it’s great that Sli Eile bought it to house us – it’s just such a big step really for them, I really admire them. Everyone in Sli Eile is so easy-going, you’ve no money worries, you’ve no worries about where you’re going, or courses, or activities, or holidays, like it’s ALL done for you.”

Another example was given in relation to the household budget (also discussed in the next section). While tenants contribute E60 a week to the house kitty, they do not seem to take responsibility for managing this budget for the week; for example, they would not notice or be concerned if there were nothing left in the kitty.

There is a need to be constantly aware that Villa Maria can become a ‘comfort zone’ where most (complex) matters, such as budget, are taken care of by the staff team. This is a difficult task as most tenants have been ‘deskilled’ in matters such as budgeting.

Recommendation:

It is important that tenants develop a greater sense of ownership over housekeeping issues. Again, it is a question of developing a method of providing support while also being consistently focused on ‘moving on’ and encouraging independence and a sense of responsibility.

If I get a job do I have to leave the house?

As previously discussed, two of the tenants expressed concern about their future in the house if they get a job. “I think when I get a job, I don’t know if I’ll be allowed stay here so I don’t know – and that makes me feel really insecure…” (tenant, March 2007). Such concerns are consistent with research on recovery, highlighting that people can be resistant to their own recovery, as they fear that support systems will be withdrawn from their lives.

On a similar note, another tenant said that she is quite frustrated with what she considered staff’s ‘pressure’ on her to make plans for the future. “I didn’t understand that we have to move on… I thought this was home [permanent]” (tenant, March 2007).

Recommendation:

-Tenants need to be clearer about their tenure rights and how these will be affected when they progress towards employment and more independence.

-More clarity is needed at the contractual level about expectations from tenants (i.e. the nature of progress expected from them).

Medication:

Three out of four tenants expressed a wish to reduce their levels of medication. The amount of medication tenants are on is a concern for some staff.

“My huge concern would be the amount of medication that they are on, and whether that can work on the notion of recovery” (staff, March 2007).

Concerns were expressed about how well people can function on high doses of medication. One tenant in particular is made very tired and sleepy by her medication and has described her brain as being ‘institutionalised’.

Recommendation:

-Achieve further clarity about the role and management of medication, as high doses of medication may hold back the process of recovery.

3.3 Administrative and organisational structures

3.3.1 The target group and the referral process

The initial plans of the Sli Eile project involved working with a group of people who had been discharged from acute inpatient care, had various admissions, and have been caught in the revolving door syndrome. The current group of tenants, however, is different as they have longer hospital experience that anticipated, and the majority of them have had long periods of extended hospitalisation.

This shift is primarily associated with the requirements of the HSE, which is also the funding body for staffing the Sli Eile project. It was felt that “that was taken out of our hands”(member of board of directors, January 2007). This can certainly have implications for the therapeutic focus and autonomy of the project. However, it is important to acknowledge the attainment of a good level of co-operation with North Cork Mental Health services. An indication of this co-operation is that the service is now available to support tenants coming from different catchment areas.

The selection process was extensively discussed with management and staff. Most staff felt that the current tenants will potentially benefit from the project, while one staff member said “not all tenants are suitable for independent living”.

As the project involves people sharing the same house, a number of issues need to be factored in. It is not just about finding tenants who will benefit from the project but also about ‘matching’ tenants so that they will support each other. “…We don’t want to misplace people either, we don’t want to engage with future tenants that it might be very difficult to work with, or certainly with the client group that we have now we have to be very careful that the match is right as well… We don’t want too much of a diverse group either, so it’s a difficult one, you don’t want a group that is too homogenous because nobody can support one another, but as I said we don’t want too many extremes either” (board of directors member, January 2007).

Staff and tenants are not currently involved in the referral process and the staff are not fully aware of the referral criteria. Tenants seemed to be particularly unclear about the reasons for their referral. One tenant said ‘I was sent here’. An issue of concern is that some tenants were also unclear about what is expected from them in terms of setting goals for the future. As one person said, “I didn’t know I had to move on”. One staff member also stressed the importance of tenants knowing in advance “what they are signing in for…and to do that on a voluntary basis”.

It can be argued that one of the main reasons for the lack of tenant engagement in the process is “the medical model [which] is strong, for example at least half the tenants were referred by their psychiatrist. It is possible that people aren’t participating fully out of choice and see the house more like a half way house”.

One staff member recommended longer trial periods in order to allow prospective tenants to get a fuller picture of the project “[a period of] two weeks doesn’t give people enough time to settle and make a decision”. Trial trips and some overnights were also suggested as part of the trial period. Another staff member acknowledged that particular attention needs to be paid to the selection and settling of the fifth tenant as the existing group of four has already settled and established a relationship.

Two staff members also recommended more involvement of staff and tenants in the selection process of future tenants.

Recommendations:

-Particular attention needs to be paid to finding tenants who will benefit from both the project and one another’s support.

-Extend the trial period and include day trips and overnights to allow prospective tenants to get a fuller picture of the project’s recovery vision and the expectations of them.

-Consider increasing staff and tenant involvement in the referral/selection process

3.3.2 Management structures and staffing issues

All staff stressed the importance of good relationships between staff and management as tensions may affect the staff-tenant relationship.

In the early days of the project a number of problems were experienced associated with a lack of focus (discussed earlier), staff turnover and changes in staffing. Such issues can be expected as part of the ‘teething process’. As already said, the project appears to be more focused on developing a shared vision for recovery. The distinction between clinical and house-running responsibilities in management was considered positive by the staff team as it helped clarify roles and responsibilities.

A particular concern expressed by a number of staff was the perceived rigidity of rotas and the need to develop more flexibility in that regard. It was also felt that such rigidity is disempowering and incompatible with the ethos of the project. “I suppose I just have to get used to it, but we’re not allowed to swap for any reason and that’s just something that I find, maybe a little disempowering, you know, because I know the whole project is about empowerment for the tenants and I feel for us to be able to empower the tenants it’s important that we also feel empowered. And that’s one aspect that I do feel a little disempowered” (staff, March 2007).

Overall, the need for more clarity around procedures (e.g. employment status, mileage expenses) and more open communication between management, staff and tenants was identified by a number of staff. They suggested the need to break the perceived divisions between staff-tenants and staff-management. The need for more involvement of tenants in decision-making forums and further opportunities for team building was also identified. “I think what would be helpful would be team building, but not just staff–tenants, staff and management, because I feel that there is still that divide – them and us and management, and because staff have supervision, and they have staff meetings and I feel that the tenants are like – what’s going on at these meetings, are we talking about them or something like that” (staff, March 2007). Furthermore, meetings between all staff and tenants were recommended, as a lot of information can be lost because of the rota system. One staff member acknowledged the potential difficulties relief staff have in connecting with the project and suggested “a regular aspect to their [relief staff] work so there will be continuity in the relationship”. It was also recommended that more time should be allocated to staff meetings, as “there is a sense that things are rushed through sometimes” (staff, March 2007).

Recommendations:

-More open communication through meetings involving all stakeholders in order to counteract the perceived divisions between staff-management as well as staff-tenants.

-Regular house meetings between all staff and tenants

-More involvement of tenants in decision-making forums

-Extended time for staff meetings

3.3.3 Resources and support to staff team

Training

The staff team is satisfied with the training opportunities provided so far by both Sli Eile and external resources. The introduction of the WRAP training was found helpful in moving towards goal-setting in their work with the tenants. The intensive training on the Glassier model also facilitated staff to focus on the purpose of the project. Staff said they feel more confident in developing a shared recovery vision. One staff member expressed interest in conflict-resolution training.

Supervision

Staff found both individual and group supervision to be supportive. Staff said it was helpful to discuss issues in a group and learn from each other. It was helpful that supervision was focused on the therapeutic rather managerial aspects of the work. The fact that the current supervisor is not viewed as ‘management’ and is not involved in contracts or appraisals is positive for the staff team as they feel safer to bring up issues in supervision. The value of involving the supervisor in such procedures in the future needs to be carefully re-considered as it might have an impact on the content and quality of supervision.

Resources

Staff were satisfied with the resources available for activities and training; they said there was flexibility in meeting their needs in that regard.

Recommendations:

-Provide training in conflict resolution

-Re-consider the value of involving the staff supervisor in staff appraisals and contractual negotiations; this may have a negative affect on the quality of supervision.

4. Sumary of findings and recommendations

4.1 Tenant’s Experiences

Positive Experiences

-tenants enjoy living in the house, they describe it as a nice and friendly environment, where they experience support and companionship

-tenants are gradually enhancing their skills in relationship-building, interaction and communication

-tenants become more involved and engaged with the group (other tenants and staff) and the community

-tenants experience a sense of normality in the house

-tenants’ confidence is developing

-tenants gradually become more assertive and willing to voice their opinion

-tenants feel they are treated with respect and that their potential is recognised

-tenants take more responsibility for aspects of their lives (e.g. household tasks, using mobile phones, texting, using ATM cards, saving money for holidays etc)

-tenants have engaged with activities in the house and in the community (e.g. education, badminton, gardening)

-tenants smoke less since moved to Villa Maria

-a vision for recovery is slowly developing

-tenants say they feel better than in previous care settings (i.e. hospital, hostels)

-there is improved interaction between the project and the community

Areas of Concern

-possibility that tenants will become complacent, dependent on staff and lose sight of recovery prospects

-some tenants are anxious that if they ‘move on’ they will have to ‘move out’ of the house

-over-reliance on medication can hold back the recovery process

4.2 Recommendations

Evaluating Progress

The impact of institutionalisation needs to be taken into account in evaluating tenants’ ‘progress’. This particular group of people have long histories of institutionalisation, where the idea of taking responsibility or even having their ‘own’ vision for the future was alien to them.

It is important to capture ‘small steps’ towards confidence building, engagement and independence.

Developing a shared vision and working towards goal setting

Focus further on developing a shared vision for recovery for tenants and staff.

Consider the development of a specific ‘space’ where staff and tenants discuss tenants’ goals and plans for the future.

A balance between facilitating tenants to identify goals for themselves and encouraging them to achieve them at their own pace needs to be struck.

Opportunities for tenant participation and self-evaluation

Create opportunities for more joint planning of activities between tenants and staff. House meetings do not always offer such opportunities.

Consider involving tenants at a broader level of decision-making (e.g. tenant or staff selection process).

Facilitate tenants to identify and evaluate their own progress (e.g. in relation to becoming ‘more vocal’).

Ownership and responsibility

It is important that tenants develop a greater sense of ownership over housekeeping issues. Again, it is a question of developing a method of providing support while also being consistently focused on ‘moving on’ and encouraging independence and a sense of responsibility.

Clarity about expectations from tenants

More clarity is needed at the contractual level about expectations from tenants (i.e. the nature of progress and commitment expected from them).

Tenants need to be clearer about their tenure rights and how these will be affected when they progress towards employment and more independence.

Medication

Achieve further clarity about the role and management of medication, as high doses of medication may hold back the process of recovery.

Community involvement

Consider greater participation of members of the local community to the board of directors

Community ‘involvement’ should not be confused with community ‘consultation’ when buying a house.

Consider what it means for present and prospective tenants ‘to be from’ the local community. For some people it can be a source of support, while for others it can be a stigmatising experience.

Referral criteria

Particular attention needs to be paid to finding tenants who will benefit from both the project and one another’s support.

Extend the trial period and include day trips and overnights to allow prospective tenants to get a fuller picture of the project’s recovery vision and the expectations of them.

Consider increasing staff and tenant involvement in the referral/selection process.

Training and Supervision

Provide training in conflict resolution.

Re-consider the value of involving the staff supervisor in staff appraisals and contractual negotiations; this may have a negative affect on the quality of supervision.

Management structures and staffing

More open communication through meetings involving all stakeholders in order to counteract the perceived divisions between staff-management as well as staff-tenants.

Regular house meetings between all staff and tenants.

More involvement of tenants in decision-making forums.

Extend time for staff meetings.