Mental Health Department, Trieste

Mental Health Department, Trieste

THE MENTAL HEALTH SERVICES GUIDE

Mental Health Department,

Trieste, Guide to the Services

http://www.triestesalutementale.it

February 2004

THE MENTAL HEALTH SERVICES GUIDE

This volume has been developed within the project of research – intervention ‘The Needs of the Relatives of People Affected by Serious Mental Disturbance’, financed by the Ministry of Health with deliberation 3962 of December 17th, 1999. Its publication forms an integral part of the project final stage, aimed at activating paths of information for relatives, primary users, and citizens.

This Guide has been developed with the contribution by all the operators of the Mental Health Department, the family associations, users, citizens, social cooperatives.

As for the section devoted to research and drawing up, the following have particularly cooperated: Renata Bracco (with a coordination role), Patrizia Rigoni, Alessandra Barbagallo, Corrado Crusiz, Caterina Ferraro, Kenka Lekovich, Isabel Cristina Marin, Elena Suklan.

Giovanna Gallio has supervised the final stage of the text editing and publishing.

A special thanks is for Ugo Pierri to have enriched the volume with his drawings.

Finished to be printed April 2004

Graphics and paging-up: Confini Social Cooperative

Printing: Tipo / Lito Astra, Trieste

‘It all occurred suddenly. Up to the day before, he was a boy like the others: He went to school, took part into contests, played soccer. He had a girl-friend, a fine and good girl. When he started feeling bad, we hardly knew what ‘mental disease’ meant’; the existence of the Department, the Mental Health Centres were totally unknown to us. Of course, living in this town, we used to meet, as one can say, ‘peculiar’ people; on the bus – you saw people avoiding them. But, that was something very far from us.

Our family was like the other ones, with its problems, but perfectly normal: We were all healthy. Then, our first son fell sick, and, immediately afterwards, there started problems with his sister.

I do not know how, I do not know why. I cannot give myself any answers, and there are many questions. Believe me. But I have to live with this situation every day, and it is not easy. Sometimes, I would like to escape. I seem not to be able to face it. I remember that, initially, I was afraid of my son, when he became bad without any reasons I could understand. I also avoided to go out with him. Everybody looked at us. It was a bad sensation.

I understand that people are afraid. People do no know, and why should they? Neither did I know, I repeat. But now, after all those years, I realise it is necessary to know. I have learnt, and many other parents like me have. It is there that we learnt that there are many ways to face sufferance, and that the first thing to do is fighting our own prejudices.

Yes, I believe that all should know. It is a very big problem, more spread and common than you believe. And then, we are all involved… or not?’

P R E S E N T A T I O N

Health in Trieste boasts, among the rest, an important and worldwide acknowledged wealth. It is the reality which more than any other one inspired the national law of psychiatry reform, the place where the reform was more thoroughly implemented. It was here, in fact, that the Basaglia experience – started at the beginning of the Seventies – grew, and led to the closure of the psychiatric hospital, with the birth and spreading of the first community-based mental health centres.

Thirty years have passed, and, meanwhile, the whole of the health assistance organisation has deeply changed. This Guide reminds that to us: Not only has the right of all citizens to health been acknowledged, but prevention, care, and rehabilitation activities have received a strong impulse by the community decentralisation policies, as well as by the establishment of the districts following the recourse to a Agency. In the past decade, especially, it was necessary to diversify resources and procedures to face the qualification of demand, suggest new staff training paths, finance new programmes. Today, the work of the community-based services increasingly tends to develop specific projects according to belts of problems and population. The Mental Health Department of the Trieste Agency is moving towards that direction, keeping on representing a reference point for all those who care of the events of mentally disturbed people and their families.

A health Agency must not however end its task giving good services. It must also develop a constant and transparent relationship with the citizens. It must give them a thorough and effective information on the services, and the way to make use of them. It must know the perception the citizens have of the services, and develop corrections and further developments of programmes and performances also on that perception. It must – in a word – organise the participation of citizens in the planning, management, and utilisation of health services.

This Guide is pleased to present some answers to those requirements. On the one hand, it witnesses the effort by the Agency to direct towards the action addressees, to increase their ability of orientation and choice on the mental health paths. On the other, it is a strong programmatic and managerial commitment. It sets up a pact with citizens, suggests innovatory programmes, shows possible developments, especially for what concerns the district integration area, which is described by this Guide, and that well represents the more general development line of the whole Agency.

This Guide will be distributed to the different operators, as well as to the interested citizens and the institutional subjects contributing with the health Agency to the promotion of health in the Trieste territory. This Guide has been also written to improve the communication quality between services, bodies, institutional and associational subjects, which are already interacting between them and are daily cooperating.

Franco Zigrino

General Manager of the Health Agency No. 1 Triestina

Trieste, February 15th, 2002

‘…I always wake up well

and become deformed through the others’

Alda Merini

Prevention, Cure, Rehabilitation: Healing is Possible

1.  The psychic welfare state can be better assessed as the ability to establish appropriate and satisfactory relationships, and adopt suitable behaviours in facing the different – environmental, relational, institutional – changes, which occur during one’s life. Before the risks of reduction, compromise, or loss of those abilities, the task of mental health services is to prevent, cure, and rehabilitate, thus involving different environments and subjects, actors, and community-resources in their action.

Prevention cannot, in a broader sense, but concern the social organisation on the whole, since promoting health – and, especially, mental health – means to improve life conditions and meet people’s basic needs, especially of the groups at risk. The prevention work partly makes social spaces liveable, favouring the community welfare and development with respect to nature, the cultures, the ethnic groups, the religious faiths; facilitating the access to education, training, information, and culture; building paths of knowledge, communication, and exchange, not only between the single people, but between the different social groups.

Cure must tend to avoid that people – exposed to a temporary or permanent difficulty condition – lose their rights and social competences, dignity and power in the exercise of their roles (affective, relational, familiar, productive). On avoiding the risks of expulsion and social outcasting, the commitment must be applied to transform attitudes and behaviours based on prejudices and intolerance, without neglecting the problems and rights of families, or of those who can be – also indirectly – involved or damaged. Gestures, knowledge, action time and spaces, instruments and programmes must be directed to bring out the meanings and contents of sufferance, the singleness of experiences and histories, appealing to the needs and requests of change, which actually concern the relationships between people and institutions, between the single individuals and the whole community.

In turn, rehabilitation must – as learning or recovery of capacities, abilities, and social competences – be able to arrange differentiated paths, suitable for the difficulties and obstacles, case by case. In its targets and implications, it goes well beyond the service borders, since the rehabilitation work must enhance the adoption of resources, and improve the capacities to defend, maintain, or give back powers and rights – both personal and social – in the exercise of citizenship.

2.  How are those criteria and principles – concerning prevention, care, rehabilitation – actually translated in the service daily organisation? with what paths, activities, programmes? with what resources?

The Guide we are presenting deals with this:

-  It gives useful information on the Mental Health Department (MHD): What and how many facilities it includes; what the services are useful for, and how to make use of them; where they are and how they work; what type of activities, actions, and performances they give;

-  It describes the map of the territory and the health districts, showing the head offices and places where different competences mingle to support special programmes;

-  It reminds the legislative principles, and goes over again the stages that marked the passage from psychiatric hospitals to community-based assistance;

-  It shows the plurality of subjects and the ‘actors’ currently involved in the field of mental health, besides the users and their relatives, agencies and services acting in the community, no-profit associations and social cooperatives, bodies, and local institutions, volunteers and private citizens.

This plurality – of places, subjects, cultures, resources – today allows to more fully express the health demand, and also authorizes the operators to more optimistically face the issues related to the mental disturbance. In the perspectives opened by the reform. It in fact seems possible to overcome the prejudice of the incurableness / chronicity of the mentally sick. Up to not so many years ago, this excluded to consider recovery as a target to be pursued.

The word ‘recovery’ here mainly means the active experience of ‘recovering’, ‘starting off again’. It is a personal and unique path every time, which involves those who suffer from a serious disturbance in the recovery of a full autonomy – both as subjects and citizens –, fully responsible of themselves, as capable of responsibility towards the others, up to the point of committing themselves in a ‘help work’ to others with similar difficulties.

Higher probabilities of recovery from the mental disturbance are today associated to the introduction of new and more suitable pharmacological and psychological actions, able to relieve mental sufferance, and reduce the sometimes destructive effects, both behavioural and relational. Those actions alone would be however insufficient, if the new service community arrangement would not allow the protagonism of users, relatives, and citizens, who – variously associated – strengthen their power of autonomy, choice, and decision, in the pursuance of health goals, and the defence of their own interests.

3.  The actual ‘discovery’, what we have gained in many years of commitment and fight against exclusion, is that those who suffer from mental disturbances must be first of all helped to safeguard and preserve their own rights within the social space: Both in the more private and daily life, as well as in the network of relationships and exchanges in the community they belong to. These rights are not supported by abstract juridical and administrative regulations, but by resources which must be actively looked for and formalised, in addition to actions and interventions guaranteeing access and the actual use.

In other words, the right exists, if it is exercised. It must be acknowledged in the actual existence of people, in the patterns of their social reproduction, as well as in their emancipation paths. If, as many acknowledge today, these are the central aspects of the therapeutic-rehabilitative work, it could be said that the originality of the Trieste experience has consisted, since the first years of the Seventies, in day-by-day inventing the access ways to opportunities and social rights – house, income, work, education, and training, network of belonging and sociality –, making use of different resources and procedures from those usually adopted in the psychiatric intervention.

There are today several people with mental disturbances (or who experienced it in the past), active in associations and groups for the defence of their own rights, often supported by operators, volunteers, or private citizens. In turn, relatives are increasingly present on the scene of services: Support, information, and burden reduction programmes are implemented with very useful results in the improvement of the quality of life within the family.

In many cases, the opportunity to access to cures, or to start rehabilitation and recovery paths are still conditioned by prejudices and consequent discrimination patterns. This is a front where you must still commit yourselves, in Trieste and Italy, even if the closure of psychiatric hospitals has produced big changes in itself in the social images of people with mental disturbances, visibly improving their possibilities to preserve social roles and competences, making the recovery expectations realistic.