Operational Units

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.

The MHCs of the Trieste Mental Healthcare Department are:

Barcola/Aurisina
District 1
Viale Miramare 111
Tel. 040 411 452 - 040 411 586
Fax 040 412601
e-mail: csm.barcola@ass1.sanita.fvg.it

Maddalena
District 2
Via Molino a Vento 123
Tel . 040 390845 - 040 396711 - 040 948768
Fax 040 396785
e-mail: csm.maddalena@ass1.sanita.fvg

Domio
District 3
Via Morpurgo 7
Tel. 040 2820024 - 040 2820039
Fax 040 2820040
e-mail: csm.domio.segr@ass1.sanita.fvg.it

Via Gambini
District 4
Via Gambini 8
Tel. 040 632195 - 040 632140
Fax 040 360457
e-mail: csm.gambini@ass1.sanita.fvg.it

San Giovanni
University Psychiatric Clinic
District 4 (with catchment area of only 12,000)
Via Paolo de Ralli 5
Tel. 040 3997301 - 040 3997302
Fax 040 3997401
e-mail: csm.psichiatrica@ass1.sanita.fvg.it

Psychiatric Diagnosis and Care Service

The Psychiatric Diagnosis and Care Service (PDCS) is located within the General Hospital (Ospedale Maggiore) but forms part of the MHD, and therefore functions as an interface between the hospital and the community. It has 6 beds, is open 24hrs and works closely both with the Hospital Emergency Room and the other MHD OUs . Because of its unique functions, it has special protocols that regulate the admission and treatment of patients.
The staff consists of 3 psychiatrists and 16 nurses, with a psychiatrist from one of the other OUs on-call (on a rotation system) nights and weekends.
The PDCS's main function is to provide psychiatric consultancy for urgent/emergency cases which enter the Emergency Room (about 2000 contacts annually), and to provide consultancy within the various medical wards of the General Hospital, at the request of the competent physicians within those wards. After an initial evaluation and, if needed, primary care, the PDCS staff must determine whether:

• the problem has been sufficiently resolved, with a possible referral to the user's GP;
• the problem is serious and unresolved, with a referral to the competent MHC;
• the problem is severe, with a referral to the competent MHC, which shall decide whether begin a therapeutic process with the user.

In keeping with the fundamental principle of a community-based service, the PDCS's primary goal is to reduce the length of hospitalisation, and any hospitalisations of longer duration should be considered as the famous exception which confirms the rule. Admission to the PDCS - whether for voluntary or mandatory treatment - should never be considered as an alternative or substutite for treatment (the so-called "shouldering the burden") by the competent MHC. In fact, admissions to the PDCS are usually carried out in collaboration with both the community OUs and Hospital staff, though in special cases they are the result of a judicial order (e.g. prison inmates with acute psychiatric distress, or in order to provide a psychiatric evaluation for persons awaiting trial).
The PDCS's organisational model and close collaboration with the MHCs has made it possible for even the most severe patients to maintain contact with their own environment, facilitating the resolution of crisis situations while avoiding institutionalisation, with the risk that PDCSs become de facto "mini-asylums".
It should also be stressed that the doors of the PDCS are always open and methods of physical restraint are never used.
During 2005, 1019 persons were referred to the PDCS, for a total of 1960 contacts. In 19% of cases, the user was sent home after an initial consultation, in 25% of cases they were sent home after being advised to contact their local MHC, in 31% of cases they were referrred to their MHC and in 25% of cases the person was referred to other healthcare services and/or other public agencies.
With respect to diagnosis, in 2005, 28% (254 persons) were diagnosed with a psychotic disorder (F20-F29, ICD - X) and 23% (216) with an anxiety syndrome (F40 - F48).
Of the nearly 2000 total contacts, 177 persons were hospitalised within the PDCS before being referred to a MHC.
With respect to the Mandatory Healthcare Treatment, after a peak of 28 persons and 389 days of MHT in 2003, in 2005 this number fell to 17 persons and 206 days of MHT. In 2005, in the Province of Trieste, MHTs were applied to 7 persons, for a total of 85 days per 100,000 population, while the Italian national average is instead 20 persons and 219 days per 100,000.
In 2005 the PDCS had a total budget of 945,981 Euro.

Residence and Rehabilitation Service

"Cantieri Sociali" - Pavilion M
Via de Pastrovich 1
Tel. 040 399 7340
Fax 040 399 7382
e-mail: segr.sar@ass1.sanita.fvg.it

Located in the San Giovanni Compound, the Service was established in the early 1990's in order to give greater impetus to the empowerment, rehabilitaton, training and social integration activities for MHD users.
Working in close collaboration with the MHCs and the Local Healthcare Districts, the Service plans, coordinates and monitors: 1) residential rehabilitation activities (in collaboration with Type A Coops), 2) occupational training and placement programmes (in collaboration with Type B Coops and other public/private training agencies, and 3) Day Centre activites (in collaboration with various training agencies).
The Service staff is composed of: 1 psychiatrist, 2 social workers, 1 nursing manager, 16 nurses, 1 rehabilitation specialist, 2 educators, 8 social-healthcare specialists, 2 social-healthcare auxiliaries, 1 technician and 1 adminstrative secretary. To these should be added the personnel of the Type A Coops which, under the direct supervision and coordination of the Rehabilitation and Residence Service, maintain and manage the residences and assist users in developing their social relations and abilities.

Specifically, the RRS provides the following services: (1) Residential Structures (Coordinating Office); (2) Office for occupational training and employment; (3) Coordination of Informal Resources.

(1) Residential Structures (Coordinating Office)

Pavilion M
Via De Pastrovich 1
Tel. 040 399 7306

The Office promotes initiatives and develops strategies aimed at enhancing the living conditions/habitat and developing rehabilitation/training projects for persons who, for varying lengths of time, are hosted in the MHD's residential structures. Its functions include monitoring the beds (ie. places within residences) available and coordinating their use.

The MHD has two types of residential structures available:

• Residences for social integration / living groups – these residences are managed directly by the MHCs and currently (December 2005) host a total of 40 persons in 11 different living groups. The residences are intended for persons with a mental disorder that results in reduced autonomy, and who therefore need support in their daily lives, and/or for persons who may derive significant benefits from a collective living situation. The residences, which are either rented or owned by the Local Healthcare Agency, are run by service operators, who provide a flexible, daytime support which is programmed based on the needs and levels of autonomy of users.
• Therapeutic/rehabilitation residences – houses or apartments which are rented or owned by the Local Healthcare Agency and managed by the RRS, either directly (through its own operators) or indirectly (through contracts with type A coops or volunteer associations), but always in close collaboration with the user's competent MHC guest. There are 10 such residences, for a total of 70 guests, with 6 of the 10 residences being located within the San Giovanni Compound (43 guests).

The residences are for persons with serious disorders and disabilities who have no family/social network (or one which is inadequate) and who require a personalised, ongoing therapeutic-rehabilitative programme. Users of this service include a small number of former longterm inmates of the psychiatric hospital who.
Residences are managed by operators on either a daytime or 24hr basis and entry into a residence is based on an evaluation of the various OUs involved in that user's rehabilitation project. However, even after a person has entered into a residence, they remain in contact with their home community and continue to receive whatever care or assistance may be needed from their MHC.
A representative from each OU and from the coops involved in managing the residences meet on a monthly basis at the RRS in order to monitor and evaluate the progress of the users living in residences, especially those who have entered recently. In 2006, the residences began to be financed through the healthcare budgets (see Programmes: Healthcare Budgets).

(2) Office for occupational training and employment

"Cantieri Sociali" -Pavilion M
Via De Pastrovich 1
Tel. 040 399 7422 - 040 399 7405
e-mail: segr.sar@ass1.sanita.fvg.it

The office was established in 1996 in order to coordinate and upgrade the occupational training and employment activities, and is staffed by operators from different OUs. It is responsible for the following programmes:

• carrying out professional training processes, in collaboration with other training agencies;
• evaluating the quality of training processes;
• monitoring the assignment of monthly occupational training grants
• training operators on training/employment issues.

So-called "disadvantaged" persons, including persons with a serious mental disorder, who are involved in the occupational training programmes are eligible for an occupational training grant, which over the years has proven itself to be an extremely effective therapeutic tool. The programmes have the following goals: acquiring interpersonal and social abilities; guiding and integrating persons in recognised occupational and professional roles; consolidating personal identity and a sense of social belonging through the gradual abandonment of the role of an ill and dependant person.
Since 1998, the Office meets regularly with representatives of the Type B Coops in order to concord strategies against social exclusion, discuss and evaluate intervention methods and draw up integration and development projects together with other partners in the community.
Persons entering this programme are referred by their MHC, which remains the primary referent for all personalised therapeutic-rehabilitative projects coordinated by the RRS (occupational training, Day Centre, residences). Once monthly the Office meets with the representatives for occupational training from the MHCs, in order to monitor and evaluate the users involved in the programmes.
During 2005, 163 persons were involved in the various RRS programmes (85 in residences, 32 in the Day Centre/Polytechnic, and 46 women in the programmes coordinated by the Family Counselling Centre in Androna degli Orti).

(3) Coordination of Informal Resources

The RRS, in collaboration with associations such as Club Zyp and Cagipota, family groups and MHCs, also provides numerous Day Centre activites in various locations, including the Polytechnic in Pavilion M, the Aurisina Day Centre and the Family Centre in Androna degli Orti (Women's Mental Health Project). A committee called "Segreteria Trasversale" is currently being created in order to coordinate the various informal resources.

(Pavilion M) Polytechnic - Day Centre
"Cantieri Sociali" - Pavilion M
Basic/continuing training (office) and training/empowerment workshops
Via De Pastrovich 1
Tel. 040 399 7384

The Polytechnic promotes and coordinates arts & crafts and cultural workshops, projects and activities. The staff is made up teachers, master craftsmen, artists, members of cultrual associations and volunteers. The activities are aimed primarily for users but are open to all. Decades of experience make for a very flexible and original workstyle that responds to the inclinations and abilities of individual users, and which combines the need for rehabilitation with ongoing qualified training by means of projects for leisure time, artistic expression and cultural promotion and production. Theatre, visual arts, music, dressmaking and self-care are the activities which have remained particularly strong and constant over the years.
The Polytechnic, in collaboration with training agencies and based on the recommendations of various OUs, also organises training courses financed by the Region or European Social Fund, with outcomes monitored and evaluated by the Training Office.

(Aurisina) Day Centre
Via del Cave 9, Aurisina
Tel. 040 200 988 - 040 201 211
Fax 040 201 236
e-mail: centrodiurno@ass1.sanita.fvg.it

The programmes of the Aurisina Day Centre form part of a wider series of activities for rehabilitation, socialisation, health promotion and active processes for citizenship and empowerment. These activities also take place within the single MHCs and are coordinated so as to enhance overall opportunities for users in both qualitative/quantitative terms. At least one operator from each Department OU dedicates a part of their working time to the Centre's activities.