COUNTRY OF ORIGIN• Italy
From the asylum to territorial services for mental health
Results
During the complex reform process to replace the asylums and implement territorial mental health services, there were structural results, in terms of both service organization and response quality for the population. The new organizational and operational setups also represent a point of reference for those interested in building local area alternatives to traditional psychiatric care.
The Department of Mental Health
The Department of Mental Health, established in 1981, is part of the Trieste Health Agency. The Agency, which covers a population of about 240,000 inhabitants, is divided into four Healthcare Districts. In each of the Healthcare Districts there is a Mental Health Centre (MHC).
The Department of Mental Health, directed by Peppe Dell’Acqua since 1995, is the operational centre for prevention, diagnosis, treatment and rehabilitation and the organization of mental health care for citizens. The Department is also responsible for removing any form of discrimination, stigmatization, and exclusion of people with mental illnesses and disturbances, and helps to actively promote the full and complete rights of citizenship. The Department ensures that the mental health services in the Health Agency operate as a single coherent whole, in coordination with other health services, with the community and its institutions. The Department also organises training and refresher courses for all professionals, for local operators and those in other Italian regions and other countries. The services offered by the Department are provided by 220 professionals (psychiatrists, psychologists, nurses, social workers, rehabilitation engineers), staff in social cooperatives, and finally trainees and volunteers, often from other cities, regions and countries of the world.
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Access to mental health services To access mental health services in Requests for appointments can be made directly, by phone, or by the attending physician. First contacts can be made at the Health District, at home, or other social or medical areas. The General Hospital’s Psychiatric Diagnosis and Treatment Service may require the intervention of the MHC for people whose application has been received by emergency services. There are no waiting lists and the first interview takes place within 24 hours of request. The application is received by the staff on duty and the first assessment, after the initial interview, is conducted by a psychiatrist or psychologist, in collaboration with the team. An assessment is made of the problematic aspects as they are presented, and of the viability of taking charge of the case. Responses and treatment are tailored to the specific problems and needs of the people concerned and the service aims to provide, as far as possible, personalized and not standardized interventions. |
The Mental Health Centres
The Department manages the 4 Mental Health Centres (MHC) in the 4 Districts into which the Trieste Health Agency is divided, each providing services to a population of about 60,000 inhabitants. Each Centre is open 7 days a week, 24 hours a day, and has 8 beds. The Centres are the access points and planning centres of the mental health system. Work practices focus on providing therapeutic and rehabilitative continuity, especially for people who suffer from severe mental disorders. The service operates in the places where the user is to be found, not only in the home but also the hospital, nursing homes, prisons and forensic hospitals. The Centres carry out the following activities:
· Night Accommodation, for varying periods of time, in response to crisis situations, to protect against specific risks, or give a respite to both patient and family.
· Daytime Accommodation, to provide protection in situations of crisis and tension, to provide pharmacological therapies and psychotherapeutic support, to stimulate participation in reintegration activities.
· Outpatient services, to offer initial consultation and monitoring of developments in the treatment program.
· Home services, to learn about the living conditions of the person and their family, to mediate in conflicts with the neighbourhood in crisis situations, to administer medication, to accompany people to hospital, government offices, work.
· Individual therapeutic work, to listen and study the problems and living conditions of the person, to look for ways out and build a new balance.
· Therapeutic work with the family, to verify and discuss dynamics and conflicts, to stimulate possible changes, build alliances in the therapeutic program.
· Group activities involving operators, volunteers, users and families, to activate a social network of friends, colleagues, neighbours, or others who play an important role in therapeutic processes and social reintegration.
· Rehabilitation and prevention, through cooperatives, expressive workshops, school, sports and recreational activities, youth groups and self-help.
· Support for the most disadvantaged and their families, through economic benefits (social integration, job training, support for rehabilitation activities) or by sending or accompanying the patient to organizations and institutions that can meet their needs.
· Support for rehabilitation at home, in housing groups and during treatment, with different degrees of assistance and protection tailored to the needs of people with disabilities.
· Consulting activities in health services, hospital wards, health districts and prison, where there are users already in the care of the MHC, for further diagnostic study, to recommend specific therapies and initiate care processes.
· Responses to calls for urgent help, advice, appointments and monitoring of therapeutic activities in progress.
The Psychiatric Diagnosis and Treatment Service in the General Hospital
The Psychiatric Diagnosis & Treatment Service is provided by the General Hospital of Trieste. It is provided with 8 beds and is open 24-hours. There are psychiatrists and nurses on duty but it also offers the services of psychiatrists from all operational units of the DSM.
It provides psychiatric consultancy for emergencies at the General Hospital Emergency Service, and offers advice to the hospital’s Departments on request. After specialist assessment and after providing initial treatment, the team can activate the competent MHC to continue the care service.
The aim of the Service is to minimize the duration of hospitalization, which in any case is not considered as an alternative or a substitute for care by territorial units. The Service makes sure that patients, even the most serious cases, maintain contact with their environment so that they can recover from the crisis more easily and avoid institutionalization. The doors are always open, and in no case is use made of constriction.
The Residential Service
This Service, which works closely with all the MHC, cooperatives and training agencies, carries out rehabilitation, training and work placement activities.
The Service set up a Day Centre, which organizes workshops and offers artistic activities, crafts and culture. There are teachers, art teachers, artists, cultural and voluntary associations. It is open to citizens that are making use of mental health services, but it is also accessible to all. Theatre, visual arts, music, cloth making, and body care activities are the most popular.
In 1996, the Office for training and work placement was set up, with the support of operators from the different services of the department. The users involved in the training/work programs can enjoy cash benefits (job training grants), which constitute a very important therapeutic tool. Since 1998, the Office has been working closely with the Trieste Province social cooperatives to develop strategies to combat social exclusion and build territorial partnership projects for integration and development.
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Social integration accommodation Managed by the Health Agency, accommodation is given to people with reduced capacity to live independently and who require support in daily life activities. One or more guests live in their homes or rented accommodation supported by service staff. Support is planned in relation to the different needs and levels of autonomy of the guests; Therapeutic-rehabilitative accommodation There are 12 houses or apartments, rented or owned by the Health Agency, managed by Service staff or affiliated social cooperatives or voluntary associations. They house people with great disability problems, who cannot rely on their family or social network, such as former long-stay psychiatric hospital patients, or people who need individualized and ongoing rehabilitation and treatment programs. |
Mental health services in the Districts
These services, which operate in the Trieste Health Districts, provide psychiatric consultation at the request of family doctors or in response to warnings, and help people who find it difficult to apply directly to the MHC. They take prompt action in cases of people with previously unrecognised psychiatric problems, improving the quality of local medical and hospital care for people with mental disorders, reducing the frequency and duration of hospital stays and their costs. Other actions are carried out in different contexts with specific programs, in conjunction with other services, to support families, provide rehabilitation services in the home and in residential areas, improve living and relational conditions in accommodation facilities.For example, there are programs for the support and socialization of the elderly, in collaboration with operators of other services and with local associations, to avoid the risk of institutionalization in nursing homes.
The University Psychiatric Clinic
The University Psychiatric Clinic carries out teaching, research and assistance activities in the field of mental health. It has 12 beds, for both inpatients and outpatients.
The Clinic is home to the School of Psychiatry and carries out epidemiological, clinical and psychopharmacological research on psychiatric disorders. Activities focus in particular on the psychopathological aspects of mood, problems related to suicidal behaviour and eating disorders. As regards dementia, the Clinic is a point of reference for the Trieste Health Agency and the Agencies of other Italian regions.
Programs operating in the territory
These programs began in the early to mid 1980s and deal with the most pressing territorial problems, creating a network of local resources involving all the operational units of the DSM. Some examples:
· The Trieste Prison Service, established in 1979 and implemented in collaboration with voluntary organizations, carries out prevention and treatment of mental health problems during detention and ensures the continuity of care for detainees and people already in the care of the mental health services; it also promotes the application of measures other than detention (parole, custody, outside work) and strives to avoid detention in forensic psychiatric hospitals.
· Self-help programs promotes clubs and other forms of association for service users, particularly people who have experienced or are experiencing personal, family and social difficulties.
· Working with the family. Launched in 1987, it helps members of the family to deal with emotional problems and the everyday difficulties of life with a relative who suffers from severe mental disorder. The DSM also organizes information programs, meetings with groups of family members from different geographical areas, meetings with parents of children showing the first signs of disorder.
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The Special Phone This was launched in 1996 to reduce the social isolation and loneliness felt by the elderly in a city where it is not rare to find people who die in solitude or commit suicide. The Free Phone is operative 24 hours a day and is connected to the social services network. In 2003, after four years of work, more than a thousand elderly women and men were cared for by the program in |
Social cooperatives
The first cooperatives to help disadvantaged people integrate into society were established in Trieste in 1980. In 1991, taking into account the positive experiences throughout the country, the Italian government passed a law regulating these cooperatives, allowing them to manage health, social and educational services and other activities (agricultural, industrial, commercial and service) aimed at helping disadvantaged people to find employment. The law stipulates that disadvantaged people must make up at least 30% of the workers in cooperatives. The Trieste Department of Mental Health has an agreement with two cooperatives to manage social, health and educational services in residential facilities, and ten cooperatives that help the disadvantaged to work in very different activities: gardening, crafts for decoration and fashion, architectural ornaments, screen printing, catering, cleaning, recovery and recycling of used materials, transport and others.
Links with voluntary associations
The Department of Mental Health has established relations with numerous organizations that defend and promote the rights of persons suffering from mental disorders and their families. These associations also work with the services in therapeutic - rehabilitation programs and activities (homes, accommodation, leisure activities, telephone help-lines). They are very effective in promoting the image of people with mental disorders in the fight against stigma, discrimination and exclusion. The DSM also works closely with 11 local associations that manage facilities and programs through agreements with local governments.
The development of the Trieste health territorial system
In 1998 the Friuli Venezia Giulia Region established the Health Agency n°1 of Trieste, to boost community health services. The Agency incorporates the Department of Mental Health and also promotes local services as an alternative to hospital care in other areas of medicine. The establishment of the Agency, greatly inspired by the work done in psychiatry, led to the development of the 4 Health Districts, which organize services to avoid and reduce hospitalization in all areas: cardiology, pneumology, geriatrics, physiotherapy and oncology.
The aim of reducing the role of hospitals was to guide the work of the health districts over the years in the development of multi-purpose services and facilities, including general practitioners and primary care, offering a vast quantity of territorial services.
This development of Trieste’s health territorial system, as well as representing an achievement of the Department of Mental Health, allows for effective local mental health interventions, with the active cooperation of a great network of facilities whose aim is to provide assistance that is closer to citizens' needs.
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•Which problem does it help to solve?
•The reform of psychiatry and the implementation of mental health services in practice