�The WHO CC Workplan2014-18

Roberto Mezzina, Director DSM / WHO CC for Research and

Training, ASS 1 Trieste

International Meeting

Trieste, 9 December 2014

The experience of collaboration – Trieste WHO CC (established 1987)

Linking with other experiences of change: e.g. with Lille, B’Ham, South Stockholm, Oviedo, Monaghan (IMHCN)

Greece (Leros)

Croatia, Bosnia-Herzegovina, Kosovo, Albania, Makedonia

Mozambique

Brasil, Colombia, Argentina, Cuba, Dominican Republic

Japan, China, Malaysia, India, South Korea.

Italian Regions: Campania, Sardegna

900 professionals visiting Trieste every year

English-speaking countries New Zealand, dec 2010, sept 2012 – ‘La via Trieste’ – Miniister of

Health, Blueprint II

Australia, sept and dec 2010, August and Sept 2012 – TheMHS conference, Minister of Health NSW, MH Commissions, RANZCP conferences, cooperation for PH campus to the community (La Rozelle)

USA, San Francisco, 2006-2009

Twinning collaboration with 3 SW England Trusts through IMHCN (UK, 2009-10 – Hertfordshire, September 2009; Study visit to Elderly Services, Cornwall, Jan 2010; Plymouth, Newtwork Conference, March 2010)

Short summary 2010-14

Activity 1 – Support to Who-Euro in Central-Asian Republics for service development: from de-institutionalisation to community services in Azerbaijan, Turkey, Armenia. Turkey was the most relevant country – as indicated by WHO – with on site support in 2 Pilot areas (Bolu in 2011-2013, Elazig in 2014) guidance and training as well as public meetings and conferences, contacts with policy makers, study visits to Trieste of several groups and delegations (2010-2014) including the attendance to the International School.

Activity 2 – Support to Who-Euro in Central and Eastern European countries for service development: collaboration for comprehensive CMH Services in Bulgaria, Romania, Czech Republic, Slovenia, Bulgaria. Romania and Czech Republic were engaged either in pilot sites (Iasi in Romania; Prague) with either policy makers (Vice Minister of Health in Czech R. and a government delegation) or professionals and leaders, in Italy and in those 2 countries.

Activity 3 – Latin America Network. Support to good practices in collaboration with PAHO, WHO-HQ and WHO-Euro in Argentina, Brazil, Colombia, Ecuador. This activity was developed in collaboration with COPERSAMM / ConfBasaglia (Italian NGO) and with las Red das Bonas Practicas in Argentina, ABRASME in Brasil, Universities (S. Paulo and Bahia, among others) and governments like the State of Minas Gerais in Brasil and the Argentinian Governemnet. A flow of trainees (psychologists and psychiatrists) was trained in Trieste for periods of 3-6 months. A Summer School – twinned with our School – was organized for Septemer 2014 in the State of S. Paulo.

Activity 4 – Support to WHO Headquarters for mhGAP Project. The WHO CC Director (dr Roberto Mezzina) was invited as speaker to the mhGAP conferences in Geneva, in 2011-12-13. He is part of the mhGAP Community. The mhGAP-IG has been translated into Italian and now published with the support of the Region Friuli-Venezia Giulia. Provision of technical support to the project entitled "Mental Health GAP" promoted by WHO Headquarters in Iran, Pakistan, China. In Iran in July 2014 the WHO National Office organised a number of meetings and visits in Tehran in collaboration with the local University (WHOCC).

Activity 5 - Training and summer school “Franca and Franco Basaglia International Summer School”

- First module: September 19-24, 2011, is entitled: “Beyond the walls - how to open the doors of psychiatric hospitals towards community based care and services. Focus on Europe and the East”. Organised by WHOCC in collaboration with WHO HQ and Euro, IMHCN, ConfBasaglia, Forum salute mentale, WAPR. The first module’s topic focuses specifically on supporting rehabilitation and social inclusion of people with mental health problems still interned or treated basically in psychiatric hospitals; participants were directors, leaders, experts and policy makers from Romania, Serbia, Bosnia-Herzegovina, Albania, Greece, Czech Republic, Azerbaijan, Iran, Turkey and other countries.

- Second module: October 22-27, 2012 with the title: “Services people need. A rationale for a fully integrated, person- centered mental health system of care”, focused on putting learning into practice based on the particular needs of participants in implementing change from institutions and their practices into community mental health services and a whole life recovery approach. 42 participants (directors, managers, WHO experts, technical governmental staff from 16 countries (Italy, Albania, Slovenia, UK, Greece, Romania, Czech Republic, the Netherlands, Spain, Montenegro, Turkey, Pakistan, Palestine, Japan, China, New Zealand, Australia, Argentina). There was a final conference with 152 participants entitled “Why Change? Creativity and Innovation in Mental Health Development”

- International Seminar, 7-8 November 2013 with the title ““Recovery and occupation: users as protagonists of social inclusion. Changing the culture - focusing on real experiences” focused on the important aspect of social inclusion policies and mental health practices (as far as vocational rehabilitation is concerned) as well as of recovery and emancipation pathways for individuals achieving full citizenship. More than 180 participants from 16 different countries came and it was the web TV transmission via streaming.

Study visits.

Every year from 600 to 900 people (professionals, managers, administrators, politicians, students, associations, carers, users, volunteers and other stakeholders) from different countries (Argentina, Australia, Austria, Brasil, California, Canada, Denmark, France, Japan, Greece, UK, Iran, Italy, Netherlands, Czech Republic, Serbia, Slovenia, Spain, Sweden, Switzerland, Turkey and so on) come to Trieste MH Services and are involved in study visits, training, short- medium and long term stages and seminars.

- Among others, there were 2 world wide meetings :

“Trieste 2010: WHAT IS ‘MENTAL HEALTH’? Towards a global network of community health. International Meeting, Trieste 9-13 February 2010. It involved about 1500 attendees from about 30 countries and “Beyond the walls: the transition from hospital to community based care. Deinstitutionalisation and International Cooperation in mental health” Trieste, 13 – 16 April 2011. The meeting was attended by 300 participants from 28 countries.

Activity 6 – Preparation of deliverables on De-institutionalisation and Community-based Mental Health Services among which: the book “Beyond the walls – Deinstitutionalisation in European Best Practices”, edited by L. Toresini and R. Mezzina, an advanced draft has been developed of a guide on how to set up community-based mental health services. The Manual for Prevention of Suicide in Jail: a project with Italian Ministry of Justice,”Trieste WHO CC” (dr Mezzina and Dr Ridente) participated to the develpoment of QuIRC (Quality Indicator for Rehabilitative Care) which is an instrument developed to measure the quality of care in longer term residential units. It is currently available on the webin ten languages.

Some other results are: ”the Trieste Declaration 2011” together with a theoretical background document, was approved and signed by all the delegates attending the meeting. As indicated by the Director of the WHO Department of Mental Health and Substance Abuse in Geneva, Dr. Shekar Saxena, and Regional Director for Mental Health-WHO Copenhagen, Dr Matt Muijen, the Declaration was officially sent to WHO and the European Commission, “The Charter of de-institutionalisation actions” that consists of a series of over 20 projects and cooperation measures attached to the Declaration. The projects and concerted actions are an indication of important business to realize the shared intention to change services emerged from the meeting. "Charter of deinstitutionalization actions in Europe and worldwide," and the WHO CC in Trieste intends to follow and support it in cooperation with the international organizations; Translation of “mh GAP Intervention Guide” into Italian (2013) and so on.

Activity 7 – Technical support on Mental Health services and Welfare Innovations actions in Republic of Serbia and the Balkan region, in Albania, Macedonia, Bosnia, Serbia, Montenegro, Greece and particularly: “The EUROStart Programme of Cooperation” between Region FVG and autonomous Province of Vojvodina started in March 2013 and will end in 2014, with the identification of 3 pilot sites and in connection with OPEN ARMS European Project for D.I. of Social Institutions. In Albania there was a mission in September 2011 to support the D.I. in Vlore and training of professionals and Policy makers in Trieste (Summer School). Macedonia (Ohrid, 2012 and a number of contacts in Trieste for the S. School and other conferences) is now proposing a convention for training of professionals and MH Leaders in Trieste. The project in Montenegro is focused in Kotor PH woth the economic support of Region Friuli Venezia Giulia.

Activity 8 – Support to the WHO Office in Palestine. There was a collaboration in 2009-10 in order to assist the Palestinian Ministry of Health in developing rehabilitation strategy and programmes in order to establish a model of best practice and improving opportunities for social inclusion for service users and their families (especially in Bethlehem). Palestinian leaders (WHO Officers) were involved in the Summer School and other conferences. The new WHO project in Gaza has required our support in the next future.

Dr Mezzina was invited to contribute to the draft of WHO Mental Health Global Action Plan and WHO European Action Plan, and also engaged on needs / possibilities to align activities of WHO CCs to the Strategy objectives.

WHO-CC Trieste hosted on 6-7 of November 2012 the Meeting of the European Collaborating Centres for the WHO Mental Health Programme, and the purpose of this meeting comprises the following:

1. To present the draft European MNH Action Plan;

2. To agree activities and products and ways of dissemination and implementation;

3. To consult with participants on the areas for future collaboration;

4. To begin the development of targets and indicators that will allow evaluation of progress.

There is a strong collaboration with other WHO CCs (Verona, Lille, Lisbon, Switzerland, Stockholm), WARP, Network of European Psychiatric Hospitals in Transition, The “COPERSAMM - Conferenza Permanente per la Salute Mentale nel Mondo (Permanent Conference for Mental Health Worldwide) – ConfBasaglia”, IMHCN (International Mental Health Collaborating Network), EAOF (European Assertive Outreach Foundation) and other relevant International organisations in Australia (as Travelling Professor), Denmark (visit of the Minister of Health in delegation to Trieste), USA (International Conferences), Japan (consistent number of delegations from Japan visit Trieste MH Services). Spain (International Seminar and visit to MH Services in Murcia), Egypt, Philippines and India.

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”.

L'Action Plan Europeo 2013 sulla Salute Mentale

e l'impatto sulle politiche nazionali.

Roberto MezzinaDirettore CC OMS –DSM ASS n.1 Trieste

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)

Il nuovo Action Plan per l’Europa

L’Action Plan Europeo rappresenta un documento strategico che è stato elaborato dall’OMS Europa in collaborazione con esperti e rappresentanti governativi.

Nella cornice del documento Health 2020, ha lo scopo di individuare gli obiettivi centrali per la salute mentale della Regione per il settennato 2013-2020, che verranno sottoposti all’approvazione di tutti gli Stati nel corso del 2013.

Esso riprende e rinnova i contenuti della Dichiarazione di Helsinki 2005, costruendo una cornice ampia anche sul piano valoriale.

Policy developments

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).

World Health Assembly passed a resolution in 2012, requesting acomprehensive Global Mental Health Action Plan.

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 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.

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 20-30 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.

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.

Obiettivi principali dell’Action Plan Europeo in sintesi

Benessere nel ciclo di vita

Diritti umani ed empowerment per i cittadini

Servizi di comunità accessibili ed attraversabili

Trattamenti rispettosi, sicuri ed efficaci, coinvolgimento nelle decisioni

Buona salute fisica e mentale garantita per tutti

Approccio intersettoriale

Informazione e conoscenza

Le principali caratteristiche dell’approccio proposto nella strategia

Sottolineando la condizione di cittadinanza, l’approccio deve essere:

basato sui diritti e centrato sulla persona (rights based and person centered), il che implica

il protagonismo e la partecipazione delle persone seguite dai servizi e delle loro associazioni, mentre si persegue

la lotta alla discriminazione alle diseguaglianze.

Viene proposta

una collocazione della salute mentale in una visione olistica della salute tout court, che deve essere garantita da

sistemi di cura orientati alla sicurezza ed all’efficacia, e da

servizi competenti, accessibili e attraversabili (affordable), che agiscano attraverso

l’intersettorialità, la partnership, e l’integrazione nei sistemi di welfare.

Implementazione dell’Action Plan

L’Action Plan è articolato in outcomes attesi e sono individuate azioni sono indicate ad interlocutori istituzionali, ovvero:

I governi degli stati membri della Regione Europea sec l’OMS

L’OMS e la rete dei suoi Centri Collaboratori europei.

Una serie di target sono stati identificati nel Meeting dei CC OMS Europei con le Direzione OMS di Copenhagen a Trieste, 6-7 novembre 2012.

Per essi sono previsti indicatori da monitorare

Objective 1. Everyone has equal opportunity to realize mental wellbeing throughout their lifespan,

particularly those who are most vulnerable or at risk.

School based mental health promotion and suicide prevention interventions (collate ‘best practices’ / working approaches) Lead: SWE-52. Involved 2nd wave: ITA-91) Prevention of child abuse: specific protocol is being developed and

implemented within a joint project with UNICEF Prevention of child abuse in ID in different contexts, inc. schools (i.e. web

activities). Mental health promotion in ageing population E-health aspects of MH promotion

Share relevant to MH promotion guidelines, tools and handbooks (suicide prevention, prevention of child abuse, MH promotion including in ageing population). All CCs

Objective 2. People with mental health problems are full citizens whose human rights

are valued, protected and promoted. Develop and disseminate a 10 point recovery message

reflecting how recovery was addressed in Trieste and Lille. Lead: FRA-34, ITA-91

Collection, analysis and dissemination of good practices on recovery across Europe. Lead: FRA-34, ITA-91

Organize an international Empowerment Conference in 2013. Lead: FRA-34Develop a curriculum for peer workers

Objective 3.Mental health services are accessible and affordable,

available in the community according to need

Aggregated info on social inclusion of socially marginalized groups / access to CBMH services and methodology. Lead: UK-244

Share guidelines / methodology on PHC and deinstitutionalisation. Lead: ITA-91

Share results of relevant surveys, guidelines, tools on mental health services. Involved: All CCs

Outcomes 4.Large institutions which are associated with neglect and abuse

are closed.

5.Hospital care is therapeutic, provided in a decent environment.

6.People with long term mental health problems lead lives as full citizens.

7.Mental health services offer appropriate care for different age groups.

8.Family capacity and needs are assessed periodically, and training and supportprovided.

9.A multi disciplinary workforce is available in sufficient numbers.

Objective 4. People are entitled to respectful, safe and

effective treatment and to share in decisions Develop papers on action points 4 (make service users share in decisions

about the prioritization, development and implementation of innovative and effective treatments).

Lead: UK-244

Develop papers on action points 7 (offer staff development opportunities and stimulating working environment, fostering morale).

Lead: UK-244

Share results of work in the area of continuous education / training of human resources for mental health.

Lead: SRB-9

Share experience / work / materials on maintaining staff morale.

Lead: FRA-17

Objective 5.Health systems provide good physical and

mental health care for all

A literature review on how to address co-morbidity Lead: NET-75 Involved: FRA-17, ITA-91, ITA-Verona, SRB-9

Develop a guideline on how to improve physical health of people with mental disorders. Lead: ITA-91 Involved: FRA-17

Share an EU tool kit ‘HELPS’, other relevant guidelines, tools and handbooks on co-morbidity. Lead: UK-244

Objective 7. Mental health governance and delivery are driven

by good information and knowledge.

Establish 1 hub in WHO CC RUS for Russian speaking countries to assist in developing a research capacity especially in Central Asian Republics.

Establish 1 hub in WHO CC SRB for SEE countries to assist in developing their research capacities.

Collect and collate good practices on empowerment. Lead: FRA-17

Mental Health Programme

Distribution of beds per 100 000 population in mental hospitals and in community psychiatric inpatient units & units in DGHs

European policy documents related to Deinstitutionalisation

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 Optimal mix of Services (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

WHO Zero draft – Global Action Plan (2012)

Reduction of 20% of long term beds within 2020.

MH laws updated within 2016 in 80% of countries.

All large institutions with neglect must be closed.

• 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.

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.”

Deinstitutionalisationas a process/

Trieste Declaration 2011The 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.

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 reconversionwhich 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.

Sistema globale?

E’ possibile creare un sistema globale di salute per un determinato territorio, tale da rispondere ai bisogni di salute e realizzazione personale degli individui seguiti dai servizi e di promuovere salute nella popolazione generale / nella comunità? E come?

In che modo un approccio di sistema alla salute non è soltanto inteso come sistema di servizi?

In che modo le risorse umane, economiche, sociali e culturali di una comunità vengono attivate e mobilizzate e coordinate operativamente? Esistono dei meccanismi che garantiscono la sostenibilità economica di tali scelte?

Polarità

i servizi clinicizzati, specialistici, centralizzati, ospedalocentrici, istituzionalizzati, fondati su prestazioni separate e rivolte a specifiche patologie da un lato, vs

i servizi integrati, comprensivi, decentralizzati, di piccola scala ed a bassa soglia, legati ai contesti di vita sociale e alla comunità locale.

il sistema di finanziamento a prestazione, a DRG vs

quello a budget individuale ed integrato, in una prospettiva di bilanciamento della spesa tra ospedale e comunità, tra sanitario e sociale.

la scarsità delle risorse istituzionali vs

l’enormità delle energie potenziali per la salute presenti nelle comunità, se i servizi si dimostrano capaci di catalizzarle ed attivarle.

il sistema di salute mentale realmente integrato nei servizi sanitari, in modo sinergico?

I servizi sono generalisti o specialistici (funzionali, per team che rispondono a popolazioni target)?

Come viene risolta la tensione tra territorialità e specializzazione? Tra domiciliarità e strutture? Tra contesti e soggetti da un lato, e professionalismo e tecnici dall’altro?

Esistono luoghi di accoglienza dell’acuzie e della crisi al di fuori degli ospedali?

Le iniziative “user-led”, gli utenti dei servizi come protagonisti, le componenti del terzo e quarto settore risultano essere partner effettivi, co-decisori o co-gestori del sistema-salute in un’ottica di democrazia partecipativa (ci riferiamo ai servizi locali di welfare, agli ONG quali associazioni, cooperative sociali, imprese no-profit etc.)?

Domande

Come intercettare le risorse sprecate, a volte sottratte legalmente o semplicemente inutilizzate, a favore di risposte essenziali garantite per tutti nel campo dell’assistenza e nelle politiche di inclusione sociale, che siano tese a ridurre le condizioni di disuguaglianza, e le differenze di genere, di etnia, di religione, di status e di potere che emergono in maniera sempre più drammatica?

Come possiamo far convergere le risorse umane e professionali esistenti nei servizi sanitari e nei servizi locali di welfare, coordinandole con le risorse delle persone e dei microcontesti?

Come recuperare la dimensione etica e politica nel lavoro di salute, contrastando i “crimini di pace” nei confronti di uomini e donne, giovani, adulti, anziani, bambini, e sperimentando collegando le pratiche innovative a favore dei soggetti e della comunità?

Come ragionare sui luoghi della cura, e su un habitat sociale che riutilizzi le risorse devastate delle nostre società, a partire dai patrimoni delle grandi istituzioni, persino dai giardini dei manicomi?

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 healthreform 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 reformprocesses 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 QualityRightsProgramme (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 mentalhealth 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).

L'International School Franca e Franco Basaglia é realizzata dal CC OMS di Trieste, col sostegno della Regione FVG, in collaborazione con Università e istituti di ricerca e formazione nazionali e internazionali.

Essa intende insegnare, trasmettere e attualizzare il pensiero e la pratica di Franca e Franco Basaglia e dell'esperienza di Trieste, fondata sulla centralità della persona come cittadino dotato di pieni diritti, e in generale l'approccio critico alla psichiatria nel senso della lotta all'istituzionalizzazione e alla medicalizzazione, promuovendo un concetto integrato di cura basato sulla comunità che esclude l'impiego di mezzi oppressivi e repressivi.

Essa pertanto intende diffondere tutte le pratiche ed esperienze che a ciò si ispirano, fondate sui medesimi valori, e riconosciute come utili all'innovazione in salute mentale.

Mira alla costruzione di curricula adeguati e riconosciuti a livello internazionale, attraverso un metodo di apprendimento teorico pratico basato sulla conoscenza e lo studio dei servizi e delle pratiche, interagendo concretamente con le realtà locali. Privilegia i giovani operatori e coloro che sono impegnati a vari livelli nei processi di cambiamento.

International School in Brasil 212 participants, 450 in Ribeirao Preto

2 universities involved (USP, UNESP)

Supported by WHOCC of Trieste and IMHCN

A wide echo of Media

Many key-leaders of change in Brasil (includign National Coordunator at Ministry of Health R. Tykanori) together with international speakers / teachers.

Interactive visit and seminars on with local services and good practices

Interest of the new Government for replication

Letter of intent for the creation of a Network of Good Practices

Details The International school took place at Mackenzie University of Campinas,

Because the amphitheater only contain 212 people, we had to reduce the number of entries. The event had simultaneous translation from Portuguese to English and from English into Portuguese.

This edition of the International School Franca and Franco Basaglia was designed by the Organizing Committee constituted by Rossana Professor Maria Seabra Sade - National Coordinator (UNESP - Marilia), Roberto Mezzina - International Coordinator (Department of Mental Health (Trieste - Italy) Clarissa Mendonça Corradi- Webster - vice coordinator (USP Ribeirão Preto), Meire Silva-vice coordinator (UNESP - Marilia). Had the help of the Scientific Committee made up of 21 researchers from universities National and International.

The part of the event held in Ribeirão Preto - SP consisted of two steps.The first stage was held in the Auditorium of Ribeirão Preto USP Law School which is located within the campus of the University of São Paulo in Ribeirão Preto - SP. That auditorium has a capacity to accommodate 450 people.

Letter of Intent “Currently, in the Brazilian context, we face many challenges to sustain the

psychiatric reform, without losing sight of a society without asylums, together with the strengthening of the Unified Health System (SUS). From which it is worth asking: when will close all psychiatric hospitals in Brazil?

Advances are unquestionable historically in Brazil, with the deinstitutionalization and increased community services. On the other hand, reposition us from deinstitutionalization strategies is essential. Structurally expand the network of services is part of the challenge; lack pursue daily change in the logic of care, based on the dialogue with / in the community and in changing the asylum paradigm.

We can not fail to highlight: the interference of the executive in Public Policy; compulsory hospitalization (care legalization and perverse autonomy of therapeutic communities); corporatism via class councils; social inequality; privatization and scrapping of SUS (a decrease of professionals in teams); among other issues.

Therefore, the central proposal is to promote the exchange of good practices as training strategies for teams, expanding the dialogue with the community and the knowledge visibility in partnership with educational institutions.”

WHO Deliverable

Contribution to implementation of the 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. (Programme Budget outputs 2.2.1 and 2.2.2).

Contribute to WHO implementation of mhGAPand 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.

ASS n.1 TS 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)

-

100

200

300

400

500

600

700

800

5.000

7.500

10.000

12.500

15.000

17.500

20.000

22.500

25.000

Adm

itte

d pe

ople n

umbe

r

Day

-night

adm

ission

day

s

Years 1981 - 2011

Day-night admissions at CMHCs

Day-night admission days at the Mental Health Centre (MHC) Admitted people

peppe dell'acqua dsm trieste who collaborating center dsm@ass1.sanita.fvg.it 70

Where are the ”beds” today? Year 1971: 1200 beds in Psychiatric Hospital

Year 2012: 78 beds of different kind in the community:

26 community crisis bedsavailable 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)

The coops: activities cleaning and building

maintenance (diverse agencies) Canteens and catering, incl.

Home service for elderly people Porterage and transport Laundry tailoring Informatic archives for councils,

etc furniture and design cafeteria and restaurant services Hotel Front-office amd call-center of

public agencies

Museums’staff

agricultural production andgardening handicraft

carpentry

photo, video and radio production

computer service, publishing trade,CD-Rom

serigraphics

theatre

administrative services

Group-homes (type A)

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 24 hrs Community Mental Health Centre

The 24-hours community mental health centre is a non-hospital residential facility, not conceived just as acrisis centre.

It is in fact multi-purpose, multi-functional: also a daycentre, an outpatient service, a base for communityteams.

The quality of the environment (home-like) and of theatmosphere (friendly) is based on staff attitudes mainlyfocused on flexibility and reasonable negotiation withthe user’s concerns and needs.

Its main duty is to be responsible and try to provide acomprehensive response.

A single multidisciplinary team acts rotating insideand outside, for those who are “guests” on a 24hours scheme and for the users attending daily orreached at home.

Knowledge and trust are the main tools for buildingup therapeutic relations.

Users’ participation and contribution in the centreordinary life is seen as crucial.

Hence crisis is addressed by ‘indirect’ strategies ofmanagement using these peculiarities.

Specialised vs. integrated and holistic models

A systematic comparison of the various aspects of the care process in an integrated and “comprehensive” approach, based in a single location (the MHC), as opposed to a specialised approach (so-called ‘functional’) in the organisation of services, which is instead based on different teams, would be extremely useful.

Implications of deinstitutionalisation in terms of costs and strategy.

the central practical-theoretical point

If the CMHs is conceived as a simple outpatient clinic, that means accepting anunavoidably subordinate situation in terms ofstructure and work similar to the hospital basedservices DCS and private clinics.

If CMHSs do not control the channels foradmission into the old and new hospitalisinginstitutions, they are placed themselves in aperipheral position.

Hence the concept of “controlling the circuit” orthe 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.

peppe dell'acqua dsm trieste who collaborating center dsm@ass1.sanita.fvg.it 78

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.

79

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

Costs of MHD - 2010Costs %

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%

Health Budge € 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

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.

the central practical-theoretical point

If the CMHs is conceived as a simple outpatient clinic, that means accepting anunavoidably subordinate situation in terms ofstructure and work similar to the hospital basedservices DCS and private clinics.

If CMHSs do not control the channels foradmission into the old and new hospitalisinginstitutions, they are placed themselves in aperipheral position.

Hence the concept of “controlling the circuit” orthe pathways of psychiatric demand

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)

And many other ordinary and straordinary things

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 / hospitalityDifficult to avoid:

Locked doors

Isolation rooms

Restraint

Violence

Illness /symptoms /body-brain

Open Door System

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 the principle ofrespecting user’s power of negotiation.

There are places, like the CMHC, group homes, day centres, socila clubs,where anybody can live health and ill mental health in their interface inpeople’s lives.

Mental health issues are recognized in their intersections with mental ill healthand social inclusion (with welfare systems), with justice, with general healthand 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 thevertiical power of psychiatric institution has been dismantled.

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 welfare-healthcare 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’.

Recovery and citizenship

Citizenship should be interpreted as a social processthat brings about individual and social transformation

not a status but a ‘practice’, which is essentially theexercise of social rights (De Leonardis).

Hence, it involves a re-distribution of power, and theexercise and development of capabilities.

As we demonstrated in qualitative cross-culturalresearches, a lived citizenship, ‘having a whole life’ canbe captured to be at the heart of a recovery process, asstated by individuals themselves.

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)

The person and not the illness at the center of the process of care for recovery and emancipation through users’ active participation in the services

(up close, nobody is normal)

Roberto Mezzina, Director WHO CC for Research and Training,

MH Dept. Trieste who.cc@ass1.sanita.fvg.itwww.triestesalutementale