Guiding principles for a community-based strategy for mental health

The experience in Trieste, from 1971 to the present, demonstrates that it is possible to establish a network of mental healthcare services which are totally alternative and antagonistic to the psychiatric hosptial, and which are able to respond to the needs of the local population.
The main principles which have inspired mental healthcare practice in Trieste for nearly 35 years now are:

• total opposition to any form of internment or confinement typical of asylum-based or institutional psychiatry;
• the overriding awareness of the paramount importance of the person’s needs as the sole point of reference for the organisation of the mental health services;
• the need to provide services which are cost effective and which meet overall healthcare budget requirements.

Ongoing analysis and reflection upon the experience in Trieste, comparison with operators and users of both Italian and foreign services which are likewise committed to deinstitutionalisation and close collaboration with national and international mental healthcare organisations have enabled us to establish a series of guidelines for institutional transformation in psychiatry.
These principles define a transformation process which is never linear and automatic, but which requires a constant and collective ethical, political, cultural and scientific effort.
In fact, the work of deinstitutionalisation cannot be enacted by decree but must be conceived – and carried out – as a process, a journey, in which anyone can take part and which involves personal and collective research, primarily practical initiatives and an ongoing verification by all the actors involved (operators, users, administrators, family members and the general public).

PRINCIPLES for a community-based mental healthcare strategy

The following factors are indispensable in order to achieve a successful and effective strategy of community-based mental healthcare:

• a fundamental shift in terms of approach and interventions from the hospital to the community;
• shifting the centre of attention from an exclusive focus on the illness to the person and their social disabilities;
• shifting from individual to collective action focussed on the user and their context(s); a collective work strategy requires (at least) the following conditions:
  multi-disciplinary widening of the skills and abilities employed
  - enhancing/promoting the user’s self-help resources
  - enhancing/promoting family resources
  - raising public awareness regarding the mythical nature of the concept of danger and other irrational prejudices concerning the mentally ill through primarily cultural initiatives that can provide a more positive social image of mental illness
  - increasing greatly the collaboration of non-professionals
  - re-evaluating the effectiveness of exclusively biological therapies and orthodox forms of psychotherapy
  - utilising the active forms of solidarity provided by the most aware, attentive and well-disposed social groups, as well as local institutions/agencies open to forms of collaboration
  - the "open door".
• the community dimension of collective action, ie. establishing a theoretical and organisational point of reference made up of a specific territory and population and the progressive assumption of responsibility and organisation of the services based upon and referring to that territory and population, and not referred to a single institution
  the practical-affective dimension of the intervention, especially in terms of meeting even the most elementary needs of users and the paramount importance given to collective action in responding to these needs; improving even minimally the user’s objective living conditions is of utmost importance.

To these strategies should be added:

• a bill of formal rights and legal and administrative norms that defend patients' rights
• the activation of social policies aimed at the personal reproduction of weak/vulnerable individuals which give priority to housing, occupational training and employment, socialisation and the quality of life of psychiatric patients.
• stipulating major agreements with various local adminstrations in order to enact the organisational changes necessary for implementing the above-described strategies.

(From: "Eight by Eight principles: For a strategy of collective, community-based psychiatry", in In search of normality: A psychiatrist’s notebook, Franco Rotelli, Asterios Editore, Trieste, 2000)