Gewoon wonen op een boerderij? Een innovatief woonproject voor een complexe doelgroep

Gewoon wonen op een boerderij? Een innovatief woonproject voor een complexe doelgroepDit artikel beschrijft een onderzoek naar “de Boerderij”: een innovatief woonproject voor mensen waarbij het door een combinatie van bijvoorbeeld verslaving, psychiatrische problemen of gedragsproblemen niet is gelukt om binnen de bestaande woonvoorzieningen een (langdurige) woonplek te vinden als alternatief voor (gesloten) verblijfsafdelingen, de gevangenis of de straat.Het idee achter de Boerderij is dat door een minimum aan regels, ondersteuning vanuit gelijkwaardigheid en het bieden van ruimte voor zelfmanagement een plek ontstaat die deze groep de mogelijkheid biedt “gewoon te wonen” en zo de cirkel van uitsluiting te doorbreken. Een sluitende samenwerking tussen gespecialiseerde GGZ (behandeling) en woonondersteuning wordt als noodzakelijk gezien om het project te laten slagen. Een kwalitatief onderzoek naar de idealen achter het project en de praktijk van de Boerderij, toont aan dat het tot stand brengen van deze idealen leidt tot een aantal spanningsvelden.Onze analyse laat zien dat verschillende invullingen van het begrip autonomie hierin centraal staan. Op bepaalde momenten treedt het team van de Boerderij bewoners tegemoet als autonome burgers die zelf eigen keuzes maken. Vanuit deze benadering is er veel tolerantie en wordt veel gedrag geaccepteerd, ook grensoverschrijdend gedrag. Dit brengt op sommige momenten het ideaal van “gewoon wonen” in gevaar, omdat op die manier onveilige situaties kunnen ontstaan. Op andere momenten ligt de nadruk juist op de kwetsbaarheid van bewoners en wordt veel van bewoners overgenomen, wat op gespannen voet staat met het ideaal van zelfmanagement. Vanuit een derde geobserveerde invulling van autonomie, wordt begrijpelijk hoe juist binnen de relatie en “het nabij zijn” ondersteuners en huismeesters bewoners kunnen structureren en begrenzen. Normal living on a farm? An innovative residential facility for people with complex needsThe article describes “de Boerderij” (“the Farm”), a residential project in Utrecht. This is an innovative housing facility for people with complex problems and needs. Its residents are people who – through a combination of addiction, psychiatric and behavioural problems – have faced repeated processes of exclusion. They had previously ended up on the street, in prison or in closed mental health wards. Existing housing facilities were inappropriate for the needs of this group, with many having caused considerable disruption and been suspended or evicted. The Boerderij facility was developed to provide a stable home for this group. Seeking to learn the lessons of previous experiences, the project was not set up with predetermined rules. Rather, mutual learning and improvisation were seen as the essential processes in truly meeting the needs of its residents. This kind of innovative housing facility can be seen as an important link in the deinstitutionalization of Dutch mental healthcare, since stable housing addresses the needs of this group, helping to break the circle of exclusion and hospitalization. To get a better understanding of the possibility of developing a residential facility that meets the needs of people with complex problems, a qualitative study was conducted at De Boerderij. We wanted to understand how the ideas behind this new residential project are put into practice and what can be learned from the tensions and dilemmas that have arisen. The study consisted of two phases. All the collected material was subjected to an interpretative analysis according to a grounded coding strategy. First, interviews were held with the initiators of the project and others involved about the ideals and ideas that were applied at the start of the project. The question of what the respondents had hoped to achieve was central to these interviews. The interviews with residents focused on their experiences of living at De Boerderij. Our analysis of the interviews revealed that there were four guiding principles at the start of the project: 1. “Normal living”; the ambition of the initiators of the project to create a stable and long-term housing facility where people’s problems and behaviour would be accepted. The aim was to create a place which people could call “home”.2. Self-management of the facility by the residents, rather than working according to predetermined rules. This was done in the hope of avoiding further exclusion. The rationale was that by minimizing rules, the chance of residents having to leave would also be minimized.3. Providing care and support based on equality: to achieve this, people without a care background provide daily support at De Boerderij. The idea is that these workers are not subject to preconceived professional ideas and knowledge, and are therefore able to build up a personal relationship with residents more easily.4. Intensive cooperation between the supported housing team and the treatment team from the mental health care institution. Again, to break the cycle of exclusion, it was seen as necessary to provide both psychiatric treatment and (housing) support in an integrated and coordinated manner. This way, care could be scaled up quickly if necessary, to avoid people dropping out of care or having to leave the housing facilities. In the second phase of the research, a small-scale ethnographic study was conducted at De Boerderij to see how the ideals and principles were being put into practice. This analysis showed that these ideals had sometimes given rise to ambivalences and tensions in practice. In the article, the authors argue that different interpretations of the notion of autonomy are central in these tensions. On the one hand, in reference to the concept of individual autonomy and self-determination, staff emphasize an almost unconditional acceptance of residents and their behaviour on the part of caregivers. This interpretation of the concept of autonomy makes the setting of rules problematic because this is perceived as compromising the autonomy of the residents. In practice, however, the acceptance of transgressive behaviour leads to unsafe situations for residents and staff and thus clashes with the ideal of “normal living” for the group.On the other hand, we also saw that there is a high level of acceptance among staff that residents are living with disabilities and therefore cannot always live up to the ideal of autonomous citizenship. For example, in the practice of daily caregiving, a lot of household work is done by staff rather than the residents, and residents are not held accountable for the running of the facility. This also undermines the ideal of self-management. In the article, we argue that the third and more relational concept of autonomy that we observed, whereby rules are defined from within the relationship between residents and staff, fosters an environment in which staff and residents can realize the ideal of creating a stable home for the group. Setting rules within a relational context enables staff to take the project forwards and reduce problematic behaviour

Working on and with Relationships: Relational Work and Spatial Understandings of Good Care in Community Mental Healthcare in Trieste

Deinstitutionalization is often described as an organizational shift of moving care from the psychiatric hospital towards the community. This paper analyses deinstitutionalization as a daily care practice by adopting an empirical ethics approach instead. Deinstitutionalization of mental healthcare is seen as an important way of improving the quality of lives of people suffering from severe mental illness. But how is this done in practice and which different goods are strived for by those involved? We examine these questions by giving an ethnographic description of community mental health care in Trieste, a city that underwent a radical process of deinstitutionalization in the 1970s. We show that paying attention to the spatial metaphors used in daily care direct us to different notions of good care in which relationships are central. Addressing the question of how daily care practices of mental healthcare outside the hospital may be constituted and the importance of spatial metaphors used may inform other practices that want to shape community mental health care

Working on and with Relationships: Relational Work and Spatial Understandings of Good Care in Community Mental Healthcare in Trieste

Deinstitutionalization is often described as an organizational shift of moving care from the psychiatric hospital towards the community. This paper analyses deinstitutionalization as a daily care practice by adopting an empirical ethics approach instead. Deinstitutionalization of mental healthcare is seen as an important way of improving the quality of lives of people suffering from severe mental illness. But how is this done in practice and which different goods are strived for by those involved? We examine these questions by giving an ethnographic description of community mental health care in Trieste, a city that underwent a radical process of deinstitutionalization in the 1970s. We show that paying attention to the spatial metaphors used in daily care direct us to different notions of good care in which relationships are central. Addressing the question of how daily care practices of mental healthcare outside the hospital may be constituted and the importance of spatial metaphors used may inform other practices that want to shape community mental health care

Frying eggs or making a treatment plan? Frictions between different modes of caring in a community mental health team

In this article, we conduct an empirical ethics approach to unravel the different perspectives on good care that are present in a community mental health team (CMHT) in Utrecht. With the deinstitutionalisation of mental health care, the importance of a close collaboration between the social and medical domains of care on the level of the local community is put in the foreground. Next to organisational thresholds or incentives, this collaboration is shaped by different notions of what good mental health care should entail. Using the concept of modes of ordering care (Moser 2005), we describe five modes of ordering mental health care that are present in the practice of the CMHT: the medical specialist, the juridical, the community, the relational and the bureaucratic perspective. These different modes of ordering care lead to frictions and misunderstandings, but are mutually enhancing at other times. Unravelling these different modes of ordering care can facilitate collaboration between professionals o

Frying eggs or making a treatment plan?: Frictions between different modes of caring in a community mental health team

In this article, we conduct an empirical ethics approach to unravel the different perspectives on good care that are present in a community mental health team (CMHT) in Utrecht. With the deinstitutionalisation of mental health care, the importance of a close collaboration between the social and medical domains of care on the level of the local community is put in the foreground. Next to organisational thresholds or incentives, this collaboration is shaped by different notions of what good mental health care should entail. Using the concept of modes of ordering care (Moser 2005), we describe five modes of ordering mental health care that are present in the practice of the CMHT: the medical specialist, the juridical, the community, the relational and the bureaucratic perspective. These different modes of ordering care lead to frictions and misunderstandings, but are mutually enhancing at other times. Unravelling these different modes of ordering care can facilitate collaboration between professionals of different care domains and support a mutual understanding of what needs to be done. More so, the analysis foregrounds that ordering care from a relational approach is important in daily practice, but is in need of stronger legitimation

"Caring for a crisis": Care and control in community mental health

In the debate on coercion in psychiatry, care and control are often juxtaposed. In this article we argue that this dichotomy is not useful to describe the more complex ways service users, care professionals and the specific care setting interrelate in a community mental health team (CMHT). Using the ethnographic approach of empirical ethics, we contrast the ways in which control and care go together in situations of a psychiatric crisis in two CMHT's: one in Trieste (Italy) and one in Utrecht (the Netherlands). The Dutch and Italian CMHT's are interesting to compare, because they differ with regard to the way community care is organized, the amount of coercive measures, the number of psychiatric beds, and the fact that Trieste applies an open door policy in all care settings. Contrasting the two teams can teach us how in situations of psychiatric crisis control and care interrelate in different choreographies. We use the term choreography as a metaphor to encapsulate the idea of a crisis situation as a set of coordinated actions from different actors in time and space. This provides two choreographies of handling a crisis in different ways. We argue that applying a strict boundary between care and control hinders the use of the relationship between caregiver and patient in care