Transcript Mental health

DEINSTITUTIONALIZATION PROCESSES IN
INTERNATIONAL AND LOCAL CONTEXT
Roberto Mezzina,
Director
MH Dept. / WHO CC for Research and Training
AAS 1, Trieste
Kotor
24 March 2015
Italy
 100.000 inpatients in 1971 in PHs
 48.000 inpatients in 1978
 All PHs closed in 2000
1978 reform law:
-no Phs admission, no new PHs
-community based care
-human rights focus / involuntary treatment duration reduced (1
week +) – 2 pych. to mayor
-No police / justice involved – just health protection
Mental Health Departments
 They are rooted in areas of about 300.000 inhabitants
and encompasses a number of components:
 -Small general hospital acute units (15 beds), 1/10.000
 -Community Mental Health Centers (up to 12hr,
sometimes 24hr) 1/80.000
 -Group-homes 2/10.000 with a wide range of support
up to 24hr (17.000 beds in Italy, mostly NGOs)
 -Day Centre (also with NGOs)
Policy documents supporting D.I.
EU Union Green paper (2006) on social inclusion
European Pact for MH and Wellbeing, 2008
 Combating stigma and social exclusion
 Develop mental health services which are well integrated in the society,
put the individual at the centre and operate in a way which avoids
stigmatisation and exclusion
WHO, 2009
 Psychiatric hospitals (PHs) have a history of serious human rights
violations, poor clinical outcomes, and inadequate rehabilitation
programmes. They also are costly and consume a disproportionate
proportion of mental health expenditures.
 WHO recommends that psychiatric hospitals be closed and replaced
by services in general hospitals, community mental health services,
and services integrated into primary health care
• As shown by a recent survey of WHO, 80% of
government spending on mental health care are
absorbed by psychiatric hospitals (Saxena et a.,
2011).
• The data regarding a number of experiences in Italy
show that savings of up to 50% can derive from such a
total reconversion into a network of community services
and related instruments for social inclusion.
INEFFICIENT USE OF RESOURCES:
High concentration of resources in mental hospitals
INEFFICIENCY: MENTAL HEALTH BUDGET, STAFF WORKING
AND USERS TREATED IN MENTAL HOSPITALS BY INCOME
(median rate per 100,000 population)
Overview of the Mental Health Action Plan
2013 -2020
Vision
 “A world in which mental health is valued, promoted,
and protected, mental disorders are prevented and
persons affected by these disorders are able to
exercise the full range of human rights and to access
high-quality, culturally appropriate health and social
care in a timely way to promote recovery, all in order to
attain the highest possible level of health and
participate fully in society and at work free from
stigmatization and discrimination”.
WHO QualityRights
Improving quality and human rights in
facilities and promoting a civil society movement
 Assessment of facilities
 Development of a change plan
 Capacity building on human rights issues
State of mental health in the European
Region
 Mental disorders affect more than a third of the population every
year, the most common of these being depression and anxiety.
 Depressive disorder is twice as common in women as in men.
 People with severe mental health problems, such as
schizophrenia, bipolar disorder or severe depression, have a 2030 year shortened life expectancy compared to the general
population. 60% of this excess mortality is accounted for by their
poor physical health.
 Mental disorders account for as much as 44% of social welfare
benefits or disability pensions in Denmark, 43% in Finland and
in Scotland and 37% in Romania.
Distribution of beds per 100 000 population
in mental hospitals and
in community psychiatric inpatient units & units in DGHs
Mental Health Programme
Home treatment
Mental Health Programme
Policy developments supporting the New
European MH Action Plan (September 2013)
 The European Commission launched its European Pact on Mental Health
and Wellbeing in 2008,
 2008 was marked by the UN Convention on the Rights of People with
Disabilities, now ratified by the large majority of European Member States
and also the European Unio participation in society, protected from stigma
and discrimination).
 In 2011, WHO statement on user empowerment was produced, with
indicators of progress towards empowering mental health service users.
 In 2008, the WHO launched the Mental Health Gap Program.
 “Reducing health inequities through action on the Social Determinants of
health” (2010).
Forgotten Europeans, forgotten rights
(OHCHR) 2011
 This report has emphasized that, under international and
European human rights law, Governments should transfer from a
system of institutional care to alternative community-based
services that enable children, persons with disabilities (including
users of mental health services) and older people to live and
participate in the community.
 They will also need to ensure compliance with human rights
standards when monitoring the situation of persons receiving
community-based residential services.
Ad Hoc Expert Group
on the Transition from Institutional to
Community-based care.
 In its report the Expert Group recommended that EU
member States should “adopt strategies and action
plans... accompanied by a clear timeframe and budget
for the development of services in the community and
the closure of long-stay institutions”, with a “proper set
of indicators to measure the implementation of these
action plans.”
 The vision of Health 2020:
 “a WHO European region where all people are enabled
and supported in achieving their full health potential
and wellbeing, and in which countries, individually and
jointly, work towards reducing inequalities in health
within the Region and beyond.”
 It puts forward an agenda for action for Europe,
corresponding to the Global Mental Health Action Plan
(WHO Geneva).
Values of European Strategy
 Empowerment: All people with mental health problems have the
right throughout their lives to be autonomous, having the
opportunity to take responsibility for and to share in all decisions
affecting their lives, mental health and wellbeing.
 Fairness: Everyone is enabled to reach the highest possible level
of mental well being, and is offered support proportional to their
needs. Any form of discrimination, prejudice or neglect that hinder
the attainment of the full rights of people with mental health
problems is tackled.
 Safety and effectiveness: People can trust that all activities and
interventions are safe and effective, able to show benefits to
population mental health or the wellbeing of people with mental
health problems.
Scope
 Improve the mental wellbeing of the population and reduce the
burden of mental disorders, with a special focus on vulnerable
groups, exposure to determinants and risk behaviours;
 Respect the rights, addressing stigma and discrimination, and
offer equitable opportunities to people with mental health
problems (including dementia and substance use disorders) to
attain the highest quality of life;
 Establish accessible, safe and effective services that meet
people's mental, physical and social needs and the expectations of
people with mental health problems and their families.
Definitions
 Mental health
 a state of well-being in which an individual realizes his or her own
abilities, can cope with the normal stresses of life, can work
productively and is able to make a contribution to his or her
community.
 Resilience
 the capacity for positive adaptation and generally refers to
individuals, organisations, communities or localities that ‘do better
than expected’ in the face of adversity.
 Recovery
 a process of change through which individuals improve their health
and wellbeing, live a self-directed life, and strive to reach their full
potential, whether or not there are ongoing or recurring symptoms
or problems.
Strategic objectives
Four core strategic objectives
 Everyone has an equal opportunity to realize mental wellbeing
throughout their lifespan, particularly those who are most
vulnerable or at risk.
 People with mental health problems are full citizens whose human
rights are valued, protected and promoted.
 Mental health services are accessible and affordable, available in
the community according to need.
 People are entitled to respectful and effective treatment, and to
share in decisions.
3 objectives
 These are supported by 3 objectives:
 Health systems provide good physical and mental
health care for all.
 Mental health systems work in well coordinated
partnerships with other sectors.
 Mental health governance and delivery are driven by
good information and knowledge.
Trieste / AAS n.1
 The Healthcare Agency is organised as follows:
 4 Healthcare Districts (each responsible for approx. 60,000
inhabitants), operating according to area (primary care and home
care, the elderly, specialised medicine, Rehabilitation, Children
and adolescents, Family counselling, District diabetes centre)
 3 Departments (Mental Health, Dependency, Prevention)
 2 Specialised Centres (Cardiovascular and Oncological).
 118 Service for health emergencies
 1215 employees.
 Budget: cash balance € 29,327,155.82
The Mission of MHD
 The MHD shall operate for the elimination of any form of
stigmatisation, discrimination and exclusion concerning the
mentally ill persons.
 The MHD is engaged to actively improve full rights of citizenship for
the mentally ill persons.
 The MHD shall ensure that the community mental health services of
the LHC have a coherent and unique organisation as a whole,
through a strict co-ordination of actions and links with the other
services of LHC, particularly with general health districts and
emphasizing the relationships with the Community and its
institutions.
Today’s features in Trieste (WHO CC lead for
service development) are:
Services:

4 Community Mental Health Centres
(equipped with 6-8 beds each and open
around the clock) incl. the University
Clinic

1 small Unit in the General Hospital with 6
emergency beds;

Service for Rehabilitation and Residential
Support (12 group-homes with a total of
60 beds, provided by staff at different
levels;

2 Day Centres including training programs
and workshops;

13 accredited Social Co-operatives);

Families and users associations, clubs
and recovery homes.
Staff:

215 people - 1/1.000 (26 psychiatrists, 9
psychologists, 130 nurses, 10 social
workers, 6 psychosocial rehabilitation
workers).
PROGRAMMES
 User training and involvement
 Information for family members
 Prison consultancy service
 Promotion of social enterprise activities
 Creative/play activities
 Promotion of self-help activities
 Intensifying relationships with health districts
 Intensifying relationships with hospitals
 Relationships with the city’s cultural agencies
 Gender difference and mental health
 Prevention of “lonely deaths”(“Amalia”project)
 Suicide prevention “Special Telephone”project)
Where are the ”beds” today?
 Year 1971:
 1200 beds in Psychiatric
Hospital
 Year 2015:
 78 beds of different kind
in the community:
 26 community crisis beds
available 24 hrs. Mental
Health Centres (11 /
100.000 inhabitants)
 6 acute beds in General
Hospital (3,5 / 100.000)
 45 places in group-homes
(20 / 100.000)
peppe dell'acqua dsm trieste who
collaborating center
[email protected]
28
The coops: activities
 cleaning
and
building
maintenance (diverse agencies)
 Canteens
and catering, incl.
Home service for elderly people
 Museums’staff
 agricultural
production
gardening handicraft
and
 Porterage and transport
 carpentry
 Laundry
 photo, video and radio production
 tailoring
 computer service, publishing trade,
 Informatic archives for councils,
etc
 furniture and design
 cafeteria and restaurant services
CD-Rom
 serigraphics
 theatre
 Hotel
 administrative services
 Front-office amd call-center of
 Group-homes (type A)
public agencies
 Parking
Overarching criteria / principles
of community practice in the MH Dept.
 Responsibility (accountability) for the mental health of
the community = single point of entry and reference,
public health perspective
 Active presence and mobility towards the demand =
low threshold accessibility, proactive and assertive
care
 Therapeutic continuity = no transitions in care
 Responding to crisis in the community = no acute
inpatient care in hospital beds
 Comprehensiveness = social and clinical care,
integrated resources
 Team work = multidisciplinarity and creativity in a
whole team approach
the central practical-theoretical
point
 If the CMHs is conceived as a simple out
patient clinic, that means accepting an
unavoidably subordinate situation in terms of
structure and work similar to the hospital based
services DCS and private clinics.
 If CMHSs do not control the channels for
admission into the old and new hospitalising
institutions, they are placed themselves in a
peripheral position.
 Hence the concept of “controlling the circuit” or
the pathways of psychiatric demand
the central practical-theoretical
point
 a new model is developing a “strong” CMHS
working 24 hours a day, equipped with beds
and having great flexibility as far as facilities,
resources, duties and modes of intervention
are concerned.
 The originally of the Italian concept of CMHS
was for it to be the main or the only point of
reference for all psychiatric requirements of the
entire catchment areas. This allows the CMHS
to conduct a continual cycle check.
Some relevant outcomes



In 2011, only 16 persons under
involuntary treatments (7 / 100.000
inhabitants), the lowest in Italy
(national ratio: 30 / 100.000); 2 /
3 are done within the 24 hrs. CMHC;
Open doors, no restraint, no ECT in
every place including hospital Unit;

No psychiatric users are homeless;

Social cooperatives employ 400
disadvantaged persons, of which 30%
suffered from a psychosis;

Every year 240 trainees in Social
Coops and open employment, of which
20-30 became employees;

The suicide prevention programme
lowered suicide ratio 40% in the
last 15 years (average measures);

No patients in Forensic Hospitals.
peppe dell'acqua dsm trieste who
collaborating center
[email protected]
33
How much does it cost?
1971:
 Psychiatric Hospital 5 billions
of Lire (today: 28 million €)
2011:
 Mental Health Department
Network 18,0 millions €
 79 € pro capita
 94% of expenditures in
community services, 6% in
hospital acute beds
34
Costs of MHD - 2010
Costs
%
Staff
€ 11.158.171,01
59%
Medications
€ 1.077.500,03
6%
General expenses
€ 2.920.853,95
16%
Social expenses
€
956.802,88
5%
Personal Health
Budgets
€ 2.645.362,81
14%
Total
€ 18.758.690,68
100%
outcome research

75% compliance to antipsichotics (n=587) related to service provision and SN
enhancement.

27 people - high priority, 5 years f-up:

Highly significant reduction of symptoms severe > 65 p at BPRS from 20% to
4%), increase of social function (50% score), 9 at work, 12 indep living, unmet
needs (CAN) from 75% to 25%, 70% reduction of night accomodations. Only 1
drop-out.

Qualitative research on recovery / social dimension (IRRG, Am J Psy Rehab
2006)

24 h services (among 13 centres) better for crisis care and 2-year f-up, trust,
continuity, comprehensive health and social care (2005). Reduction of
emergency presentations in the GH casualty of 70 % in 20 years.

1983-1987, first f-up after reform law showed better outcomes for Trieste and
Arezzo among 20 centres due to better organisation and social integration.

Satisfaction of users is 78% (2008)
The experience in the Region Friuli Venezia
Giulia for reform implementation
 A clear action for deinstitutionalisation of PH
 The development of 24 hrs CMH Centres
 The develpoment of a network of services for rehab
and social integration, e.g. group homes, day centres
and social cooperatives
 The creation of “strong” MH Departments in order to
co-ordinate all services according to principles of
contrasting social exclusion, stigma and discrimination
and promoting social inclusion.
What is a 24hrs CMH Centre?
 An open door on the street
 A multidisciplinary team in a normalised therapeutic
environment (domestic) for day care and respite, socialisation
and social inclusion
 A multifunctional service: outpatient care, day care, night care
for the guests, social care & work, team base for home
treatment and network interventions, group & family meetings /
therapies, team meetings, mutual support, relatives and other
lay people visits, inputs and burden relief.
 Social cooperative home management
 Leisure and daily life support (self care; brekfast, lunch and
dinner)
Hospitalisation / hospitality
 Institutional rules
 Institutionalised Time
 Institutionalised (ritualised) relations:
among workers / and with users
Time of crisis disconnected from
ordinary life
Stay inside
A stronger patients' role
Minimum network’s inputs
 Agreed / flexible rules
 Mediated time according to
user’s needs
 Relations tend to break rituals
 Continuity of care
before/during/after the crisis
 Inside only for shelter /respite
 Maximum co-presence of SN
Hospitalisation / hospitality
Difficult to avoid:
 Open Door System
Locked doors
 Isolation rooms
 Restraint
 Violence
Illness /symptoms /body-brain
 Crisis / life events / experience
/ problems
CSM DOMIO
CSM
BARCOLA
Personalised Plan (PP)
 PP funded by Personalised Healthcare Budget and organised
along 3 axes indispensable for full social functioning and
empowerment : housing, work, socialisation.
 The PP accesses other services (mental health services,
healthcare districts, social services) and community resources
(volunteers, social coops, associations, families), and works as
much as possible within the user’s family, physical and social
setting.
 The Healthcare Agency must guarantee the quality of the PP.
Trieste demonstration
 A town without a psychiatric hospital for 30 years.
 From total institution to a fully community based service, without barriers,
immersed in the community, and a low threshold of access.
 Practice with the highest degree of freedom, following
respecting user’s power of negotiation.
the principle of
 There are places, like the CMHC, group homes, day centres, socila clubs,
where anybody can live health and ill mental health in their interface in
people’s lives.
 Mental health issues are recognized in their intersections with mental ill health
and social inclusion (with welfare systems), with justice, with general health
and health needs.
 The paradigm of illness is broken in favor of that of the person.
 It is possible to open an issue of diverse stakeholders and collective subjects
(users, families, networks, community, society) and of their power, while the
vertiical power of psychiatric institution has been dismantled.
Deinstitutionalisation
as a process
The process of the deinstitutionalisation of PHs
necessarily implies a major involvement on the
part of both the general population and
psychiatric operators. In fact, these latter do not
necessarily have a decision-making role in cases
involving a purely administrative deconstruction and
the emptying of hospitals, which can only be
activated by policymakers.
By deinstitutionalisation we mean that process which
aims at the gradual transformation of living
conditions, treatment and care and the
restoration/construction of patient rights, together
with the progressive substitution of the rules of
internment with procedures based on a full
negotiability between patients and operators.
a) staff culture
• criticism of psychiatry’s custodial mandate and the re-elaboration of
the mandate for control;
• abolishing practices of violence and restraint as a form of
institutional management vs ‘no restraint’ at all levels;
• top-down vs bottom-up lead of change;
• contributions of new, diverse actors who are not part of ‘normal’
institutional life (e.g. volunteers, citizens, artists, intellectuals, family
members, non-profit organisations).
b) relations with the user
• changing institutionalised behaviour, responding to needs, listening
and reconstructing life stories, restoring voices, instigating and
sustaining empowerment, creating participation
c) the organisation of life in the hospital
• ‘humanisation’ (e.g. dignity of habitat; personalising patient living
spaces; private possessions, clothes, keys, wardrobes; managing own
money,; contacts with outside world; first outings; finding life stories)
• ‘liberalisation’ (e.g. opening up wards; mixed m/f wards; therapeutic
community-type meetings; break up totalised life of patients; giving
patients a voice; focus on primary needs such as income and housing;
individual and group outings; parties; invite family members)
• deinstitutionalisation (e.g. planning the phasing out and suppression of
the PH through sectoralisation and internal reorganisation; closing
wards and a gradual reconversion moving towards community services;
transfer resources to services and directly to users, guaranteeing life in
the community through economic resources for subsidies and training;
opening the first group homes and single residences, with appropriate
support; create social enterprises / coops, etc.)
d) interventions and deinstitutionalisation policies
• involving and influencing administrations and policies, administrative
management of transformation;
• involving civil society, creating public awareness and fighting stigma;
• contaminating the judicial and forensic psychiatric system;
• changing the legal framework for Mental Health and inclusion;
• integrating Mental Health into general healthcare (e.g. at the
community level / primary care and not just hospitalisation for acute
cases);
• integrating Mental Health with welfare systems (e.g. inter-sectorial
link with social services for housing, work, free time, education and
cultural training);
• reconverting or restoring psychiatric hospital sites to the community.
• The decisive step in the process of phasing out PHs is
identifying where to accept or admit new psychiatric
cases.
• Generally, one opts for a mix between the use of specific
wards (or beds) in general hospitals and hospitality in
mental health centres or in other types of non-hospital
residential structures, with preferably a very limited
number of beds.
• The suppression of the PH should coincide with the
creation of networks of totally alternative services
capable of providing care for a given population (as in
sector policies), but which stress the recovery and
reinclusion of patients/inmates (as opposed to the sector
model).
 Despite international recommendations, even those of
the WHO (The Optimal Mix of Services for Mental
Health, 2011) which stress that PHs can be reduced or
suppressed only if community services and structures
have already been established – and thus thanks to new
funds specifically allocated for that purpose –we believe
that a contemporaneous process of reconversion
which can impact profoundly not only on the renewal of
services but also on the community and its culture, is not
only practicable but desirable.
 Despite the significant disparities due to national and
local contexts, we believe that while this process can be
instigated by a top-down impetus and be guided by a
responsible institutional leadership, it can only be fully
achieved thanks to a bottom-up process which
mobilises actors and resources.
 working directly within total institutions but without deceiving
ourselves that their closure can come from outside or due to a
‘natural death’;
 creating alternative networks of coherent services that work in
synergy within the community, thereby avoiding useless and
often harmful fragmentation and specialisations, and thus working
not according to preconceived models but by processes that are
verified collectively by users, families and caregivers, and the
community and its institutions;
• avoiding priority implementation of hospital services for
crisis/emergencies instead of community structures.
• assign to the community services the task of taking responsibility
for persons who come from their territory of competence, who
are still interned in the PH;
• plan the phasing out of PHs at the local, regional and state levels,
with specific time-frames and the possibility of applying
administrative sanctions in cases of non-compliance.
 The deinstitutionalisation process is not only downsizing or
even suppressing psychiatric hospitals, but undertaking a
complex process of removing the ideology and power of the
institution by putting the person over the institution with
their subjectivity, needs, life story, significant relationships,
social networks, social capital.
 In order to do that, it is necessary to shift the power in order
to empower people with mental health problems, shift
resources from hospitals to a range of community based
services useful for his/her whole life. It opens pathways of
care and programs that integrate social and health responses
and actions.
 This complex process of change involves users, carers,
professionals and the general citizenry, and extends to the
legislative and political level.
• This latter means no longer managing processes for
exclusion through the segregation of persons, but placing the
individual at the centre of the system, with their human and
social rights, and their needs, in a perspective which is based
on the person’s ‘whole life’ and on recovery from the
experience of a mental disorder.
Based on what we have described above, the transformation
process takes place at the following multiple levels:
• movements (civil society)
• political
• legislation
• service models and practices
• networks and organised actors, autonomously or through the
institutions, and community development, as a general raising
of awareness regarding these issues, and the activation of
non-technical resources and initiatives.
Terms of reference
 TOR 1 - Assist WHO in guiding countries in
deinstitutionalisation and development of integrated
and comprehensive Community Mental Health
services.
 TOR 2 - Contribute to WHO work on person centred
care through applying Whole Systems & Recovery
approaches: innovative practices in community Mental
Health.
 TOR 3 - Support WHO in strengthening Human
Resources for Mental Health.
To support WHO in promoting mental health
reform processes with focus on
deinstitutionalization
 (1) Technical support in countries as agreed with WHO, particularly
in South/East Europe for deinstitutionalization and development of
integrated and comprehensive Community Mental Health services.
 (2) Promoting intersectoral and integrated approaches and related
technologies for governance in low, medium (Czech Republic) and
also for high income countries (e.g. Australia and New Zealand,
Japan, the Netherlands, the UK), to support social inclusion.
 In collaboration with GOs, NGOs, community organisations and
welfare and general health services incl. Primary Care.
Deliverables
 (1) Guidelines for phasing out psychiatric hospitals, based on
actual experiences in deinstitutionalization.
 (2) Guidelines for setting comprehensive community-based
services.
 (3) Local report of activities for each countries of pilot sites.
 (4) Contribute to the collection of Europan good practices on
recovery and to the 10 point recovery message (FRA 17).

WHO deliverable: contribution to implementation of th European and Global Mental
Health Action Plans. Relevant outputs described under WHO/EURO Key Priority
Outcome 7 as per WHO/EURO MNH workplan 2014-15: Member States offer
evidence based interventions to improve mental wellbeing of the population and the
quality of life of people with mental disorders by applying the Global and European
Mental Health Action Plans.
To support the development of reform
processes in South America through Latin
American networks
 The activity is aimed at providing support to the
implementation of Reform Law of 2010 in Argentina,
through WHO, by enhancing a network of good
practicies and offer training in Trieste to young
professionals;
 in Brazil the shift from institutions to community
services will be promoted through training (twinning
conventions with Universities).
 Other countries can be involved in agreement with
WHO.
Deliverables
 (1) Organization of the International School in Brazil.
 (2) Local reports of activities for each project.
 (3) Training material related to deinstitutionalization and
rehabilitation.
 WHO deliverable: Contribution to implementation of the Global
MH Action Plan: Objective 2: To provide comprehensive,
integrated and responsive mental health and social care services
in community-based settings.
Collaboration with WHO QualityRights
Programme (implementation of WHO programmes and
activities at country level)
 To support human right issues and developments in institutions
together with NGOs – collaboration with WHO QualityRights in
identified countries such as Malaysia and India.
 Deliverables: (1) A project to implement a no restraint approach in
Johor Bahru (Malaysia) and related report.
 (2) A project for implementing WHO QualityRights toolkit in India
(Chennay) and related report
 WHO deliverable - Contribution to implementation of the Global
Mental Health Action Plan. Programme Budget outputs 2.2.1 and
2.2.2.
Strengthening Human Resources for mental
health through Franca and Franco Basaglia
International School
 (1) In coordination with WHO, to offer study visits and training courses in
Trieste and other relevant demonstration sites from countries named in all
other activities or proposed by WHO; and (2) to develop a formal
curriculum (International School / Master Course) on organization of
community based MH Services, together with other International NGOs
and Institutes, as agreed with WHO.The latter is organized in modules
(study visits; training packages; workshops; longer stage periods).
 Deliverables: (1) Each year: n. 5 study visits with 2/3 daystraining
packages; a 5-7 days workshop; stage periods of 3-6 months. Trainees:
from 40 to150 per year ca.; an expected number of about15 trainee mh
professionals will be trained in Trieste for longer stage periods. (2)
Diffusion of documents and other material focused on innovative practices
in community MH (e.g. alternatives for acute care; comprehensive CMH
Centres; rehabilitation,recovery & social inclusion services;
deinstitutionalisation & whole systems change; early intervention
integrated network; social enterprises & Cooperatives technology,
operation & policies).
Contribute to WHO implementation of mhGAP
and related support to specific countries
 In countries where the WHOCC already established contacts with WHO
National Counterparts or Programme Leaders and Officers, mhGAP
outcomes are addressed through specific agreements within WHO
mhGAP Programme. Local developments in Primary and Secondary Care
will be supported by mhGAP training and development of multidisciplinary
teams.
 Deliverables: (1) Local report of activities. (2) Planning and adaptation of
toolkits and training packages. (3) Related seminars and courses. All
deliverables will be shared and exchanged through mhGAP community.
Participation tomhGAP annual meeting.
 WHO deliverable: Contribution to implementation of the Global Mental
Health Action Plan. Programme Budget outputs 2.2.1 and 2.2.2.
Conclusions:
a paradigm shift
 This process must be linked to an awareness that
creating a new paradigm is indispensable: this means a
new way to conceive of the relationship with mental
disorder, and a new way to organise social welfarehealthcare for the population that is more emancipatory
in its content.
 The focus must be shifted from ‘illness and
custodianship’ to ‘responding to the needs of
persons’.
Toward a value-driven service
 A citizen with rights
 Helping a person and not treating a illness
 Understand events of life, overcome crisis
 Explain and discuss experience
 Not losing value as a person (invalidation, neglect, violence)
 Keep social roles and maintaining social networks / systems
 Develop growth potential (recovery)
 Have opportunities – real empowerment
 Change (living conditions, style)
 Material resources (work, money, practical help)
Roberto Mezzina,
Director WHO CC for Research and Training,
MH Dept. Trieste
[email protected]
www.triestesalutementale.it