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Since Franco Basaglia's appointment in 1971 as director of the former San Giovanni mental hospital, Trieste has played an international benchmark role in community mental health care. Moving from deinstitutionalization, the Department of Mental Health (DMH) has become a laboratory for innovation on social psychiatry, developing a model that can be defined as the "whole system, whole community" approach. The DMH provides care through a network of community services but also places great emphasis on working with the wider community with a view to promoting mental health and taking care of the social fabric. The network of services is based on 24/7 Community Mental Health Services.
Mental Health Centres
Each Mental Healthc Centre (MHC) is responsible for responding to the request for care by adults in its local catchment area. Contrary to what is commonly believed, MHC programmes and interventions are not only for persons with serious mental disorders, but for all those who during various phases of their lives or in a cyclical manner experience more or less prolonged states of anguish, sadness, fear and anxiety and often in conjunction with certain life-events (loss of work or productive role, solitude and/or social isolation, serious family conflicts, grief and separation, etc). In many cases, the relationship with the MHC is limited to a single (or very few) consultations; in other cases, and with a different style of intervention, this relationship can last much longer.
In recent years, the mental healthcare services have had to deal increasingly with a demand which can be defined as one of diffused distress and malaise, a situation of ill-being linked to traumatic and/or stressful events caused by relational problems, family conflicts, violence, abuse, grief, separation and serious illness, but also economic, housing, employment or social integration problems. Persons are also referred to the services by GPs with possible diagnoses of depression, insomnia, anxiety attacks and so forth. There is an elevated risk that these forms of illbeing can transform themselves into illness, leading to invalidation. Because the local Healthcare Districts must also often deal with this demand, the MHCs must work closely with the District OUs (consulting services, child and adolescent, handicap OUs, etc.) and with GPs.
The Mental Health Department must therefore deal with this generalised ill-being with prevention programmes, and develop specific strategies for dealing with major social problems and distress that involve the risk of mental disorder for both individuals and groups, as well as the mental health of the population in general.
MHCs: Activities, interventions, services
The MHCs are places for encounters and exchanges, and provide services, interventions and programmes for persons in difficulty and/or with mental disorders and to their families. They operate on a 24hr basis, with 6-8 beds for daytime and overnight hospitality and deal with a wide range of demands, responding to crises and emergencies, while also providing out-patient, day hospital and day centre activites. In addition, they manage group homes, transitional therapeutic communities and other living groups. Their workstyle stresses a continuity in therapeutic-rehabilitation interventions, especially for persons with severe mental disorders. This approach involves supporting the person in the exercise of their fundamental rights and in accessing social opportunities (housing, education, occupational training, health management and leisure activities), accompanying them in their rehabilitation processes and orienting them in their relations with other services and institutions. The service is therefore organised in order to intervene directly in those places where the person in difficulty or with a mental disorder actually lives: not only in their home and community, but also in hospital, in nursing homes and even in prison or in a forensic hospital.
Listed below are the main activities, interventions and services provided by the MHCs, while the MHD's current programmes, which are implemented by different OUs, can be found at [Programmes - link]:
Overnight hospitality - MHCs can provide overnight hospitality for varying lengths of time, from a single night to several weeks, though the average length of stay is 14 days. Each MHC has 6-8 beds, which are available as one of the responses during crisis, for periods in which they need added protection from specific risk situations, or in order to provide "space" and respite for both the user and their family (voluntary and/or mandatory healthcare treatments). In Trieste, the Mandatory Healthcare Treatment is generally carried out in the MHC, or in the Psychiatric Diagnosis and Care Service in the General Hospital.
Daytime hospitality/ Day Hospital - Hospitality can also be provided for several hours during the day, or for the entire day, in order to offer temporary protection or safeguarding, especially during periods of crisis and tension, and in order to reduce the family burden or provide "space" for the person with respect to their normal living situation. This form of hospitality is also indispensable for administering drug therapies and providing psycho-therapeutic support, for encouraging participation in individual/group activities, orientation programmes and for carrying out informational and training processes.
Outpatient service - This corresponds to the first contact (or simple consultation) or subsequent contacts, and enables operators to verify the therapeutic programme. During outpatient visits, it is possible to exchange information and opinions with the user and/or their family members, verify the drug treatment, offer advice and intervene in crisis situations. Medical certificates and specialised medical reports are also prepared during these visits.
Home visits – Home visits can be either programmed or used as a response to emergency situations, and make it possible for operators to learn more about the person's living conditions and their family situation. In certain cases, they can serve to mediate conflictions with neighbours, especially during crisis situations. For persons who have difficulty going to an MHC, they are used for administering drug therapies and providing support and accompaniment from the home to hospital, public agencies, training courses or work.
Personalised therapeutic work - Programmed encounters, in order to listen and talk in-depth about the user's problems and living conditions. The one-on-one approach facilitates the acquisition of new points of view, creates a climate for learning and reassurance and stimulates greater awareness, thus helping the user to see possible solutions to difficult situations and creating new forms of stability.
Family therapeutic work - Programmed encounters with family members in order to verify and discuss family dynamics and conflicts. The aim of these meetings is to promote greater knowledge and participation in problems, stimulate possible changes, create alliances and foster a self-aware adhesion to the therapeutic programme.
Group activites - Programmed encounters, where dealing with and talking about common problems reinforces the capacity for mutual recognition, encourages the organised participation in leisure activities, and helps build and widen the social network. The group work involves operators, persons in difficulty and/or with mental disorders and volunteers, and aims primarily at activating a social network outside of the family which can involve significant others (friends, fellow workers, neighbours) or other actors who play an important role in the therapeutic process and in social reintegration. Some group encounters are also open to family members, in order to improve their knowledge of mental disorders, enhance their ability to deal with problems and crises and build and widen the relational network upon which mutual assistance is based.
Rehabilitation and prevention interventions - Direct and indirect interventions aimed at helping to access information and culture, and occupational training and placement. These interventions take place through the social coops, creative workshops, schools, sport and recreational activities, self help groups and forms of socialisation for young people.
Support for accessing rights and social opportunities - Interventions and programmes for disadvantaged persons and their families, which involve either the direct delivery of economic subsidies (social integration, occupational training, support for rehabilitation activites) or referrals and/or accompaniment of users to agencies and institutions that have the same goals (eg. Council Housing Agency, Law Courts, Foundations, Social Security, Employment Agency). In agreement with the person involved, these programmes can also manage and administrate their personal finances and patrimony.
Home support - A therapeutic/rehabilitation programme carried out in the home or in a residential situation (group homes, living community, therapeutic community), which aims at supporting daily living abilities, in order to preserve or re-learn the social and interpersonal skills necessary for group living. The programmes provide different levels of assistance and protection, depending on user needs.
Consultancy service - Intervention in healthcare services or hospital wards, both for persons already in contact with an MHC, as well as new users of the Mental Healthcare Services, in order to provide diagnoses, suggest specific therapies and/or initiate a therapeutic process with the MHD. This service is also provided in prison, both for inmates with pre-existing problems as well as those who develop mental disorders during incarceration. More intensive consultations are available in the Healthcare Districts, in collaboration with GPs, and in public/private nursing homes.
From the Asylum to territorial Services for Mental Health Innovation for Development and South-South Cooperation Presentation by Peppe dell’Acqua, 2010
Recovery Oriented Acute and Crisis Services in Trieste
Roberto Mezzina, Director, Department of Mental Health, WHO CC, Trieste, Whole life –whole systems Symposium
21 March 2014, Stevenage, UK
The Mental Health Department The Trieste Mental Health Department was established in 1981, and since then has continued to evolve and redefine its own tasks and functions. 4 Mental Healthcare Centres (MHC) - operational 24 hours a day, 7 days a week, with a catchment area of approximately 60,000 each and furnished with 6-8 beds (together with an experimental MHC managed by the University Psychiatric Clinic with a catchment area of 11,500 and equipped with 4 beds). The MHCs are the entry-point to the mental healthcare system and function as the pivotal centre for the coordination of activities and the programming of services and intervention. The MHCs developed out of the original 5 workgroups formed during the deinstitutionalisation period in the 1970s and currently cover the same territory as the 4 corresponding Healthcare Districts.