In your view how do the CMHTs contribute psychologically to service users with severe mental illness?
Raluca: Support is important for every person, as for every human being. The idea is the support is delivered in our beneficiaries’ regular settings in the form of diverse mental health needs satisfaction. It is important for every human being to know that if you are alone in your house, there will be someone available to support you, especially if that someone knows how to provide support in a proper way. So from psychological point of view such support is really important.
How are psychologists involved in the project?
Tiberiu: I think psychologists play an important role in CMHTs, because we contribute to the methods used as both of us are trained in clinical psychology, CBT and motivational interviewing. Psychologists can be useful in at least two ways. The first one, the psychological issues and solutions they identify for patients and psychological information we provide to patients and their families; the second one, psychologists put the team together as psychiatrists and social workers can always discuss their work with psychologists, who are liaising with the whole team expertise. So, psychologists serve the patients and the team.
Raluca: Even though psychiatrists have a long history of being central in the treatment process, over the time due to education, practical examples, overseas experience, many of our citizens understand the importance of psychologist in dealing with diverse mental health issues. Protocols for depression indicate psychotherapy for mild and moderate episodes as first line of intervention. Psychologists have an essential role in the treatment of mental health issues. So the role of psychologists is increasing.
Who are the psychologists involved in the CMHT? What was the selection process?
Raluca: As for qualification, it is definitely important, but the key is to love your profession and strive to implement your skills and knowledge in the best way possible. Any effort you make for professional development will contribute to your work.Tiberiu: Clinical expertise is definitely important, but we also see the need in community expertise. And Recover-E project helps in gaining more community experience.
Raluca: There was a selection to this project in a sense. We both worked in the mental health area for a number of years, starting from the scratch, e.g. by introducing the idea of mental health in the 90’s which was new for Romania. Since then, we are trying to develop the area and to participate in diverse projects. Over the long period we have started and developed quite a number of projects, and were somehow visible for the Recover-E consortium then they were looking for the partners.
And why have you chosen to be the part of this project?
Raluca: There are five countries which are now implementing this project. So, it was interesting to see how it would be implemented here in Romania. Would this work in the same way as in Eastern Europe as it works in the Western ones? Would it be beneficial for our patients?Tiberiu: I guess for every professional, e.g. nurses, not only psychologists, it is important to move out of the classical clinical settings into community settings. And it is also the need of the beneficiaries. So, it was a very obvious step.
How is the collaboration between different professionals organised in the CMHTs?
Raluca: Our team consists of one psychiatrist, two nurses, two psychologists, one social worker, and two peers. We are very lucky as we work with our colleagues in a very natural and easy way. There are divided responsibilities, but no one is acting without communicating with the other members of the team. E.g. social workers, they possess some information we don’t have, hence we listen to her suggestion regarding the support provided to a particular patient.
Tiberiu: we’ve been working together with our colleagues for a long time and mental health is a multidisciplinary area. Without medical input, without social input there won’t be such progress. Only together we can improve the life of our beneficiaries. If there is someone, we are answering to it is our beneficiaries. We are telling them if we se some positive developments in their state.
Raluca: As psychologists’ work, Tiberiu is mostly involved with patients’ needs, and he supports them in the way they request which is initially directed to the whole team. I work mostly with the team members to discuss the ways they execute their duties and do things, the ways to improve that. As these two aspects come together very often, there is no clear line “it is my work, and this is yours” we are just trying our best to provide professional input.
What is the process of work with your patients?
Tiberiu: Because we’ve been working in this classical clinical environment for so many years, we knew most of the patients before the project started because it is intended for chronical conditions. As all other colleagues are in the hospital at least once a week we meet together, and invite peer-workers too, to discuss concrete needs of our patients. Of course now due to Covid-19 we use computer and phone more to communicate with our team and our patients.
Do you connect with psychologists from other RECOVER-E sites to exchange experiences and idea for your work as a psychologist?
Raluca: Because the project is built in such a way that each of us has some responsibilities and we lead a certain workpackage, I had an opportunity to visit colleagues in two countries: North Macedonia and Bulgaria to learn about the work of my colleagues there. Implementation meetings happen every month where we discuss the way things are going in each site of the project and exchange practices. So, we know that this model of community mental health is implemented pretty in much the same way across the five countries with some cultural adjustments, of course.Tiberiu: It was very easy and beneficial for our team to communicate with other teams. We received the training, the same one as was received by the others so it is very easy to communicate with them as we have the same background.
What is your role and responsibilities in the CMHT? How big is your caseload? Do you share your tasks with other members of the CMHT?
Tiberiu: As case managers we have 15 cases, but as psychologists we are involved in every case which requires psychological input. We share tasks with the social worker or with the psychiatrist as the psychiatrist is not always available. But we share these tasks due to good communication in our CMHT and with our colleagues. For example, then the beneficiary needs a change in medication or doesn’t have an idea on which medications would be required, then we invite psychiatrist to provide education on why it is important to take this medication. Or with social workers: when beneficiary needs to prepare papers for local administration and doesn’t know how to do that and the social worker is not available, we are assisting in this matter. At the beginning we support peer-workers to make them feel confident.
What does a day in your working life look like now you are working in the community mental health team (CMHT) if you compare it to what it looked like before the project?
Tiberiu: The day starts with the meeting where we go through cases, we think need more support. There we establish the best ways to interact both with the patient and with the team. For example, we see that making the home visit in Romania is a very formal event, the beneficiary may be stressed by the fact that a big group of people visiting their house which might not be ready (not clean enough or else), so we’ve found that there is a need to identify one or two people within the team who will visit the patient. Or if we need to meet elsewhere, e.g. a park or a cafeteria. These arrangements that are not happening in the professional institutional environment are very effective.
Raluca: we have a number of cases as case managers, so we calling the beneficiaries to check on their state: e.g. the challenges they are facing, their daily routine. We need to ask more questions to reveal hidden issues as usually the answer to the question “How are you?” is “I’m fine”. So we need to identify if this “fine” is justified or if we have to consider the situation in a bit more details. We have patients who are staying well, and those, who are not. For example, the prescribed medication doesn’t work well anymore. So, after those calls, we discuss with the team the cases that need some intervention as other team members might have more information on the case, e.g. the social worker as she deals with all the patients helping to apply for social benefits she may have additional information. And if we identify the need in additional intervention we identify, who is the most suitable to deliver this intervention. Or we send the team member who interacted with a patient more so gained the trust, to identify the issues and collect information. So basically, the task of the day is to collect information and to discuss with the team in the next few days the cases that require more attention.Before we were working only with the patients admitted in the hospital, there was nothing provided beyond the hospital work. And now CMHT’s work is a continuation of what is going on in the hospital.
How did you experience shifting from a focus on problem/symptoms of the patient to recovery oriented method of delivering care?
Raluca: It is not easy, as many of them do not know what to do with their life, how to adapt in the society, as they were told before that they are ill and the only thing, they needed to do was to take care of their sickness. And many patients have to learn on how to open opportunities for their life, or how to find a company to drink coffee or to play chess.
How do you focus your approach towards recovery?
Raluca: once the patients make a few steps and see that they can do more, they start trusting themselves. We start with them with minor steps to strengthen their self-esteem.
What changes do you see – using a recovery oriented care approach among patients?
Tiberiu: Before the project clinical environment was very safe for both, the professionals and the patients. Patients came, told their symptoms, stayed in the hospital till they got better and the they left the institution. And that was the end of the interaction. But now through this project we are really recovery oriented. The goal is not to get better in the institution, but in the environment, they came from, to feel secure and empowered in their regular settings, to have the life they want to have. It’s not the goal they can achieve alone, it is the goal we have to achieve together. We have to draw the recovery path through the community, to find points that can help to follow the path and get better.
Raluca: We can’t expect that a person with 20 years of schizophrenia would suddenly reintegrate professionally, but for such person to socialize and to go together for a holiday is a real achievement. So, recovery orientation means a better quality of life.
How is your work different now during COVID than before the pandemic?Raluca: It is not very easy as “human touch” is relatively minor in digital interaction. On the other hand, we need to teach ourselves self-support in such circumstances as many social interactions and habits are on pause. So, we help each other to identify new sources of energy. And then we teach others and share our experience.
Tiberiu: There is a positive side as our patients needed to learn how to use online environment. Also, if before they could visit the hospital if they feel worse, now they have to think twice due to the risk of being infected. So they learn to interact digitally and it is the real gain in the long run as they need to acquire new skills to perform regular tasks (e.g. getting a medical prescription in a new way). It wasn’t easy for them, but they have to learn that there are other ways of communication. Also, they now need to be more proactive in calling their doctor to report on their state or to ask for help. We did a series of trainings for them on how to use their smartphones or to use zoom meetings.
Raluca: The patients now are calling to us just to talk and by that we understand that the patient might need more attention and we communicate that to our team members.
What are your insights from participation in this project? Is there any important information you’d like to share with your colleagues around Europe or in your country?
Tiberiu: The training we received was very useful. It was also interesting to work with our peer-colleagues as the energy of the team has changed. They also help us to identify patients’ strengths to build the recovery process. Another thing is that professionals have to be aware of the cultural settings, e.g. for home visits in Romania which oblige the host to be prepared, so professional has to ensure that visiting beneficiary’s house is not a stressful event, but a helpful event. And the visitor has to be a relevant visitor, not just anybody from the team.
How has this experience changed you professionally?
Raluca: It was definitely professionally developing as it is a new way of work and we had to adapt and improve ourselves in some areas. We communicate more, to share tasks, to educate ourselves a bit more. Community team work is not very easy, but very rewarding as we see the progress in our beneficiaries.Tiberiu: It was very helpful to feel that there is always someone around you in the team who can give you extra resources. Also, it is something we previously saw only in books now we see it live: if the patient becomes more active his or her recovery becomes more successful. Clinical stings make patients more passive while community settings make them more active.