Characterization of the Therapeutic Communities “Montesanto” (Rome, 2008- 2012) And “Casa de Alba” (Estremoz, 2020-2022): Brief Notes

Marcelo Azeredo Leone Lino Rodrigo

Co-founder of Psychikós Clinic (Lisbon, Portugal) & Vice President of the International Network of Democratic Therapeutic Communities

*Correspondence to: Dr. Marcelo Azeredo Leone Lino Rodrigo, Psychikós Clinic & International Network of Democratic Therapeutic Communities.

Copyright © 2022 Dr. Marcelo Azeredo Leone Lino Rodrigo. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction
Throughout and after my academic training in the field of psychology and psychotherapy, which took place in Rome, I had the opportunity to get to know and participate in the daily life of the Montesanto Community (2008-2012).

More recently, in Portugal, since February 2020, I have been part of the technical team of Casa de Alba, in Estremoz.

According to the name “Therapeutic Community” (which refers to intervention models tried out in the United Kingdom during the Second World War), these institutions are aimed at promoting personal recovery and mitigating mental distress. They present, however, specificities to achieve their main goal.

It is these specificities that form the basis of the present article.

With regard to the Montesanto Community, which in this study we address first, two interviews were conducted: one with Giorgio Villa (2021a) [1] and the other with Dino Ermini (2021) [2] who, among others and with different roles, made a relevant contribution.

Montesanto Community (CMS): a brief framework relating to the period 2008-2012 which was directed by Professor Giorgio Villa, anthropologist, psychiatrist/analytic psychologist and poet.

The CMS, in terms of the geography of the city of Rome, is today located in the XVII (seventeenth) district, more specifically in the Prati district: a prestigious district, in the vicinity of the Vatican, where, for example, we can find the Palatine headquarters of the Court of Auditors, Criminal and Administrative Courts, as well as the headquarters of RAI and LA7 (public and private television).

The CMS is the pole of a wider network of public mental health care (Azienda Sanitaria Locale RM2), founded in 1997 by decision of Dir. Renato Piccione, which filled a gap in this area of the city of Rome (XVII Municipio).

Since its opening, the CMS has been housed in Via Montesanto No. 71, Rome, in a building rented from the Rome Transport Company (ATAC), sometimes living under the threat of eviction, which has even been reported in the media and has led to civic mobilisations. This centre, which operates around the clock, is intended to receive patients with mental disorders for a maximum period of two years. At the end of the residential programme, the patient may continue in a half- board regime, with the possibility of enjoying meals (prepared and brought in by a catering company) and participating in activities, as well as receiving support in his/her own residence that will have to be in the aforementioned XVII district. There is also the possibility to host a patient who is in a crisis situation for a short period of time. CMS has an availability of a total of fourteen beds.

The work carried out with the families is very important, it is one of the parts of the therapeutic contract as specified below. Furthermore, and in a complementary way, a multi-family therapy is carried out in loco, in which relatives/caregivers of all residents are invited to participate. Over the years, this group became a “flying” intervention group, which made home visits at the request of critically ill patients (Villa 2021b, 55- 63) [3].

It should be noted that individual consultations for psychiatry and psychotherapy do not always take place at the CMS but at another location (known as presidio territoriale) or mental health centre situated in the XVII municipality. It is these health units that write the referral to the CMS.

As for the technical team at the CMS, it was made up of civil servants, namely psychiatrists, and private sector employees, hired by a social cooperative, to which the ASL RM had sub-delegated the provision of mental health services in this and other structures in its area of jurisdiction.

CMS’s partners include the Alpine Club, which already had its headquarters in the CMS building, and the Associazione di Volontari Ospedalieri. It is worth mentioning that this Association has successfully applied for a funding programme, and has been allocating the funds received to carrying out work in the dilapidated dwellings of some of the residents, so that they can go back to live there as soon as they finish the residential programme in the CMS, being able to share a house, as already happened, with other former residents.

Therapeutic Contract
The admission to the CMS requires the signing of a written therapeutic contract where the various contracting parties - “psi’s” (an inclusive expression used in daily work to encompass the various skills of the members of the technical team), residents and their relatives - defined a goal or goals which, at intervals of 4 to 6 weeks, can be revisited and changed, whenever necessary, by mutual agreement.

Pietro Salemme (2006) [4], who, for many years and from the beginning, was part of the CS Team and led some activities, such as Weekly Newspaper reading and Maintenance work (see below) addressed the use of the contract in community in his publication Abitare. Dodici storie ai margini. It is important to mention, however, that the therapeutic contract is a methodology of Transactional Analysis, implemented some decades ago in clinical and business contexts, given the need to work by objectives, which are observable and evaluable (Berne 1966) [5].

Group Activities
We will now highlight some group activities that, over the years, have taken place in the Montesanto Community:

- Community meeting on a weekly basis and always in the presence of the Director, who is generally very mobilising;
- Drawing;
- Aquarium and its maintenance;
- Tea and poetry. Writing and reading in a convivial atmosphere;
- Weekly reading of newspapers at CMS and monthly at the Senior Citizens Day Centre;
- Weekly reading of newspapers at CMS and monthly at the Senior Citizens Day Centre;
- Small maintenance tasks in the spaces of the CMS, of individual and collective use, as well as in the dwellings of the former residents, now in a semi-interned situation. The tasks were only started after a meeting of about 30 to 40 minutes in which they reflected on the need to carry out the work and the ways in which to carry it out, which provided a co-responsibility and a more careful look at the inhabited space. Once the meeting was over and the task was carried out, as a group, refreshments were sometimes offered at a local café. And finally, there was a moment of reflection by the technical staff regarding the activity developed before;
- Group excursion. Organisation and carrying out of mountain excursions, which allowed the temporary escape from the dense city environment and the exploration of new spaces and new landscapes. In symbolic terms, it was like “setting out on a journey” and experiencing that the path is made by walking - a well marked out journey, planned and with realistic objectives bearing in mind all the limitations and capacities of those involved. The person responsible for this activity was Dino Ermini (2021) [2], who, in an interview, refers to the importance of the excursionist group as a response to the moments of leisure in the community, in the middle of summer.

Neighbourhood and CMS: an Enduring Cohabitation
The CMS is a mental health care unit, among others, which finds its roots in the Basaglia Law of 1978. This law called for the end of asylums and for alternative forms of support for the mentally ill that would contribute to their inclusion in the social fabric.

In 1997, the year the CMS was founded, its acceptance in the neighbourhood was not immediate. After all, what once could have been a small asylum could bring along all the associated fears: fear of differences, namely of mental disorder, and fear of seeing a human condition that could also become one’s own.

Over time, a modus vivendi based on good coexistence was created. And this is reflected in the fact that no physical or other aggression episodes are known from either side, and that several donations (books and articulated beds) have been made to the CMS. It is also very relevant that, in terms of some exchange, literature and poetry conferences are held at the CMS (one of the poets involved is a former resident), free of charge, open to the neighbourhood and to the city.

A term often used in work meetings was “grafting”, which is the insertion of a new element into an existing plant body. Applied in symbolic terms to community treatment, either the word or the example of the action (simple and inexpensive tools) could produce change within the scope of the therapeutic contract concluded (Villa 2021b, 55-63) [3].

As a mere example of how a word, even a simple one, can open a clearing: shortly after a decent lunch, a resident approaches the technician and asks for money to go and eat and is answered in a firm but serene tone of voice “watch out, eating disorders are also mental disorders”. Yet another example: two technicians and some trainees preparing a home visit in which waste and papers have to be removed, and a technician says to the others: “remember, each bag we remove is one less bag of psychosis”.

Casa de Alba (CA): Brief background regarding the period 2020-2022 which was directed by Dr. João G. Pereira, Psychologist and Psychotherapist

CA is a therapeutic mental health community and is part of the Romão de Sousa Foundation - an IPSS [Private Institution of Social Solidarity], recognised and registered as such in 2010.

It is part of a line of experiences aimed at dignifying people with mental health problems in the ante April 25 period (marcelist [named after Marcello Caetano] spring) and in the post April 25 period, with emphasis on the two therapeutic communities founded by Professor Carlos Caldeira (following an anthropo-analytic model), one in a hospital context ( Júlio de Matos Hospital) operating in the period 1969/72-1978, and one in the Boavista social neighbourhood operating from May 1975 to 1978, which meanwhile had no continuity (Campiche et al. 1992, 66-81) [6]. Still in Lisbon and of great interest for the study of Mental Health in Portugal, the Miguel Bombarda Hospital went through several historical periods (1848-2012), with moments of innovation and moments of stagnation (Cintra 2012) [7].

CA is located on a not too steep hillside with olive groves and surrounding orchards, in the higher Alentejo region, municipality of Estremoz, parish of São Bento do Cortiço, on the way to Sousel. White architecture and straight lines, a single floor, with the exception of a mansard used whenever necessary for meetings. Still in the surrounding space, it is worth mentioning the existence of some domestic animals, such as chickens and a dog - the female dog Alba, which gave the house its name.

CA is a round the clock structure. It has a residential programme which normally lasts a minimum of 3 months and a maximum of 18 months. Even so, shorter stays are foreseen, for example one month, in order to enable the applicant’s carers, sometimes seniors, to rest. On the other hand, the CA also has an external consultation service which, at this time of pandemic, is suspended.

As for access, this can be done by the candidate himself (man or woman with 18 years of age or older), residing anywhere in the country, by a relative or by a technician who has been accompanying him, whether in the public or private area. The CA, as a private entity, has full autonomy to receive or refuse the proposed candidate, based on its own criteria.

A monthly fee is payable, the amount of which depends on various factors.

The CA has a maximum accommodation capacity for 16 residents, spread over 7 double rooms and 2 single rooms.

Among its partners, the Pestana/Pousadas de Portugal Group stands out, allowing residents to carry out professional internships there.

Psychiatric and Psychological Monitoring/Assessment Meetings
Residents have psychotherapy appointments (individual, group and multi-family, the first weekly, the second twice a week and the last monthly).

They also participate in path evaluation meetings, open to the members of the proximity team and to family members, by videoconference, given the present restrictions of lockdown. These meetings do not have a fixed schedule: they take place whenever justified.

It is important to highlight that during my brief stay in the CA, I have witnessed the implementation of what has been called Open Dialogue (Seikkula et al. 2011) [8]. The first “admission” into the Commission of Audit is by telephone and is very important, to the extent that the receptionist becomes an obligatory element of the proximity team, in view of a possible entry. And the telephone call should not be a mere formal moment, but one of “exploration” of individual and family specificities. It is important not to lose this opportunity of closeness and complicity from the very first moment, as it marks the beginning of a whole future work process.

Another more recent peculiarity regarding the meetings to evaluate the path is the increasing introduction of one or more reflexive elements - those who, during the meeting, make a direct dialogue with the facilitator, sharing sensations and raising here and there some questions, as an Open Dialogue. It was with this intention that learning exercises were carried out for all the staff through role playing in which the roles of the different actors of a consultation were put on stage: the patient identified with his symptoms, the family members with their concerns, the technicians/meeting facilitators with the reflective elements, each one focused on a specific element of the family.

This methodology, being very participative and inclusive, fits well in a democratic perspective of treatment in a community that wants the person to be more capable, more autonomous and more self-confident.

Some of these activities are still in force. However, given the current conditions of lockdown, some of them have been suspended or limited (Azeredo Rodrigo & Goncalves Pereira, in press) [9]. They are as follows:

- Community meetings (held during weekday mornings and afternoons)
- Drawing and plastic arts;
- Therapeutic plans (residents are asked to stipulate their own objectives or micro-objectives, in order to give greater meaning to their stay in the CA);
- MBTi - Mentalization-based Treatment Training Introduction (this activity aims to develop the ability to recognise one’s own mental state at that moment, as well as that of others)
- Psychomotricity;
- Music therapy;
- Creative writing;
- Work in the vegetable garden and in the orchard;
- Domestic animal care;
- Walks and transport of waste to the collection point;
- Visits to Estremoz or other places in Alto Alentejo, such as Vila Viçosa and Évora-Monte;
- Visits to the supermarket (currently, to avoid the risk of contagion, only one resident goes with the assistants);
- Cooking food with residents and staff;
- Aquatic psychomotricity in the municipal swimming pools of Estremoz (this activity is also suspended. However, although small in size, the CA has recently acquired a swimming pool).

Brief Final Analysis
In continuing our work, we must now elaborate on the features in terms of similarities and differences between the two institutions.

The most visible similarities, we believe, are the following:
1) the emphasis given to the democratic relationship in a mental health context;
2) the existence of a multidisciplinary technical team.

As for the differences, it seems relevant to mention the following:

1) the first one is a public institution, although it resorts a lot to cooperative staff, and is inserted in a complex healthcare network. The second is private and defines its action with greater autonomy;
2) CMS is located in a dense urban environment and promotes, among others, group excursions to the mountains, while CA is in the middle of the Alentejo hills, in a sparsely populated area, organising trips to relatively nearby cities and towns;
3) In the Italian context, since the enactment of the Basaglia law in 1978, the inclusive community treatment model is very present. In Portugal, this model was tried out immediately before (marcelist spring) and following the April 1974 revolution, with intermitttencies;
4) In the case of the CMS, we are facing a historical neoclassical building architecture, with different renovations over the times, while in the CA we have a functional architecture, designed for the specific function it performs;
5) Finally, in terms of working methodology, in the case of the CMS, the director has a constant and very mobilising presence, particularly in decision-making processes, with frequent reminders of the community’s history. It is also important to highlight the existence of only one community meeting per week, which is always very well attended. Staff works with a clear intention of maintaining close contact with the residents during their stay and post-stay, through home visits and by opening up to attendance to the CMS, in a semiinternship regime. In the CA, the word “dialogue” is very frequent and it is based on the fact that decisions are matured and taken in a group, in the Open Dialogue way. One tries to create a family environment, where the room is not a dormitory, where the taste and smell of the meal prepared is present and where it is possible to visit and feed the surrounding domestic animals - aspects that may be conducive to a good return to the place of origin.

Bibliography

1. Villa, G. (2021a). Entrevista não presencial, por correspondência, terminada a 27 de Outubro de 2021 e tendo como tema a Comunidade Terapêutica Montesanto.
2. Ermini, D. (2021). Entrevista não presencial, por correspondência, terminada a 1 de Novembro de 2021 e tendo como tema a Comunidade Terapêutica Montesanto.
3. Salemme, P. (2006). Abitare: Dodici storie ai margini, Edizioni Universitarie Romane, Roma, 2006.
4. Berne, E. (1966). Principles of Group Treatment, Grove Press, New York.
5. Campiche, C., Hippolyte, J. C. & Hipólito, J. (1992). A comunidade como centro, Fundação Calouste Gulbenkian, Lisboa.
6. Cintra, M. (2012). Miguel Bombarda. Preservar a memória, Casa das Letras, Alfragide.
7. Gonçalves Pereira, J., et al. (in press), Denouncement without announcement. Part destruens, part construens: an experience in the therapeutic community Casa de Alba (Estremoz) in times of COVID-19.
8. Villa, G. (2021b). In comunità. Malattia mentale e cura, Edizioni dell’Asino, Roma.